Christine Stopka

The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making.

Effect of moderate-intensity exercise training on the cognitive function of young adults with intellectual disabilities.

Abstract Pastula RM, Stopka CB, Delisle AT, and Hass CJ. Effect of moderate-intensity exercise training on the cognitive function of young adults with intellectual disabilities. J Strength Cond Res 26(12): 3441–3448, 2012—In addition to cognitive impairment, young adults with intellectual disabilities (IDs) are also more likely to be in poor health. Exercise may help ameliorate both of these deficits. While the health benefits of exercise are well documented and understood, the cognitive benefits of exercise are emerging. Exercise has been shown to improve the cognitive function of young, old, and diseased populations but few studies have evaluated the effect of exercise training on the cognitive functioning of individuals with IDs. The purpose of this study was to determine the effect of moderate-intensity exercise training on the cognitive function of young adults with IDs. Fourteen students (age, 19.4 ± 1.3 years) with mild to moderate IDs participated in an 8-week comprehensive exercise intervention program based on circuit training, aerobic dancing, and adapted sport activities. Sessions lasted 45 minutes, and intensity was maintained at 60–70% of maximum heart rate (HRmax). Aerobic fitness was assessed via the Young Men’s Christian Association (YMCA) step test, and intellectual functioning was assessed via 3 subtests from the Woodcock-Johnson III Tests of Cognitive Abilities once before and after the intervention. Performance was significantly improved on all 3 cognitive tests (all, p < 0.002). Aerobic fitness also significantly improved (p < 0.002). The mean percent increase in processing speed, a measure taking into account each individuals performance on the 3 subtests, was 103%. The mean individual improvement in aerobic fitness was 17.5%. Moderate-intensity exercise training can yield robust improvements in the cognitive functioning and aerobic fitness of young adults with IDs. These effects support the inclusion of exercise into the lives of young adults with ID to promote their physical and cognitive health. Fourteen students (age, 19.4 ± 1.3 years) with mild to moderate IDs participated in an 8-week comprehensive exercise intervention program based on circuit training, aerobic dancing, and adapted sport activities. Sessions lasted 45 minutes and intensity Powered by Editorial Manager and Preprint Manager from Aries Systems Corporation was maintained at 60–70% of HRmax. Aerobic fitness was assessed via the YMCA step test, and intellectual functioning was assessed via 3 subtests from the Woodcock-Johnson III Tests of Cognitive Abilities once before and after the intervention. Performance was significantly improved on all 3 cognitive tests (all, p < 0.002). Aerobic fitness also significantly improved (p < 0.002). The mean percent increase in processing speed, a measure taking into account each individuals performance on the 3 subtests, was 103%. The mean individual improvement in aerobic fitness was 17.5%. Moderate-intensity exercise training can yield robust improvements in the cognitive functioning and aerobic fitness of young adults with IDs. These effects support the inclusion of exercise into the lives of young adults with ID to promote their physical and cognitive health.

Benefits of Low-Intensity Pain-Free Treadmill Exercise on Functional Capacity of Individuals Presenting With Intermittent Claudication Due to Peripheral Arterial Disease:

Patients with intermittent claudication due to peripheral arterial disease (PAD) experience muscle aching during walking secondary to ischemia. The purpose of this study was to examine the effects of low-intensity pain-free exercise (LIPFE) on functional capacity of individuals with PAD. A total of 12 participants with PAD underwent training on treadmill for 6 weeks, twice a week, for about 45 minutes. Outcome measures included walking distance (WDI), walking duration (WDU), mean walking rate (WR), estimated oxygen consumption (EVO2), metabolic equivalent (MET), estimated total energy expenditure (ETEE), and estimated rate of energy expenditure (EREE). Mean improvement of WDI, WDU, and MWR were 104% (an addition of 1.0 km), 55% (an addition of 13.3 minutes), and 41% (0.9 km/h faster), respectively. Mean improvement of EVO2, MET, ETEE, and EREE, were 20%, 20%, 80%, and 20%, respectively. In conclusion, it appears that LIPFE training is an effective intervention for individuals presenting with PAD.

Supervised moderate intensity resistance exercise training improves strength in Special Olympic athletes.

Tamse, TR, Tillman, MD, Stopka, CB, Weimer, AC, Abrams, GL, and Issa, IM. Supervised moderate intensity resistance exercise training improves strength in special Olympic athletes. J Strength Cond Res 24(3): 695-700, 2010-The purpose of this study was to examine the effects of a moderate intensity resistance training program on Special Olympic athletes (SOAs) and similarly aged typically developed volunteers (TDs) who also served as coaches. Fifteen SOAs and 17 TDs participated (age range 19-24 years). The intervention consisted of resistance training: 1 set, 8-12 reps, over 10-12 sessions, on Med-X weight equipment. Exercises tested were seated row (SR), leg curl (LC), leg extension (LE), chest press (CP), and the abdominal crunch (AC). The weight lifted, and the amount of repetitions performed at the beginning and end of training, were used to determine the predicted 1 repetition max (1RM). A 2-way (2:group × 2:time) analysis of variance was computed for each exercise. Time main effects were detected, which indicated that predicted 1RM increased significantly for all participants. Specifically, these were the SR (F(1,30) = 99.238, p < 0.001); the LC (F(1,30) = 91.578, p < 0.001); the LE (F(1,30) = 83.253, p < 0.001); the CP (F(1,30) = 53.675, p < 0.001); and the AC (F(1,30) = 57.759, p < 0.001). The predicted 1RM values increased between 25 and 50% across the exercises tested. There were no group main effects or interactions. Thus, with minimal training time, both similar and significant strength gains can be accomplished by both SOAs and TDs, respectively. Supervised moderate intensity resistance training is recommended for the populations tested and may result in vocational and athletic performance gains.

Effects of Low-Intensity Exercise on Patients with Peripheral Artery Disease

Abstract Background: Peripheral artery disease (PAD) is one of the many unhealthy conditions that may get worse with age. Its most common symptom is intermittent claudication (IC). Intermittent claudication is the exercise-induced ischemic pain caused by the reduced blood flow to the lower extremities. Objectives: To investigate the effects of low intensity treadmill walking on the functional capacity of PAD patients with IC. Walking ability (time, rate, and distance), heart rate, and blood pressure responses were recorded before, during, and after each exercise session. Only the initial and final values recorded were used for data analysis. This 6-week program of low-intensity, pain-free endurance training was designed to keep the exercise level low enough to minimize ischemic leg pain. Methods: Thirteen PAD patients volunteered for twice weekly exercise sessions for 6 consecutive weeks. Each session consisted of a 10-minute warm-up consisting of routine, pain-free static and proprioceptive neuromuscular facilitation stretching. Each patient exercised for 10 to 20 minutes as tolerated on the treadmill. Proprioceptive neuromuscular facilitation was conducted following walking. Results: As a group the patients with PAD had an average 148% improvement in distance, 34% in rate, and 94% in duration of walking. Five of the 13 patients had over 100% improvement in distance, with the maximum being 525%. One of the 13 patients had a 100% improvement in rate. Four of the 13 patients had over 100% improvement in duration, with the maximum being 500%. Conclusions: This study introduces a new method of low-intensity treadmill walking exercise, which seems to be an effective nonpharmacologic treatment even within a 6-week period for patients with IC due to PAD. It also supports the benefits of walking exercise to increase the mobility of these patients, thus improving functional capacity of life.

Changes in pain-free walking based on time in accommodating pain-free exercise therapy for peripheral arterial disease

Symptoms of intermittent claudication (IC) can be relieved by lifestyle modification, medications, and walking exercises. The intensity of the walking exercise is still debatable. The goal of this study was to determine the effects of accommodating pain-free walking exercise therapy program length on pain-free walking. A descriptive, longitudinal study with repeated measures of exercise capacity was conducted. An IC questionnaire was administered to assess IC signs, symptoms, and lifestyle. Walking was performed on a treadmill for 30 to 50 minutes below the participants individualized walking pain threshold. The study included patients diagnosed with IC due to peripheral arterial disease. All participants were randomly assigned to three groups. Group A (n = 28) participated in the walking program for 2-9 weeks, group B (n = 30) for 10-14 weeks, and group C (n = 26) for 15-94 weeks. The main outcome measure of the study was to determine changes in exercise capacity: walking distance (miles), walking duration (minutes), and walking speed (mph). Group A increased the amount of distance, duration, and speed walked from pretest to posttest by 80% (P < .001), 27% (P < .001), and 37% (P < .001), respectively. Group B increased the amount of distance, duration, and speed walked from pretest to posttest by 122% (P < .001), 56% (P < .001), and 43% (P < .001), respectively. Group C increased the amount of distance, duration, and speed walked from pretest to posttest by 26% (P = .002), 22% (P = .002), and 5% (P = .541) respectively. We reached the conclusion that a walking program of 10-14 weeks is optimal for achieving the best improvements in walking distance, duration, and speed.

Physical Capacity and Functional Abilities Improve in Young Adults with Intellectual Disabilities after Functional Training

Abstract Barwick, RB, Tillman, MD, Stopka, CB, Dipnarine, K, Delisle, A, and Sayedul Huq, M. Physical capacity and functional abilities improve in young adults with intellectual disabilities after functional training. J Strength Cond Res 26(6): 1638–1643, 2012—Individuals with an intellectual disability (ID) have higher rates of obesity, lower rates of physical activity, cardiorespiratory fitness, and muscular endurance than do typically developed individuals (TDI) and are twice as likely to develop chronic disease, living half as long as TDIs do. The purpose of this study was to examine the improvements in physical capacity and functional ability in Special Olympic Athletes (SOAs) aged 19–22 years after participating in a functional training (FT) program and compare these scores with those of the SOAs in a resistance weight training (WT) program. Twenty SOAs (13 men, 7 women with mild to moderate ID) participated in a 1-hour FT program, twice a week, for 10 weeks, compared with 22 same-aged SOAs (14 men, 8 women) participating in a 1-hour WT program (2× week for 8 weeks). Prefitness and postfitness tests consisting of heart rate (HR) for the 3-minute step test, static plank, body weight squats, static bar hang, and knee push-ups were conducted. Two-tailed, paired sample t-tests (p < 0.05) were used to evaluate the differences in the FT group. Change scores were used to compare FTG with the WT group. The HR decreased by 31.8 b·min−1 pre-post in the FTG (p < 0.001). Static plank duration improved by 22.4 seconds in the FTG (p = 0.016); static plank change scores improved (p = 0.037) for the FTG (26.5 ± 32.1 seconds compared with that for the WT group (4.6 ± 22 seconds). Height and weight values were unchanged in both the groups. The results of this study demonstrate the value of FT programs for this population, because weight equipment is not always available in many settings.

Pain-free treadmill exercise for patients with intermittent claudication: Are there gender differences?

Intermittent claudication, a common symptom of peripheral arterial disease, results in insufficient blood flow and oxygen supply to lower extremity muscles. Compared to men, women with peripheral arterial disease have a higher rate of mobility loss with peripheral arterial disease due to poorer lower extremity functioning. This study evaluates the effect of supervised pain-free treadmill exercise on improving performance in women with intermittent claudication due to peripheral arterial disease in comparison to men. A total of 26 participants (women, n = 9, 34.62%; mean age = 67.58 ± 5.59 years; averaging 23.46 ± 3.91 visits and 10.46 ± 0.99 weeks in the program) diagnosed with peripheral arterial disease, with symptoms of intermittent claudication, partook in a 45 min treadmill walk, twice per week, below the participant’s minimal pain threshold. Female participants’ change scores showed 752%, 278% and 115% improvement in mean walking distance, duration and rate, respectively. Men improved 334%, 149% and 80%, respectively. Significant differences (p < 0.05) in pre and post measurements within each group support positive outcomes. No significant differences between groups were observed (Cohen’s d effect size > 0.80). Our results suggest that women reap similar benefits from this low-intensity treadmill program in comparison to men.

Evaluation of Skeletal Muscle Metabolic Responses Following Exercise Training in Patients with Intermittent Claudication

Objective: Factors responsible for the exercise intolerance occurring in patients with peripheral arterial occlusive disease (PAOD) manifesting intermittent claudication (IC) and contributing to the observed improvements in walking capacity after exercise training have not been elucidated. The authors characterized the resting and exercise responses of high-energy phosphate species in affected calf skeletal muscle as detected by phosphorus (P)-31 magnetic resonance spectroscopy (MRS) to determine whether metabolic derangements were present in patients with mild to moderate PAOD and IC and whether these abnormalities could be altered by training. Subjects: Thirteen patients evaluated for IC with resting ankle-brachial indices (ABIs) < 0.9 and positive exercise testing were enrolled in a supervised 10-week walking exercise program (IC training). Separate control groups were composed of (1) patients with PAOD and IC (IC control, n = 4) and (2) healthy, age-matched individuals (n = 4) without PAOD or IC who did not undergo exercise training. Outcome Measures: Resting ABIs and constant-load treadmill testing were performed prior to and following exercise training. ABIs, ankle pressure drop, and calf muscle bioenergetic response (P-31 MRS) of the most symptomatic limb were measured during inmagnet, lowand high-intensity calf exercise done before and after training. Results: Compared with healthy controls, patients with PAOD and IC before training had lower resting ABIs (0.66 ±0.11), larger ankle pressure drops (35 ±15%), shorter symptom-free walking distances during treadmill testing and significantly slower phosphocreatine recovery (Pcr t½) during in-magnet low-intensity (61 ±46 v. 36 ±40 sec, p=0.05) and high (119 ±93 v. 31 ±10 sec, p=0.003) exercise but had otherwise similar bioenergetic responses. Despite improved symptom-free walking distance (1,080 ±316 v. 498 ±367 ft, p < 0.001), patients with PAOD and IC exhibited no changes in resting ABI, ankle pressure drop or high-energy phosphate responses after training. Furthermore, no significant correlation was found between high-energy phosphate species and limb hemodynamics. Conclusions: The relatively subtle abnormalities in high-energy phosphate muscle metabolism present in patients with PAOD and IC may only partially account for their marked exercise intolerance and do not appear to contribute to the observed improvement in walking capacity after supervised training.

Proposing a Transactional Model of eHealth Literacy: Concept Analysis

Background Electronic health (eHealth) literacy was conceptualized in 2006 as the ability of internet users to locate, evaluate, and act upon web-based health information. Now, advances in eHealth technology have cultivated transactional opportunities for patients to access, share, and monitor health information. However, empirical evidence shows that existing models and measures of eHealth literacy have limited theoretical underpinnings that reflect the transactional capabilities of eHealth. This paper describes a conceptual model based on the Transactional Model of Communication (TMC), in which eHealth literacy is described as an intrapersonal skillset hypothesized as being dynamic; reciprocal; and shaped by social, relational, and cultural contexts. Objective The objective of our study was to systematically examine eHealth literacy definitions, models, and measures to propose a refined conceptual and operational definition based on the TMC. Methods Walker and Avant’s concept analysis method was used to guide the systematic review of eHealth literacy definitions (n=10), rating scales (n=6), models (n=4), and peer-reviewed model applications (n=16). Subsequent cluster analyses showed salient themes across definitions. Dimensions, antecedents, and consequences reflected in models and measures were extracted and deductively analyzed based on codes consistent with the TMC. Results Systematic review evidence revealed incongruity between operational eHealth literacy included in definitions compared with literacies included within models and measures. Theoretical underpinnings of eHealth literacy also remain dismal. Despite the transactional capabilities of eHealth, the role of “communication” in eHealth literacy remains underdeveloped and does not account for physical and cognitive processing abilities necessary for multiway transactions. Conclusions The Transactional Model of eHealth Literacy and a corresponding definition are proposed. In this novel model, eHealth literacy comprises a hierarchical intrapersonal skillset that mediates the reciprocal effect of contextual factors (ie, user oriented and task oriented) on patient engagement in health care. More specifically, the intrapersonal skillset counteracts the negative effect of “noise” (or impediments) produced by social and relational contexts. Cutting across health and technology literacies, the intrapersonal skillset of eHealth literacy is operationalized through four literacies that correspond with discrete operative skills: (1) functional (ie, locate and understand); (2) communicative (ie, exchange); (3) critical (ie, evaluate); and (4) translational (ie, apply).