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The strangest things happen sometimes, and I do believe on this last day of 2005 I experienced my most odd and unlikely physical therapy practice experience to-date. Here is how it goes:
Well, I must start my blog with a confession - I found the research article I am about to share with you by reading the Feb 2006 issue of "Runner's World". It is amazing where you will stumble onto good research...
The Runner's World article by Amby Burfoot (funny name for a Runner's World writer) starts with a common question we all receive in our clinics - will running over time increase my risk for pain when I am older? She explains that this is a rather logical question based on our use of "mechanical" products. She explains that it is intuitive to everyone from using mechanical systems (from cars to toothbrushes) the concept of wear-and-tear. But, she goes on to point out that our bodies are "biomechanical" systems - "and those three little letters make all the difference."
The article cites the published article by Bruce et al: "Aerobic exercise and its impact on musculoskeletal pain in older adults: a 14 year prospective longitudinal study" in Arthritis Research and Therapy; September 2005.
Starting in 1984 they followed runners and non-runners that were > 50 years of age. In the 14 year prospective study - they compared those that average > 26 miles/week to a set of controls that averaged 2 miles/week to measure the effects of aging on musculoskeletal pain. These groups were selected so that if running did create cumulative trauma - they would expect to see a 10-fold increase in pain by the > 26 mile/week group. Overall they found the opposite, runners experienced a bout 25% less musculoskeletal pain than controls.
The article is attached Download bruce_2005_arth_res_ther_running_oa.pdf .
One of the neat findings is the percent of complaints of musculoskeletal pain in those 60-80 years old.
Female Runners: 11.8%
Female Non-Runners: 70.6%
Male Runners: 17.6%
Male Non-Runners: 41.1%
So, although complaints of pain increases with age - no observed progressive increase in pain was noted by the runners. So, although many of our patients fall somewhere between the 2 groups studied, there is now some clinical evidence that collaborates some of the biomechanical basic science literature that suggests that biomechanical systems require optimal loading to maintain health over time - or what we state in the clinic - "motion is lotion"
One side note - It is really exciting to see how open access journals are allowing research to trickle down faster to magazines meant for the general population...Very exciting!
Happy Running and Happy New Years!
Deydre
A
couple of weeks ago, a therapist asked the Section on Geriatrics listserv
readership about their experiences using resistive exercise in geriatrics
and/or home care. The therapist said he didn’t feel “max-out” repetitions
worked in older individuals and preferred instead to prescribe 30-50 reps. He
went on to say “I also seldom use weights with the elderly. And find theraband
awkward
I would like to set the record straight here, as I did to the Geri list serv, with some Myth and Fact statements. I hope you will find this post enlightening as you intervene with older adults.
1. MYTH: Older adults can’t gain strength as they get older.
FACT:
FALSE! Older people gain strength
in similar ways as young adults. Frontera et al, 1988, 1990 found a 2-3x
increase in strength in 3-4 months (5%/session) and 11.4% increase in muscle
area with high intensity (70-80% 1RM) exercise (Nelson et al 1994; Fiatarone,
1994). Muscle strength increases with 60-100% 1RM training stimulus (McDonagh
& Davies, 1984). The principle of overload must be incorporated as a major
feature in an exercise prescription for older adults (ACSM 2000).
2. MYTH: Older adults don’t need to
strength train.
FACT: FALSE! There is NO group more in need of
strengthening than people on the verge of loosing function or who need to
regain function. Age has been associated with a loss of muscle mass, strength,
and muscle quality (Roubenoff 2000). Inactive older adults loose their strength
and power reserve at the minimal rate of 1 and 3%/year respectively (Metter et
al, 1997). Leg strength and power has been unequivocally correlated to
functional independence (Galvao & Taaffe, 2005, Bassey et al, 2002, Mazzeo
et al, 1998, Chandler et al, 1998). While strength loss is a normal aspect of
aging, exercise can slow the rate of this loss by half and therefore allows
older individuals to maintain their independence until the end of their
lifespan (compression of morbidity).
3. MYTH: Strength gains are
guaranteed to produce functional gains.
FACT: TRUE, if resistance is true overload. Leg
strength and power have been unequivocally correlated with gait speed, stair
climbing, and rising from a chair (Galvao & Taafee, 2005; Bassey et al
1998, 2002; Mazzeo et al, 1998, Chandler et al, 1998). Specifically improving
power is an important aspect of functional training in older adults. In
4. MYTH: MMT is an appropriate way of assessing the strength necessary to get up out of a chair or stair climb.
FACT: FALSE! MMT was developed for individuals
with polio. It is NOT valid to determine whether someone has enough strength to
get up out of a chair or to climb stairs. I often see the term WFL used when
someone has been determined to have 4 or 5/5 strength of the quads. However,
even with 5/5 bilaterally, an individual may not be able to stand up without
using his/her arms. Try this for yourself on an older patient. Clinically, the
gold standard for testing dynamic muscle strength is the 1 repetition maximum
(RM) which is the maximal amount of resistance/load that can be moved once and
once only through full range. To calculate 1 RM, the following web site might
be helpful http://www.exrx.net/Calculators/OneRepMax.html. Rikli & Jones 2001 have established
normative data for the chair rise test from over 3000 60-90 year olds. They
have established the chair rise test as a valid measure of quad strength;
therefore I never use a MMT on the quads. It just isn’t accurate. The Rikli
& Jones Senior Fitness Manual can be obtained at
http://www.humankinetics.com/products/showproduct.cfm?isbn=0736033564
5. MYTH: Low intensity exercise is
appropriate for older adults, especially if they are frail.
FACT:
Not true! Functional improvements do
NOT occur when exercise intensity is low (<50% 1RM) although modest strength
gains will occur (Aniansson & Gustafsson 1981; Larsson
1982; Mazzeo 1998). The concept of task specificity is key for older individuals, but
especially frail individuals where energy and strength reserves are low. For
example, if you train the quad in an open chain manner, then you should expect
the person to be a better kicker. However, if you train the quad by doing
resisted chair rises (lowering the surface of the chair or using a weighted
vest to increase intensity), you will see functional gains. De vreede (2005)
compared task specific activities to resistive training and found in healthy
older adults that both were effective. It seems the energy and strength
required to do the task was the equivalent of moderate to high intensity.
6. MYTH: Strength can improve in as
little as two weeks.
FACT:
Partially true! Strength gains even with low to moderate intensity exercise are
seen in the first two weeks. This response is attributed to neural adaptation
that is not affected by age (Bemben
& Murphy, 2001; Phillips, 2000). Achieving good form while increasing
intensity is good practice during the period of neural adaptation. I have found
this early response in strength to be a great motivator. In frail older adults,
a strength gain of 10-15% per week with 80% 1RM was seen (Evans, 1999). Despite
the fact that strength gains are seen within 2 weeks, these gains cannot be
attributed to hypertrophy or to an increase in cross sectional area of Type I
and Type II muscle fibers. Therefore to avoid rapid detraining effects, an
individual needs to perform resistive exercise for 6-16 weeks minimum to
achieve hypertrophy. Thereafter, 1x week can maintain strength if done at the
same intensity (Lexell et al, 1995; Graves et al, 1988).
7. MYTH: 3 sets of 15-30 reps is the preferred exercise prescription to improve function in an older individual.
FACT: FALSE! In Berger’s original study (1962)
that found 3 sets achieved more strength gains than 1 set, only a 2.3% increase
in younger, healthy males was realized. Many studies have shown that 1 set at
60-80% 1RM (8-15 reps) is entirely sufficient to achieve desired strength gains
in younger and older untrained individuals (Galvao & Taaffe, 2005; Feigenbaum
et al 1999; Messier & Dill 1985; Silvester et al, 1981; Stowers et al,
1983; Carpinelli 2002; Starkey, 1996; Vincent 2002; Hass 2000).
8. MYTH: Older individuals with pathology are better off engaging in
aerobic exercise and shouldn’t engage in moderate to high resistive exercise.
FACT:
Not true! Resistive exercise may be safer for people with COPD (Simpson et al
1992; Bernard 1999), CHF (Pu et al 2001), and arthritis (Fransen et al 2002)
than aerobic exercise. Blood pressure responses are less intense with resistive
exercise as compared with aerobic exercise (Martel et al, 1999; McCartney
1999). Following a program of high intensity resistive
exercise in individuals with CAD, reductions in systolic pressure, diastolic
pressure, and the rate-pressure product of 17-27% were found (McCartney 1999). Pierson
et al in 2001 found that older individuals exercising at both 50% and 80% 1RM
increased their aerobic capacity by 20% and 23% respectively.
9. MYTH: It is not safe for older adults to exercise at high
intensities.
FACT: FALSE! Older adults of any age exercising at
80% 1RM have demonstrated safe, effective gains in strength of up to 273% (in
90+ y.o.) depending on initial baseline (Fiatarone 1990; Evans 1999) (based on
the curvilinear relationship Bean et al 2004).
FACT: There is no evidence
of adverse cardiac or other homodynamic events with high resistance exercise
(Gordon et al, 1995; McCartney 1999; 1996; Barnard et al 1999; Verrill 1999;
Kaelin 1999; de Vos et al <platform presentation at 2005 American
Gerontolgical Society Annual Meeting>).
FACT: There is no evidence that supports a higher
rate of injury with higher resistive loads when appropriately supervised (Rooks
et al, 1997; Di Fabio 2001, Barnard et al 1999, Coleman et al 1996). Higher
resistance requires good form and proper technique necessitating the skills of
a PT (the definition of skilled care!). However, individualization is key here.
If pain is present and limiting the ability to perform a maximum contraction,
then what the person is able to do may be their 1RM.
10. MYTH: Ok, so it may be good for older folks to exercise at high intensities, but they aren’t going to do it!
FACT: Many older folks LIKE
(relatively) the intensity of exercise (60-80%) because they can see the
results (remember – in as little at 2 weeks). I believe many people are not
“compliant” with a HEP because they don’t see the benefits – often because of
poor form or inadequate resistance. They DO need to be taught how to exercise
with intensity, which increases their confidence and self-efficacy that
exercise does work. Nelson et al (1994) demonstrated a whopping 87% compliance
rate in the high intensity (87% 1RM for 52 consecutive weeks) intervention
group compared with a 60% compliance rate in the control group. Again,
individualization is the key. Imagine if every time you went to the doctor you
got the same prescription? Certainly your confidence and enthusiasm for
complying would diminish.
FACT:
Recognize that years ago, when >75 aged individuals were sick or hurt, they
went to bed (remember all the pelvic traction and bed rest we used for LBP?)!
Older individuals need to be taught that there isn’t value in bed rest – in
fact bed rest (and hospitalizations) are deadly for older individuals (Gill
2004). Additionally, people who haven’t routinely exercised throughout their
life will need a lot of encouragement, positive attitude, and evidence.
Intensity may be a foreign concept to them. Explaining the principle of dose
helps – you get out of it what you put into it (Spirduso 2001). Strength is
going to allow them freedom of mobility, prevent falls, and prevent osteoporotic
fractures (Nelson 1994; Sinaki 2002) alleviate depression, and improve the
immune system (Fiatarone Singh 2002). Older adults, especially frail ones, can’t
afford not to do it – and in light of these effects, we are obligated to be the
best salespeople we can.
TIP: Functional evaluation outcome tools are a
great way to motivate individuals and to objectively document functional loss
and progress. When an individual can only perform 5 chair rises (10% of their
age group), the evidence can be a powerful motivator. Additionally, you can
easily and objectively monitor changes.
11. MYTH: Elastic bands and exercise balls aren’t appropriate for older adults.
FACT: It’s not the mode but intensity that is
important. To get functional strength gains, you need to use appropriate
resistance. Rarely will I use yellow Theraband after the individual can execute
proper form. Many of my patients/clients use blue, black and gray Theraband as
they progress their exercise program. In fact, I have just completed a 10 week
research study using elastic bands and exercise balls to build strength and
balance skills with a group of relatively high functioning older adults. We
measured a 30% strength gain on average in biceps curls, chair stands, and
dorsiflexion strength placing most of the individuals in at least the 75% for
their age group. These folks worked at an average intensity of 14 (hard level)
on the Borg Scale of Perceived Exertion (Borg 1982).
In
summary,
there is EVERY reason to use resistance exercise with older adults. I believe
that to not apply appropriate exercise principles based on ACSM guidelines and
the literature (and there is a lot of it out there) is ageist and unethical. My
hope is that some day, instead of avoiding appropriate resistance for fear of a
lawsuit, you will fear a lawsuit because you under treated someone! With the
Medicare cap again realized, it is imperative to maximize every visit an older
individual has available. IMHO, to do otherwise is grounds for malpractice.
It
is disheartening to hear a PT not respecting the power of exercise. It is the
most effective tool we have to improve function in an older person. There is so
much evidence to support resistive exercise that others outside of our
profession will use it (and well they should) if we don’t recognize its
significance and use it appropriately.
Thank
you for allowing me this opportunity to post on my favorite topic. I’ll keep
you abreast of the latest evidence about exercise and older adults.
Dale
Avers PT, DPT, PhD
In the book Alice
Through the Looking Glass, Humpty Dumpty pours scorn on word
definitions. When challenged by Alice, he replies “When I use a word it means just what I choose
it to mean—neither more nor less”.
I evaluated a Workman’s Comp patient with LBP last week (a pretty
common occurrence in PT). The patient,
who’s symptoms began 3 months prior, had already received 10-12 physical
therapy treatments at the beginning of his episode without relief (don’t know
what constituted the treatments). He had
been referred to us for additional care after being evaluated by a spine
surgeon (?!). The patient met 3/5 CPR criteria
for lumbo-pelvic manipulation and had an initial favorable response based on
pain and ROM findings following intervention (Childs
et al, 2004). He was to see me twice
the following week and then once a week for a couple of weeks after that if needed (our average number of visits
for this type of patient is about 4.5 to complete a course of care).
Well, Humpty Dumpty called to me from his wall last week in the form of a physician reviewer who had reviewed this man’s case and denied further treatment. His review was based on the abbreviated report I had sent to the physician. All our progress notes sent to referring providers are written in a terse, no-fat fashion in which current response to treatment is graphically documented and in this case, had the citation of supporting evidence for the intervention being rendered as well as the probability of a 50% reduction in disability in 1 week (68% in this case).
Given the lack of evidence to support the management of patients with cervical radiculopathy, attached is a nice case series from Dr. Cleland and colleagues just published in JOSPT. JOSPT offers a nice supplementary video of one of the treatment techniques. Thanks for this valuable contribution.
Download Cleland-JOSPT-2005-CxRadicCaseSeries.pdf
John
This article in BMC Medical Education reminds us that the task of familiarizing health care professionals in the 'nuts and bolts' of EBP is one thing. Achieving behavior changes after this familiarization has occurred is yet another. The task is formidable, but it can be done.
Download McCluskey-BMCMedEduc-2005-EBPNoBehaviorChange.pdf
John
A recent RCT published in Annals of Internal Medicine compared the effects of yoga versus an exercise program directed by a physical therapist versus a self-help book. There are many interesting aspects to this study. For the sake of brevity, we can let the comments sort out the implications. Regardless, this study will likely get much press during the 1st quarter of 2006. Have a look at the video news release associated with the paper's publication. They actually interview patients in the study and show detailed video of the yoga program. Much credit goes out to the American College of Physicians. They readily understand the value of using 'push' forms of media such as press releases to disseminate information. This is a great idea.
John
Tom Peter's posted his rant on healthcare listing 27 of his beliefs. Whether you agree or disagree with all 27, they are all very interesting, especially #12 which promotes EBP. He also lists his health care reads that allowed him to "buff" up on healthcare knowledge. Although both the Herzlinger (Market Driven Healthcare) and Millenson ( Demanding Medical Excellence) books have been written a few years ago, they are still relevant and insightful. Herzlinger expanded on her thoughts in a 2004 book that was written more toward policy makers, providers, and payers. I like the whole notion of consumer driven healthcare but unfortunately have not seen it a lot in practice. I remain optimistic that more of it is forthcoming and am supportive of these efforts. Thoughts?
larry
This article is a nice follow-up to the blog on the frequency of use of internet as Jane &
John Q. Public seek health information. The Dec.1 issue of Spine offers this analysis of a
survey of Website available to the public. The aurthors used 5 search engines to identify
sites using the word 'scoliosis'. They chose 50 sites, then evaluated them according to type
(e.g. academic, commercial), quality of content (points 1-4), and informational
accuracy (12 max) & scoliosis specific content and given a point value (i.e. quality 1-32
disease specific words). Three board certified academic orthopaedic surgeons with a
fellowship in spine. The outcomes of the study found 44% academic, 18% physician based,
16% commercial, 12% unidentified and 10% were non-physician health professionals [PT-like
creatures]. The quality scores ranged from 7.0 [PT like creatures] to 12.6 (academic). The
accuracy scores (max 12 points) ranged from 5.0 (commercial) to 6.6 (academic sites) with
the non-physician HP at 5.5. All with wide confidence intervals. The authors conclusion was
that information on the internet (including academic centers) was of poor overall quality.
Here you go Selena....you were right on the mark.
Take care and Merry Christmas,
Britt
“Fortune favors the prepared mind” –Louis Pasteur
Prepare daily.
Rob
