Facilitator Notes for Exercise Cases

SGIM 2003 Workshop WE04

Musculoskeletal Problems

and Immobility in Older Adults

Handout #3, page 1

Facilitator Notes for Exercise Cases

(Participants only have the information in italics. The rest are your notes)

LEARNING OBJECTIVES FOR OUR SMALL GROUP:

• Describe exercises that have been associated with improved outcomes for specific medical conditions
• Assess your patient’s interest and willingness to exercise, using the “stages of change” model
• Describe approaches to increase your patients’ self efficacy in exercising
• Develop an approach to writing an exercise prescription using the FITTS method (frequency, intensity, type, time, and specific modifications)

Participants should be oriented to their materials, which include:

• Power point presentation on exercise
• Power point presentation on writing an exercise prescription

2 page handout on the 5 step approach to writing an exercise prescription

Cases

• References

The 2 page handout on the 5 step approach to writing an exercise prescription

and the Cases should be the primary documents used in discussing the cases. The rest of the handouts are for reference. Tell the participants that you will give them the facilitator notes and “answers” at the end of the session.

Spend the first 10 minutes going over the 5 step approach to writing an exercise prescription that is on the two page handout. This draws heavily on work by Proshaska, so it might be worth asking participants if they are familiar with the “Stages of Change” model. If they are not, this might go slowly. Although three cases are included (case #1 has part A and part B), it is quite likely you will not get through all of the material. It is included so that they can use it for teaching at their institution.

CASE #1

Mr. Fine is a 70 year old man who is fairly healthy and active. He has hypertension, hyperlipidemia, and early cataracts. He is on aspirin, a multivitamin, HCTZ, and simvastatin.

He is retired, but enjoys reading, movies, friends, and occasional gardening. He occasionally takes walks with his wife, but becomes quite winded if he goes up any hills, and finds that he has to stop to rest. He used to be a very active hiker, but has dropped this over the past 10 years.

His exam is normal today. His blood pressure is 140/88, P 84, R 16

What do you do in the following scenarios?

Scenario A. His wife is concerned that he has put on 5 pounds over the past few years, he is becoming a “couch potato” and is going to have a stroke like his brother Harry. He thinks things are OK and says “you can’t teach an old dog new tricks”.

Step 1. A first step is for you to think about what type of exercise is most important for your patient. (try not to spend more than 2 minutes on this part). For this man, overall cardiovascular fitness and prevention of frailty is likely to be the most important (you could discuss other outcomes as well).

Step 2. You should then determine Your Patient’s Values

YOUR QUESTIONPATIENT’S ANSWER

• What does your patient value?Independence

Autonomy

• What are your patient’s beliefs about exercise? He’s too old to start
• What barriers does your patient perceive? Scared of a heart attack or stroke
• How much support does your patient have?Lots from his wife
• Does your patient believe they can succeed?Not really

Step 3. Next, determine where in the “Stages of Change” model your patient is

Sounds like a precontemplator, “What, me exercise?”

But do you have enough to go on yet to determine his stage of change? How would you get more information?

PRACTICE ASKING if you have time.

Example: You say “your wife seems to think you really need to exercise, what do you think?” He says, “well, maybe I would start, but I’m scared that I am so old that I will have a heart attack if I start”.

So your patient is really a contemplator

Step 4. Tailor intervention to patient stage

You can work with him on discussing what he is willing to do and discussing safety with him.

Help move him from contemplation, to preparation, to action.

Given that he gets winded going up hills, it would be most prudent to begin him on a very gradually increasing exercise program that he 1) could succeed at and 2) would be safe. This might include beginning to take slow walks on level ground for 5 minutes a day for a week, gradually increasing by 5 minutes every week until up to 20 minutes a day or you could follow the “Pep up Your Life” schedule. He should be taught to take his pulse and not exceed about 60% of MPHR initially, gradually increasing. After discussion with him, he might also want to have an ETT prior to starting exercise. This could not be faulted, given his symptoms, but is not required if he begins to exercise extremely gradually on flat surfaces.

Step 5. Write the FITTS Rx

Practice writing the exercise prescription together.

(hand out the example exercise Rx at the end of the small group)

Now let’s use a different scenario for him

(You may not have time to do this one, so I recommend skipping it and coming back if you have time):

Scenario B: The patient’s son wants to take the patient and his wife and him on a hiking trip in the Sierras in 6 months. His son, a mountaineer, says that the trails he has picked out are “easy compared to what I usually do. They are only at 6000 feet, are mildly hilly, and we can walk an easy 5 miles a day”. We’ll have horses to pack our things.” He further states that his parents need to get more active and see more.” Your patient wants to go, but thinks he should probably start a vigorous exercise program first.

Step 1. Your patient has already chosen an aerobic, endurance exercise program.

For this man, overall cardiovascular fitness and prevention of frailty is likely to be the most important (you could discuss other outcomes as well).

Step 2. Your Patient’s Values

In this scenario, your patient values family time, physical fitness, and enjoying the outdoors.

Step 3. Your Patient’s Stage of Change – He is in the preparation stage

“I want to train for this trip” so you move on to step 4.

Step 4. Tailor intervention to patient stage

• Assess barriers

• Assess/increase patient’s self efficacy

• Provide specific information/education

• Assess risks, do ETT if indicated

• Write prescription that has 70% chance of success

In this scenario, he is prepared to exercise, but is in a higher risk situation. Backpacking in the mountains at 6000 feet will be a significant circulatory stressor, and he already gets winded just with going up hills. He likely would have to undergo a vigorous exercise program in order to prepare for this level of stress (even if his son thinks it is easy). Given that he gets winded going up hills, he should have an ETT, particularly if a vigorous exercise program will be started.

His ETT is normal.

In order to write a prescription that has a 70% chance of success, he will still have to begin his program gradually to avoid injury and improve self efficacy. However, given that we have a training goal, we will aim for a higher heart rate (HR = 80-90% of [220-70] = 120-135, can talk, but cannot sing). If he has the resources, starting his exercise program in a supervised setting or with a trainer might be wise to reduce the risk of injury. For him, warm up, cool down, and stretching will be very important for reducing the risk of injury.

If he does not have a trainer, you can use the “Pep Up your Life” endurance program, while teaching him how to take his own pulse. For Level 1, you would begin with moderate exercise, or a heart rate goal of 60-79% of MPHR, and for Level II and III, you would aim for “vigorous” exercise or a heart rate goal of 80-90% MPHR.

In preparation for the mountain hike, he should practice hill climbing as part of his endurance program and spend a few days in the mountains getting acclimatized before any exercise begins. For him, warm up, cool down, and stretching will be very important for reducing the risk of injury.

Step 5. Write the FITTS Rx

Practice writing the exercise prescription together if you have time.

(hand out the example exercise Rx at the end of the small group)

CASE #2

Ms. Good is a 79 year old woman who lives alone in an apartment building. She is obese, has osteoarthritis, type II Diabetes, CAD, and HTN. Recently her osteoarthritis has been acting up, she has increased pain, decreased mobility, and has had a couple of falls recently. She also says she is a “little unsteady at times”. She is now fairly scared that she may be “heading downhill”. She very much wants to continue living where she is and interacting with her daughter and grandchildren who live in the neighborhood. She rarely leaves home, unless her daughter accompanies her and assists. She is on aspirin, HCTZ, metformin, Tylenol, atenolol, and simvastatin.

On exam, her Bp is 130/80, P 64, R 16. She is moderately obese, and in no distress. Her heart, lung, and abdominal exams are normal. She has changes of osteoarthritis of both her hands, and her right knee. She has decreased range of motion of both of her hips. Her neurological exam shows mild peripheral neuropathy. Her “up and go test” shows that she has difficulty with going from a sitting to standing position without using her arms to assist and her gait is slightly wide based. Although she is able to walk without a cane, she prefers to use a cane on the left for walking.

Step 1. What kind of exercise would be most beneficial for her?

Limit discussions to 2 minutes.

Ms. Goode has a number of target conditions, including falls, osteoarthritis, diabetes mellitus, obesity, CAD, and HTN. Based on her exam, she also likely has quadriceps weakness and neuropathy. Different exercises will be beneficial for the different conditions. The bottom line is that the evidence strongly supports endurance/aerobic exercises for overall health and cardiovascular fitness (HTN, CAD, obesity, DM). For falls/frailty, resistance training, Tai Chi, balance, and PT have been associated with positive outcomes. For OA, both strengthening and endurance are beneficial.

So what to prescribe? This will depend, in part, on other factors, including her confidence, motivation, and ability to leave the home.

Step 2. Next, you should then determine Your Patient’s Values

• What does your patient value? Independence, living alone, not

burdening others

• What are your patient’s beliefs about exercise?She can’t do it
• What barriers does your patient perceive? Fear of falling, crime
• How much support does your patient have?Neighbor
• Does your patient believe she can succeed?Not really

Step 3. Next, determine where in the “Stages of Change” model your patient is

She is a precontemplator, and has little confidence in her ability to succeed.

Step 4. Tailor intervention to patient stage

Identify barriers, increase support, increase self efficacy

Identify patient’s conception of physical activity

Provide information/education

“Think about becoming active, think about what benefits you might gain, talk to other people who are active”

How would you move her along to contemplation, preparation, and then action?

Lower barriers, increase support, increase self-efficacy:

Given your patient’s situation, it may be wise to begin with a physical therapist, and she would likely qualify under Medicare with her recent falls and decline in mobility. A physical therapist could begin the process and increase the patient’s confidence.

Most physical therapy is geared toward “fixing” an acute problem, rather than beginning an exercise program. But PT could be used as a first step. PT will focus on quadriceps weakness, gait instability/ gait training (falls assessment). If you are lucky, you can work with the physical therapist to “transition” the patient from PT to an ongoing exercise program/prescription

Step 5. Write the FITTS Rx:

The PT has worked on balance exercises and strengthening exercises. You are now ready to write a prescription at the end of therapy. Practice writing the exercise prescription together if you have time.

(hand out the example exercise Rx at the end of the small group)

How do you follow up?

Remember the maintenance/ relapse Stage of Change!

Reinforce successes, rewrite prescription as goals change (more endurance, less strengthening, perhaps) and continue to monitor stages of change

At the end:

Remember to distribute Handout #2 that contains facilitator notes and examples of exercise prescriptions.

Mr. Fine, Scenario A

Mr. Fine, Scenario B

NAME : Ms GoodeDate:_5/3/03______

FREQUENCY 3x weekly

INTENSITYModerate Heart rate not to exceed ~ 100

Comfortable Pace, can sustain for 20 minutes

TYPE & TIME

Warm upStretches and balance exercises prescribed by PT5 minutes

EnduranceWalking in halls of apartment house10 minutes

StrengtheningAs prescribed by PT10 minutes

Cool downStretches as prescribed by PT5 minutes

SPECIFIC Instructions, Precauations, Modifications

Call MD for shortness of breath, chest pressure, or other symptoms

Eat extra food prior to exercise and monitor blood glucoses after first few sessions to make certain the exercise does not cause low blood sugar

Use cane

Do not do exercises if joints are red, hot, or swollen

How do you follow up?

Remember the maintenance/ relapse Stage of Change!

Stage I – Physical therapy (Helps move precontemplation to contemplation and good for beginning a frail elder on an exercise program.)

Stage II – Transition to long term program (Appropriate for “action” stage, will require more self-directed work.)

Stage III – Reinforce successes, rewrite prescription as goals change (more endurance, less strengthening, perhaps) and continue to monitor stages of change

A sample walking program (after NIH recommendations):

NAME______DATE______

Warm up / Target zone exercising
(Mod. 60-79%MPHR, Vigorous 80-90% MPHR) / Cool down / Total time
Week I
Session A / Walk 5 min. / Then walk briskly 5 min. / Then walk more slowly 5 min. / 15 min.
Session B / Repeat above pattern
Session C / Repeat above pattern
Continue with at least three exercise sessions during each week of the program.
Week 2 / Walk 5 min. / Walk briskly 7 min. / Walk 5 min. / 17 min.
Week 3 / Walk 5 min. / Walk briskly 9 min. / Walk 5 min. / 19 min.
Week 4 / Walk 5 min. / Walk briskly 11 min. / Walk 5 min. / 21 min.
Week 5 / Walk 5 min. / Walk briskly 13 min. / Walk 5 min. / 23 min.
Week 6 / Walk 5 min. / Walk briskly 15 min. / Walk 5 min. / 25 min.
Week 7 / Walk 5 min. / Walk briskly 18 min. / Walk 5 min. / 28 min.
Week 8 / Walk 5 min. / Walk briskly 20 min. / Walk 5 min. / 30 min.
Week 9 / Walk 5 min. / Walk briskly 23 min. / Walk 5 min. / 33 min.
Week 10 / Walk 5 min. / Walk briskly 26 min. / Walk 5 min. / 36 min.
Week 11 / Walk 5 min. / Walk briskly 28 min. / Walk 5 min. / 38 min.
Week 12 / Walk 5 min. / Walk briskly 30 min. / Walk 5 min. / 40 min.
Week 13 on:
Check your pulse periodically to see if you are exercising within your target zone. As you become more fit, try exercising within the upper range of your target zone. Gradually increase your brisk walking time to 30 to 60 minutes, three or four times a week. Remember that your goal is to get the benefits you are seeking and enjoy your activity.