Evidence-Based, Optimal Strength Exercise Parameters: Practice Considerations for Speech Therapists

Transcription

1 Evidence-Based, Optimal Strength Exercise Parameters: Practice Considerations for Speech Therapists Mark Richards, PT, MS, CEEAA Vice President of Clinical Services Accelerated Care Plus office phone:

2 Disclosures I have relevant financial relationship(s) with the products or services described in this presentation as I am an employee of Accelerated Care Plus, Inc., Reno, NV. ACP manufactures 2 products that are indirectly referenced in my presentation: Omniband (elastic bands) and Synchrony (a surface EMG assessment and exercise system). 2

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4 Session Schedule THE PROBLEM OF WEAKNESS IN SPEECH THERAPY PATIENTS BRIEF REVIEW OF LITERATURE: S.T. STRENGTH EXERCISE S.T. STRENGTH EXERCISE NEEDS & RECOMMENDATIONS OPTIMAL STRENGTH EXERCISES & PARAMETERS DOCUMENTATION OF STRENGTH EXERCISE EXERCISE DEMONSTRATION EXERCISE LAB Q & A 4

5 THE PROBLEM OF MUSCLE WEAKNESS Speech Therapy Patients

6 Weakness ST Correlations Reductions in 1. Neural activation and, 2. Muscle force output are correlated to functional deficits commonly addressed by speech therapists: Oral motor function: Dysarthria Bolus preparation Bolus management Pharyngeal phases of swallow Voice production and support 6

7 Average Loss of Strength Across Lifespan Age 30 to 50-1/2 # mm per year (Evans and Rosenberg, Biomarkers 1992) Age 50-1 # mm per year (Nelson, et al, JAMA, 1994) Deposition of fat Losses of muscle strength 60 s and 70 s 15% each decade 80 s and 90 s 30% each decade (Med Sci Sports Ex, 1998) Muscle atrophy AND neural decay 7

8 Sarcopenia Donna CT Scans: Mid-thigh 24 year old 64 year old Occurs throughout the body including oropharyngeal mm. Greater loss of Type II fibers (motor neurons and fiber size) 8

9 Muscle Fiber Types Type I Aerobic (oxidative system) Slow Twitch Weaker but fatigue resistant Type II (IIa, IIb, IIc) Anaerobic (alactic & creatine phosphate energy systems) Fast Twitch Stronger but fatigue more readily Percentage of fiber types in each muscle to varies by location in the body (strength vs. endurance demands/ requirements) 9

10 Weakness - Averages Leg Strength

11 Weakness: Oropharyngeal Muscle weakness directly affects these functions: Oral Motor Function Oral Phases of Swallow Dysphagia (MANY. MOST?) Pharyngeal Phases of Swallow In older adults, swallows are typically characterized by a delay between the time of bolus entry into the pharynx and hyoid descent, allowing the bolus to be adjacent to an unprotected airway for a precarious moment. (Kays S, Seminars in Speech and Language, 2006) 11

12 Weakness: Posture & Function Muscle weakness contributes to poorer posture and indirectly affects these functions: Respiration Voice production TMJ position and function Swallowing (degree?) 12

13 Causes of Muscle Weakness Natural aging Hormonal decrements leading to: Neural decrements Histological decrements Inactivity Lifestyle Illness and chronic impairments Neuromuscular diseases 13

14 Neural Decrements Alpha motor neuron death (corticospinal) and loss of mm. fibers (Larson and Ansved, Prog Neurobiol 1995) afferent input & motoneuron excitability (mm. tension, ROM, etc.) and decreased ability to sense degree of effort (Corden and Lippold, J Neurophysiol, 1996) (Thelen, et al; J Gerontol Med Sci, 1998 Decreased force-frequency response and firing rates; slower and less coordination (Narci, et al; J Appl Physiol, 1991) (Laidlaw, Bilodeau, Enoka, Muscle Nerve, 2000) (Erim, Journal of Neurophysiology, 1999) Increased coactivation of agonists/antagonists (Macaluso, et al; Muscle Nerve, 2002) 14

15 Histological Decrements Fiber mass motor fiber atrophy and death Largest contributor to strength loss Increased motor neuron span of control (Larsson and Kaulsson, Acta Physiol Scand 1978) (Newman, et al; JAGS, 2003) Adoption by slow twitch motor neurons Fiber ratios (Bellew, Issues on Aging 1998) Decreased ability to produce force rapidly (Izquierdo, et al; Acta Physiol Scand, 1999) Reduced muscle fiber specific tension (Larson and Frontera, Am J Physiol, 1999) 15

16 BRIEF REVIEW OF LITERATURE Speech Therapy Strength Exercise

17 ST Strength Research Investigations have included the following S.T. strength exercises: Oral motor, such as Lip closure Biting Tongue pressure Pharyngeal, such as Effortful swallow Mendelsohn maneuver Shaker (head lift) Chin tuck against resistance Resisted expiration 17

18 Muscle Strengthening Benefits Increasing muscle performance has been shown to: Increase lingual isometric strength and volume with carryover into greater dynamic swallow pressures Decrease laryngeal vestibule penetration, tracheal aspiration, and pharyngeal residue Improve hyoid range of motion including elevation, anterior excursion, and upper esophageal sphincter opening Enhance bolus clearance, reduce aspiration and lead to less restrictive diet (Kays S, Seminars in Speech and Language, 2006) 18

19 SPEECH THERAPY STRENGTH EXERCISE Needs & Recommendations

20 ST Strength Exercise Needs Presently, a gold standard does not exist for the most optimal prescription for the majority of treatment options. Sapienza, Exercise Prescription for Dysphagia: Intensity and Duration Manipulation, ASHA Perspectives 20

21 ST Strength Exercise Needs The principle of overload holds that in order to increase the forcegenerating ability of a muscle, that muscle must be taxed beyond its current capacity to respond. That is, it must be exposed to a load greater than what it is typically exposed to on a daily basis. Wheeler-Hegland, Submental semg and Hyoid Movement during Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training, Journal of Speech, Language, and Hearing Research,

22 ST Strength Exercise Needs A case control study of patients receiving swallow therapy demonstrated that progressive resistive boluses may result in superior clinical outcomes compared to using a bolus of the same/ constant resistance bolus The methods included lower repetitions for the progressive resistance bolus compared to high repetitions for the constant bolus Carnaby-Mann, McNeill Dysphagia Therapy Program (MDTP): A case control study. Archives Physical Medicine Rehabilitation,

23 ST Strength Exercise Needs Specific exercises recommended to improve voice production include: Neck retractors Infrahyoid group Neck flexors Scapular retractors Wilson Arboleda, Considerations for Maintenance of Postural Alignment for Voice Production, J Voice,

24 ST Strength Exercise Needs What lessons learned can we borrow from the thousands of strength training RCTs involving healthy and morbid subject populations? Further more, how may these lessons be applied in a clinically practicable manner: Time-efficient Realistic modes of delivery Safely Good patient compliance/ willingness With the ultimate goal being enhanced therapy outcomes delivered in less time 24

25 Strength Exercise Research Summary Slide Hundreds of studies published in peer reviewed journals STRONGLY demonstrate the effectiveness and safety of strength exercise. This includes a preponderance of studies with methods that included high intensity protocols. There are no reports of any serious injuries or serious exacerbations of medical conditions in response to strength exercises. These findings include studies that have investigated the impact on subjects with specific diseases. The list of organizations that formally RECOMMEND strength exercise as essential to health and function is impressive 25

26 Strength Exercise Advocates World Health Organization Centers for Disease Control & Prevention U.S. Department of Health and Human Services National Institutes of Health National Institute on Aging UK National Health Service American College of Sports Medicine American Geriatrics Society American Family Physicians American Medical Association The Cleveland Clinic Johns Hopkins Mayo Clinic and furthermore, disease-specific organizations 26

27 Strength Exercise Advocates International Osteoporosis Foundation Osteoarthritis Research Society International Arthritis Foundation American Heart Association American Association of Cardiovascular and Pulmonary Rehabilitation American Academy of Orthopedic Surgeons American Stroke Association National Multiple Sclerosis Society National Parkinson s Foundation National Kidney Foundation American Diabetes Association 27

28 Strength Exercise Physiologic Effects Recruitment and motor learning (Fiatarone, JAMA 1990) Synchronization and motor control (Patten, Topics Geriatr Rehab 2000) Swallow exercise, activation of/ increased reliance on supplemental brain regions Fiber hypertrophy and muscle mass (Lexell, Topics Geriatr Rehab, 2000) Enhanced agonist/antagonist coactivation and neuromuscular coordination (i.e., timing) (Gabriel, Sports Med, 2006) Strength Time (months) 28

29 Summary of the Evidence It is relatively easy to generate strength gains in weakened patients of all ages Generally, weakened patients strengthen quickly (Evans, % gains per week for first 8 weeks) The weaker the individual, the more functionally meaningful the strength gain The more disabled the individual, the more strength gains positively impact quality of life 29

30 Absolute Contraindications Open and/or healing trachs (Shaker) Airway obstruction Recent fractures (unstable) Advanced CHF Cancer (tumors in target area) Recent, unstable MI Acute illness Acute inflammatory neurological disease 30

31 Exercise Termination Criteria ONSET OR WORSENING OF THE FOLLOWING: Onset of angina Blood pressure changes as outlined Lightheadedness Confusion Ataxia Palor Cyanosis Cold and clammy skin Noticeable changes in heart rhythm 31

32 OPTIMAL STRENGTH EXERCISES & PARAMETERS

33 Isometric Isometric: Muscle contraction where joint angle and muscle length do not change. Contractions held from a few to several seconds. Examples of Speech Therapy Isometric Exercises Lip press (closure) Lip protraction/ retraction Tongue pressure Bite Mendelsohn Maneuver Shaker (3, extended holds) Chin tuck against resistance (CTAR: ISO-SED, inflatable rubber ball) 33

34 Isotonic ( Isokinetic ) Isotonic: Muscle contractions that generate dynamic joint movement and includes shortening and lengthening of the muscle tissue. Muscle tension remains relatively constant. Examples of Speech Therapy Isotonic Exercises Shaker (repeated head lifts) Mastication exercise Resisted tongue movements Jaw opening against resistance Effortful swallow Resisted expiration Cervical movements (flexion, extension) 34

35 Optimal Strength Exercise Parameters Exercise Intensities High Moderate Repetitions, Sets & Frequency Progression and Documentation 35

36 Keys To Strength Exercise: 1. Intensity Classic Study: David Buchner Topics In Geriatric Rehabilitation 1993 Meta analysis: Effect sizes (standardized difference between means) Why did aged subjects get stronger?: - Frequency: statistically significant - Duration: statistically significant - Intensity: AHA! (p<0.001) The American College of Sports Medicine Position Stands include similar intensity (and exercise) recommendations for individuals of all ages 36

37 Exercise Intensities Repetitions

38 Exercise Intensities Strength Exercise Aerobic Exercise 30 Possible, Unlikely for Most, Inefficient

39 High Exercise Intensity WHY? Greatest strength gains Shortest period of time Longest lasting strength gains if/ when exercise is stopped Hard 8 12 Somewhat hard 80% of maximum (likely) 70% of maximum (likely)

40 Moderate Exercise Intensity WHY? Starting PRE s, to gauge exercise response When exercising the cervical spine Somewhat hard 12 Fairly light 20 70% of maximum (likely) 50% of maximum (likely)

41 Exercise Intensities: Subjective Determining subjective exercise intensities: No need to perform 1 Rep Max test Choose an amount of resistance you think: Your patient can complete the minimum rep target number But not more than the maximum rep target Example, 8 to 12 reps (high intensity or 70% to 80% of max): choose an elastic band resistance (color) you think the patient is likely to complete at least 8 good quality repetitions but not more than 12 41

42 Exercise Intensities: Subjective Determining subjective exercise intensities: Does your patient/ client have a look of concentration? Borg Scale: AFTER 2 nd REPETITION ASK, High: 8 12 reps: somewhat hard to hard Moderate: reps: fairly light to somewhat hard Mild tremor Respiration increases slightly 42

43 Calculating % of Max. Effort Determining objective exercise intensities: Doable with any exercise for which objective performance data or resistance can be objectively determined Surface EMG (percentage of muscle activity during repetition test trials) Manometer (pressure measurement; e.g. expiratory lung pressure, Iowa Oral Performance Instrument [IOPI], Madison Oral Strengthening Therapeutic Device [MOST]) Isotonic machines (e.g. Nautilus Cervical) 43

44 REPETITIONS, SETS & FREQUENCY

45 Repetition Performance Every repetition should be high quality: speed, ROM, form, and breathing For our OT and PT colleagues, Therapeutic Exercise, CPT code 97110, is a directly attended code requiring a therapist s undivided attention Observe every repetition and correct patient when needed. Stop the set of exercise when the patient cannot self-correct poor rep performance: - Moves too quickly - Incomplete ROM - Poor form (substitution) - Holds breath 45

46 Repetition Performance Do not tell patients how many reps to do As discussed, stop set when despite your cues and instructions for the patient to improve repetition performance, he/she cannot self-correct and has to cheat to continue Document the last, properly performed rep 46

47 Set Performance How many sets of multiple repetitions? Traditional - 3 Sets Research shows that excellent strength gains are achieved by performing one set of exercise Some studies show that two or three sets may generate greater strength than one set but a single set should be used when exercise time is an issue. Quality, not quantity. 47

48 Strength Exercise Frequency Rest days are required for muscles to grow and are increasingly important the longer the training period Therapy: - At least 2 to 3 times per week - Because average therapy LOS is 4 to 6 weeks, and this is the neural adaptation time zone, daily? - Spinal musculature: Perhaps one set to momentary fatigue, 1x per week? 48

49 Endurance? Are high repetitions required to improve functional muscle endurance? Perhaps not. In addition to Type II fibers, high intensity, low repetition resistance exercise engages fatigue-resistant Type I fibers and improves functional endurance: - Time to exhaustion improved 47% for cycling and 12% for running in healthy men in response to quad strengthening (Hickson RC, et al, Med Sci Sports Exer, 1980) - Walking endurance in aged subjects increased 38% (Ades PA, et al, Ann Intern Med 1996) - The initial goal of a training program to enhance muscular endurance should be to increase maximum strength (Naclerio, J Strength Cond, 2009) 49

50 Keys To Strength Exercise: 2. Progression In order for a muscle to continue to strengthen, the resistance applied must be increased as the muscle becomes stronger. Therefore: Isometrics: A stronger muscle contracts more forcefully so inherently, resistance is progressed if the exercise rating of perceived exertion remains constant Isotonics: Switch to more resistive elastic band (different color) as muscle strength increases Percentage of 1RM: A stronger muscle contracts harder so inherently, resistance is progressed if the patient continues to exercise at the same percentage of a 1 RM 50

51 Progression of Resistance As muscles strengthen, steady increases in resistance are REQUIRED for muscle strengthening to continue When to increase isotonic exercise resistance? 51

52 Progression of Resistance When patient can perform good quality repetitions equal to the upper repetition target number for the desired intensity Normally, using the same resistance, the number of repetitions a patient can perform increases during subsequent treatment sessions High Moderate to High

53 Progression? CTAR Exercises Issues: Shaker too difficult or uncomfortable for some patients to perform Shaker: Once 3 repetitions of 60 hold time accomplished, no longer a progressive resistive exercise Exercise apparatus may also have fixed, non-progressive resistance Solution?: Elastic bands? 53

54 Isometrics: Recommendations Optimal Isometric Exercise Parameters Hard intensity Six second hold, each repetition Ten repetitions Breathe (Mendelsohn Maneuver the exception) 54

55 Isotonics: Recommendations Optimal Isotonic Exercise Parameters Elastic resistance Identify appropriate resistance band (color) per as outlined per desired exercise intensity Have patients exercise to momentary fatigue while moving slowly, through the fullest available ROM, with good form and technique without holding their breath Switch to next, more resistive band (color) as strength increases 55

56 DOCUMENTATION OF STRENGTH EXERCISE

57 Exercise Termination Criteria MUST track for each exercise: Exercise description Comments, special patient cues, important observations Date Resistance Repetitions 57

58 Document Progress EXERCISE DATE 2/4 2/6 2/8 2/11 2/13 2/15 2/18 2/20 2/22 2/25 1. Chin Tuck Against Elastic Resistance RES Patient cued to sit up right, move slowly, and touch chin to sternum for each rep. REPS Y Y R R R G G G G B RES REPS 3. RES REPS 4. RES REPS 58

59 Progress Notes Correlate strength gains to functional status citing objective measures. Example: Patient has increased CTAR against elastic resistance 2 band colors and is now able to perform 9 typical (normal) swallows with nectar thick, 10ml bolus before demonstrating double swallow vs. 3 reps 1 week ago. See PRE flow sheet for exercise details 59

60 STRENGTH EXERCISE DEMONSTRATION

61 STRENGTH EXERCISE LAB

62 Lab: Do One or Both 1. Chin Tuck Against Resistance Benefits: Increased hyolaryngeal motion and increased UES opening Mode: Elastic resistance Intensity: Moderate Repetitions: To momentary fatigue Sets: 1 2. Scapular Retraction Benefits: Improves head-on-neck posture (kinetic chain) to facilitate better voice production Mode: Elastic Resistance Intensity: High Repetitions: To momentary fatigue Sets: 1 62

63 Session Schedule THE PROBLEM OF WEAKNESS IN SPEECH THERAPY PATIENTS BRIEF REVIEW OF LITERATURE: S.T. STRENGTH EXERCISE S.T. STRENGTH EXERCISE NEEDS & RECOMMENDATIONS OPTIMAL STRENGTH EXERCISES & PARAMETERS DOCUMENTATION OF STRENGTH EXERCISE EXERCISE DEMONSTRATION EXERCISE LAB Q & A 63

64 QUESTIONS & ANSWERS 64

65 65 Illustration courtesy of NovaCare, Inc.