will help to overcome these fears. Older adults report that receiving supervision from a knowledgeable person helps to assure and motivate them (Costello et al., 2011; Franco et al., 2015; McPhail et al., 2014). It may be helpful to perform several exercise sessions with the patient until he or she becomes comfortable with the exercises, knows how to operate the equipment safely, and understands the intensity level he or she is supposed to achieve during the session. Education on the benefits of exercise as well as what to expect may be reassuring to those who are not familiar with exercise. For example, an older adult who has never participated in resistance training may find muscle soreness after an initial resistance training disconcerting or even perceive it as harmful. Providing individuals the knowledge that muscle soreness can be expected prior to its occurrence may help them to continue.
some of these concerns. Many options to reduce the cost of a fitness facility exist. Insurance programs frequently offer no cost or low cost memberships to fitness facilities in an effort to encourage older adults to be more active. Low cost community programs targeting specific disease comorbidities such as diabetes or arthritis can also be found in many communities, helping to defray the cost of participation in an exercise program and also providing a social support group to encourage exercise. Older adults living in a retirement community or assisted living center also frequently have access to a community gym. Retaining and providing these resources to older adults can be a valuable tool to assist in overcoming barriers to exercise. Finally, many older adults report a fear of injury or a lack of knowledge about exercise as a reason they avoid starting or progressing a program (Costello et al., 2011; Franco et al., 2015; McPhail et al., 2014). Personal encouragement and education
MEASURING CHANGE CLINICALLY
tests are available for individual populations, such as those who have suffered a stroke, heart attack, or have multiple comorbid conditions. The functional tests presented here have been chosen because they have generally been found to be valid and reliable for a large population of older adults and have been used with a large variety of individuals having multiple diagnoses and comorbidities. Additionally, all the functional tests presented here can be performed with minimal space and equipment, which allows for easy implementation in most PT settings. laps plus any extra distance should be recorded. For example, a patient who walks 2 complete laps during the test, plus an additional 9 meters, has walked 129 meters. Normative values for the 6-minute walk for older adults can be found in Table 3. The minimal clinically important difference, or the difference that reflects meaningful change for the patient, is approximately 50 meters for older adults (Perera, Mody, Woodman, & Studenski, 2006; Wise & Brown, 2005). 2-minute step test If there is not sufficient room to complete the 6-minute walk test, one alternative measure is the 2-minute step test. While the 2-minute step test has not been as widely used as the 6-minute walk test, it has been administered to a variety of populations, including those with heart disease and to institutionalized frail older adults (Beck, Damkjaer, & Beyer, 2008; Liu, Baiqing, & Shnider, 2010). Like the 6-minute walk test, the 2-minute step test is self-paced, which allows individuals to take rest breaks as needed, and can therefore be used with individuals having very low fitness. In the 2-minute step test, the knee stepping height needs to be, at a minimum, halfway between the kneecap and the iliac crest. Once this distance is measured, it can be marked on the wall with a piece of tape. Upon starting the test, the patient will be marching in place as many times as possible in 2 minutes. For this test, only the number of times the right knee reaches the target height is counted. If patients become fatigued and can no longer reach the target height, they are asked to slow down or rest until they can once again reach the target height. However, even with a slowdown or rest, the timing of the test continues without pausing. The final score is the number of times the right knee reaches the target height within the 2-minute period. If patients have balance difficulties, this test can be done with an assistive device nearby in case of a loss of balance, but patients should be discouraged from using their arms continuously during the test because this may alter the results. The normal range of values for the 2-minute step test can be found in Table 3. The norms presented in Table 3 are only for those individuals who did not touch another object during the test. Using hands during this test causes an individual to score a 0. In those instances in which an individual puts a fingertip on the wall, a measurement of where the fingertip is placed or how many fingers are used from one point in time to another will
Increasingly, PTs are being asked to provide evidence of effective treatments by documenting outcomes following an intervention. Aerobic and resistance exercise both have clear physiologic and functional benefits. The use of functional fitness tests will allow for an objective measurement of both the physical and fitness function of older adults. When used prior to starting an exercise intervention, these tests will allow a PT to make objective recommendations about appropriate aerobic and resistive interventions and to document functional changes that occur after the exercise intervention. Many functional fitness How to measure changes after aerobic exercise While aerobic fitness has traditionally been measured with a maximal VO 2 test, it is not feasible to perform this test clinically in most PT settings. Many older adults have comorbid conditions that would require a physician to be present for a VO 2 max test. The time and equipment required to perform a VO 2 max test are also not readily available in most clinics. However, the 6-minute walk test, the 2-minute step test, and the gait-speed test can be quickly and easily administered in almost any setting and with any population, making these tests appropriate for most older adult populations seen in PT. These tests also allow for progress to be documented as changes are made with improved fitness and function. 6-minute walk test The 6-minute walk test is a submaximal aerobic test that measures the distance that an individual can walk in 6 minutes around a 30-meter course. It has been used to determine fitness in a variety of older adult populations, including frail individuals, those with comorbid conditions, such as diabetes and heart disease, and those who have undergone total hip arthroplasty (Hernandez & Franke, 2005; Lambers, Van Laethem, Van Acker, & Calders, 2008). The 6-minute walk test is easy to administer and is generally well tolerated. The benefit of using the 6-minute walk test is that even individuals with very low fitness can complete the test, because they are able to take rest breaks as needed (“ATS statement: Guidelines for the six-minute walk test,” 2002). The 6-minute walk test should be performed indoors along a long, straight, flat surface to minimize the need to navigate obstacles during the test. The walking course should be 30 meters long, with marks every 3 meters, and each end of the course should be marked with a cone. This will provide a 60-meter walking course (30 meters down and 30 meters back) for the patient to walk around. Patients are allowed to use their usual walking aids during the test. Patients should be instructed to walk as far as they can during the 6-minute period. They should be informed when each minute has passed in the same way. For example, “You are doing well; you have 5 minutes to go.” They are allowed to slow down, stop, and rest without sitting down, as needed, but the timer does not pause for the duration of the test. If the patient does require a seated rest break, the test is terminated and the distance is recorded along with the amount of time the test lasted. The number of
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