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Recommending Exercise to Healthy Older Adults

The Preparticipation Evaluation and Exercise Prescription

Evan W. Kligman, MD; Michael J. Hewitt, PhD; Douglas L. Crowell, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 11 - OCTOBER 15, 1999


In Brief: The office-based preparticipation evaluation for older adults addresses cardiovascular status, muscle strength, flexibility, balance, and agility. The Kasch pulse-recovery test and the sit-and-reach test are practical methods for evaluating aerobic capacity and flexibility, respectively. Other measures, such as assessment of body composition or bone density, help establish goals and provide baselines for measuring exercise progress. The prescription for older people is aimed at maintaining current function and moving patients to the next activity level. The prescription specifies type, frequency, duration, and intensity of exercise. Case reports describe how key pieces of information from the preparticipation exam can lead to specific exercise recommendations.

In recent decades, research has validated the effectiveness of regular exercise as a way to reduce and/or prevent age-related functional decline and reduce the risks of a sedentary lifestyle (1). Most medical groups recommend regular physical activity (2). People over age 65 carry the highest load of chronic disease, disability, and healthcare utilization (3). Though many of these problems are preventable, primary care physicians rarely provide their older patients with an appropriate exercise recommendation that includes an individualized motivational message, a preparticipation evaluation to ensure a safe exercise program, and a tailored exercise prescription (4).

Office-based practitioners can complete a preparticipation evaluation during routine visits to identify healthy older patients who are good candidates for exercise training. We define health as the absence of conditions that would preclude participation in regular physical activity that can reduce the risk for certain chronic degenerative diseases and improve metabolic fitness, VO2 max, and daily functioning.

History

The first step in the preparticipation evaluation is to assess for contraindications to exercise testing and training and to identify any risks or limitations relevant to the exercise prescription. An efficient screening questionnaire (table 1) addresses previous exercise programs; present activity (frequency, duration, and intensity); existing chronic or acute disease(s), especially chronic obstructive pulmonary disease, cardiovascular disease, and extreme motor limitations because of severe arthritis; family history of cardiorespiratory disease; and coronary artery disease risk factors. The history should also include a current systems review, risk factors that are possibly modifiable through exercise (see "Patient 1," below), and a medication review to determine any potential interaction with exercise testing or training.


TABLE 1. Patient Profile and History


Date:___________________________________________

Name:_______________________________________________

Address:______________________________________________

Telephone:________________ Age:________ Weight:__________

Percent fat:_______________ Lean mass in lb:____________

Goals: ___________________________________

Risk factors (circle):
Family History
Diabetes
Sedentary
Hyperlipidemia
Hypertension
Stress
Smoker (Quit___)
Other


Limitations (circle):
Asthma
Osteoporosis
Arthritis
Recent surgery
Menopausal
Menstrual irregularity
Heart disease


Orthopedic:
Low back
Knees
Shoulder
Other/additional information:________________

Medications:
Type:___________ Function:________________
Type:___________ Function:________________
Type:___________ Function:________________
Type:___________ Function:________________

Equipment Available:
Home: _____________________________________
Club: _____________________________________
Work: _____________________________________
Sports: _____________________________________

Current Exercise Program:
Cardiovascular Types:_____________________________________
Frequency:_____________________________________
Duration:_____________________________________
Intensity:_____________________________________

Strength
Types:_____________________________________
Frequency:_____________________________________
Sets:_____________________________________
Reps:_____________________________________
To failure?:_____________________________________
Flexibility:_____________________________________

Summary and recommendations: ___________________________________

Physician: ___________________________________


Though most risk of exercise-related morbidity and mortality is associated with preexisting cardiac conditions, contraindications to exercise testing and training are the same for older and younger adults. Absolute contraindications to formal exercise testing include recent electrocardiographic changes or acute myocardial infarction, unstable angina, third-degree heart block, and acute congestive heart failure (5). Relative contraindications to exercise testing include elevated blood pressure, cardiomyopathies, valvular heart disease, complex ventricular ectopy, and uncontrolled metabolic diseases.

Physical Examination and Lab Tests

The physical exam and related evaluation measures focus on patients' functional abilities and/or limitations. A medical assistant, nurse, or other midlevel practitioner under a physician's supervision can accomplish most of the steps of the preparticipation exam. The average office-based evaluation takes about 20 minutes, though additional time is required if treadmill testing, bone mineral density scans, or respiratory function tests are needed. The physical examination should include vital signs and cardiorespiratory and musculoskeletal evaluation.

Cardiovascular fitness. The American College of Sports Medicine (ACSM) recommends cardiac treadmill stress testing before commencing vigorous exercise (exercise intensity greater than 60% of maximal oxygen uptake) for men over age 40, women over age 50, and all older patients who have cardiac risk factors with or without symptoms (5). A stress test is needed if the patient is older than 65 and sedentary.

Treadmill tests, which can be used to estimate the patient's aerobic capacity, are useful for prescribing exercise intensity. If a treadmill test is unavailable, the Kasch pulse-recovery test (table 2) can be performed in the office to give physicians a general idea of a patient's functional and aerobic capacities. The test is based on the principle that the better one's level of fitness, the sooner the heart rate returns to baseline after exercise. The patient's pulse and blood pressure are measured at rest and 1 minute after he or she has stepped up and down (with both feet) a 12-in. step 24 times per minute for 3 minutes (6). To help patients adhere to this pace, setting a metronome to 96 bpm may be helpful. Respiratory function can be determined simply by measuring the patient's forced vital capacity and forced expiratory volume in 1 second.


TABLE 2. How to Administer the Kasch Pulse-Recovery Test (6)

1. Measure pulse at rest.
2. Ask the patient to step up and down (with both feet) a 12-in. step 24 times per minute for 3 min.
3. Measure pulse 1 min after the test.
4. Determine patient's fitness level on the following scale:

Postexercise Beats/Minute
Fitness Level Age 56-65 Age 66+
Men
Excellent 72-82 72-86
Good 89-97 89-95
Above average 98-101 97-102
Average 105-111 104-113
Below average 113-118 114-119
Poor 122-128 122-128
Very poor 131-150 133-152
Women
Excellent 74-92 73-86
Good 97-103 93-100
Above average 106-111 104-114
Average 113-117 117-121
Below average 119-127 123-127
Poor 129-136 129-134
Very poor 142-151 135-151

Musculoskeletal function. Musculoskeletal function can be evaluated by gross measurement of motor strength (simple and handgrip) and range of motion. Handgrip strength, measured with a dynamometer, is highly predictive of functional limitations (7). Having patients do as many push-ups as they can is a simple assessment of muscle strength and endurance and provides a baseline to evaluate the benefits of exercise. Another general index of strength and function is the sit-and-rise test (figure 1), which is easy to administer.

[Figure 1]

Balance can be assessed by a standard Romberg's test (standing with the feet together, arms at the side with eyes open, then with eyes closed). Also, Tinetti (8) has developed an excellent performance-oriented assessment of balance. The physician observes the patient walking, then rates his or her gait on a 12-point scale. The patient's total score is based on gait initiation, step length and height, symmetry, continuity, ability to walk a path, trunk movement, and stance.

Flexibility can be measured by the sit-and-reach test (figure 2) and range-of-motion assessment. Agility can be determined by asking the patient to walk a heel-to-toe balance line. (See "Patient 5," below.)

[Figure 2]


Yardstick Position (in.)
Flexibility Level Age 50-59 Age 60+
Men
High 16+ 15+
Average 10-15 9-14
Below average 7-9 6-8
Low 6 5

Women
High 19+ 18+
Average 13-18 12-17
Below average 10-12 9-11
Low 9 8

Body composition. Assessing patients' body composition helps set exercise goals and establish a baseline for measuring progress. Pounds of lean mass better defines exercise needs than does percentage of fat. Skinfold calipers can be used to estimate body fat percentage by summing the values from three (9) or four body sites (10) and using a skinfold equation to compare this sum with a table of norms. For men, 25% or more body fat elevates the risk for health problems such as adult-onset diabetes, cardiovascular disease, and hypertension; for women, 38% or more body fat presents an elevated risk. For further information on how to measure skinfolds, actual sites recommended, skinfold equation, tables of standardization norms, and sources of calipers, please see the work by Lohman and colleagues (11-13). Bioelectrical impedance devices are useful for in-office evaluation of body composition if patients are adequately hydrated.

Body mass index (BMI), a rough indicator of body composition, can be calculated by dividing body weight in kilograms by height in meters squared. This index is generally useful, but is suspect in older patients, especially those who have decreased bone mineralization and masters athletes who have greater-than-normal musculature. A BMI of 25 or more for men or women now constitutes overweight. BMI is a good starting point because it is easy to use and can be used to evaluate change, but it should not replace skinfold measurement.

Bone density. Dual-energy x-ray absorptiometry or heel ultrasonography can help in assessing the patient's risk of fracture and provide a baseline for measuring bone density improvements with exercise.

Lipid levels. A fasting lipid profile to measure total cholesterol, high-density and low-density lipoprotein subfractions, and triglycerides can provide a baseline for the sedentary patient to assess exercise benefits.

The Exercise Prescription

Prescribing exercise is like prescribing medications, surgery, or other therapy: It is a thoughtful compromise between the potential benefits and side effects. After careful consideration of these factors, the physician and the patient reach an agreement on the most effective plan. Important considerations include the goal of exercise (eg, osteoporosis prevention, weight loss, marathon training) and patient preferences. Expanding on his or her current exercise habits is a good starting point because choosing activities the patient already enjoys improves adherence.

Setting goals. The ACSM recently published separate position statements on exercise for healthy adults (14) and older adults (see reprint, page 115) (15). We have adapted these recommendations, combined with those from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) (16), into a chart that outlines basic exercise prescriptions for a range of health and fitness goals (table 3).


TABLE 3. Basic Exercise Prescriptions for a Range of Health and Fitness Goals for Older Persons, Adapted From Federal Exercise Guidelines
Fitness Dimension Disease Prevention Basic Health Fitness Performance

Cardiovascular capacity Accumulate 30 min of physical activity most days Large-muscle repetitive exercise or equivalent sports activity, 20 min, 3x/wk Aerobic exercise or equivalent sports activity, 40-60+ min, 4-6x/wk Add competition and/or interval training

Strength Include weight-bearing activity "Core four"* or equivalent program, one set, 8-12 or 12-15 repetitions at challenge weight,** 2x/wk, Pilates work*** Balanced whole-body free weights or machines, 1-3 sets, 8-12 repetitions reaching functional failure,++ 2-3x/wk, Pilates work Add ascending and descending pyramids+++ and muscle endurance or power training, Pilates work

Flexibility Maintain range of motion by bending and stretching in daily activities 2-4 stretches after activity, 1 repetition, hold 30 sec 6-10 whole-body stretches before and after activity, 1-2 repetitions Add yoga, Pilates, and/ or facilitated stretches with a partner

Body composition
   Men >5%-<25% fat; maintain lean body mass at >125-150 lb 12%-20% fat; maintain lean body mass at >125-150 lb 8%-15% fat
   Women >14<38% fat; maintain lean body mass at >90-110 lb 20%-30% fat; maintain lean body mass at >90-110 lb 17%-25% fat

Balance and agility "Act like a child"; balance line; "Don't step on a crack"; brush teeth while standing on one foot Recreational sports (eg, tennis, biking); tai chi; social dance; therapy ball training Agility or skill sports (ie, surfing, skiing, skating); martial arts; performance dance; agility drills

*Core four: double-leg press, chest press, latissimus dorsi pulldowns, abdominal crunch.

**Challenge weight: the lift is difficult but can be accomplished.

***Pilates: a series of stretching and strengthening exercises performed on a mat without equipment, developed by Joseph Pilates in the 1930s.

++Functional failure: unable to complete another repetition without sacrificing form.

+++Ascending pyramids: more weight is added to each set to cause fatigue with fewer repetitions; descending pyramids: weight is removed from each set to allow more repetitions until fatigue.


Like the preparticipation exam, the exercise prescription should address the five major fitness components: cardiovascular fitness, muscle strength and endurance (see "Patient 2" and "Patient 4," below), flexibility, body composition, and balance and agility. Many older patients have low lean mass and/or decreased strength, underscoring the importance of strength training. The ACSM recently added formal strength training recommendations to its exercise guidelines for adults (14).

Within the five categories, the physician and patient should select the desired fitness level. The objective is to allow patients to indefinitely maintain their current level of function and, ideally, help them reach the next category. The types and dosages of exercise will change as the patient's physiologic function changes.

Selecting activities. The exercise prescription addresses the type, frequency, duration, and intensity of physical activity for each fitness component. Though the type of exercise is often determined by available facilities and equipment, the patient's preference should carry considerable weight. For example, a patient who enjoys golf should be encouraged to occasionally substitute that activity for a treadmill and resistance training session. (See "Patient 3," below.)

Physicians should balance the benefits of each exercise mode with the patient's health goals and physical limitations. For example, walking, bicycling, and swimming provide excellent cardiovascular benefits, but the weight-bearing nature of walking provides a greater stimulus for bone mineral deposition than cycling or swimming does. On the other hand, swimming is better tolerated by patients who have joint limitations.

Cross-training is an effective compromise among several appropriate options. Patients can mix exercise modes within any given week or within a single session. Cross-training programs help prevent boredom, condition more muscle groups, and reduce the risk of overuse injury.

Determining frequency, duration, and intensity. Exercise variables can be manipulated to enhance compliance, but the dose-response relationship must be considered. Though exercising more often, longer, or harder affords greater conditioning, the relationship between effort and outcome is rarely linear. The point of diminishing return is often reached even before patients approach levels that pose a risk of excessive fatigue or injury.

Surprisingly little exercise is required to meet the recommendations for disease prevention (CDC-NIH recommendations) (16). Physicians and exercise physiologists often make frequency and duration recommendations at minimal and optimal levels, with instructions to perform the minimal exercise during the busiest weeks and meet the optimal criteria on all others (table 4).

TABLE 4. Exercise Prescription


Fitness Component Type(s) Frequency Duration Intensity


Cardiorespiratory fitness ______________
______________
______________
______________ days/wk ______________ min ______________ beats/min
______________ beats/10 sec


Strength Free weights
Machines
Elastic exercise band
Floor work
______________ days/wk ______________ min ______________ sets ______________ repetitions


Flexibility Static stretch ______________ days/wk ______________ sec ______________ repetitions Hold below pain threshold


Balance and agility ______________
______________
______________
______________ days/wk ______________ min


Comments/progression:____________________________________________

Signature:____________________________________________


Exercise intensity is always prescribed as a range (eg, a target-heart-rate range of 120 to 145 beats per minute or muscle fatigue in 8 to 12 repetitions). Using an age-predicted target heart rate has limited value and is often misleading, especially as patients age, because 70% to 85% of age-predicted maximal heart rate is often off by 15 to 20 beats per minute. Physiologic change occurs when the body is exposed to stimuli greater than it can currently handle, a concept called "teasing the physiologic threshold." The concept is useful even in balance and agility training.

Many patients underestimate their exercise capacity, considering physical activity to be uncomfortable, hazardous, or medically unwise. However, Fiatarone et al (17) demonstrated the safety and effectiveness of a strength training program even for nonagenarians. The quantity and load of the exercise were adjusted as function improved. Thus, the exercise prescription should involve monitoring or teaching patients to assess their own progress.

MET levels are useful for setting exercise goals. A list of common physical activities classified by intensity in METs is available (18). We encourage practitioners to obtain a copy of this original comprehensive list to share with patients and customize exercise recommendations according to the patient's skill level and geographic location. See table 5 (not shown) for a list of MET values for selected common leisure activities.

The Borg perceived exertion scale (table 6: not shown) is frequently used to evaluate aerobic exercise intensity; it can also be used to rate the intensity of resistance training and stretching. Exercise physiologists often recommend aerobic exercise in the moderate to heavy range (13 to 15 on the Borg scale) for healthy young adults, and may modify their recommendations to light to moderate (11 to 13 on the Borg scale) for older adults.

As function improves, the challenge should be raised by increasing the intensity or duration of exercise. In strength training, a common recommendation is to lift to muscle fatigue (inability to complete another lift while maintaining good form) in 8 to 12 repetitions. For older adults, 12 to 15 repetitions using slightly lighter weights may be more appropriate. Weight is increased when the patient can consistently complete 13 repetitions; then he or she repeats the process. The rate of improvement varies among individuals and may be slower in older adults.

Patient Empowerment

Prescribing exercise to older adults helps prevent disability and promote optimal functioning. A preparticipation evaluation is essential to assure physicians—and patients—that they are capable of further exercise testing and training.

References

  1. US Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. Atlanta, DHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996
  2. US Preventive Services Task Force: Guide to Clinical Preventive Services, ed 2. Baltimore, Williams & Wilkins, 1996
  3. King AC, Rejeski WJ, Buchner DM: Physical activity interventions targeting older adults: a critical review and recommendations. Am J Prev Med 1998;15(4):316-333
  4. Will PM, Demko TM, George DI: Prescribing exercise for health: a simple framework for primary care. Am Fam Physician 1996;53(2):579-585
  5. Mahler DA, American College of Sports Medicine: Guidelines for Exercise Testing and Prescription, ed 5. Baltimore, Williams & Wilkins, 1995, pp 1-37
  6. Kasch FW, Phillips WH, Ross WD, et al: A comparison of maximal oxygen uptake by treadmill and step-test procedures. J Appl Physiol 1966;21(4):1387-1388
  7. Rantanen T, Guralnik JM, Foley D, et al: Midlife hand grip strength as a predictor of old age disability. JAMA 1999;281(6):558-560
  8. Tinetti ME: Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34(2):119-126
  9. Jackson AS, Pollock ML: Practical assessment of body composition. Phys Sportsmed 1985;13(5):76-90
  10. Lohman TG: Advances in Body Composition Assessment: Current Issues in Exercise Science, monograph 3. Champaign, IL, Human Kinetics, 1992, pp 25-55
  11. Lohman TG, Houtkooper LB, Going SB: Body fat measurement goes high-tech: not all are created equal. ACSM Health Fit J 1997;1(1):30-35
  12. Williams DP, Going SB, Lohman TG, et al: Estimation of body fat from skinfold thicknesses in middle-aged and older men and women: a multiple component approach. Am J Human Biol 1992;4:595-605
  13. Lohman TG, Roche AF, Martorell R: Anthropometric Standardization Reference Manual. Champaign, IL, Human Kinetics, 1988, pp 55-80, 161-166
  14. Pollock ML, Gaesser GA, Butcher JD, et al: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975-991
  15. Mazzeo RS, Cavanagh P, Evans WJ, et al: ACSM position stand on exercise and physical activity for older adults. Med Sci Sports Exerc 1998;30(6):991-1008
  16. Pate R, Pratt M, Blair SN, et al: Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-407
  17. Fiatarone MA, Marks EC, Ryan ND, et al: High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990;263(22):3029-3034
  18. Ainsworth BE, Haskell WL, Leon AS, et al: Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc 1993;25(1):71-80


Exercise Prescription Case Studies: Medical Conditions, Fitness Deficits

Older patients come to the preparticipation examination with an array of physical abilities and body compositions. Systematic evaluation, as in the reports below describing patients who visited a health resort, helps physicians quickly assess patients' functional status and note what areas of the body need special emphasis and what medical conditions need to be considered in the exercise prescription. The keys to successfully motivating patients are professional support, regular assessments, new goals, self-control, and social support.

Patient 1

History. A 58-year-old woman had a good medical history except for osteoporosis (no fractures). Her activity history includes walking.

Physical examination. Submaximal exercise testing predicted that the patient had a maximal aerobic capacity of 9.8 METs, which corresponds to a VO2 max of 34 mL/kg/min. The patient's body fat was 34%, which represented 40 lb of fat weight and 78 lb of lean body mass for her weight (118 lb). Balance testing was not done.

Assessment. This is a classic case of normal weight but "underlean" body mass. The low lean mass and bone mineral density suggested a need for aggressive resistance training. Her cardiovascular fitness level was excellent for her age and gender.

Exercise prescription. The patient's exercise prescription was modified to include interval training to further enhance cardiorespiratory fitness and decrease her percent body fat. It was also recommended that she work with a personal trainer 2 to 3 days per week to improve her overall strength, lean body mass, and bone mineral density. She did a series of 8 to 10 exercises of varying volume and intensity, along with site-specific exercises for osteoporosis. Balance and agility exercises were recommended to decrease her risk of falls, and recreational activities of 4 to 5 METs with an agility component (such as tai chi and social dance) were recommended. Because of her osteoporosis, she was advised to avoid abdominal crunches and modify other abdominal exercises.

Patient 2

History. A 68-year-old man in good health said he exercised on his treadmill 6 to 7 days per week for 45 minutes at 4 mph, using a 4% grade some of the time. He had not included any strength training or flexibility training.

Physical examination. His upper- and lower-body strength had decreased from previous years, and he had a decreased score in his flexibility rating based on previous annual sit-and-reach tests. His body fat was 29%, which represented 51 lb of fat weight and 125 lb of lean body mass for his weight (176 lb).

Assessment. His body fat was above the "basic health" classification, and his lean body mass was on the lowest edge of ideal. This patient fit the profile reported by Pollock et al (1) of older athletes who do not include strength training in their fitness program.

Exercise prescription. The patient's training was enhanced by adding a basic weight training program to improve strength and body composition. He was advised to start a home-based program of six to seven exercises 2 to 3 days a week.

Patient 3

History. A 61-year-old woman had a good medical history. Her activity level was minimal; she walked occasionally.

Physical examination. Submaximal exercise testing predicted a maximal aerobic capacity of 7.2 METs. Her body fat level was 37%, which represented 50 lb of fat weight and 85 lb of lean body mass for her weight (135 lb).

Assessment. Her fitness level was average, based on her maximal aerobic capacity.

Exercise prescription. Her exercise program was adjusted to include more cardiorespiratory activities, focusing on fun and play to enhance adherence. Activities within the 4- to 6-MET range were recommended. She was advised to undertake basic strength training at a fitness center using resistance machines. The goal was for the patient to learn motor movement patterns to possibly graduate her to a free-weight program that could enhance activities of daily living.

Patient 4

History. A 69-year-old woman had no known medical problems. Her current exercise program consisted of treadmill exercise, walking, and occasional skiing.

Physical examination. The patient had a predicted maximal aerobic capacity of 9.7 METs. She had average leg strength but good upper body strength. Her sit-and-reach test result was average. Her body fat was 29%, which represented 39 lb of fat weight and 97 lb lean body mass for her weight (136 lb).

Assessment. The patient's cardiovascular fitness level and lean mass were excellent for any age.

Exercise prescription. The patient was advised to begin a strength training program to enhance daily and recreational activities and to enhance joint stability. Balance and agility exercise were advised for the same reason. Activities in the 6- to 8-MET range were appropriate.

Patient 5

History. A 72-year-old woman had a history of ataxia and normal pressure hydrocephalus. Guided by a personal trainer, she was exercising on a treadmill and weight training three times per week.

Physical examination. Range of motion was decreased in the patient's hamstrings and hip flexors. Muscle symmetry was good, except in the lower legs, but she had mild-to-moderate general muscle atrophy. She could not walk a straight line and had little trunk flexibility.

Assessment. The patient needed to focus on her balance and decreasing the risk of falls.

Exercise prescription. Her exercise prescription was modified to include additional lower-body resistance exercises on machines, especially targeting the calves and shins. In addition, swimming pool Romberg's practice (standing on one leg) and linear walking were included. Stretching exercises for her hamstrings and hip flexors were prescribed.

REFERENCE

1. Pollock ML, Mengelkoch JL, Granes JE, et al: Twenty-year follow-up of aerobic power and body composition of older track athletes. J Appl Physiol 1997;82(5):1508-1516


Dr Kligman is a geriatrician and family practice physician, Dr Hewitt is director of exercise physiology, and Mr Crowell is an exercise physiologist and fitness specialist at Canyon Ranch Health Resort in Tucson. Address correspondence to Evan W. Kligman, MD, 8600 E Rockcliff Rd, Tucson, AZ 85718.


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