3/30/2016
Geriatric Exercise
Making Therapeutic Exercise
Efficient and Effective
Stephanie Prinster, DPT, GCS
Medicare Reform
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Review evidence-based recommendations in recent
research and apply these conclusions appropriately to
therapeutic exercise in the geriatric population
Review and understand the principles of motor learning
Review and understand the principles of specificity
training
Session Outline
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Care-Item Set and B-Care2
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In 2009 physical therapy accounted for 74% of Medicare’s
outpatient therapy payments which totaled over 3.6 billion
dollars
Of that 3.6 billion Therapeutic Exercise accounted for 1.9
billion3
“Strengthening without
rationale/adequate stimulus is
tantamount to Malpractice”
Let’s Make It Count!
Medicare Reform
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Normal Aging
Motor Learning:
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Exercise Prescription:
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 Bundle payments1
 Changes to patients co-pay amounts
 Continuation of therapy cap for Medicare Part B
Why Should You Care?
Session Learning Objectives
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New proposals are being presented that will
affect reimbursement in the SNF, outpatient,
and home health settings including
 External Cues
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Sleep
Feedback
Random Practice
Repetition
Dual Task
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Frequency
Overload Principle
Repetitions
Sets
Specificity
Functional Strength
Power
Contraindications
Aerobic Exercise
Flexibility
Warm Up/Cool Down
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Normal Aging
 With prolonged bed rest, strength is lost at a rate of 2 – 3% per
day & after 3- 5 weeks of bed rest almost half of strength is lost
 Strength decreases at a rate of 10% per decade starting at 30,
accelerating to 15% after age 60. By age 80 there is a 50% muscle
mass loss
 The loss of power with aging is even greater than the loss of
muscle strength, occurring at 20% - 30% per decade after the age
of 30
 After 35 bone loss is approximately 0.5% per year for males & 1%
for females, in immediately post-menopausal women, bone loss is
about 4% per year for 5 years4
Clinical Questions: Research tells us that it takes
a minimum of 6 weeks to achieve a true
strengthening response in muscle tissue. So why do
patients demonstrate gains (e.g. in the 30 Second
chair test, transfers, bed mobility) after just a few
minutes, hours or days of training?
Ways To Improve Motor
Learning:
• External cues > Internal Cues
• Sleep
• Delayed Feedback > Concurrent
Feedback
• Low Frequency > High Frequency
Feedback
• Random Practice > Blocked
Practice
• More Practice/Repetitions = Better
Retention
• Dual Tasking
External Cues > Internal Cues
Internal Cues (Focus on body part) vs. External Cues (Target or the
effect of the action)
• Emanuel and colleagues: With dart throwing task. Internal focus group was told to
think about wrist flexion; elbow extension & finger positioning external focus group
was cued to think of the target. The external focus group not only had better accuracy
and lower EMG activity near the wrist; it also showed decreased activity on muscles
away from the wrist. When internal focus is used, ALL muscles, not just those subject
to internal focus, show increased activity. A focus on one body part makes the whole
motor system work harder, sometimes in undesirable ways.6
• Stoate and colleagues: Expert swimmers were instructed to swim under 1 of 3 focus
conditions: internal focus (“pull hands back”), external focus (“push water back”), and
control group (no instructions). Both the external focus group and control group had
faster times than the internal focus group7
• Sit <-> Stand Application Focus on External Cues
• External cues “Lean towards wall/target”, “Push the floor down with feet & punch the
mat ” “stand tall with proud chest” vs. Internal Cues of “extend hips & tighten quads”
or “flex trunk towards knees” & “pinch shoulder blades together”
What Is Motor Learning?
Motor Learning
 Refers to a set of internal processes associated with practice or experience
leading to relatively permanent changes in motor behavior
 Acquisition = Fast; initial phase; seen during
an initial training session & across the first few
sessions
 Retention
 Transfer = Later; slow phase; progresses across
multiple training sessions; able to apply original
principle across different settings
 Sit <-> Stand (Quicker Acquisition ->
Transfer)
 Swinging a Golf Club (Longer
Acquisition -> Transfer)5
Sleep
• Fischer and colleagues: Reported findings that
the consolidation of motor sequence learning
benefits from sleep, independently of whether
subjects slept during the night or during the
daytime. In a finger to thumb opposition task
Independent of whether placed during daytime
or nighttime, sleep after practice enhanced speed
of sequence performance on average by 33.5%
and reduced error rate by 30.1% as compared
with corresponding intervals of wakefulness.8
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Delayed Feedback > Concurrent
Feedback
• Concurrent feedback (provided simultaneously with the task) is
detrimental to learning compared to terminal feedback
(provided after the task is completed)
• Giving feedback immediately after a task is less effective than
delaying it for a few seconds9
• Safety comes first but try allowing your patients to make some
mistakes and learn from them on their own, without giving feedback
too quickly. After a trial of a task, ask your patient his/her
impression – “was it correct or not?” “What was good about it?”
“What didn’t go well?” Processing the answers can actually help
with learning.
Random Practice >
Blocked Practice
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Random practice facilitates better retention than blocked
practice (especially for patients with CVA’s)
Blocked Practice: 15min of sit to stands, 15min gait training,
15min strengthening (this type of practice is better for patient’s
with Parkinson’s Disease)
The controlled environment of most rehabilitation departments
does not simulate the demands encountered by the aging
population in the home environment. Challenging the aging
adult in a variety of contexts to increase the likelihood of skill
learning and retention become important.10
Repetition
• Darcy Reisman, PT, PhD “Repetition
is the single
most important variable affecting
motor learning & even after a person
learns a new task, repetition is required
for neuroplasticity.”11
• 24 Subjects with recent TBI: In addition to their usual rehab
exercise program subjects in the experimental group participated
in four weeks of intensive training of sit-to-stand (87/day) and
step-up exercises (42/day) with the aim of improving
performance of sit-to-stand. The control group did no additional
sit-to-stand or step-up training. The extra repetitions resulted in
a 62% improvement in motor performance of sit <-> stand
(number of repetitions of sit-to-stand in 3 min) for the
experimental group compared with the control group's 18%
improvement12
Dual Tasking
 Connection between dual task capacity &
balance/fall risk
 Improvements in dual task can be made with
training
 Measure progress by comparing single task
versus dual task times
 (e.g walking vs. walking & retrieving an item from
pocket, talking, carrying object, turning head,
texting)
 TUG vs TUGman or TUG-COG
Exercise Prescription
Should contain14:
• Muscle
• Aerobic
Strengthening
exercise
• Flexibility/
• Balance
stretches
Frequency
 Resistance/Strength = (2 – 3) days/week with
at least 48 hour separation per muscle group
 Aerobic = (3 – 7) days/week for 30 – 60 minutes
 Flexibility = (5 – 7) days/week
 Balance = (up to 7) days/week
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Stages of Strength
Improvements
Neural improvements (short term/ completed in 4 – 12 weeks) account for
strength gains prior to muscle hypertrophy.
 Recruitment of additional motor units (small/slow ->
fast/large) 4 – 6 weeks
 Motor unit recruitment depends on the force/resistance of the exercise. With light intensity exercise
the Type I (slow twitch) motor units are recruited. When the load is increased, the Type IIa (fast
twitch) will be recruited with the help of the Type I fibers. When the load becomes even greater, the
Type IIb/x will be recruited with the help of the Type IIa and Type I motor units. Therefore Type I
motor units are always firing no matter what the intensity.
 Increased firing rates of motor units completed in 4 – 6 weeks
 Counteraction or Reduction of autogenic inhibition which
allows for greater force production completed in 4 – 16 weeks
 Reduction in coactivation of agonist & antagonist muscles 4 –
16 weeks
Stages of Strength
Improvements
Muscle hypertrophy
• (Long term completed in 6 – 12
weeks)
• Muscle Fiber Hypertrophy =
Increase in size of contractile
proteins (actin & myosin)
• Sarcoplasmic hypertrophy =
increases size of sarcoplasmic
volume (ATP, glycogen,
mitochondria & myoglobin) in the
muscle cell
The Minimum Stimulus:
Overload Principle
 Skeletal muscle requires a workload of
approximately 60% - 80% of 1 Rep Max (RM)
to create significant strength gains that will
also translate to functional gains
 A 60% threshold equates to 15 repetitions,
where Fatigue is observed in the last 1 – 2
repetitions, and/or a rate of perceived
exertion (RPE) of 12 – 13
 The 80% threshold equates to 10 repetitions,
where Fatigue is observed in the last 1 to 2
repetitions
Overload Principle
 Rather than creating an artificial target by asking for a
set number of repetitions, Ask the patient to do as many
repetitions as possible
 If more than 20 reps can be completed without Fatigue
the chosen resistance is below 60% threshold necessary
for strengthening and needs to be increased
 Fatigue is indicated when the patient:
 Is unable to move through their full, available ROM
 Begins to use substitution patterns
 Begins to hold their breath
Repetitions
• When beginning a strengthening program for aging adults with
physical and functional frailty, using a load just below the desired
threshold for overload (i.e. 60% 1 RM or 15 repetitions), will insure
good form, proper technique, neural adapations and allow opportunity
for motor learning of the specific movement of the exercise.
• Start at 40% to 50% of 1 RM or 20 - 30 repetitions for neural
adaptations and for formation of proper technique
• Remember 20 - 30 repetitions without fatigue is
NOT strength training but likely endurance
training.
• 1 week is often sufficient time for consistency in performance to
develop; once the routine is mastered, the resistance is increased
exercise to load that will stimulate muscle adaptation4
Sets
Initial research found 3 sets to be
more effective than 1 or 2 sets, but
the difference in strength gain
between 1 & 3 sets was only 2.9% 15
 Currently many authors suggest 1 set due to most
strength gains being made in 1st set & to avoid injury &
boredom 16, 17
 What can we do? Instead of having patient perform
multiple sets of same exercise, we should devise exercises
that challenge the muscle in different ways
 1 set of Sit to Stand -> Lunges - > Wall
Squats to improve quadriceps strength
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Specificity
 The specificity principle states that the physiologic adaptations to exercise are
specific to the type of exercise performed 18
 Athletes have been doing this for years
 To Run a marathon you need to Run!
 Open Chain strength training does not increase strength for closed chain
tasks as effective as closed chain training would
 So If you want to improve Stair Climbing, Work on Stair Climbing and not
supine hip flexion or LAQ
 If you want to improve sit <-> stand, Work on Sit <-> Stand
Functional Strength
Training
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Strengthen the movement rather than the muscle
• Sale study: When ability to squat was
used as the outcome measure; subjects
who trained by performing squat
exercise improved twice as much as
those performing either the leg press or
open chain knee extension exercises. 19
Strengthening is insufficient to alter abnormal movement
patterns, because strengthening activates different areas of
the motor cortex than does skills training. 20
Functional Strength
Training
• Getting the Most out of our limited
time with patient by performing
exercises that mimic daily activities
• Sit <-> Stand progression from
different heights
• This Functional Exercise will
Result in Both Improved Sit <->
Stand and improved Quadriceps
strength
• While performing LAQ may lead to
increased quadriceps strength but
little carry over to sit <-> stand
Power Training
Power Training = Force x
Velocity
 Depends on the ability of the muscular system to produce force
and the neural system to quickly recruit motor units to produce
movement.
 Loss of Muscle Power has an earlier onset and faster rate of
decline than strength (20% – 30% per decade after 30)
 The loss of speed & power is associated with frailty, falls, slow
gait speed; slow gait speed is predictive of future
institutionalization 14
Power Training
• When a patient is able to do 2 sets of an exercise
with good form and no pain, incorporate power
training
• Concentric Phase as fast as possible with
controlled eccentric phase of 2 – 4 seconds
• Overload the speed (time the patient as they
perform a task)
• Weight Machines, Weighted Vests, Medicine
Balls, Body Weight or Therabands
• Start at 30 – 45% of 1 Rep Max (20 – 30 reps) and
progress to 80% (8 – 10 reps)
• Weighted Vests/belt – Start at 2% of Body Weight
and add 1 – 2% of body weight as able4
General Contraindications
for Strength Training4
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Inflammation- can be worsened by resistive exercises
Pain- severe joint/ muscle pain during or for more than
24 hours after exercise
Post- surgical/ procedural limitations
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Indications to Terminate
Exercise4
Aerobic Exercise
 ACSM suggests exercise stimulus of 60% – 80% of
Heart Rate Reserve to achieve cardiovascular
adaptation.
 Karvonen Formula
 Target Heart Rate = ((HR max − HR rest) × % intensity) +
HRrest
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 Borg’s Rating of Perceived Exertion
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 Monitor Vitals
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 6 – 20 a measure of how hard you feel like your body is
working (RPE of 12 – 16 = 60 %– 80% of HRR)
 Heart Rate, o2 Saturation, Respiratory Rate, Blood Pressure
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Chest Pain
Severe Shortness of Breath
BP >200/110 (diastolic up to 100 is “ok”)
BP drops >20 mmHg below baseline
Oxygen Saturation < 90%
Sudden drop in Heart rate > 15 beats per minute
Sudden confusion
Sudden numbness or weakness
Severe headache
Ataxia
Flexibility
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It is recommended for the Geriatric
population to perform a 60second hold
with 2-3 reps for all major muscle groups
5-7days a week in order to maintain
flexibility21
• Is your therapy “skilled”?
• Could “Anyone” do your job?
• Would your patients pay privately for the services
you rendered?
• Monitor Vitals!!!
• Willingness to change is critical
Warm Up and Cool Down
•Geriatric Cardiopulmonary
System needs time to adapt
and prepare for Exercise
•Great Education time for
patient
•Discuss Goals, complaints &
answer questions
•Monitor Vitals during this
time
Geriatric Exercise
Think about it
Is there
appropriate
rationale
behind what
you do bill in
97110
“Therapeutic
Exercise”
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Questions?
References
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10.
11.
12.
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Post-Acute Quality Initiatives: The Continuity Assessment
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Levinson, D. R. (2010, December). Questionable Billing for
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