Exercise with physically restrained nursing home residents: maximizing benefits of restraint reduction.

OBJECTIVE: To evaluate an exercise protocol designed to improve strength and mobility, and to decrease injury risk factors in physically restrained nursing home residents. DESIGN: A randomized controlled trial. PARTICIPANTS: Ninety-seven residents were randomized into either exercise or control groups. Thirty-five exercise and 37 control group residents completed all post-assessments after a 9-week trial. INTERVENTION: Walking or wheelchair movement training was supplemented by rowing exercise three times per week. Practice in behaviors related to safe movement was provided incidental to the exercise. MEASUREMENT: Endurance, speed, and injury risk measures relevant to walking, wheelchair propulsion, and standing were assessed by standardized protocols. Rowing endurance, rowing range of motion, and handgrip strength measures were collected to assess the effect of the rowing component of the exercise protocol. RESULTS: Fifty-four percent of the subjects who provided consent did not complete the protocol because of health status changes, lack of cooperation, or physical limitations that precluded exercise. The subjects who completed the exercise program showed significant improvement on injury risk and measures related to upper body strength (handgrip strength, rowing endurance, wheelchair endurance, and speed). Measures related to lower body strength did not significantly improve. CONCLUSION: Physically restrained residents are very frail, and it is difficult to implement a long-term exercise program with many residents because of the frailty. However, a substantial proportion of residents did cooperate well with the exercise program and showed improvement on measures correlated with decreased injury risk. The exercise program could be easily modified to include more lower body exercise, and the resultant protocol would be an important adjunct to restraint reduction programs.

A walking program for nursing home residents: effects on walk endurance, physical activity, mobility, and quality of life.

OBJECTIVES: To determine the effects of a 12-week walking program on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents who had been identified as having low physical activity levels and low walk endurance capacities. To determine the effects of 12 versus 22 weeks of walk training on walk endurance capacity, physical activity level, mobility, and quality of life in ambulatory nursing home residents. DESIGN: Experiment 1: Residents of one nursing home campus were assigned to the walking program, and residents of a second campus were assigned to the social visit control group. Outcome measures were taken before and after 12 weeks. Experiment 2: Pretest/posttest with outcome measures taken before and, again, after 12 and 22 weeks of walking. SETTING: Two campuses of the Jewish Homes for the Aging in the Los Angeles area. PARTICIPANTS: Experiment 1: Nineteen of 22 residents in the walking group completed the walking program, and 12 of 15 residents in the control group completed the study. Experiment 2: Thirty of 41 residents (from the two nursing homes) completed the 22-week walking program. INTERVENTION: Experiment 1: The walking program involved each resident walking with research staff at his/her self-selected walking pace, 5 days per week for 12 weeks, for a maximum of 30 minutes per day; while the control group had weekly individual social visits, which lasted 30 minutes, from a research assistant. Experiment 2: All residents, those in both the walking and the control group, were offered the opportunity to complete 22 weeks of walking. MAIN OUTCOME MEASURES: Maximal walk endurance capacity, the resident's maximum walk time performed in a single day of walking (distance and speed also were measured); physical activity level based on time-sampled observations and physical activity monitors; mobility as measured with the Timed-Up-and-Go test, left handgrip strength, and Tinetti's Mobility Assessment; and quality of life as assessed with the Geriatric Depression Scale (a bodily pain scale) and the Dartmouth Primary Care Cooperative Information Project (COOP) physical work chart. RESULTS: Experiment 1: The walking group significantly improved their maximal walk endurance time by 77% and distance by 92%, with no significant change in walk speed; however, the control group showed no significant changes in these variables. There were no significant group by time interactions on measures of physical activity, mobility, and quality of life. Experiment 2: No further significant changes were found from 12 to 22 weeks in walk endurance capacity, physical activity, mobility, or quality of life. CONCLUSION: Twelve weeks of daily walking at a self-selected walking pace by ambulatory nursing home residents produced significant improvements in walk endurance capacity. No other significant changes were noted in physical activity level, mobility, or quality of life in either group after the intervention. Also, there were no side effects, such as increases in falls or cardiovascular complications, due to the walking intervention. Lengthening the walking program to 22 weeks produced no further significant changes in any outcome measures.

Functional Incidental Training, mobility performance, and incontinence care with nursing home residents.

OBJECTIVE: To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents. DESIGN: Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols. PARTICIPANTS: Seventy-six incontinent nursing home residents completed all phases of the trial. MEASURES: The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8-week intervention. RESULTS: The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group x time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56, 2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group x time interaction. CONCLUSION: The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES: To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents. DESIGN: Controlled trials of two physical activity programs. SETTING: Seven community nursing homes in the Los Angeles area. PARTICIPANTS: Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1. INTERVENTION: The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks. MEASUREMENTS: The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day. RESULTS: Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline. CONCLUSION: This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.

Wheelchairs as mobility restraints: predictors of wheelchair activity in nonambulatory nursing home residents.

OBJECTIVE: The purpose of this paper is to describe factors affecting wheelchair mobility in nonambulatory nursing home (NH) residents. DESIGN: Prospective descriptive study of a convenience sample of nonambulatory NH residents. SETTING: Seven nursing homes. PARTICIPANTS: Sixty-five nonambulatory residents. MEASUREMENTS: One-minute, time-sampled observations of behavior for each resident were made every 15 minutes for 8 to 11 hours across 2 days, noting wheelchair propulsion activity for the dependent variable; independent variables included measures of wheelchair level of assistance, speed, endurance, handgrip strength, and balance. MAIN RESULTS: A stepwise Multiple Regression analysis found wheelchair speed to be the single best predictor of the percentage of time residents were behaviorally observed wheelchair propelling (Multiple r = .45, P < .02). Handgrip strength and wheelchair endurance measures were highly intercorrelated with wheelchair speed. Wheelchairs that were either dysfunctional or inappropriately fitted to the residents' size were a major barrier to wheelchair use, affecting 46% of residents using wheelchairs. CONCLUSION: Improving wheelchair skills with targeted intervention programs, along with making chairs more "user friendly" (e.g., grip extensions on brakes, foot pedals that one can move without bending over), could result in more wheelchair propulsion with resultant improvements in the NH resident's independence, freedom of movement, and quality of life.

Strength training effects on rearfoot motion in running.

The investigation examined isokinetic (IK) and nonisokinetic (NIK) strength training programs for the inversion (INV) and eversion (EV) muscles on pronation during running. Seventy-seven volunteers were videotaped running on a treadmill at 3.8 m.s-1 and total pronation (delta beta PRO) was computed. Eighteen heel-strike runners with the largest values of delta beta PRO (X = 16.7 degrees) were selected as subjects. During the pre- and posttests, isokinetic muscle strength at 20 and 180 degrees.s-1 was determined for the concentric (CON) and eccentric (ECC) actions of the INV and EV muscle groups. The subjects also were videotaped running on a treadmill (3.8 m.s-1). The IK training group performed three sets of eight CON and ECC repetitions at 20, 90, and 180 degrees.s-1 for both muscle groups; and the NIK subjects did exercises commonly used in ankle rehabilitation. Each group trained three times weekly for 8 wk. The IK group showed significantly (P < or = 0.05) CON and ECC strength increases for all INV test conditions and three of the four EV conditions (20 degrees.s-1 CON and ECC, and 180 degrees.s-1 CON). They also demonstrated significant decreases in the rearfoot (2.2 degrees) and pronation/supination (2.9 degrees) angles at heel strike and in delta beta PRO (-2.2 degrees).l The NIK group exhibited no change in rearfoot motion and only increased INV strength at the 180 degrees.s-1 ECC test condition. The findings suggest that pronation can be decreased by an isokinetic strength training program for the INV and EV muscles.

Quantitative gait assessment as a predictor of prospective and retrospective falls in community-dwelling older women.

The purpose of this investigation was to identify gait-related risk factors associated with both retrospective and prospective falls in 17 community-dwelling older women (mean age 73.4 years). The subjects were videotaped walking at their freely-chosen speed and 21 quantitative kinematic biomechanical variables describing the gait of each individual were computed. Faller status in the preceding year was determined by retrospective self reports and was monitored by an investigator for 10 months after the subjects were videotaped. None of the variables distinguished the retrospective fallers from nonfallers or were a significant predictor of prospective falls. The findings suggest that quantitative kinematic gait variables alone may not identify risk factors associated with falling in community-dwelling older women.

Effects of exercise on hip range of motion, trunk muscle performance, and gait economy.

BACKGROUND AND PURPOSE: The purposes of this study were (1) to examine the effects of a passive hip extension stretching exercise program on hip extension range of motion (ROM), (2) to examine the effects of a trunk flexor exercise program on trunk flexor muscle performance, and (3) to examine the effects of passive hip extension stretching or trunk flexor exercises on walking and running economy. ("Gait economy" is defined as the steady-state oxygen consumption per unit of body weight required to walk or run at a specified velocity.) SUBJECTS: Twenty-five healthy, athletic, male college students (mean age = 21 years, mean weight = 75 kg, mean height = 172 cm) were randomly assigned to one of three groups: a control group (n = 7), a hip extension stretching group (n = 9), or a trunk flexor exercise group (n = 9). METHODS: Before and after 3 weeks of intervention, the following measurements were obtained: right and left hip extension ROM, trunk flexor muscle performance, and walking and running economy. A three x two-way (groups x test sessions) analysis of variance (ANOVA) for repeated measures for unequal subject numbers was performed on each of the five dependent measures, with analysis of simple main effects applied when significant interactions were found. RESULTS: The ANOVA on right and left hip extension ROM revealed a significant interaction. Analyses of simple main effects showed that 3 weeks (six sessions) of passive hip extension stretching significantly improved right hip extension ROM (pretest = -20.4 degrees, posttest = -8.3 degrees) and left hip extension ROM (pretest = -16.8 degrees, posttest = -7.0 degrees). There also was a significant interaction for trunk flexor muscle performance. The analysis of simple main effects revealed that 3 weeks of daily trunk flexor exercises significantly improved trunk flexor muscle performance (pretest = 41.5 degrees, posttest = 60.4 degrees). The 3-week intervention program of hip extension stretching or trunk flexion exercises, however, did not produce significant changes in walking or running economy. CONCLUSION AND DISCUSSION: The results suggest that (1) six treatment sessions of passive stretching were sufficient to improve hip extension ROM; (2) 3 weeks of exercises performed daily improved trunk flexor muscle performance; and (3) training of isolated tasks, such as hip flexibility or trunk strengthening activities, did not produce the desired outcome in the economy of walking or running. Possible reasons for the results are discussed.

Physical performance measures that predict faller status in community-dwelling older adults.

Falls are a leading cause of fatal and nonfatal injuries among the elderly. Accurate determination of risk factors associated with falls in older adults is necessary, not only for individual patient management, but also for the development of fall prevention programs. The purpose of this study was to evaluate the effectiveness of clinical measures, such as the one-legged stance test (OLST), sit-to-stand test (STST), manual muscle tests (MMT), and response speed in predicting faller status in community-dwelling older adults (N = 94, age 60-89 years). The variables assessed were single-leg standing (as measured by OLST), STST, and MMT of 12 different muscle groups (hip flexors, hip abductors, hip adductors, knee flexors, knee extensors, ankle dorsiflexors, ankle plantarflexors, shoulder flexors, shoulder abductors, elbow flexors, elbow extensors, and finger flexors), and speed of response (as measured by a visual hand reaction and movement time task). Of the 94 older adults assessed, 28 (29.7%) reported at least one fall within the previous year. The discriminant analysis revealed that there were six variables that significantly discriminated between fallers and nonfallers. These variables included MMT of the ankle dorsiflexors, knee flexors, hip abductors, and knee extensors, as well as time on the OLST and the STST. The results indicate that simple clinical measures of musculoskeletal function can discriminate fallers from nonfallers in community-dwelling older adults. J Orthop Sports Phys Ther 1992;16(3):123-128.

Adjusting for recall bias with the proportional hazards model.

In studying falling frequency in the elderly, we observed that having subjects keep a diary led to a larger number of falls reported than had been noted in a previous study in the same population. The previous study asked subjects to report any falls in the previous three months. We considered two related explanations for the observation of lower incidence reports with a 3-month recall survey. First, there may have been under-reporting of falls due to recall bias. Second, the less severe falls (which did not result in injuries) may not be reported. We suggest that the proportional hazards model may be used to adjust studies in which recall is used to determine incidence and time to falls.

The effects of two stretching procedures on hip range of motion and gait economy.

The purpose of this study was to 1) compare two commonly practiced stretching techniques to determine which is most effective for improving hip range of motion, and 2) evaluate the effect of these techniques on gait economy. Seven asymptomatic males, 18-22 years of age, served as subjects. Goniometric measurements of hip range of motion (ROM) and gait economy, as measured by submaximal oxygen consumption of walking and running on a treadmill, were taken before and after each of the two stretching procedures, (a) static stretching, and (b) soft tissue mobilization with proprioceptive neuromuscular facilitation (STM/PNF). Static stretching procedures resulted in significant improvements in ROM for hip extension (p < 0.01) and hip flexion (p < 0.01). The STM/PNF also resulted in significant improvements in hip extension ROM (p < 0.01) and hip flexion ROM (p < 0.05). There was a significant improvement in gait economy at 40% VO2max (p < 0.05), at 60% VO2max (p < 0.05), and at 80% VO2max (p < 0.01) following the static stretching procedure. The STM/PNF procedure improved gait economy only at one workload, 60% of VO2max (p < 0.05). These results suggest that a single bout of static stretching or STM/PNF was effective for improving hip ROM but static stretching was more effective for improving gait economy in young, asymptomatic males. J Orthop Sports Phys Ther 1989;10(9):350-357.

Reaction time and nigrostriatal dopamine function: the effects of age and practice.

Normal aged and Parkinsonian individuals lose the ability to initiate movements rapidly (increased reaction time) in parallel with changes in the nigrostriatal dopamine (DA) system. However, the ability of these individuals to improve their reaction time with practice has not been adequately assessed. We have developed a rodent model of human reaction time in which reaction time performance correlates highly with neurochemical measures of nigrostriatal DA integrity. In the present report, 15 young and 10 old male Sprague-Dawley rats were conditioned in a reaction time task to release a lever quickly in response to external stimuli in order to avoid a mild footshock. In order to examine the effects of practice on this reaction time task, the young animals were tested for 5 days at 3, 6 and 9 months of age and the old animals were tested for 5 days at 18, 21, and 24 months of age. From this well-practiced task, reaction time response latencies were measured and compared to measures of nigrostriatal DA function (steady-state levels of DA and its metabolites, D2DA receptor affinity and density). The old animals were slower in response latencies than the young animals. These age differences in response latencies, however, disappeared after several days of testing at each of the 3 test sessions, so that the old animals were not significantly slower than the young animals on days 4 and 5 of each session. As expected, the old animals showed reduced striatal D2DA receptor density with no age differences in DA receptor affinity.(ABSTRACT TRUNCATED AT 250 WORDS)

Endurance training effects on striatal D2 dopamine receptor binding and striatal dopamine metabolite levels.

We have previously shown that endurance training is associated with higher binding of [3H]spiperone to striatal D2 dopamine (DA) receptors of presenescent (21 months old) rats. In the present study we investigated the effects of 6 months of endurance training of young adults on the relationship between steady-state levels of DA and its metabolites in striatum and the affinity and density of striatal D2 DA receptors. The extent of training was confirmed by evaluating the maximal oxygen consumption (VO2 max) in the subjects. D2 DA binding was significantly increased at each of 3 [3H]spiperone concentrations in the young runners. A 'synaptic coupling ratio' calculated as the specific DA binding/DOPAC concentration was significantly increased in runners for the 0.1 and 0.4 nM radioligand concentrations. Across experimental groups levels of DA were highly and positively correlated with specific DA binding at the 0.1, 0.2 and 0.4 nM [3H]spiperone concentrations. Together, these results suggest that exercise can alter the number of DA binding sites and the metabolism of DA in young adult animals.

Endurance training effects on striatal D2 dopamine receptor binding and striatal dopamine metabolites in presenescent older rats.

Endurance training is associated with higher binding of 3H-spiperone to striatal D2 dopamine receptors of rats sacrificed 48 h following the last exercise bout (Gilliam et al. 1984). In the present study we investigated the effects of endurance training in presenescent older rats on the relationship between steady-state levels of DA and its metabolites in striatum versus the affinity and density of striatal D2 DA receptors. Citrate synthase activity of the gastrocnemius-plantaris muscle was 29.06 +/- 2.27 mumole/g wet wt in 21-month-old trained rats versus 22.88 +/- 1.13 mumole/g wet wt in 21-month-old untrained animals. DOPAC levels and DOPAC/DA ratios were greater in the old controls. Endurance training was associated with lower DOPAC levels in the 21-month-old animals. Thus, endurance training may postpone selectively changes in DA metabolism over a portion of the lifespan. As expected, the number of D2 DA binding sites was reduced with age (6 months Bmax:429 +/- 21 fmoles/mg protein; 21 months:355 +/- 20) with no change in affinity. The Bmax of old runners was significantly higher (457 +/- 38 fmoles/mg protein) than that of old controls. Thus, endurance training appears to exert a protective effect on D2 dopamine receptors during the lifespan. Taken together, the present results suggest that there may be a possible reciprocal relationship between changes in DA metabolites and DA binding as a function of exercise in presenescent older rats, and that endurance training may decelerate the effects of age both on nigrostriatal dopamine neurons and on striatal D2 dopamine receptors during a portion of the lifespan.