Department of Physical Medicine & Rehabilitation Harvard Medical School Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s

Department of Physical Medicine & Rehabilitation

Harvard Medical School

Spaulding Rehabilitation Hospital

Massachusetts General Hospital

Brigham & Women’s Hospital

Functional Decline and Aging: How can exercise influence

these changes?

Jonathan F. Bean MD, MS, MPH

Associate Professor

Dept. PM&R, Harvard Medical School






Disclosures

• Federal Funding– NIH

• NIA, NICHD

• No other disclosures






Outline

• Outline– Background/conceptual issues– Exercise and Functional Activities– Exercise and Participation in Life Roles– Medical conditions relevant to PM&R care and

the maintenance of independence






Aging and Demographics

• Older adults are the fastest growing segment of the population

0

10

20

30

1940 1960 1990 2020 2040

Per

cent

Women 65 yMen 65 y

U.S. Bureau of the Census, 2000






Changes with AgingBoth Strength and power decline after age 35

1995, Metter et al., Baltimore Longitudinal Study on Aging






Perc

en

t

70 y 70-74 y 75-79 y 80-84 y 85 yW M W M W M W M W M

DifficultyInability

0

10

20

30

40

50

60

Supplement on Aging II, NCHS

Percent of Older Persons with Difficulty or Inability in ADLs by Age and Sex, United States, 1995






OLDER PATIENTS HAVE HIGHRATES OF COMORBIDITY

• In 1995, 79% of the 70+ age group had 1 or more of the following chronic disorders:

Arthritis Hypertension Heart disease Diabetes mellitus Respiratory disease Cancer Stroke

• Functional disability is highly associated with chronic disorders






Does the disease model help us conceptually?

• Geriatric impairments more strongly associated with incident disability than chronic diseases– Cardiovascular Health Study– Chaudhry et al. JAGS, 2010

MC Escher: http://www.wisdom.weizmann.ac.il/~glasner/courses/CV_2009_2/im

g/escher-relativity.jpg

Let’s consider the disablement model






Mobility is predictive of adverse outcomes

Short Physical Performance Battery

• Performance of 3 tasks• Each scored between 0-4

– Standing Balance– Gait Speed over 4 meters– 5 repeated chair stands

• Best performance is 12

4-year disability rates according to SPPB

From: Guralnik: N Engl J Med, Volume 332(9).Mar 2, 1995.556-561






JAMA April 2014

“Measuring gait speed is simple, quick, reproducible, inexpensive, and feasible in

clinical settings.”






Mobility within the disablement paradigm

Body System Impairment

Functional Limitation

Disability

Mobility problems cause limitations that impact participation and disability

Impairment

Restricted Participation

Activity Limitation

ICF Model

Nagi Model






Clinical PracticePRIMARY CARE OF OLDER ADULTS

Chronic Disease Management Advocated Mobility Screening

Observed Physical Performance

ArthritisCHDStrokeDiabetesOsteoporosisEtc.

Rehabilitative Exercise

FallsDisabilityMorbidityMortality

FinalCommonPathway






Realties of independent living for older adults






Exercise and Impairment

Body System Impairment

Impairment

ICF Model

Nagi Model

IMPAIRMENT






% MVC needed to perform ADLs

Loss of Strength with Aging: a theoretical model

0102030405060708090

100

Percentage of Maximum voluntary

contraction(MVC)

25 years 75 years

MVC






Changes in 1 RM with Progressive Resistance Training among older adults

0

5

10

15

20

25

30

35

40

kg

0 4 8 12

weeks of training

KEKF

Frontera et al. , 1988

Strength Training






Co-Impairments can have augmentative effectsStrength and Balance as predictors of walking ability

Rantanen et al., JAGS, 2001

Incidence rates of severe walking disability based on baseline knee-extension strength and standing balance






Changes in Power and CMD in

Function

Bean et al. J Am Geriatr Soc 2010






Trunk Muscle Integrity and Aging• Trunk muscle endurance is also linked to back pain• Trunk muscle integrity is critical for optimal peripheral power

generation

http://www.bandbhac.org.ukwww.gc4health.com

http://www.brandeis.edu/hbi











Exercise and Mobility

Functional Limitation

ActivityICF Model

Nagi Model

Mobility






What impairments should be prioritized?Impairments

Balance

Strength

Power asymmetry

Velocity of movement

Reaction time

Aerobic Capacity

Range of Motion

Core muscle integrity

Kyphosis

Obesity

Pain

Sensory Loss

Cognitive Impairment

Depression

Visual Impairment

Rehabilitative Impairments

Medical Impairments






The Boston RISE StudyBean et al., Arch Phys Med Rehab; 2013






Multivariable models prediction LLFDI function

Note: Standardized estimates presented as absolute values. Both models were adjusted for age, sex, overweight status, obese status, and the manifestation of sensory loss






Issues that may impact design of Exercise

• Specificity of training

• New models to optimize compliance and adherence






Exercise for Fall PreventionSherrington et al.

Effective Exercise for the Prevention of Falls: A Systematic Review and Meta AnalysisJ Am Geriatr Soc, 2008






Does one size fit all?... Implications of specificity of training

• RCT comparing two 16-week exercise programs– N=138, mean age 75 years– 62% had ≥2 chronic

musculoskeletal conditions– ~30% with h/o heart disease

0.5 1 1.5 2 2.5

VelocityImpaired (N=68)

StrengthImpaired (N=67)

All subjects

SPPB difference (week 16 - week 0)

InVEST NIA

0.5 units = clinically meaningful difference

*Bean, JF et al. Increased Velocity Exercise Specific to Task (InVEST) training vs. the National Institute on Aging’s (NIA) strength training program: changes in limb power and mobility, Jnl Gerontol Med Sci, 2009






Hip Rehab Trial






Hip Rehab Results

Main Findings• Improvements at 6 months

– Performance-based Mobility– Patient reported Mobility– Patient reported Activities

• Findings persisted till 9 months






Exercise and Disablement

ICF Model

Nagi Model

Participation

Disability





Harvard Medical SchoolDepartment of PM&R, Harvard Medical School

Prehabilitation• “Prehabilitation”

– 188 community dwelling older adults (75+ years)• Gill, TM et al, NEJM

http://content.nejm.org/content/vol347/issue14/images/large/04f1.jpeg






LIFE study, JAMA 2014






LIFE study-sub groups






Developing new care paradigms:The Live Long Walk Strong Program

• Focused on mobility and fall injury prevention

• Integration with Primary Care • Medicare compatible• Treats those with MCI






MA

CIP

A P

CP

P M

& R

Re

ha

bilita

tive

Ca

re C

om

mu

nity

PCP SCREEN

PM&R EVAL

+

PTPROGRAM

MANAGEROT

COMMUNITY EXERCISE/ACTIVITY

PROGRAMS

EDUCATION/ REFERRAL

_

+

The Live Long Walk Strong Program






How should rehab be designed?

http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong

http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong






PCORI/NIA funded trial

Implementation Trial• Multicenter RCT• Targeting the prevention of

fall related injuries• Pepper Centers• Ancillary studies welcomed






Cognitive Function and Mobility

• Cognitive decline linked to mobility decline– Alzheimer’s– Mild Cognitive Impairment

• Role of executive function– Dual task performance

• Walking while talking• Predictive of falls and functional decline






MCI and Mobility in Boston RISE






Prevalence of Musculoskeletal Pain

Leveille et al; JAMA, 2009






Pain and the onset of mobility problems and disability

Eggermont et al. , JAGS, 2014






Mskl Pain and Mobility






Summary Points

• Exercise can help slow functional decline among older adults

• We must be aware of conditions such as MCI and Pain that can impact participation

• PM&R clinicians should embrace this challenge– Take advantage of available resources– Geriatrics at your finger tips






Questions and Comments

Documents

Department of Physical Medicine & Rehabilitation Harvard Medical School Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s