Mary Stuart

Community-Based Adaptive Physical Activity Program for Chronic Stroke: Feasibility, Safety, and Efficacy of the Empoli Model

Objective. To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community. Methods. Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain. Results. After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P < .00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P < .003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P = .01). Conclusion. APA-stroke appears to be safe, feasible, and efficacious in a community setting.

Adherence to a community-based exercise program is a strong predictor of improved back pain status in older adults: An observational study

ObjectivesTo identify factors that were predictive of improved pain status among older adults with chronic back pain participating in the Adaptive Physical Activity (APA) program and to identify factors that were predictive of adherence to APA. MethodsAn observational cohort study of 392 older adults (ages 50 to 88) with chronic back pain participating in APA for 12 months. APA was a community-based group exercise program given for 1-hour, twice weekly, in local gyms. Primary outcome measures were improved pain based on a global rating of change evaluation and adherence to the APA program (defined as participation in >75% of exercise sessions). Potential predictor variables were entered into multivariate logistic regression models to determine the most accurate set of variables for predicting improved pain and adherence. ResultsPresence of depressive symptoms, poor self-rated health and adherence to APA were the best predictors of improved pain status, with adherence being the strongest predictor [odds ratio: 13.88 (95% confidence interval: 8.17, 23.59)]. Better physical function, longer pain duration, and positive rating of the trainer were all positively associated with adherence to APA; whereas poor self-rated health and further distance from the gym were inversely associated. ConclusionsGiven that adherence to APA is the key predictor of improved back pain, future efforts should focus on strategies to improve adherence. Our data suggest that enhanced training of exercise trainers, development of separate classes for people with different functional levels, and use of psychosocial interventions to reduce health pessimism and depression may be potential targets for improving adherence.

Beyond managing Medicaid costs: restructuring care.

The apparent success of managed care plans in controlling medical costs has made the prospect of managed care for Medicaid recipients attractive for state health policy makers. However, because the principles upon which managed care was created do not apply to the most costly segments of the Medicaid population, efforts to address their needs through traditional managed care strategies are likely to be self-defeating. The Maryland Medicaid database was used to review and analyze the successes and failures of managed care Medicaid initiatives to date. This review led to the suggestion that the integration of specialized systems for specific subgroups of the Medicaid population into managed care, in conjunction with broader public policies, could lead to improved quality and lower costs.

Community-Based Exercise for Upper Limb Paresis A Controlled Trial With Telerehabilitation

Background. Arm paresis remains a major impairment after stroke despite the best conventional rehabilitation. Randomized, controlled trials of intensive exercise programs have demonstrated improvements in arm function for patients with chronic stroke. However, the gains achieved have been relatively modest for the large investments in patient and therapist time. Objective. To evaluate the safety, acceptance, adherence, and effectiveness of a community-based exercise program for upper limb paresis in patients with chronic stroke and the effects of telerehabilitation monitoring in kiosks distributed through the community. Methods. Longitudinal cohort with geographic control group. The experimental group received devices needed for a home exercise program based on the Carr and Shepherd “Motor Learning Program” and were instructed to practice the exercises at least twice a week at the kiosk and at least 3 more days a week at home. The control group received usual care. Results. Compared with the control group, patients in the experimental group demonstrated significant gains in arm function as measured by the Wolf Motor Function Test, 9-Hole Peg Test, Motricity Index, and Nottingham Extended Activities of Daily Living Questionnaire. The intervention received high satisfaction ratings and produced no adverse events. Only 30% of the subjects attended kiosks regularly. Outcomes for this group did not differ significantly from those who only practiced at home. Conclusions. Home- and community-based exercise for arm paresis is safe and effective. Telerehabilitation interventions will need additional enhancements to improve effectiveness. The optimal upper extremity exercise prescription poststroke remains to be established.

Redefining Boundaries in the Financing and Care of Diabetes: The Maryland Experience

The story of the development of the Maryland Medicaid Diabetes Care Program is narrated in this policy case study. Maryland Medicaid, a funding authority willing to assume a proactive role, decided to promote health care system changes expected to improve the health status of its recipients with diabetes. A state Medicaid budget crisis presented opportunities for financing new and expanded preventive services for those with this chronic disease. Specifically recounted is how Maryland Medicaid redefined its financing boundaries in an effort to overcome finance-induced fragmentation in diabetes health care delivery. The difficulties encountered by a single payer in moving unilaterally to alter health care practices are discussed. Two commentaries follow.

Home Is Where the Help Is: Community-Based Care in Denmark

Abstract Policy regarding long-term care has been an issue of rising national concern. In this paper we examine the transition of Danish long-term care policy with special attention to Skævinge, the first community in Denmark to integrate institutional and community-based services for the elderly. Recent studies on the variation between costs and services in Danish communities and the results of U.S. studies on community-based care suggest that successful implementation of integrated institutional and community-based long-term care is feasible in the United States. Lessons from Denmark highlight conditions that will facilitate success in this endeavor.

Impact of Adapted Physical Activity and Therapeutic Patient Education on Functioning and Quality of Life in Patients With Postacute Strokes

Objective. The aim of this study was to assess whether the combination of Adapted Physical Activity (APA) and Therapeutic Patient Education (TPE) improves function and quality of life in survivors of strokes. Methods. This nonrandomized controlled study enrolled patients with mild to moderate hemiparesis referred to 2 physical medicine and rehabilitation units in Emilia-Romagna, Italy, 3 to 18 months after a single unilateral mild to moderate stroke. The experimental group (n = 126) received 16 APA sessions and 3 sessions of TPE, and the control group (n = 103) received usual care; 86.9% completed treatment. The main outcome measure was a 4-month change in gait endurance (that corresponds to 2 months after intervention in the experimental group), and secondary outcomes included the Short Physical Performance Battery, Berg Balance Scale, Barthel Index, Geriatric Depression Scale, 12-item Short-Form Health Survey, and Caregiver Strain Index. Changes in scores at 4 months were compared between groups using analysis of variance and controlling for group imbalance by means of the propensity score. Results. Gait endurance, physical performance, balance, and the physical component of the quality of life score increased significantly at 4 months in the APA group and remained stable in the control group. The propensity-adjusted between-group change was significant for these scores at P < .01. Conclusions. Our results confirm that it is feasible and potentially effective to implement APA programs for elderly patients with complex clinical conditions as early as 3 months after a stroke and suggest that, when combined with TPE, the effects of a postrehabilitation APA program are relatively enduring.

An Ecological Perspective on the Community Translation of Exercise Research for Older Adults

Regular exercise lowers the risk of disease progression for many chronic illnesses, but older adults experience relatively low rates of exercise. Although multiple intervention studies indicate that community-based programs can facilitate exercise participation, whether this research has resulted in widespread targeted exercise programs within communities is unknown. This study seeks to understand the ecological context of exercise for older adults through a cross-sectional survey of community exercise facilities within a mid-Atlantic city. The findings highlight the limited nature of the existing exercise infrastructure and reveal gaps in the community translation of research evidence regarding exercise adherence. An expansion in the availability of community exercise programs for older adults and more uniform policies to support older adult exercise are needed.

Methodological Issues in Monitoring Health Services and Outcomes for Stroke Survivors: A Case Study

BACKGROUNDnObtaining comprehensive health outcomes and health services utilization data on stroke patients has been difficult. This research grew out of a memorandum of understanding between the NIH and the ISS (its Italian equivalent) to foster collaborative research on rehabilitation.nnnOBJECTIVEnThe purpose of this study was to pilot a methodology using administrative data to monitor and improve health outcomes for stroke survivors in Tuscany.nnnMETHODSnThis study used qualitative and quantitative methods to study health resources available to and utilized by stroke survivors during the first 12 months post-stroke in two Italian health authorities (AUSL10 and 11). Mortality rates were used as an outcome measure.nnnRESULTSnNumber of inpatient days, number of prescriptions, and prescription costs were significantly higher for patients in AUSL 10 compared to AUSL 11. There was no significant difference between mortality rates.nnnCONCLUSIONnUsing administrative data to monitor process and outcomes for chronic stroke has the potential to save money and improve outcomes. However, measures of functional impairment and more sensitive outcome measures than mortality are important. Additional recommendations for enhanced data collection and reporting are discussed.

Community-Based Exercise for Chronic Disease Management An Italian Design for the United States?

Although only a small proportion of older adults in the United States engage in recommended amounts of physical exercise, the health benefits of exercise for this population and the potential for lowering health care costs are substantial. However, access to regular exercise programs for the frail elderly and individuals with disabilities remains limited. In the context of health reform and emerging opportunities in developing integrated systems of care, the experience in Tuscany in implementing a community-based program of exercise for the elderly should be of interest.