Another Example of 'Use It or Lose It'

Summarized by Robert W. Griffith, MD
October 25, 2002 (Reviewed: October 19, 2004)

Introduction

Many of us as we get older become quite frail, without really doing anything about it. It's not because we're ill, it's just 'getting old'. Or is it? A study has shown that it's possible to slow down the process, provided one starts soon enough.

If you have a stroke or break a hip you probably get intensive rehab. Some Yale researchers decided to see if a similar sort of physical therapy could help older citizens who seem to be losing their strength to the extent that it interferes with daily living.

What was done

People over 75 who were living in Connecticut, USA, were invited to take part in a clinical study. They had to be frail. That is to say, they needed more than 10 seconds to walk a 10-foot course there-and-back, or be unable to stand from a sitting position in a hard chair with their arms folded. A failure on one of these tests meant they were moderately frail, failure on both tests that they were severely frail.

Volunteers were excluded if they couldn't walk, or had been severely ill recently. And they had to score fairly well on a test of their mental capabilities (thee Mini-Mental State Examination - MMSE). A questionnaire was used to get information on 8 activities of daily living: walking, bathing, upper- and lower-body dressing, standing up from a chair, using the toilet, eating, and grooming. Each was scored, using 0 for 'no difficulty', 1 for 'difficulty, but no help needed', and 2 for 'help needed'. The total disability scores ranged therefore from 0-16. The questionnaires were repeated at 3, 7, and 12 months.

The participants were assigned by chance to have a physical therapy program, or an educational program; the latter group served as controls for the effects of physical therapy. A physical therapist visited the selected participants about 16 times over a 6-month period. At every visit, the therapist used exercises that were designed to specifically deal with each participant's actual problem areas; they were balance, muscle strength, movement, or mobility exercises. Participants completed a daily exercise diary, which was reviewed by the therapist at every visit. After the 6-month visiting period, the therapist phoned the participant each month for another 6 months, to answer questions and provide encouragement.

The control group received equivalent visits from a health educator; they reviewed together practices to promote good health, such as proper nutrition, management of medications, physical activity, and so on. After 6 months of visits, the educator phoned participants each month for another 6 months.

Results

There were 188 participants, equally divided between the physical therapy and the control groups. Their average age was 83 years, and 80% of them were women. About 2/3 of them had moderate frailty, and 1/3 had severe frailty. About 2/3 of the physical therapy participants completed the program, while 80% of the controls completed the educational program.

At baseline, both groups had roughly the same average disability scores - 2.3 and 2.8, respectively. By 7 months, the physical therapy group had reduced their average score to 2.0, while the control group's had increased to 3.6. After 12 months, the average physical therapy group score had increased to 2.7, while the control group score was 4.2. In other words, both groups had shown some decline in their general abilities, but the decline was greater, and present already by 7 months, in the control group.

Interestingly, the 'improvement' (i.e. delay in deterioration) was greatest in the participants with only moderate frailty, while it was hardly apparent in those with severe frailty.

Participants who scored lower on the mental testing seemed to benefit less from the physical therapy than those with higher scores. Those who lived alone slowed their deterioration with the physical therapy, while those who lived with others didn't.

The total cost of this physical therapy program was an average of $2,000 per patient. There were no differences between two groups with respect to possible side effects - falls, injuries, sprains, or chest pains.

Comment

This study shows that a relatively cheap program is able to delay increasing disability in moderately frail, home-dwelling, elderly people. The authors of the study call this a 'prehabilitation' program. What's important, however, is the finding that physical therapy is most helpful for older people when it's used before deterioration has reached the "severe frailty" level, and while the subjects are in good mental condition.

Although there was no obvious effect on nursing home admissions (they were 14% for the physical therapy group, and 19% for the control group), this may have been because not enough people were studied to show a significant difference. Certainly, the reduction in disability scores may be expected to lead to a better 'quality-of-life' for someone in the program, which would probably be associated with delayed admission to a nursing home.

Source

• A program to prevent functional decline in physically frail, elderly persons who live at home. TM. Gill, DI. Baker, M. Gottschalk,  et al., N Engl J Med, 2002, vol. 347, pp. 1068--1074

Related Links
Exercise May Boost Immunity
Lift Weights to Stay Flexible