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Nuts and Bolts of Physical Activity Counseling 2008 Miriam C. Morey, Ph.D. GRECC Associate Director Research VA Medical Center 1.

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Presentation on theme: "Nuts and Bolts of Physical Activity Counseling 2008 Miriam C. Morey, Ph.D. GRECC Associate Director Research VA Medical Center 1."— Presentation transcript:

1 Nuts and Bolts of Physical Activity Counseling 2008 Miriam C. Morey, Ph.D. GRECC Associate Director Research VA Medical Center 1

2 Objectives Discuss overview of physical activity literature – Risk/Benefit – Prevalence – Relevance to veterans Physical activity counseling – Provider role – Evidence based approach Functional assessment – Link to exercise program 2

3 Consult your family doctor before beginning an exercise program What do you think about? How do you respond? 3

4 A simple test 4

5 Ways Physical Activity Can Help You Helpful things you can get right away:Helpful things you get later: more energy/vitality maintain independence helps with balance/falling improves quality of life feel better live longer get stronger walk unassisted sleep better household chores easier better attitude/mood gardening/yard work easier better circulation dress, shave, groom self improves flexibility travel outside local area easier can reduce pain look better feel better about yourself blood pressure control blood sugar control strengthen bones and joints reduces stress lower risk of heart attacks & strokes cholesterol control reduces risk of colon & breast CA reduces anger, anxiety, depression reduces risk of getting diabetes can help quit smoking strengthens immune system can help maintain diet improves health of arthritic joints improves blood flow to brain helps weight loss breathe easier reduces body fat more energy to play with grandchildren reduces depression and anxiety makes your heart stronger reduces risk of dementia 5

6 Risk Assessment What is the risk? – Mortality – very low risk Gerofit – 1 death unwitnessed (possibly within 2 hrs after leaving Gerofit) in 22 years 1/320,00 person hours) Literature – 1/60,000 – 1,000,000 person hours – Injury – low risk 6

7 Contraindications Unstable Angina or severe left main coronary disease End-stage Congestive Heart Failure Malignant or unstable arrhythmias Uncontrolled hypertension (i.e. resting -systolic >200mmHg, diastolic >110mmHg) Large or expanding aortic aneurysm Known cerebral aneurysm or recent intracranial bleed Acute retinal hemorrhage or recent ophthalmologic surgery Acute or unstable musculoskeletal injury Severe dementia or behavioral disturbance 7

8 Risk/Benefit Ratio Benefits far outweigh risk!!!! More risk of adverse health is associated with sedentary lifestyle 8

9 Known Benefits of Exercise Reduces Risk of: – Dying prematurely – Developing diabetes – Developing high blood pressure – High blood pressure among hypertensives – Colon, breast and other types of cancer – Depression and anxiety Promotes – Maintenance of healthy weight – Build and maintain healthy bones – Older adults to become stronger and better able to move without falling – Psychological well-being – Cognitive Function 9

10 Physical Activity and Psychological Well-Being Decreased depressive symptoms Decreased anxiety Improved mood Increased vitality Increased life satisfaction 10

11 Physical Activity and Economic Well-Being Being out of shape is expensive 11

12 Economic Well-Being National Cost of Medical Treatments (in billions) Disease Cost Heart Diseases$183 Cancer$157 Obesity$117 Diabetes$100 Physical Inactivity $77 Arthritis $65 SOURCE: National Institutes of Health and CDC, 2000 12

13 Costs of Physical Inactivity One-third of total healthcare expenditures is for older adults Direct medical costs attributable to inactivity and obesity account for 10% of all health care expenditures This excess cost is especially notable in women Agency for Healthcare Research and Quality, Centers for Disease Control, 2001 13

14 Medical Cost by Activity Status Among Women Without Physical Limitations Medical Costs/ Year Age Group Agency for Healthcare Research and Quality, Centers for Disease Control, 2001 14

15 Focus on Longevity 15

16 Physical Activity and Longevity Extensive data supports the relationship between exercise and longevity There is a noted dose-response effect From a population standpoint, the biggest benefit is obtained by moving sedentary people to active people 16

17 Health Benefit Accrual l Dose response (CDC, ACSM, Surg. Gen) l From Pate 1995 17

18 So What is the Problem? 18

19 Prevalence of Individuals Not Meeting Physical Activity Guidelines BRFSS, 2000, 2003 NHIS, 1991 Age Strength Training Moderate Physical Activity 19

20 Conceptual Functional Cost of Physical Inactivity Difference of Biological Age Probable minimum for independence Mets Age Shephard, JAGS 1990 20

21 What about the Older Veteran? Compared to the general population and veterans who do not use the VA for health care, veterans report: – higher rates of chronic conditions – higher rates of negative health behaviors – higher rates of functional limitations – higher rates poor self-rated health BRFSS 2000, National Veterans Health Study 1996 21

22 What about the Older Veteran? From our own Gerofit data, newly enrolled Gerofit participants (i.e., sedentary) – Scored significantly lower on repeated chair stands than national normative data – Scored significantly lower on 6-minute walk time than national normative data Peterson, J Rehab Res Dev 2004 in press 22

23 From Gerofit to Project LIFE Over the past 19 years, Gerofit outcomes published include – Significant mortality benefit among participants – Significant improvement in fitness parameters – Significant improvement in psychological well- being – Improvement in risk factor profile – Improved functional status 23

24 What Did Happen with Exercise We reported significant overall (baseline, 3 and 12 months) improvements: – aerobic capacity, p = 0.0001 – axial rotation, p = 0. 0011 – SF-36 Physical Function, p = 0.0016 – self-reported overall health, p = 0.0025 – reduced number of symptoms, p=0.0008 – reduced effect of symptoms on function, p = 0.002 24

25 Surgeon General Guidelines for Physical Activity 1996 Significant health benefits can be obtained by including a moderate amount of physical activity, i.e. 30 minutes or more, on most, if not all, days of the week. 25

26 Evidence Based Approach to Counseling for Older adults Pocket Guide (Available in English and Spanish) With support from a Healthier US Veterans mini-grant New Guidelines Specific to Older Adults Published in 2007, 2008 26

27 27

28 Physical Activity (PA) Counseling for Older Adults: An Evidence- Based Pocket Guide Recommendations: 1 ≥ 30 min or 3 bouts of ≥10 min/day ≥ 5 days/week moderate intensity = 5-6 on a 10-point scale (where 0 = sitting, 5-6 = “can talk”, and 10 = all-out effort) in addition to routine ADL’s 8-10 exercises (major muscle groups), 10-15 repetitions ≥2 nonconsecutive days/week moderate to high intensity = 5-8 on a 10-pt scale ≥ 10 min ≥2 days/week flexibility to maintain/improve range of motion (i.e. stretching of major muscle groups, yoga) balance exercises for those at risk for falls (i.e. tai chi, individualized balance exercises) create a single PA plan that integrates preventive and therapeutic treatment of chronic conditions Aerobic: Strength: Flexibility/ Balance: Prevention: Prescription pad attached below 28

29 YOUR EXERCISE PRESCRIPTION Walking or Other Goal: 30 min/day Minutes: _____ Sessions/Day: _____ Days/Week: _____ Strength Goal: 2 days/wk Squat (#): _____ Chair Stand (#): _____ Wall Sit (#): _____ Flight of Stairs (#): _____ Date: _____________ Physician’s Signature: __________________ For prescription pad refills email: On last sheet of pad, for refills and tracking purposes 29

30 Squat Wall Sit Stair Climbing Chair Stand 30

31 Sponsored by Durham VA GRECC Gerofit Program, NCP, and HealthierUS Veterans Program Tips for Follow-up Review PA plan Revise to enhance progress Reinforce positive behavior & activity documentation Reaffirm that more PA enhances benefits Resources/Additional Handouts: Citations: 1.Physical Activity and Public Health in Older Adults: Recommendation from the ACSM and the AHA, Nelson, et. al., Circulation, 2007; 116(9): 1081-93. 2.Celebrating 20 Years of Excellence in Exercise for the Older Veteran. Fed. Pract., Morey, 2007; 24(10):49- 50,53,57,65. If patient is:Planned Approach Not ready to change  Educate on benefits of exercise Ready to change  Develop a specific PA plan Active  Support continued activity Provider Advocacy is Key: Tips for Counseling Define benefits relative to medical history Decide what to do where, when & for how long Discuss barriers & strategize solutions Determine social support: who & how Determine if patient is “very sure” of success Document PA plan in Chart & on Rx to patient

32 Healthcare Counselor’s Role First and Foremost- BE AN ADVOCATE! What can you do? – Set specific detailed and individualized exercise prescription Identifying personally defined benefits Setting a specific exercise prescription with patient Identifying social support for exercise Discussing barriers and overcoming them 32

33 START LOW AND GO SLOW! Encourage physical activity Set reasonable and specific goals Discuss barriers Address medical conditions How 33

34 From Fitness to Function Simple functional tests can determine risk for future adverse health events Some functional tests are highly related to certain aspects of fitness – Chair stand and lower leg strength 34

35 Identifying Risk Lower extremity function predictive of nursing home placement and institutionalization (Guralnik 1995) Balance measures are predictive of falls and subsequent disability (Okumiya) Low endurance associated increased mortality and disability (Young) Gait speed (usual not maximum) is highly predictive of nursing home placement and institutionalization (Guralnik 2000) 35

36 Functional Testing – *Lower Extremity Function - Chair stands – *Balance - Up & Go test – *Endurance - 6 minute walk – Gait Speed *Norms to estimate functional risk Rikkli & Jones J Aging Phys Act 1999 36

37 Summary We have provided an overview of literature summarizing the multiple benefits of physical activity. Risks associated with sedentary lifestyle are numerous. Tips for physical activity counseling include identifying “stage of change” of patient and counseling accordingly. Provider advocacy is key! Thoughts on utilization of functional fitness 37

38 Contact Information For information about this specific presentation please contact Miriam Morey, PhD at For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at or call (734) 222-4328 For the link to the evaluation form for this conference that will confer CE credit please go to =24710 and click the “ Handout: Registration and Evaluation ” link =24710

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