raise each leg to a point midway between the patella and the iliac crest of the stance leg for it to count as a full step. The therapist counts the number of times the right knee reaches the target height. As with the 6MWT, the subject can stop and rest in a standing position, but sitting is not permitted. The clock continues until the 2 minutes are up (Jones & Rikli, 2002). Strength is an essential component of human movement. Adequate strength is necessary for an individual to meet the demands of participation in daily life. Evidence suggests that age-related muscle loss occurs as early as the fourth decade of life (Walston, 2012). Muscle weakness in older adults is associated with both mortality and physical disability (Manini & Clark, 2012). The term sarcopenia , technically defined as the age-related loss of skeletal muscle mass, is often used to describe both cellular processes and outcomes such as decreased muscle strength and function (Lang et al., 2010; Rosenberg, 1997). Sarcopenia is recognized as a syndrome characterized by progressive loss of muscle strength with a risk of adverse outcomes such as physical disability, poor quality of life, and death (Cruz-Jentoft et al., 2010). At present, a sarcopenia diagnosis requires documentation of low muscle mass, assessed using dual energy X-ray absorptiometry (DXA) or bioimpedance analysis (BIA), and documentation of either low muscle strength, or low physical performance. Muscle strength is tested with the assessment of handgrip strength. Physical performance is tested with the Short Physical Performance Battery or usual gait speed (Mijnarends et al., 2013). While the primary causes of sarcopenia – such as declines in neuromuscular junctions and age-related changes in the mitochondria appear to be internal in nature, behavioral factors such as activity levels and nutrition are also found to be contributory (Walston, 2012). Unfortunately, most patients with sarcopenia are not aware of their condition until the loss is enough to affect physical and functional independence (Visvanathan & Chapman, 2010). In a large study of 12,000 community dwellers in Tokyo, aged greater than 65 years, 14.2% of the men and 22.1% of the women were found to have sarcopenia. Compared with the healthier subjects, those with sarcopenia were less active regardless of gender. By gender, the women with sarcopenia had greater incidence of hypertension, the men had more strokes, and both genders had significantly greater incidence of osteoporosis (Ishii et al., 2014). Similar findings in the United States have been reported, with estimates indicating that approximately 45% of the older U.S. population is affected by sarcopenia (Janssen, Shepard, Katzmarzyk, & Roubenoff, 2004). Recent studies also suggest that the prevalence of sarcopenia among nursing home residents is almost 50% (Buckinx et al., 2017). Some evidence suggests that in older adults muscle power (usable force generated by muscles) is more indicative of function than muscle strength (ability to generate movement), most likely due to a reduction in Type II muscle fibers over time (ACSM et al., 2009; Berger & Doherty, 2010). While these declines do appear to exist, there is strong evidence that the appropriate dosage of resistance exercise training has a positive effect on strength, physical performance, and ADL/IADL function (Keysor & Brembs, 2011; Toto et al., 2012). Additionally, resistance exercise training may reduce the risk of osteoporosis and promote bone density in older adults (Guadalupe-Grau, Fuentes, Guerra, & Calbet, 2009). The following outcome measures may be helpful for assessing body structure changes in strength. Included are upper and lower extremity tests and a basic mobility assessment. The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and Quick DASH are self-report questionnaires that can be used to evaluate the upper limbs for impairments and monitor change or function over time. This test, which is appropriate for any upper-extremity joint, takes up to one-half hour to administer (De Smet, 2008; Slobogean, Noonan, & O’Brien, 2010).
Exertion Scale (Borg, 1970). (See the Resources section of this course for a link to this scale.) This scale directly correlates to the percentage of the maximum heart rate at which the subject is working. There are two commonly used forms; one scale of rated perception of exertion (RPE) extends from 6 to 20, while the other is a range from 1 to 10. The subject is asked to describe the level of exertion experienced during the activity by using descriptors such as very light, light, somewhat hard, or extremely hard. Each descriptor is assigned a number relative to the scale. Since this tool has been found to reflect the percentage of maximum heart rate at which a person is working, it is beneficial when working with a person on medications that blunt cardiac responses to activity. A tool such as this is invaluable and simple to use. Many IADL activities such as work, shopping, laundry, and lawn care are dependent on sufficient levels of endurance for task completion. The Borg scale can be applied by the trained older adult to himself or herself. For example: A patient has been taught to keep his level of exercise/ activity exertion between 3 and 6 out of a possible maximum of 10 after recent stent placement. After bringing in the mail from the end of the driveway, a distance of 200 feet, he rates himself at 5 on a scale of 1 to 10. This score of 5 out of 10 represents moderate exertion and is about 50% of his maximum heart rate. The older adult knows that he is within guidelines. Given his present situation, this may mean that he is just where he should be based on his aerobic capacity. Next, without pacing or resting in any way, he takes the garbage out and reports that his exertion is 8 on a scale of 1 to 10. This level of exertion is too hard for him, and the well-trained patient will stop this activity and resume after resting. When older adults have insufficient levels of endurance, they often need either to simplify the activity (e.g., switch from homemade cooked meals to microwave dinners), eliminate the activity altogether (e.g., hire someone to do their laundry and housecleaning), or break the task down into manageable parts. Although these options present solutions to endurance-related barriers, such changes to an older adult’s routines may result in a reduction of physical activity that often might lead to even further declines in endurance and related function. The physical therapist must educate the patient to recognize that reduced physical activity lends itself to a vicious cycle of increases in deconditioning. Even so, the choice to reduce certain activities based on limited endurance can enable older adults to spend their time and energy on activities that are meaningful to them. The following tests may be appropriate for patients who have aerobic impairments. These tests have been used with older adults, and the clinician can compare the results obtained during the evaluation with published norms to determine the degree of functional limitation. The 6-Minute Walk Test (6MWT) is an assessment of functional endurance that has been validated for multiple populations, including the pulmonary, cardiac, Parkinson’s disease, and community-dwelling older adult populations. There are norms available for this test for each of these populations. This test requires a 30-meter area that can serve as a course. The subject is instructed to walk around the course for 6 minutes in an attempt to walk as far as possible during this time. The distance covered is recorded. The subject may stop and rest in a standing position, but no sitting is permitted. The same verbal encouragement is given every minute (Enright et al., 2003). The therapist records heart rate, blood pressure, and respiratory rate before the test begins and immediately after the test is completed, along with recording the total distance covered in the 6 minutes There are other timed walking tests to meet the needs of different patients. The 2-Minute Step Test (2MST) can serve as an alternative to the 6MWT, as the subject must step in place continuously for 2 minutes. It can be performed near a wall for subjects with questionable balance. With each step, the subject must
EliteLearning.com/Physical-Therapy
Page 42
Powered by FlippingBook