NWRA is proud to welcome and host the practice of Grant Bortnem, PT, DPT, OCS. Grant graduated with an Exercise Science degree from Oregon State University and his DPT in physical therapy from Pacific University. He obtained his OCS – Orthopedic Clinical Specialist designation in 2007 and has continued to push himself in learning how to provide this expert-level of care ever since.
From a Salem-area endurance athlete, came this:
I am writing to thank you and the staff at NWRA for making such a significant improvement in the quality of my life.
I realize you have your technical ways of assessing my progress. But I want to share with you my assessment and translate to you that progress into the actual changes I have realized in my day to day living.
In August 2015 I lost my hearing and most of my balance. For a month I walked with a cane. That change in my life and shock to my abilities was almost incomprehensible for my endurance athlete spirit.
One day while out on a personal errand, I tripped and fell down a number of concrete steps. After that, I was nauseous every day, the entire day. My balance improved some in autumn 2015 but my balance was still hugely impaired. Walking was unsteady and uncomfortable. I would regularly collide with the walls and doorways in my own home. Sleeping was sporadic – I would wake during the night with vertigo, cold sweats, and even greater nausea. Training to maintain my health and fitness was crushing. My first day back in the weight room, my one hour routine took three hours and at the end I was so physically sick I had to go to bed for 6 hours. I had also lost my balance in the water, so I had lost my swim stroke and one of my special pleasures in life – long distance swimming.
NWRA has changed my life. I walk with much more comfort, confidence and stability. I have zero vertigo – which is a blessing hard to describe or imagine unless you have lived with constant nausea for many months. I can now lay horizontal without vertigo and nausea; so i mostly sleep through the night. My weight room training is near normal. I run 30+ miles a week and my running form and stability continue to improve. I have a swim coach and am relearning to swim. And I can cycle at an acceptable level. In summary, I feel significantly better than I did before I came to NWRA and I’m able to comfortably be more active. NWRA has helped me regain much of my balance; and because of that, I have been able to regain a quality life.
The improvement in my balance and consequently in the quality of my life is major. I am so very grateful for what NWRA has done for me.
Thanks to you and your staff so very much for your skills, your insights, your patience, your kindness, your encouragements, and your help. I particularly value the way you personally can judge my capabilities and set goals that challenge me and stretch my abilities while maintaining my confidence and motivation.
NWRA is thrilled to welcome Scott Newberry, PT, DPT! Scott will be joining our team starting in January! He is moving to Oregon from Texas after graduating from a well-established PT program, generating some of the best PTs in manual therapy, Hardin-Simmons University. In addition to his classroom performance, Scott excelled in the application of manual therapy and was granted one of the most sought-after clinical rotations, at the Steamboat Springs site – a center for the Institute of Physical Art and Functional Mobilization Therapy. Welcome Scott!”
- Billinger S, Boyne P, Coughenour E, Dunning K, Mattlage A. Does aerobic exercise and the FITT principle fit into stroke recovery? Curr Neurol Neurosci Rep. 2015;15(2), 519.
- Yázigi F, Espanha M, Vieira F, Messier S, Monteiro C, Veloso A. The PICO project: aquatic exercise for knee osteoarthritis in overweight and obese individuals. BMC Musculoskelet Disorders. 2013;14: 320.
- Bove A. Pulmonary aspects of exercise and sports. Methodist Debakey Cardiovasc Journal. 2016;12(2), 93-97.
Those with Good Habits Live Long
The science of rehabilitating elderly patients that face weakness, imbalance, or both is improving and must continue to advance in both proficiency and popularity. The cost of functional dependence, due to care giving expenses, or the medical care after a fall – is saddling our economy and Medicare to a greater extent each year.1
Many medical professionals have the opportunity to influence the quality of life in our aging population, whether it be directly in exercise, rehabilitation, pain control or indirectly in the referral to those that can. To this end, this article will review the true science and practical capacities to improve strength, balance and endurance after 65, detail the financial attributes associated with falls, debunk the myths of aging, and suggest avenues for meaningful change.
The Myths of Aging – “Too old to improve?”
Myths of aging are both pervasive and insidious. Many healthcare professionals and more laypersons continue to hold the opinion that, “falling is a part of aging” and that , “an individual over 80 cannot gain strength”. When elderly patients believe these to be true, it can be even more subversive. The facts are, balance rehabilitation in the elderly and strengthening for those that have lost conditioning – are effective.2-5
The financial and societal impact
“Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.”6
The cost of medical care after a fall is over 13,000 on average.7 If a hospitalization is required, over $35,000 per fall. If you were concerned about medical costs expanding in the U.S. – you may consider prioritizing falls screening and prevention, should you consider product of 11 seconds x $13,000? By 2020, the annual cost for healthcare after a fall (including emergency, surgical, hospitalization and rehabilitative) will exceed 43.8 billion dollars. 8 To improve the application of falls prevention, the CDC developed a sophisticated falls screening tool, known as STEADI (Stopping Elderly Accident and Death Injuries).9
A change in the reimbursement landscape…
The financial incentives of preventing a fall, as detailed above, have now expanded into financial DISINCENTIVES (penalties) of readmission due to a fall. Beginning in October 2008 Medicare stopped reimbursing hospitals for certain injuries if they were the result of a fall that occurred during hospitalization. Earlier this year, the test markets for Medicare’s Commission on Joint Rehabilitation (CJR) program started, which essentially places a financial cap for the cost of post-surgical care.10 Clearly, a fall prevented means dollars saved – affecting the entire continuum of care.
Reimbursement changes have not, and will not, stop there. Estimates are that by 2019 the MACRA (Medicare and CHIP Reauthorization Act). APTA Director of Regulatory Affairs Roshunda Drummond–Dye says that members of the profession can be assured that it’s only a matter of time. “It’s clear that CMS hasn’t forgotten physical therapy,” she said. “MACRA is the first tangible step toward mandating a payment system that bases reimbursement on quality of care and outcomes…”11. Therapists should hold themselves accountable and take pride in standardized, objective measures and data collection regarding fall prevention and strengthening in the elderly. If what you are doing is not working – change it! If what you are doing IS working – measure, refine, disseminate, and continue to apply “it”.
Importance of and evidence for intensity in training
People over 65, even over 85 can and should improve – if the science is applied with the appropriate dosage. No matter whether we are speaking of pre-habilitation (before joint replacement) or falls prevention (when STEADI indicates the need); “dosage matters”. Frequency, intensity, time and type (FITT)12 must be considered in regard to strength, endurance and balance training. It takes hard work to improve in any of these capacities, as Bette Davis said, “Old age is no place for sissies.” Many times, therapists’ under-dose or practice without sufficient intensity, allowing their own perceptions to limit the (intensity) of care, before the elderly patient’s body does.
Readers are directed to excellent literature on the science of strength training in the elderly. 2-5 While it is an injustice to attempt to summarize the research here, a few points of application should be highlighted:
- Training should be 3x/week at a resistance that is 80% of a person’s one repetition maximum – for 2 sets of 8-10 repetitions.
- Consider High Intensity Interval Training (HIIT) applications – especially in conditions of lower impact (water, body weight support, etc)
Strengthening does not have to be equipment-based. Consider 10 repetitions of sitting to standing with some intensity, three times per week. This can be adjusted to include upper extremity support, at different heights, with controlled eccentric loading, etc.
With bed rest after medical complications, pneumonia, fall, or surgery – the ill-effects of disuse atrophy are more prevalent in the elderly. However, there appears to be some confusion when it comes to seeing a difference between “getting stronger with aging” and “recovering strength in old age”. There is no disputing that the aging process includes sarcopenia, decreased force production and loss of both type I and type II muscle fibers. So,“Do we lose strength as we age?” Yes, we do. However, “Can seniors regain strength after inactivity or medical complication?” Yes. BOTH are true. Rehabilitation plays a key role after periods of deconditioning, or in response to reversing the effects of disuse. We need to recognize, apply, and educate on these facts.
Endurance training: Muscular and cardiovascular
As with strength training, I will not attempt a meta-analysis on endurance training in the elderly here. Some of these cited articles have defined the science of endurance “dosage”.2 A summary includes:
- Muscular endurance training includes 3-5x/week at a resistance that is 50-60% of one repetition maximum, for 2-3 sets of 15-20 repetitions.
- Cardiovascular and muscular endurance training programs can include High Intensity Interval Training (HIIT) applications – using a preferred modality of exercise: dance, swimming, walking, running, elliptical, cycling, etc.2, 13
- Patients can benefit ideally from 30 minutes of sustained exercise, or an accumulation of 30 minutes, spread throughout the day (ex. 3 sets of 10 minute bouts).
Again, as with the confusion about gaining strength with aging, we debunk the myths and clarify, “Do we lose aerobic capacity as we age?” Yes, we do, as a function of heart rate, cardiac output and VO2 max. However, “Can seniors regain endurance” after periods of deconditioning, or in response to reversing the effects of inactivity – again, yes.
Who is at risk for falls? The science of balance rehabilitation is becoming more sophisticated each month, through research on valid testing/screening, through technology for examination, and technological advances in treatment. As noted above, the Centers for Disease Control (CDC) released a comprehensive approach to falls screening, called STEADI in 2012. Using fall history, performance on a 3-item battery and other risk factor calculations, this is a quick, reliable, and user-friendly tool that should be a staple of fall prevention for all primary care practitioners.
Technological advances in balance testing help therapists to more accurately define the parameters of a balance problem, and more precisely rehabilitate the same. Recent advances include wireless gyroscopes capable of detecting three-dimensional motion for sway, coordination and symmetry; as well as forceplate-enabled treadmills, for motion and ground reaction force analysis. 14
We know that balance activities must be processed regularly to be effective. Some citations report 50 hours of practice15, others report 1-7x/week5. We do have more to learn about the science of dosage both for frequency AND difficulty. A recent study from the 2014 meeting of the Society of General Internal Medicine revealed the effectiveness of four recommendations (and their respective utilization) to prevent falls in the elderly: physical therapy (81%), exercise (71%), Vitamin D (46%), and opthamology (46%). The intervention tracked 32 subjects and found that of the 28/32 patients who fell prior to the FC visit, only 12/28 fell after the FC visit. The average number of falls in the 6 months prior to the appointment was 2.97 versus 0.28 in the 6 months following the appointment.16
What we do know, is that with the aging process, even community-dwelling elderly experience a reduction in sensory and motor conduction velocity. This leads to increased reaction times. When combined with sarcopenia – the result is reduced power (force applied within a constrained time) for a quick and effective balance reaction. Balance, therefore, cannot be trained in isolation from strength and endurance.
Additionally, the battle against the epidemic of falls has led to policy and practice changes, bringing us community-based fall-prevention programs that are both affordable and accessible. The most well-known and widely practiced of these—OTAGO, Tai Chi, Stepping-On, and a Matter of Balance—are endorsed by the NIH and CDC fall-prevention action committee.1, 17, 18 We are coming to believe that many falls can be prevented through increased exercise and regular activity, as the OTAGO exercise program has shown.17
Go forth and prevent!
No matter if you are in a position to directly provide rehabilitative or exercise interventions, or make the necessary referral to those qualified to do so. Know that it is not only possible to improve – it is evidence-based that we can effect a positive change. If we continue to perpetrate the message that failing function is a part of aging that we cannot impact, we create a self-fulfilling prophecy for all of our community-dwelling elderly. We can do better to help those that have lost strength, endurance, or balance. We must commit to them, or they have no reason to commit to the work that it will take to improve. Be ready to effect a change – to your practice and your patients – before National Falls Prevention Awareness Day (the first day of Fall, every year) on September 24th, 2016. Perhaps, it is time to change the phrase and meaning of, “Old habits die hard”, to, “Those with good habits, live long.”.
- Studer MT. Fall Prevention: The science, statistics, and solution. Physcial Therapy Products. 2015 October. 22-25.
- Studer MT. The aging endurance athlete: An analysis of the latest evidence for optimal training schedules, expected gains, and recovery strategies. Topics in geriatric rehabilitation. 2016 January; 32(1):34-38
- Borde R, Hortobágyi T, Granacher U. Dose–Response Relationships of Resistance Training in Healthy Old Adults: A Systematic Review and Meta-Analysis. Sports Medicine (Auckland, N.z). 2015;45(12):1693-1720.
- Aagaard P, Suetta C, Caserotti P, Magnusson SP, Kjaer M. Role of the nervous system in sarcopenia and muscle atrophy with aging: strength training as a countermeasure. Scand J Med Sci Spor. 2010;20:49–64
- American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc :41, 687–708; 2009
- National Council on Aging. Available at: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/ Accessed June 24, 2016
- Centers for Disease Control and Prevention. The Cost of Falls Among Older Adults. 2012. Available at: http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Accessed June 24, 2016.
- Adams PE, Martinez ME, Vickerie JI, Kirzinger WK. Summary health statistics for the US population: National Health Interview Survey, 2010. Vital Health Stat 10. 2011;251:1-117.
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention and Control.STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Tool Kit for Health Care Providers. Available at: http://www.cdc.gov/homeandrecreationalsafety/falls/steadi/index.html. Accessed June 24, 2016.
- American Health Care Association. Comprehensive Care for Joint Replacement (CJR) Final Rule Summary. https://www.ahcancal.org/facility_operations/medicare/Documents/AHCA%20Summary%20of%20CJR%20Final%20Rule.pdf Accessed June 24, 2016.
- American Physical Therapy Association. PT In Motion. New MACRA Systems Could Affect PTs by 2019: Here Are 5 Things You Need to Know Now. http://www.apta.org/PTinMotion/News/2016/5/6/MACRA/
- Brubaker PH. Steps for Improving Physical Activity Orientation Among Health-care Providers of Older Cardiovascular Patients. Current geriatrics reports. 2014;3(4):291-298.
- Effectiveness of High-Intensity Interval Training (HIT) and Continuous Endurance Training for VO2max Improvements: A Systematic Review and Meta-Analysis of Controlled Trials.Milanović Z, Sporiš G, Weston M.Sports Med. 2015 Oct; 45(10):1469-81.
- Studer MT, Horak F. • The Future Of Movement Monitoring: Body-Worn Sensors for Accurate Measures of Function and Progress. Physical Therapy Products. 2014 July;10-12
- Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations.N S W Public Health Bull. 2011;22(3–4):78–83.
- Abstracts from the 37th Annual Meeting of the Society of General Internal Medicine.Journal of General Internal Medicine. 2014;29(Suppl 1):1-545.
- Avin KG, Hanke TA, Kirk-Sanchez N, et al. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Physical Therapy. 2015;95(6):815-834.
- Thomas S. Does the Otago Exercise Programme reduce mortality and falls in older adults? A Systematic review and meta-analysis.Age Ageing. 2010;39:681-687.
Rehabilitation medicine continues to push the envelope – and win! Individuals with sufficient drive to succeed, are doing so in greater numbers – and in later years. Although there are physiologic changes associated with aging, that impact performance: skeletal muscle hypertrophy, conduction velocity of nerves, and maximum heart rate (among others), we do have means to combat the effects and rates of impact on performance.
Five main factors are relevant to the sustained and ever-increasing window of performance for aging athletes:
- The science of human performance, specifically exercise science, has helped us to understand and to maximize both training techniques and schedules. Higher intensity training can now be more safely engaged than previously considered.
- The ubiquitous nature of gyms, programs, and facilities has increased interest and access to equipment, reaching more athletes than ever.
- Social media. Need I say more? One person in their 40’s hearing a story about another aging athlete winning a gold medal, or qualifying for the Boston Marathon, or winning a local race – can be all the motivation needed.
- The prevalence of races. It seems that most every small town, no matter the size, hosts a 5k, a run-walk or triathlon, giving interested athletes a goal-directed focus.
- Nutritional science, the rehabilitation of injuries, as well as both preventative and recovery strategies – are all becoming more sophisticated than in recent years.
Some of the most applicable advancements that aging athletes can utilize include: high intensity interval training (HIIT); the specific dosages for optimal recovery using cold water immersion; the use of strength training in endurance athletics. Another advancement that is less-readily available, yet significant, includes the application of: underwater treadmill training – a favorite of the long distance runners and a mainstay of project Oregon on the Nike campus in Beaverton. http://northwestrehab.com/new/virtual-tour/virtual-tour3220/
There is no fountain of youth that we know of. Limits remain in skeletal muscle development – leaving us with a reduced access to power; in nerve conduction velocity – leaving us with slower reaction times; and in maximal heart rate – leaving us with a reduced workload capacity per minute…it appears as though we are not at the “human limits” in age and performance, just yet.
Our 4th annual “all-day/all-nighter” to raise funds for the Marion Polk Food Share!
Thank you Bill for sending this summer 2015 photo capturing several of the folks who walk together on Friday mornings at Minto Brown Park in Salem. Walking together each week was initiated by a wellness participant last Spring and has quickly become a vital tradition for those who want to walk together! Everyone welcome. Call me (Tricia c: 408.507.7187) if you want to be kept up-to-date with the walking schedule throughout the year!
At about the time Bill sent this photo, a friend shared a poem that she wrote in 2009 while delving more deeply into her own wellness in the midst of non-hodgkins lymphoma. She gave me permission to share it here on our blog in honor of our shared path of vitality and peace.
I walk the path.
I walk the path one foot in front of the other.
I walk the path
birds sing their welcome song.
I walk the path
a daffodil smiles at me.
I walk the path
the breeze kisses my face.
I walk the path
my connection to the earth is strong.
I walk the path
the sun wraps my shoulders in warmth.
I walk the path in peace and serenity.
I’m glad I walk the path.