What might it take to get Medicare to pay for exercise the way it pays for drugs?
At least that’s what Christopher Sciamanna, a primary-care doctor at Penn State College of Medicine, hopes.
He is leading a large clinical trial that is testing whether a cheap, community-based exercise program that uses stretchy, color-coded bands can keep older people who’ve already broken one bone from breaking another. That’s an expensive injury that he knows Medicare — not to mention patients — would like to avoid.
His study, Working to Increase Stability Through Exercise (WISE), is aimed particularly at people with “fragility fractures,” or breaks that likely would not have occurred in those with strong bones. Funded by a three-year, $13 million grant from the Patient-Centered Outcomes Research Institute (PCORI), it is based near the medical school in Hershey but also is opening sites in Pittsburgh and Philadelphia with help from the University of Pittsburgh and Temple University. The goal is to enroll 2,100 people, including 900 in Pittsburgh and 300 in Philadelphia.
“If it does prevent fractures, Medicare would probably have to pay for it,” said Sciamanna, who leads Penn State’s division of population health research and development. He estimates that, once the study is done, it would take less than $200 a participant a year to keep it running.
The program, which mixes strength and balance exercises with short breaks for conversation, has the added benefit of giving older people, who often live alone, a regular chance to socialize. Isolation is increasingly viewed as being bad for both mental and physical health.
“It’s nice to watch the exercise, but it’s even better to watch the interactions,” said Jonathan Woodall, minister of GracePointe Church of Christ in Elizabethtown, Dauphin County. He offered his building for one of the classes, and several church members volunteered to be exercise leaders.
Tracey Murray, who is the lead exercise coach in Pittsburgh, said seniors love the chance to meet in their own communities, where they can talk to neighbors about shopping and gardening between exercises. Participants have the option of doing the work at home, but few do. Once they try a class, she said, “they’re hooked.”
A cheerful group of seniors ranging in age from 65 to 91 showed how the program works at GracePointe one recent morning. They have been coming to the church on Mondays, Wednesdays and Fridays since July. Each chose one or more rainbow-hued bands. They had all started with the easiest, yellow, which is the rough equivalent of curling two- to five-pound weights. Then, in order of difficulty, came blue, green, black, red, and, finally, orange, which is like doing bicep curls with 30- to 35-pound weights.
Many can now do blue and green bands. Only one can do the orange bands, sometimes using two at once. They worked through six strength-building exercises, doing two 12-repetition sets of each. As soon as they can do the full second set, they are instructed to try a tougher band. The exercises can be modified for people who are less steady on their feet and may need to stay seated.
For the “pull,” they sit and loop the band around their feet, then straighten their legs, sit up straight, and pull their elbows back. There’s a version of the shoulder press, curls, deep-knee bends and chest press. If you pick an appropriate band, it’s a serious workout.
When those were done, the class did balance exercises without resistance and then cooled down.
Most seemed to be having fun. There were some jokes, questions about one class member’s European vacation, and lots of encouragement. Some actually smiled while they exercised. They counted in Ukrainian, Spanish, French, and German to liven things up.
Afterward, some students and the volunteer teachers alike said they already felt stronger and more confident.
“It’s limbered up some muscles and tendons that have been laying dormant a long time,” said Donald Morgan, 87, of Elizabethtown. A fall that broke several ribs made him eligible for the study. An enthusiastic member of the class, he’s using blue and green bands. He likes feeling stronger and hanging out with classmates.
“I believe everyone over a certain age, maybe 75, should be involved in a program like this,” he said.
Pat Pacella, 77, one of the class leaders, is an avid walker — she and her daughter walk two to three miles, three or four times a week — who used to work for Curves gym. She has grandchildren and great-grandchildren she wants to stay in shape for, and she likes working with people. She sees the class getting stronger and no longer complaining about sore muscles. Their balance is better, too. “I don’t see them so frightened as they were in the beginning,” she said.
Sciamanna’s interest in the program grew, in part, from his frustration with patients who are a lot more likely to take a pill than to exercise regularly. Some Medicare Advantage plans will pay for a fitness program called Silver Sneakers, but his patients didn’t like it much. He and his team thought they could design something better. They started Band Together, the program on which WISE is based, in 2013.
Seniors like strength training because of the quick results. “When people start doing strength training, they see pretty rapid gains in terms of what they can move,” Sciamanna said. “The average 80-year-old will double their bench press in 12 weeks. That creates a powerful reinforcer.”
But, he said, most seniors aren’t used to exercising and need a class or personal trainer to push them. They won’t build muscle unless they keep increasing resistance.
“I think we baby seniors a bit,” he said. “They can definitely get a lot stronger if we put them in a situation where it’s safe and it’s basically progressing.”
You can find detailed information on how to do the strength exercises at Penn State’s Band Together website. Call this toll-free number if you are interested in joining the trial: 1-844-598-9598.
A Pitt program teaches seniors to walk properly
Most of us learn to walk in our first year or so, and then take that ability for granted. In late life, though, many can benefit from learning to walk again, University of Pittsburgh researchers have found.
They showed that a program they developed called On the Move helped older adults walk farther and faster than a typical exercise program. On the Move emphasizes improving balance, strengthening muscles needed specifically for walking, and teaching proper walking form with the sole goal of making people “better walkers,” said Jennifer Brach, an associate professor in the department of physical therapy at Pitt. Faster walking speed is strongly associated with a lower likelihood of hospitalization, nursing home placement, and death, she said.
The results of the study of On the Move, which Brach led, were published in August in JAMA Internal Medicine. It involved nearly 300 participants, with an average age of 80, who took two 50-minute classes a week for 12 weeks. Those in “usual-care” did strength, endurance, and stretching exercises. The On the Move group got instruction on timing and coordination of walking, strengthening and stretching. When the classes finished, the On the Move group could walk 55 more feet in six minutes than those in usual-care. People who took On the Move did not report greater improvements in function and disability, possibly, the research team guessed, because the classes didn’t last long enough.
When people walk properly, their forward foot strikes first on the heel. They then roll to a flat foot and up to the toes as they launch the other leg. But many older people walk flat-footed. They take short steps or shuffle. Poor form can make them more vulnerable to falls. It also takes more energy than good form. People get tired more easily and they exercise less, a vicious circle that can hasten disability.
Brach said no one knows why older people tend to get into these bad habits. The change likely happens slowly, possibly because of pain or muscle weakness.
Her program doesn’t use weights or exercise bands. Participants do some exercises that strengthen leg and hip muscles. Physical therapists help them learn and practice proper form and coordination. Brach said an attempt to let lay workers teach this was not successful.
Her next step is to apply for evidence-based status from the National Council on Older Adults. That would allow community centers to use government funds to offer the program. Brach hopes On the Move will spread throughout the state, including Philadelphia.