Tiffany E. Shubert

Effects of Resistance Exercise Training and Nandrolone Decanoate on Body Composition and Muscle Function among Patients Who Receive Hemodialysis: A Randomized, Controlled Trial

Patients who are on hemodialysis commonly experience muscle wasting and weakness, which have a negative effect on physical functioning and quality of life. The objective of this study was to determine whether anabolic steroid administration and resistance exercise training induce anabolic effects among patients who receive maintenance hemodialysis. A randomized 2 x 2 factorial trial of anabolic steroid administration and resistance exercise training was conducted in 79 patients who were receiving maintenance hemodialysis at University of California, San Francisco-affiliated dialysis units. Interventions included double-blinded weekly nandrolone decanoate (100 mg for women; 200 mg for men) or placebo injections and lower extremity resistance exercise training for 12 wk during hemodialysis sessions three times per week using ankle weights. Primary outcomes included change in lean body mass (LBM) measured by dual-energy x-ray absorptiometry, quadriceps muscle cross-sectional area measured by magnetic resonance imaging, and knee extensor muscle strength. Secondary outcomes included changes in physical performance, self-reported physical functioning, and physical activity. Sixty-eight patients completed the study. Patients who received nandrolone decanoate increased their LBM by 3.1 +/- 2.2 kg (P < 0.0001). Exercise did not result in a significant increase in LBM. Quadriceps muscle cross-sectional area increased in patients who were assigned to exercise (P = 0.01) and to nandrolone (P < 0.0001) in an additive manner. Patients who exercised increased their strength in a training-specific fashion, and exercise was associated with an improvement in self-reported physical functioning (P = 0.04 compared with nonexercising groups). Nandrolone decanoate and resistance exercise produced anabolic effects among patients who were on hemodialysis. Further studies are needed to determine whether these interventions improve survival.

Evidence-based exercise prescription for balance and falls prevention: a current review of the literature

Falls are the leading cause of emergency department visits, hospital admissions, and unintentional death for older adults. Balance and strength impairments are common falls risk factors for community-dwelling older adults. Though physical therapists commonly treat balance and strength, standardized falls screening has not been fully incorporated into physical therapy practice and there is much variation in the frequency, intensity, and duration of therapy prescribed to achieve optimal results. For community-dwelling older adults, a progressive exercise program that focuses on moderate to high-intensity balance exercises appears to be one of the most effective interventions to prevent falls. For more frail older adults in institutional settings, exercise programs in addition to multifactorial interventions appear to show promise as effective falls prevention interventions. The minimum dose of exercise to protect an older adult against falls is 50 hours. This article describes the current best practices for physical therapists to effectively improve balance and manage falls risk in patients. The unique challenges and opportunities for physical therapists to incorporate evidence-based fall-prevention strategies are discussed. Innovative practice models incorporating evidence-based fall-prevention programs and partnerships with public health and aging service providers to create a continuum of care and achieve the optimal dose of balance training are presented.

Are scores on balance screening tests associated with mobility in older adults

Purpose: To examine associations between measures of static and dynamic balance and performance of mobility tasks in older adults. Methods: A cross‐sectional analysis from 195 community dwelling participants (mean age 80.9 years, range 65 –103 years). Participants performed tests of static (tandem stance) and dynamic (360° turn) balance and mobility (walking speed and timed chair rise). Associations among balance and mobility measures were examined using correlation and logistic regression. Results: Static and dynamic balance were moderately associated (r = −.462). Relationships between dynamic balance and mobility were stronger than those between static balance and mobility. The association between dynamic balance and walking speed was particularly strong (r = −.701). Using logistic regression, age, and balance performance were significant predictors for outcomes of walking speed (dichotomized to < 1.0 m/s, ≥ 1.0 m/s), and timed chair rise (dichotomized to ≤ 13.6 s, > 13.6 s). Faster 360° turn times were independently associated with faster walking speed and chair rise time. Conclusion: Mobility tasks require both dynamic and static balance. As falls are a major health risk for older adults, including brief assessments of dynamic and static balance in the examination of older adults provides valuable information about physical function and mobility.

The effect of an exercise-based balance intervention on physical and cognitive performance for older adults: a pilot study

Background:Several exercise-based falls prevention interventions produced significant long-term reductions in fall rate, but few demonstrate long-term improvements in falls risk factors. A strong body of evidence supports a protective effect of aerobic or strength-training exercise on cognition. Individuals participating in an exercise-based balance improvement program may also experience this protective effect. This may contribute to the decreased rate of falls reported in the literature. Purpose:To determine if individuals participating in an evidence-based exercise program to reduce falls would demonstrate improvements in both physical and cognitive performance. Methods:In this nonexperimental, pretest, posttest design study, 76 adults (65-93 years) participated in a scripted 12-week, 24 session exercise-based balance improvement program. Each 60 minute class incorporated balance, strength, endurance, and flexibility exercises. Participants completed baseline assessments of physical and cognitive performance measures 1 week prior and 1 week following the intervention. Results:Fifty-two participants completed posttest measures. There were significant improvements in 3 physical performance measures (chair rise time, 360° turn, and 4 square step test). There also was similar improvement in the Symbol Digit Modality Test, a measure of processing speed and mental flexibility. When participants were dichotomized into 2 groups based on achieving/not achieving, a baseline walking speed of at least 1.0 meters/second, secondary analysis revealed greater improvements in cognitive performance measures of Trails A and Trails B tests by faster walkers compared to slower walkers. Conclusions:Participation in balance programs can have a positive impact on cognition and physical outcomes. This may provide insight about how exercise influences fall risk. Therapists can utilize this information clinically by educating patients about the potential positive effect of balance exercises on cognition.

Management of Falls in Community-Dwelling Older Adults: Clinical Guidance Statement From the Academy of Geriatric Physical Therapy of the American Physical Therapy Association

Background Falls in older adults are a major public health concern due to high prevalence, impact on health outcomes and quality of life, and treatment costs. Physical therapists can play a major role in reducing fall risk for older adults; however, existing clinical practice guidelines (CPGs) related to fall prevention and management are not targeted to physical therapists. Objective The purpose of this clinical guidance statement (CGS) is to provide recommendations to physical therapists to help improve outcomes in the identification and management of fall risk in community-dwelling older adults. Design and Methods The Subcommittee on Evidence-Based Documents of the Practice Committee of the Academy of Geriatric Physical Therapy developed this CGS. Existing CPGs were identified by systematic search and critically appraised using the Appraisal of Guidelines, Research, and Evaluation in Europe II (AGREE II) tool. Through this process, 3 CPGs were recommended for inclusion in the CGS and were synthesized and summarized. Results Screening recommendations include asking all older adults in contact with a health care provider whether they have fallen in the previous year or have concerns about balance or walking. Follow-up should include screening for balance and mobility impairments. Older adults who screen positive should have a targeted multifactorial assessment and targeted intervention. The components of this assessment and intervention are reviewed in this CGS, and barriers and issues related to implementation are discussed. Limitations A gap analysis supports the need for the development of a physical therapy–specific CPG to provide more precise recommendations for screening and assessment measures, exercise parameters, and delivery models. Conclusion This CGS provides recommendations to assist physical therapists in the identification and management of fall risk in older community-dwelling adults.

Complexities of Fall Prevention in Clinical Settings: A Commentary

Falls and associated injury and mortality are of increasing concern among aging Americans. Effective fall risk management is a complicated process requiring involvement by both health care professionals and older adults for three related actions: (a) early screening to detect risk factors; (b) prescription of tailored interventions; and (c) implementation of, adherence to, and compliance with the intervention by the older adult. Early detection of fall risk can prevent future falls; however, uptake of evidence-based screening and assessment protocols in the clinical setting has been limited. A variety of practice guidelines and financial incentives are available to health care professionals to facilitate adoption. Yet, there remains a gap between recommended practices and current clinical activities. This commentary addresses the complexities of fall prevention practices and offers solutions that can facilitate adoption by clinical practices. Toward this end, this commentary will present two models (i.e., a clinical approach and a financial incentive approach) to summarize current clinical recommendations and practice guidelines for fall risk management in clinical settings. The various drivers to encourage adoption of evidence-based fall risk management strategies will be described. In this context, we will discuss how understanding the different system wide practice improvement initiatives and factors that drive action in physician groups, can facilitate adoption and implementation of fall risk management behaviors by clinicians. Additional efforts are needed to explore and assess similar initiatives to adopt and implement fall risk management practices at different entry points into the system (e.g., community settings, patients, caregivers).

Translation of the otago exercise program for adoption and implementation in the United States.

Background The Otago Exercise Program (OEP) is an evidence-based fall prevention program developed, evaluated, and disseminated in New Zealand. The program was designed for delivery in the home by physical therapists (PTs). It was not known if American PTs would require additional training and resources to adopt the OEP. This article describes the process of translating the OEP for dissemination in the US. Processes included reviewing and piloting the New Zealand training materials to identify implementation challenges, updating training materials to be consistent with American physical therapy practices, piloting the updated training materials in an online format, and determining if the online format reached the target PT audience. Methods – Process Activities The New Zealand manual was reviewed by expert American PTs and a training webinar was piloted with 56 American PTs. Feedback suggested that the program itself was understood by PTs, but training materials required modification related to documentation and reimbursement policies. Additional content was developed and integrated into an online training module. The online training was piloted and then deemed adequate by seven PT subject matter experts. The online training was launched in March 2013. Demographic and practice data were collected to characterize the PTs attending the online training as well as perceived barriers and facilitators to implementation (n = 522). Perceived facilitators include the effectiveness of the OEP to facilitate adoption, but the lack of agency support, billing and reimbursement challenges pose a significant barrier to OEP implementation. Conclusion The OEP required additional information to facilitate adoption by American PTs. Online training that specifically targets PTs appears to effectively reach the target audience and be well received by participants. More research is required to determine the impact of online training on a PT’s adoption and implementation of this material into their practice.

Using the RE-AIM Framework to translate a research-based falls prevention intervention into a community-based program: Lessons Learned

PROBLEM Exercise-based research interventions demonstrate reduced risk and rates of falls for community dwelling older adults; however, little is known about effective mechanisms for the translation, implementation, and maintenance of these interventions in community settings. METHOD The RE-AIM framework was used to assess the translatability of an effective exercise-based research intervention in a community setting. Questions included: Reach - Would the target population attend? Effectiveness - What was the adherence and compliance to the program? Were there individual improvements in falls risk factors? Adoption: Would staff at the center adopt the program and offer it past the funding period? Implementation - What adaptations, including optimal frequency and duration, should be made to meet the community needs, still adhere to core elements and achieve similar outcomes? Maintenance - Would the program be sustained by our community partners? DISCUSSION The process of translating a controlled research intervention targeting older adults at risk of falls into a community setting was challenging. Licensed professionals developed the infrastructure to safely and effectively deliver the program. The end product was highly appealing program to our target audience, resulted in improved outcomes and was successfully adopted and maintained by the community partner. SUMMARY Partnerships between community and healthcare providers are key to successful implementation of falls prevention interventions. Lessons learned from this experience can be applied to the translation of future exercise-based falls prevention interventions.

The impact of a home-based computerized cognitive training intervention on fall risk measure performance in community dwelling older adults, a pilot study

ObjectivesCognitive intervention studies have reported improvements in various domains of cognition as well as a transfer effect of improved function post training. Despite the availability of web based cognitive training programs, most intervention studies have been performed under the supervision of researchers. Therefore, the purpose of this study was to first, examine the feasibility of a six week home based computerized cognitive training (CCT) program in a group of community dwelling older adults and, second, to determine if a CCT program which focused on set shifting, attention, and visual spatial ability impacted fall risk measure performance.DesignThis pilot study used a pretest/posttest experimental design with randomization by testing site to an intervention or control group.ParticipantsCommunity dwelling older adults (mean age = 74.6 years) participated in either the control (N=25) or the intervention group (N=19).InterventionIntervention group subjects participated in 6 weeks of home based CCT 3x/week for an average of 23 minutes/session, using an online CCT program.MeasurementsComparisons of mean scores on three measures of physical function (usual gait speed, five times sit to stand, timed up and go) were completed at baseline and week 7.ResultsFollowing the completion of an average of 18 sessions of CCT at home with good adherence (86%) and retention (92%) rates, a statistically significant difference in gait speed was found between groups with an average improvement of 0.14m/s in the intervention group.ConclusionA home based CCT program is a feasible approach to targeting cognitive impairments known to influence fall risk and changes in gait in older adults.

Otago Exercise Program in the United States: Comparison of 2 Implementation Models

Background The Otago Exercise Program (OEP) is an evidence-based fall prevention program delivered by a physical therapist in 6 visits over a year. Despite documented effectiveness, there has been limited adoption of the OEP by physical therapists in the United States. To facilitate dissemination, 2 models have been developed: (1) the US OEP provided by a physical therapist or physical therapist assistant in the home or outpatient setting and (2) the community OEP provided by a non–physical therapist and a physical therapist consultant. It is unknown whether such modifications result in similar outcomes. Objective The aims of this study were to identify the components of these 2 models, to compare participant characteristics for those components reached by each model, and to examine outcome changes by model and between models. Design This was a translational cohort study with physical therapists implementing the US OEP and trained providers implementing the community OEP. Methods Data for physical performance, sociodemographic characteristics, and self-perception of function were collected at baseline and at 8 weeks. Results Participants in the community OEP were significantly younger and reported more falls compared with those in US OEP. Both sites reported significant improvements in most physical and self-reported measures of function, with larger effect sizes reported by the community OEP for the Timed “Up & Go” Test. There was no significant difference in improvements in outcome measures between sites. Limitations This was an evaluation of a translational research project with limited control over delivery processes. The sample was 96% white, which may limit application to a more diverse population. Conclusion Alternative, less expensive implementation models of the OEP can achieve results similar to those achieved with traditional methods, especially improvements in Timed “Up & Go” Test scores. The data suggest that the action of doing the exercises may be the essential element of the OEP, providing opportunities to develop and test new delivery models to ensure that the best outcomes are achieved by participants.