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Wellness, Health Promotion, and Exercise Training in Geriatrics

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1 Wellness, Health Promotion, and Exercise Training in Geriatrics
Min H. Huang, PT, PhD, NCS

2 Learning objectives Analyze the factors contributing to physical, psychological, and social wellness in older adults Discuss the role of physical therapists in the promotion of wellness for geriatric practice

3 Reading assignments Guccione: Ch 24 Guccione: Ch 5

4 What is Wellness? WHO: health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Wellness is described in the domains of physical, psychological, and social wellbeing. Optimal aging implies maximizing one's ability to function across physical, psychological, and social domains to one's satisfaction and despite one's medical conditions Wellness is often described in terms of these three interconnected domains of physical, psychological (mental), and social well-being. Wellness is viewed by some as a process and by others as an outcome achieved through health promotion and disease prevention processes.

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6 Physical activity resources and publications for health professionals
alactivity/resources/i ndex.html alactivity/everyone/g uidelines/olderadults .html

7 Physical Activity Guidelines
For older adults 65 years of age or older who are generally fit and have no limiting health conditions Only 34% of older adults (ages 65 to 74 years) and 17% of older adults (aged 75+ years) exercise regularly.

8 Physical Activity Guidelines
10 minutes at a time is fine We know 150 minutes each week sounds like a lot of time, but it's not. That's 2 hours and 30 minutes, about the same amount of time you might spend watching a movie. The good news is that you can spread your activity out during the week, so you don't have to do it all at once. You can even break it up into smaller chunks of time during the day. It's about what works best for you, as long as you're doing physical activity at a moderate or vigorous effort for at least 10 minutes at a time.

9 Psychological wellness
Emotional wellness Control of stress and effective coping with life situations High stress levels with poor coping  negative physiological (e.g., CVP, MS), emotional (e.g., depression, anxiety), behavioral (e.g., inability to work, inefficiency) responses

10 Psychological wellness
Cognitive wellness Skills and self-efficacy (a person's confidence in his or her ability to achieve a goal) Interest in engaging intellectually in the world Spiritual health Values, morals, and ethics that guide an individual's search for a state of harmony and inner balance

11 Mental Health Issues that can affect Wellness
Depression Risk factors: family hx, personal hx, hx emotional trauma, chronic illness or pain, widowers, divorcees Perceived control greater satisfaction in life if the patient has this Self-efficacy perceive self as functional  greater happiness Problem solving coping strategies information seeking or behavioral/cognitive actions are most effective Self efficacy: belief that one can organize and execute courses of action needed to achieve a desired goal or undertaking J. Blackwood

12 Social wellness Social wellness is the ability
to develop and maintain healthy relationships with others to feel connected to a community or group to interact well with other people to have a support structure to call on during difficult times Social supports significantly influence the ability to cope with life's stressors People considered socially well are usually involved with others, rather than isolated, and they report satisfactory levels of perceived social support.

13 Five major factors in the construct of social wellness
Social integration (“I feel close to other people in my community”) Social contribution (“My daily activities are worthwhile to my community”) Social coherence (“I can make sense of what's going on in the world”) Social actualization (“Society is improving for people like me”) Social acceptance (“People care about the social issues that are important to me”)

14 Health Behavior Change
For interventions to be effective, behavior must be altered Transtheoretical Model: a continuum of motivational readiness leading to change of a problem behavior Precontemplation Contemplation Preparation Action Maintenance J. Blackwood

15 Transtheoretical Model
Processes of Change involve a set of independent variables promoting the transitions between the stages of change

16 Precontemplation No intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or under-aware of their problems.

17 Contemplation People are aware that a problem exists
People are seriously thinking about overcoming it but have not yet made a commitment to take action

18 Preparation Combines intention and behavioral criteria.
Individuals are intending to take action in the next month Individuals have unsuccessfully taken action in the past year

19 Action Individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy.

20 Maintenance People work to prevent relapse and consolidate the gains attained during action For addictive behaviors this stage extends from 6 months to an indeterminate period past the initial action

21 5 steps for a Wellness/ Health Promotion Plan
Identify the problem, explain why it is a problem, describe its implications, identify all behaviors that might influence Determine readiness to participate: past hx of compliance, support systems Develop intervention plan with specific goals and realistic time frames Begin the intervention, give support prn Evaluate the person’s success and eliminate risk behaviors J. Blackwood

22 Strategies for Health Behavior Change
Health literacy Chronic disease self-management Lifestyle redesign J. Blackwood

23 Chronic Disease Self-Management
Purpose to enable persons to prevent complications and control/manage their health conditions Individuals and families Participate actively in the health care process Self-monitoring of symptoms or physiological processes Make informed decisions Manage the impact of their health on daily life J. Blackwood

24 Designing a Wellness Program
Population based Address the problems of the population, e.g. sedentary lifestyle, overweight Programs are implemented outside of traditional health care settings Mechanisms for funding are different Personal, government, industry support Emphasis is on prevention not remediation J. Blackwood

25 Barriers to a wellness program
Starting the activity/changing the behavior Social intervention Reward system Goal setting and monitoring Decrease financial barriers by promoting an activity that can be done anywhere without lots of equipment J. Blackwood

26 Ethical Issues with Wellness Programs
Many elderly are reluctant to spend their savings on themselves Belief systems, locus of control and religious preferences support a person’s self esteem Some risky behaviors are coping behaviors Cultural norms may interfere with behavioral outcomes Are values about health practices changing? cheaper to pay for health promotion than treating the illness. J. Blackwood

27 Screening tool for physical activities and wellness programs - EASY
Six-question online screening tool Identifies potential health problems that require health care provider clearance before exercising Provides education about each problem and the value of exercise Helps older adults choose appropriate exercises that may not first require a physician's approval

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29 Screening for osteoporosis: PT can ask for
Central DEXA (hip or pelvis) or Peripheral DEXA (heel, finger) (T-score below indicates osteoporosis) Family history of osteoporosis (mother, sisters, grandmother) Low body mass index History of vertebral or wrist fractures Observe presence of kyphosis Loss of height of >4 cm

30 Measurements of Physical Activity (Box 24-7)
Physical Activity Scale for the Elderly (PASE) Self-reported occupational, household, and leisure activities during a 1-wk period providing prompts with examples of specific activities Administer by phone, mail, or personal interview Focus on activities commonly performed by older adults by giving more weight to these activities instead of sports

31 Measurements of Physical Activity (Box 24-7)
Pedometer Simple, inexpensive Generally, 10,000 steps per day is considered to afford a health benefit Accelerometer Computerized measures of step count and movement Applicable for research

32 How do you assess strength in the geriatric client?
MMT ‘Make test’ ‘Break test’ Difficult to differentiate between 4/5 to 5/5 - Ceiling effect Measurement error with MMT as high as 50% 5/5 strength does not accurately reflect strength for functional activities Other ways? e.g. Holding a standing heel rise on one leg = 3/5 Resistance applied throughout the range is termed a 'make test'. Break test, Manual resistance applied at an end of range (isometric contraction). Lunsford, BR, Perry, J: The standing heel-rise test for ankle plantar flexion: criterion for normal. Phys Ther. 75, 1995, 694–698

33 Supine hip extension MMT
Easier to perform in the clinic because so many older adults have difficulty lying prone Distinct difference between the forces elicited at each muscle grade grade 5, N; grade 4, N; grade 3, 66.7 N; and grade 2, 19.1 N NOT validated against the gold standard of hand-held dynamometry in the prone position. Perry J, Weiss WB, Burnfield JM, Gronley JK. The supine hip extensor manual muscle test: a reliability and validity study. Arch Phys Med Rehabil 2004;85: Perry et al. Arch Phys Med Rehabil 2004;85:

34 examiner. The hip maintains the fully extended, neutral position
A. Starting position for test. B. Ending position for grade 5 (normal). Pelvis and back elevate as a locked unit while the leg is raised by the examiner. The hip maintains the fully extended, neutral position throughout the test. C. Ending position for grade 4 (good). Hip flexion occurs before pelvis elevates while the examiner raises the leg. D. Ending position for grades 3 (fair) and 2 (poor). Full elevation of the limb to the end of the straight-leg raising range with no elevation of the pelvis. Examiner feels “good” resistance for grade 3, little resistance for grade 2, and no active resistance for grade 0. Fig 2. Supine hip extensor MMT. (A) Starting position for test. (B) Ending position for grade 5 (normal). Pelvis and back elevate as a locked unit while the leg is raised by the examiner. The hip maintains the fully extended, neutral position throughout the test. (C) Ending position for grade 4 (good). Hip flexion occurs before pelvis elevates while the examiner raises the leg. (D) Ending position for grades 3 (fair) and 2 (poor). Full elevation of the limb to the end of the straight-leg raising range with no elevation of the pelvis. Examiner feels “good” resistance for grade 3, little resistance for grade 2, and no active resistance for grade 0.

35 Measure RM for functional movements
Example: If the chair is 21 in. high and the person can stand 10 times without using his or her arms  that is the 10 RM If the person does more or less than 10 repetitions, the surface can be raised or lowered Apply this principle to other movements e.g. Bridges, lunges, wall squats, and step ups and step downs

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37 Strength Leg Strength has been found to be the SINGLE most important predictor of institutionalization and more important than physiological markers or disease. An individual needs a certain level of strength (about 45% of his or her body weight) to rise from a chair Older adults gain strength the same way that younger people gain strength Page 66 guccione.

38 Conditions associated with muscle weakness
Iron deficiency anemia Decreased Hgb and Hct Hypercalcemia Elevated Ca++ depress nervous system responses and muscle actions become sluggish and weak Hypokalemia Weakness progresses over weeks Hypophosphatemia Disrupt energy metabolism Hyponatremia Hypernatremia Hypercalcemia: increased Ca due to hyperparathyroidism and paget’s disease; elevated calcium levels depress nervous system responses and muscle actions become sluggish and weak Hypokalemia: decresed serum potassium due to chronic use of diuretics, muscle weakness progresses over weeks Hypophophatemia: low serum phosphate levels: stored in the bone as hydroxyapatite and contributes to energy metabolism and cell membrane function and regulation Hyponatremia:; decreased serum sodium, diuretics, diarrhea, vomiting Hypernatremia: J. Blackwood

39 Principles of Specificity & Overload
Specific challenges with aerobic capacity result in endurance-training adaptations Specific strength training results in strength adaptations. Overload: challenge the muscle/system more than what is normal stimulus. J. Blackwood

40 The ability of tissue to absorb and dissipate forces is dependent on many variables, including the time over which the stressor is applied; the direction, magnitude, and combination of stressors applied; the physiological condition of the tissue, organ, or system; the frequency of the application of a stressor and length of time between the applications; and even the psychological state of the person and the “environment” in which the stressor is applied. In the clinic, physical therapists can modify these variables within an exercise program to achieve a desired outcome. For example, the PST can be used to positively impact the cardiopulmonary, musculoskeletal, and vestibular systems in a frail older woman who has been sedentary for several years and now has increased fall risk and an inability to tolerate walking 1000 feet (community distance) at a reasonable pace. The physical therapist may choose initially to promote safety and reduce the risk of falling by having her use a walker for support and to decrease her unsteadiness, thus reducing the demand of the task to a level that matches the patient's current capabilities. Resistance exercise of an appropriate intensity, based on a 10 RM can then be prescribed to stress the tissue beyond what is typically experienced and at a level that will promote change in muscle tissue. Physical activity in the form of walking may be encouraged through the use of a pedometer to monitor required levels of physical activity to promote conditioning of the cardiopulmonary system. The standard of a percentage of V· O2 max can be used to determine the appropriate level of response, monitored through vital signs and/or pulse oximetry.

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42 Strengthening Exercise Prescription in Geriatrics
60% 1RM minimal overload or 15 RM necessary for muscle adaptation in untrained individuals 80% 1 RM X 10 reps is preferred, especially for concerns with pain or joint forces a gradual increase beginning at 50% of 1RM for an individual who has been sedentary Strengthening exercise would be the first type of exercise prescribed

43 Remember….. Slow walking or lifting light weights such as 2 lb ankle weights to stimulate the quadriceps will NOT appreciably improve aerobic capacity or strength in most individuals.

44 ACSM adopted

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46 Progression to Power After an older adult can do 2 sets with good form and no pain Incorporate training to increase power Move quickly through concentric phase followed by a slow and controlled lowering of the load Initial loads at 20% 1RM and progress towards 60% 1RM Power found to be a strong predictor of loss of function, e.g. climbing stairs White paper exercise. J. Blackwood

47 Guidelines for ex RX with CV
Consider: intensity, mode, frequency, duration, and progression Monitor: HR, BP, SaO2, ECG, BORG scale (RPE), estimated VO2 max, MET levels. J. Blackwood

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49 Injuries? Many authors demonstrate safety of high intensity exercises
Requires 1:1 supervision Monitoring of vitals There are no absolute contraindications for strengthening exercises Care must be taken to have the person use proper form and avoid holding his or her breath There are no absolute contraindications for strengthening exercises. Although care must be taken to have the person use proper form and avoid holding his or her breath, there have been very few reported problems with strength training.

50 Specificity of training
Specificity leads to the concepts of functional strengthening, i.e. strengthening a movement rather than a muscle. Simply walking may not improve the patient's walking above a critical threshold if there is no overload or challenge present. Overload the patient's gait Increase speed of walking, ambulate on uneven surfaces, head turns while walking, carry a large object, obstacle course.

51 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, and an emphasis on form to an emphasis on intensity and the working over from base of support to working outside the base of support

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53 Walking: 60% is eccentric, 40% is concentric

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55 FIGURE 5-5 Modified side plank
FIGURE 5-6 Eccentric step down. FIGURE 5-7 Concentric followed by eccentric contraction of tibialis anterior FIGURE 5-8 Overload principle applied to supine to sit transfer.

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63 Types of muscle contractions
Analyze functional activities to identify the type of muscle contraction needed Trunk muscles  stabilizers  isometric contraction Gait cycle  60% eccentric contractions e.g. dorsiflexors contract eccentrically at heel strike to foot flat, gluteus medius contracts eccentrically during midstance Slowing the speed of the movement overloads the activity, e.g. sit down as slow as possible

64 Eccentric contraction training for gluteus medius to improve gait
If right gluteus medius is weak  have a patient stand on the right leg while performing a rapid contraction of the left gluteus medius against an elastic band  causes the right gluteus medius to contract both rapidly and eccentrically (similar to the way it is used in gait)

65 Aerobic/Endurance Training
Endurance training, which is the best exercise to increase/maintain mitochondrial concentration with aging, has generally resulted in relatively small functional benefits, e.g. in nursing home patients, older adults with Parkinson’s disease Strength and aerobic training attenuate muscle wasting and improve resistance to the development of disability with aging. Source: The journals of gerontology. Series A, Biological sciences and medical sciences (J Gerontol A Biol Sci Med Sci) 1995 Nov; 50 Spec No: 113-9 J. Blackwood

66 Calculating Target Heart Rate for older adults
Traditional formula (60% to 80%) × [220 − age] May underestimate the heart rate load Karvonen method Solution is to use a percentage of heart rate reserve [(60% to 80%)×(220− age− resting heart rate)] + resting heart rate

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68 Stretching A 60-second hold is required to achieve a long-term effect in older adults 65+ years 4 reps X 60-second hold 5 to 7 days a week Static stretching is preferred to dynamic stretching to improve muscle length. Loss of joint ROM is not just from muscle-tendon complex and other soft tissue, e.g. joint capsule or ligaments, fascia, and connective tissue.

69 Measurement of functional ROM: Two items from Senior Fitness Test
Chair sit and reach test Back scratch test Chair sit and reach test Instructions for participant Sit close to the front of the seat with the crease between the top of the thigh and the buttocks on the edge of the seat. Have one leg extended straight with the heel on the floor and the foot flexed at 90 degrees to the leg. Have the other leg bent at right angles at the knee with the foot flat on the floor. Place one hand over the other with finger tips level. Slowly reach forward as far as you can towards the toes in the outstretched leg. Do not bounce forward. Hold the maximum reach for 2 seconds. Try with the other leg extended and see which one is able to allow the greater reach. Back scratch Place one hand over the same shoulder with the palm touching the back and reach down the back. Place the other hand up the back from the waist with the palm facing outwards. Reach up the back. Point the middle fingers of each of hand towards each other. Try and touch the fingers of each hand in the middle of the back. Do not bounce the arms towards each other. Do grasp the fingers and pull the hands together. Try two warm ups with the arms in opposite positions to determine the preferred side for reaching over the shoulder. toolboxes.flexiblelearning. net.au/demosites/series8/ 805/fit_tb/fit011_1_lr10/fit0 11_1_lr10_1_6.htm toolboxes.flexiblelearning. net.au/demosites/series8/ 805/fit_tb/fit011_1_lr10/fit0 11_1_lr10_1_5.htm

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72 For example, while attempting to stretch the hamstrings by using trunk forward flexion, one may inadvertently be causing flexion forces to the lumbar spine. An alternate method may be to lie supine and use a rope on the foot to pull the lower extremity into a straight leg raise

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76 Plyometrics (“Plyos”) exercise
Use the stretch reflex of the muscle spindle and the elastic energy that is stored in a stretched muscle to enhance an immediate reciprocal contraction in that muscle. Usually consists of an eccentric (lengthening) contraction followed by a concentric (shortening) contraction of the same muscles The ability to increase the explosiveness (speed & power) of the muscle contraction May improve bone formation Plyometrics, also known as "jump training" or "plyos", are exercises based around having muscles exert maximum force in as short a time as possible, with the goal of increasing both speed and power.

77 Plyometric exercise jumping onto and off of a step.
Rapidly squat  jump (energy is stored in the gastrocnemius as the ankle dorsiflexes and in the quadriceps as the knee extends) Plyometric exercise jumping onto and off of a step.

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80 Interval training in patients with COPD
Severe COP with FEV1 <50%, patients can only sustain 4-5 min of work (and up to 13 minutes for lower intensities) Implementing continuous exercise for patients with advanced COPD may be ineffective Frequency: 3-4x/wk, 30 seconds exercise, 30 seconds rest, (or 20 sec/40 sec) Sept 2010 article. J. Blackwood

81 Effect of progressive resistive training on balance function in older adults
2008 systematic review by Orr et al. 29 studies with RCT design Various interventions with PRT Conclusion: “limited evidence presented in currently published data has not consistently shown that the use of PRT in isolation improves balance in this population” J. Blackwood

82 Effect of progressive resistive training on balance function in older adults
Further research should explore optimal resistance training regimens that Focus on the muscles most pertinent to balance control Best target neuromuscular adaptations that protect against postural challenges Elucidate mechanism(s) by which PRT may affect balance control J. Blackwood

83 Low v. High Intensity PRT exercise in frail elderly (Seynnes et 2004)
RCT of institutionalized adults (age = 81.5) Low: 40%1RM vs. High: 80% 1RM vs. Placebo 3 sets 8 reps, 3x/wk for 10wks Assessed: knee strength, endurance, 6MWT, chair rising time, stair climbing power Results: Supervised HIGH INTENSITY, free weight-based training for frail elders appears to be as safe as lower intensity training but is more effective physiologically and functionally Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. Source: The journals of gerontology. Series A, Biological sciences and medical sciences (J Gerontol A Biol Sci Med Sci) 2004 May; 59(5): 503-9 J. Blackwood

84 Optimal load for increasing muscle power in older adults (deVos 2008)
112 older adults (average age = 69) 20%, 50%, 80% 1RM 2x/wk; 3 sets of 5 exercises ; 8-12 wks Fast concentric, slowed eccentric Results: A dose-response relationship between training intensity and muscle strength and endurance changes Heavy loads: most improvement in strength, power, and endurance Optimal load for increasing muscle power during explosive resistance training in older adults. Source: The journals of gerontology. Series A, Biological sciences and medical sciences (J Gerontol A Biol Sci Med Sci) 2008 May; 60(5): J. Blackwood

85 Muscle Weakness and markers of inflammation
High serum levels of inflammation: interleukin (IL-6) are strong predictors of disability. Chronically elevated levels of IL-6 accelerate muscle catabolism 2008 JAGs study: Older women with high IL-6 serum levels have a higher risk of developing physical disability and experience a steeper decline in walking ability than those with lower levels Parallel decline in muscle strength. Change in Muscle Strength Explains Accelerated Decline of Physical Function in Older Women With High Interleukin-6 Serum Levels Luigi Ferrucci, MD, PhD J. Blackwood

86 Exercise & Osteoporosis
High intensity strength ex provided for post menopausal women 2x/wk for 1yr Results: High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women. J. Blackwood


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