Julie Halbert

The effectiveness of exercise training in lowering blood pressure: a meta-analysis of randomised controlled trials of 4 weeks or longer

Objective: To identify the features of an optimal exercise programme in terms of type of exercise, intensity and frequency that would maximise the training induced decrease in blood pressure (BP).Data identification: Trials were identified by a systematic search of Medline, Embase and Science Citation Index (SCI), previous review articles and the references of relevant trials, from 1980 until 1996, including only English language studies.Study selection: The inclusion criteria were limited to randomised controlled trials of aerobic or resistance exercise training conducted over a minimum of 4 weeks where systolic and diastolic BP was measured.Results: A total of 29 studies (1533 hypertensive and normotensive participants) were included, 26 used aerobic exercise training, two trials used resistance training and one study had both resistance and aerobic training groups. Aerobic exercise training reduced systolic BP by 4.7 mm Hg (95% CI: 4.4, 5.0) and diastolic BP by 3.1 mm Hg (95% CI: 3.0, 3.3) as compared to a non-exercising control group, however, significant heterogeneity was observed between trials in the analysis. The BP reduction seen with aerobic exercise training was independent of the intensity of exercise and the number of exercise sessions per week. The evidence for the effect of resistance exercise training was inconclusive.Conclusions: Aerobic exercise training had a small but clinically significant effect in reducing systolic and diastolic BP. Increasing exercise intensity above 70% VO2 max or increasing exercise frequency to more than three sessions per week did not have any additional impact on reducing BP.

Evidence for the optimal management of acute and chronic phantom pain: a systematic review.

ObjectivesThe objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. MethodsTrials were identified by a systematic search of MEDLINE, review articles, and references of relevant trials from the period 1966–1999, including only English-language articles. Included trials involved a control group, any intervention, and reported phantom pain as an outcome. ResultsTwelve trials were identified, including 375 patients whose follow-ups ranged in duration from 1 week to 2 years. Only three randomized, controlled studies with parallel groups and three randomized crossover trials were identified. Eight trials examined treatment of acute phantom pain, including epidural treatments (three trials), regional nerve blocks (three trials), treatment with calcitonin (one trial), and transcutaneous electrical nerve stimulation (one trial). Three trials demonstrated a positive impact of the intervention on phantom limb pain, but the remainder demonstrated no difference between the intervention and control groups. Four trials examined late postoperative interventions, including transcutaneous electrical nerve stimulation (two trials) and the use of Farabloc (a metal threaded sock) and ketamine (one trial each). With regard to late postoperative interventions, three of the four trials showed modest short-term reduction of phantom limb pain. There was no relation between the quality of the trial and a positive result of the intervention. ConclusionsAlthough up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.

Exercise training and blood lipids in hyperlipidemic and normolipidemic adults: A meta-analysis of randomized, controlled trials

Objective: To determine the effectiveness of exercise training (aerobic and resistance) in modifying blood lipids, and to determine the most effective training programme with regard to duration, intensity and frequency for optimizing the blood lipid profile.Design: Trials were identified by a systematic search of Medline, Embase, Science Citation Index (SCI), published reviews and the references of relevant trials. The inclusion criteria were limited to randomized, controlled trials of aerobic and resistance exercise training which were conducted over a minimum of four weeks and involved measurement of one or more of the following: total cholesterol (TC), high density lipoprotein (HDL-C), low density lipoprotein (LDL-C) and triglycerides (TG).Subjects: A total of 31 trials (1833 hyperlipidemic and normolipidemic participants) were included.Results: Aerobic exercise training resulted in small but statistically significant decreases of 0.10 mmol/L (95% CI: 0.02, 0.18), 0.10 (95% CI: 0.02, 0.19), 0.08 mmol/L (95% CI: 0.02, 0.14), for TC, LDL-C, and TG, respectively, with an increase in HDL-C of 0.05 mmol/L (95% CI: 0.02, 0.08). Comparisons between the intensities of the aerobic exercise programmes produced inconsistent results; but more frequent exercise did not appear to result in greater improvements to the lipid profile than exercise three times per week. The evidence for the effect of resistance exercise training was inconclusive.Conclusions: Caution is required when drawing firm conclusions from this study given the significant heterogeneity with comparisons. However, the results appear to indicate that aerobic exercise training produced small but favourable modifications to blood lipids in previously sedentary adults.Sponsorship: Public Health Research and Development Project Grant, National Health and Medical Research Council, Department of Health, Housing, Local Government and Community Services, 1995.

Home versus day rehabilitation: a randomised controlled trial

Objective: to assess the effect of home versus day rehabilitation on patient outcomes. Design: randomised controlled trial. Setting: post-hospital rehabilitation. Participants: two hundred and twenty-nine hospitalised patients referred for ambulatory rehabilitation. Interventions: hospital-based day rehabilitation programme versus home-based rehabilitation programme. Main Outcome Measures: at 3 months, information was collected on hospital readmission, transfer to residential care, functional level, quality of life, carer stress and carer quality of life. At 6 months, place of residence, hospital re-admissions and mortality status were collected. Results: there were significant improvements in the functional outcomes from baseline to 3 months for all participants. At discharge, carers of patients in day hospital reported higher Caregiver Strain Index (CSI) scores in comparison to home rehabilitation carers (4.95 versus 3.56, P = 0.047). Patients in day hospital had double the risk of readmission compared to those in home rehabilitation (RR = 2.1; 95% CI 1.2–3.9). This effect persisted at 6 months. Conclusions: day hospital patients are more likely to be readmitted to hospital possibly due to increased access to admitting medical staff. This small trial favours the home as a better site for post-hospital rehabilitation.

Recruitment of Older Adults for a Randomized, Controlled Trial of Exercise Advice in a General Practice Setting

OBJECTIVES: The success of any clinical trial depends strongly on recruiting enough participants in a reasonable time period. This paper aims to identify the obstacles, as well as the successful aspects, of recruiting of older participants into an exercise study.

Exercise profile and subsequent mortality in an elderly Australian population

Abstract: Although the importance of exercise as a public health issue is increasingly recognised, little attention has been paid to exercise in very old people. We examined exercise patterns in 1788 subjects aged 70 years and over who were participating in the Australian Longitudinal Study of Ageing. In the two weeks before interview, 39 per cent of subjects had taken no exercise and only four per cent had exercised vigorously. When compared with those who took no exercise, exercisers were more likely to be male and younger, to self–report better health, to be former smokers and regular alcohol users. Mortality rates at two years follow–up were inversely related to the level of exercise at baseline. This research indicates that exercise is important for the very old as well as younger groups.

The distribution of health services for older people in Australia: where does transition care fit?

INTRODUCTION The purpose of this study was to describe the distribution of hospital and aged care services for older people, with a particular focus on transition care places, across Australia and to determine the relationships between the provision of these services. METHODS Aggregation of health and aged care service indicators by Aged Care Assessment Team (ACAT) region including: public and private acute and subacute (rehabilitation and geriatric evaluation and management) hospital beds, flexible and mainstream aged care places as at 30 June 2006. RESULTS There was marked variation in the distribution of acute and subacute hospital beds among the 79 ACAT regions. Aged care places were more evenly distributed. However, the distribution of transition care places was uneven. Rural areas had poorer provision of all beds. There was no evidence of coordination in the allocation of hospital and aged care services between the Commonwealth and state/territory governments. There was a weak relationship between the allocation of transition care places and the distribution of health and aged care services. DISCUSSION Overall, the distribution of services available to older persons is uneven across Australia. While the Transition Care Program is flexible and is providing rural communities with access to rehabilitation, it will not be adequate to address the increasing needs associated with the ageing of the Australian population. An integrated national plan for aged care and rehabilitation services should be considered.

Motor function in 5-year-old children with cerebral palsy in the South Australian population.

The aim of this study was to describe the motor function of a population of children at age 5 years enrolled on the South Australian Cerebral Palsy Register. Among children born between 1993 and 1998, there were 333 with confirmed cerebral palsy (prevalence rate 2.2 per 1000 live births), in whom 247 assessments (56.7% males, 43.3% females) were completed. The distribution by Gross Motor Function Classification System (GMFCS) level was: level I, 50.6%; level II, 18.2%; level III, 9.3%; level IV, 9.7%; level V, 12.1%. The most common topographical classification was spastic diplegia (38.5%), followed by spastic hemiplegia (34.8%) and spastic quadriplegia (14.6%). Abnormal movements occurred at rest or with intention in 19.4% of children. A high proportion of the population with relatively mild gross motor impairments have difficulty with everyday bimanual tasks, reinforcing the need to assess upper limb function independently of gross motor function. The use of ankle–foot orthoses was common, particularly across GMFCS levels II to IV. Further refinement is indicated for this population’s motor dataset, to include more recently described classification measures as well as future novel measures to better describe the presence of both spasticity and dystonia.

Sociodemographic factors associated with self-reported exercise and physical activity behaviors and attitudes of South Australians: results of a population-based survey.

Objective: To determine self-reported physical activity barriers, behaviors, and beliefs about exercise of a representative sample and to identify associated sociodemographic factors. Method: Face-to-face interviews conducted between September and December 2008, using a random stratified sampling technique. Results: Barriers injury and illness were associated with being older, single, and not engaged in full-time work; lack of time was associated with being married, younger, female, and working full-time; and lack of motivation and cost were associated with being younger than 65 years. Advancing age was significantly associated (p < .001) with reduced physical activity. Factors including age, education, marital status, and area of residence were all associated with preferences for environment to exercise in, while all age groups (74%) felt that walking was the most important type of exercise for older adults. Discussion Barriers to physical activity participation are multifaceted with different sociodemographic factors associated with different barriers. A better understanding of these factors may improve uptake of and adherence to exercise programs across the ages.

Determining Current Physical Therapist Management of Hip Fracture in an Acute Care Hospital and Physical Therapists' Rationale for This Management

Background Physical therapy has an important role in hip fracture rehabilitation to address issues of mobility and function, yet current best practice guidelines fail to make recommendations for specific physical therapy interventions beyond the first 24 hours postsurgery. Objectives The aims of this study were: (1) to gain an understanding of current physical therapist practice in an Australian acute care setting and (2) to determine what physical therapists consider to be best practice physical therapist management and their rationale for their assessment and treatment techniques. Design and Methods Three focus group interviews were conducted with physical therapists and physical therapist students, as well as a retrospective case note audit of 51 patients who had undergone surgery for hip fracture. Results Beyond early mobilization and a thorough day 1 postoperative assessment, great variability in what was considered to be best practice management was displayed. Senior physical therapists considered previous clinical experience to be more important than available research evidence, and junior physical therapists modeled their behavior on that of senior physical therapists. The amount of therapy provided to patients during their acute inpatient stay varied considerably, and none of the patients audited were seen on every day of their admission. Conclusions Current physical therapist management in the acute setting for patients following hip fracture varies and is driven by system pressures as opposed to evidence-based practice.