No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections. 03/2015 1 Geriatric Rehab: A Functional Testing Approach Geriatric Rehab: A Functional Testing Approach Michael Kett, PT, MS, CEEAA People do not quit playing because they grow old; they grow old because they quit playing. - Oliver Wendell Holmes 1. Discuss the key clinically significant anatomical and physiological changes in the aging adult that can impact exercise. 2. Understand and be able to select and perform the best research-based functional tests for assessing aging adults 3. Understand the key assessment tools and treatment concepts involved in fall prevention 4. Understand the role and application of functional exercise in a rehab program 5. Prescribe evidence-based exercises for strength, flexibility, and balance 3 Key Take-Aways for Today • Importance of gait speed • Role of the ankle in functional activities • Stressing the system (tissue adaptation) Who is this guy? • PT • Exercise enthusiast • Magician • Author • Circus ringmaster • Thought reader • Lipsologist The Aging Population •70% of aging adults function independently • 25% of aging adults are dependent • 5% fit/elite – highly active (Rikli, Jones, 2001)
Transcript
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Geriatric Rehab: A Functional Testing Approach
Geriatric Rehab: A Functional Testing
Approach
Michael Kett, PT, MS, CEEAA
People do not quit playing because they grow old;
they grow old because they quit playing.
- Oliver Wendell Holmes
1. Discuss the key clinically significant anatomical and physiological changes in the aging adult that can impact exercise.
2. Understand and be able to select and perform the best research-based functional tests for assessing aging adults
3. Understand the key assessment tools and treatment concepts involved in fall prevention
4. Understand the role and application of functional exercise in a rehab program
5. Prescribe evidence-based exercises for strength, flexibility, and balance
3 Key Take-Aways for Today
• Importance of gait speed
• Role of the ankle in functional activities
• Stressing the system (tissue adaptation)
Who is this guy?
• PT
• Exercise enthusiast
• Magician
• Author
• Circus ringmaster
• Thought reader
• Lipsologist
The Aging Population
•70% of aging adults function independently
• 25% of aging adults are dependent
• 5% fit/elite – highly active
(Rikli, Jones, 2001)
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Geriatric Rehab: A Functional Testing Approach
Almost 75% of aging adults are sedentary.
Amount of time spent in sedentary behaviors 2003-2004
American Journal of Epidemiology 2007
650,000 people from 6 studies Brigham Young University
• Ages 21 – 90 years
• Followed them for 10 years
• Low amount of activity – walking 75 minutes/week: gain of 1.8 years of life
• At least 150 minutes of exercise/week: 3.4 - 4.5 extra years of life
• Inactive with normal weight: 3.1 fewer years of life compared to active and obese
The Hazards of Sitting
• Americans sit more than they sleep (an average of 10 hours/day)
• Sitting for long periods of time increase the risk for obesity, diabetes, cancer, and early death…………….even for people who exercise daily
• Put your computer on a higher table and stand, put the waste basket on the other side of the office, set your computer to remind you to stand up every 30’, deliver messages to colleagues in person rather than email, etc
The Easiest Exercise
• Walking 5,000 steps or less a day is considered sedentary
• Work up to 10,000 steps/day which is considered active
• To estimate walking speed in mph – count the number of steps you walk (at your exercise walking pace) in 1 minute and divide by 30
• Best way to prevent Alzheimer’s?
• Leisure time vs. life style exercise
The Good News!
Smith & Serfass 1981
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Geriatric Rehab: A Functional Testing Approach
Community Living: Functional Requirements
• Walk about a quarter of a mile
• Gait speed of 1.2 m/sec
• Carry a package of about 7 lb.
• Need to be able to climb stairs, curbs, inclines/declines, walk on grass, gravel, etc
• Errands in the community
(Shumway-Cook, 2002)
Assessment
WNL?
WFL?
Does the standard PT evaluation really address function?
“Evaluation based on objective measurements…of patient performance and functional abilities.”
- Medicare Benefit Manual
Start with functional researched based tests and then narrow the focus with standard OT/PT assessment techniques
Standard PT/OT Assessment
• Medical history: surgeries, recent hospitalizations, vision history, LE sensory changes, etc.
• ADL’s: recent falls, need assistance to leave house, assistive devices, etc
• Reported pain
• Patient centered goals
• ROM – especially cervical AROM
• Specific muscle strength/flexibility
• Dexterity – 9 hole peg test, box & block test
• Joint integrity
• Balance (subjective: unsteady vs. dizzy)
• Palpation
• Sensation
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Geriatric Rehab: A Functional Testing Approach
Balance Aging Related Balance Changes
• Impacts sense of balance
Decreased number of Pacinian corpuscles resulting in decreased joint position awareness
Decreased function of golgi tendon organs and muscle spindles which also effects joint position sense and muscle awareness
Decreased reflex speed
(VanPutte, 2011)
Romberg
• Assesses equilibrium
• Progression
Feet together
Semi tandem
Tandem - < 10 sec is fall risk (Guralnik, 2000)
Sharpened Romberg
• No equipment needed. Stand with feet together and arms crossed or at side. 30 seconds. Eyes closed.
• Note sway. Positive test = ?
Single Leg Stance Test
• Difficult for many older individuals
• Really measures fall risk?
• Use of cane or walker as test component
• Exercise progression
One Leg Stance Test Norms
Age (yrs) Eyes Open (sec) Eyes Closed (sec)
20-29 30.0 28.8
30-39 30.0 27.8
40-49 29.7 24.2
50-59 29.4 21.0
60-69 22.5 10.2
70-79 14.2 4.3
(Bohannon, 2006)
Alternate Step Test Tiedmann et al, 2008
– Compared 8 functional tests
– 3 “best”
Chair rise
Gait speed
Alternate step test – best single predictor- 130% increased fall risk if 8 steps > 10 sec
– Increased risk of multiple falls with poor performance on 2 of these 3 tests
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Geriatric Rehab: A Functional Testing Approach
Berg Alternate Foot on Step
360 Degree Turn Shubert et al, 2006
• Patient turns in complete circle – 1 complete turn in either direction
• Highly correlated with walking speed
• Start on “go” and stop timing when patient’s shoulders are squarely facing you
• “Turn around as quickly as possible”
• > than 3.8 sec is fall risk
Functional Reach
• Assesses anterior/posterior movement of center of gravity over static base of support.
• Yardstick/ruler
• Greater than 10” is a negative test
• 6-10” - 2x more likely to fall
• Less than 6” – 4x more likely to fall
• Ankle plantar flexion strength is important component
(Duncan et al 1990, 1992)
Lateral Functional Reach Norms Isles et al, 2004
AGE DISTANCE (inches)
20-29 9.04
30-39 9.1
40-49 7.47
50-59 7.2
60-69 6.7
70-79 6.18
Modified Functional Reach Thompson, 2007
• Leveled yardstick attached to wall at height of patient’s acromion on non-affected arm while sitting in a chair
• Hips, knees and ankles positioned are at 90 degree of flexion
• Forward reach – patient sits at the back of the chair with the upper-extremity flexed to 90 degrees. Measure taken from third metacarpal with closed fist.
• Lateral reach - Sitting with the back to the wall and leaning right and left
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Modified Clinical Test for Sensory Interaction of Balance
• Original version tested 6 conditions
• Assesses interaction of vision, somato-sensory, and vestibular systems
• 30 seconds each condition
• Timing is stopped if patient deviates from crossed arm position, opens eyes, or moves feet/requires manual assistance
• Not a definitive test – many other conditions can influence results
Shumway-Cook, A, Horak, F, 1986
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Geriatric Rehab: A Functional Testing Approach
Modified Clinical Test for Sensory Interaction of Balance (CTSIB)
• Conditions
Arms crossed against chest/feet shoulder width
Firm surface – eyes open
Firm surface – eyes closed
Foam surface – eyes open
Foam surface eyes closed
30 second trials
• Sway is assessed for each condition
1= minimal sway
2= mild sway
3= moderate sway
4= fall
Berg Balance Test Berg, 1992
• Static and dynamic balance
• Ceiling effect with community dwellers
• No assistive device
• Utilized with many diagnoses
• SLS, picking object from floor, placing alternate feet on stool best fall predictors
• Time factor
• Verbal instructions/demonstration important
Berg Balance Components
• Sit to stand
• Standing unsupported
• Stand to sit
• Sitting – back unsupported
• Pivot transfer
• Standing unsupported – eyes closed
• Standing unsupported
• Forward reach
• Picking up object from floor
• Turning to look behind over shoulder
• Turning 360 degrees
• Alternate foot on stair
• Standing – one foot in front of other
• SLS
Berg Balance Test
• 56 total points – 4 points max/item Norms
48-56; low risk for falls
40-47; medium risk for falls
<40; high risk for falls
• Clinically significant change (Donoghue, 2009)
4 points if scored initially 45-56
5 points if scored initially 35-44
7 points if scored initially 25-34
5 points if scored initially 0-24
Four Square Step Test Dite, 2002
• A timed test assessing multi-direction stepping combined with obstacle avoidance
• Patient selection is important
• Assistive device permitted
• “Move as quickly and as safely as possible”
• > 15 seconds – identifies multiple fallers
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Geriatric Rehab: A Functional Testing Approach
Four Square Step Test
2 3
1 4
Fullerton Advanced Balance (FAB) Scale
Hernandez, 2008
• Assesses static and dynamic balance in independent aging adults
• Examines somatosenory, visual, and vestibular systems
• Scoring
10 items – maximum of 4 points/item
Scores of 25 and lower are at high risk for falls
Tell me and I forget, Show me and I remember, Involve me and I learn. Benjamin Franklin
Lab
• Comparison of Romberg, Semi-tandem, & Sharpened Romberg
• Single leg stance with 1 finger support/sliding
• Four Square Step Test
Balance is controlling your center of gravity in relation to
the base of support, whether it is stationary or moving.
What is good, fair+, or poor balance?
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Geriatric Rehab: A Functional Testing Approach
Fall Statistics
• Many falls go unreported due to no injury
• CDC statistics
1 out of 3 adults 65 and older fall each year
20-30% of falls result in moderate/severe injuries
#1 injury- fractures: 25% die within first year
Most common cause of traumatic brain injury. TBI accounts for 46% of fatal falls in older adults.
• People who fall even if they are not injured develop a fear of falling resulting in limiting their activities leading to reduced mobility and loss of physical fitness
Fall Risk
• Taking more than 4 medications: higher risk for falls
• Use of assistive device: 2.5 x’s more likely to fall
• If person has a history of falls: 3x’s more likely to fall again
• Gait and balance disorders: 3x’s more likely to fall
• 80% of falls on stairs occur when descending stairs
• The #1 reason for falls (4x’s more likely to fall) is……
…Lower Extremity Weakness
• Recurrent fallers have decreased quad strength - associated with decreased gait speed (Lord et al, 1991)
• 19% of dynamic balance attributable to knee strength
• Ankle dorsiflexion accounts for 58% of BBS, plantarflexion strength accounts for 48% of TUG/13% of FR (Daubney 1999)
• “Rehabilitation programs aimed at addressing deficits in SCK performance should focus on improving distal strength.” (Hernandez, et al 2010)
Lower Extremity Function
“Measures of lower extremity function in a nondisabled population predict the subsequent
onset of disability.” Guralnik et al, 1995
• 1122 community dwelling subjects > 71 years old
• 4 year follow up
• Tested gait speed, 5 rep chair rise, and balance (semi-tandem and tandem stance)
• Those with the poorest baseline functional test scores had a 4-5x increased likelihood of disability 4 years later
Fall Prevention
• Difficult to distinguish between intrinsic and extrinsic factors
• Four areas to assess
Ecologic – extrinsic factors
Biomedical – medical issues that can contribute to falls
Physiologic – deficits in postural control
Functional – routine movements that is difficult for the individual
(Studenski et al, 1991)
Seated Balance Progression
• Supported
• Double to single UE support
• Unsupported – feet on floor
• Weight shifting/UE reaching/LE movements
• Head movements
• Perturbations
• Resisted UE/LE/trunk movements
• Compliant surface (dyna disc, airex pad)
• Feet: supported to partial support to unsupported
• Continue with developmental sequence progression
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Geriatric Rehab: A Functional Testing Approach
Standing Balance Training Components
• Ankle ROM
• Fixed support activities
• Change in support activities
• Multi-task training
• Perturbation
• Obstacle course – fear of falling
• LE and trunk strengthening
Strength and flexibility should be performed after balance activities (Behm, 2004)
Staggering- sudden/unexpected lateral loss of balance
Foot contact- degree which heel strikes ground
Hip ROM- degree of loss of hip AROM during gait
Shoulder extension- decreased shoulder AROM
Arm-heel strike synchrony- contralateral movements of UE/LE
• 0-3 points/item
• Best score is 0/worst score is 21
AMA Walking Test to Identify At-Risk Elderly Drivers
• Walk a measured 10’ distance down and back as quickly and safely as possible.
• Longer than 9 seconds is associated with an increased risk of an at-fault motor accident.
• Assessment of vision, cognition, strength, and ROM are also a part of the assessment.
Timed Up and Go Test (TUG) Podsiadlo, 1991
• Assesses basic ADL skills of sit to stand, gait speed, turning, stand to sit
• Good initial screening tool for appropriate population
• Assistive device permitted
• Identifies fall risk
• Use standard chair and measure 3 m distance from chair
• Good correlation to gait speed testing
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Geriatric Rehab: A Functional Testing Approach
Community Dweller TUG Norms
Age (years) Time ( average -seconds)
60-69 8.1
70-79 9.2
80-89 11.3
(Bohanon 2006)
TUG Norms
• < 20 seconds – independent transfers/gait
• 20 – 30 seconds – “grey zone”
• > 30 seconds – dependent
(Podsiadlo & Richardson 1991)
Dynamic Gait Index Marchetti, 2006
• Assesses gait, balance and fall risk. Includes a vestibular component.
• 8 and 4 item versions
• Good correlation with Activities Balance Confidence Scale (Legters, Whitney, 2005)
Dynamic Gait Index
• Gait on level surface*
• Gait with speed changes*
• Horizontal head turns*
• Vertical head turns*
• Gait with pivot and stop
• Stepping over obstacle
• Stepping around obstacle
• Stairs
* 4 item test
Dynamic Gait Index
• Rating scale of 0-3. Maximum of 24 points.
• < 20 - fall risk
• 22-24 - safe
• 4 item test: scores < 10 out of 12 - fall risk
(Marchetti & Whitney, 2006)
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Geriatric Rehab: A Functional Testing Approach
Gait Challenges (aka Silly Walks)
• Increase/decrease speed of forward walking on command
• Abrupt stops and turns on command
• Large steps/small steps/marching/lateral stepping/skipping
• Forward/backward walking with different speeds on command
• Stepping over objects
• Mental challenges
• Heel/toe walking
• Head turns
• Braiding
• Resisted walking – manually, theraband
• 360 degree turns
Elderly Mobility Scale Smith 1994
• Assesses mobility in frail elderly adults /acute hospital setting
• Components
Lying to sitting
2 – independent
1 – requires assist of 1 person
0 – requires assist of 2+ people
Sitting to Lying
2 – independent
1 – requires assist of 1 person
0 – requires assist of 2+ people
Sit to stand
3 – independent in 3 seconds
2 – independent in over 3 seconds
1 – requires assist of 1 person (verbal or physical)
0 – requires assist of 2+ people
Elderly Mobility Scale
Standing
3 – 10 sec (timed unsupported static stand)
2– stands without support but needs to reach
1 – stands but requires support
0 – stands only with physical support of 1 person
Gait
3 – independent with/without cane
2 – independent with walker
1 – mobile with AD but erratic or unsafe turning
0 – requires physical assistance or constant supervision
Timed walk (6 meters with 180 degree turn)
3 – < 15 seconds
2 – 16-30 seconds
1 – > 30 seconds
Elderly Mobility Scale
Functional reach
4 – over 8”
2 – 4-8”
0 – under 4” or unable
Norms
Score of 14-20; independent in basic ADL, safe to go home
Score of 10-13; borderline with mobility safety and ADL independence. Will require some assistance with mobility.
Score of < 10; dependent in mobility and requires help with basic ADL’s (home care or long term care)
Lab
• Gait speed
– Normal pace
– Normal pace with cognitive component
– Fast pace
– Patient pace
Flexibility
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Geriatric Rehab: A Functional Testing Approach
Aging Related Connective Tissue Changes
• Decreased flexibility due to increased number of cross-links between collagen molecules
• Articular cartilage – no change in density of chondrocytes or the amount of collagen. Reduced water content which may reduce ability to dissipate forces across a joint
OA is not always a result of the natural fragmentation of collagen
(Guccione, 1993)
Flexibility
• Considerations to “stress the system”
Warm tissue = better stretching result
60 seconds most effective for increasing hamstring length in 65-97 year olds (Feland, Myrer et al, 2001)
Low load/long duration for more permanent tissue length changes (PEC) (Warren et al, 1971)
• Assess ROM during functional activities
• Yoga/Tai Chi
• Kendall/Sahrmann/Janda’s Cross Syndrome
Janda’s Cross Syndrome
Janda Musculoskeletal Pain Syndrome Seminar, 1993
Back Scratch Test Jones, Rikli, 2002
• Assesses shoulder flexibility
• Detects expected declines in shoulder flexibility from 60 – 80+ years
• No equipment except ruler/tape measure
• Use of preferred position (used to develop norms)
• What is the source of the deficit?
Back Scratch Test Norms
50th Percentile
• 60- 64 yrs: women -.7”/men -3.4”
• 65- 69 yrs: women -1.2”/men -4.1”
• 70-74 yrs: women 1.7”/men -4.5”
• 75-79 yrs: women -2.1”/men -5.6”
• 80- 84 yrs: women -2.6”/men -5.7”
• 85- 89 yrs: women -3.9”/men -6.2”
• 90- 94 yrs: women -4.5”/men -7.2”
Closed Chain Dorsiflexion
• Standing squat with emphasis on ankle dorsiflexion
At least 5 degrees?
• Compare left to right
• Limitation due to muscle or joint capsule?
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Geriatric Rehab: A Functional Testing Approach
Cardiovascular Aging & the Cardiovascular
System
• Changes are relatively minor at rest but becomes more significant with exercise
• Decreased max VO2 and max HR
• Decreased stroke volume (CO = HR x SV)
• Increased TPR – can contribute to HTN
• Decreased flexibility of heart valve connective tissue can effect valve function
Standing Lean Back Abdominal Progression 3 Seated Lean Back Variation
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Geriatric Rehab: A Functional Testing Approach
Abdominal Progression 4 Lab
• Step excursion test
Multiple planes
Stepping and toe taps
• Supine hip extensor strength
• Push up progression for abdominals
Wall, table, chair, floor
• Wall lean progression for abdominals/LE
• Posterior lean sitting and standing
Functional Testing Continuum
Gait Speed
FSST
Berg
Chair Rise
Drives Treatment Plan
The Next Step: Using Functional Test Results to Direct Further
Assessment
• Berg: difficulty turning to look over shoulder
• Functional Reach: 7”
• Forward step excursion R LE 14” and L 5”
• FSST: 16 seconds
• Gait Speed: .6m/sec
• CTSIB – 10 seconds with eyes closed on foam
• Chair Rise Test: inability to stand without UE assist
• DGI: difficulty stepping over obstacle
7 Reasons Why Everyone Should Strength Train…
• Minimize muscle loss – increase muscle mass
• Increase metabolic rate
• Reduce body fat
• Increase bone mineral density
• Improve glucose metabolism
• Reduce resting blood pressure
• Reduce arthritic pain
Recruitment Order
Type I fibers
Type IIa fibers (FOG)
Type IIb fibers (FG)
Exercise intensity rather than duration is
the key!
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Geriatric Rehab: A Functional Testing Approach
Force Development
Curwin, C, Stanish, W., 1984
Concentric vs. Eccentric
Curwin, S, Stanish, W, 1984
Holten Curve Open vs. Closed Chain
• Muscle function
• Joint ROM
• 3 plane stabilization/movement
• Mechanoreceptors
Golgi-mazzoni corpuscles
Hip proprioceptors are more active in frontal and transverse planes compared to sagittal plane
The “Magical 3 Sets of 10”
• DeLorme (DeLorme, 1948) – 3 sets of 10 with increasing load based on 10 RM
• DAPRE (Cordova , 1995)
First set at 50% working weight x 10 reps
Second set 75% of working weight x 6 reps
Third set of 100% of working weight to fatigue
Fourth set weight based on number of 3rd set reps
• 1990 ACSM recommended at least one set of 8-12 reps for strength training
Are You Kidding Me?
• Study by Frontera (1988)
80% of 1RM (tested 1RM)
Twelve independent males: 60-72 years
Exercised quads/hamstrings 3x/wk for 12 weeks
3 sets of 8 reps
Demonstrated 117% increase in 1RM quads and 227% for hamstrings
No injuries
Type I and II hypertrophy. (Average of 5% improvement per training day)
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Geriatric Rehab: A Functional Testing Approach
Are You Kidding Me?…Part 2
• Study by Fiatarone (1990)
80% of 1RM (tested 1 RM)
10 skilled nursing residents – average age 90 yrs
Exercised 3x/week for 8 weeks
3 sets of 8 reps
Average strength gain – 174% increase in 1RM leg strength
No injuries
97% attendance
2 residents no longer needed a cane to walk
One resident gained ability to rise from chair without UE assist
Functional improvements in gait speed and stair climbing
32% loss of max. strength after 4 wks of detraining
Strength Training Research
• Seynnes et al, 2004
Participants > 70 years old
Tested sit to stand, stairs, 6’ walk
3 sets of 8 reps (80% and 40% of 1 RM using ankle wts)
Only 80% 1RM group improved functional performance
Strength Training Research
• Once weekly resistance training and once week functional training have similar benefits to resistance training twice/week (Henwood, T, Taaffee, D, 2006)
Strengthening Time Frame
• First 8 weeks of strength training: 10 -15% increase per week (Evans, 1999)
• Early changes in strength are due to neural factors Increased neural drive to muscles
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Geriatric Rehab: A Functional Testing Approach
Strength Training Intensity
• Training intensity is the key factor in the degree of improvement (Fleck S, Kraemer, W, 1987)
• Muscle strength increases with 60-100% 1RM training stimulus (Fleck S, Kraemer, W, 1987)
• Older adults show strength gains of 2-3x’s in the first few months similarly to younger adults
Determining Strength Training Intensity
(With permission of CEEAA and SOG)
• 1 RM determination is NOT recommended
• Most aging adults can safely exercise at 70 - 80% of 1 RM
• Determining intensity regardless of equipment (weights, tubing, pulleys, etc)
First select a resistance/weight that you think the individual will experience momentary muscle fatigue at about 10 reps
After they perform 1-2 reps ask them to stop and tell you if that specific resistance was “fairly light”, “somewhat hard”, or “hard” (12-14 on the Borg Scale) (Day, 2004)
If they report it as “fairly light” increase the weight and test again. If they report as “hard” decrease the weight and test again
Momentary muscular fatigue should occur between 8-12 reps
Training Intensity
(With permission of CEEAA and SOG)
• Intensity of 30-60% of 1 RM – generally 12-25 reps before muscular fatigue. Initially choose a resistance that you feel would result in muscular fatigue around 15 reps then ask perceived exertion question.
Appropriate for frail, deconditioned individuals
• AROM against gravity, gravity eliminated postures with/without resistance can also meet intensity guidelines
Strength Training Guidelines (With permission of CEEAA and SOG)
• Strength movement should be slow – “able to stop on a dime” without any overflow movement
• Use full pain-free ROM
• 2-3 second concentric/4-6 second eccentric contractions
• Good form/technique – avoid substitution (ie skilled care)
• Work to muscular fatigue NOT to a specific number of reps
If speed of movement increases
If form deteriorates
Unable to complete full ROM
Strength Training Guidelines (With permission of CEEAA and SOG)
• Progression
If able to perform 12 or more reps (70-80% 1 RM) or more than 25 reps (30-60% 1RM) increase the resistance by about 5%
If able to perform within specific guidelines based on % of 1RM, use the same amount of resistance
• Frequency
Initially: 3 times/week for first 6-8 wks… neurological adaptation
After 2 months – 2-3 x/week
After several months: 1-2 times/week (combine one day of strength training and one day of functional training?)
Strength Training Guidelines
• Number of sets
Research shows that a single set of exercise provides similar but slightly less strength gains than 2 or 3 sets (Westcott 1996, Carpinelli 1999)
• Power improves with strength training due to increased force capacity
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Geriatric Rehab: A Functional Testing Approach
Power = Force X Velocity
Muscle power is a better predictor of
function than muscle strength (Sayers, 2005)
Strength x Speed
“Power training improves balance in healthy older adults”
Orr, 2006
• Dynamic balance system test and strength baseline
• 3 training groups (20%, 50%, 80% of 1 RM)
• Trained 2x/wk for 10 weeks – 3 sets of 8 reps
• Concentric as fast as possible/eccentric 3 seconds
• Significant improvement in balance in 20% 1RM group
(high velocity/low load)
• Improved balance due to increased contraction velocity and neural function
Speed of Contraction
Strength Power & Stretch-Shortening Cycle
Slow Fast
Additional Strength Considerations
• Delayed Onset Muscle Soreness
Symptoms peak at about 48 hours post exercise (Type II fibers)
Due to eccentric contractions (SEC)
Warn patient about muscle soreness
• Proximal LE muscles particularly effected by decreased muscle mass with aging (fiber size, number)
• Hip abductor strength and medial knee
• TKA sit to stand technique
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Geriatric Rehab: A Functional Testing Approach
Lab
• Determine the strength training intensity based on the Borg Scale using thera-band/manual resistance and then perform the appropriate number of repetitions at the appropriate speed for:
– Seated rowing (70-80% 1RM with t-band)
– Standing hip abduction (30-60% 1RM with t-band)
– Shoulder flexion (70-80% 1RM with t-band)
– Shoulder external rotation (30-60%1RM with manual resistance)
– Power movement
– Stretch-shortening contraction
Functional Training
• Developmental sequence - Mobility or stability limitation?
– Sitting
– Hands/knees
– Kneeling Start where patient is
– Half kneeling stable and has control
– Standing
– Walking
• Proximal stability before distal mobility
• Incorporates strength, balance, motor sequencing, multi-plane etc
• Brain recognizes pattern of movement not individual muscles
• Train movements NOT muscles
• Stretch-shortening cycle
• Progression: sagittal to frontal to transverse plane
Four Pillars of Human Movement
(With permission from Juan Carlos Santana)
1. Standing and locomotion
2. Level changes
3. Pushing and pulling
4. Rotation
1. Standing and Locomotion
Frontal and transverse planes drive sagittal plane movement
• Static stance to dynamic stance (BOS challenges)
• Resisted gait – emphasis on sagittal and frontal planes
Sagittal and Frontal Plane Resisted Gait 2. Level Change
Change in the body’s center of mass
• Moving the trunk, extremities, or both
• Squatting progression
Sit to stand from appropriate chair height
Possible need of UE assist to stand – not to sit (eccentric emphasis)
Stance progression
• Stepping/lunges
– Sagittal (forward/backward) to frontal plane
– Small to large steps
– Holding ball/wt
– Touching knee
– Overhead reach on return
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