In older hospitalized medical patients, self-reported decline in functional skills is common before and during hospitalization (
In healthy older adults, even a few days of experimental immobilization or periods of bed rest can reduce muscle strength and functional performance (
According to recent systematic reviews, loss of muscle strength and functional performance can be prevented by systematic strength training in both healthy and ill older adults (
The ideal exercise program for a hospitalized patient should be feasible to perform within a busy care setting. It should be relatively simple requiring minimal equipment and also address the impairments (poor limb strength) and functional deficits (poor mobility skills) common to hospitalized patients (
The study is a prospective cohort study conducted as a feasibility study (
Older medical patients (≥65 yrs) acutely admitted from their own home to the medical services of the hospital, via the emergency department, were included by random sampling. The exclusion criteria were: (1) inability to rise from a chair with help; (2) inability to cooperate in measurements; (3) inability to give informed consent to participate; (4) diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and participation in a COPD rehabilitation program; (5) terminal illness or being in cancer treatment; (6) inability to speak or understand Danish; (7) isolation-room stay; (8) transferral to the intensive care unit; (9) an expected hospitalization of one day or less.
All assessments were performed by two skilled physiotherapists—one with 15 years of experience (the primary investigator, MMP), and one with two years of experience (HGJ). The same physiotherapist performed all assessments for a given patient. Before initiation of the study, HGJ was trained in all assessments and the progression model and assisted MMP in assessing the first two patients to ensure standardization.
Medical records were extracted for demographic data, co-morbidities, length of hospital stay, admission diagnosis, and discharge destination. The patients underwent a structured baseline interview within the initial 48 h of the hospital stay, to collect information about marital status, residence before hospitalization, recent weight loss, basic mobility, functional independence, physical activity level 2 weeks prior to admission, health status, nutritional status, cognitive status, and mobility: the Cumulated Ambulation Score (CAS) was used as an objective measure of basic mobility. It quantifies the patients’ independence in three basic activities: getting in and out of bed, sit-to-stand from a chair, and walking (
We developed a progression model for loaded sit-to-stands as a strength training exercise and named the model STAND (
Seated on a standard chair with armrests, and a seat height of approximately 45 cm, the individual should perform 5 unloaded knee extensions for each limb as a warm-up.
Perform all exercises at a moderate velocity with both the concentric (raising) and the eccentric (lowering) component being performed over 2 s, separated by a 1-second quasi-isometric pause after the concentric and eccentric phases, respectively.
Perform as many repetitions as possible maintaining the same pace to ensure training to muscular fatigue.
If muscular fatigue is reached within 8–12 repetitions, stay at the same level.
If muscular fatigue is reached before 8 repetitions, perform the exercise at a lower level.
If muscular fatigue is reached after more than 12 repetitions, perform the exercise at a higher level.
Aim at 3 sets of 8–12 repetitions to muscular fatigue (3 × 8–12 RM).
Allow minimal extra support after 6 non-compensatory repetitions to attain muscular fatigue—if a proper technique is maintained.
Allow increased speed in the last two repetitions if necessary to ensure training at the highest possible level.
Adjust loads/levels on a set-by-set basis.
Ensure a 1-minute pause between sets.
All levels are started from a seated position.
Level 1: Attach an appropriate weight cuff (≥0.5 kg) around the ankle. Fully extend the knee and bend it reaching 90° flexion.
Level 2: From a seated position, rise to a fully extended position and sit down using the armrests as support and with additional support from the physiotherapist.
Level 3: From a seated position, rise to a fully extended position and sit down using the armrests as support.
Level 4: From a seated position, rise to a fully extended position using the armrests as support. Sit down with the arms crossed over the chest.
Level 5: From a seated position with arm crossed over the chest, rise to a fully extended position and sit down.
Level 6: From a seated position with arm crossed over the chest and wearing a weight vest (1–30 kg), rise to a fully extended position and sit down.
Level 7: From a seated position (hands on chair in front of you for balance support), rise to a fully extended position on one leg and sit down (shift legs after each set, aiming at 3 sets per leg).
Level 8: From a seated position wearing a weight vest (1–30 kg) (hands on chair in front of you for balance support), rise to a fully extended position on one leg and sit down (shift legs after each set, aiming at 3 sets per leg).
The patient was seated on a standard chair with armrests, and a seat height of approximately 45 cm. As a warm-up exercise, the patient was asked to perform five unloaded knee extensions for each limb. The starting point in STAND was level 5 (
STAND was considered feasible if three criteria were fulfilled: (1) 75% of the assessed acute-phase patients and stable-phase patients, respectively, could perform the exercise at a given level of the model without session failure. In the hospital, a session failure was defined as inability to perform at least one set of 8–12 RM, and at home a session failure was defined as inability to perform at least two sets of 8–12 RM. One to three sets are recommended for improving muscular strength in older adults (
For each set in the two sessions (in-hospital and at home), the level in STAND, the extra load added (kg), and the number of repetitions were noted.
The Borg Scale was administered immediately after each set of the exercise as a measure of perceived exertion (
Before and after assessment of the DEMMI and before, during, and 10 min after the exercise, the patients were asked if they felt pain and wherefrom by the use of the VRS (
No formal sample size calculation was performed due to the descriptive character of the study and as no efficacy testing was to be performed (
A total of 248 patients were assessed for eligibility and fulfilled the inclusion criteria. Of these, 200 were excluded based on our exclusion criteria: six were unable to rise from a chair with help; 65 were not able to participate (e.g., due to dementia or confusion); one was participating in a COPD rehabilitation program; 15 were in cancer treatment or terminally ill; four were unable to speak or understand Danish; three were transferred to an isolation room; and 106 were discharged within the first 24 h (
Age; mean (SD) | 24 | 77 ± 7 |
Gender, female; |
24 | 12 (50%) |
Living alone, yes; |
24 | 13 (54%) |
Use of gait devices, yes; |
24 | 9 (37.5%) |
Reason for admission; |
24 | |
Pneumonia | 10 (41.7%) | |
COPD exacerbation | 2 (8.3%) | |
Dyspnea | 1 (4.2%) | |
Urinary tract infection | 3 (12.5%) | |
Gastroenteritis | 1 (4.2%) | |
Pulmonary embolism | 2 (8.3%) | |
Atrial fibrillation | 3 (12.5%) | |
Anemia | 2 (8.3%) | |
Physical activity level (PA); |
23 | |
Low PA | 5 (21.7%) | |
Moderate PA | 5 (21.7%) | |
High PA | 13 (56.6%) | |
Comorbidities; |
24 | 5 (3.5;5.5) |
Medications; |
24 | 6 (2.5;7.5) |
Length of stay; median (IQR) | 24 | 4.5 (3;7) |
Follow-up—number of days after discharge; median (IQR) | 19 | 9 (6;13) |
Nutritional risk screening | 24 | |
At risk; |
19 (79.2%) | |
OMC; median (IQR)/ |
24 | 26 (22;28) |
CAS; median (IQR) | 24 | 6 (6;6) |
NMS, 14 days prior to admission; median (IQR) | 24 | 9 (5.5;9) |
NMS at admission; median (IQR) | 24 | 3 (2;9) |
DEMMI; mean (SD) | 23 | 66.1 ± 15.18 |
The Short Orientation-Memory-Concentration test The Cumulated Ambulation Score The New Mobility Score The De Morton Mobility Index
Performance measure | Admission | Home-visit | |||
---|---|---|---|---|---|
CAS; median (IQR) | 24 | 6 (6;6) | 20 | 6 (6;6) | NA |
NMS admission; median (IQR) | 24 | 3 (2;9) | 20 | 6.5 (3;9) | 0.13 |
DEMMI; mean (SD) | 23 | 66.1 (15.18) | 19 | 70.6 (14.7) | 0.12 |
EQ-VAS; mean (SD) | 24 | 56.6 (24.3) | 20 | 67.4 (23.8) | 0.01 |
No participants changed in CAS.
At the hospital, 20 of the 23 patients (83%) were able to perform at least one set of 8–12 RM at a given level of STAND—the remaining three patients stopped after 6–7 repetitions; one due to dyspnea, one due to muscular fatigue, and one due to back pain that was present before performing the exercise. All three patients were subsequently able to perform several sets of 8–12 RM in their own home.
At home, 15 of the 19 patients (79%) were able to perform two sets of 8–12 RM, and 8 of these were able to perform three sets of 8–12 RM. Reasons for not attaining the goal of two sets of 8–12 RM were: one patient could perform seven repetitions in set one and 10 repetitions in set two; one patient stopped after one set due to knee pain—this pain did not persist after ending the exercise; one patient wanted to stop after one set due to a sensation of muscular fatigue during the first set; one patient wanted to stop in set two due to a sensation of muscular fatigue.
The 20 patients completing one set at the hospital were distributed in STAND as follows: two seated knee extensions, two sit-to-stand using the arm rests when standing and sitting down, two sit-to-stand using the arm rests when sitting down, six sit-to-stand with the arms crossed over the chest, six sit-to-stand with extra load, one unilateral sit-to-stand, and one unilateral sit-to-stand with extra load. The 15 patients completing two sets at home were distributed in STAND as follows: three sit-to-stand using the arm rests when standing up and sitting down, one sit-to-stand using the arm rests when sitting down, four sit-to-stand with the arms crossed over the chest, four sit-to-stand with extra load, one unilateral sit-to-stand, and two unilateral sit-to-stand with extra load (
Level in STAND | Description of level | Illustration | In hospital ( |
At home ( |
---|---|---|---|---|
1 | Seated knee extensions with or without added load, e.g., weight cuffs. |
|
2 | 0 |
2 | STS with armrest support and support from another person allowed; own body weight. |
|
0 | 0 |
3 | STS with armrest support in eccentric and concentric phase allowed; own body weight. |
|
2 | 3 |
4 | STS with armrest support in concentric phase allowed; own body weight. |
|
2 | 1 |
5 Starting point | STS without support; own body weight. |
|
6 | 4 |
6 | STS with added load; e.g., weight vest. |
|
6 | 4 |
7 | Unilateral STS with balance support allowed; own body weight. |
|
1 | 1 |
8 | Unilateral STS with balance support allowed and with added load; e.g., weight vest. |
|
1 | 2 |
sit-to-stand
Two patients were at the lowest level of STAND at the hospital (knee-extensions with three and six kg, respectively). For both patients, further regression was possible by using less weight (they both performed the exercise at level 3 at home). One patient was at the highest level of STAND at the hospital and two were at the highest level at home (unilateral sit-to-stand with six kg and four kg, respectively)—for both patients, further progression was possible by adding more weight.
Four patients and two patients, respectively, reported an increase in pain after the DEMMI test at the hospital and at home. None of these patients reported any pain before the exercise.
Four patients reported light to moderate pain in the shoulder, leg and chest, respectively, before performing the exercise at the hospital. The pain remained unchanged during and after the exercise for three of the patients and one patient reported no pain after ended exercise. Three patients reported light leg pain during the exercise but no pain before and after the exercise. Four patients reported light to moderate pain in the shoulder, back, leg and head, respectively, before performing the exercise at home. The pain remained unchanged during and after the exercise for three of the patients and one patient reported less pain after ended exercise. Two patients reported light back pain during the exercise but no pain before and after the exercise.
As shown in
DEMMI score: score on the De Morton Mobility Index (0–100). The higher the score the better mobility. OMC score: score on the Short Orientation-Memory-Concentration test (0–28). The higher the score the better cognition. STAND level: 1 indicates lowest level of the model (seated knee-extensions) and 8 indicates highest level of the model (unilateral sit-to-stand with added load).
The major finding of our feasibility study was that our exercise model of progressive sit-to-stands (STAND) was feasible among hospitalized older adults and demonstrated potential for being used in a future study appropriately powered to evaluate the effect of the exercise on mobility, physical activity, functional performance and independence in this population. Specifically, we found that more than 75% of the patients assessed during hospitalization and shortly following discharge in their own home were able to perform the sit-to-stand exercise at a given level of STAND reaching an intensity of 8–12 RM for 8–12 repetitions. No clustering of patients at the highest or lowest level of STAND was seen, suggesting no ceiling or floor effect, and for all patients assessed a possibility of either progression or regression was possible. Finally, no adverse events were reported.
Consistent with this study, previous studies have found resistance training to be feasible in older hospitalized patients (
A limitation of the study is that the assessed patients represent a select group of acutely admitted older medical patients as 90% of the patients fulfilling the inclusion criteria were either excluded (80%) or declined to participate (10%). The proportion of patients consenting to participate, however, is equal to (
A major strength of our study is that the exercise, following STAND, is well-described, simple and low in cost making it possible to implement both in an acute hospital ward as well as in the patients’ homes. A study by
We are now conducting a randomized controlled trial to test a cross-continuum strength training intervention in older medical patients (NCT01964482). The goal of the trial is to investigate the effect of a simple, supervised strength training program consisting of two lower-extremity strength training exercises. The exercises are based on STAND and performed during hospitalization and the first four weeks after discharge at home.
Based on our pre-defined criteria for feasibility we found that a simple progression model for loaded sit-to-stands (STAND) was feasible in acutely admitted older medical patients (+65 yrs) in the hospital- and home setting. Following the progression model, a strength-training intensity of 8–12 RM for 8–12 repetitions was reached for two thirds of the assessed patients with no indication of ceiling or floor effect for load, and no report of adverse events.
Thanks to the physiotherapists in the municipality of Copenhagen for helping in the development of the model.
The authors declare there are no competing interests.
The following information was supplied relating to ethical approvals (i.e., approving body and any reference numbers):
The Ethics Committee of the Capital Region of Copenhagen (H-2-2012-115).
The following information was supplied regarding data availability:
Raw data can be found in the