How to Adjust for Regressions in Exercise Interventions

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the effects of terzepatide on older adult patients. Take a listen to learn how to better serve this population of patients & athletes.

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EPISODE TRANSCRIPTION

00:00 INTROWhat's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:43 Dr. Julie Brauer, PT, DPT Good morning, Instagram. Happy Wednesday. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. My name is Julie Brauer, member of the older adult division. We are going to jump right into our topic this morning. It's Wednesday, so all Wednesdays we talk all things older adults. This morning, we are going to talk about terzepatide and the older adults. And this is going to be a case study type discussion. So what is terzepatide? You probably have heard it all over the news by its brand name, Mount Jaro. So terzepatide is a FDA approved drug for glycemic control in individuals with type 2 diabetes. The problem is that many folks, including my 72 year old patient who does not have type 2 diabetes, these folks are getting their hands on it for weight loss. And many of these folks, including my clients, is not considered overweight. So this morning we are going to talk about what this drug is, what we know from the clinical trials, how it works, what are the side effects. We will briefly touch on that. And then I am going to tell you the story of my client Martha, who experienced some pretty negative side effects and consequences from taking this drug. And we will talk about how to navigate this challenging situation where your client is doing something that you know is probably not good for them. You don't necessarily support the decision, but you need to support your client in general, through this decision. We will talk about how you have to be a master of scale and adjust your exercise interventions to keep an individual safe as they are going through something like this. And then we will talk about the scary and unfortunate event that occurred for Martha to finally decide that was the nail in the coffin and she was going to go off of this drug. Okay, so Mount Jero Terzapatide has gotten a lot of attention in the media about how it potentially can be more effective as a glucose lowering therapy over other glucose lowering therapy drugs like Ozempic and Wigobi, or others that you have probably heard about. Those are just the brand names for the drug Semiglutide. What are these drugs and what is the difference here? Semiglutide is a single receptor agonist. Mount Jero or Terzapatide is considered a dual receptor agonist. What you will see in the literature is that it is a dual GIP GLP-1 agonist. What those are are hormones. These are hormones that are released from the gut that regulate insulin response to a meal. What they do is they increase insulin secretions, increase insulin synthesis, they decrease gastric emptying, which in turn promotes this feeling of feeling really full. And then it promotes a decrease in appetite. So individuals are just not hungry. They're not eating as much. And so why this drug is getting so much attention is that because it's a dual receptor agonist, it's having this synergistic effect of having an even more potent dose on decreasing glucose as well as weight loss than the more commonly known drugs of Ozampic and Wigoby. So that's the basis there. Now let's talk side effects because that's really important to know that what are the side effects that come along with this drug. So many of the side effects are primarily having to do with GI discomfort. And now there are so many, like nine plus clinical trials, they are called the Surpass and Sermout trials that are going on, looking at the safety and efficacy of turzapetide. And they're looking at the safety and efficacy of individuals who are on glucose lowering therapies already. And then they're looking at it in individuals who are not on glucose lowering therapies. They're looking at individuals who are also doing intensive lifestyle and exercise interventions. I think those studies would be really interesting to actually see what those exercise interventions are. They're even looking at the cardiovascular benefits and then just the benefits in individuals who are considered obese and looking at the benefits for weight loss for individuals who are not even living with type 2 diabetes. Okay. So what they have found in terms of side effects, those GI side effects. So you're going to see individuals who are going to have really extreme nausea, diarrhea, vomiting, constipation, and you see this dose dependent response. So the higher dose that people are taking of turzapetide, and this is a once weekly subcutaneous injection, you're seeing those side effects increase with the higher doses that people take. And so some of the clinical trials, even up to 66% of individuals were experiencing GI distress. And so many individuals who start taking this drug actually stop taking this drug because of those adverse GI effects. They just feel like crap, literally. Okay. So that is an overview of the drug. I will post a article link to the Surpass and Surmount clinical trials. If you guys want to get into a little bit more detail about these specific drugs. Okay, let's talk about Martha, my client. So she is someone who started working with me. She has severe arthritis in her knees, very, very weak. She's a yoga gal, never lifted any weights. She could barely do a sit to stand from a workout bench without using her hands. It caused a lot of pain. We have been working together for months and got her to a point where she is lifting. She's doing goblet squats, 35 pound dumbbell for 12. We've been working together for months. She is doing high intensity interval training. She is repping out burpees and slam balls. I mean, she's absolutely crushing it. Like we were building her reserve and resiliency, her arthritis in her knees. That pain was starting to decrease. She's starting to feel really, really good. She is so on board. It's been this beautiful, beautiful journey. And then one day, Martha hits me with, so I'm going to start this weight loss drug, Mongero. And it took everything for me to not automatically question that and show on my face that I was upset about this decision. And so I want to emphasize to you all how to go about this, how to react, how not to react. I know that we're going to have some regression here. I know that we're going to have some challenges. The important thing to remember is that we need to be the guide and not the hero. Be the guide, not the hero. That doesn't sound or look like this when Martha drops that bomb. You do not say, Martha, wait, huh? Why? Why would you do that? You don't need to do that. We're crushing it. You're doing so well. You're going to lose weight by exercise and lifestyle intervention and nutrition. What are you doing? That's going to make you feel like crap. Don't do it. Don't do it. We do not want to do that. Even in our head, if that's kind of what we're feeling, we do not show that. We do not say that. That is not being the guide. It does sound like this. Being the guide sounds like this. Got it. Martha, I'm so curious. This is totally new to me. Tell me a little bit more. Why have you decided to go on this? Hey, Martha, we may experience some challenges here. There may be some side effects. We may have to switch some stuff up with our exercise approach, but we will get through it together. That is what being the guide sounds like. We have to remember that older adults are allowed to assume their own risk and they're allowed to make their own decisions. For some reason, when it comes to older adults, and this is based in ageism, this is based in ableism, it's like we believe that they're little children who don't have fully developed frontal lobes. We assume because they're old, they need us to make decisions for them. That's not the case with many older adults. They are fully, fully capable of making their own medical decisions. We have to remember that this is not our life to live. This is not our journey. It is a journey for us to come alongside our clients, not to decide what that looks like. We want to gently try to get them back on track into our fitness forward lane, right? It's not a time to drop them from our care because they're not following along with our philosophy. I remember a very specific day. I was in the gym. I was on the GHD. Why I was looking at my phone, I don't know, but Martha texted me. She had been on this job for a few weeks now. She's like, I have such low energy. I feel awful. I just can't do the intensity that you're putting me through in these workouts anymore while I'm going through this weight loss period. I just can't do it. That was so upsetting, right? Because it felt like a failure. It felt like we were going to go backwards so many steps. My gosh, what had we worked so hard to get to? I was glad I'm at the gym, right? Because then I was like, you know what? I'm just going to go lift some heavy weights and I'm going to feel better. Obviously, 10 out of 10 times, you always feel better when you're stressed out and you lift some weights. I started to think about it and I was like, okay, I can't drop her. Even though it felt like, well, what skill am I bringing if I'm not appropriately dosing her? What else can I do here? I had to reflect and be like, no, I'm with her. Martha, I'm with you regardless of what you decide to do and how this looks like throughout this journey. And why is this important? Because when we spend so much time getting someone into a fitness forward lane, we're doing this because we want to build this long lasting relationship with them. Martha is going to get to a point where she's crushing it again. And I probably back off and I don't see her anymore for a while. But what do I want for our relationship? I want that if anything else comes up with Martha, right? She has an injury, she has pain, she's hearing some, you know, maybe some things are discouraging from her doctor. I want me to be the first person she thinks of. I want her to think, I want to run this by Julie or you know what? I know Julie could help me. We went through a lot together so far. I trust her. She's with me. I'm going to make sure to contact her. That's what we want guys. Like we want to develop that long term trusting relationship so that when something else comes up, we can get her right back into our fitness forward lane and we can keep her there. Okay. So that's number one. We have to remind ourselves that we are the guide, not the hero. All right. Now, how did I have to adjust for these regressions? How did I adjust our exercise interventions? So number one, she's right. I had to decrease the intensity of these exercises. I had to cut out a lot of the high intensity interval training. She had zero energy. She was feeling a little bit uncomfortable, a little dizzy. I mean, vitals and everything were fine, but she just felt like crap. And I would see her, you know, get a little wobbly when we were exercising. So I'm like, all right, we got to switch this up. So decreasing the cardiovascular intensity, I stopped having her do exercises that were high intensity with a lot of positional changes. So burpees and mountain climbers, supermans, hollow holds, thrusters, all of that took that out. And I just kept her on the bike. I just went back to getting her on the bike and just pedaling and maybe taking that RPE from an eight or nine down to a four to a five, right? She's sitting, she's safe on the bike, but I can still get a little bit of intensity there. Next, what I did is increase the amount of just raw strength training that we were doing. So taking away the high intensity interval, the full body functional movements, and I went more towards isolation and really just tried to focus on strength, right? Heavy, low amount of reps to where she's not getting a cardiovascular stimulant. It's more just muscular fatigue. So we started just going really heavy and really slow. And we became, I put her closer to the ground with all these positions. So instead of doing a standing press, I had her do a sitting press. We did a lot of supine, like hamstring, sliders, many times at tempo, right? That was another way to increase intensity without driving cardiovascular stimulus up. Supine chest press in a bridge position, sitting tricep extensions. Instead of bent over rows, that could get her a little bit dizzy. I had her do some standing banded rows, right? So I'm just changing things a little bit. I'm being a master of scale. I'm meeting her where she's at, prioritizing that raw strength training over intensity intervals. Next, I had to remind myself that something is better than nothing. When Martha texted me to say, I just don't think I can do anything. Like, I don't think I can do much. Should we still get together? Should we still meet? And part of my brain was like, again, it was like, well, what's the point? But then I'm like, you know what? Yes, something is always better than nothing. And 10 out of 10, Martha's been doing nothing. Her joints are becoming more achy. Her energy is getting lower because she's not moving. I know that if I help her just move her body and give her things to do that don't exhaust her, but make her feel good, that is going to make her emotionally feel better, physically feel better. It can be a gateway to opening up a little bit more activity because she had become so sedentary. And so that's exactly what we did. I modified everything for her. I gave her a workout specifically that was called, when Martha feels like crap, like, here you go. Here are the things you can do that make you feel good. And at the end of that session, she was so thankful. And she said, you know, I am so glad we met. I feel so much better that I did a little bit of something. So something is always better than nothing. Next, we have to talk about the nutritional aspect here because she got to where she was only eating a smoothie in the morning. And then she would eat like a spoonful of cottage cheese and maybe some crackers for the rest of the day. And she was telling me she was having these weird cravings for like hemp hearts and artichokes. Very strange. And she said, I can't really eat solids a lot. Like, I'm too full to eat solid food, but I really like my smoothie. So I was like, cool, let's make that smoothie as calorically dense and packed full of protein as humanly possible. We know that malnutrition is so, so detrimental to older adults. We know how that can lead to clinical geriatric syndromes like frailty and sarcopenia. So I wanted to try and make sure that I was making the food that she could eat as nutritionally dense as possible. So packing that smoothie with chia seeds and flax seeds and peanut butter and making sure it's high protein, full fat Greek yogurt, all of that. Really trying to make that one smoothie as nutritious as possible. So remembering when folks are, they don't feel like they can eat their calories, can they drink those calories and tolerate that a little bit better? Lastly here, the most important thing to remember is that you want to be thinking about maximizing reserve and resiliency, even when things are going really well. Like even when you're crushing it with your clients, your older adult clients, the job is not done. All right, I think about Kobe Bryant and the 2009 NBA Finals. They were 2-0 over the Magic and the reporter at the end of the game was like, you don't look happy. Like what's wrong? And he's like, what's there to be happy about? The game's not finished yet, right? The job's not finished yet. That is the attitude that we have to have, is that even when you have built reserve and resiliency and things are going well, you do not want to take your foot off the gas pedal. You want to continue to instill this person becoming robust and resilient because something's going to come along, right? It could be that they decide to go on this darn weight loss drug and they lose a lot of their strength and their resiliency or they get sick or they have a family member who passes away and they become emotionally depressed and they become, they socially withdrawal, right? All of the complexities that can happen in our lives. Like we want to be building reserve and resiliency and do not take your foot off that gas pedal, right? The job is not done yet, okay? All right, so what happened to Martha? What is this scary ending that happened? So Martha has a partner and her partner was also taking Mongero. He was outside working in the yard, something that he loves to do. He had lost 20 pounds over a period of six weeks, whereas Martha didn't lose any more than just a few pounds, but her partner really experienced significant weight loss. He wasn't eating, he wasn't hydrating, he was trying to maintain his normal level of activity. He was outside in the yard, it was really, really hot and he passed out and like fell down an embankment, rolled a bunch of times, bruises all over the place. I mean, went to the emergency room, bruised a bunch of ribs, got a bunch of x-rays, he's okay, but Martha said to me, he's like, Julie, if that would have been me, I don't know what would have happened. I mean, he's a big strong guy. I could have gotten seriously hurt and even more so, I mean, if I hadn't built the strength that I had working with you over the past however many months, I don't even know. Maybe I would have died. Maybe I would have died if that happened to me. So she's seeing something really awful happen to the person that she loves. She's thinking if it had been her and she's saying to me, you know what, I just, I love being active, right? I miss how strong I felt. This sucks. I don't like this, right? And she wasn't even someone, she didn't have negative GI effects. She wasn't having nausea, vomiting, all of that stuff. She simply wanted to feel good again and full of energy. She was sick of feeling like crap, you know, and obviously saw something really awful happen to someone that she loves. So she has discontinued this medication just recently and we are going to be seeing each other again next week and we're going to just have to rebuild, you know? But she was able to come to her own conclusion. I didn't have to tell her not to do this. She decided to get off this drug on her own because she had built up this belief in this fitness forward philosophy. She knows how good it feels to work hard, to do her high intensity intervals, to lift those heavy weights. She wants to get back to that. And so this was a beautiful example of how we have to let people make their own mistakes and come to their own conclusions. All right. That was a long one. That is all I have for you all. So some things to think about. I hope this helps if any of your clients are taking this drug or you're just trying to navigate a situation where maybe they are doing something in a way that you don't fully support and how do you continue to support them on their journey and maintain a good relationship? I will end things here by telling you guys a little bit about our courses that are coming up in the older adult division. In July, we are in Connecticut, Idaho, and Georgia. In August, we are in Maryland, Kentucky, Minnesota, and Texas. And our next eight week online course, Essential Foundations, starts August 9th. So PTI Nice is where all of that information lives. Feel free to reach out if you have any questions. Have a wonderful rest of your Wednesday.