At the direction of her physical therapist, Katherine stood in front of a mat table wearing a weighted vest and crossed her arms in an X across her chest. She was instructed to sit down on the edge of the mat table in a slow and controlled manner. As soon as she had contact with the mat table, she was directed to quickly pop back up to standing. The positive connection between the patient and therapist was obvious as Katherine repeated this exercise with precision and focus.
Katherine, 79, repeated this exercise 10 times and then completed two more sets. A patient in an ongoing, clinically based research program that is designed to target community dwelling older adults (65 and older), Katherine had dislocated one of her total hip replacements in a fall.
The program, called Live Long Walk Strong, is part of the Research Center for Lifelong Health and Fitness at Spaulding Cambridge Rehabilitation Center in Cambridge, MA. At the core of this program is an approach somewhat unprecedented in older adults: exercise and physical activity.
Informally and lovingly referred to as "Geriatric Boot Camp," the Live Long Walk Strong program has developed a laser focus on improving function and preventing falls among its older patients. Many of the patients have experienced difficulty with functional tasks such as walking, climbing stairs and rising from a chair.
Developed through a grant from the Tufts Healthcare Foundation in collaboration with the Mount Auburn Cambridge Independent Physicians Association, the program encompasses the continuum of care beginning with the primary care physician and ending with community based programs to help the patient sustain and improve upon gains made in the skilled care setting.
"This program is especially important in today's world because we know the population 70 years old and older is the fastest growing segment of the population," explained Lorna Brown, DPT, MSPT, GCS, one of the program's developers.
According to the U.S. Census Bureau, more than 70 million people will be over the age of 65 by 2030 and 20 percent of the U.S. population will be 65 years or older by 2050. Of that population, 80 percent is predicted to have at least one chronic illness, and 50 percent will have two or more.
"Many of the problems we see as we age are directly related to behavioral issues such as poor exercise and eating habits," said Dr. Brown. "With medical advances, we have prolonged the years of our lives but many of those years are spent in morbidity. It's important to encourage physical fitness and exercise in the older adult population."
Additionally, these patients are often managing multiple comorbidities, illnesses and chronic diseases. "The incidence of a fall and fall-related injuries are associated with a high amount of costly hospital time," said Jonathan F. Bean, MD, MS, MPH, medical director, Spaulding Cambridge Rehabilitation Center; director of research training and education, Department of PM&R, Harvard Medical School; and director, Research Center for Lifelong Health and Fitness.
Power to the People
Under the direction of Dr. Bean, Live Long Walk Strong endeavors to provide the highest intensity stimulus for the purpose of producing the greatest gains. Research has shown that older adults are able to work up to a moderately high exercise intensity.
"Early on, it was thought that older adults couldn't work to the intensity to strengthen muscle and to make gains," Dr. Brown shared. "We know that to make functional gains, we have to stimulate the muscle sufficiently."
The PTs need to be mindful, however, of the many underlying health problems that can sometimes get in the way of working harder. "We have to watch this patient population closely to make sure that their form is good and that they are safe," Dr. Brown said. "A patient may have spinal stenosis, for example, that is compromising his progress."
Katherine, a patient in the Live Long Walk Strong program at Spaulding Cambridge Rehabilitation Center, performs exercises that address functional decline at the direction of physical therapist Lorna Brown, DPT, MSPT, GCS, one of the program's developers.
In Dr. Brown's experience, the older adult population is generally undertreated in skilled settings. "There is much evidence that meaningful gains can be made and that higher intensity interventions are well tolerated," she shared. "Given limited time and resources, interventions are chosen that are the most likely to produce the greatest gains in the least amount of time."
Based on research conducted by Dr. Bean, the team advocates multi-dimensional functional patterns of movement that replicate real-life tasks so the work is applicable in the home and community. In addition, assessment and treatment tools are chosen that are low-tech, economical and readily available in most clinical settings.
The purpose of the weighted sit-to-stand exercise, in which the weight is kept central during a functional task, was designed to improve Katherine's power. "Power is related to strength, but it's also different," Dr. Bean told ADVANCE. "Power is the combination of strength and speed of movement."
According to Dr. Bean, elderly patients need to develop power so that they can sufficiently activate their muscles to prevent themselves from falling. When an elderly man performs a daily task such as rising from a chair and momentarily loses his balance, it's important that he can generate a counterforce quickly in order to prevent a fall from occurring.
"We already know the importance of power for athletic performance but it's also important for everyday activity performance for the elderly," said Dr. Bean. "Our program is sports-specific training for older adults, but the 'sport' is living independently."
The population at risk for falls is unique because there is a lot of evidence about how to manage their care but it's difficult to implement in current paradigms. "Along with other providers, we wrestled with, 'how can we deliver the care based on the evidence in ways that will work for today?'" asked Dr. Bean.
That's the very premise that led the team to develop the Live Long Walk Strong program. "We wanted to develop a research-based clinical program that is effective and doable within the current Medicare funding guidelines and the current realities of health care," said Dr. Bean.
Spaulding Rehab was approached by one of the large primary care groups in northwest Boston that was managing a large group of older adults with multiple comorbidities.
"When the physicians looked at their patients, they saw a high rate of hospitalizations and injuries and increased costs for these individuals," stated Dr. Bean. "Overall, they felt they could do a better job of serving functional needs."
The team developed easy-to-use screening tools to be used at the primary care stage to identify people who are at risk for falls. The findings are used as criteria for referrals to rehabilitative care.
"We have tools in the rehabilitative setting that look at stratifying the level of risk and assist in designing an individualized program," said Dr. Bean. "Those at low risk will receive more education and a little bit of rehab, whereas those with higher risk will get more rehab."
Once referred, a patient undergoes an evaluation by a physiatrist who determines each patient's readiness to be engaged in physical activity and indicates the need for occupational, physical and speech therapy.
Designing and implementing a comprehensive program targeting the older adult who presents with declining function and increased risk of falling is a daunting task.
"This target population often has a complex set of medical and social needs that makes determining the most effective approach to their care difficult," shared Dr. Brown. "As a clinician, I often ask myself 'where do I start?' Once I start, I wonder 'where do I end?'"
The PT/OT Connection
One of the challenges in rehabilitative care, according to Dr. Bean, is that there may not be a lot of cross talk between the therapists and/or the referring physician.
"The physical therapist is working on strength and function and the occupational therapist is looking at the home and the environment, and in many cases, there is a communication disconnect," he said.
To solve this issue, Spaulding Rehab created the program manager position, much like a case manager, to close the link and keep the communication open among the various health care providers.
The rehab program includes moderate to high intensity training in endurance, strength, power, speed of movement and postural stability (dynamic balance) and education regarding the role the environment can play in optimizing safety in the home and community.
PTs may prescribe independent exercise programs to be performed at home or in community based settings that are accessible and acceptable to the patients. To prevent falls, the OTs assess patients for community safety and ability to perform activities of daily living (ADLs) in the home.
"The OT evaluates a person's safety in the home while performing day-to-day activities such as bathing, dressing and doing laundry," shared Catherine Wee, OTR/L, CHT. "We also look at his ability to be safe in the community-does he drive? Does he need to walk on an uneven sidewalk?"
During the evaluation process, the OT interviews patients in great detail. "To identify problems, I ask whether they dress in the bedroom after bathing or if they dress right in the bathroom," Wee explained. "Sometimes I have the patients simulate those activities in a closed area in the clinic to ensure that they are doing it safely."
The outpatient clinic features "Easy Street," which is a simulated home and community environment used by both PT and OT. Patients can practice car and tub transfers, getting on a bus, using an ATM machine and making a bed.
"Especially in today's climate with the shrinking health care dollar, we need to figure out how to use the resources we have in the best way possible," Dr. Brown said. "Prevention is the key."
Functional decline and falls are a major issue with the older adult, both in terms of the financial impact on the health care system as well as the human cost in quality of life.
"The rapid growth of the older adult population is bringing this issue into sharper focus as our overburdened health care system is facing increasing strain," said Dr. Brown. "Optimal use of limited health care dollars should concern every person involved in health care delivery."
The program's eventual goal is to develop clinical decision making tools that can assist health care providers in identifying approaches to treatment that are most likely to achieve measurable, sustainable gains.
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org