Kathleen Kline Mangione

Detectable Changes in Physical Performance Measures in Elderly African Americans

Background African American older adults have higher rates of self-reported disability and lower physical performance scores compared with white older adults. Measures of physical performance are used to predict future morbidity and to determine the effect of exercise. Characteristics of performance measures are not known for African American older adults. Objective The purpose of this study was to estimate the standard error of measurement (SEM) and minimal detectable change (MDC) for the Short Physical Performance Battery (SPPB), Timed “Up & Go” Test (TUG) time, free gait speed, fast gait speed, and Six-Minute Walk Test (6MWT) distance in frail African American adults. Design This observational measurement study used a test-retest design. Methods Individuals were tested 2 times over a 1-week period. Demographic data collected included height, weight, number of medications, assistive device use, and Mini-Mental Status Examination (MMSE) scores. Participants then completed the 5 physical performance tests. Results Fifty-two participants (mean age=78 years) completed the study. The average MMSE score was 25 points, and the average body mass index was 29.4 kg/m2. On average, participants took 7 medications, and the majority used assistive devices. Intraclass correlation coefficients (ICC [2,1]) were greater than .90, except for the SPPB score (ICC=.81). The SEMs were 1.2 points for the SPPB, 1.7 seconds for the TUG, 0.08 m/s for free gait speed, 0.09 m/s for fast gait speed, and 28 m for 6MWT distance. The MDC values were 2.9 points for the SPPB, 4 seconds for the TUG, 0.19 m/s for free gait speed, 0.21 m/s for fast gait speed, and 65 m for 6MWT distance. Limitations The entire sample was from an urban area. Conclusions The SEMs were similar to previously reported values and can be used when working with African American and white older adults. Estimates of MDC were calculated to assist in clinical interpretation.

Home-Based Leg-Strengthening Exercise Improves Function 1 Year After Hip Fracture: A Randomized Controlled Study

OBJECTIVES: To compare the effectiveness of a short‐term leg‐strengthening exercise program with that of attentional control on improving strength, walking abilities, and function 1 year after hip fracture.

Cochrane Review: Improving Physical Function and Performance With Progressive Resistance Strength Training in Older Adults

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Meaningful improvement in gait speed in hip fracture recovery.

OBJECTIVES: To estimate meaningful improvements in gait speed observed during recovery from hip fracture and to evaluate the sensitivity and specificity of gait speed changes in detecting change in self‐reported mobility.

Case report: an evidence-based approach to examination and intervention following hip fracture.

Background and Purpose: A majority of older adults with hip fracture retain longstanding disabilities following surgery. Research suggests that more aggressive treatment techniques can improve outcome. The purpose of this case report is to describe an evidence‐based approach to guide physical therapy examination and intervention for a woman with significant frailty recovering from hip fracture. Case Description: The patient is a 97‐year‐old woman residing in a skilled nursing facility 3 months status‐postsurgical repair of an intertrochanteric hip fracture. She had received 2 ½ months of physical therapy care using conventional interventions, however, had not regained her prefracture mobility status. She agreed to participate in a progressive high‐intensity resistance training program over a 2‐month period to augment her lower‐extremity strength and function. The 5‐day training regimen emphasized resistance training with a weighted belt twice‐weekly with endurance and balance training interposed on nonstrength training days. The patients goal was to return to community dwelling. Examination: Lower‐extremity isometric force was measured using handheld dynamometry. Functional mobility was assessed via Timed Up and Go, Six‐Minute Walk, Berg Balance, and gait speed tests. A 9‐item Physical Performance Test gauged degree of frailty. Results: Hip extension, hip abduction, and knee extension isometric force scores on the involved lower‐extremity increased by 8 kg, 3 kg, and 7 kg, respectively. Balance, frailty, and gait speed indices improved from 14 to 45, 8 to 18, and 0.50 to 0.83 m/s, respectively. Conclusion: Prescribed high‐intensity resistance training was used to improve the patients functional status 2 months after completing a conventional physical therapy program.

Interventions Used by Physical Therapists in Home Care for People After Hip Fracture

Background and Purpose: The majority of older people who survive a hip fracture have residual mobility disabilities. Any attempt to systematically reduce mobility disabilities after hip fracture, however, requires knowledge of the adequacy of current management practices. Therefore, the purpose of this study was to begin to understand the nature of physical therapy home care management by describing “usual care” for people after hip fracture. Subjects and Methods: In 2003 and 2004, a national survey was conducted of all members of the American Physical Therapy Association who identified home care as their primary practice setting (n=3,130). “Usual care” was operationally defined as when more than 50% of respondents reported that they “always” or “often” use a specific intervention. Results: Survey questionnaires (1,029) were returned with a response rate of 32.9%. Functional training activities, including bed mobility, transfer and gait training, balance training, safety training, and patient education, were reported very frequently. Active-range-of-motion exercises were performed much more frequently than exercises involving added resistance. Discussion and Conclusion: This study provides a detailed description of the physical therapy interventions provided in the home care setting for patients after hip fracture. The sample size and national representation increase our confidence that this description accurately depicts physical therapist practice.

Recruitment and Retention Strategies Among Older African American Women Enrolled in an Exercise Study at a PACE Program

PURPOSE This study examined employment of specific recruitment and retention strategies in a study evaluating outcomes of a moderate activity exercise program for older African American women with functional impairments attending a Program for All-Inclusive Care of Elders (PACE). DESIGN AND METHODS Recruitment and retention strategies focused on (1) partnership between researchers and participants, (2) partnership between researchers and clinicians, (3) overcoming administrative issues, and (4) reducing burden on clinicians and participants. The exercise protocol consisted of strength and endurance activity 2 to 3 times per week for 16 weeks. RESULTS Fifty-two African American women (61.2% of target) were enrolled and 37 (71.2%) completed the 16-week exercise program. Fifteen did not complete due to non-descript reasons and/or preference for other program activities (n = 11), medical problems (n = 2), or need for physical therapy (n = 2). IMPLICATIONS Success in recruitment and retention included use of a PACE program, hiring an advanced practice nurse to improve retention, and integration with site activities and sustaining the exercise program at the site. Challenges for recruitment and retention remain to engage older, frail adults in exercise as a life habit, and availability of time and place to do so.

Gait Variability Detects Women in Early Postmenopause With Low Bone Mineral Density

Background Women in early postmenopause and with low bone mineral density (BMD) may exhibit early markers for physical frailty as a result of sarcopenia and osteopenia. Objective The purpose of this study was to determine whether women in early postmenopause and with low BMD exhibit decreased physical performance and differences in gait variability and fall and fracture rates. Design This study was an observational cohort design with participants assigned to groups on the basis of BMD status. Methods Fifty-four women, 31 with low BMD and 23 with normal BMD, participated. This study was conducted in a university research facility. Physical performance was measured by assessment of dynamic balance (timed backward tandem walk test), strength (handheld dynamometry of isometric quadriceps muscle force production), and free gait speed. Gait variability was assessed on the basis of the coefficient of variation for temporal-spatial gait characteristics. Falls and fractures were assessed for the year after initial testing. Results Significant between-group differences were found for step time and stance time variability. Limitations The limitations of this study included group assignment on the basis of the results of the most recent bone density scan within the preceding 2 years. Conclusions Women in early postmenopause and with low BMD exhibited increased gait variability in step time and stance time but did not exhibit differences in balance, strength, or gait speed. Gait variability may be more sensitive for detecting differences in women in early postmenopause and with or without low BMD than more typical measures of physical performance.

Predictors of Gait Speed in Patients after Hip Fracture

PURPOSE Following hip fracture, patients demonstrate greatly reduced walking speeds 1 year later compared with age-matched elders. The purpose of our study was to examine the factors that relate to gait speed in patients after hip fracture. METHODS Forty-two men and women (mean age 79 +/- 7.5 years) who sustained a hip fracture participated in this study. Linear regression analysis was used to determine a statistical model that best predicted gait speed, the dependent variable. Gait speed was measured with a computerized gait mat. The independent variables were age, sex, height, weight, time post-fracture, medications, mental status, depression, balance confidence, Medical Outcome Studies, Short Form (SF-36), balance, and lower extremity isometric force. All subjects were discharged from physical therapy services, and measurements were taken, on average, 17 weeks post-fracture. RESULTS Using stepwise regression, 72% of the variance in gait speed was explained by summed lower extremity strength normalized by body weight, general health (SF-36), and balance confidence (Activities-specific Balance Confidence Scale). CONCLUSIONS Impairments (summed lower extremity strength) and risk factors (perception of general health and balance confidence) are important predictors of gait speed in elders after hip fracture.

Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift

Physical therapists often treat older adults with marked deficits in physical function secondary to an acute hospitalization. These deficits are often collectively defined as hospital-associated deconditioning (HAD). However, there is a paucity of evidence that objectively demonstrates the efficacy of physical therapy for older adults with HAD. Older adults with HAD represent a highly variable and complex population and thus may be difficult to study and develop effective interventions for using our current rehabilitation strategies. This perspective article outlines an innovative framework to operationalize and treat older adults with HAD. This framework may help therapists apply emerging exercise strategies to this population and facilitate additional research to support the total value of physical therapy for older adults in postacute care settings—with value measured not only by improvements in physical performance but perhaps also by reduced rates of disability development, rehospitalization, and institutionalization.