Nancy K. Latham

A Randomized, Controlled Trial of Quadriceps Resistance Exercise and Vitamin D in Frail Older People: The Frailty Interventions Trial in Elderly Subjects (FITNESS)

OBJECTIVES:  To determine the effectiveness of vitamin D and home‐based quadriceps resistance exercise on reducing falls and improving the physical health of frail older people after hospital discharge.

Effects of vitamin D supplementation on strength, physical performance, and falls in older persons: a systematic review

Objectives: To identify, appraise, and synthesize data from randomized, controlled trials of vitamin D supplementation in older people.

Performance-Based or Self-Report Measures of Physical Function : Which Should Be Used in Clinical Trials of Hip Fracture Patients?

OBJECTIVES To assess the validity, sensitivity to change, and responsiveness of 3 self-report and 4 performance-based measures of physical function: activity measure for postacute care (AM-PAC) Physical Mobility and Personal Care scales, the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function scale (SF-36 PF), the Physical Functional Performance test (PFP-10), the Short Physical Performance Battery (SPPB), a 4-meter gait speed, and the six-minute walk test (6MWT). DESIGN A prospective observational study of patients after a hip fracture. Assessments were performed at baseline and 12 weeks postenrollment. SETTING Inpatient and outpatient rehabilitation facilities in Norway, the United Kingdom, Sweden, Israel, Germany, the United States, Denmark, and Spain. PARTICIPANTS A sample of study participants (N=108) who had a hip fracture. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Assessments of validity (known-groups, concurrent, construct, and predictive), sensitivity to change (effect size, standardized response mean [SRM], SE of measure, minimal detectable change (MDC), and responsiveness (optimal operating cut-points and area under the curve) between baseline and 12-week follow-up. RESULTS All physical function measures achieved comparably acceptable levels of validity. Odds ratios in predicting patient Global Assessment of Improvement at 12 weeks were as follows: AM-PAC Physical Mobility scale, 5.3; AM-PAC Personal Care scale, 3.6; SF-36 PF, 4.3; SPPB, 2.0; PFP-10, 2.5; gait speed, 1.9; and 6MWT, 2.4. Effect sizes and SRM exceeded 1 SD for all 7 measures. Percent of patients who exceeded the MDC(90) at week 12 were as follows: AM-PAC Physical Mobility scale, 90%; AM-PAC Personal Care scale, 74%; SF-36 PF, 66%; SPPB, 36%; PFP-10, 75%; gait speed, 69%; and 6MWT, 75%. When evaluating responsiveness using the area under receiver operating curves for each measure, all measures had acceptable responsiveness, and no pattern emerged of superior responsiveness depending on the type of measure used. CONCLUSIONS Findings reveal that the validity, sensitivity, and responsiveness of self-report measures of physical function are comparable to performance-based measures in a sample of patients followed after fracturing a hip. From a psychometric perspective, either type of functional measure would be suitable for use in clinical trials where improvement in function is an endpoint of interest. The selection of the most appropriate type of functional measure as the primary endpoint for a clinical trial will depend on other factors, such as the measures feasibility or the strength of the association between the hypothesized mechanism of action of the study intervention and a functional outcome measure.

Sensitivity to Change and Responsiveness of Four Balance Measures for Community-Dwelling Older Adults

Background Impaired balance has a significant negative impact on mobility, functional independence, and fall risk in older adults. Although several, well-respected balance measures are currently in use, there is limited evidence regarding the most appropriate measure to assess change in community-dwelling older adults. Objective The aim of this study was to compare floor and ceiling effects, sensitivity to change, and responsiveness across the following balance measures in community-dwelling elderly people with functional limitations: Berg Balance Scale (BBS), Performance-Oriented Mobility Assessment total scale (POMA-T), POMA balance subscale (POMA-B), and Dynamic Gait Index (DGI). Design Retrospective data from a 16-week exercise trial were used. Secondary analyses were conducted on the total sample and by subgroups of baseline functional limitation or baseline balance scores. Methods Participants were 111 community-dwelling older adults 65 years of age or older, with functional limitations. Sensitivity to change was assessed using effect size, standardized response mean, and paired t tests. Responsiveness was assessed using minimally important difference (MID) estimates. Results No floor effects were noted. Ceiling effects were observed on all measures, including in people with moderate to severe functional limitations. The POMA-T, POMA-B, and DGI showed significantly larger ceiling effects compared with the BBS. All measures had low sensitivity to change in total sample analyses. Subgroup analyses revealed significantly better sensitivity to change in people with lower compared with higher baseline balance scores. Although both the total sample and lower baseline balance subgroups showed statistically significant improvement from baseline to 16 weeks on all measures, only the lower balance subgroup showed change scores that consistently exceeded corresponding MID estimates. Limitations This study was limited to comparing 4 measures of balance, and anchor-based methods for assessing MID could not be reported. Conclusions Important limitations, including ceiling effects and relatively low sensitivity to change and responsiveness, were noted across all balance measures, highlighting their limited utility across the full spectrum of the community-dwelling elderly population. New, more challenging measures are needed for better discrimination of balance ability in community-dwelling elderly people at higher functional levels.

Does a Functional Activity Programme Improve Function, Quality of Life, and Falls for Residents in Long Term Care? Cluster Randomised Controlled Trial

Objective To assess the effectiveness of an activity programme in improving function, quality of life, and falls in older people in residential care. Design Cluster randomised controlled trial with one year follow-up. Setting 41 low level dependency residential care homes in New Zealand. Participants 682 people aged 65 years or over. Interventions 330 residents were offered a goal setting and individualised activities of daily living activity programme by a gerontology nurse, reinforced by usual healthcare assistants; 352 residents received social visits. Main outcome measures Function (late life function and disability instruments, elderly mobility scale, FICSIT-4 balance test, timed up and go test), quality of life (life satisfaction index, EuroQol), and falls (time to fall over 12 months). Secondary outcomes were depressive symptoms and hospital admissions. Results 473 (70%) participants completed the trial. The programme had no impact overall. However, in contrast to residents with impaired cognition (no differences between intervention and control group), those with normal cognition in the intervention group may have maintained overall function (late life function and disability instrument total function, P=0.024) and lower limb function (late life function and disability instrument basic lower extremity, P=0.015). In residents with cognitive impairment, the likelihood of depression increased in the intervention group. No other outcomes differed between groups. Conclusion A programme of functional rehabilitation had minimal impact for elderly people in residential care with normal cognition but was not beneficial for those with poor cognition. Trial registration Australian Clinical Trials Register ACTRN12605000667617.

Determinants of physical health in frail older people: the importance of self-efficacy

Objective: There is continued uncertainty regarding the strength of association between performance-based and self-report measures of physical functioning, and of their relationship to self-efficacy and health-related quality of life (HRQoL). This study assessed the inter-relationships between such measures, and the predictors of ‘physical’ aspects of HRQoL in frail older patients. Design: We used statistical models to determine the predictors of ‘physical’ HRQoL, according to the physical component summary score and the physical functioning domain of the 36-item short form (SF-36) questionnaire. Setting: Patients were recruited from hospitals in Australia and New Zealand and followed up in their homes. Subjects: Two hundred and forty-three frail older patients. Main measures: Physical functioning was assessed using three performance-based measures (Timed Up and Go Test, gait speed and the Berg Balance Scale) and five self-report measures, including the modified falls self-efficacy scale, at three and six months after registration. Results: A moderate association (r=0.48=0.55) was found between each of the performance-based and self-report measures, including the SF-36 physical component summary score. Multiple linear regression analyses showed that the performance-based measures and falls self-efficacy predicted 33% of the SF-36 physical component summary score. Falls self-efficacy was the single highest predictor of both the SF-36 physical component summary score and SF-36 physical functioning domain. A curvilinear relationship was found between the SF-36 physical functioning domain and two variables: falls self-efficacy and the Berg Balance Scale. Conclusions: Although performance-based and self-report measures provide complementary but distinct measures of physical function, psychosocial factors such as self-efficacy have a strong influence on the HRQoL of frail older people.

Can progressive resistance strength training reduce physical disability in older adults? A meta-analysis study

Purpose. The decline of muscle strength is associated with physical disability in late adulthood. Progressive resistance strength training has been demonstrated to be an effective intervention to increase muscle strength, however, its effect on reducing physical disability in older adults is unclear. The purpose of this study is to examine the effect of progressive resistance strength training on physical disability via meta-analysis. Method. Two reviewers independently searched for qualified trials, assessed trial quality and extracted data. Trial inclusion criteria are: (1) Randomised controlled trials, (2) Mean age of participant sample is ≥60 years, (3) Progressive resistance strength training as the primary intervention and (4) the trial included outcome measures of physical disability (i.e. physical function domain of the Short-Form 36). Results. Thirty-three trials were analysed. Although the effect size is small, the intervention groups showed reduced physical disability when compared to the control groups (SMD = 0.14, 95% CI = 0.05 to 0.22). Conclusions. Progressive resistance strength training appears to be an effective intervention to reduce physical disability in older adults. To maximise the effect, we suggest therapists use responsive outcome measures and multi-component intervention approach.

Adverse Events Reported in Progressive Resistance Strength Training Trials in Older Adults: 2 Sides of a Coin

OBJECTIVES To summarize adverse events reported in randomized controlled trials that applied progressive resistance strength training in older adults and to examine factors that might be associated with these events. DESIGN After systematic searches of databases, 2 reviewers independently screened and extracted adverse event-related information from identified trials. SETTING Not applicable. PARTICIPANTS Older adults 60 years of age and above (N = 6700). INTERVENTION Muscle strength training exercise that increases load gradually. MAIN OUTCOME MEASURES Adverse events and reasons for dropout. Adverse events include any undesirable outcomes that may be directly related or unrelated to the intervention. RESULTS Among 121 trials identified, 53 trials provided no comments about adverse events, 25 trials reported no adverse events occurred, and 43 trials reported some types of adverse events. Most adverse events reported were musculoskeletal problems such as muscle strain or joint pain. Adverse events were reported more often in trials that recruited participants with certain health conditions, functional limitations, or sedentary lifestyle; in trials that applied high intensity; and in trials that were published after the 2001 Consolidated Standards of Reporting Trials statement had been published. Reasons reported for dropout in 58 trials might be related to adverse events. The most frequent reasons for dropout were illness or medical problems. CONCLUSIONS Adverse events may be underreported because there is no consensus on the definition. Reporting adverse events associated with progressive resistance strength training in older adults is informative for practitioners to translate clinical research to clinical practice by knowing both the benefits and risks. Future trials should clearly define adverse events and report them in the published article.

Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture: A Randomized Clinical Trial

IMPORTANCE For many older people, long-term functional limitations persist after a hip fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established. OBJECTIVE To determine whether a home exercise program with minimal contact with a physical therapist improved function after formal hip fracture rehabilitation ended. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from September 2008 to October 2012 in the homes of 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture. INTERVENTIONS The intervention group (n = 120) received functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months. The attention control group (n = 112) received in-home and telephone-based cardiovascular nutrition education. MAIN OUTCOMES AND MEASURES Physical function assessed at baseline, 6 months (ie, at completion of the intervention), and 9 months by blinded assessors. The primary outcome was change in function at 6 months measured by the Short Physical Performance Battery (SPPB; range 0-12, higher score indicates better function) and the Activity Measure for Post-Acute Care (AM-PAC) mobility and daily activity (range, 23-85 and 9-101, higher score indicates better function). RESULTS Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed significant improvement relative to the control group (n=95) in functional mobility (mean SPPB scores for intervention group: 6.2 [SD, 2.7] at baseline, 7.2 [SD, 3] at 6 months; control group: 6.0 [SD, 2.8] at baseline, 6.2 [SD, 3] at 6 months; and between-group differences: 0.8 [95% CI, 0.4 to 1.2], P < .001; mean AM-PAC mobility scores for intervention group: 56.2 [SD, 7.3] at baseline, 58.1 [SD, 7.9] at 6 months; control group: 56 [SD, 7.1] at baseline, 56.6 [SD, 8.1] at 6 months; and between-group difference, 1.3 [95% CI, 0.2 to 2.4], P = .03; and mean AM-PAC daily activity scores for intervention group: 57.4 [SD, 13.7] at baseline, 61.3 [SD, 15.7] at 6 months; control group: 58.2 [SD, 15.2] at baseline, 58.6 [SD, 15.3] at 6 months; and between-group difference, 3.5 [95% CI, 0.9 to 6.0], P = .03). In multiple imputation analyses, between-group differences remained significant for SPPB and AM-PAC daily activity, but not for mobility. Significant between-group differences persisted at 9 months for all functional measures with and without imputation. CONCLUSIONS AND RELEVANCE Among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization. The clinical importance of these findings remains to be determined. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00592813.

Strength training in older adults: The benefits for osteoarthritis

This review summarizes the findings of randomized controlled trials of progressive resistance training (PRT) by older people with osteoarthritis (OA). A significant benefit was found in lower-extremity extensor strength, function, and pain reduction. Across all 3 outcomes, the estimated effect size was moderate, which contrasted with trials of PRT in non-OA-specific groups of older adults where a large effect was found in strength but a small effect on function. This suggests that strength training has strong functional benefits for older adults with OA. Older adults with OA benefit from a strength-training program that provides progressive overload to maintain intensity throughout an exercise program.