Assessing Muscle Function and Balance Problems at Home, in the

Assessing Muscle Function and
Balance Problems
at Home, in the Clinic, and in Research
25th IOA Colloquium on Aging
September 17, 2013
Bjoern Buehring, M.D.
University of Wisconsin School of Medicine and Public Health
GRECC, William S. Middleton Memorial Veterans Hospital
Madison, WI, USA
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Disclosures/Conflicts of Interest
None
Outline
  How
independent and active are older
Americans?
  Muscle and Biomechanics 101
  How do you know how well your muscles
work?
  The impact of poor muscle function on
health
Activities of Daily Living are Parameters of
Independence and Mobility
Activity of Daily Living
Instrumental Activities of Daily
Living
Personal hygiene and grooming
Taking medications as prescribed
Bowel and bladder management
Managing money
Self feeding
Use of telephone or other technology
Dressing and undressing
Housework
Functional transfers (getting into and Shopping for groceries or clothing
out of bed or wheelchair, getting onto
or off toilet, etc.)
Ambulation (walking with or without
use of an assistive device)
Transportation within the community
Impaired Function is Common in Older
Adults
 
 
 
Several governmental and non-governmental agencies
collect survey and health data on older adults
The “Older Americans 2012: Key Indicators of Well-Being”
report by the Federal Interagency Forum on Aging-Related
Statistics (Forum) summarizes several of these indicators
Data presented here are based on:
 
 
 
 
 
Centers for Medicare and Medicaid Services
Medicare Current Beneficiary Survey
Centers for Disease Control and Prevention
National Center for Health Statistics
National Health Interview Survey
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
2012_Documents/Docs/EntireChartbook.pdf#page=140
INDICATOR 20 Functional Limitations
Impaired Function is Common in Older
Adults
INDICATOR 20 Functional Limitations
Table 20a. Percentage of Medicare enrollees age 65 and over who have limitations in activities of daily living (ADLs) or
instrumental activities of daily living (IADLs), or who are in a long-term care facility, selected years 1992–2009
1992
1997
2001
2005
2007
2009
Total
48.8
42.5
43.7
42.1
42.2
41.4
IADLs only
13.7
12.7
13.4
12.3
13.8
12.1
17.7
17.6
4.5
5.1
1–2 ADLs
19.6who have limitations
16.6
17.2of daily living
18.3
Table 20a. Percentage
of Medicare enrollees age 65 and over
in activities
(ADLs) or
instrumental
activities of daily living (IADLs), or6.1
who are in a long-term
care facility,
1992–2009
3–4 ADLs
4.9
5.3selected years4.7
5–6 ADLs
Total
1992
1997 3.5
2001 3.2
2005 3.0
2007
2.5
2009
2.3
2.7
Long-term care facility 48.8
42.5 5.9
43.7 5.1
42.1 4.8
42.2
4.3
41.4
3.9
3.9
12.7
13.4
12.3
13.8
IADLs only
13.7
12.1
1–2 ADLs
18.3getting in/out of 17.7
17.6
inability to perform for a health19.6
reason) one or more 16.6
of the following tasks:17.2
bathing, dressing, eating,
chairs, walking, or using
the toilet. IADL limitations refer to
3–4 ADLs
6.1 are age-adjusted
4.9
5.3 population.
shopping, or managing money. Rates
using the 2000 standard
4.7
4.5
5.1
5–6 ADLs
Reference population: These data
3.5refer to Medicare enrollees.
3.2
3.0
2.5
2.3
2.7
4.8
4.3
3.9
3.9
Long-term care facility
5.9
5.1
Table 20b. Percentage of Medicare enrollees age 65 and over who have limitations in activities of daily living (ADLs) or
instrumental activities of daily living (IADLs), or who are in a long-term care facility, by sex, 2009
inability to perform for a health reason) one or more of the following tasks: bathing, dressing, eating, getting in/out of chairs, walking, or using the toilet. IADL limitations refer to
shopping, or managing money. Rates are age-adjusted using the 2000 standard population.
Reference population: These data refer to Medicare enrollees.
Total
Both Sexes
Men
Women
41.4
35.5
45.8
IADLs only
12.1
9.5
Table 20b. Percentage of Medicare enrollees age 65 and over who have limitations in activities of daily living (ADLs) or
1–2 ADLs
17.6
instrumental
activities of daily living (IADLs), or who are in a long-term
care facility, by sex, 200916.1
3–4 ADLs
5.1
4.3
Both Sexes
Men
Women
5–6 ADLs
2.7
2.7
Total
41.4
35.5
45.8
Long-term
care
facility
3.9
2.9
IADLs only
12.1
9.5
14.2
1–2 ADLs
3–4 ADLs
5–6 ADLs
14.2
18.8
5.8
2.6
4.4
17.6
16.1
18.8
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
5.1
4.3
5.8
2012_Documents/Docs/EntireChartbook.pdf#page=140
shopping, or managing money. Rates are age-adjusted using the 2000 standard population.
inability to perform for a health reason) one or more of the following tasks: bathing, dressing, eating, getting in/out of chairs, walking, or using the toilet. IADL limitations refer to
2.7
Reference population: These data refer to Medicare enrollees.
2.7
2.6
Impaired Function is Common in Older
Limitations
INDICATOR 20 Functional Adults
Table 20c. Percentage of Medicare enrollees age 65 and over who are unable to perform certain physical functions, by
sex, 1991 and 2009
Function
1991
2009
Stoop/kneel
8.0
10.2
Reach over head
3.1
3.1
Write/grasp small objects
2.3
1.5
14.2
14.5
9.4
7.1
19.1
19.0
15.2
17.9
Reach over head
6.2
4.1
Write/grasp small objects
2.6
1.8
Walk 2–3 blocks
23.1
21.4
Lift 10 lbs.
18.4
13.5
32.0
29.7
Men
Walk 2–3 blocks
Lift 10 lbs.
Women
Stoop/kneel
NOTES: Rates for 1991 are age-adjusted to the 2009 population.
Reference population: These data refer to Medicare enrollees.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
2012_Documents/Docs/EntireChartbook.pdf#page=140
Walk 2–3 blocks
23.1
21.4
Impaired Function is Common in Older
Adults
Lift 10 lbs.
18.4
13.5
32.0
29.7
Men
Women
65–74
12.9
18.7
75–84
22.1
33.7
85 and over
39.6
53.0
White, not Hispanic or Latino
18.4
28.6
Black, not Hispanic or Latino
23.1
33.4
Hispanic or Latino (any race)
20.4
33.6
NOTES: Rates for 1991 are age-adjusted to the 2009 population.
Reference population: These data refer to Medicare enrollees.
functions, by selected characteristics 2009
Selected characteristic
Age
Race
Reference population: These data refer to Medicare enrollees.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
2012_Documents/Docs/EntireChartbook.pdf#page=140
Purchasing goods and services
0.8
3.5
0.9
3.9
0.7
3.1
Grooming
0.7
2.7
0.6
2.7
0.6
2.6
Other activities
1.2
4.8
1.4
5.9
1.4
5.9
Watching TV is THE Leisure Activity of
Older Adults
NOTE: “Other activities” includes activities such as educational activities; organizational, civic and religious activities; and telephone calls. Table includes people who did not
work at all.
Reference population: These data refer to the civilian noninstitutionalized population.
SOURCE: Bureau of Labor Statistics, American Time Use Survey.
Table 28b. Average number of hours and percentage of total leisure time that people age 55 and over spent doing
selected leisure activities on an average day, by age group, 2010
55–64
Average
hours
per day
Socializing and communicating
65–74
Percent of
leisure time
Average
hours
per day
0.6
11.3
Watching TV
3.0
Participation in sports, exercise,
and recreation
75 and over
Percent of
leisure time
Average
hours
per day
Percent of
leisure time
0.7
10.3
0.6
8.0
57.8
3.8
55.6
4.4
57.7
0.3
4.9
0.3
4.3
0.2
3.0
Relaxing and thinking
0.3
5.2
0.5
7.8
0.7
8.6
Reading
0.4
7.1
0.6
9.5
0.9
12.2
Other leisure activities
0.7
13.7
0.8
12.2
0.8
10.6
Selected leisure activities
NOTE: “Other leisure activities” includes activities such as playing games, using the computer for leisure, arts and crafts as a hobby, arts and entertainment (other than sports),
and related travel.
Reference population: These data refer to the civilian noninstitutionalized population.
SOURCE: Bureau of Labor Statistics, American Time Use Survey.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
2012_Documents/Docs/EntireChartbook.pdf#page=140
Aerobic and Strength Training is
INDICATORUncommon
24 Physical Activity
in Older Adults
Table 24a. Percentage of people age 45 and over who reported participating in leisure-time aerobic and musclestrengthening activities that meet the 2008 Federal physical activity guidelines, by age group, 1998–2010
Year
45–64
65 and over
65–74
75–84
85 and over
1998
11.4
5.5
7.0
3.9
2.0
1999
11.9
5.9
7.7
4.5
0.9
2000
12.8
6.9
8.4
5.7
1.9
2001
13.1
6.7
7.7
6.1
3.1
2002
14.2
7.1
8.8
5.8
2.1
2003
14.6
7.6
9.2
6.7
2.9
2004
14.0
7.8
9.7
6.4
3.5
2005
14.4
7.9
10.5
5.7
3.0
2006
13.8
7.5
9.1
6.5
3.0
2007
15.0
7.9
9.5
6.6
4.1
2008
16.3
9.5
11.3
9.3
2.3
2009
16.9
10.0
12.8
7.9
2.8
2010
17.8
10.5
13.6
7.3
4.0
NOTE: This measure of physical activity differs from previous editions of Older Americans.
(available from:
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed
in episodes of at least 10 minutes, and preferably, it should be spread throughout the
2012_Documents/Docs/EntireChartbook.pdf#page=140
2010
17.8
10.5
13.6
7.3
4.0
Aerobic and Strength Training is
Uncommon in Older Adults
NOTE: This measure of physical activity differs from previous editions of Older Americans.
(available from:
of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the
activity and muscle-strengthening guidelines.
Table 24b. Percentage of people age 65 and over who reported participating in leisure-time aerobic and musclestrengthening activities that meet the 2008 Federal physical activity guidelines, by sex and race and
ethnicity, 2010
Aerobic activity only
Both sexes
Men
Women
All
White, not Hispanic or Latino
Black, not Hispanic or Latino
Hispanic or Latino
10.5
11.5
5.2
5.6
13.6
14.6
7.8
9.0
8.0
9.0
3.6
3.0
NOTE: This measure of physical activity differs from previous editions of Older Americans.
(available from:
of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the
activity and muscle-strengthening guidelines.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/
2012_Documents/Docs/EntireChartbook.pdf#page=140
Muscle 101
 
 
 
 
The musculoskeletal system is
needed for locomotion and
posture
It consists of several tissues
including bone, muscle, joints,
ligaments and tendons
Muscle is attached to bone
through tendons
Muscle contractions lead to body
movement
www.orthoinfo.aaos.org, www.predatornutrition.com
Muscle 101
 
 
 
 
Muscle cells (or fibers) are
long and are grouped into
fascicles
Several fascicles make up a
muscle
Muscle cells contain
proteins that move within
the cell and shorten their
length
The nervous system is
responsible for initiating,
controlling and coordinating
contractions
http://www.sciencelearn.org.nz
Biomechanics 101
 
There are different types of muscle contractions
  Concentric
= muscle shortens as it contracts
  Eccentric = muscle lengthens as it contracts
  Isometric = muscle remains at the same length
Biomechanics 101
 
Force (F, Newton) = Mass (m, kilogram) x Acceleration (a,
meters/second2)
 
Velocity (v, meters/second) = Distance (d, meters) / Time
(t, seconds)
 
Power (P, Watts) = Force (F, Newton) x Velocity (v,
meters/second) = Work (W, Joule) / Time (t, seconds)
 
Sway can be measured in “Path length” (Length, meters) or
“Area of Sway” (Area, meter2)
Grip Strength
  Can
you open a jar?
  Power
grip (232.8 N), Precision grip (248.6 N)
Kuo, Proc Inst Mech Eng H, 2009
http://bobonews.tumblr.com/
Grip Strength
  Grip
strength is measured with a
dynamometer
  It is an isometric
contraction
  It measures
maximal force
http://www.physicalcompany.co.uk
Leg Power
  Can
you get up
  from
a chair?
  out of bed?
  out of a car?
http://www.avin.ca/
Leg Power
  Leg
power can be measured with
  the
repeated chair
rise test
  the get up and go
test
  Power
assesses
muscle force and
speed (velocity)
http://tle.tafevc.com.au
Leg Power
  Repeated
chair rises can be measured with
a stop watch or force platform
http://www.galileotraining.com
Gait speed
 
How long does it take you to cross the street?
 
 
 
Distance: 28 meters (91.9 feet)
Time the light is green: 20 seconds (plus 10 seconds of
flashing)
Although walking
requires muscle power
it is largely dependent
on velocity (not force)
Gait speed
  How
long does it take you to cross the
street?
  If
 
 
 
 
gait speed is:
1.3 m/s à 21.5 seconds
1.0 m/s à 28 seconds
0.8 m/s à 35 seconds
0.5 m/s à 56 seconds
Gait speed
Balance / Sway
  Do
you have difficulties getting out of a
bathtub?
http://i.ytimg.com/vi/9afRaaNXpbY/0.jpg
Balance / Sway
  Balance
  The
and Sway can be measured with
Romberg stance test
  The semi-tandem and tandem stance test
  The functional reach test
  On a force platform
Balance / Sway
  The
Romberg and Tandem Stance tests
  These
tests examine static balance
http://www.osceskills.com/
http://drxuacupuncture.wordpress.com
Balance / Sway
  The
functional reach
test
  This
test examines
dynamic balance
  Individuals are asked
to lean forward as far
as they can without
taking a step forward
Pérennou, 2005
Balance / Sway
  Sway
can be quantified with a force platform
http://www.galileotraining.com
How Do you Measure Muscle
Mass and Function?
  Muscle
mass is often measured by dual
energy x-ray absorptiometry (DXA)
http://
info.blockimaging.com
Measuring Muscle and Fat with
DXA
• 
• 
Individuals with the same body mass
index can have different body
composition
Older individuals have more fat mass
and lower muscle mass
Cut-off values for muscle function tests
Muscle function test
Cut-off
Grip strength (dynamometer)
Females: <20kg; Males: <30kg
Chair rise (5 chair rises)
> 11.5 – 15 seconds (depending on
age and gender)
Get up and go
Females and Males > 12 seconds
(get up from chair walk 10 feet, turn
around, walk back and sit down)
Walking speed (20 feet)
Females and males < 0.8 – 1.0 m/s
Romberg, (semi-) tandem stance
Able to stand for 60 (or 30) seconds
Functional reach (leaning forward)
< 6-7 inches
Muscle mass (DXA appendicular
lean mass, arms + legs)
Females: <5.45 kg/m2 Males < 7.45
kg/m2
Grip Strength is Associated with ADLs / IADLs
§  6089 45 to 68year-old healthy
men had grip
strength
measured 1965
through 1970
§  3218 surviving
participants had
disability
assessment 25
years later
Rantanen, JAMA, 1999, 10;281(6):558-60
Impaired Physical Performance
Increases Hip Fracture Risk
Data from the
MrOS study,
which included
5995 men age
65+
Adapted from Cawthon, et. al., J Bone Miner Res, 2008, 23:1037-1044
Slow Walking Speed is Associated with
Increased Mortality
 
Relationship of walking
speed and mortality
 
InChianti Study (Aging
in the Chianti area
study), started 1998,
~1,150 participants,
between ages 65 and
102
Cesari, J Gerontol A Biol Sci Med Sci, 2009, 64:377-84
Summary
Impaired physical function is common in older
adults
  The (Neuro-) Musculoskeletal system consists of
many tissues including bones, muscles, joints and
the nervous system
  Muscle contractions are the origin of movement
  Muscle functions include force, power, speed and
balance
  Poor muscle function is associated with decreased
physical function, hospitalizations and death
 
Thank You