Use It or Lose It-How to Treat Deconditioning

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Geriatric Function

Deconditioning is an extremely important factor in outcomes. An early study by Harris found that failure to improve significantly at one year is related to a primary diagnosis of general deconditioning, or cerebrovascular accident.1 In addition, Hill recently examined the factors associated with older patients’ engagement in exercise after hospital discharge. He found that older patients have low levels of engagement in exercise after hospital discharge and concluded that exercise programs should address barriers and facilitators to enhance motivation in this sub-population of older people.2

Coyle found aerobic exercise improved aerobic fitness and decreased depressive symptoms. Reduction in depressive symptoms may result from physical and/or behavioral mechanisms associated with aerobic exercise.3 Singh, in a randomized controlled study examining progressive resistance training in depressed older adults, found that progressive resistive training is an effective antidepressant in depressed elders, while also improving strength, morale, and quality of life.4

A study by LaCroix found that walking more than four hours per week may significantly reduce the risk of hospitalization for cardiovascular disease and reduce risk of death when age and sex were adjusted.5

Essential to Recovery

As we can see from the literature, there are considerable benefits to alleviating deconditioning. It is recommended that individuals should stretch muscles that are tight and that restrict mobility. It is essential that therapists accurately assess strength and strengthen any muscles that demonstrate weakness.

We need to get our patients up as quickly as possible while being careful not to overload them. In terms of frequency of sessions, it is more beneficial for patients to do several smaller sessions within their heart rate range than one long session that pushes them above a safe heart rate limit.

The best way to determine the appropriate heart rate range is to use a heart rate formula. These are easily available on the Internet (www.exrx.net/Calculators/TargetHeartRate.html).

Having older patients work out for three short sessions per day for 10 minutes in their heart rate range has been shown to be of the most benefit.

Finally, remember that reconditioning takes twice as long as deconditioning; therefore, we need to inform our patients that if it has taken them three months to get to this low level, it will take them six months of diligent work to get back to their prior level of function and conditioned status.6

Guidelines for physical activity for community dwelling older adults are readily available in the literature. The recommendations put forth by the Journal of American Family Physician in 2010 is one such source and is cited below.6

Recommendations for Physical Activity in Older Adults

Minimum activity for achieving important health benefits includes:

  • Two hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (e.g., brisk walking) per week, plus muscle-strengthening activities on at least two days of the week; or
  • One hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (e.g., jogging, running) per week, plus muscle-strengthening activities on at least two days of the week; or
  • A combination of moderate- and vigorous-intensity aerobic activity equivalent to the recommendations above, plus muscle-strengthening activities on at least two days of the week.
  • Increased activity for achieving additional health benefits includes:
  • Five hours (300 minutes) of moderate-intensity aerobic activity per week, plus muscle-strengthening activities on at least two days of the week; or
  • Two hours and 30 minutes (150 minutes) of vigorous-intensity aerobic activity per week, plus muscle-strengthening activities on at least two days a week; or
  • A combination of moderate- and vigorous-intensity aerobic activity equivalent to the recommendations above, plus muscle-strengthening activities on at least two days of the week.
  • Activity level should be relative to physical ability, and exercises to improve balance and flexibility may also be beneficial. Aerobic activity should occur throughout the week, with each session lasting at least 10 minutes. Muscle-strengthening activities should work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms), and consist of eight to 12 repetitions per activity, or should continue until it would be difficult to do another repetition without help.

For additional guidelines visit www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html.

Schnelle and Ouslander explored simple and easy ways to work on deconditioning for patients living in skilled nursing facilities and developed a specific nursing intervention called the FIT intervention.7,8

The FIT intervention requires six minutes more nursing time, and improves mobility and physical activity in patients who are deconditioned. While the nurses work with patients on continence care, they also complete the following: 1) assist patients to practice sit-to-stand to fatigue; 2) lead each patient in progressive resistive exercise to all large joints, using weights) and 3) encourage and help the patient to walk or propel a wheelchair for five to 20 minutes. This program would be a wonderful adjunct to a traditional physical therapy program.

If we want the best outcomes for our patients, it is necessary for therapists to work in conjunction with nurses and others to assure that we are evaluating and designing effective programs for reconditioning.

References

  1. Harris, R., O’Hara, P., Harper, D. (1995). Functional status of geriatric rehabilitation patients: A one-year follow-up study. Journal of the American Geriatrics Society, 43, 51-55.
  2. Hill, A., Hoffman, T., McPhail, S., et al (2011). 11 factors associated with older patients’ engagement in exercise after hospital discharge. Archives of Physical Medicine and Rehabilitation, 92(9), 1395-1403.
  3. Coyle, C., & Santiago, M. (1995). Aerobic exercise training and depressive symptomatology in adults with physical disabilities. Archives of Physical Medicine and Rehabilitation, 76, 647-652.
  4. Singh, N., Clements, K., & Fiatarone, M. (1997). A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology: Medical Sciences, 52A(1), M27-M35.
  5. LaCroix, A., Leveille, S., Hecht, J., Grothaus, L., & Wagner, E. (1996). Does walking decrease the risk of cardiovascular disease, hospitalizations and death in older adults? Journal of the American Geriatrics Society, 44(2), 113-120.
  6. Elsawy, B., & Higgins, K. Physical activity guidelines for older adults. American Family Physician, 81(1), 55-59.
  7. Schnelle, J., Alessi, C., Simmons, S., Al-Samarrai, N., Beck, J., & Ouslander, J. (2002). Translating clinical research into pracitce: A randomized controlled trial of exercise and incontinence care with nursing home residents. Journal of the American Geriatrics Society, 50, 1476-1483.
  8. Ouslander, J., et al. (2005). Functional incidental training: A randomized, controlled, crossover trial in Veterans Affairs nursing homes. Journal of the American Geriatrics Society, 53, 1091-1100.

 

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About Author

Carole Lewis, PhD, PT, MSG, MPA
Carole Lewis, PhD, PT, MSG, MPA

Dr. Lewis is a physical therapist in private practice and president of Premier Physical Therapy of Washington, DC. She lectures exclusively for GREAT Seminars and Books, Inc. Dr. Lewis is also the author of numerous textbooks. Her Website address is www.greatseminarsandbooks.com.

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