Contemporary Long Term Care - Walk This Way
Silverado, May 1, 1999 — When Rita Donath suffered a stroke last September, she thought she would never walk again. "I didn't think I would be able to do anything anymore," says the 55-year-old. "At first I couldn't even talk."
But after spending nearly two months in rehabilitation at Loretto Geriatric Nursing Home in Syracuse, New York, she went from a wheelchair to a walker. By winter, Donath was an outpatient at Lorett's Crossroads Rehab and was able to walk with a four-pronged cane inside her house. "That's what I use now but I can walk without anything," she boasts.
While a resident at Loretto, Donath took advantage of every opportunity to gain to do strength in her legs and arms. "I liked to do strength training all the time because if you don't try to do it, you never get any better," she says. "I saw a lot of people who didn't do anything and they didn't get better."
Getting residents out of wheelchairs...
According to experts in adult exercise, strength training is the key to helping residents regain mobility and improve to the point where a wheelchair is replaced by a walker, or a walker by a cane. "There are wonderful studies that show the frail can benefit dramatically from strength training," says Kay Van Norman, president of Seniors Unlimited, a Bozeman, Montana, consulting firm that provides services in exercise and wellness programming for seniors. (For details, see "Iron supplements" in Contemporary's July 1996 issue.) But strength training alone isn't enough. Caregivers must get people moving under thew own steam in many ways throughout the day. And that means working on how they think as well as how they move.
Build strong bodies
The key to success in strength training is intensity. "To improve that sit-to-stand function, you must train at a high enough level to impact muscle strength," says Van Norman. "A person should tram with 80 percent of the total weight he or she can lift one time with good form."
And back on their own two feet
Van Norman recalls a 90-year-old man who lifted weights unsupervised, usually doing 30 repetitions. "The standard amount at 80 percent would be 8 to 10 repetitions," says Van Norman. She suggested to the resident that if he wanted to gain strength, he should increase the weight and lower the reps. "His response was 'Oh, I don't need all that bulk at my age.' I said 'strength' and he heard 'bulk,' " she says. "There needs to be education and supervision."
In addition, exercises need to be patient-specific. Otherwise, even state-of-the-art equipment is useless, says Mike Foley, an exercise physiologist at East Tennessee State University. A resident with Parkinson's Disease, for example, will need different strengthening exercises than one with a cardiopulmonary disorder.
A physical therapist should work with staff members to teach them what needs to be done on a daily basis, adds Foley. "A lot of people fall through the cracks. The exercise regimen should be designed by a therapist based upon deficits and abilities."
Miriam Nelson, PhD, associate chief of the Human Physiology Laboratory at the Tufts University Center on Aging, agrees. "The equipment is not the most important part of the programming. If there is not the right training and staff, people don't use it." Nelson helps nursing homes and assisted living facilities; implement strength training and exercise programs to promote mobility and independence, through a program called Strong Living.
"It comes out of research we've been doing with adults from age 50 to 100," says Nelson. "With strength-training and balance training, older individuals can get stronger at any age. Their sense of wellbeing improves. If someone has a walker, our focus isn't that they should throw it away. Our mission is to help them be as independent as possible."
People can train with free weights or, if you've got the money, high-tech equipment. Seated step machines are recommended because they stimulate an important real life activity. At Crossroads Rehab, clients use step machines to strengthen the legs and pedal machines to improve endurance and range of motion.
Pat Willis, 78, was just beginning to walk with a cane when she came to Maple Knoll Village, a Cincinnati CCRC. "I had a hip replacement, and I had this terrible pain in my hip," she says. "I was anxious to get well so I went to the wellness center."
Her therapist put her on a recumbent stepping machine and soon her pain went away. "In no time at all, I was able to not use my cane," Willis says. "I noticed my legs and calves were developing, and my instructor put me on other machines." Willis now works out on eight machines three times a week, and swims three times a week.
Exercise equipment should "have a very low starting weight with minimum increments for increase," Van Norman says. "It should be easy to adjust and accommodate smaller people."
Electric-powered high-low mat tables allow residents to do strengthening exercises for their upper and lower extremities and to practice bed mobility, such as rolling from side to side and moving from a supine to a sitting position.
Another useful piece of equipment is the electric standing frame, which takes a wheelchair-bound person from a sitting to a standing position. While the frame does the work, it allows the client to remember what it's like to bear weight on the lower extremities. "Once they do it, it improves everything," says Crossroads Rehab Director Lena Chase. "It stimulates them physically and gets the blood flowing inside." In addition, people can exercise their upper extremities while standing in the frame.
Electric parallel bars, which can be automatically raised and lowered, allow clients to practice walking and work on their gait. "We use mirrors so residents can correct their posture and know what their balance looks like," says Chase.
People who are in wheelchairs because of falls or injuries have a better chance of walking again than those with neurological disorders. But even for them, training should begin as soon as possible. As the body atrophies, the chances of regaining mobility lessen.
And exercise must be regular. "If they're not being worked with on a daily basis, clients lose ground," Van Norman says. "It's a vicious cycle. They lose confidence."
'Normal daily activities'
If residents do well on the parallel bars, they are ready for a walker, says Chase. They can then work on balance and coordination by practicing normal daily activities such as picking up or hanging up items. From there, a resident may stay on a walker or progress to a four-pronged or single-point cane.
Wheeled walkers may be less taxing than standard ones. In a study published in the December 1996 issue of Physical Therapy, Foley found that standard walkers require 104 percent more oxygen per meter than wheel walkers. "If it takes a lot of energy to ambulate, there's going to be less ambulation going on. The ultimate goal is to increase functional mobility," Foley says. If weight bearing status is a concern, however, such as after a total hip replacement, a standard walker should be used initially.
Someone trying to go from wheelchair to walker might need to practice walking 15 feet three or four times a day. Sunrise Assisted Living incorporates such forays into residents' daffy routines, says Carolyn Inman, director of wellness services for Virginia facilities. For instance, a staff member might walk with a resident to a meal and then bring him or her back in a wheelchair. "If they're walking to a meal, they see how it increases independence and improves the quality of their life," Inman says.
People with Alzheimer's may need to be reminded how to walk. "A lot of the decline stems from disuse that comes about because they forget how to walk," says Wendy Graca, director of health services for Silverado Senior Living, an Aliso Viejo, California-based assisted living company specializing in dementia. "We've found it's possible to make gains for people who arrived immobile because they had been isolated in some way, were medicated or restrained, broke a hip and were in wheelchair for a while, or were depressed and in bed all the time, and then forgot how to walk. As long as they haven't been in that condition too long-which could result in contracture, causing permanent disability and weakening their chances to regain their mobility-they can learn to walk again."
Silverado does simple things. "We take people to the bathroom every two hours," Graca says. "Getting up and down helps them gain muscle strength and balance. If someone's in a wheelchair, we'll take him or her to the bathroom door and then have them walk a few steps. As their tolerance increases, so does the distance." Whenever Silverado residents are in the common areas, they're helped out of wheelchairs and into regular chairs. "If they're sitting in a regular chair, they're feeling like a regular person," Graca says. "And by getting them out of the wheelchair and into a regular chair, that's two times they're getting up, stretching, and using all their limbs."
Mealtime is another opportunity for mobility training. "We walk everyone into the dining room and they sit in regular chairs," Graca says. "When you start simulating normal life, their old habits kick in. Their long term memories are intact." Also important: room to roam. "Our communities are very big," says Graca. "To get to and from meals is a major hike. Outdoors, there's a lot of space for them to walk. Everybody is encouraged to have some daily outdoor activity. They're walking thousands of feet this way, versus 50 or 100 feet inside."
Not all residents can move under their own power. But some who rely on help to get around could do more on their own if they're encouraged to do what they can for themselves throughout the day.
Of course, it's usually much faster to do something for residents than to wait for them to do it themselves, and extra time is not something most CNAs have a lot of. But remember- You're not always doing someone a favor by doing for them. Sometimes it's better just to be there, to supervise and provide assistance as needed.
# Make sure residents know why they're doing exercises and how these exercises will improve their mobility. Otherwise, the unspoken question is, "Why am I doing this?"
# Incorporate exercise into residents' daffy routine. For example, if a resident needs to practice walking, help the resident walk to dinner or to a social function.
# Help people focus on the progress they're making, not how well they're doing compared to others. If someone can lift a leg for one second longer than he or she did the day before, that person is getting stronger.
# Plan exercises for times when residents are waiting. For instance, residents can do ankle flexions, toe curls, shoulder blade squeezes, and knee lifts while sitting in a wheelchair waiting for dinner to begin. Put up posters to remind residents to practice their exercises while waiting for something.
# Remind residents in wheelchairs to sit as straight as possible. This helps improve respiration and begins to stimulate poor muscles. If a resident can stand, remind him or her to stand as straight and tall as possible.
# Encourage independence. Give residents the opportunity to do everything they can do.
# Arrange furniture so that there is plenty of room to move around. Make sure resident's rooms don't get too cluttered.
# Remember the adage, "Use it or lose it." If muscles aren't used, they will atrophy.
BY ALICE DANIEL
Overcoming resident resistance
To help reluctant residents start exercising, emphasize why they need strengthening. "We have to bring back the concept that we're doing this for a functional purpose," says Karl Knopf, president of Fitness Educators of Older Adults Association. He recalls a woman feeling degraded upon discovering that she was physically unable to get up off the commode. "That was her wake-up call. And she never missed exercise class after that," he says.
A program needs to connect with a client's goals, says Jan Montague, president of Montague, Eippert and Associates, a consulting firm that develops wellness programs. For instance, Montague recalls giving several talks on fitness at one facility where the same 10 women showed up. But when she changed the topic to fall prevention, 42 of the 58 residents showed up. "When you talk about fall prevention and regaining balance-things that are relevant-then you start tapping into their personal belief system and they get more motivated to try," she says.
At Maple Knoll Village, fitness coordinator and exercise physiologist Tony Poggiali interviews new clients to find out about their entire lives, not just their physical health. "I try to find out what makes them tick. Then I push those buttons in a tactful way to inspire them," says Poggiali. "People have different reasons for dropping out. In some cases, maybe it's fear."
Staffers at Silverado have even tricked residents into getting off their duffs. "People always have a fear of falling, and once they've fallen, they may never want to walk again," Graca says. "One of our caregivers would put a resident's walker under the bed and say she couldn't find it, then say: 'Why don't we walk together?' Or she would say the wheelchair has a flat tire.
"The important thing is to give them the emotional support that you'll always be there."
Alice Daniel is a freelance writer based in Knoxville, Tennessee.