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.
2
Physical Activity for Severely Impaired Wheelchair-Bound Nursing
Home Residents – the Use of a Standing Device
Netz Yael1
Argov Esther1
Burstin Arie2
Brown Riki2
Alexander Neil3
Heyman Samuel4
Dunsky Ayelet1
1. The Zinman College 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, Hadassah Hospital, Mt. Scopus, Israel
This study was supported by the Miles Fund for Physical Activity and Nutrition
in Nursing Homes, through ESHEL – 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.
3
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.
4
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 demonstrated the 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 functioning resulting 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
5
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 dependent wheelchair-bound nursing 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 by changing
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 questions were whether it was actually possible to apply the program on
6
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 fundamental question
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 Hadassah
Hospital, Jerusalem. Informed consent to participate in the program was signed by
each participant'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 (postexercise) – T3. The physiotherapists submitted their measurements immediately
following each examination, and were not allowed to review them.
Participants
Participants were wheelchair-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 cooperate so 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
7
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 86 nursing residents. Prior to
the baseline examination, physiotherapists excluded eight individuals for not meeting
the criteria (two functioned relatively independently, three were able to walk with a
walking frame, one refused to cooperate, 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 cooperative and 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
8
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
9
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 extension and 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 validity scores for this test
among the elderly population, coupled with its simplicity and 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. As in Functional Reach, distance is
10
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 closely with 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
11
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 teacher
and 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 attended five 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.
The exercise program was conducted while participants were positioned in the
standing device and/or while sitting in the wheelchair. Orthostatic hypotension was
assessed by measuring participants' blood pressure a week before the program started,
while supine, after one minute of sitting, and after 10 minutes of sitting. If systolic
pressure dropped 15mm/Hg or more, participants were treated with special caution
while brought to standing.
The maximum standing time in the first week was limited to a few minutes.
Standing time duration gradually increased when it was certain that participants could
12
physically tolerate the position change. During the activity sessions, participants were
positioned in a half circle so that they could see both teacher and other participants.
In order to stimulate cooperation and alertness, teachers used one of the following
recreation equipment in each session: small balls, ropes, wooden sticks, rubber rings,
hula hoops, or elastic resistance bands (Theraband). Each session included several
parts: Warm-up by means of small movements of different body parts, for example:
finger extension, wrist circles, shoulder shrugs, body sways. The main part was
designed to challenge all major muscle groups and to enhance strength, body handling
skills, flexibility, balance, coordination, and to some extent, cardiovascular
endurance. Examples: reach forward with alternate arms and with both arms, or trunk
side flexion and rotation, or leg lift (if possible). In addition, some participantparticipant or participant-teacher interaction was included in each session. For
example: passing a rubber ring to each other or to the teacher. The intensity level of
the exercise program was very low and increased gradually as the program
progressed, although it did not reach a meaningful intensity.
Data Analysis
As it is difficult to accurately measure strength and flexibility in these
participants, we chose to transform our findings into categorical data and report it in
terms of the number of people who improved or deteriorated in each period (T1-T2
and T2-T3). Means and SDs are provided, however, in the appendix.
Improvement or deterioration in strength was determined as a full-stage change only
(moving from 3 to 4- , for example was not considered a change). Improvement or
deterioration in flexibility was determined as a change of at least 100. This criterion is
13
more conservative than the 60 used on institutionalized elderly in a previous study
(39).
Based on the approach that improvement in these fitness components in frail
elderly is best described by an accumulation of measurements rather than by specific
individual muscle groups (40, 41), we reported the changes in strength and flexibility
in terms of upper and lower extremities in addition to changes in individual muscle
groups.
Results
Participants generally attended 77.56% of the sessions. Of 60 sessions they attended
46.54 (range: 13-60). Mean standing time for all sessions was 945 (+482.8) minutes.
Mean standing time per session was 15.75 (+8.05) minutes. The percentage of
sessions in which participants stood the whole session (at least 25 minutes) was
36.9% (0-53 sessions).
Table 1 presents the distribution of participants who improved, deteriorated and
remained with same on strength (MMT) and flexibility (ROM) of specific muscle
groups in two time periods: between T1 and T2, and between T2 and T3.
Insert Table 1 about here
More significant differences indicating 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.
14
Table 2 presents number of improvements in strength and flexibility for upper and
lower extremities. Mann-Whitney tests were conducted for comparing improvements
between T1 and T2 and those between T2 and T3. For strength of lower extremities
the z score was 3.66, p=.000, for upper extremities 1.93, p=0.054, for ROM of lower
extremities 2.89, p=0.004, and for ROM upper extremities 2.65, p=0.008.
Insert Table 2 about here
Results of FR, LR and wheelchair propulsion are presented in Table 3.
Insert Table 3 about here
As for standing time in T3 – nine out of 13 participants were able to stand 53.9
(+52.1) seconds without support, the rest were not able to stand without support.
Eight participants were able to walk 13.9 (+10.4) meters with a walking frame in T3,
while five were not able to walk at all.
Results of the FIM scores are presented in Table 4.
Insert Table 4 about here
Discussion
Functionally impaired older adults have not been given much attention in
terms of physical activity, from a belief that it is a waste of time. Where exercise was
offered in a nursing home, programming usually included only non-weight-bearing,
range-of-motion exercises which were not challenging enough for frail residents (13).
The present study indicates that it is possible to apply a physical activity
program using a standing device for wheelchair-bound extremely low-functioning
individuals living in a nursing home. Furthermore, results of the present study
15
indicate that the program was effective both in terms of improving strength and
flexibility and in terms of altering functioning measurements.
While previous studies reported improvement in strength (4-9) and flexibility
(10, 13) of frail elderly as a result of low intensity physical activity program, the
present study has gone beyond the hitherto lowest functioning individuals to apply a
weight-bearing physical activity program in wheelchair-bound severely impaired
individuals. Our results support the ACSM statement (1) that chronic conditions and
functional impairment do not impede adaptation to training. Like previous studies (4,
13), they underscore the importance of physical activity for the deceleration of
degeneration processes even among very low functioning individuals. It seems that
some age-related physiological changes are modifiable by exercise even in extremely
low functioning elderly.
Unlike a previous study of low functioning (mainly wheelchair bound) elderly
(18), which reported improvement on measures related to upper body but not to lower
body strength, our study found a greater improvement in strength in the lower
extremities than in the upper extremities. This was probably the result of having
participants standing as they exercised. The fact that more frequent cases of
improvements in strength were observed in hip extensors and abductors, knee
extensors and ankle dorsi and plantar flexors is of particular importance, because leg
extensor power is needed for many basic activities in daily life (5, 7).
Although adaptation to training in terms of strength and flexibility is
important, it is not necessarily an indication of change in functioning. Participants of
the current study are so frail and dependent that the progress achieved by the physical
activity intervention may not be sufficient to initiate a meaningful improvement in
daily functioning. Our findings on functioning measurements, specifically the FIM,
16
are therefore more meaningful in terms of functional improvement. The implications
are that participants need less assistance in daily functioning which means fewer
burdens on staff and families. This may be translated into fewer expenses to the
nursing home system and the economic potential to serve more elderly for the same
cost.
Unfortunately, nursing home residents are not encouraged to perform activities
that they are capable of doing by themselves (13, 18, 42). Residents capable of
walking spend most of their time either lying down or sitting. This is one of the
reasons why in the process of selecting participants for our study we had to exclude
participants who had been classified as wheelchair-bound by the nurses but were
found during screening to be capable of walking. Many residents become wheelchair
dependent due to staff concerns about the risk of falling. Frequently, residents are not
given the opportunity to dress themselves, or walk to the dining room because of
liability concerns, time constraints, or underestimation of capabilities.
In the daily routine of the nursing home, dependency is therefore endorsed and
sustained by the staff and family members. Clearly, they tend to overly assist the
dependent elderly.
We feel that family members, and even more so the nursing home staff, face a
daunting task in translating fitness improvements into daily functioning
improvements. Their role should be to stimulate participants to move and act as
independently as they can, and practice the improved mobility gained in the physical
activity program. At first this approach may take more time and energy from staff, but
eventually, if such a program leads to improved daily functional living of the elderly,
the staff's work will become easier.
17
The present study adds to the growing body of literature on the feasibility of
group-based exercise programming for frail elderly (4, 8, 10, 11, 13). As a pilot study
in terms of participants and program, implementation was complicated due to the
extreme impairment of the participants and the uniquely challenging program. The
process of selecting participants was based on trial and error despite pre-determined
inclusion/exclusion criteria. For example, we were not able to predict the extent of
cooperation of participants, or whether they will be able to carry on the program for
12 weeks. We therefore had a high drop-out rate, leaving only 13 who participated
fully and were tested three times. Also, relatively many people were needed for
conducting this new program (physiotherapists, nurses, students and other nursing
home staff). It should be noted that the program is continuing currently with a
physical activity teacher assisted occasionally only by one member of the nursing
home staff – mainly for placing participants in the standing device or back to their
wheelchair. Furthermore, participants also include other frail elderly who can stand
and walk but do not practice these skills in the daily nursing home routine.
One crucial question remained unanswered in our study. To what extent do
the participants themselves perceive an improvement in their quality of life following
the program? This is difficult to assess as participants were not very communicative
and not fully oriented. Nevertheless, we tried to interview them as well as their
families. These results will be presented in a different study.
18
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