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Having been awarded the Bulpitt Cardiovascular fellowship prize by the BGS Cardiovascular Section, I used the grant to help fund my elective placement in Sydney, Australia at the Centre for STRONG Medicine in Balmain Hospital. This unique program uses exercise based medicine as a treatment, primarily for the elderly suffering from chronic disease or syndromes. More recently, it has included individuals of any age who have a chronic condition for whom exercise has been deemed beneficial.

My elective provided me with valuable experience in geriatrics that I could not have obtained from a placement in a more conventional hospital setting. Prior to visiting STRONG I had not realised that exercise could modify so many disease states and chronic conditions. I was able to learn a number of new skills which reinforced my knowledge of human physiology as well as the pathology of many medical conditions. I was introduced to a different form of multidisciplinary team from any I had experienced before. Being made very much a member of this team was challenging as I was not only learning a new skill in a new country and different environment, but I was doing so whilst attempting to integrate this with my medical knowledge. This was very satisfying as by the end of the placement I felt myself ‘thinking outside the box’ in that I could see the way in which conventional medicine and therapies, and this more radical form of treatment worked together synergistically. As well as learning a new skill, I was able to improve my skills in full medical assessment in the geriatric population from history through to multi-system examination of some common conditions as well as rare ones. The most important thing I learnt was that age and fragility should never be a barrier to physical activity.

I commenced the placement with formalised training which involved shadowing the exercise physiologists and volunteers working in the purpose built gym. This was to ensure I became familiar with all the equipment (largely for resistance training) as some machines were quite technically advanced. I also needed to learn the correct form the patients should adopt when using each piece of equipment to ensure safe and effective exercises were performed consistently. Through reading patients’ notes prior to training them, I began to learn the appropriate exercise prescriptions for patients suffering from specific conditions and how they would be tailored according to individual limitations, strengths and weaknesses. I feel I made myself useful to the centre as my visit coincided with one member of staff leaving for a 5 week trip, hence putting the staff under pressure. Although I was given a good deal of support and guidance from the remaining staff members, I was motivated to learn quickly in order to be a help rather than a hindrance in this short-staffed situation. I was soon being given two to three patients per one hour session to work with myself, which was challenging due to the vast range of ability levels and varying amounts of input required. Whilst training the patients, I discussed their medical histories and was able to gain an insight into their degree of disability, symptoms and specific problems, physically and mentally both pre and post-STRONG, followed by an understanding of the perceived benefits of their treatment. Through working with the same patients regularly I was able to review their progress by comparing past performance in terms of their strength on each individual part of their program, such as their balance (according to pre-determined measurement levels), specific muscle groups (looking at increase in weights lifted and regular ‘strength tests’) and aerobic fitness.

I attended consultant clinics where existing patients were reviewed and new patients were assessed for eligibility. I was given the opportunity to assess some patients myself, deciding on their individual needs through formulating gym programs. This coupled with educational meetings, critiquing literature and case discussions enabled me to gain significant insight into the vast but ultimately under-utilised clinical effectiveness of exercise as a treatment. Of particular interest to me was the way in which power training can be used to improve balance as described by Orr et al, as well as through observing individual’s documented and observed improvements. Also of interest, was the way in which knee osteoarthritis could be improved in terms of pain, disability and physical performance through aerobic and resistance training, for this is not a condition which one would necessarily consider suitable. The combination of clinical and practical experience in the centre, coupled with familiarising myself with the science behind it made for a valuable learning experience.

My time at STRONG enabled me to view members of the geriatric population from a new perspective and altered my perception of their ability to adopt new behaviours, learn new skills and to motivate themselves despite suffering from chronic conditions that caused them physical and/or mental discomfort. This was an important revelation, particularly when assessing them myself in the clinic, for instinctively one would not prescribe exercise to a frail, sarcopaenic 80-year-old woman. My experience has brought new meaning to the importance of a holistic approach to history taking and examination, for many of the patients were highly intelligent and independent individuals whose lives were limited only by their physical conditions which they did not know how to improve.

An example of my experience involved elderly women with histories of multiple fractures or skeletal deformities, such as scoliosis, who had not had bone scans to determine whether they were osteoporotic, an important consideration when being accepted into STRONG. I felt that this experience increased my confidence in examining geriatric patients due to the range of medical conditions I was exposed to. Also, working with the exercise physiologists in the centre, using alternative assessment methods, contributed to an holistic approach and made me increasingly aware of nutritional support and the importance of immediate supplementation following exercise.

Carly Walker

References

1. Orr R et al. Power Training Improves Balance in Healthy Older Adults. Journal of Gerontology. 2006; 61A: 1:78-85.
2. Ettinger W.H et al. A Randomised Trial Comparing Aerobic Exercise and Resistance Exercise with a Health Education Program in Older Adults with Knee Osteoarthritis. JAMA. 1997; 277:1.
3. Fiatarone M et al. Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People. NEJM. 1994; 277:1.

BGS Newsletter, Aug 2008
Issue 17 ISSN 1748-6343 17