ChoosingWisely( Appropriate(Exercise(Prescrip+on( … · 2018. 4. 3. · 1mile/wk • Dependent...

Exercise Prescrip+on in Older Adults 2015 FPTA Spring Conference

3/2015

© William McGehee, PT PhD All Rights Reserved 1

Appropriate Exercise Prescrip+on for Older Adults Bill McGehee, PT PhD

Clinical Assistant Professor Department of Physical Therapy

University of Florida

Choosing Wisely

•  Don’t prescribe under-‐dosed strength training programs for older adults. Instead, match the frequency, intensity and dura<on of exercise to the individual’s abili<es and goals.

Choosing Wisely

•  Improved strength in older adults is associated with improved health, quality of life and func+onal capacity, and with a reduced risk of falls. Older adults are oSen prescribed low dose exercise and physical ac+vity that are physiologically inadequate to increase gains in muscle strength. Failure to establish accurate baseline levels of strength limits the adequacy of the strength training dosage and progression, and thus limits the benefits of the training. A carefully developed and individualized strength training program may have significant health benefits for older adults.

The Slippery Slope of Aging Schwartz, 1997


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Frailty Prevalence in Community Dwelling Older Persons: A systema+c

review

•  The overall weighted prevalence of frailty was 10.7%

•  The weighted prevalence was 9.9% for physical frailty

•  13.6% for the broad phenotype of frailty Prevalence increased with age and was higher in women than in men

Cycle of Frailty

Xue QL, Bandeen-‐Roche K, Varadhan R, et al. Ini+al manifesta+ons of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2008;63(9):984–90

Swartz, RS (1997) Sarcopenia and Physical Performance in Old Age: Introduc+on. Muscle & Nerve Suppl. 5:S10-‐12.

CDC Physical Activity Guidelines for Older Adults

•  2 h and 30 min (150 min) of moderate–intense aerobic activity (i.e., brisk walking) every week AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR


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•  1 h and 15 min (75 min) of vigorous–intense aerobic activity (i.e., jogging or running) every week AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR


•  An equivalent mix of moderate- and vigorous-intensity aerobic activity AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)

•  Guccione, Andrew A.; Avers, Dale; Wong, Rita (2011-03-07). Geriatric Physical Therapy (Kindle Locations 31175-31183). Elsevier Health Sciences. Kindle Edition.

ACSM Exercise Guidelines for ST Programs for Seniors

•  Thorough health screening and medical exam needed.

•  Frequency of strength training à 2 days/week •  Rest à Minimum of 48 hours between

sessions –  Seniors tend to have more soreness and may need

a longer recovery up to 3-4 days.

ACSM Exercise Guidelines for Strength Training Programs for Seniors

•  Sets/Reps à – Start with 1 of 10-15 reps. – Gradually increase to 2 or 3 sets

•  Intensity à – Start with 40-60% of 1 rep max – Gradually increase to 70-80% of 1 rep max

•  Rated Perceived Exertion à – 12-13 (mild to moderate)


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ACSM Exercise Guidelines for Strength Training Programs for

Seniors •  Include at least one exercise for all major

muscle groups. Which are? •  Focus upon functional, multi-joint exercises.

Examples are? •  For many clients, you many need to start with

single joint exercises / machine exercises à perceived as easier by the client.

•  Progress them from machine to functional when they become accustomed to the exercise.


Seniors •  Complete session within 30 minutes •  1st 8 wks should use only minimal

resistance to allow for connective tissue adaptation.

•  1st few sessions should be supervised. •  Emphasize proper technique within a

painfree range of motion •  Encourage normal breathing pattern.


Seniors

•  Initial overload should be achieved by increasing the number of reps then the weight.

•  When returning from a layoff, use a resistance of 50% of the previous intensity.

•  Should be a year-round program.


Seniors

•  Avoid isometrics and other exercises that may increase blood pressure.

•  Work large muscle groups first and opposing muscle groups in succession.

•  Machines preferred over free weights initially.


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BMI and Older Adults BMI and Older Adults

BMI and Older Adults Func+onal Markers (CEEAA)

•  FUN –  TUG –  Gait Speed –  400M walk –  6 Min walk –  FSST –  BBS –  DGI –  Chair Rise

–  <8sec –  >1.5m/sec –  <5min (~20min mile) –  >480m (1575S, 1.3m/s) –  <10 sec –  54-‐56/56 –  24/24 –  >15


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Func+onal Markers

•  FUNCTION –  TUG –  Gait Speed –  400M walk –  6 Min walk –  FSST –  BBS –  DGI –  Chair Rise

–  9-‐20sec –  .9-‐1.5m/sec –  5-‐7.5min (20-‐30min mile) –  360-‐480m (1181-‐1575S) –  10-‐15 sec –  46-‐53/56 –  19-‐23/24 –  9-‐14

Func+onal Markers

•  FRAIL –  TUG –  Gait Speed –  400M walk –  6 Min walk –  FSST –  BBS –  DGI –  Chair Rise

–  >20sec –  .5-‐.8m/sec –  7.5-‐13 (30-‐52min mile) –  180-‐360m (591-‐1181S) –  15-‐20 sec –  30-‐45/56 –  14-‐18/24 –  <8

Func+onal Markers

•  FAILURE –  Gait Speed –  400M walk –  6 Min walk –  FSST –  BBS –  DGI –  Chair Rise

–  <.5 m/sec –  >13 min (>52 min/mile) –  <180m (600S) –  >20 sec –  <30/56 –  <14/24 –  0


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Gait Speed

•  Studenski, S, et. al (2011, JAMA) – Analysis of 9 cohort studies – 34,485 Adults – Gait Speed of .8 m/sec predicted median life expectancy

– Gait Speed of > 1.0 m/sec predicted longer than expected survival

– Gait speed added to age and sex substan+ally added to successfully predic+ng survival

Overload Principle—figh+ng Sarcopenia

•  Tissue must be exposed to load not normally exposed to improve func+on

•  Applies to endurance, strength, balance, flexibility

•  Skeletal muscle requires workload of 60% max available strength to increase

•  Ac+vity < 60%-‐-‐probably motor learning – No reversal of muscle atrophy – Further decline in func+on

Exercise Prescrip+on

•  Muscle Strength – American Academy of Sports Medicine – American Geriatrics Society – APTA SOG

•  Recommend using 60% or higher of 1RM to improve strength and func+on

•  80% of 1 RM is the preferred workout to obtain op+mal results

Intensity

•  How do we know we are working our pa+ents hard enough?


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Intensity

•  One Repe++on Maximum – What is it? – How do you test it? – Any concerns?

Alterna+ves

Alterna+ves

•  Weight/(1.0278-‐(.0278*Reps) – 10 # @ 8 Reps

•  10/(1.0278-‐(.0278*8) •  10/.8054 •  12.4 #

•  Weight * (Reps * .033)+1) – 10 # @ 8 Reps

•  10 * (8 * .033) + 1) •  10 * 1.264 •  12.6#

Sets and Repe++ons

•  Only modest (2.3%) differences in strength gains have been demonstrated with >1set.

•  “Complete as many as possible” vs. set number – When should you stop?


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Determining Baseline

•  10 RM is about 75% of 1 RM •  Target 8-‐12 repe++ons •  12 repe++ons is about 60% 1 RM •  > 20 repe++ons not overloading enough

Specificity and Func+onal Strength Training

•  Must train for what you want to be able to do!

•  How do you make strengthening func+onal?

Progression

•  Frequent reassessment is important! •  Methods of progression

Contraindica+ons For Exercise* (ACSM, 2005; Fletcher, BJ et al., 1993)

•  Res+ng HR < 50 bpm, > 100 bpm •  Res+ng SBP < 90 mmHg, >200 mmHg •  Res+ng DPB > 110 mmHg •  O2 sat < 90%* •  SOB, angina, DVT, cyanosis, •  increased edema, headache, •  abnormal heart or breath sounds


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Func+onal Tests

•  Berg •  Tinez •  TUG •  10 m walk •  6 min walk

What does the literature say regarding effects of physical exercise

for COPD? Langer et al.

•  Endurance training: •  posi+ve effects on func+onal exercise capacity, HRQOL, dyspnea

•  Moderate intensity (50-‐60% peak work rate, modified Borrg 5-‐6/10) needed to improved physical fitness.

•  Should be supervised, at least ini+ally. •  Treadmill or cycle ergometer or combina+on

–  3x/wk

•  Interval training: •  Effects comparable to endurance training •  Two studies showed pa+ents were able to achieve higher work rate with less dyspnea compared to high-‐intensity endurance training (Vogiatzis 2002, 2005).

•  In general, studies used exercise bouts of 30-‐180 sec at min of 70-‐80% peak work rate with work/recovery ra+os of 1:2.

•  Circuit Training: regular walking program enhanced with sta+ons of alterna+ve ac+vi+es


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•  Lower Extremity Resistance Training: •  RCTs comparing endurance training with combined endurance and resistance found larger improvements in muscle strength in combined interven+on.

•  2-‐3x/wk recommended, 60-‐80% 1RM, 8-‐15 reps •  Upper Extremity Resistance training: •  evidence inconclusive •  Recommend free weight training and func+onal task training for those with impairments.

Knee OA and Frailty

Misra, D., et al. , J Gerontol A Biol Sci Med Sci. 2015 March;70(3):339–344


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Falling, Fear of Falling, and Balance

The Impact of Fear of Falling on Activity Performance

•  Fear of falling Restricts activity Physical capabilities reduced

Restricts more activities

More impaired physical capabilities

Risk Factors

•  1. Muscle weakness •  2. History of falls •  3. Gait deficit •  4. Balance deficit •  5. Use of AD •  6. visual deficit

•  7. arthritis •  8. impaired ADL •  9. depression •  10. cognitive

impairment •  11. age > 80


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Intervention—what works?

•  Modifiable risk factors – Muscle weakness – Medication side effects – Hypotension – Environment

•  Non-modifiable risk factors – Blindness – Hemiplegia – dementia

Intervention—what works?

•  Different approaches needed for different types of patients – Community-dwelling older adults – Frail and/or institutionalized older adults –  (Shubert T, JGPT 2011;34:100-108.)

Community-Dwelling, Frail, and Institutionalized Older Adults

(J Geriatr Phys Ther 2011;34:100-108.)

Multifactorial Intervention—Community Dwelling Population

•  Customized exercise program—strength, gait, balance

•  Review of medications with modifications –  Min/no psychoactive

and antipsychotics –  Reduce total number

of meds

•  Treatment of postural hypotension

•  Environmental modification

•  Management of foot problems/footwear

•  Treatment of cardiovascular disorders


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Frail or Institutionalized Older Adults

•  Exercise Dose – May respond in shorter amount of time – Minimum 8wks

•  Mode – Functional balance training, high intensity

strength training, gait, supervised power training, perturbation training

•  Frequency and Duration – Consistent, structured progression, individual

Multifactorial Intervention Long-term Care & Assisted Living

•  Less conclusive evidence – Staff Education – Gait training – Exercise programs for variety of benefits, but

may/may not prevent future falls – Medication review – Vitamin D supplementation

General Mobility Issues and their Potential Consequences

Factors Impacting Independence within Community

•  Walking – Crosswalk signals assume walking speed of

1.22m/s, curb ht of 8 inches – One study—0.86m/s – < 1% walked fast enough – Distance—post office, dr. office, pharmacy—

need at least 300m, curb ht 18-20cm (7-8 in.)


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Changes in Ambulation with Aging

•  Gait speed—marker of disability and dependence

•  Higher mortality associated with walking < 1mile/wk

•  Dependent ambulation—common reasons for NH placement

Exercise Prescription for a Patient 3 Months

after Hip Fracture Case report (Mangione et al, PTJ, 2005)

–  2x/wk x 8wks –  8-RM—leg press, hip

abd supine, standing hip ext

–  Stationary bike at 70-80% age-predicted max HR

–  Floor to standing transfer, HEP

•  Results –  increased walking

distance (22.5%) –  Balance (400%) and

balance confidence (41%)

–  isometric force (33-138%)

Case Studies 76 yo male Independent, High Func+oning


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83 y.o. female Hip Fracture with Hemiarthoplasty

ChoosingWisely( Appropriate(Exercise(Prescrip+on( … · 2018. 4. 3. · 1mile/wk • Dependent...

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