1

Collaboration with the Association for the Planning and Development of Services for the Aged in Israel (ESHEL).

A fruitful collaboration between an academic institute (Wingate College) and a service agency (ESHEL) has yielded the development of infrastructure that provides physical activity programs in advanced age, on local and national levels. At the same time, this collaboration provides research opportunities for academicians and clinicians. A number of service programs were developed, including “education and in-service courses for teachers and service providers”, “physical activity programs specifically tailored to meet the needs of specific groups (frail elderly, nursing home residents, daycare centers, community clubs)”, “training elderly volunteers as health promoters (for example: leaders of walking groups)”. An example of this collaboration was a unique research project - assessing the use of a standing support device in a physical activity program designed to improve function in disabled wheelchair-bound nursing home residents. This complex pioneering study reflects the collaboration between researchers, students, physicians, physiotherapists, nursing home staff, service providers and policy makers. Following is the article, published in Disability and Rehabilitation: Assistive Technology, January 2007; 2(1): 43 – 49, based on this collaboration.

Physical Activity for Severely Impaired Wheelchair-BoundNursing Home Residents – the Use of a Standing Device

Netz Yael1

Argov Esther1

Burstin Arie2

Brown Riki2

Alexander Neil3

Heyman Samuel4

Dunsky Ayelet1

1.The ZinmanCollege of Physical Education and Sport Sciences, Wingate Institute, Israel

2. Beit Rivka, Geriatric Rehabilitation Center, Israel

3. Mobility Research Center & Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan, USA
4. Department of Medicine, HadassahHospital, Mt. Scopus, Israel

This study was supported by the Miles Fund for Physical Activity and Nutrition in Nursing Homes, throughESHEL – The Association for the Planning and Development of Services for the Aged in Israel.

We would like to thank all the staff and residents of Beit Bayer who participated in this study.

Abstract

In the present study we applied a physical activity program, using a standing device, on 13 wheelchair-bound nursing home residents aged 57-102 (mean 86.14+10.8). Participants attended the program five days a week for 20-30 minutes. Measurements were collected at baseline (T1), following two months with no activity (T2), and after 12 weeks of the physical activity program. Participants attended 77.56% of the sessions, and their mean standing time was 945 (+482.8) minutes.

As for strength and flexibility of specific muscle groups, results indicated that a greater number of people who improved and fewer who deteriorated were found between T2 to T3 than between T1 to T2, mainly in measures of strength of lower extremities. In terms of global measures of improvements of upper and lower extremities, significantly more improvements were indicated between T2 to T3 than between T1 to T2 on all measurements: strength of lower extremities, strength of upper extremities, flexibility of lower extremities, and flexibility of upper extremities.

On functional and lateral reach, significantly higher scores in left lateral reach were indicated in T3 than in T1 and T2, but pattern of improvement was also indicated on functional and right lateral reach. As for the FIM, significant improvement was indicated in motor ability, especially in locomotion and sphincter control, and in the total FIM score.

The implications are that physical activity program using a standing device may reduce the staff assistance needed for wheelchair bound nursing home residents. The role of the staff, however is to stimulate participants to move and act as independently as they can, and practice the improved mobility gained in the physical activity program.

Physical Activity for Severely Impaired Wheelchair-Bound Nursing Home Residents – the Use of a Standing Device

Regular physical activity has long been praised for its positive impact on well being and quality of life. A vast amount of well-documented publications unequivocally substantiates the physiological and psychological benefits of physical activity among older adults (1, 2). Some researchers argue that no other group in our society can benefit more from regularly performed exercise, than the elderly(3). According to the ACSM (1) age, specific chronic conditions, dementia, and functional impairment have not been shown to influence the adaptation to training, and many common geriatric syndromes contributing to frailty are responsive to increased levels of appropriate physical activity.

While many studies have demonstratedthe positive effect of physical activity on muscle strength(4-9), balance (10-12), and flexibility (10, 13) in frail older adults, some of them and others, have focused mainly on functional performance measurements such as chair rising, bed rise, stair climbing, timed get up and go, sit and reach(4, 6, 10, 11, 13-15), or on the ability of regular physical activity to prevent falls (9, 16, 17).

Some studies have shown improvement in functioningresulting from exercise even in extremely frail and impaired elderly. Schnelle et al. (18) reported improvement on injury risk measures related to upper body - handgrip strength, rowing endurance, wheelchair endurance and speed, while measures related to lower body strength did not significantly improve. Two studies reported exercise with incontinent nursing home residents. One,assessing sit-to-stand, walking and wheelchair propulsion endurance(19),reported no improvement in the experimental group, but a decline in the control group. Another study (20)found improvement in walking, wheelchair and standing endurance measured in time (mobility endurance). Two other studies reported improvement in rising from a bed and from a chair (21) and from the floor (22) following a task-specific resistance-training program. However, none of the above-mentioned studies has conducted a physical activity program on severely impaired extremely dependentwheelchair-boundnursing home residents.

In the present study, we applied a physical activity program on subjects who are unable to stand,rise from a wheelchair or from a bed without assistance, and generally are unable to wheel their chair. In addition, they are in most cases incontinent and/or not fully oriented.

In order to enhance mobility in the physical activity sessions, and to increase strength in the lower extremities, we tested a new approach: using a standing device in the physical activity sessions. Assisted standing and other alternative positioning techniques are used quite commonly in clinical practice in an effort to prevent complications of disease and disability (23, 24). The reported benefits are improved trunk strength and balance, improved respiratory abilities, pressure relief bychanging positions, improved range of motion (spine, hips, knees, ankles) to prevent contractures, maintenance of bone density, improved renal and bowel function, and improved quality of life (25). However, users of standing mobility devices are mostly spinal cord-injured patients(26). In the present study we applied a physical activity program in a weight-bearing position, using standing devices, to severely impaired but not spinal cord-injured nursing home residents.

As this is a pilot study in terms of both population and program, our preliminary questionswere whether it was actually possible to apply the program on these extremely low functioning individuals, whether they could tolerate it, whether the program was applicable in the nursing home routine, and whether the nursing home staff would cooperate and assist in the program. Another fundamentalquestion was how to assess the usefulness of the program. In the present paper we focus on two types of measurements: adaptation to training in terms of strength and flexibility of specific muscle groups and measures of functioning.

Methods

This study was approved by the Human Ethics Committee of the HadassahHospital, Jerusalem. Informed consent to participate in the program was signed by eachparticipant's family. Examinations were conducted three times by two experienced physiotherapists: at baseline – T1; following two months with no activity (pre-exercise) – T2; and after 12 weeks of the physical activity program (post-exercise) – T3. The physiotherapists submitted their measurements immediately following each examination, and were not allowed to review them.

Participants

Participants werewheelchair-bound (not able to stand or to walk, but able to be placed in a weight-bearing position) nursing home residents aged 57-102 (mean 86.14+10.8). They had the mental capacity to cooperateso they did not become combative when placed in the stander, but full orientation was not required. Medical exclusion criteria included: recent lower-limb fracture with a special indication for non-weight bearing; recent painful vertebral fracture; severe lower limb contractures; active ischemic heart disease; congestive heart failure, functional capacity III-IV (NYHA); orthostatic hypotension; any other medical or psychiatric condition indicated by the screening physician that seemed to predispose participants to any potential risk. Based on previous recommendations (13) and available space in the nursing home, we purchased five standing devices for working in a group of five in each session. As we had about two hours in the morning that participants were free from the nursing home routine, we calculated that we could conduct four activity sessions, one after the other, consisting of five participants each. This meant selecting not more than 20 participants. The process of recruiting participants was as follows: local nurses were told to select potential participants based on the above criteria. They provided a list of 33 potential candidates out of 86nursing residents. Prior to the baselineexamination, physiotherapistsexcluded eight individuals for not meeting the criteria (twofunctioned relatively independently, threewere able to walk with a walking frame, one refused tocooperate, one had severe lower limb contracture and was also too demented, and one had attention disorders). The other 25 participants were then screened and approved by a senior physician.They were then examined by the physiotherapists to determine baseline status. Based on the baseline examination, only 19 qualified to participate in the study (one was able to walk with a walking frame;another was disoriented and also able to use a walking frame; another one was not cooperativeand also unable to be placed in a weight-bearing position; two were not cooperative and one had attention disorders). Out of the 19, only 17 were examined in the second (pre-exercise) assessment (one refused to be re-examined, and one deteriorated in the time between the two assessments to a point that it was impossible to communicate with him in the second examination). Two who were assessed in the baseline and pre-exercise examinations did not start the physical activity program (one became very passive, and one depressive). Out of the 15 who began the activity program one died after two weeks, and one took ill toward the end and was not assessed in the third (post-exercise) assessment. The final number of individuals who took part in the physical activity program and completed all three assessments was 13.

Measures

The following measurements were collected at each of the three examinations (baseline, pre-exercise, post-exercise):

Strength.

Manual Muscle Testing (MMT) (27) was used to assess strength. This measurement is mostly used for assessment in clinical settings, but has also been used for assessing changes as a result of treatment (28). The scores of this test were found to correlate well with other strength measurements in older adults such as hand-held dynamometry (29). The principles of manual muscle testing follow the basic tenets of muscle length-tension relationships as well as those of joint mechanics. It is applied to a limb or other body part after it has completed its range of movement or after it has been placed at end range by the examiner. At the end of the available range or at a point in the range where the muscle is most challenged, the individual is asked to hold the part at that point and not allow the examiner to ''break'' the hold with manual resistance. The grades for this test are recorded as numerical scores ranging as follows: 0 = no movement, 1 = a flicker of movement is seen or felt in the muscle, 2 = muscle moves the joint when gravity is eliminated, 3 = muscle cannot hold the joint against resistance, but moves the joint fully against gravity, 4 = muscle holds the joint against a combination of gravity and moderate resistance, 5 = normal strength. In addition, we used plus and minus designations (29, 30). For example: 3+ = muscle moves the joint fully against gravity and is capable of transient resistance, but collapses abruptly, or 3- = muscle moves the joint against gravity, but not through full mechanical range of motion. In the current study we examined the upper and lower extremities (both sides). In the lower extremities: hip flexors, extensors and abductors, knee extensors and flexors, and ankle dorsi-flexors and plantar-flexors. In the upper extremities: shoulder abductors, extensors and flexors, elbow extensors and flexors, and wrist palmar-flexors and dorsi-flexors.

Flexibility (Range of Motion). Range of motion (ROM) measures were obtained using standard goniometric measures (31)of passive shoulder abduction, flexion, internal and external rotation;elbow flexion and extensionand wrist palmar and dorsal flexion; hip extension flexion and abduction; knee extension and flexion; and ankle plantar and dorsal flexion. ROM has been found to be reliable in clinical settings, especially when measurements are taken by the same physical therapists (32), and has been used for assessing changes following exercise programs in older adults (15).

Functional Measurements

Functional Reach (FR). Functional reach is the maximal distance one can reach forward beyond arm's length while maintaining a fixed base of support in the standing position or sitting position(33, 34). This distance is measured by a simple clinical apparatus (yardstick). The reported high reliability and validityscores forthis test among the elderly population, coupled with itssimplicityand ease of use have made that test popular as a balance measure in impaired older persons(34).

Lateral Reach (LR). This test assesses medio-lateral postural instability. The subject is asked to reach laterally beyond arm's length while maintaining a fixed base of support in the standing or sitting position. Asin Functional Reach, distance is measured by a simple yardstick. Its promising reliability and validity results support its use in clinical populations(35).

Mobility endurance. The distance a person can wheel his/her wheelchair independently(in meters), the length of time a person can stand independently, and the length a person can walk independently or with a walking aid.

The Functional Independence Measure (FIM) (36). This instrument assesses physical and cognitive disability in terms of burden of care. It is used to monitor patient progress and to assess outcomes of rehabilitation. It is a rating scale applicable to patients of all ages and diagnoses, by clinicians or by non-clinicians, and has been widely adopted by rehabilitation facilities (36). It includes 18 items covering independence in self-care, sphincter control, mobility, locomotion, communication, and social cognition. It is a widely used scale with proven reliability and validity (37). The FIM has also been widely used in Israel, in long term care facilities, including nursing homes (38). In the present study, the physiotherapists, who are well trained in administering the FIM, collected the FIM data by interviewing the staff (nurse aids), who work closelywith the participants on a daily basis.

Procedure

The team leading the physical activity program included physical activity teachers (who had previous experience with older adults but no experience in working with extremely frail elderly), a supervisor (a teacher with wide experience with frail elderly, although not with extremely frail), physiotherapists well trained in working with extremely frail elderly, and a student assistant. The physiotherapists gave the physical activity teachers and the supervisor a two-day training session on the standing device. In the first two weeks of the program, the physiotherapists attended all sessions, assisting the team in transferring participants to and from the standing device. They also provided solutions to problematic situations such as transferring a heavy person.

Generally, each activity session was attended by a physical activity teacherand a student assistant whose role was to assist in placing participants in the standing device or back in the wheelchair, and also to help participants to follow the teacher's instructions. In addition, one member of the nursing home staff was in charge (not necessarily attending all sessions) in case more help was needed in the transfer from standing device to wheelchair.

Participants attendedfive daily supervised 20-30 minutes exercise sessions per week, for 12 weeks. The activity was performed in the morning in four groups of five participants each(of whom only 13 were included in the present study).The staff brought five participants and returned them to their previous occupation following the activity. On the way back, participants were encouraged to wheel their chair independently. This procedure was repeated for each of the four groups each morning.