Why Moving Matters

Even prior to admission to hospital, 5-13% of older persons of 65 years and older have low muscle mass; increasing to 50% in persons that are over 80 years old. Declining muscle mass in the lower extremities with ageing is most significant to mobility status, and the cross-sectional area of the vastus lateralis (quadriceps) muscle decreases by up to 40% between the ages of 20 and 80 years.

Older patients are most likely to come to hospital and become deconditioned; increased immobility for prolonged periods significantly reduces muscle mass and function, with 30-60% experiencing functional decline after hospitalisation, resulting in a decline in health-related quality of life and autonomy. Frailer older people (those who require a walker), those who report unsteadiness at hospital admission, and those with cognitive impairment are significantly more likely to suffer functional decline whilst in hospital. This hospitalisation-associated decline in function is associated with increased risk of readmission, nursing home placement and mortality.

Evidence demonstrates that age is not a barrier to improve aerobic fitness and strength gains through appropriate training, and the changes seen are similar to what younger people can achieve.

References

Kleinpell RM, Fletcher K, Jennings BM. Reducing Functional Decline in Hospitalized Elderly. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 11. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2629/

Baumgartner, R. N., Waters, D. L., Gallagher, D., Morley, J. E. & Garry, P. J. Predictors of skeletal muscle mass in elderly men and women. Mech. Ageing Dev. (1999) doi:10.1016/S0047-6374(98)00130-4

Evans, W. J. & Lexell, J. Human Aging, Muscle Mass, and Fiber Type Composition. Journals Gerontol. Ser. A Biol. Sci. Med. Sci. (1995); doi:10.1093/gerona/50a.special_issue.11

Seals DR, Hagberg JM, Hurley BF, Ehsani AA, Holloszy JO. Endurance training in older men and women. I. Cardiovascular responses to exercise. J Appl Physiol. 1984;57:1024-1029

Frontera WR, Meredith CN, O’Reilly KP, Knuttgen HG, Evans WJ. Strength conditioning in older men: skeletal muscle hypertrophy and improved function. J Appl Physiol. 1988;64:1038-1044.

p>Patients in hospital are particularly sedentary. Patients on a rehabilitation ward were shown to be non-sedentary for only 70 (± 50) min a day, with 70% of this time spent in standing or walking in bouts of less than 5 minutes.

Immobilisation can lead to 3-4% reduction in muscle strength per day during the first week and there is a 40% decrease in isokinetic muscle strength after 3 weeks of immobilisation.

Even in young, healthy adults, there has been shown to be a loss of lower body lean mass in the order of 100-200 g·wk^-1. A total body lean mass loss of 2.6 kg following 119 days of bed rest in healthy young males has been demonstrated; of this, 2.4 kg was from the legs (0.14 kg·wk^-1).

Hospital associated deconditioning leads to adverse outcomes;

• Poor functional ability below that of pre-hospital admission
• Increased risk of activity of daily living disability
• Decline in muscle strength
• Decline in muscle mass
• Decline in cognitive function
• Older people with deconditioning have higher rates of re-admission and lower rates of community discharge.

These adverse outcomes are in part (if not completely) avoidable during acute hospitalisation. Systematic reviews have shown that improvement in mobility and balance over the first 48 hrs of admission are associated with prevention of hospital associated deconditioning by maintaining or improving physical functioning, as well as shorter recovery times and reduced length of stay.

References:

Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extrem Physiol Med. 2015;4:16. Published 2015 Oct 9. doi:10.1186/s13728-015-0036-7

Grant, P & Granat, Malcolm & Thow, Morag & Maclaren, William. (2010). Analyzing Free-Living Physical Activity of Older Adults in Different Environments Using Body-Worn Activity Monitors. Journal of aging and physical activity. 18. 171-84. 10.1123/japa.18.2.171.

LeBlanc AD, Schneider VS, Evans HJ, et al. Regional changes in muscle mass following 17 weeks of bed rest. J Appl Physiol. 1992;73:2172–2178

Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc . 2009;57:1660–1665.

HM Krumholz. Post-hospital syndrome—an acquired, transient condition of generalized risk. New England Journal of Medicine, 2013 – Mass Medical Soc
Falvey JR, Mangione KK, Stevens-Lapsley JE. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Phys Ther. 2015; 95(9): 1307-1315.

Cortes OL, Delgado S, Esparza M. Systematic review and meta-analysis of experimental studies: in-hospital mobilization for patients admitted for medical treatment. J Adv Nurs. 2019; January 22.

The impact of physical inactivity during hospitalisation is well documented. It has shown to be an independent predictor of negative outcomes for older patients, which leads to longer stays and a reduction in quality of life. Longer hospital stays results in increased risk of complications such as hospital acquired infections, and prolonged mobilisation can lead to deep vein thrombosis formation, and eventually pulmonary emboli.

• A systematic review of 13 studies, with 2703 participants, demonstrated mobilisation programmes reduce hospital stay on average by 2.18 days compared to the control group (95% CI -3.44 to -0.92; five studies, 1,355 participants).
• In patients with pulmonary emboli, fewer developed new clots in the lungs on mobilisation programmes: 9 (5.4%) new clots versus 21(13%) treated with usual care (odds ratio [OR] 0.33, 95% CI 0.14 to 0.78; two studies, 321 participants).
• Functional exercise training and balance activities in a subacute hospital setting showed a reduction in falls within the hospital setting.

References

Doherty-King, B., & Bowers, B. (2011). How Nurses Decide to Ambulate Hospitalized Older Adults: Development of a Conceptual Model. The Gerontologist, 51(6), 786–797. doi:10.1093/geront/gnr044

Cortes OL, Delgado S, Esparza M. Systematic review and meta-analysis of experimental studies: in-hospital mobilisation for patients admitted for medical treatment. J Adv Nurs. 2019; January 22

Haines, TP. Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation. Clinical Rehabilitation 2007; 21: 742–753

Patients who have non-communicable diseases are the least physically active in society and have most to gain from becoming physically active – people with long-term conditions are twice as likely to be inactive (35% versus 14%).

Healthcare professionals having a lack of knowledge around the benefits of physical activity is a key driver in this. Despite the multiple benefits of physical activity in patients with cancer such as helping with symptoms of fatigue and depression, 10% of healthcare professionals feel that rest is needed for cancer patients. Only 23% of oncologists talk about physical activity with patients during and after cancer treatment.

Those who are inactive (less than 30 minutes per week) can significantly lower their risk of mortality with only small increases in their physical activity levels.

References

https://www.sportengland.org/media/13898/active-lives-adult-november-17-18-report.pdf

Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;175(6):959–967. doi:10.1001/jamainternmed.2015.0533

https://www.macmillan.org.uk/documents/aboutus/commissioners/physicalactivityevidencereview.pdf

Non-vigorous physical activity and all-cause mortality: Systematic review and meta-analysis of cohort studies; Woodcock, J; International Journal of Epidemiology; 2011

https://www.macmillan.org.uk/documents/aboutus/newsroom/physicalactivityreport.pdf

A key component of the NHS Long Term Plan (LTP) which was published in January 2019 is around prevention, and ways to stop 500,000 preventable deaths over the next 10 years.

Physical inactivity ranks fourth in the Global Burden of Disease study, causing more premature deaths than obesity. Preventing the burden of ill-health requires a concerted effort from individuals, communities, government and hospitals, with the Active Hospitals toolkit strongly aligning with this agenda.

Public Health’s initiative of Everybody Active, Every day, also closely aligns with this strategy, with healthcare professionals having a key role. Fundamentally, cultural change is needed to make physical activity part of everyday life.

• Active Society: Creating a social movement
• Active Environments: Creating the right spaces
• Moving at scale:: scaling up interventions that make us active
• Moving Healthcare Professionals programme
• Training existing healthcare professionals
  • 22000 healthcare practitioners received practical training on physical activity
  • 35 clinical physical activity champions
  • 15 GP clinical champions
  • 4 non-medical clinical champions
  • 18 nurse clinical champions

References:

WHO (2009) Global health risks: mortality and burden of disease attributable to selected major risks

NHS England Long Term Plan – https://www.longtermplan.nhs.uk/

Everybody Active Every day

If physical activity were a pill, it would be the most commonly prescribed medication in the world. No other intervention has such wide-reaching benefits.

Beyond prevention, there is good evidence to demonstrate that regular physical activity can benefit patients with a number of diseases. Check out our Moving Medicine Prescribing Movement modules for the evidence for a number of conditions including but not limited to, cancer, diabetes, dementia and COPD.

In depression for example, strong evidence exists that physical activity improves mood and scores on validated depression screening tools.

A recent edition of Public Health England Health Matters focuses on the benefit of physical activity for the prevention and management of long-term conditions in adults.

References:

Start Active, Stay Active (2011) based on US Department of Health and Human Services Physical Activity Guidelines Advisory Committee Report (2008), Washington DC

https://www.gov.uk/government/publications/physical-activity-applying-all-our-health/physical-activity-applying-all-our-health

The Chief Medical Officers’ report provided guidance as to how much physical activity children, young people, adults and older adults should be getting.

• Since the 1960s we are over 20% less active, and by 2030 we are projected to be 35% less active
• In the UK, 25% of women and 20% of men are physically inactive, which is defined as not even getting 30 minutes of physical activity a week
• Only 20% of boys and 15% of girls between the ages of 5-15 are reaching recommended physical activity levels
• The consequences of this are already taking a huge toll on society
• One person dies of physical inactivity every 15 minutes – that is more than cigarette smoking – causing 1 in 6 deaths in the UK
• Physical inactivity costs the UK £7.4billion annually, costing the NHS £1 billion

References:

PHE Guidance Health matters: getting every adult active every day (July 2016)

Muscle strength reaches its peak at 30 years of age, and though there is a small decline till the age of 50, it is in the 5^th decade of life that most changes occur. Muscle loss occurs at 0.5-1%, and muscle strength declines at even greater rate, 3-5% per year. Major diagnosis, pregnancy, the starting of medical treatment and hospitalisation have all been shown to increase the rate of muscle strength and mass decline.

Regular physical activity can offset much of the changes in muscle function seen with ageing.

Major diagnoses, disease event, pregnancy and hospitalisation are teachable moments for behaviour change, and offer healthcare professionals an opportunity to create a positive impact in their patient’s lives. For example, of the 2 million cancer survivors in the UK, 1.6 million are not physically active to recommended levels, despite the well documented benefits.

References

Keller K, Engelhardt M. Strength and muscle mass loss with aging process. Age and strength loss. Muscles Ligaments Tendons J. 2014;3(4):346–350. Published 2014 Feb 24.

Health Survey for England 2016; Skelton DA, Mavroedi A (2018) JFSF 3(2):74-84; PHE / Ipsos MORI, unpublished data

Maddams J, et al. Cancer prevalence in the United Kingdom: estimates for 2008. British Journal of Cancer. 2009. 101: 541-5472

https://www.macmillan.org.uk/documents/aboutus/newsroom/physicalactivityreport.pdf

Healthcare professionals have always been considered well placed to provide physical activity advice to patients. 25% of patients would be more active if advised by a healthcare professional. Patients also trust the advice of hospital healthcare professionals:

• 93% of people trust advice from hospital doctors
• 91% of people would accept advice from hospital doctors

Therefore, hospital staff are well placed to provide positive change to patients and even brief education about physical activity can make huge changes.

References

Kohl HW, Craig CL, Lambert EV, et al. The pandemic of physical inactivity: global action for public health. Lancet. 2012;380(9838):294–305. doi: 10.1016/S0140-6736(12)60898-8
https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day
7th International Society for Physical Activity and Health Congress. (2018). Journal of Physical Activity and Health, 15(10 Suppl 1), S1–S249. doi:10.1123/jpah.2018-0535

NICE Guideline PH44 – recommendation 3. Incorporating brief advice in commissioning

NICE recommends that when commissioning services to prevent or treat conditions such as cardiovascular disease, type 2 diabetes and stroke or to improve mental health, ensure brief advice on physical activity is incorporated into the care pathway.

Ensure brief advice on physical activity is incorporated into services for groups that are particularly likely to be inactive. This includes people aged 65 years and over, people with a disability and people from certain minority ethnic groups.

• Include physical activity assessment and brief advice as part of a strategy for addressing domain 2 of the public health outcomes framework Proportion of physically active and inactive adults indicator.
• Ensure assessment of physical activity and the delivery of, and follow up on, brief advice  (see Nice Guidance PH44 – recommendations 1–2) are built into local long-term disease management strategies. Highlight physical activity as an independent modifiable risk factor for many conditions. Strategies should also raise awareness of physical activity assessment as part of relevant quality and outcomes framework (QOF) indicators.

The UK Faculty of Sport and Exercise Medicine has produced documents on the application of exercise medicine ‘A Fresh Approach’ and ‘A Fresh Approach in Practice’, which outline the benefits of sport and exercise services to patients and the NHS.

Reference:

RCGP Physical Activity and Lifestyle Toolkit, accessed at https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/physical-activity-and-lifestyle.aspx