This was our Journal Club for October while I was out from the blog with computer issues. So now we’ll catch you up.
This article looks at Hospital-Associated Deconditioning (HAD) which is characterized by loss of functional reserve which results in a decline in physical function (ability to stand up, walk, etc.),and activities of daily living (ADL) such as dressing and showering oneself weakness, decreased stamina, poor appetite, and fatigue. The article proposes that HAD is a hospital phenotype of frailty.
With this definition in our pockets, therapists are challenged to stand in the gap– to make sure people (mostly the elderly) that are at high risk to get HAD get therapy services while hospitalized to prevent hospital readmission and to create a diagnosis specific plan of care in which to treat these folk for better outcomes. The article focuses on the second portion there, because people with HAD are more likely to be readmitted and it is proposed it is because they do not have a clearly defined diagnosis nor diagnosis specific plan of care.
Here is a visual diagram comparing the current plan vs. the authors’ proposed plan of care for HAD.
So as you can see, we are replacing general conditioning activities (CGAs) which include activities that do not apply skilled therapeutic frequency, intensity, duration or specificity, like supine AROM therex with high intensity resistance training as our base. Followed up with moderate-high intensity gait, balance and ADL training, moderate aerobic training then iced with the CGAs.
What does that look like in real life? Obviously, we’re minimizing the supine and seated AROM therex with no appropriate dosage of intensity and utilizing ACSM’s recommendations for appropriate resistance training dosage in the older adult. We’re wanting more quality in our gait, balance and ADL training activities and pushing our patients to go just a little further than they think possible. Then add a little aerobic training on an endurance machine (bike, treadmill, elliptical, etc.). Perhaps a little supine exercise every now and again as a “space holder”– that’s what I call activities that are easier that I put between higher intensity activities. Perhaps this also means breaking our sessions out into multiple smaller sessions, so we can make the intensity appropriate.
Bottom line: leave traditional treatment strategies in the past. Apply evidenced based frequency, intensity, duration and specificity to this population. Just because they’re old, doesn’t mean they’re going to break. They’re muscles still react to stress, but it takes more stress to increase them than in the young and probably have sarcopenia. Consider breaking up your time into multiple high intensity sessions to keep your patients safe. Sell your product to these people. Get them to buy into the program and they’ll get the results they want: to get back to their pre-hospitalization independence.