The Continuum of Care

The Continuum of Care

From Rehabilitation to Fitness: Improving the Quality of Life

Trent Nessler, PT, DPT, MPT

Area Vice President – Physiotherapy Associates

CEO - Accelerated Conditioning and Learning

Statistics Related to StrokeStatistics Related to Stroke

In 2007, there were 11, 538 Strokes in Middle TN

~7,500 of those received outpatient Physical, Occupational or Physical Therapy

Average Health Care cost per covered Life in 2007 was ~$7,500

Statistics Related to StrokeStatistics Related to Stroke

TN Rankings: TN has the 3rd highest rate of obesity in the

country TN ranks 2nd in the country for percentage

of adults with diabetes TN ranks 4th in the county for percentage of

adults with HTN With rise in risk factors relates to

expected rise in cost per covered life ~$14,700/covered life

Outpatient RehabilitationOutpatient Rehabilitation

Typical services offered: Physical therapy – movement

disorders, gait, balance issues Occupational therapy – UE weakness,

shoulder pain, daily activities Speech therapy – problems with

cognition, speech, swallowing

Outpatient RehabilitationOutpatient Rehabilitation

Other additional services: Bioness – advance technology for

drop foot Neuropsychology – neuro psych

testingCounseling

Nutritional counseling Light gait or other like devices Transitional programs

Outpatient RehabilitationOutpatient Rehabilitation How do you pick a provider????

Your physician – great resource Stroke coordinator – great resource Look what is available in your

communityServices offered – min all 3 disciplinesYears of experienceCertified specialistsTechnology Convenience Customer service

Outpatient RehabilitationOutpatient Rehabilitation

What difference can it make? Increased functional ability with ADLs Increased independence within the home,

work and life Improved quality of life Improved sense of wellbeing Endless

Should it end there?

Benefits of ExerciseBenefits of Exercise Benefits are endless Improved Strength

Improved independence with ADLs Showering, stairs, dressing, etc

Improved gait Balance with, cadence, safety

Decreased risk for fall (decreases by 90%) Improved bone density

Improved cardiovascular health Decreased risk for stroke Cardiovascular disease Improve BP

Disease/Illness Decreased risk for cancer Alzheimer's Dementia

Improved sends of wellbeing

Benefits of ExerciseBenefits of Exercise 75 y.o. community

dwellers, 2 groups 2 year study Exercisers: 1/2 rate

of falls Non-exercisers:

Hospital length of stay = 3 days or more

Hospital costs average $5,000 more per case

Take Home:1. Exercise alone

reduces risk for fall by 90%

2. Exercisers spent less days in the hospital

3. Cost less per case (less meds, stay, est.)

Buchner et al, The Effect of Strength and Endurance Training on Gait, Balance, Fall Risk, and Health Services Use in Community Living Older Adults. Journal of Gerontology, 1997, Vol 52A, No. 4, M218-224.

Precautions: Before You StartPrecautions: Before You Start Cleared by your MD! Fitness assessment by qualified personal trainer,

physical therapist or athletic trainer Full assessment of your baseline

Need to consider orthopedic health/screen Upper extremity weakness/sulcus/RC impingement Need to make sure program is not going to compromise Strengthen without injuring

Medications: Some medications have a significant impact on HR, BP,

ECG and exercise capacity. Your exercise expert should follow ACSM guidelines if

you are prescribed calcium/beta blockers, nitrates, vasodilators or antiarrhythmic agents (ask your doctor or pharmacist).

Importance of AssessmentImportance of Assessment 105 Community

Dwellers (+ Fall Hx.) Eval & program

addressing 5 components of fitness Specific to balance deficits

& individualized for their deficits

2x/week training + home exercise program

8 to 12 weeks of training Exercise adherence =

decrease in fall risk by ~80%

Take Home:1. Your program

should be individualized to you

2. Improves results and reduces risk for falls

Shumway-Cook A et al, the effect of multidimensional exercises on balance, mobility, and fallrisk in community dwelling older adults. Phys Ther. 1997:77:46-57.

Fitness 101:5 Components of Fitness

Fitness 101:5 Components of Fitness

Cardiovascular endurance Cardiovascular training

Muscular Strength Weight training

Muscular Endurance Weight training

Body Composition Nutrition

Flexibility Stretching

Cardiovascular FitnessCardiovascular Fitness

Activity which results in large muscle group movements for sustained period of time >1 minute.

Examples of: Walking TM Bike/Stationary Swimming Arm Bike/UBE

Muscular Strength and Endurance

Muscular Strength and Endurance

Address both of these together Go hand in hand Strength = resistance you use Endurance = moving the resistance

for set # repetitions Lot of research on!

Lot of misconceptions about

Can You Strength Training at My Age?Can You Strength Training at My Age?

8 weeks high intensity resistance training

Subject age = 90 (+/- 1 year)

Long Term Care residents

Compliance = 9 of 10 subjects

Strength gains = 174% (+/- 31%)

Mean tandem gait speed = +48%

Take Home1. Huge Strength

gains no matter what age

2. Improved gait speed

3. Associated with decreased fall risk

Fiatarone M et al. High intensity strength training in nonagenarians. JAMA 1990, 263 (22):3029-3034.

How Many Days/Week?How Many Days/Week?

High Intensity Studies 113 community

dwellers: 60 to 80 years old

High intensity (80%) circuit machines

Twice week training Strength gains > 60% 10 week break = 12%

strength loss

Take Home1. 60-80 y/o respond

well with high intensity training (80% max)

2. 2x/wk with intense training results in 60% increase in strength

3. Layoff in routine results in 12 % strength loss

McCartney N et al. A longitudinal trial of weight training in the Elderly. Journal of Gerontology, 1996, Vol 51A, No. 6, B425-B433.

Squat ProgressionSquat Progression

#1 exercise for fall prevention #1 exercise for

quad/ham strength

Form: sit to stand Progression

Pre-Squat Squat Advanced

Side Step ProgressionSide Step Progression

#1 exercise for G.med

Important for stabilizing the hip and fall prevention

Progression: Step out/back Side step w/o resist Side step w/ resist

Calf RaisesCalf Raises

#1 exercise for gastroc Important for

balance

Progression Up on toes Off 2” surface Off 6” surface

FlexibilityFlexibility

Increases in LE flexibility decreases risk for: Orthopedic injury Falls Muscle pain

Should not Cause pain Bounce with Feel uncomfortable or weird

NutritionNutrition

One of the most under emphasized areas in fitness

Should get a consult from a RD Caution with at fitness centers Make aware of medications

Nutrition 101Nutrition 101

Journal of Epidemiology (June 2002) Women who drink 5 glasses of water a day

reduce potential for heart disease by 41% Men who drink 5 glasses of water a day

reduce the potential for heart disease by 56% Nearly 50% of the American population is

considered clinically dehydrated As little as 1% dehydration results in 10%

decrease in performance

Caffeine is a diuretic and postulated to increase bone loss Recommended daily dose 420 mg/day,

average over 800-1600 mg/day

Contact InformationContact Information

Trent Nessler, PT, DPT, MPT

Trent.nessler@physiocorp.com

info@aclprogram.com