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  * Col Health & Senior Advisor (PSM), HQ Southern Command (Med), Pune. + Dy DGAFMS (Plg & Trg), O/o DGAFMS, 'M' Block,Ministry of Defence, New Delhi. # Medical Officer, INS, Beas, C/o FMO, Mumbai.Received : 21.01.09; Accepted : 25.02.10E-mail : rajendra.harnagle@gmail.com Original Article Introduction A geing is associated with a number of physiological conditions that can contribute to increased disability,frailty and accidental falls. The main contributing factorsare the loss of muscle mass and strength due tosarcopenia. Current research has demonstrated thatstrength training exercises have the ability to combatweakness, frailty and their debilitating consequences bybuilding muscle strength and muscle mass and preservingbone density so as to reduce signs and symptoms of numerous chronic diseases such as heart diseases,arthritis, type 2 diabetes mellitus (DM) and alsoimproving sleep and depression [1-2].American Heart Association and American Collegeof Sports Medicine (AHA& ACSM) recommend regularpumping of iron as it improves functions of heart andlung, enhances glucose metabolism, reduces coronarydisease risk factors and boosts well being [3]. Elderlypatients who had a hip fracture can perform moderateto high intensity weight training at home [4]. Ex-servicemen (ESM) are generally left to fend forthemselves due to widely prevalent nuclear family norm.Furthermore, children are not staying with parents dueto reasons of education and employment. The study wascarried out to determine feasibility of strengthening of ESM in view of non availability of children/ relatives toassist in old age. Material and Methods The ESM aged between 47 to 94 years, who were admittedin a military hospital at the time of study, were selected. Someof them, despite being relatively young, were unemployedand were dependent on their children for psychological,physical and financial support. ESM as young as 47 years of age were also included to delineate early changes due toageing and to account for ESM personnel below officer rank (PBOR) who retire at an early age.This was an interventional 'Before and After' prospectivehospital based study. A total of 68 subjects were selected Modalities of Empowerment and Strengthening of Ex-servicemen Col R Harnagle * , Brig R Bhalwar + , Surg Lt Cdr SV Bhaskar # AbstractBackground: Older people including ex-servicemen (ESM) in India are left to fend for themselves due to nuclear family system.Most children are not staying with them due to reasons such as acquiring of education or employment at distant places. Thesefactors, coupled with deteriorating health with advancing age, change in value system and attitude amongst children who givemore importance to materialism, it was felt necessary to find modalities to empower and strengthen ESM by available methodsof including progressive weight training, yoga and meditation.Methods: An interventional “Before and After” study was planned for a period of three months for in-patient ESM of a militaryhospital for common lifestyle diseases namely stroke, diabetes, senile depression, acute myocardial infarction and hypertension.Data of anthropometry, laboratory investigations and Hamilton rating scale for depression (HRSD) were taken before the study.These cases were then subjected to interventions (progressive weight training and spiritual health enhancement by yoga withmeditation for three months) followed by same measurements again.Result: Statistically significant differences were observed before and after study with respect to pulse, respiratory rate, bloodpressure, blood glucose, total cholesterol, low density lipoproteins (LDL), very low density lipoproteins (VLDL) and Hamiltondepression score (p<0.05). The sleep pattern, sense of well being and posture while sitting to standing and walking with degree of support (stick/other person’s help) improved considerably after the interventions.Conclusion: ESM are recommended to be trained much before retirement on progressive weight training and yoga in regimentalcentre/station institute. Provision to be made in existing ex-servicemen contributory health scheme (ECHS) polyclinics foremployment of part time trainers for weight training and yoga. The physical and spiritual strengthening results in bettercapability to deal with old age and its problems.MJAFI 2010; 66 : 138-141Key Words : Ex-servicemen; Progressive weight training; Yoga; Spiritual health   MJAFI, Vol. 66, No. 2, 2010 Empowerment and Strengthening of Ex-servicemen139 amongst freshly admitted and already admitted patients in amilitary hospital who were suffering from any or multiplecomplications of DM, ischemic heart diseases (IHD), stroke,hypertension and senile depression. Out of 68 subjects, only58 could complete the study. The study was conducted on allvolunteer ESM subjects without calculating sample sizebecause of operational /logistic difficulties. However, whensample size was calculated retrospectively for variables suchas haemoglobin (Hb), blood sugar, total cholesterol, andblood pressure (BP) with 10% level of significance, 80% powerand two tailed tests, the sample size ranged between 20 and52. In our study, 58 could complete the study and thus samplesize was adequate.The study was conducted for a period of three months.All patients were admitted in chronic medical or chronicsurgical ward till end of the study. These patients weremedically examined including anthropometry, laboratoryinvestigations and recording of Hamilton rating scale fordepression (HRSD) before commencing interventions andafter 90 days of termination of interventions.The training modalities included weekly programme for all58 study subjects together. It comprisedg of weight trainingon alternate days for one hour under the guidance of agymnasium instructor from a reputed gymnasium hired for aperiod of three months. Yoga and Pranayama training wasconducted on alternate days under the guidance of a yogateacher. Apart from specific medications and physiotherapy,appropriate specialist consultation and treatment requiredfor specific ailments were also given. Furthermore, dependingon religious denomination, religious teachers from nearbyregimental centres visited on alternate days in the afternoon.All subjects, irrespective of religious beliefs, were givenspiritual enhancement by an instructor from Sirshree TejParkhi’s “Happy Thoughts” organisation, who covered topicson aspects of being a good human being, methods of self-realisation by meditation without reference to any particularreligion etc. All subjects were imparted yoga training at yogahall of the military hospital. Efforts were made to reduce biasby detailing same medical and paramedical staff on sameequipments for evaluation of 'Before and After' parameters.The observer’s bias was removed by including group of observers who examined and evaluated all the study subjectsbefore starting the intervention and then after three monthsof follow-up. The same observers except for one, againevaluated same subjects without knowing the baseline data.Further, since the observers were not co-authors, thereforetheir assessments were totally independent and withoutprejudice. Results A total of 58 (out of 68) subjects were followed up fromstart to end. Ten subjects discontinued the study due todomestic reasons. The age of subjects ranged from 47 to 94years with maximum concentration between 55 and 70 years.A statistically significant decrease was observed withrespect to pulse, respiratory rate, blood pressure (both systolicand diastolic), fasting glucose, post-prandial glucose, totalcholesterol, low density lipoprotein (LDL) cholesterol andvery low density lipoprotein(VLDL) cholesterol (Table 1).All 58 subjects were evaluated on 15 points of HRSD. Thereduction in HRSD was statistically significant after threemonths of interventions (Table 2). All cases who had scoreranging from six to ten and their score improved to normal i.e.score less than five after three months of interventions (Table3).There was high degree of subjective improvement inproblems of posture of sitting, standing, sitting to standing,walking, wheel chair/stretcher borne, walking with supportand quality of sleep (Table 4). Discussion The present study has revealed that ESM are easilymotivated (after removing doubts causing initialreluctance) for initiating them to regular physical Table 1Anthropometry and biochemical parameters before and after the interventions Mean valueSD beforeMean valueSD afterMeanT test‘p’ valuebeforeinterventionsafterinterventionschangevalueinterventions interventionsHaemoglobin12.462.0913.1291.7479-.671-5.631< 0.001Weight59.3013.57459.3513.369-.01-.1350.89BMI24.134.9224.0105.32.124.3860.70Waist measurement82.1913.5382.4512.71-.26-.6450.52Pulse rate79.575.4276.364.703.215.172< 0.001Resp rate19.750.9919.371.07.392.6540.01BP (Systolic)131.5112.59125.757.8385.753.438< 0.001BP (Diastolic)84.048.5778.9110.305.123.223< 0.01Fasting glucose87.7120.5881.7612.685.954.793< 0.001Post prandial glucose122.6271.86109.6942.4612.933.236< 0.01Total cholesterol185.8419.52178.0319.237.816.207< 0.001Triglycerides147.69103.89153.22137.7-5.53-.3850.70HDL50.345.6549.846.432.523.535< 0.001LDL105.5919.31101.918.213.699.503< 0.001VLDL33.3426.9228.7821.694.573.375< 0.001   MJAFI, Vol. 66, No. 2, 2010 140Harnagle, Bhalwar and Bhaskar exercise as well as continuing or stepping up of measuresfor spiritual well being.Once ESM were motivated, their age was not ahindrance to continuation of interventions on their ownwith three monthly refresher capsule of one day each.The benefits accruing due to progressive weight trainingin the study is in agreement with other studies [1-4]. Arandomised controlled trial has similarly shown 50%reduction in HRSD along with strength gain andimproved quality sleep [5].A total of 19 parameters were studied includinganthropometric, biochemical and HRSD before the onsetof intervention and then after subjecting ESM to threemonths of intervention. There was a significant decreasein pulse rate, respiratory rate, systolic BP, diastolic BP,fasting and post- prandial glucose, total cholesterol, LDLand VLDL.A study in Delhi has shown reduction in fastingglucose and decrease in total cholesterol and VLDLwith similar intervention program [6]. Regular physicalactivity is important for primary and secondaryprevention of many chronic diseases and delays loss of independence [7].The HRSD was found to be statistically significantfollowing intervention after three months. Beforeintervention 39 (67.26%) subjects had HRSD less thanfive, which is considered to be normal, while 19 (32.75%)had HRSD in the range between six and ten, which isconsidered to be moderate depression. After theintervention all 58 (100%) subject had HRSD less thanfive i.e. normal.There was considerable subjective improvement inmost of the parameter from severe to moderate/mildand from moderate to mild.Community based exercise programme reduced risk factors for accidental falls in 65 to 75 years old adultswith osteoporosis in a randomised controlled trial [8].Therefore, the importance of regular physical activityat a community level, including progressive weighttraining, cannot be overemphasized.It is recommended that ESM be provided withfacilities for weight training and spiritual healthenhancement by employing a physical trainer and a yogateacher. However, motivation as well as emphasis onimportance and benefit of regular exercise may beimparted from the time of enrolment and continued Table 2Hamilton rating scale of depression before and after theinterventions ScoreBefore interventionAfter interventionn (%)n (%)<539 (67.24%)58 (100%)06-1019 (32.75%)0 (0%)11-150 (0%)0 (0%)Total58 (100%)58 (100%)Test statistics (Z) = +7.484; p< 0.001There was a significant decrease in HRSDafter the intervention(p<0.001). Table 3Changes in Hamilton rating scale for depression after theinterventions TimenMeanSDMinimumMaximumBefore585.191.5339After581.581.0703All 58 patients had subjective improvement as per HRSD. Table 4Subjective changes in physical posture, mobility and sleep after the interventions ParametersBefore interventionAfter interventionMildModerateSevereMildModerateSevereSitting posture problems211720130809Standing posture problems181613090807Sitting to standing posture problems231415110809Walking ambulatory problems120913060506Wheel chair borne problems050404030202Stretcher borne problems060504030201Walking with support110709030304Sleep patternDepth140911070405Duration121110060605Quality160812080406Continuity151208080604Sleeping pills use050405030202Sense of wellbeing0705030301-For the purpose of study, the definition of severity is taken as: Mild-Able to complete with pain/difficulty; Moderate-Barely able to complete;Severe-Incapacitated.   MJAFI, Vol. 66, No. 2, 2010 Empowerment and Strengthening of Ex-servicemen141 throughout. The effects of regular strength training aswell as enhancement of spiritual health will result inbetter coping ability and adaptation to old age.Being a hospital based study and also having arelatively small sample size, more studies on a largersample size are required for extrapolating the inferencedrawn in this study to the population at large. Conflicts of Interest None identified Intellectual Contribution of Authors Study Concept   : Col R Harnagle, Brig R Bhalwar  Drafting & Manuscript Revision  : Col R Harnagle,Surg Lt Cdr S V Bhaskar Statistical Analysis  : Col R Harnagle, Brig R Bhalwar,Surg Lt Cdr SV Bhaskar Study Supervision  : Col R Harnagle References 1.Gerald J, Dorothy R, Mary J. The benefits of strength trainingfor older adults. American Journal of Preventive Medicine 2003;3: 141-9.2.Sims J, Still K, Davider S, Guerin J, Naney A. Explore thefeasibility of community based strength programme for olderpeople with depressive symptoms. BMC Geriatrics 2006; 6:18.3.Nelson Me, Rejeski WJ, Blair SN,Duncan PW, Judge JO, KingAC, et al. Physical activity and public health in older adults:Recommendation from American College of Sports Medicineand American Heart Association. Circulation 2007; 39: 254-62.4.Mangroic KK, Craik RL, Tamlinson S, Palambaro KM. Canelderly patient who have hip fraction perform moderate to highintensity exercise at home. Physical Therapy 2005; 85: 727-39.5.Singh NA, Starvinos M, Yuonne H, Scarbel Gary. A Randomizedcontrolled trial of high versus low weight intensity trainingversus general practitioner care of clinical depression in olderadults. Journal of Gerontology Series A, Biological Science andMedical Science 2005; 604: 768-76.6.L Jerome Brandon. Promoting physically active lifestyles inolder adults. Journal of Physical Education, Recreation andDance 1999; 70: 254-62.7.Noylma H, Watanabe H, Yamane K, Kitahara Y, Sekikawak,Yamamoto H, et al. Effects of aerobic exercises training onoxidative stress in patients with type-2 diabetes mellitus 2008;57: 170- 6.8.CDC, National Centre For Chronic Disease Prevention andHealth Promotion, US Dept of health and human services;Promoting active lifestyle among older adults, 106-14.9.Cartel ND, Khan KM, Mckay HA, Petit Ma, Waterman C,Heinanen A, et al. Community based exercise programmereduces risk factors for falls in 65 to 75 years old women withosteoporosis: Randomized controlled trial. CMAJ 2002; 167:997-1004. BEST ARTICLE AWARD 2009 All srcinal articles published in the year 2009 were evaluated based on the average of marks given forsrcinality of work, correctness of methodology, logical interpretation of results and quality of discussionby referees, editorial board and governing council members. The article scoring maximum points is giventhe best article award and the one scoring next highest points is given the second best article award. Thebest article award carries a cash award of Rs.5000, the second best article Rs.3000 and certificatessigned by the DGAFMS given during the conduct of AFMRC.The best article award for the year 2009 was awarded to:Urodynamic Management of Neurogenic Bladder in Spinal Cord Injury(a)Lt Col R Khanna (Principal Author), Classified Specialist (Surg & Urology), BH Delhi(b)Col AS Sandhu (Co-Author), Senior Advisor (Surg & Urology), Command Hospital (SC) Pune(c)Lt Col D Doddamani (Co-Author), Classified Specialist (Surg & Urology), MH JalandharThe second best article award for the year 2009 was awarded to :Conventional versus Endoscopic Powered Adenoidectomy: A Comparative Study(a)Lt Col R Dutta (Principal Author), Classified Specialist (ENT), BH Delhi(b)Col VP Singh (Co-Author), Classified Specialist (ENT), MH, Dehradun(c)Col Deshpal (Co-Author), Senior Advisor (ENT), INHS Asvini, Mumbai
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