The promise of strength training: are the frail elderly past beneficial strength building? Think again.

Imagine what would happen to your quality indicators if Mrs. Smith could discard her feeding tube and feed herself. Or if Mr. Jones could rise from the confines of his bed and walk down the hall with his cane. Imagine the possibilities in enhanced quality of life and reduced burden of care if residents could do more for themselves. Such is the promise of strength training for nursing home residents.

"We liken strength training to sports medicine for 95-year-olds," says Mark Richards, national director of clinical services at Aegis Therapies. "It is exciting that a frail nursing home population can exercise and realize huge increases in strength and, more importantly, improved functional ability."

One of the most common sources of increasing frailty among the elderly is muscle weakness--often simply from inactivity. "Many people are in nursing facilities because they have lost their strength and can no longer perform the activities of daily living or keep themselves sufficiently mobile," says Richards. But muscle weakness can be reversed.

A groundbreaking study published in 1990 in the Journal of the American Medical Association by Maria Fiatarone, MD, at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in Boston, involved ten females, mean age 92, living in a nursing home. After exercising three times a week for eight weeks on strength-building machines, using 80% of their ability, these women increased their strength an average of 174%. No injuries were reported, nor any worsening of medical problems. Their increased strength translated into a 48% increase in walking speed.

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Dr. Fiatarone went on to publish another study in 1994 in the New England Journal of Medicine involving 100 nursing home residents with diagnoses ranging from arthritis to lung disease to dementia. Residents worked on exercise machines for resistance training three times a week to strengthen their thighs and knees. After a ten-week period, their muscle strength increased 113%, walking speed accelerated by 12%, and ability to climb stairs rose by 28%. Four residents were able to discard their walkers and walk with only a cane.

"The advantage of using such machines in the strength-building process is that they provide the postural support people need to safely exercise," explains Richards. "The machines also control the exercise range of motion and, to provide resistance, allow us to increase the load by increments as small as one pound at a time."

As the frail become stronger, they spend less time in bed, move more easily around their rooms, and participate in more activities of daily living--all reportable as enhanced chronic-care measures endorsed by the National Quality Forum.

Case Studies

Irene's story is an illuminating comparison of traditional therapy versus strength training. Unable to care for herself, Irene was admitted to Birchwood Care Center in Fitchburg, Massachusetts, with complications from Parkinson's, polypharmacy, and depression. Because she was unable to raise her head from resting on her chest, she was unable to walk safely. Tremors and the angle of her head made it virtually impossible for her to feed herself or even to chew or swallow. Through 41 sessions of traditional therapy in all three rehab disciplines--including combined stretching, strengthening, and compensatory and adaptive strategies, such as splinting--Irene did not substantially improve.

She then entered the newly established strength-training program at Birchwood, using five Nautilus machines under the direction of her therapists. Within a few weeks, Irene held her head at ten degrees short of neutral, fed herself, and walked independently throughout the facility with a wheeled walker.

There is also the case of a male resident at Continental Manor Health & Rehab in Randolph, Wisconsin. Diagnosed with left hip fracture with "open reduction and internal fixation" (ORIF), pneumonia, obstructive sleep apnea, and extremely limited active range of motion in both shoulders because of rotator cuff tears, he was unable to bathe, dress, or groom himself, and required help with transfers and toileting. After resistance training on Nautilus machines twice a week for seven weeks in Aegis's "Freedom through Functionality" program, he was able to care for himself, toilet with supervision only, and finally return home.

"The equipment enhances and strengthens the resident's overall condition--and that is reflected in our quality indicator numbers," notes Continental Manor's executive director, Vicky Grant, Grant has been so pleased with these strength-training outcomes that she has expanded the base of patients participating. "Even nontherapy patients benefit from working on the equipment," says Grant. "And that benefits us."

She cites the example of one nontherapy resident who was ambulatory but growing increasingly weak. "Therapy screened her, and we put her on Medicare Part B to set up a program for the restorative nurse to work with her on the equipment every day," says Grant. "We've been able to keep her mobile. What a terrific enhancement to the quality of her time with us. It also has certainly helped with our quality indicators."

Residents at Continental Manor's assisted living facility also use the Nautilus equipment. "Our assisted living residents use it not as part of therapy, but as an activity," explains Grant. "It's wonderful, because if they can maintain their strength, they can live more independently rather than require increased levels of assistance."

Maintaining strength once patients have been discharged from therapy is a key element of resident care. Says Steve Goold, executive director of Cohasset Knoll in Cohasset, Massachusetts, "I've seen patients decline after being discharged from therapy. But with the Nautilus program, using restorative nursing, we are able to maintain these folks at a higher level of functioning." He adds that strength training often becomes a plus for the facility beyond therapy. Cohasset, for example, opens the program to the community as part of a wellness program, which according to Goold has greatly enhanced the facility's image.

At Country Villa Healthcare in Murrieta, California, Administrator Doug Lehnhoff reports that, since introducing the Nautilus equipment, Country Villa has seen a definite increase in its Medicare census. "We are the facility of choice for two acute hospitals," he says. "I think it directly correlates to our strength-building program."

Aegis's Richards notes that establishing a good strength-training program involves more than simply installing the machines. "It's the protocols and the training of our clinicians and facility staff, as well as the ongoing clinical management, that make a difference," he says. "We track utilization on a weekly, patient-by-patient basis, and we have a training network and clinical support system that provide ongoing monitoring. That's what makes for a successful program."

As a facility's quality indicators and quality measures improve, the cost of caregiving is reduced. According to a study by the Uniform Data Set (UDS), which governs the FIM, the reduced cost of care to a nursing home for one FIM point is -$.50 per day. In the John Knox study (see "Case Study: Pumping Iron at John Knox Village"), the 19 residents involved in strength training made an 11-point gain on FIM scores, translating to a $104.50 per day reduced burden of care and an annual savings of $38,142.50.

"There is almost a societal attitude in this country that, as people get older, they should be more inactive--they should retire and hit the rocking chair," says Richards. "In cultures where elders remain active we don't see the same kind of strength and functional declines. If osteoporosis is considered a disease process, with billions of dollars spent to treat and research it, muscle weakness should be as well. Osteoporosis substantially affects roughly 20% of the population, whereas muscle weakness affects virtually all seniors. So why shouldn't we give seniors the opportunity to strengthen and become healthier?"

RELATED ARTICLE: Case Study: Pumping Iron at John Knox Village

A study at John Knox Village in Orange City, Florida, involved 19 residents with a mean age of 88 years. In a 14-week, twice-weekly course of therapist-assisted strength building resembling Aegis Therapies' "Freedom through Functionality" program, residents performed 8 to 12 repetitions of one set of exercises on each of the following five Nautilus machines geared toward function-related outcomes:

1. Leg press -- involving quadriceps, hamstrings, and gluteus maximus muscles, used for moving between seated and standing positions.

2. Low-back machine -- isolating the trunk extensor muscles to strengthen the erector spinae muscles that improve posture and the ability to sit on the edge of the bed or the commode.

3. Triceps press -- targeting upper body pushing muscles to aid in rising from a wheelchair.

4. Compound row machine -- addressing upper body pulling muscles and shoulder retraction muscles of the upper back to improve posture, and thus breathing, and straighten rounded shoulders.

5. Four-way neck machine -- facilitating neck extensions and neck flexions to help patients turn their heads and hold them erect, which assists in breathing, drinking, and swallowing.

The following results were reported:

* 3.8% increase in lean body weight, which translates into increased muscle tissue

* 9.7% reduction in body fat

* 9.8% decrease in fat weight

* 81.2% increase in strength from using the leg press

* 38.8% increase in strength on the triceps press

* 9.0% increase in shoulder range of motion

* 14.0% improvement in the FIM score (11-point increase)

The study reported these improvements:

* Improved body composition

* Increased muscle strength

* Enhanced joint flexibility

* Increased functional capacity

* Improved mobility

Medical staff and residents reported further possibilities:

* Increased potential for patient independence

* Improved cooperation between caregivers and patients

* Improved cooperation among nurses, therapists, and recreation specialists

* Enhanced potential for recruiting new residents

* Enhanced potential for recruiting new professional staff

* Reduced healthcare costs

RELATED ARTICLE: QI Contributions

Strength training contributes to the following quality indicators (QIs):

* Falls -- increases balance.

* Depression -- enhances mood. A study published in January 1997 in The Journal of Gerontology shows that strength building alone was as effective as antidepressant medication in reversing depression.

* Bowel and Bladder -- increases strength in the legs and the pelvic floor, with a positive influence on incontinence.

* Feeding Tubes -- improves neck strength to enhance swallowing and feeding.

* ADLs -- increases strength, enabling residents to improve dressing and feeding skills.

* Range of Motion -- increases range of motion.