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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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Disclosures
• Federal Funding– NIH
• NIA, NICHD
• No other disclosures
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Changes with AgingBoth Strength and power decline after age 35
1995, Metter et al., Baltimore Longitudinal Study on Aging
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
JAMA April 2014
“Measuring gait speed is simple, quick, reproducible, inexpensive, and feasible in
clinical settings.”
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Clinical PracticePRIMARY CARE OF OLDER ADULTS
Chronic Disease Management Advocated Mobility Screening
Observed Physical Performance
ArthritisCHDStrokeDiabetesOsteoporosisEtc.
Rehabilitative Exercise
FallsDisabilityMorbidityMortality
FinalCommonPathway
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Realties of independent living for older adults
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Exercise and Impairment
Body System Impairment
Impairment
ICF Model
Nagi Model
IMPAIRMENT
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
% 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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Changes in Power and CMD in
Function
Bean et al. J Am Geriatr Soc 2010
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Exercise and Mobility
Functional Limitation
ActivityICF Model
Nagi Model
Mobility
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
The Boston RISE StudyBean et al., Arch Phys Med Rehab; 2013
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Issues that may impact design of Exercise
• Specificity of training
• New models to optimize compliance and adherence
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Exercise for Fall PreventionSherrington et al.
Effective Exercise for the Prevention of Falls: A Systematic Review and Meta AnalysisJ Am Geriatr Soc, 2008
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Hip Rehab Trial
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Hip Rehab Results
Main Findings• Improvements at 6 months
– Performance-based Mobility– Patient reported Mobility– Patient reported Activities
• Findings persisted till 9 months
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Exercise and Disablement
ICF Model
Nagi Model
Participation
Disability
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical SchoolDepartment of PM&R, Harvard Medical School
Prehabilitation• “Prehabilitation”
– 188 community dwelling older adults (75+ years)• Gill, TM et al, NEJM
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
LIFE study, JAMA 2014
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
LIFE study-sub groups
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
How should rehab be designed?
http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
PCORI/NIA funded trial
Implementation Trial• Multicenter RCT• Targeting the prevention of
fall related injuries• Pepper Centers• Ancillary studies welcomed
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
MCI and Mobility in Boston RISE
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Prevalence of Musculoskeletal Pain
Leveille et al; JAMA, 2009
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Pain and the onset of mobility problems and disability
Eggermont et al. , JAGS, 2014
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Mskl Pain and Mobility
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
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
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Brigham & Women’s Hospital
Department of Physical Medicine & Rehabilitation
Harvard Medical School
Questions and Comments