Multi-Component Exercise Program and Improving Physical Performances in Older Inpatients: Results from A Pilot Interventional Study

Results: The 21 patients who refused the training had a significant lower MMSE than those who accepted. The body mass index of the 13 patients who completed a single session only was significantly higher. A total of 17 patients completed the entire training program. With the training, patients improved chair standing of 29%, TUG of 33% and gait speed of 50%. No adverse effect or medical complication occurred. Patients completed 83% of the program. The causes for which sessions were missed were mainly due to simultaneous conventional hospital care or shortcomings. Sessions were perceived as hard for 0.3% of them, moderate for 33% and light for 67%. 98 % sessions were reported as pleasant.


Introduction
its a number of favorable responses that contribute to healthy aging and reduce the risk of frailty [4]. Indeed, exercise has consistently been found to improve physical function, sarcopenia, cognitive performance, and mood, which all are significant components of frailty [5][6][7][8][9][10]. Optimized exercise training has been proposed on a multi-component basis, including endurance, balance, and resistance training [11], to which recently released guidelines added a greater emphasis on high intensity exercise including muscle strengthening activities [12]. In a recent meta-analysis involving 18 interventional studies (n=2517 participants with age at inclusion ranged from 60 to 85 years) published from 1998 to 2009, the authors showed that a multi-component exercise program was more effective in limiting or reducing sarcopenia than low intensity interventions [6], and, in turn, to limit adverse associated outcomes, including falls, fractures, frailty, and mortality [13][14][15][16][17][18]. But, most of interventional studies concerned in-home participants. Few studies were devoted to inpatients and the feasibility of multi-component exercise program remains unclear in this population. We aimed to assess the feasibility and the effects on extremity physical performances of a multi-component exercise program in older inpatients.

Study Design and Population
An interventional pilot study of a multi-component exercise training program (MCETP), was performed in a department of geriatric medicine (Rene Muret Hospital, Sevran, France), between June 1 to December 30, 2016.
Patients were eligible for this study if they were aged 70 and over, and if they were independent to walk. Patients with stroke, acute coronary syndrome, hip or knee intervention lasting for less than 6 months, severe heart failure and pulmonary insufficiency were excluded from this study. Informed consent was obtained from the patients before inclusion. This study was approved by the local ethics committee (CLEA, Avicenne Hospital, Bobigny, France).

Clinical Data
Demographic data (age, sex), blood pressure (mmHg), and a screening for sarcopenia which was defined in agreement with the European Working Group on Sarcopenia (EWGOS) consensus as a gait speed (measured over 10 meters) ≤ 0.8m/s, and a reduced muscle mass as assessed by a calf circumference <31cm [19].

Pre-MCETP Geriatric Assessment
Geriatric assessment (GA) was performed at inclusion, and included the three following domains: comorbidities assessed by the cumulative illness rating scale geriatric (CIRSG); malnutrition was defined in agreement with the French nutritional guidelines as: body mass index (BMI) < 21kg/m² and or weight loss > 5% in 1 month or > 10% in 6 months and or albumin level < 35g/l; and cognitive impairment was defined as a mini mental state examination (MMSE) < 24/30.

Physical Performances
We performed three measures of physical performances. Rising from a chair (RC) defined as the time (in seconds) needed to stand up and sit down 5 consecutive times as fast as possible [20] Gait speed (GS) over 10 meters. Patients had to walk along a corridor with the following indication: "please begin walking at your normal pace", and after the running order: "go". GS was measured in "m/s" with a chronometer by dividing the distance in meters (4m) by the time in seconds. If a participant could not walk, GS was "0" [21].
Timed Get Up and Go test (TGUG), a composite walking test that measures the time (in seconds) needed to rise from a chair, walk over 3 meters and a return to the chair [22].

Intervention
Patients were exercised 3 times a week for 12 weeks in a specifically devoted room. They were managed by a sport coach and supervised by a physician involved in geriatric medicine. Each training session comprises three 20-minutes activities, during which the patient is exercised successively for endurance, resistance, and balance. Endurance training consisted in slowly biking or walking.
Resistance training consisted in exercising on strength machines specifically designed for older patients (Gamme R'Line Plus RG14, RG 20, RG 50, RG 39S, RG41).Swith small loads, joint and muscle safety protections, pneumatic resistances, and improved accessibility. Balance training consisted in both static and dynamic balance exercising. Extremity physical performances were measured at baseline (week 0, W0), after 6 (W6) and 12 (W12) training weeks.
When the patients live hospital and do not want to pursue the training, the three tests were measured as well (hospital discharge).

Outcome
The primary outcome was the feasibility of a MCETP defined as percentage of refusal, abandonment (≤1 session) and participation rate (> 1 session) at least 80% of sessions the patients were able to achieve without pain or any other adverse events. The secondary outcome was the effect on physical performances (RC, TGUG and GS) of MCETP.

Statistical Analyses
Categorical results are presented as counts and percentages and as means  standard deviations (SD) for quantitative data. Feasibility of a MCETP was estimated by percentage and 95% confi-

Self-Perception Of MCETP
A record about how the session was perceived was collected after 320 (88.9%) sessions, 1 (0.3%) was qualified hard, 105 (32.8%) moderate and 214 (66.9%) light. Table 2 shows self-   In this preliminary study, high-intensity training can be proposed safety and improves functional capacity and physical performance of frail hospitalized older patients. These results have to be confirmed in a prospective, randomized controlled trial to follow.