Therapeutic Exercise & Dosing to Enhance Strength, Endurance, Flexibility, and Balance in Older Adults

Endurance - Age Considerations • Max O2 consumption decreased ________________ with age beginning in middle 3rd decade men, end 2nd decade women • (4) decline with age • ______________________ increases but total lung capacity unchanged with age = ? • Lungs / chest wall lose elasticity • Body composition? 1. All factors serve as deterrent to active lifestyle / regular physical activity (P.A.) 2. All of these factors can be slowed by?

1. 10%/decade: men (3rd) and women (2nd) 2. Max HR, SV,CO, peripheral blood flow 3. Residual volume: less air/gas exchange with each breath 4. increase body fat, decrease in fat-free mass 5. participation regular P.A.

Strengthening Exercises 1. How many exercises to give older people? 2. Consider ________________ approach -> goals in ___________, not in_______

1. 4-5 exercises (more compliance) 2. Consider multi-modal approach -> goals in parallel, not in isolation

Flexibility - Age Considerations Be mindful of: Normal aging at the tissue level Hydration levels Prior injuries, occupational risks/likelihood of repetitive stress, surgeries and length of time since surgery , etc. Contractures proximal & distal to the joint of focus Need to adapt HEP from younger adults (ex: supine hams flex, SKTC) • risk of injury/strain elsewhere, Valsalva, etc. Prior exercise history Variability with target tissue estasticity, limitations, etc. •Order of interventions may need to change Extended warm-up / cool-down activities 1. what raised HR and BP the most? 2. importance of Cool down? - cardiopulmonary = ? - MSK = ?

1. Arm bikes rise HR and BP more than LE bikes 2. CP = calm HR MSK = prevent blood from pooling, prevent delayed onset muscle soreness

General Exercise Guidelines 1. Energy cost of ___________ exercise is greater than ____________ exercise - what does this mean? 2. Frail elders with assistive devices, joint deformities, gait disorders...BEGIN with _______________________ training before ________________________ to increase reserve 3. Enhanced cardio-respiratory/cardio-vascular training is achieved with combining _____________ WITH ____________ •Ex: weighted vest, incline treadmill, step ups with hand weights

1. Energy cost of aerobic exercise is greater than resistance exercise - focus more on strength for all. (try to do both). 2. Frail elders with assistive devices, joint deformities, gait disorders...BEGIN with strength and balance training before aerobic training to increase reserve 3. Enhanced cardio-respiratory/cardio-vascular training is achieved with combining aerobic WITH resistance •Ex: weighted vest, incline treadmill, step ups with hand weights

1. Exercise Prescription DOSING: - 5 things?? 2. Dosing Considerations: (3) *Say __________ instead of exercise*

1. Exercise Prescription DOSING: oFrequency oRepetitions oIntensity oDuration oType 2. Dosing Considerations: •Frequency of Errors •Risk of Injury •Task: motor, sensory, distraction, environment *Say physical activity not exercise*

TRAINING TERMINOLOGY STRENGTH 1. Force output of contracting muscle(s) directly related to? 2. Force exerted by muscle or group of muscles to overcome a resistance under specific circumstances where are isometrics effective? can be strong _____________ but not higher or lower

1. Force output of contracting muscle(s) directly related to the amount of tension a contracting muscle can produce 2. Force exerted by muscle or group of muscles to overcome a resistance under specific circumstances Isometrics (effective 15 degrees each way) midrange

Balance - Age Considerations 1. GOAL 2 main ways?? •__________________ and _________________ cueing are a must!

1. GOAL - Allow the patient to struggle - Challenge enough during safe practice that drives the system to change •Skilled guarding and effective tactile / verbal cueing are a must! Dont end with failure but should fail 25% of the time (need external support).

Exercise Prescription Primary Factors in Decision Making 1. which is under control of patient? 2. which is under control of us? 2 Biggest influence on exercise prescription?

1. Goals/problems perceived by client (only one that is only from the client - everything else we need to figure out for the assessment) 2. Functional deficits perceived by clinician, Clinician perception of client adherence to exercise, Clinician perception of client safety with exercise, Clinician knowledge / understanding of exercise principles, physiologic considerations associated with aging Clintion: functional deficits, adherence to program, safety and understanding of principles F ASU usually increase weights or sets or both (why not both?? - underusing them) *Increasing mobility but not strength = more of a fall risk* 3. finding in assessment and response to exercise

Forms of Resistance Exercise 1.4 main?

1. Manual Resistance 2. Body Weight Resistance (or partial BW) 3. Isokinetic / Accommodating Resistance 4. Constant / Variable Load Resistance • Free weights, machines

Physical Stress Theory 1.Overload 2.Specificity 3.Progression 4.Recuperation / Recovery 5.Use /Disuse

1. Overload (muscle hypertrophy) 2. Specificity (TRAIN SPECIFIC FOR WHAT YOU WANT TO DO) - NEED STAIRS IN THE OUTPATIENT CLINIC 3. Progression (DOSING - 1RM) 4. Recuperation / Recovery (POWER = MORE REST) -MUST WORK ON VELOCITY TRAINING 5. Use /Disuse

ACSM Position on Exercise & Physical Activity Older Adults 1. ________________ is essential for healthy aging. Adults aged ________ gain substantial health benefits from regular physical activity, and these benefits continue to occur throughout their lives. Promoting physical activity for older adults is especially important because this population is? 2. Regular physical activity reduces the risk of many adverse health outcomes. The guidelines state that all adults should avoid inactivity, that _________ physical activity is better than _____________, and that adults who participate in any amount of physical activity gain some health benefits. However, the guidelines emphasize that for most health outcomes, additional benefits occur as the amount of physical activity increases through? (3)

1. Regular physical activity is essential for healthy aging. Adults aged 65+ gain substantial health benefits from regular physical activity, and these benefits continue to occur throughout their lives. Promoting physical activity for older adults is especially important because this population is the least physically active of any age group 2. Regular physical activity reduces the risk of many adverse health outcomes. The guidelines state that all adults should avoid inactivity, that some physical activity is better than none, and that adults who participate in any amount of physical activity gain some health benefits. However, the guidelines emphasize that for most health outcomes, additional benefits occur as the amount of physical activity increases through *higher intensity, greater frequency, and/or longer duration*.

Strength Training for Balance 1. Strength changes alone have variable effect on? (2) 2. Key components that translate to improved balance and reduced falls risk: (3) •focus is typically on? •minimal? •delivered at either a ______________ or ________ intensity

1. Strength changes alone have variable effect on balance and mobility 2. Key components that translate to improved balance and reduced falls risk: •focus is typically on lower-extremity and postural muscles •minimal upper-extremity support •delivered at either a moderate or high intensity

1. Why does WB help the older adult?

1. allows nutrition

MMT grading system Advantages/Limitations 2. Scores help to? - gives us a _____________ and __________ Which is best? - 0-5 Scale - 0-10 Scale Gravity Eliminated vs.. Antigravity 3. Is MMT bad? 4. where to start exercise with a 1+

2. Scores help *guide exercise prescription* - Starting point and progression *0-5 Scale* 0-10 Scale Gravity Eliminated vs.. Antigravity 3. Inter-rater relaibility 4-5 - 0-3 (better = no manual resistance)

min gait speed for comm ambulatory?

2.5 m/s

Strength VS Function Does MMT correlate with performance/ function? Is strength just peak force? Does not account for? (2) Testing is ____________ specific Specificity of training principles Does not always reflect the ________________ & _________________________ that is necessary for performance

Is strength just peak force? Does not account for *joint dysfunction* Does not account for posture dysfunction Testing is position specific Specificity of training principles Does not always reflect the (engram) proprioception & neuromuscular coordination that is necessary for performance

Prevention, Health Promotion, Wellness, & Fitness 1. Traditionally, PT's role in prevention and wellness has been narrowly focused on _______________________________ OR _____________________________. 2. PT's efforts in health & wellness require an expanded view of health beyond the biomedical or disablement models •Role is included in the? •Primary: takes place in the _____________________- period; goal to prevent? (3) •Secondary: takes place ______________________; goal to?

Prevention, Health Promotion, Wellness, & Fitness 1. Traditionally, PT's role in prevention and wellness has been narrowly focused on preventing a recurrence of an injury, illness a patient already experienced OR identifying risk factors and preventing escalation into disease. 2. PT's efforts in health & wellness require an expanded view of health beyond the biomedical or disablement models •Role is included in the Guide to Physical Therapist Practice •Primary: takes place in the pre-pathogenesis period; goal to prevent disease, illness, injury, pathology •Secondary: takes place after the onset of disease, illness, or injury, in the presence of pathology, and in the early diagnostic process/ Rx of disease; goal to minimize disability

White Paper: Strengthening for the Older Adult Describe the talk test Where they should be?

Should be at moderate or better

ENDURANCE the ability of a muscle to sustain forces repeatedly or generate forces? o ability to resist?

endurance: generate forces over a prolonged period of time. Fatigue

Balance - Age Considerations Before you do balance activity? • ___________________________ should lead to more accurately diagnosing the attributes, factors of impairing the postural control systems > essential to effective RX •Incorporate_______________________ and ______________________ approaches to replicate higher risk activities and/or factors associated with prior falls, near falls **Be mindful of: (4)

figure out what systems are most impaired. •Comprehensive assessment should lead to more accurately diagnosing the attributes, factors of impairing the postural control systems > essential to effective RX •Incorporate environment and task-specific approaches to replicate higher risk activities and/or factors associated with prior falls, near falls **Be mindful of: o Normal aging at the tissue level o Hydration levels o Contractures particularly at the ankles, hips, spine o Extended warm-up / cool-down activities NHCE

Power Units? Expressed as? what type of fibers are lost when old? Rate of force development depends on? (3)

force x velocity (distance/time) Watts Type 2b

how long to treat the patients knowing all of this? 1. improving health related QOL with ___________ week exercise program 2. no longer __________ must be?

improving health related QOL with 12 week exercise program *no longer 3x/4 weeks = needs to be months*

lidt 4 things that changed with the MSK system after training? MOST IMPORTNT?

increased torque, cross sectional area and muscle fiber size - Increased BMD and deceased risk of fracture. *Improved aerobics after training*

Adapt vs. Challenge vs. Injury when you stretch old people? - all about two things?

low load long duration (30 seconds is good and 15 is the minimum) - about frequency and duration

Majority of PT's are?

majority of PT's are not helping elderly patients enough.

Exercise Dosing minimum dose of exercise to effectively reduce the risk and rate of falls is? ____________________________________ was the ONLY mode of exercise that had a significant protective effect on the rates of falls (estimated 25% reduction in fall rates) •Individuals who start an exercise program to improve balance, but do not achieve the minimum dose may? Possibility that gains achieved in strength / balance are enough to improve __________, but not enough to achieve a?

minimum dose of exercise to effectively reduce the risk and rate of falls is? - 50 hours over period of 3 - months moderate to high challenge balance training was the only mode of exercise that had a significant protective effect on the rates of falls (estimated 25% reduction in fall rates) •Individuals who start an exercise program to improve balance, but do not achieve the minimum dose may? - higher risk of falling (high confidence) mobility: not protective runs

Exercise Intensity o Most primary and secondary agers can safely exercise at? o Many studies confirm the majority of older adults, even the aged and/or frail are able to exercise at? o Assess quality of muscle control, safety, breathing, technique/ form when deciding appropriate strength training intensity

oMost primary and secondary agers can safely exercise at 70-80% of 1 rep max (RM) oMany studies confirm the majority of older adults, even the aged and/or frail are able to exercise at 80% 1RM oAssess quality of muscle control, safety, breathing, technique/ form when deciding appropriate strength training intensity

physical activity: highest risk factors? biggest risk factor reduction seen in?

people going from no activity to vigorous people going form no MVPA to some MVPA

Therapists are known as? Best way to train reaction time?

pharmacists of exercise perturbations

what do we start with first for someone that is very bad off?

resistance

American College of Sports Medicine (ACSM) Repetitions and % of 1RM (ACSM) 95% 1RM= ______ reps 90% 1RM= ______ reps 80% 1RM = _______ reps 70% 1RM = _______ reps 60% 1RM = _______ reps

should be 70% 1MR 95% 1RM= 2-3 reps 90% 1RM= 4-5 reps 80% 1RM = 8-9 reps 70% 1RM = 12-13 reps 60% 1RM = 16-20 reps

Pulmonary changes with aging main point?? as far as cardiovascular benefits? - 2 things you can fix most benefits go where? exercise helps what musculoskeletal wise?

submaximal training can help not much - main one: relative oxygen uptake efficiency and SV peripheral More capillaries

APTA's "Choosing Wisely Campaign" 1. APTA's 5 recommendations Dont prescribe ______________________________, instead?

under dosed strength training programs: match frequency, intensity and duration to goals

Aerobic Conditioning / Endurance Training • Consider MET level of demand for? • Consider the __________________ of the activity in determining the FREQUENCY- DURATION • _________ days per week or endurance training (ACSM, 2014) • Emphasis on more frequent activity (_______ days/week) with older adults if they exercise at very low intensity of short duration

•Consider MET level of demand for *functional activity* •Consider the INTENSITY of the activity in determining the FREQUENCY- DURATION •3-7 days per week (ACSM, 2014) •Emphasis on more frequent activity (5-7 days/week) with older adults if they exercise at very low intensity of short duration

Flexibility Training - Older Adults •Intensity > Sufficient to? • performed on _____________ muscle groups •Duration > Ideally, stretches in elderly are held for? •Incorporate ____________ with stretch •Mode: (4) •Consider target tissue (joint connective tissue vs. muscle tissue) how to get them to breath in supine??

•Intensity > Sufficient to maintain ROM with slight sensation of resistance and mild discomfort •All major muscle groups •Duration > Ideally, stretches in elderly are held >30 seconds •Incorporate breathing with stretch •Mode: gravity, stretch straps, weights, body position. •Consider target tissue (joint connective tissue vs. muscle tissue) have them count

Considerations for Assessing Strength: **Peek torque, work, power, fatigue, ave torque, impulse Harris-Love, GWU;**

•Magnitude (max/submax) •Duration (intermittent/continuous) •Velocity (slow/fast) •Mode (isometric/isokinetic/eccentric/isoinertial) •Task (familiar/novel) Magnitude, duration, velocity, task and mode M and M DVT

Strength - Age Considerations Be mindful of: •Normal aging at the? •Hydration levels (typically they are?) -drink water after •Prior injuries, occupational risks/likelihood of repetitive stress, surgeries and length of time since surgery , etc. •Contractures where? •Need to adapt HEP from younger adults (ex: supine hams flex, SKTC) - risk of injury/strain elsewhere, Valsalva, etc. •Prior exercise experience •Variability with target tissue estasticity, limitations, etc. •Order of interventions may need to? •Extended? (2)

•Normal aging at the tissue level •Hydration levels (typically dehydrated) -drink water after •Prior injuries, occupational risks/likelihood of repetitive stress, surgeries and length of time since surgery , etc. •Contractures proximal & distal to the joint of focus •Need to adapt HEP from younger adults (ex: supine hams flex, SKTC) - NEED VARIETY - risk of injury/strain elsewhere, Valsalva, etc. •Prior exercise experience •Variability with target tissue estasticity, limitations, etc. •Order of interventions may need to change •Extended warm up/cool down activities.

Intensity % Tertiary Aging •Older adults with some diagnoses and/or frail older adults should decrease intensity to ____________% 1RM (___+ reps up to ______) including but not limited to... use what type of load?

•Older adults with some diagnoses and/or frail older adults should decrease intensity to 30-60% 1RM (12+ reps up to 25) including but not limited to... o *Advanced rheumatoid arthritis* o *Acute musculoskeletal conditions* o Extremely frail or severely deconditioned o *Patients whom resistance exercise could* negatively affect post-surgical healing o Advanced CP disorders o Progressive neurological disorders o Comorbidities limiting exertion Maximize benefit and minimize compensation *Submaximal loading*

Power •Power is highly correlated with? •Training that develops the maximum power output will increase force levels at the _______________ velocity end of the force-velocity curve (Brandon). •Testing power: -List 3?? •Applicable and adaptable to? (3)

•Power is highly correlated with level of performance •Training that develops the maximum power output will increase force levels at the mid-to-high velocity end of the force-velocity curve (Brandon). Testing power: •Biodex/isokinetic machines •Practical testing in sports; jumping, throwing, lifting •Functional testing in geriatric clients •Applicable and adaptable to sedentary, well elderly, geri-athlete spectrum

RPE / Borg Scale •Talk test -> correlates with? - met level for walking and talking? •Effective for? •ACSM guidelines for exercise intensity are levels associated with RPEs from _______ to _______ for most individuals ("_________________" to "_______" verbal descriptors) and initial intensities of ______ to _______ for de-/un-conditioned individuals •An RPE of _____ is approximately equal to 85% Max HR. •For patients whose HR is artificially depressed (e.g., those on beta-blockers) an RPE of ____________ is approximately equal to 60%max HR •If beta-blockers, recommendations are ______ to _____ RPE - An additional safeguard for these patients is to avoid increases in HR of?

•Talk test -> correlates with ventilatory threshold - 13 •Effective for self-monitoring •ACSM guidelines for exercise intensity are levels associated with RPEs from 13 to 16 for most individuals ("somewhat hard" to "hard" verbal descriptors) and initial intensities of 11 to 12 for de-/un-conditioned individuals •An RPE of 16 is approximately equal to 85% max HR •For patients whose HR is artificially depressed (e.g., those on beta-blockers) an RPE of 12-13 is approximately equal to 60%max HR •If beta-blockers, recommendations are 13 to 15 RPE - An additional safeguard for these patients is to avoid increases in HR of greater that 20 beats per minute over resting HR

Intensity - SAID Principle *Specific Adaptation to Imposed Demands (SAID)* • When the body is placed under some form of stress, the body will? • Adaptation process does not occur by? - Innumerable separate mechanisms • Body is always "trying" to get batter at?

•When the body is placed under some form of stress, the body makes adaptations that will allow the body to get better at withstanding that specific stress/force/demand in the future •Adaptation process does not occur by one mechanism - Innumerable separate mechanisms •Body is always "trying" to get better at what is practiced!