PT31 LEC - Geriatric PT EXERCISE AND PHYSICAL ACTIVITY FOR OLDER ADULTS

Exercise Role of Physical Activity (cont.)

- the single most efficacious intervention for older adults used - Accelerated Loss of Strength
by physical therapists - end result of inactivity
- known to simultaneously impact and mediate chronic disease, - Ultimate Goal of Exercise/Activity
many impairments, functional deficits, quality of life, and - to improve mobility and function and thereby decrease
cognition and prevent the negative sequelae associated with the patient’s mobility disability
sedentary lifestyles - Mobility/Disability
- an inability to walk one quarter of a mile and to climb a
Physical Activity flight of stairs
- any bodily movement that involves skeletal muscle - Study of Simonsick et al:
contraction and that substantially increases energy - 23% achieve the CDC’s physical activity
expenditure recommendations
- leisurely activity, requires little to no supervision, is of lower - 12% participate in strengthening exercises
intensity (3 to 6 METs) than exercise, and may be thought of
as usual activity The Slippery Slope of Aging
- 10,000 steps/day ○ Age-related Loss of Strength
○ CDC Recommendations for Older Adults: - one of the most critical factors contributing to mobility
- 150 minutes of moderate-intensity physical disability
activity/week ⬞ 10% per decade
- Strengthening exercise (2 or more days/week)(major - decrease in strength (30 y/o)
muscle groups) ⬞ 15% per decade
- decrease in strength (60 y/o)
Role of Physical Activity ○ Fun
○ CDC Physical Activity Guidelines for Older Adults - the physical ability to do whatever one wants,
⬞ Option 1 whenever one desires, for as long as desired
- 2 hours 30 minutes (150 minutes) of ○ Function
moderate-intensity aerobic activity every week - represents those who have to make choices about their
- muscle strengthening exercise on 2 or more days activities based on some decreased physical capacity
a week: all major muscle groups - represents those who are at risk for mobility
⬞ Option 2 disability or have some degree of mobility
- 1 hour 15 minutes (75 minutes) of disability
vigorous-intensity aerobic activity every week ○ Frail
- muscle strengthening exercise on 2 or more days - those who require help with IADLs and BADLs
a week: all major muscle groups ○ Failure
⬞ Option 3 - those who are completely dependent and often
- an equivalent mix of moderate- and bedbound
vigorous-intensity aerobic activity ⬞ 24% of baseline strength
- muscle strengthening exercise on 2 or more days - required for walking
a week: all major muscle groups ⬞ Leg strength
○ Common Chronic Health Conditions due to Physical Inactivity: - the single most important predictor of subsequent
⬞ Heart disease institutionalization, and it is more important than
⬞ Cancer: breast, colon, prostate, and pancreatic physiological markers or disease
⬞ Congestive heart disease
○ Criteria for Frailty as a Clinical Syndrome (Fried)
⬞ Depression
⬞ Hypertension
- Unintentional weight loss of 10 lb or more in the past
⬞ Cognitive disease year
⬞ Type 2 diabetes - Self-reported exhaustion
⬞ Obesity - Muscle weakness (grip strength in lowest 20%: <23 lb
⬞ Osteoporosis for women; <32 lb for men)
⬞ Peripheral vascular disease Physical frailty
- Walking speed in the lowest 20% (<0.8 m/sec)
⬞ Sleep apnea
⬞ Osteoarthritis
- Low level of activity (kcal/week–lowest 20%: 270
⬞ Stroke kcal/wk for women; 383 kcal/wk for men equivalent to
⬞ Balance problems and falls sitting quietly and/ or lying down for the vast majority
○ Physical Inactivity Increases the Risk of Disability in of the day)
Individuals with Various Chronic Health Conditions including: ⬞ frail if he or she meets 3 of these 5 frailty criteria
⬞ Chronic back pain ⬞ prefrail if he or she meets one or two of these frailty
⬞ Balance problems and falls criteria
⬞ Stroke
⬞ Arthritis
⬞ Frailty
⬞ Debilitating illness
⬞ Long-term chemotherapy
⬞ Total joint arthroplasties
⬞ Lower extremity fracture
⬞ Parkinson’s disease
PT31 LEC - Geriatric PT EXERCISE AND PHYSICAL ACTIVITY FOR OLDER ADULTS

The Slippery Slope of Aging (cont.) Elements of an Exercise Prescription

○ Estimated Values for Functional Markers ○ Overload
⬞ critical parameter needed to extend the limits of
Fun Function Frail Failure
muscular performance
⬞ Intensity of exercise
Gait Speed >1.5m/sec 0.8-1.5m/sec 0.3-0.8m/sec <0.3m/sec
- needed to achieve high levels of function
Six-minute >500m 350-500m 200-350m <200m ⬞ 60% of the muscle’s maximum force
walk test - improve muscle force
⬞ Dose-response relationship
Chair rise 30 >15 reps 8-15 reps <8 reps unable - the greater the stimulus, the greater the
sec w/o hands
improvement
Stair climbing <10 sec 10-30 sec 30-50 sec unable
⬞ Intensity of 80% of a 1RM
10 stairs without rails with or with rails - to obtain optimal result
without rails ⬞ Assessment of Overload Stimulus
- determining the appropriate overload stimulus to
Floor transfer <10 sec 10-30 sec >30 sec with unable
without assist with or assist achieve an adaptive response requires knowledge
without assist of thresholds for adaptation for the aerobic and
muscular systems
- VO2 max
Strengthening Exercise
- 1 RM
○ Thomas DeLorme (strengthening)
- RPE
- progressive sets of each exercise based on a 10RM
- Modified scale of perceived exertion
○ ACSM (cardiac fitness and body composition)
- Talk test
○ Fiatarone (strengthening in older adults)
○ Specificity
- 80% of 1RM
- specificity is achieved by prescribing exercises that
○ Evans (strength training for older adults)
match the type of muscle contraction, the speed of
- high-intensity exercise
contraction, and consideration of the functional
movement inherent in the desired outcome
Physical Stress Theory
- functional strengthening
- foundation of exercise prescription
⬞ Overloading the patient’s gait
- the predictable response of tissues, organs, and systems to
- challenge their speed of walking
mechanical and physiological stressors
- ambulate on unlevel surfaces
- explains the effect of overload or insufficient load on tissues,
- incorporating head turns while walking
organs or systems, as well as the lack of change in tissues,
- carry a large object that blocks direct vision of the
organs, and systems if a “usual” stress is applied consistently
patient’s feet or have the patient move through an
○ The ability of tissue to absorb and dissipate forces is
obstacle course
dependent on many variables:
⬞ Functional Movement
⬞ time over which the stressor is applied
○ Bed mobility
⬞ direction, magnitude, and combination of stressors
⬝ Key Muscles
applied
- abdominals
⬞ physiological condition of the tissue, organ, or system
- erector spinae
⬞ frequency of the application of a stressor and length of
- gluteus maximus
time between the applications
⬝ Exercises
⬞ psychological state of the person and the “environment”
- Bridge progression
in which the stressor is applied
- Sit backs
- Plank (modified and full)
Physical Stress Theory
- Prone hip extension (single and
Too much stress (>100% of maximum) Injury or tissue death double)
- Side plank (regular and modified)
Appropriate (60% to 100% of Strengthening ○ Transfers and squats
overload maximum) ⬝ Key Muscles
- gluteus maximus, medius
Usual stress (40% to 60% of maximum) No change in tissue - obturator externus
- piriformis
Too little stress (<40% of maximum) Atrophy - quadriceps
⬝ Exercises
No stress (0% of maximum) Loss of ability to adapt (death) - sit to stand
- squats with knees abducted and hips
externally rotated
- leg press, wall slides
PT31 LEC - Geriatric PT EXERCISE AND PHYSICAL ACTIVITY FOR OLDER ADULTS

Elements of an Exercise Prescription ○ Functional Training (cont.)

○ Specificity - can be used for balance and strengthening
⬞ Functional Movement (cont.) - can be incorporated into gait training
○ Ambulation and stair climbing ⬞ Speed and Power
⬝ Key Muscles ⬝ Power
- abdominals - time rate of force development
- ES - loss of speed and power is associated with frailty,
- Gmax and Gmed falls, and slow gait speed; slow gait speed is
- Ob Ext predictive of loss of ADL ability and future
- piriformis institutionalization
- quads ⬝ Slowness of movements and gait occurs with
- TA aging:
- gastroc-soleus - loss of type II or fast-twitch muscle fibers
⬝ Exercises ○ Types of Contractions
- Bridge progression ○ Motor Learning
- Sit backs ○ Frequency
- Plank (modified and full) - number of exercise sessions per week that are
- Prone hip extension (single and necessary or advisable to obtain optimum results
double) Recommended Frequency for Types of Exercise
- Step ups (varied heights)
Activity Frequency
○ Floor transfers
⬝ Key Muscles
- abdominals Aerobic (cardiovascular 3–5 times per week
- ES conditioning) With higher intensity, frequency
- Gmax and Gmed can be decreased
- Ob Ext
- piriformis Skills (motor learning) Daily
- quads and balance
- gastroc-soleus
⬝ Exercises Stretching 5–7 times per week
- kneeling with trunk rotations
- extension Strengthening 2–3 times per week for each
- UE movements muscle group
- quadruped trunk rotations and hip
extensions
○ Fast gait and jumping ○ Sets
⬝ Key Muscles - one set of each exercise are effective for the first 3
- Gastroc-soleus months of training, in untrained and novice weight
- Gmax and Gmed lifters, and in older adults
- quads ○ Duration
⬝ Exercises - amount of time of each exercise bout or the length of
- skipping time of an exercise session
- fast foot placement on target - skill and balance activities are practiced 20 to 30
- hopping minutes per session
- fast walking and jogging for short - aerobic exercise durations are 30 minutes, with short
distances periods of 5 to 10 minutes of warm-up and cool-down
○ Functional Training ⬞ Stretching exercise:
- overloading the movement or activity of interest to - 30 seconds in younger people
challenge the whole neuromuscular system rather than - four repetitions of 60 seconds in older adults
simply challenging a muscle ⬞ Strengthening exercise:
- muscular and articular systems - 10RM
- proprioceptive and cutaneous sensory systems
- vestibular and visual systems
⬞ Progression of a functional exercise program is
obtained by moving from:
⬝ simple movements to more complex movements
⬝ normal speed to either quicker or slower
movements
⬝ stable surfaces to unstable or compliant surfaces
⬝ eyes open to eyes closed
⬝ an emphasis on form to an emphasis on intensity
and the working over from base of support to
working outside the base of support
PT31 LEC - Geriatric PT
Types of Exercises for Older Adults
○ Aerobic Exercise
⬞ Measurement
⬞ Target HR
⬞ RPE: subjective measure of exercise intensity
⬞ Clinical Functional Measures of Aerobic Capacity
⬞ 6MWT
⬞ 400-m walk test
⬞ 60%-80% exercise stimulus: to achieve CV
adaptation and fitness
⬞ Measurement
- THR = 60% to 80% X [220 - age]
- Karvonen method of THR =
([60% to 80% x (220 - age - resting HR)] + resting HR)
⬞ Measurement
⬞ Subjective Measures of Perceived Exertion
- RPE: tool to monitor exercise intensity has
been validated in older adults, and is
particularly useful in those who may have a
blunted heart rate response, such as those
taking b-blockers
⬞ Exercise Stress Test
- gold standard for determining readiness to
exercise
⬞ 6MWT
- useful objective baseline measure and has
normative results and minimal clinically
important differences established for a range
of older individuals
⬞ Measurement
⬞ 400-m Walk Test
⬞ Indications for Aerobic Exercise
- indicated for patients who lack the ability to
sustain activity for a desired period of time
because of decreased cardiovascular efficiency
⬞ Contraindications and Safety for Aerobic Exercise
⬞ resting heart rate greater than 100 bpm
⬞ systolic blood pressure higher than 200 mmHg
⬞ diastolic blood pressure higher than 120 mmHg
○ Aquatic Exercise
- the buoyancy of the water allows a deconditioned
individual or an individual with significant joint
pathology to exercise by decreasing the forces needed
to move and decreasing the forces on the joint
⬞ Indications for Aquatic Exercise
⬞ patients who have painful joints in weight bearing
to exercise
⬞ patients who have osteoarthritis, who are
overweight, or who have recently undergone
surgery may initially benefit from this form of
exercise
⬞ patients who have significant balance disorders or
a fear of falling
⬞ Contraindications and Safety for Aquatic Exercise
⬞ same with aerobic exercise
⬞ individual with open wounds
EXERCISE AND PHYSICAL ACTIVITY FOR OLDER ADULTS
○ Strengthening Exercise
⬞ Measurement
⬞ MMT
⬞ Muscle dynamometry
⬞ Isokinetic dynamometers
⬞ RM test
⬞ 60% of 1RM
- minimum training stimulus for strengthening
exercise
⬞ Leg Press
- body weight
⬞ Indications for Strengthening Exercise
⬞ insidious loss of strength with age
⬞ to add reserve to provide a protective effect in the
event that the person has a period of enforced
bed rest
⬞ SLOWNESS OF MOVEMENT: hallmark of frailty
(strength and power training)
⬞ Contraindications and Safety for Strengthening Exercise
⬞ use proper form and avoid holding breath
○ Stretching Exercise
- stretching is indicated to promote adaptation of
shortened muscles to a more lengthened position to
achieve better posture and movement patterns
⬞ 30-second hold - younger adult
⬞ 60 seconds hold - adults age 65 years or older
⬞ four repetitions of a 60-second hold performed
regularly, 5 to 7 days a week
⬞ slow static stretching
⬞ Measurement
⬞ ROM
⬞ Functional ranges
⬞ Indications for Stretching Exercise
⬞ pain syndromes, painful postures, abnormal
movement patterns, and loss of function
⬞ future painful conditions and loss of function
⬞ Typical muscles requiring stretching in older
adults:
⬝ Suboccipital muscles
⬝ Pectoralis minor and downward rotators
and protractors of the shoulder girdle
⬝ Extensors of the lumbar spine
⬝ Hip flexors and external rotators
⬝ Ankle plantar flexors
⬞ Contraindications and Safety for Stretching Exercise
⬞ presence of joint instability
○ Plyometrics
- plyometric exercise is an attempt to use the stretch re-
flex of the muscle spindle and the elastic energy that is
stored in a stretched muscle to enhance an immediate
reciprocal contraction in that muscle
- eccentric and concentric
⬞ Measurement
- Isokinetic dynamometer
- Functional testing
- Rose’s Fullerton balance test
⬞ Indications for Plyometrics
- Loss of power
- Decreasing fall risk
- Increasing UE power
PT31 LEC - Geriatric PT EXERCISE AND PHYSICAL ACTIVITY FOR OLDER ADULTS

○ Tai Chi
- fall risk benefits
- involves learning multiple poses that are linked
together with slow movements that emphasize control
and balance.
- the focus required to complete the movements and
postures and recalling the sequence of postures has
been credited with both the mental calm and the
cognitive benefits associated with Tai Chi
⬞ Indications for Tai Chi
⬞ mediates the effects of chronic conditions such as
arthritis, cancer, CVD, and DM
⬞ decreases stress
⬞ lessens depression
⬞ improves mental health and cognitive function
while improving balance and fitness
⬞ decreasing falls and lessening fall risks