Nuts and Bolts of Physical Nuts and Bolts of Physical Activity CounselingActivity Counseling

20082008

Miriam C. Morey, Ph.D.

GRECC Associate Director Research

VA Medical Center

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ObjectivesObjectives Discuss overview of physical activity literature

– Risk/Benefit– Prevalence– Relevance to veterans

Physical activity counseling– Provider role– Evidence based approach

Functional assessment– Link to exercise program

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Consult your family doctor before beginning an exercise program

What do you think about?How do you respond?

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A simple test

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Ways Physical Activity Can Help You

Helpful things you can get right away:Helpful things you get later:• more energy/vitality • maintain independence• helps with balance/falling • improves quality of life• feel better • live longer• get stronger • walk unassisted• sleep better • household chores easier• better attitude/mood • gardening/yard work easier• better circulation • dress, shave, groom self• improves flexibility • travel outside local area easier• can reduce pain • look better• feel better about yourself • blood pressure control• blood sugar control • strengthen bones and joints• reduces stress • lower risk of heart attacks & strokes• cholesterol control • reduces risk of colon & breast CA

• reduces anger, anxiety, depression • reduces risk of getting diabetes• can help quit smoking • strengthens immune system• can help maintain diet • improves health of arthritic joints• improves blood flow to brain • helps weight loss• breathe easier • reduces body fat

• more energy to play with grandchildren • reduces depression and anxiety• makes your heart stronger • reduces risk of dementia

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Risk AssessmentRisk Assessment

What is the risk?– Mortality – very low risk

Gerofit – 1 death unwitnessed (possibly within 2 hrs after leaving Gerofit) in 22 years 1/320,00 person hours)

Literature – 1/60,000 – 1,000,000 person hours

– Injury – low risk

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ContraindicationsContraindications Unstable Angina or severe left main coronary

disease End-stage Congestive Heart Failure Malignant or unstable arrhythmias Uncontrolled hypertension (i.e. resting -systolic

>200mmHg, diastolic >110mmHg) Large or expanding aortic aneurysm Known cerebral aneurysm or recent intracranial

bleed Acute retinal hemorrhage or recent

ophthalmologic surgery Acute or unstable musculoskeletal injury Severe dementia or behavioral disturbance

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Risk/Benefit RatioRisk/Benefit Ratio

Benefits far outweigh risk!!!!

More risk of adverse health is associated with sedentary lifestyle

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Known Benefits of ExerciseKnown Benefits of Exercise

Reduces Risk of:– Dying prematurely – Developing diabetes– Developing high blood

pressure– High blood pressure

among hypertensives – Colon, breast and other

types of cancer– Depression and anxiety

Promotes– Maintenance of healthy

weight– Build and maintain

healthy bones– Older adults to become

stronger and better able to move without falling

– Psychological well-being– Cognitive Function

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Physical Activity and Physical Activity and Psychological Well-BeingPsychological Well-Being

Decreased depressive symptoms

Decreased anxiety

Improved mood

Increased vitality

Increased life satisfaction

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Physical Activity and Physical Activity and Economic Well-BeingEconomic Well-Being

Being out of shape is expensive

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Economic Well-BeingEconomic Well-Being

National Cost of Medical Treatments (in billions)

Disease CostHeart Diseases $183 Cancer $157 Obesity $117Diabetes $100Physical Inactivity $77 Arthritis $65

SOURCE: National Institutes of Health and CDC, 2000

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Costs of Physical InactivityCosts of Physical Inactivity One-third of total healthcare expenditures is for

older adults

Direct medical costs attributable to inactivity and obesity account for 10% of all health care expenditures

This excess cost is especially notable in women

Agency for Healthcare Research and Quality, Centers for Disease Control, 2001

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Medical Cost by Activity Medical Cost by Activity StatusStatus

Among Women Without Among Women Without Physical LimitationsPhysical Limitations

0

500

1,000

1,500

2,000

2,500

3,000

3,500

45-54 55-64 65-74 >75

ActiveWomen

InactiveWomen

Med

ical C

osts

/ Y

ear

Age Group

Agency for Healthcare Research and Quality, Centers for Disease Control, 2001

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Focus on Focus on LongevityLongevity

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Physical Activity andPhysical Activity andLongevityLongevity

Extensive data supports the relationship between exercise and longevity

There is a noted dose-response effect

From a population standpoint, the biggest benefit is obtained by moving sedentary people to active people

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Health Benefit Accrual Dose response

(CDC, ACSM, Surg. Gen)

From Pate 1995

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So What is the Problem?So What is the Problem?

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Prevalence of Prevalence of Individuals Not Meeting Physical Individuals Not Meeting Physical

Activity GuidelinesActivity Guidelines

0102030405060708090

100

45-64

65-74

75+ 65-74

75+

National

North Carolina

BRFSS, 2000, 2003BRFSS, 2000, 2003NHIS, 1991NHIS, 1991

Age

Strength TrainingStrength TrainingModerate Physical ActivityModerate Physical Activity

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Conceptual Functional Cost of Conceptual Functional Cost of Physical InactivityPhysical Inactivity

2

4

6

8

10

12

14

16

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20 30 40 50 60 70 80 90 100 110

Regularly active

Sedentary Adult

Differenceof Biological Age

Probable minimum for independence

Mets

Age Shephard, JAGS 1990

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What about the Older Veteran?What about the Older Veteran?

• Compared to the general population and veterans who do not use the VA for health care, veterans report:

– higher rates of chronic conditions – higher rates of negative health behaviors– higher rates of functional limitations – higher rates poor self-rated health

BRFSS 2000, National Veterans Health Study 1996BRFSS 2000, National Veterans Health Study 1996

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What about the Older Veteran?What about the Older Veteran?

• From our own Gerofit data, newly enrolled Gerofit participants (i.e., sedentary) – Scored significantly lower on repeated

chair stands than national normative data

– Scored significantly lower on 6-minute walk time than national normative data

Peterson, et.al J Rehab Res Dev 2004 in pressPeterson, et.al J Rehab Res Dev 2004 in press

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From Gerofit to Project LIFEFrom Gerofit to Project LIFE

• Over the past 19 years, Gerofit outcomes published include– Significant mortality benefit among participants– Significant improvement in fitness parameters– Significant improvement in psychological well-

being– Improvement in risk factor profile– Improved functional status

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What Did Happen with ExerciseWhat Did Happen with Exercise

• We reported significant overall (baseline, 3 and 12 months) improvements:– aerobic capacity, p = 0.0001– axial rotation, p = 0. 0011– SF-36 Physical Function, p = 0.0016– self-reported overall health, p = 0.0025– reduced number of symptoms, p=0.0008– reduced effect of symptoms on function, p = 0.002

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Surgeon General Guidelines for Surgeon General Guidelines for Physical Activity 1996Physical Activity 1996

• Significant health benefits can be obtained by including a moderate amount of physical activity, i.e. 30 minutes or more, on most, if not all, days of the week.

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Evidence Based Approach to Evidence Based Approach to Counseling for Older adultsCounseling for Older adults

Pocket Guide(Available in English and Spanish)With support from a Healthier US

Veterans mini-grant

New Guidelines Specific to Older Adults Published in 2007, 2008

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Physical Activity (PA) Counseling for Older Adults: An Evidence-Based Pocket Guide

Recommendations:1

• ≥ 30 min or 3 bouts of ≥10 min/day • ≥ 5 days/week• moderate intensity = 5-6 on a 10-point scale (where 0 = sitting, 5-6 = “can talk”, and 10 = all-out effort)

• in addition to routine ADL’s

• 8-10 exercises (major muscle groups), 10-15 repetitions• ≥2 nonconsecutive days/week • moderate to high intensity = 5-8 on a 10-pt scale

• ≥ 10 min ≥2 days/week • flexibility to maintain/improve range of motion (i.e. stretching of major muscle groups, yoga)

• balance exercises for those at risk for falls (i.e. tai chi, individualized balance exercises)

• create a single PA plan that integrates preventive and therapeutic treatment of chronic conditions

Aerobic:

Strength:

Flexibility/Balance:

Prevention:

Prescription pad attached below

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YOUR EXERCISE PRESCRIPTION

Walking or Other Goal: 30 min/dayMinutes: _____ Sessions/Day: _____Days/Week: _____

Strength Goal: 2 days/wk Squat (#): _____ Chair Stand (#): _____Wall Sit (#): _____ Flight of Stairs (#): _____

Date: _____________Physician’s Signature: __________________

For prescription pad refills email: Miriam.morey@va.gov On last sheet of pad, for refills and tracking purposes

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Squat

Wall Sit

StairClimbing

Chair Stand

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Sponsored by Durham VA GRECC Gerofit Program, NCP, and HealthierUS Veterans Program

Tips for Follow-up • Review PA plan• Revise to enhance progress• Reinforce positive behavior & activity documentation• Reaffirm that more PA enhances benefits

Resources/Additional Handouts:

www1.va.gov/GRECC/page.cfm?pg=22

Citations:

1. Physical Activity and Public Health in Older Adults: Recommendation from the ACSM and the AHA, Nelson, et. al., Circulation, 2007; 116(9): 1081-93.

2. Celebrating 20 Years of Excellence in Exercise for the Older Veteran. Fed. Pract., Morey, 2007; 24(10):49-50,53,57,65.

If patient is: Planned Approach

Not ready to change Educate on benefits of exercise

Ready to change Develop a specific PA plan

Active Support continued activity

Provider Advocacy is Key: Tips for Counseling

•Define benefits relative to medical history•Decide what to do where, when & for how long•Discuss barriers & strategize solutions•Determine social support: who & how•Determine if patient is “very sure” of success•Document PA plan in Chart & on Rx to patient

Healthcare Counselor’s RoleHealthcare Counselor’s Role

• First and Foremost- BE AN ADVOCATE!• What can you do?

– Set specific detailed and individualized exercise prescription

Identifying personally defined benefits Setting a specific exercise prescription with patient Identifying social support for exercise Discussing barriers and overcoming them

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START LOW AND GO SLOW!

Encourage physical activitySet reasonable and specific goalsDiscuss barriersAddress medical conditions

HowHow

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From Fitness to Function From Fitness to Function

Simple functional tests can determine risk for future adverse health events

Some functional tests are highly related to certain aspects of fitness– Chair stand and lower leg strength

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Identifying RiskIdentifying Risk

Lower extremity function predictive of nursing home placement and institutionalization (Guralnik 1995)

Balance measures are predictive of falls and subsequent disability (Okumiya)

Low endurance associated increased mortality and disability (Young)

Gait speed (usual not maximum) is highly predictive of nursing home placement and institutionalization (Guralnik 2000)

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Functional Testing Functional Testing

– *Lower Extremity Function - Chair stands

– *Balance - Up & Go test

– *Endurance - 6 minute walk

– Gait Speed

*Norms to estimate functional riskRikkli & Jones J Aging Phys Act 1999

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SummarySummary

We have provided an overview of literature summarizing the multiple benefits of physical activity. Risks associated with sedentary lifestyle are numerous.

Tips for physical activity counseling include identifying “stage of change” of patient and counseling accordingly. Provider advocacy is key!

Thoughts on utilization of functional fitness

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Contact InformationContact Information

For information about this specific presentation please contact Miriam Morey, PhD at miriam.morey@va.gov

For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328

For the link to the evaluation form for this conference that will confer CE credit please go to http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=24710 and click the “Handout: Registration and Evaluation” link