1. Department of Physical Medicine & Rehabilitation Harvard Medical School Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Functional Decline and Aging: How can exercise influence these changes? Jonathan F. Bean MD, MS, MPH Associate Professor Dept. PM&R, Harvard Medical School

2. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Disclosures Federal Funding –NIH NIA, NICHD No other disclosures

3. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Outline –Background/conceptual issues –Exercise and Functional Activities –Exercise and Participation in Life Roles –Medical conditions relevant to PM&R care and the maintenance of independence

4. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Aging and Demographics Older adults are the fastest growing segment of the population 0 10 20 30 19401960199020202040 Percent Women  65 y Men  65 y U.S. Bureau of the Census, 2000

5. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Changes with Aging Both Strength and power decline after age 35 1995, Metter et al., Baltimore Longitudinal Study on Aging

6. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Percent  70 y 70-74 y75-79 y80-84 y  85 y WMWMWMWMWM Difficulty Inability 0 10 20 30 40 50 60 Supplement on Aging II, NCHS Percent of Older Persons with Difficulty or Inability in ADLs by Age and Sex, United States, 1995

7. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School OLDER PATIENTS HAVE HIGH RATES OF COMORBIDITY In 1995, 79% of the 70+ age group had 1 or more of the following chronic disorders:  Arthritis  Hypertension  Heart disease  Diabetes mellitus  Respiratory disease  Cancer  Stroke Functional disability is highly associated with chronic disorders

8. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Does the disease model help us conceptually? Geriatric impairments more strongly associated with incident disability than chronic diseases –Cardiovascular Health Study –Chaudhry et al. JAGS, 2010 MC Escher: http://www.wisdom.weizmann.ac.il/~glasner/courses/CV_2009_2/im g/escher-relativity.jpg Let’s consider the disablement model

9. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Mobility is predictive of adverse outcomes Short Physical Performance Battery Performance of 3 tasks Each scored between 0-4 –Standing Balance –Gait Speed over 4 meters –5 repeated chair stands Best performance is 12 4-year disability rates according to SPPB From: Guralnik: N Engl J Med, Volume 332(9).Mar 2, 1995.556-561

10. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School JAMA April 2014 “Measuring gait speed is simple, quick, reproducible, inexpensive, and feasible in clinical settings.”

11. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Mobility within the disablement paradigm Body System Impairment Functional Limitation Disability Mobility problems cause limitations that impact participation and disability Impairment Restricted Participation Activity Limitation ICF Model Nagi Model

12. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Clinical Practice PRIMARY CARE OF OLDER ADULTS Chronic Disease ManagementAdvocated Mobility Screening Observed Physical Performance Arthritis CHD Stroke Diabetes Osteoporosis Etc. Rehabilitative Exercise Falls Disability Morbidity Mortality Final Common Pathway

13. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Realties of independent living for older adults

14. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Exercise and Impairment Body System Impairment Impairment ICF Model Nagi Model IMPAIRMENT

15. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School % MVC needed to perform ADLs Loss of Strength with Aging: a theoretical model

16. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Changes in 1 RM with Progressive Resistance Training among older adults Frontera et al., 1988 Strength Training

17. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Co-Impairments can have augmentative effects Strength and Balance as predictors of walking ability Rantanen et al., JAGS, 2001 Incidence rates of severe walking disability based on baseline knee-extension strength and standing balance

18. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Changes in Power and CMD in Function Bean et al. J Am Geriatr Soc 2010

19. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Trunk Muscle Integrity and Aging Trunk muscle endurance is also linked to back pain Trunk muscle integrity is critical for optimal peripheral power generation http://www.bandbhac.org.uk www.gc4health.com http://www.brandeis.edu/hbi

20. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School

21. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Exercise and Mobility Functional Limitation Activity ICF Model Nagi Model Mobility

22. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School What impairments should be prioritized? Impairments Balance Strength Power asymmetry Velocity of movement Reaction time Aerobic Capacity Range of Motion Core muscle integrity Kyphosis Obesity Pain Sensory Loss Cognitive Impairment Depression Visual Impairment Rehabilitative Impairments Medical Impairments

23. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School The Boston RISE Study Bean et al., Arch Phys Med Rehab; 2013

24. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Multivariable models prediction LLFDI function Note: Standardized estimates presented as absolute values. Both models were adjusted for age, sex, overweight status, obese status, and the manifestation of sensory loss

25. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Issues that may impact design of Exercise Specificity of training New models to optimize compliance and adherence

26. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Exercise for Fall Prevention Sherrington et al. Effective Exercise for the Prevention of Falls: A Systematic Review and Meta Analysis J Am Geriatr Soc, 2008

27. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Does one size fit all?... Implications of specificity of training RCT comparing two 16-week exercise programs –N=138, mean age 75 years –62% had ≥2 chronic musculoskeletal conditions –~30% with h/o heart disease 0.5 units = clinically meaningful difference *Bean, JF et al. Increased Velocity Exercise Specific to Task (InVEST) training vs. the National Institute on Aging’s (NIA) strength training program: changes in limb power and mobility, Jnl Gerontol Med Sci, 2009

28. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Hip Rehab Trial

29. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Hip Rehab Results Main Findings Improvements at 6 months –Performance-based Mobility –Patient reported Mobility –Patient reported Activities Findings persisted till 9 months

30. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Exercise and Disablement ICF Model Nagi Model Participation Disability

31. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Department of PM&R, Harvard Medical School Prehabilitation “Prehabilitation” –188 community dwelling older adults (75+ years) Gill, TM et al, NEJM

32. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School LIFE study, JAMA 2014

33. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School LIFE study-sub groups

34. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Developing new care paradigms: The Live Long Walk Strong Program Focused on mobility and fall injury prevention Integration with Primary Care Medicare compatible Treats those with MCI

35. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School MACIPA PCP P M & R Rehabilitative Care Community PCP SCREEN PM&R EVAL + PT PROGRAM MANAGER OT COMMUNITY EXERCISE/ACTIVITY PROGRAMS EDUCATION/ REFERRAL _ + The Live Long Walk Strong Program

36. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School How should rehab be designed? http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strongspauldingrehab.org/conditions-and-treatments/live-long-walk-strong

37. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School PCORI/NIA funded trial Implementation Trial Multicenter RCT Targeting the prevention of fall related injuries Pepper Centers Ancillary studies welcomed

38. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Cognitive Function and Mobility Cognitive decline linked to mobility decline –Alzheimer’s –Mild Cognitive Impairment Role of executive function –Dual task performance Walking while talking Predictive of falls and functional decline

39. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School MCI and Mobility in Boston RISE

40. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Prevalence of Musculoskeletal Pain Leveille et al; JAMA, 2009

41. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Pain and the onset of mobility problems and disability Eggermont et al., JAGS, 2014

42. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Mskl Pain and Mobility

43. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Summary Points Exercise can help slow functional decline among older adults We must be aware of conditions such as MCI and Pain that can impact participation PM&R clinicians should embrace this challenge –Take advantage of available resources –Geriatrics at your finger tips

44. Spaulding Rehabilitation Hospital Massachusetts General Hospital Brigham & Women’s Hospital Department of Physical Medicine & Rehabilitation Harvard Medical School Questions and Comments