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ABSTRACTS

APTA Geriatrics Combined Sections Meeting 2021 Platform Abstracts

Journal of Geriatric Physical Therapy: January/March 2021 - Volume 44 - Issue 1 - p E94-E122
doi: 10.1519/JPT.0000000000000293
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TITLE: Comparing Single Question Physical Activity Questionnaire With Common Assessments of Physical Activity in Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Jerneja Uhan, Julia M. Wright, Jane Freund, Chitra Lakshmi K Balasubramanian, Srikant Vallabhajosula

ABSTRACT BODY:

Purpose/Hypothesis: Long questionnaires which consist of several validated tools typically provide an overbearing experience. Also several of the available validated tests are subjective in nature. Recently the Single Question Physical Activity Questionnaire (SinglePAQ) was developed and validated to be used to assess physical activity. However, it is currently not known how the results of this self-reported single question compare to those that are routinely used to assess physical activity among older adults. Therefore, our purpose was to compare the SinglePAQ with established subjective and objective assessments of physical activity among older adults.

Number of Subjects: 30 community-dwelling older adults, comprising of 13 men and 17 women with a mean age of 73 (+/− 6.6) years.

Materials and Methods: Participants completed the SinglePAQ and the Community Health Activities Questionnaire for Older Adults (CHAMPS). Both these questionnaires have been validated to be used in community-dwelling older adults. The SinglePAQ consisted of a single question on a Likert scale about the participant's perception of their physical activity in the past 6 months. The CHAMPS questionnaire consists of 41 questions related to physical activity within the past month. The frequency of all exercise related activities completed in a week from CHAMPS was used for data analysis. Objective assessment of physical activity was done using StepWatch, a research-grade step activity monitor (SAM). Participants wore SAM for a week on their ankles and average of the total number of steps per day for 7 days were used for data analysis. Spearman's correlation was used to assess the relationship between objective and subjective tests.

Results: There was a significant moderate relationship between the SinglePAQ and CHAMPS (spearman's rho = 0.43; p = 0.016). However, a weak non-significant relationship was found between the SinglePAQ and SAM (spearman's rho = 0.30; p = 0.115). There was a significant moderate relationship between the SAM and CHAMPS (spearman's rho = 0.40; p = 0.030).

Conclusions: Results from the current study indicate that SinglePAQ, CHAMPS and SAM may not be assessing physical activity levels in older adults in a similar manner. This could be due to different time periods under each assessment (6 months for SinglePAQ, 1 month for CHAMPS and 1 week for SAM). Subjective and objective assessments of physical activity cannot be used inter-changeably, and researchers and clinicians should be prudent about how they use these measures in older adults. Future studies need to examine the association of SinglePAQ with fall-risk level in older adults.

Clinical Relevance: Assessment of physical activity levels among older adults is important due to multimodal benefits including minimizing fall risk, cardiovascular health and functional mobility. Results of the current study indicate that there is a difference between interpretation of subjective and objective techniques to assess physical activity. This could be critical in evaluating physical activity levels in a geriatric clinical setting. Use of SinglePAQ though less time consuming, may not encompass a holistic physical activity assessment.

TITLE: Movement-Evoked Pain Among Older Adults Undergoing Total Knee Arthroplasty: A Systematic Review

CURRENT SECTION: Geriatrics

AUTHORS: Brigid Brennan, Lydia Elaine Friz, Daniel Fleming, Janae Chinn, Lance Bennett, Leila Ledbetter, Corey B. Simon

ABSTRACT BODY:

Purpose/Hypothesis: Approximately 5 million individuals undergo total knee arthroplasty (TKA), the majority of which are older adults. The primary indication for TKA is movement-evoked pain (MEP), i.e., pain experienced with physical performance. Amongst surgical populations, MEP is more severe than resting pain. MEP is highly correlated with physical function decline, which increases morbidity and mortality risks among older adults. Despite its prevalence and impact, MEP has not been systematically appraised in the context of TKA. Therefore, the purpose of this review was to systematically appraise MEP measurement, severity, and associations with recovery among in older adults undergoing TKA.

Number of Subjects:

n=7145 across 22 studies

Materials and Methods: A systematic literature review was conducted using Embase, Pubmed, and Scopus databases for studies published all time. Eligibility criteria for the studies included: 1) older adults (mean age greater than 55) undergoing TKA; and 2) MEP as a clinical outcome measure. Studies were appraised using a stepwise process (title, abstract, full-text) and three blinded reviewers. Eligible studies were assessed for risk of bias using the Modified Downs and Black Instrument.

Results: Twenty-two studies met eligibility criteria. Studies utilized cross-sectional (n=2), cohort (n=10), retrospective (n=2) and randomized experimental (n=8) designs. MEP was measured in both clinical (hospital) and natural (home after discharge) environments. MEP was assessed using recall questionnaire and range of motion (e.g., knee flexion); however, no study measured MEP through standardized physical performance tasks. Most studies measured MEP less than one week post operatively. In every study comparing MEP to resting pain, MEP was more severe. Though MEP commonly improved with TKA, recovery was also associated with many factors; including but not limited to psychological distress and physical function. Importantly, a majority of studies were found to have moderate to high risk of bias.

Conclusions: Less than half of the included studies were clinical trials, the majority of which were rated as moderate to high risk of bias. MEP in older adults undergoing TKA is measured predominately through verbal and written questionnaires, is almost always more severe than resting pain, and is primarily measured in the acute postoperative phase. MEP improves with TKA, though is associated with other factors including psychological distress and physical function.

Clinical Relevance: Due to its impact on patient health, MEP measurement is increasing in research and clinical care. However, numerous limitations exist in TKA literature, including MEP measurement predominantly though recall questionnaires, and in the acute postoperative phase. In absence of research, clinicians are advised to follow recent pain research recommendations of measuring movement-evoked pain through standardized physical tasks and up to a year post-operatively.

TITLE: Does a Novel Measure of Total Walking Speed Range Predict Function, Disability, and Life Space?

CURRENT SECTION: Geriatrics

AUTHORS: Michelle Germaine Criss, Jennifer Canbek, Kevin K. Chui, Joann Gallichio

ABSTRACT BODY:

Purpose/Hypothesis: Fully independent, community mobility requires a person to be able to adjust walking to the environment and task. Measurement of multiple walking speeds, from very slow to fast, might have the ability to indicate the capacity a person has to adapt walking speed. If a specific person cannot change walking speed at all or can only change walking speed in a small range, then this person might restrict tasks or environments to those that are more predictable and do not require as much walking speed adaptability. Self-selected walking speed has been shown to slow with age, but the ability to produce a range of speeds has not been investigated. The aims of this project were to explore a proposed measure of walking speed adaptability, called total walking speed range (TWSR), in older adults, to assess if this measure could predict function, disability or community mobility, and to compare the predictive ability of TWSR to single walking speeds.

Number of Subjects: 110

Materials and Methods: This was a cross-sectional, observational study using a convenience sample comprised of older adults living independently in the community. Subjects were assessed in a single testing session with a battery of tests measuring common correlates to walking speed, different walking speeds, and outcome measures for function, disability, and community mobility. The ability of TWSR to predict function and disability measured with the Late Life Function and Disability Instrument (LLFDI) and community mobility measured with the University of Alabama Life Space Assessment (LSA) was calculated with both univariate and hierarchical linear regression models.

Results: TWSR significantly predicted function, disability, and life-space. In comparisons, SSWS predicted more variance in function, disability limitation and frequency than TWSR or MWS, but TWSR better predicted life-space. When covariates were included in models, neither TWSR, SSWS, nor MWS contributed independently to prediction of the outcomes. The hierarchical models for TWSR/SSWS/MWS all performed similarly and final explained variances were within 1% of each other, except for the prediction of life-space. The model with covariates + TWSR predicted more life-space variance than covariates + SSWS.

Conclusions: TWSR did predict function, disability, and life-space. However, the predictive ability of TWSR was not superior to SSWS or MWS.

Clinical Relevance: Self-selected (SSWS) and maximum walking speeds (MWS) are frequently studied and related to multiple body systems, function, falls, and mortality. Measuring a range of walking speeds, however, has rarely been investigated. Single walking speeds, especially SSWS, predicted almost as much variance in function as models with multiple variables. Explaining a large amount of the variance in function by assessing one variable, walking speed, is extremely efficient for busy clinicians. While there was no clear advantage of using TWSR, it was as effective as multiple variables in predicting life-space and performed better than SSWS or MWS, which indicates that it may warrant further investigation.

TITLE: Umbilical Mesenchymal Stem Cell Injection and Geriatric Shoulder Pathology Functional Outcomes: A Case Report Analysis

CURRENT SECTION: Geriatrics

AUTHORS: Nicole Leigh Schroeder

ABSTRACT BODY:

Background and Purpose: The use of stem cells for treatment of orthopaedic pathologies has increased significantly in the past decade despite limited high-level clinical evidence to support their usage.1 The purpose of this case report is to examine the effect of umbilical mesenchymal stem cell injection on the functional outcomes of a geriatric patient diagnosed with shoulder osteoarthritis and incomplete rotator cuff tear, confirmed via magnetic resonance imaging (MRI).

Case Description: A 72 year-old male was referred to physical therapy secondary to complaints of right shoulder pain and difficulty with functional tasks. Past medical history was unremarkable. The patient underwent two episodes of physical therapy treatment, pre and post, stem cell injection. Each episode consisted of 12 visits.

Outcomes: After the first treatment episode, the patient reported decreased pain with movement from a 7/10 to a 3/10 via numerical scale and a 25% global improvement in pain and function. He displayed a 25 degree increase in shoulder scaption active range of motion (AROM), a significant increase compared to the goniometer minimal detectable change (MDC) of 7.7 degrees.2 Strength via manual muscle test (MMT) improved in all planes from 3+/5 or 4-/5 to 4+/5. The second episode of physical therapy occurred 23 months later, six weeks post umbilical mesenchymal stem cell injection. After the second treatment episode, the patient reported a decrease in pain with movement from 8/10 to 3/10 and 40% global improvement in pain and function. He significantly increased right shoulder scaption AROM by 38 degrees. Shoulder strength was improved from 3+/5 or 4-/5 to 4+/5 in all planes. The Upper Extremity Functional Index (UEFI) change was three points, insignificant compared to the MDC of nine points.3

Discussion: The patient reported greater improvements in global function and pain following physical therapy combined with stem cell injection. However, the numerical pain rating after each treatment episode was the same and the UEFI change insignificant. Furthermore, the patient improved shoulder scaption AROM, strength, and pain following both physical therapy episodes, regardless of stem cell injection. Based on this case report, the addition of umbilical mesenchymal stem cell injections did not produce more favorable functional outcomes than physical therapy alone. The discrepancy between subjective report and objective measurements is an important point of discussion as well as the effects of patient age and tissue injury severity on therapy outcomes. Furthermore, attention should be given to the length of time between injury and treatment, and the type of stem cells utilized. While a limitation of this report includes small sample size, the findings of this case contribute to the limited body of knowledge regarding the safety, efficacy, protocols and composition of stem cell treatment for orthopaedic conditions.4-8 The results of this study should be taken into consideration when discussing methods to improve the functional outcomes of geriatric populations with shoulder pathology.

TITLE: Pivot to Telehealth Annual Community Wellness Exams for Senior Adults: A Three-Fold Perspective

CURRENT SECTION: Geriatrics

AUTHORS: Catherine Elizabeth Crandell, Sonja Karin Bareiss, Christopher J. Wingard, Gina Lynne Pariser

ABSTRACT BODY:

Purpose: The purpose of this study was to examine client, student and faculty perceptions of experiences with a pivot to telehealth annual community wellness exams for older adults during the Covid-19 pandemic in the spring 2020.

Description: Each spring, first-year DPT students and faculty provide annual community wellness exams to older adults as part of a health promotion course. Due to the Covid-19 pandemic, this face-to-face experience pivoted to a telehealth platform. After screening, clients completed the following tests: 30 sec Chair Stand or Timed Arm Curl; Chair Sit-and-Reach or Back Scratch; and TUG or 4-Stage Balance Test. Clients were provided an explanation on how they compared with age/sex matched normative values and were given exercise recommendations. 34 volunteer clients (avg age 72.2±6.5, 20♀, 14♂) were invited to complete a modified version of the Telemedicine Satisfaction Questionnaire (TSQ), a 14-item survey about their experience. 70 students (41♀, 29♂) and 9 faculty instructors (8♀, 1♂) completed either reflection paper (students) or survey (faculty) asking what did you learn and the value of the experience.

Summary of Use: Client responses: 17/34 = 50% response rate. Avg response results of 3 factors in the TSQ: Quality of care provided: 87.5% Agree (A) or Strongly Agree (SA); Similarity to face-to-face encounter: 92.8% A or SA and Perception of the interaction: 100% A or SA. Student reflection papers contained 2 consistent themes regarding learning through the telehealth experience: it highlighted the importance of communication skills (communication was a key to the wellness exam success) and it required adaptability (to overcome challenges such as technology issues, testing set-up constraints in client's home and limited camera view on client during testing). Three themes emerged from the student's perception of the telehealth value: 1. application of knowledge using new telehealth skills; 2. ability to see client's home environment and 3. connection with older adults during pandemic. Students also reported telehealth challenges including safety concerns with clients who lived alone and suggested family-member assistance for safety, improved camera angles and recording measurements. Faculty reflections mirrored student-learning comments emphasizing importance of communication and adaptability. Faculty noted the experience was valuable for students to learn telehealth in a controlled environment and it sharpened their observation and teaching skills.

Importance to Members: The Covid-19 pandemic created a fast-track learning opportunity for clients, students and faculty who participated in the telehealth wellness exams. The pivot from face-to-face to telehealth wellness exams was well received by the clients. Students recognized the benefit of the telehealth experience and were grateful for the immersion. Students and faculty believed the telehealth skills will carry over to full-time clinical experiences. Overall, the telehealth wellness exams were viewed as a positive experience by clients, students and faculty.

TITLE: A Train-the-Trainer Exercise Program in Adult Day Health: Facilitators and Barriers to Implementation

CURRENT SECTION: Geriatrics

AUTHORS: Jennifer Tritz, Rachel Ann Prusynski, Eva Barth, Ellen L. McGough

ABSTRACT BODY:

Purpose/Hypothesis: Decreased levels of physical activity in people with dementia (PWD) has significant detrimental effects on physical function and independence with mobility. Cognitive impairment can limit active participation in typical group exercise programs for older adults. Increasing physical activity for PWD is a common goal for rehabilitation professionals (RPs). The EM-STAR (Exercise for Mobility and Staff Training in Assisted Living Residences) train-the-trainer program is a mode of delivering moderate intensity group exercise for PWD led by direct care staff exercise leaders with oversight from RPs. The purpose of this study was to identify facilitators and barriers for implementing EM-STAR train-the-trainer program in adult day health (ADH) programs.

Number of Subjects: Eight RPs including physical, occupational, and recreation therapists completed the training and focus groups. Five RPs participated in semi-structured interviews following program implementation.

Materials and Methods: This was a qualitative study using focus groups and semi-structured interviews. The EM-STAR two-phase train-the-trainer program was implemented in three ADH centers (NIH/NIA: 2P30AG034592). Focus groups and interviews were recorded, transcribed, and independently analyzed by three researchers to identify major concepts and themes. Transcripts were coded using Dedoose software.

Results: Post-training RP focus groups revealed concerns regarding staff buy-in, impact on daily routine, safety and quality of care. Post-implementation interviews revealed three major concepts including: (1) facilitators of successful implementation, (2) barriers to successful implementation, and (3) client response to EM-STAR classes. Themes associated with facilitators of successful implementation included buy-in by both RPs and direct-care staff, an exercise class integrated in the daily ADH routine, and engaged direct care staff. Themes associated with barriers to successful implementation included staffing shortages and staff discomfort with standing and walking activities. The walking portion of EM-STAR was universally identified as a safety concern due to staffing limitations. Themes related to client response to EM-STAR included a noticeable increase in client engagement, but this was influenced by instructor methods and engagement.

Conclusions: RPs emphasized the importance of staff buy-in, pragmatic integration of the exercise class into the daily routine of the ADH program, and training engaged and dynamic instructors in the successful implementation of a train-the-trainer exercise program for PWD.

Clinical Relevance: Increasing physical activity in PWD is an important health intervention that may be successfully implemented via a train-the trainer model by considering buy-in, direct care staff engagement, and staffing. To achieve levels of physical activity that mitigate functional decline in PWD, exercise program development and training that emphasize staff buy-in and engagement appear to be critical for success.

Key Words: train the trainer, dementia, adult day health, physical activity

TITLE: Effects of Cogxergaming on Cognitive-Motor Interference in Older Adults With Mild Cognitive Impairment

CURRENT SECTION: Geriatrics

AUTHORS: Lakshmi Kannan, Tanvi Bhatt

ABSTRACT BODY:

Purpose/Hypothesis: In addition to cognitive decline, older adults with mild cognitive impairment (OAwMCI) exhibit balance and gait deficits which are more pronounced during dual-tasking (simultaneous performance of motor and cognitive task) leading to increased cognitive-motor interference (CMI) - which predisposes them to a greater fall-risk during daily living. This study aimed to determine the effect of a combined cognitive and exergaming (CogXergaming) paradigm to reduce CMI and improve dual-task performance in OAwMCI. We hypothesized that CogXergaming will result in increased dual-task performance during volitional balance control task. Further, this training will result in an increased performance on NIH toolbox measures.

Number of Subjects: 10

Materials and Methods: Older adults with score <24/30 on Montreal Cognitive Assessment (n=10) were considered for the study. Participants were examined at baseline and at week 5 (post-training) on the limits of stability (Neurocom Inc.) test to measure volitional balance control quantified by maximum center of pressure excursion (MXE) under single and dual-task conditions (i.e., with a cognitive task- Auditory clock test and letter number sequencing). NIH balance toolbox was used to measure endurance (2-minute walk test), gait speed (4-meter walk test) and postural control (standing balance test). NIH cognitive toolbox measured working memory (list sort memory test), episodic memory (picture sequence memory test) and executive functioning (dimensional change card sort test). CogXergaming lasted for 4 weeks (12 sessions; 1 hour/session) which consisted of playing the Wii-fit games while simultaneously performing cognitive tasks. The Wii-fit games comprised of multidirectional weight-shifting, stepping up and down and walking with immediate biofeedback and reward (via game scores). The cognitive tasks addressed working memory (mental arithmetic), verbal and category fluency, abstract memory (analogies), attention (digit recall, repeated letter).

Results: Participants displayed significant improvement in MXE post-training under dual-task conditions (i.e., Auditory clock test and letter number sequencing) (p<0.05). However, post-training, cognitive performance under dual-task conditions remained the same. Further, participants improved gait speed (p<0.05) and showed significant improvement in all measures under NIH cognitive toolbox (p<0.05), post-training.

Conclusions: CogXergaming paradigm was effective in OAwMCI for reducing CMI by improving motor performance and maintaining cognitive performance under dual-task conditions. Further, the training aided in improving working memory, episodic memory, and executive function which are often impaired in OAwMCI.

Clinical Relevance: CogXergaming training is an effective and feasible method to be implemented as part of fall-prevention programs in OAwMCI for slowing progression of physical and cognitive decline. Future studies need to examine efficacy of such paradigm in this population for determining real-life generalization effects.

TITLE: Optimistic Contentment: Lived Experience of Older Adults With Non-Traumatic Lower Limb Amputations Receiving Physical Therapy

CURRENT SECTION: Geriatrics

AUTHORS: Logan Halbritter, Christopher Camacho, Ellen Kroog Donald, Mark R. Erickson

ABSTRACT BODY:

Purpose/Hypothesis: This study explored patient perceptions of the quality of social and emotional care and how it relates to self-efficacy throughout the rehabilitation process following lower-limb amputation.

Number of Subjects: Ten subjects between the ages of 62 and 88 with unilateral, non-traumatic lower-extremity amputations participated in this qualitative study.

Materials and Methods: A grounded qualitative research method used a phenomenological approach where open-ended questions were asked by individual interviews. Questions were derived from the literature, and focused on five themes that emerged from the existing research: social support, hope, self-efficacy, identity, and meaning. Follow-up questions ensured the participant had the opportunity to share all relevant information related to the initial query. Recorded interviews were manually transcribed, analyzed, and open coded. Axial coding was then conducted with all members of the research team, establishing themes and a central phenomenon.

Results: From this analysis, a central phenomenon emerged that was classified as “optimistic contentment”. This phenomenon, previously unidentified in peer-reviewed literature, was operationalized as the feeling of contentment in the one's current physical status, while still expressing optimism for the future. Subject responses clearly indicated a dynamic beyond acceptance, yet not achieving situational satisfaction. To support the central phenomenon, participants' responses were categorized into themes of intrinsic and extrinsic factors. Intrinsic factors were subdivided into ‘perseverance’ and ‘acceptance’. The perseverance factor included patient's hopefulness, optimism, positivity, drive and determination, and internalization of external motivators. The acceptance factor included the patients' new identity and pragmatism. Extrinsic factors that became evident in the data related to the therapeutic relationship that developed, such as building trust, setting realistic goals, providing encouragement, and therapists serving as a counselor or confidant.

Conclusions: This qualitative study identifies a novel central phenomenon, optimistic contentment, for individuals going through physical therapy following lower extremity amputation. The intrinsic factors of perseverance and acceptance, and an extrinsic factor of the importance of the therapeutic relationship emerged from these data. It became clear that patients regain a strong sense of continued improvement grounded in resilience and positivity, accepting their new identity with a pragmatic perspective. The key aspects of the therapeutic relationship were trust, realistic goal setting, encouragement, and the therapist being present as a counselor and/or confidant.

Clinical Relevance: This research supports a vital need for physical therapists to provide social and emotional support, in addition to physical aspects of rehabilitation, to promote self-efficacy for those who have had a lower-limb amputation. Embedding these intrinsic and extrinsic factors in the physical therapy patient/client management model may contribute to patients' functional activity and participation levels, as well as quality of life.

TITLE: Including Cognitive Assessments With Functional Testing Predicts Real-World Walking in Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Alexa Haggard, Jaclyn E Tennant, Renee Nicole Hamel, Lisa A Zukowski

ABSTRACT BODY:

Purpose/Hypothesis: For community-dwelling older adults, safe ambulation is vital to maintaining independence. Previous research suggests that typical age-related declines in cognitive reaction time and gait speed affect an older adult's quality of life and participation in everyday activities. Dual-task (DT) conditions are reflective of the cognitive and mobility demands of real-world walking (e.g., talking while walking). DT testing is not always feasible and not commonly performed in clinical settings. It is often assumed that functional mobility, cognitive performance measures, and self-report measures that predict ST performance also predict DT performance, but this assumption has not been fully explored. The purpose of this study was to determine if the predictive relationship of mediating social factors, cognitive performance, functional mobility, and self-reported physical activity and balance confidence on gait speed and cognitive reaction time differs in ST and DT conditions in community-dwelling older adults. We hypothesized that scores from the various assessments have different predictive relationships of gait speed and cognitive reaction time in ST and DT trial conditions, respectively.

Number of Subjects: 62 Community Dwelling Older Adults (60+y/o).

Materials and Methods: Demographic data were collected. Participants completed measures of cognitive performance [Computerized Stroop Interference Reaction Time Test (Stroop), Wechsler Adult Intelligence Scale (WAIS-IV) Coding subtest, and Comprehensive Trail Making Test (CTMT)], measures of functional mobility [Timed Up and Go (TUG), 30-Second Sit to Stand (30STS), 10-Meter Walk Test (10MWT), and Four Square Step Test (FSST)], and self-report assessments of balance confidence [Activities-Specific Balance Confidence Scale (ABC)] and physical activity [Physical Activity Scale for the Elderly (PASE)]. Three trial conditions were performed in a quasi-randomized order: 1) ST Cognition (Clock Task), 2) ST Gait and 3) DT Cognition + Gait.

Results: Four separate multivariate regressions were largely similar across ST and DT trial conditions. The CTMT significantly predicted Reaction Time in ST cognitive and DT trials (both p<.001). Gait speed measured in 10MWT significantly predicted Gait Speed in ST and DT trials (both p<.001). The FSST score significantly predicted Gait Speed in the ST trial only (p=0.035). The CTMT score marginally predicted Gait Speed in the DT (p=.054) trial.

Conclusions: These results suggest that the CTMT is the best predictor of Reaction Time in ST and DT conditions, while the 10MWT is the best predictor of Gait Speed in both conditions. Thus, utilizing the CTMT and 10MWT together would provide a robust assessment of real-world cognitive and functional abilities in this population.

Clinical Relevance: Including a cognitive assessment like the CTMT during initial evaluation could indicate real-world walking readiness in this population. This study also suggests that the 10MWT is a good measure of real-world walking speed and should be utilized in the clinic to create objective and meaningful gait goals.

TITLE: Management of an Aging Athlete With OA Using Systematic Evaluation and Blood Flow Restriction Training

CURRENT SECTION: Geriatrics

AUTHORS: Jeffrey Adam Miller, Naoaki Ito, Lynn Snyder-Mackler, Tara Jo Manal

ABSTRACT BODY:

Background and Purpose: Radiographic evidence of knee osteoarthritis (OA) is prevalent, but the decision on when to proceed with surgical intervention can be difficult. Evidence supports the benefit of exercise and quadriceps strengthening for successful conservative management of knee OA.1,2,3,4,5 A systematic “OA Profile” evaluation can identify impairments to be addressed with conservative interventions. The OA Profile consists of a 6 minute walk test, timed up and go, 30 second sit to stand, stair climb test, single leg balance, knee range of motion, isometric quadriceps strength index (QI), and the Knee Outcome Survey (KOS-ADL).6,7 Test data identifies impairments and functional performance compared to age matched norms to guide care decisions. Repeat assessment allows comparison over time that could indicate progress or the need to alter the treatment plan.

A primary focus of non-operative management of knee OA is quadriceps strengthening.1,2,3,4,5 High load resistive training along with neuromuscular electrical stimulation (NMES) is the primary method of increasing quadriceps strength.4,5 Blood flow restriction training (BFR) has demonstrated comparable gains in quadriceps strength and function in patients with knee OA, while inducing less pain and joint stress particularly with lower intensity training.8,9 BFR may be a viable alternative for patients with knee OA who do not respond to high load resistive training.

Case Description: An 80 year old male with radiographic evidence of L>R knee OA was referred to physical therapy for an OA Profile evaluation. He experienced pain with walking and playing tennis. The OA Profile showed he far exceeded age-matched norms on all functional performance tests and only had mild knee ROM limitations. His QI (L/R=63%) and KOS-ADLS (66%) were low. All parties agreed a focus on quadriceps strengthening rather than immediate surgical intervention was indicated. The first 6 weeks focused on high load resistive training (dosed at 75% of 1 rep max), but BFR was introduced during the following 5 weeks.

Outcomes: After 6 weeks of high load resistive training and quadriceps NMES, his QI showed no change (64%). His KOS-ADLS improved (77%), but did not meet minimum detectable change (MDC=12.5%),10 and pain during tennis persisted. After 5 weeks of transitioning all strengthening exercises to low load resistive training with BFR and continuing NMES, his QI increased (80%), KOS-ADLS (90%) improvements met MDC, and the patient returned to playing tennis pain free.

Discussion: The systematic OA Profile evaluation assisted in identifying an individual appropriate for non-operative management of knee OA. Repeat testing of strength impairments helped identify the need to modify interventions when progress was not seen. While not painful, the patient was not responsive to high load resistive training. Low load strengthening with BFR was more effective, and produced measurable gains in strength, function, and reduced pain. The combination of using a systematic assessment, such as the OA Profile, and timely implementation of BFR led to a pain free return to tennis without a need for surgical intervention.

TITLE: Geriatric Functional Milestones: Promoting Movement While Aging

CURRENT SECTION: Geriatrics

AUTHORS: Logan Taulbee, Ashleigh Dyanne Trapuzzano, Timothy Nguyen, Jacqueline Alicia Osborne

ABSTRACT BODY:

Theory/Body: Adults over the age of 60 are a functionally diverse group who utilize varied movement patterns to participate in activity. In children, developmental milestones provide guidance on the stages of movement from infancy to adolescence. No clear understanding exists of how movement continues to change after adolescence, through adulthood and into elderhood due to heterogeneity among aging adults and the challenge of differentiating between age-related and pathological processes. Many aging adults do not seek care until they have experienced adverse health events. In this theory report, we propose that the routine assessment of Geriatric Functional Milestones (GFMs) could assist in the timely identification of suboptimal movements, mitigate or prevent adverse health events, and standardize movement patterns required for optimal activity and participation in life.

GFMs are functional tasks that assist aging adults and healthcare providers to identify when a change in functional abilities has occurred. A score threshold on each GFM would indicate a risk toward functional decline and prompt the need for a comprehensive functional movement assessment and subsequent development of intervention strategies to improve function and prevent decline. The proposed GFMs include walking without an assistive device, rising to toes, alternating steps on stairs, getting on/off the floor, picking up an item from the floor, single limb stance, jumping, sitting to standing without hands, reaching for an object overhead, and carrying an object while walking.

Muscle performance over time include clinical changes that contribute to pathological onset. An inability to rise to toes, rise from sitting without using hands, or carry/reach for an item with upper extremities may indicate an increased rate of strength loss. Muscle power is also associated with increased fall risk and can be quantified by the ability to navigate stairs and jump. Traditionally, these clinical measures are collected after pathological onset, reducing the possibility for prevention and cost savings associated with resource utilization.

Further research is needed to identify the cluster of GFMs that can inform the timely identification of functional decline to allow for proactive rather than reactive intervention strategies. Research should include identifying a threshold for suboptimal movements and standardized values for meaningful change. The routine assessment of movement throughout elderhood using GFM performance may help to identify risk functional decline, frailty, and/or hospitalization. A meaningful change could also help identify changes in disease onset or progression, underlying infection, adverse responses from medications, or a change in nutritional status.

Physical therapists can guide and optimize movement through the lifespan, which should include aging beyond adolescence. Utilizing GFMs to standardize practice can facilitate a shift from tertiary reaction to primary coordination in order to empower aging adults to optimally age.

TITLE: Determinants of Exercise Adherence to a 2-Month Moderate-Intensity Aerobic Exercise Intervention in Sedentary Aging Adults

CURRENT SECTION: Geriatrics

AUTHORS: Danylo Lucio Ferreira Cabral, Christina Nunez, Jordyn Leigh Rice, Alicia Kaye Hartstack, Daniel A. Light, Rayla Nogueira Noqueira Frota, Sean Michael O'Gara, Lawrence P. Cahalin, David A. Loewenstein, Tatjana Rundek, Gregory W. Hartley, Alvaro Pascual-Leone, Joyce Gomes Osman

ABSTRACT BODY:

Purpose/Hypothesis: At least 50 meta-analyses provide evidence that exercise promotes cognitive brain health in aging adults. However, limited adherence is a major barrier for the systematic implementation of exercise for cognitive brain health in aging. Low self-efficacy, sedentary behavior and low baseline fitness levels have all been independently demonstrated to influence exercise adherence, but studies that address the relative contribution of each of these factors are lacking. The purpose of this study was to investigate the influence of four baseline exercise-related variables on adherence to a 2-month moderate-to-vigorous intensity aerobic exercise intervention in sedentary aging adults.

Number of Subjects: 34 sedentary aging adults (age= 62 ± 6.4y, 53% female) with no clinically detectable cognitive impairment (Montreal Cognitive Assessment score ≥ 24) were included.

Materials and Methods: All participants engaged in a 2-month supervised aerobic exercise intervention 3x/week. Each 60-minute session was delivered at moderate intensity (55-64% Karvonen equation) for the first 4 weeks and high intensity (65%-90%) for the subsequent 4 weeks. The dependent variable was exercise adherence, defined as time in days to complete the 24 sessions of exercise. The independent variables were: Exercise Lifetime History, Exercise Self-Efficacy, and Exercise Barriers questionnaires, and Physical Fitness Level. Fitness was assessed using resting heart rate, heart rate reserve, and estimated VO2 peak from the Incremental Shuttle Walk Test. We used Pooled-t-test and Chi square tests to compare baseline characteristics between individuals who completed the study and those lost to follow-up. We performed a multivariable stepwise regression model to analyze the effect of independent variables on exercise adherence using data from all ‘completer’ participants.

Results: Of the 34 individuals, 19 completed the intervention (64.4 ± 9.2 days) and 15 were lost to follow-up. ‘Lost to follow-up’ participants had significantly higher rate of smoking and resting heart rate, when compared with ‘completers’ (p<.05). For ‘completers’, higher self-efficacy (β= −0.56, t= −2.57, p= 0.02) and lower exercise lifetime history (β= 0.017, t= 1.83, p= 0.08) significantly predicted study adherence but only explained 31% of the variance (F2,17 = 4.8, p= .024, adjusted R2= 0.31). Exercise barriers and fitness levels were not significant predictors of exercise adherence.

Conclusions: Our preliminary findings suggest that while self-efficacy and exercise lifetime history significantly predicted adherence to a 2-month aerobic exercise intervention in sedentary aging adults, they only explained about a third of the variance. Therefore, other relevant variables might play major roles and need addressing to ensure adherence with physical exercise programs in aging adults.

Clinical Relevance: Given that exercise is more effective than any therapeutic that currently exists to maintain and improve cognitive brain health, a better understanding of these variables will allow therapists to refine, optimize, and individualize exercise interventions for cognitive brain health.

TITLE: Influence of Secondary Cognitive Task Type on Reach-to-Grasp Balance Responses in Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Ruth Y. Akinlosotu, Nesreen Alissa, Kelly Westlake

ABSTRACT BODY:

Purpose/Hypothesis: Although older adults (OA) tend to rely more on grasping than stepping to restore balance, the result is often ineffective. Quick attention shifting from an ongoing cognitive task is needed to accurately reach out and secure a grasp following a perturbation. However, since anxiety-provoking cognitive tasks are known to impair attention shifting more so than other cognitive tasks, questions as to whether the type of pre-perturbation cognitive task influences the grasp response remain. The purpose of this study was to compare the effect of varied cognitive tasks (i.e. none, neutral, and mentally stressful) on reach to grasp reactive balance responses in OA.

Number of Subjects: Twenty-three community dwelling OA (10 M, 13 F; age (mean±SD) = 70.5±5.38 years; Height = 168.2±9.59 cm; Weight = 78.8±14.09 kg).

Materials and Methods: This was a cross-sectional study. An ActiveStep treadmill delivered individualized lateral perturbations at each subject's threshold for perceived loss of balance under 3 randomized conditions (4 trials each); no cognitive task, neutral cognitive task (verb generation), and mental stress task (paced serial addition task). A subjective unit of distress scale (SUDs) assessed distress levels experienced prior to perturbations. Handrails equipped with contact sensors were placed on each side of the subjects with instructions to grasp one rail to restore balance. An overhead safety harness with an integrated load cell prevented actual falls and determined the amount of harness assistance, defined as percent body weight on harness. A Kruskal Wallis test determined differences between conditions for the primary outcomes of percent grasp accuracy and mid deltoid reaction time (i.e. time of perturbation onset to mid deltoid EMG onset), followed by a Dunn's multiple comparison test. The relationship between harness supported percent body weight and the primary outcomes were determined using a Spearman's rank order correlation.

Results: There was a significant difference in percent grasp accuracy among the 3 conditions (H(2)=9.09, p=0.01). Post hoc tests revealed reduced grasp accuracy in the mental stress task compared to no cognitive task conditions (p=0.011) despite having no significant differences in reaction time (H(2)=0.4782, p=0.7873) among the 3 conditions. Mean reaction time for no task, neutral task, and mental stress task were 100ms±27ms, 102ms±32.7ms, and 96ms±27ms, respectively. There was a moderate negative correlation between grasp accuracy and percent body weight supported falls (r=-0.31, p=0.004).

Conclusions: The presence of a mentally stressful cognitive task immediately prior to a balance perturbation results in reduced grasp accuracy when compared to a no cognitive task or neutral cognitive task. Results also demonstrated that OA with reduced grasp accuracy are more likely to require harness assistance to prevent a fall.

Clinical Relevance: Balance assessment and training protocols should consider including cognitive tasks with increasing levels of mental stress to elicit task specific and ecologically valid responses.

TITLE: Comparison of Performance-Based Outcome Measures Used in Two Fall Risk Assessment Tools for Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Kevin Michael Parcetich, Daniel Miner, Arco Prabha Paul

ABSTRACT BODY:

Purpose/Hypothesis: The 3 performance-based outcomes measures (OM) used in CDC's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool to analyze fall risk are timed up and go (TUG), 30 second chair stand test (30SCST) and 4 stage balance test (4SBT). Recently, APTA and Academy of Geriatric Physical Therapy sponsored research to develop an assessment tool (APTA-SR) that recommends 5 OMs, Berg balance scale (BBS), TUG, single limb stance time test (SLSTT), 5 times sit to stand (5TSTS) and 10 meter walk test (10MWT) to calculate fall risk using post-test probability. The purpose of this study was to compare diagnostic utility of the sets of OMs used in these 2 fall risk assessment tools based on history of falls.

Number of Subjects: 33 community-dwelling older adults (25 females, 8 males), with ages from 66-93 years (mean 79.45 ± 7.64 years).

Materials and Methods: A cross-sectional study was used to recruit older adults from a local independent senior living community. Within a month, all subjects were interviewed via telephone to inquire about any falls in the past year. All 7 OMs were administered on all subjects in a single day followed by education on fall-prevention. Subjects were then asked to continue their daily life. Subjects were categorized as “at risk” or “not at risk” according to STEADI and APTA-SR guidelines. A fall event was considered to be the ‘gold standard’ and a fall prevalence rate of 30% in community-dwelling older adults was used for calculations. Sensitivity (Sn), specificity (Sp), positive (LR+) and negative (LR-) likelihood ratios were used to calculate diagnostic accuracy (where, accuracy = Sn × prevalence + Sp × (1 - prevalence)).

Results: The STEADI OMs were found to have a Sn of 88.2% (95% CI, 63.6-98.5), Sp of 43.8% (95% CI, 19.8-70.1), LR+ of 1.57 (95% CI, 0.98-2.5), LR- of 0.27 (95% CI, 0.07-1.11), and diagnostic accuracy of 57.1% (95% CI, 38.8-74.1). Using post-test probability analysis, the APTA-SR OMs were found to have a Sn of 82.4% (95% CI, 56.6-96.2), Sp of 62.5% (95% CI, 35.4-84.8), LR+ of 2.2 (95% CI, 1.12 to 4.29), LR- of 0.28 (95% CI, 0.09 to 0.84), and accuracy of 68.5% (95% CI, 50-83.5). When using 3 outcome measures, BBS, TUG and 5TSTS of APTA-SR, accuracy was 70.2% (95% CI, 51.8-84.8), with Sn, Sp, LR+ and LR- being 88.2% (95% CI, 63.6-98.5), 62.5% (95% CI, 35.4-84.8), 2.35 (95% CI, 1.22 to 4.53), 0.19 (95% CI, 0.05 to 0.73), respectively.

Conclusions: Although STEADI OMs were more sensitive to fall risk, APTA-SR OMs showed better specificity, positive likelihood ratio and accuracy in assessing fall risk. When only using the BBS, TUG and 5TSTS from the APTA-SR OMs these tests were just as sensitive as STEADI, and demonstrated improved specificity, likelihood ratios and diagnostic accuracy.

Clinical Relevance: While STEADI may be more sensitive for reducing fall-related injuries, APTA-SR may be more accurate in differentiating non-fallers from fallers. Importantly, the subset OMs of BBS, TUG and 5TSTS might offer better clinical utility than conducting all 5 APTA-SR OMs to minimize fall-related healthcare costs and allocation of limited fall prevention resources for older adults.

TITLE: Description and Outcomes of an Interprofessional Education Activity Regarding Elder Abuse for Health Professional Students

CURRENT SECTION: Geriatrics

AUTHORS: David B. Gillette, Deepti Vyas, PharmD, Gabriella Musacchia, Tracey DelNero, MSPAS, PA-C, Todd Eldon Davenport

ABSTRACT BODY:

Purpose/Hypothesis: Approximately 1 to 2 million patients in the United States over the age of 65 years have been victims of elder abuse and neglect (EAN). Identification of EAN can be complex because it may involve several different types. Because a patient care involves teams, optimal identification of EAN also may require communication with other health care providers. These observations indicate that EAN is an important issue for health professions programs to address in an interprofessional manner. The purpose of this project was to describe and measure outcomes associated with an IPE activity that addresses EAN.

Number of Subjects: 408 students in five health-professions programs.

Materials and Methods: A total of 408 students participated in the IPE activity, which consisted of a combination of individual pre-event learning activities and a team activity. For the individual pre-event learning activity, students received three case vignettes distributed through the learning management system. One week later, students received the Caregiving Scenario Questionnaire and a knowledge survey. Students then met for a 4-hour, in-person IPE event for team activities. After icebreaker and role definition activities, students then attended a one-hour lecture on EAN. At the end of the lecture, students watched a video, which depicted elder abuse and the appropriate response by a healthcare professional. Two weeks after the in-person event, students completed the CSQ and knowledge survey again, as well as an evaluation of the IPE event. Statistical significance of differences in the proportion of correct responses between pre-test and post-test were assessed using related-samples McNemar's tests. Significance was determined at α≤.05.

Results: Four hundred and eight students participated in the IPE event, including students in pharmacy (n=192), physician assistant (n=101), physical therapy (n=68), speech-language pathology (n=38), and athletic training (n=9) programs. Teams were more accurate than individuals for identifying EAN on the video vignettes. For scenarios coded as “abusive” on the CSQ, students were significantly more likely to recognize EAN after the IPE activity. Students also were more likely to list those as either “potentially abusive or abusive” for the items listing potentially abusive behaviors. All students in all health professions reported significantly increased confidence in reporting a case of suspected elder EAN after the IPE activity. Ninety percent of students reported the IPE module “very beneficial” or “beneficial.”

Conclusions: An IPE activity utilizing video vignettes, large classroom lecture, and team-based activities in an IPE setting can significantly increase knowledge and confidence to recognize and report EAN. In addition, addressing this content through an IPE activity may be associated with high student satisfaction.

Clinical Relevance: EAN is a major public health concern and may be included effectively in health professions curricula using IPE methodology.

TITLE: Falls and Risk Metrics of HOP-up-PT Participants: Preliminary Outcomes of a Randomized Control Trial

CURRENT SECTION: Geriatrics

AUTHORS: Sara Kathryn Arena, Christopher Matthew Wilson, Lori Elizabeth Boright

ABSTRACT BODY:

Purpose/Hypothesis: Positive reductions in fall risk metrics have been identified among older adults referred from local community centers to the HOP-UP-PT (Home-based Older Persons-Upstreaming Prevention-Physical Therapy) program in a previously published observational study. However, a randomized control trial aimed at comparing outcomes to a control group is warranted. The purpose of this study was to compare fall risk metrics between HOP-UP-PT program participants and non-participants utilizing outcomes from preliminary data collected in the first year of the two-year study.

Number of Subjects: 85 participants were randomized to either an experimental group (EG) or a control group (CG) (EG=47, CG=38).

Materials and Methods: Six Michigan community centers referred adults ≥ 65 years identified as at risk for functional decline or falls to participate in the HOP-UP-PT program. Physical therapists (PTs) delivered physical, environmental, and health interventions to the EG over 9 encounters (6 in-person, 3 telerehabilitation) over 6 months. The CG participants were told to continue their usual physical activity routines during the same timeframe. The PT collected data for both the EG and CG at 0-and 6-months. Data from both groups (Jan-Jun 2020) was analyzed. Age and the STEADI Fall Risk Assessment category (low, medium (med) or high risk for falls) were recorded at the first encounter. At 6 months, frequency of falls, and physical measures (5-Time Sit to Stand (STS), 3-meter walk test (3MWT), and Timed Up and Go (TUG)) were assessed and recorded. Additionally, the Short Physical Performance Battery (SPPB) outcomes were calculated. Descriptive statistics were generated for demographic and outcome variables. Comparisons from the 0- and 6-month encounter data was analyzed using a paired t-tests with significance set at p ≤ 0.05.

Results: Participants ages were EG = 76.6 ± 6.6 and CG = 77.1 ± 8.2 years. Fall rates by STEADI fall risk category were low risk: EG=19, CG=15; med risk: EG=22, CG=16; and high risk: EG=6, CG=7. Falls during the program: EG = 5, CG=11. Among those at med- and high-fall risk, a significant improvement was noted at 6-months in the EG vs CG for SPPB (p=0.0004), STS (p=0.03) and 3MWT (p= 0.02). No significant improvements were identified in the TUG (p=0.18) between groups.

Conclusions: Reduced falls and improved fall risk indicators were identified among older adults who participated in the HOP-UP-PT program. Participants with med and high STEADI risk scores demonstrated statistically significant improvements when compared to the CG. It is possible that those with low STEADI risk scores did have benefit from participation, but a ceiling effect among assessment measures may contribute to less significant improvements among this subgroup.

Clinical Relevance: The HOP-UP-PT Program has emerging evidence for its efficacy in reducing falls and fall risk indicators in an older adult population at risk for functional decline.

TITLE: Racial and Ethnic Variation in Age of Onset of Functional Limitations

CURRENT SECTION: Geriatrics

AUTHORS: Christopher S Walter, Marie-Rachelle Narcisse, Jennifer Lynn Vincenzo, Pearl A McElfish, Holly C Felix

ABSTRACT BODY:

Purpose/Hypothesis: Physical therapists have the opportunity to observe first hand disparities in health-related functional outcomes of their patients. There is a clear association between age and physical function, such that older individuals are more likely to experience functional limitations compared to younger individuals.1,2 Racial and ethnic disparities in physical function have been investigated, although studies have primarily focused on Black, Whites, and Hispanic racial and ethnic categories.3,4 Findings show that minority groups are more likely than Whites to report limitations in mobility and in activities of daily living.5 In our clinical practice, we observed Native Hawaiian and Other Pacific Islander (NHPI) community members presenting with functional limitations at younger ages than patients do from other racial/ethnic groups. Our search of the literature did not reveal research on onset of functional limitations that included NHPI. Therefore, the purpose of this exploratory study was to examine variation in onset of functional limitations in middle-age and older individuals across racial and ethnic groups in the US.

Number of Subjects: Adults age 45 years and older who responded to the Functioning and Disability module within the 2014 NHPI-National Health Interview Survey (NHIS) and the general 2014 NHIS survey (n=628 NHPI; 7,122 non-Hispanic Whites; 1,418 Blacks; 470 Asians; and 1,216 Hispanic adults).

Materials and Methods: The NHIS Functioning and Disability module included 13 items which we organized into three domains of functional limitations using factor analysis: Mobility, Gross motor skills (GMS), and Fine motor skills (FMS). Responses were coded numerically and summed within each domain; higher scores indicated more difficulties. Age was measured in five-year age groups starting at age 45.

Results: After adjusting for age and sex, we found that racial/ethnic minority groups, with the exception of Asians, experience more functional limitations than Whites. Specifically, NHPI and Blacks had significantly higher Mobility scores than Whites (β=0.11, SE=0.05; β=0.13, SE=0.03, respectively). NHPI (β=0.26, SE=0.09), Blacks (β=0.41, SE=0.07), and Hispanics (β=0.21, SE=0.07) had significantly higher GMS scores than Whites while Asians had significantly lower scores than Whites (β=-0.31, SE=0.08). NHPIs (β=0.11, SE=0.05), Blacks (β=0.09, SE=0.03), and Hispanics (β=0.17, SE=0.04) had significantly higher FMS scores than Whites. Results indicate NHPI adults experienced an earlier surge in all three domains compared to other racial/ethnic groups.

Conclusions: NHPI individuals experience greater functional limitations at an earlier age than other racial/ethnic groups in the US. Further studies are required to incorporate additional factors to provide a better understanding of racial/ethnic variation in onset of functional limitations.

Clinical Relevance: These results begin to highlight disparities in functional health outcomes in the most vulnerable populations. Awareness of these disparities is critical to providing equitable care in rehabilitation practice.

TITLE: Empathy and Ageism Decrease after Task Completion with Simulated Aging

CURRENT SECTION: Geriatrics

AUTHORS: David B. Gillette, Todd Eldon Davenport

ABSTRACT BODY:

Purpose/Hypothesis: Empathy is the capability to understand and identify with what another person is experiencing or feeling, and is crucial for professional development of students. Ageism is discrimination against people because of age, is based on stereotypes and prejudice, and can be hostile or benevolent. Ageism does occur in the provision of healthcare. Activities with simulated aging are used in healthcare education programs to improve empathy and are reported in the literature. We examined data from a class activity using aging simulation activities to see the correlation between the activities and empathy, ageism, and attitudes.

Number of Subjects: Seventy second-year students in a two cohorts of a Geriatric Physical Therapy class.

Materials and Methods: As a part of Geriatrics curriculum, students donned items to simulate aspects of pathological aging including in the sensory, cognitive, and musculoskeletal systems and completed a series of tasks. Before and after the tasks, students completed the Kiersma-Chen Empathy Scale (KCES), the modified Geriatrics Attitudes Scale (mGAS), and the Ambivalent Ageism Scale (AAS). IRB approval was obtained to examine data from two cohorts.

Descriptive statistics were calculated for KCES, mGAS, and AAS, consisting of means and 95% confidence intervals (95%CI). Paired samples t-tests were undertaken to ascertain the significance of differences in KCES, mGAS, and AAS after the learning activity. Change scores were calculated for KCES, mGAS, and AAS total scores. Significance of observed associations between KCES with mGAS and AAS were assessed using Pearson correlations. Analyses were considered significant at α≤.05.

Results: Data for n=70 students was available for analysis. Mean scores demonstrated significant changes for KCES cognitive subscale (-2.6; 95%CI: −3.4, −1.7; p<.001) and KCES total score (−2.8; 95%CI: −3.9, −1.7; p<.001); mGAS Social View (0.5; 95%CI: 0.1, 0.9), mGAS Financial Support (0.6; 95%CI: 0.2, 1.0), mGAS Geriatric Care (0.8; 95%CI: 0.3, 1.4), and mGAS total score (1.9; 95%CI: 1.2, 2.7); and AAS Hostile (−1.1; 95%CI: −1.6, −0.5) and AAS total score (−1.6; 95%CI: −2.7, −0.4). Change in KCES total score was not significantly correlated with changes in total and subscale scores for mGAS and AAS.

Conclusions: Task completion with simulated aging corresponded with a statistically significant unanticipated reduction in empathy as well as in ageism, and an increase in positive attitudes towards older adults. Further research is needed to duplicate results and determine the cause of the unanticipated reduction in empathy.

Clinical Relevance: A learning activity intended to increase empathy for older adults may slightly reduce empathy but also reduce ageism and increase positive attitudes toward them.

TITLE: Sternal Precautions: Can Older Patients Change Pectoralis Major Recruitment By Altering Movement Strategy during ADL

CURRENT SECTION: Geriatrics

AUTHORS: Kimberly Klein Cleary, Sean Douglas Degn, Elizabeth Ann Biancosino, Tanya Kinney LaPier

ABSTRACT BODY:

Purpose/Hypothesis: Patients who have undergone cardiac surgery with median sternotomy are often instructed to limit unilateral pushing, pulling, and lifting with their upper extremities (UE) to less than 10 lb. A movement strategy, called “Keep Your Move in the Tube” (MINT), has proposed that keeping the arms close to the body creating a shorter lever arm could allow patients to perform more activity without increasing stress across the sternum. The purposes of this study were to determine in older patients: 1) how much the pectoralis major (PM) muscle is recruited during activities of daily living (ADL) and 2) if the MINT strategy can alter PM muscle recruitment (total and symmetry).

Number of Subjects: Study participants (n = 28) were 60-85 years old, free of acute orthopedic and cardiovascular problems, capable of walking 25’ independently, and able to perform UE activities without pain.

Materials and Methods: Study participants performed 10 ADL tasks using self-selected movement strategy (SMS) while PM muscle EMG data was obtained. Next, study participants were taught a modified movement strategy (MINT) focused on keeping the upper arm close to the trunk during functional activities. Then PM muscle EMG data was obtained again during the same 10 ADL tasks. Data were processed and expressed relative to PM muscle maximal voluntary contraction (%MVIC). The difference between left and right PM muscle EMG was also calculated as a measure of movement asymmetry. Statistical analyses of PM muscle EMG total (left plus right) and absolute difference were done using t-tests with a Bonferroni Correction (P<0.005).

Results: PM muscle EMG values for each ADL task were pulling a chair 4.2%, lifting a basket 10.8%, vacuuming 12.1%, pulling a door 15.8%, lifting a bag 13.3%, scooting a chair 17.1%, pushing a door 19.4%, pouring a gallon 19.7%, pushing a chair 21.2%, and supine to sit 22.1%. Sum EMG values were greater with MINT than SMS during 5 of the 10 ADL tasks studied. Degree of PM muscle recruitment asymmetry increased while study participants lifted a 10 lb basket using MINT (8.5%) as compared to SMS (3.9%).

Conclusions: Many functional activities involve recruitment of the PM muscle but total activation is often relatively low. Since it is the primary muscle attaching to the sternum and pulls laterally the degree of PM muscle activation should reflect force across the bone. Results of this study did not support that use of MINT to reduce total PM EMG or improve asymmetry between bilateral PM muscle activation. Cuing to keep the humerus in neutral may increase PM muscle activation due to isometric shoulder adduction.

Clinical Relevance: Current sternal precautions may be overly restrictive and many common ADL tasks only involve limited recruitment of the PM muscle and therefore pull across the sternum. Furthermore, study findings suggest that using MINT does not reduce total pull of the PM muscle on the sternum or symmetry. Future studies are needed to elucidate the potential benefits of MINT training for patients recovering from median sternotomy.

TITLE: Effects of Walk With Ease™ on Dyanmic Balance and Fall Risk in People With Osteoarthritis

CURRENT SECTION: Geriatrics

AUTHORS: Andrew Kerr, Adam William Klingeman, Austin T. Black, Leann Oreel Kerr, Gina Lynne Pariser

ABSTRACT BODY:

Purpose/Hypothesis: In the U.S. arthritis is the leading cause of physical activity and work limitations. One in four adults with arthritis report severe joint pain. Older adults with arthritis are 2.5 times more likely to have an injurious fall compared to older adults without arthritis. WWE™ is a 6-week community-based program that has been shown to reduce arthritis pain and stiffness and abate physical performance limitations, including endurance and static balance. There is a paucity of research on the effects of WWE™ on dynamic balance and risk of falling. The purpose of this study was to evaluate the effects of WWE™ on participant's dynamic balance, risk of falling, and arthritis symptoms.

Number of Subjects: Ninety-seven community dwelling adults with arthritis (66 ± 9 yrs old)

Materials and Methods: Participants completed the Functional Gait Assessment (FGA) and the Arthritis Impact Measurement Scale before and after WWE™. Additional measures included gait speed and two minute walk distance. WWE™ classes were led by DPT students two times per year over three years. Means for outcome measures before and after WWE™ were compared using paired t-tests. Changes in mean scores were compared to minimal detectable differences (MDD).

Results: An FGA score < 22 points is indicative of fall risk. Prior to WWE™ the mean FGA score was 21.2 ± 5.1 pts; 56% of the participants were at risk for falls. Afterwards the mean score was 25.8 ± 4.8 pts; 13% of participants were at risk of falls. The difference was significant and greater than the MDD for older adults. Consistent with previous studies, participants exhibited a decrease in arthritic symptoms and increases in endurance and gait speed.

Conclusions: Participants in this study, who were more physically impaired than subjects in published studies about WWE™, exhibited positive changes in their dynamic balance and risk of falling. In addition to poor balance, moderate to severe arthritis symptoms and poor endurance increase risk of falling. Consistent with previous studies, our participants’ endurance, and arthritis pain and stiffness both improved.

Clinical Relevance: New guidelines for arthritis emphasize the importance of balance training to reduce risk of falls. WWE™ has been shown to improve static balance. This study indicates it is also effective in improving dynamic balance. Physical therapists are in an ideal position to reduce risk of falling and improve health and wellness in vulnerable populations with arthritis through both physical therapy intervention and referral to community-based programs like WWE™.

TITLE: Using Subjective Vs. Objective Outcome Measures to Identify Pre-Clinical Disability Community Dweller Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Moshe Marko

ABSTRACT BODY:

Purpose/Hypothesis: Modifying tasks of daily living is an important early transitional symptom of pre-clinical disability among older adults living independently in the community.1 Assessing mobility tasks using time to completion and self-reported ratings of perceived exertion (RPE)2 are, both, linked to several physiological indices and are often elevated in older adults. The aim of this study was to compare the strength of the association between time to complete the 400 meters walk test (400MWT)3 VS. RPE, and pre-clinical disability in older adults living independently in the community. We hypothesized that, both 400MWT and RPE could each provide an independent, equally accurate, relevant indicator of a need to modify daily tasks.

Number of Subjects: 53 Older adults (mean age=76.4 years, SD=5.2) living independently in the community.

Materials and Methods: Following 400MWT, participants rated task difficulty (6 − 20).4 Level of difficulty was then categorized as “none” (difficulty rated as 6, 7, or 8), “light” (9-12), “somewhat hard” (13-16), or “hard” (>16). To quantify levels of daily task modifications, we used a previously validated summary task modification scale (MOD).1 The MOD quantifies a person's ability to perform 8 commonly observed daily tasks while assigning a quantifiable measure of the amount of task modification s/he uses during each activity. Specifically, participants were asked to perform a chair rise from 30, 38, and 43 cm, ascend/descend 14 stairs, to stand up from left/right kneeling positions, move from a supine to standing. Each activity scored between “0” (“no task modification”), and “4” (“unable to perform task”). The MOD score was calculated by summing all the individual scores (summary score between “0” and “32”). A cumulative score of ≤5 & >5 were considered non—task modifiers (NTM) and task modifiers (TM), respectively.

Results: Twenty-six of the participants were classified as TMs, 27 participants as NTM. The NTM completed the 400MT faster than the TM (mean time=3.8 (SD: ±0.7) vs 5.1 (SD: ±1.2) minutes) (P<.001), respectively. RPE was no different (t51=−1.286, P=.204) between the NTM and TM reporting an average RPE of 10.6 (SD: ±2.2) and 11.4 (SD: ±2.5), respectively. While the RPE failed to predict group assignment (OR=0.511, Exp[B]=1.955, 95% CI=0.810-4.716, P=.136), each 1 minute increase in time to complete the 400WT corresponded with almost 6-fold increased likelihood being in the TM group (OR=0.179, Exp[B]=5.599, 95% CI=2.000-15.676, P=.001).

Conclusions: Compared to RPE, 400MWT is a more relevant and accurate indicator of a need to modify daily task in older adults living independently in the community.

Clinical Relevance: 30%-40% of older adults observed to modify tasks of daily living report no mobility disability. Although, self-reported and timed outcome measures have been used to identify pre-clinically disabled older adults,5,6. there are no known studies of the relationships between self-reported and timed outcome measures and task modification in this unique, population. Examining these relationships will help establish an objective criterion for screening for pre-disability and early onset of mobility declines.

TITLE: ACE Genotype Interacts With Fear of Falling in Relation to Rapid Stepping in Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Allon Goldberg, Joseph F. Sucic, Kurt Shuler, Susan Ann Talley

ABSTRACT BODY:

Purpose/Hypothesis: Physical performance measures such as step execution time (SET)—a composite of reaction plus movement time—are associated with fear of falling (FOF) in older adults. ACE genotype is associated with SET through interactions with lower extremity strength. The purpose of the present study was to determine whether ACE genotypes interact with FOF in relation to SET in older adults. Examining this interaction facilitates comparisons of relationships between FOF and SET among ACE genotypes, while elucidating effects of ACE genotype on SET in older adults with FOF compared to those without FOF.

Number of Subjects: Eighty-eight community-dwelling adults age 60 years and older

Materials and Methods: Participants attended a single study visit responding “yes” or “no” to “do you have a fear of falling” ? SET was measured using a reaction time device as participants stepped rapidly a distance of 18 inches in response to an auditory stimulus. Participants provided a saliva sample for DNA extraction and ACE genotyping. General linear model analysis of covariance (GLM ANCOVA) evaluated ACE genotype x FOF interaction effects in relation to SET. SET marginal means were computed based on GLMs adjusting for age and gender. Models for II and DD were analyzed. Statistical significance was set at p<.013 (.05/4 comparisons within each general linear model).

Results:ACE insertion (I) and deletion (D) alleles resulted in 3 genotypes: II; DD and ID. GLM ANCOVA highlighted a significant interaction between II genotype status and FOF on SET (p=.011). The analyses indicate a significant relationship between FOF and SET in individuals with II genotype, with SET significantly slower (29.2%) in individuals with FOF (965.8 ms) than non-FOF (747.5 ms) (p=.001). In the DD/ID subgroup the relationship between FOF and SET was not significant (p=.221). In individuals with FOF, SET was significantly slower (18.6%) in the II genotype (965.8 ms) than in DD/ID (814.0 ms) subgroup (p=.01), whereas in individuals with non-FOF, there was no significant difference in SET between II and DD/ID subgroups (p=.436). There was no significant interaction of DD genotype with FOF on SET.

Conclusions: II genotype status (II versus DD/ID) interacts with FOF in relation to SET, indicating that FOF is associated with SET in older adults with the II genotype, but not in the DD/ID subgroup. The II genotype status × FOF interaction effect on SET uncovered significantly slower stepping speed in individuals with the II genotype and FOF than in DD/ID individuals with FOF.

Clinical Relevance: These results suggest a deleterious effect of FOF on stepping performance in the II genotype subgroup but not in the DD/ID subgroup. In addition these results show a deleterious effect of ACE II genotype on stepping performance in individuals with FOF. Older adults with the ACE II genotype and FOF may be at increased risk for poor stepping performance. As poor stepping performance is an established intermediate phenotype for falls in older adults, it is plausible that individuals with the II genotype and FOF may be at increased risk for falls and associated functional declines.

TITLE: The Virtual Evolution of Programs for Older Adults’ Engagement in Physical Activity During the Pandemic

CURRENT SECTION: Geriatrics

AUTHORS: Jennifer Lynn Vincenzo, Colleen Griffin Hergott, Lori A. Schrodt, Beth L. Rohrer, Jennifer Sokol Brach, Jennifer Tripken, Kathleen DeMolli Shirley, Jennifer C. Sidelinker, Holly Brook Bennett, Tiffany Elisa Shubert

ABSTRACT BODY:

Purpose: Prior to the pandemic, organizations provided in-person activities for older adults (OA) to improve health and well-being by reducing disease severity, disability, and/or injury. The pandemic necessitated virtual availability of resources. Physical therapy providers (PTs) are strategically positioned to leverage virtual community resources to support older adults in continued progress and overall well-being beyond an episode of care.

Description: Most community programs are offered in-person; however, due to the pandemic, onsite access was restricted. As a result, many programs modified access from onsite to virtual. The APTA - Geriatrics/National Council on Aging (NCOA) Task Force gathered data between April and June of 2020 on the details and virtual availability of some of these programs.

Summary of Use: A survey by the NCOA indicated that over 75% of programs they support were offering or planning to be offered virtually. Programs successfully transitioned to virtual delivery by mailing OA a step-by-step packet to assist with access through Zoom (developed and shared by Rush University Medical Center). Other programs such as Chronic Disease Self-Management Education, transitioned to virtual or mail. SilverSneakers®, a fitness program for OA available in many fitness centers, conducted a 6-week series surveys and found that over half of respondents indicated exercise was the largest health behavior disrupted due to closure of gyms and inability to utilize equipment or attend classes. Technology adoption increased in one month from 27% to 74%, and 67% of respondents reported an increase in comfort with digital solutions (Zoom being the preferred platform) compared to pre-pandemic. One-third of OA surveyed indicated they would continue to incorporate digital solutions for activities beyond exercise after stay-at-home orders were lifted. SilverSneakers® also launched live and on-demand exercise classes and workshops. Weekly instructor-led Facebook live classes generated over 7.7 million minutes viewed in 6 weeks. Similarly, the YMCA offered on-demand exercise videos for strengthening, aerobic training, and tai chi via ‘Your Y at Home for Active Older Adults’ and YMCA apps and local websites. An example of the perceptions of in-person compared to virtual exercise programs was determined through focus group interviews among OA with Parkinson's disease who attended onsite exercise classes at a Geriatric Medical Center and transitioned to the same program virtually. Participants felt the virtual program was safe and efficacious, preferred virtual to on-site, and would like the continued option to attend a combination of in-person and virtual classes despite missing group interactions. Convenience, increased comfort and room at home, and not having to navigate issues related to time or transportation were reasons for preferring the virtual program option.

Importance to Members: PTs have a responsibility to develop clinical-community partnerships and connect OA to newly available virtual resources to promote health and well-being during the pandemic and continuum of care after an episode of physical therapy.

TITLE: Trunk Extension Endurance and Walking Performance Among Community-Dwelling Older Adults With Different Pain Distribution Phenotypes

CURRENT SECTION: Geriatrics

AUTHORS: Peter C. Coyle, Subashan Perera, Jonathan F Bean, Gregory Evan Hicks, Jennifer Sokol Brach

ABSTRACT BODY:

Purpose/Hypothesis: Poor trunk extension endurance (TEE) predicts declines in self-reported activity and participation, but its impact on walking performance is not well-understood. Furthermore, chronic pain conditions can modify relationships between impairments and outcomes. We sought to investigate the association between TEE and walking performance in older adults, and to explore if/how chronic pain distribution phenotypes (i.e. no, single-site, or multisite pain) modify those relationships.

Number of Subjects: Community-dwelling older adults (age ≥65) independently ambulatory at a usual walking speed of 0.60-1.20 m/s (n=127).

Materials and Methods: Participants reported chronic pain in seven different sites (i.e. neck, low back, shoulders, hands/wrists, hips, knees, feet) and were classified as having no, single-site, or multisite pain. A specialized plinth, positioned at 45 deg from vertical, was used to measure TEE. Participants maintained a neutral trunk position within the sagittal plane for as long as possible with their arms across their chest and feet fixed on a footplate, and performance time was recorded. Walking efficiency (i.e. oxygen consumption normalized to gait speed) was measured at usual walking speed on a treadmill. Walking speed was measured over a computerized walkway at the participant's usual pace, with unmeasured zones for acceleration and deceleration. Walking endurance was measured using the Six-Minute Walk Test. Separate linear regression models were used to investigate the relationship between TEE and each walking performance outcome, adjusting for age, sex, and body weight. Then, pain phenotype and pain phenotype × TEE performance were added to the model.

Results: Equal proportions had single-site (30.7%) or multisite (29.1%) pain, while 40.2% had no pain. Beyond age, sex and body weight, TEE explained 4.2% (p=.009) and 5.5% (p=.003) of the variance in walking speed and endurance, respectively; TEE was not associated with walking efficiency. Neither the main effect for pain phenotype nor the interaction between pain phenotype and TEE was statistically significant. However, pain phenotype specific slopes descriptively revealed the associations of TEE with walking speed and endurance were most pronounced in those with no pain (no pain phenotype: p=.001-.002; pain phenotypes: all p>.050), indicating that we may have been underpowered to detect an underlying interaction effect.

Conclusions: Impaired TEE may be a contributing factor to poor walking performance in older adults, especially for those without pain. Future research is needed to investigate the synergism between pain distribution and TEE more comprehensively.

Clinical Relevance: Impaired TEE may be an important factor to consider in the context of poor walking performance, especially for older adults without pain.

TITLE: Using Non-Invasive Stimulation to Investigate Sensorimotor Integration at the Spinal Cord in Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Alison Eve Herrera, Tyler Alexander Randolph, Alexis Kate Spahn, Kailey Morgan Yocca, Alejandro Lopez, Lena H. Ting, Michael Robert Borich, Trisha M. Kesar

ABSTRACT BODY:

Purpose/Hypothesis: Insufficient understanding of neural circuit dysfunctions underlying sensorimotor impairments is a major barrier limiting the efficacy of neurologic rehabilitation. To parse out the effects of normal aging versus neurologic lesions such as stroke, there is a need to characterize age-related influences on neuromotor circuit physiology. The purpose of this study was to evaluate the influence of descending cortical inputs on spinal reflex excitability in older adults. Using transcranial magnetic stimulation (TMS) conditioning of the Hoffman's reflex (H-reflex), we evaluated the effect of activation state and the timing between TMS and peripheral nerve pulses, i.e. interstimulus interval (ISI) on H-reflex conditioning.

Number of Subjects: Seven older adults (aged 40 to 80 years) with no history of neurologic or orthopedic disease effecting the lower extremity and no contraindications to TMS have been evaluated to date.

Materials and Methods: Peripheral nerve stimulation (PNS) was delivered to the posterior tibial nerve to elicit H-reflexes in the soleus muscle. H-reflex recruitment curves were used to calculate maximal H-reflex response (Hmax) during rest and active muscle states. TMS pulses were delivered to the motor cortex hotspot of the soleus muscle. During TMS conditioning of the H-reflex, a PNS intensity eliciting 50% Hmax was paired with TMS at 90% motor threshold using ISIs ranging from −10ms to +40 ms. Percent facilitation of conditioned to unconditioned H-reflexes was the primary outcome measure.

Results: A two-way ANOVA showed a significant main effect of ISI (p<0.001), a statistical trend towards a main effect of activation state (p=0.055), and a significant interaction (p=0.021) on % H-reflex facilitation. Post-hoc analyses revealed significant differences between rest versus active states at 30 and 40ms ISIs (p<0.012), with H-reflex inhibition in the active state. A one-way ANOVA showed a significant main effect of ISI on % facilitation (p=0.01). Post-hoc analyses revealed significantly greater facilitation at 10ms vs. at ISIs from −10 to −3 ms. The longest ISIs (> +25 ms) showed significantly lower % facilitation (i.e. inhibition) compared to most ISIs.

Conclusions: Our preliminary results suggest that the magnitude of spinal reflex conditioning depends on motor state in older adults, and is modulated by ISI. Similar to previous studies in younger individuals, greater facilitation was observed for late vs. early facilitation windows. However, an inhibition of H-reflex (instead of facilitation) occurred at longest interval ISIs (>25ms), which is a novel finding.

Clinical Relevance: Our results provide the first characterization of the strength of descending cortical inputs to spinal circuits of older adults. Given the prevalence of many neurologic disorders increases with age (e.g. stroke), our findings address an important knowledge gap. Future studies comparing the current results with those in young adults and stroke survivors will parse out the effects of aging versus neurologic lesions such as stroke on sensorimotor integration within the spinal cord.

TITLE: Associations Between Life Space Assessment and Gait Quality: Informing Assessment and Treatment of Older Adults

CURRENT SECTION: Geriatrics

AUTHORS: Leslie Coffman, Anisha Suri, Ervin Sejdic, Andrea L Rosso, Jessie M. VanSwearingen, Jennifer Sokol Brach

ABSTRACT BODY:

Purpose/Hypothesis: The Life Space Assessment (LSA) is a measure of community mobility that assesses a person's frequency of movement and need for assistance in five life zones beginning at home and progressing further into the community. While gait speed is related to LSA, it is not known if gait quality indicates more about community mobility than gait speed alone. We examined the association of LSA and gait quality, defined by spatiotemporal and acceleration gait measures. We hypothesize better community mobility (i.e. higher LSA scores) will associate with better gait quality.

Number of Subjects: Subjects included 232 community-dwelling older adults (mean age = 77.54±6.56; 60% females) who participated in the baseline assessment for an exercise trial. Participants with gait speeds between 0.60 m/sec and 1.20 m/sec and who walked independently for household distances were included.

Materials and Methods: LSA was completed through interview, total score range, 0-120. Mean gait speed and step time variability (coefficient of variation, CoV) obtained from six passes over an instrumented walkway; processed using PKMAS software (ProtoKinetics, Havertown, PA). Acceleration gait measures recorded by a body-worn tri-axial accelerometer placed at the L3 spinal level during a 6 minute walk; processed using signal processing techniques with a robust event-detection algorithm, to define gait quality in anterior-posterior (AP), vertical (V), and mediolateral (ML) directions for variability (standard deviation), symmetry (Kurtosis [decay of distribution], cross-correlation), regularity (entropy), predictability (Lempel-Ziv), and smoothness (harmonic ratio) and power (peak frequency). Spearman correlations (r) and partial correlations (rp) adjusted for gait speed performed to describe the bivariate association of LSA with gait quality.

Results: Subjects had a mean LSA score of 74.66 (SD=18.57) and mean gait speed of 107.57 cm/sec (SD=16.09). Higher LSA scores were correlated with faster gait speed (r=.26) and lesser step time variability (r=-.19); greater acceleration variability (r=.15-.23), rapid decay in V and AP acceleration (R=-.18, −.13), greater AP-V (r=.23) symmetry, lesser V regularity (r=-.18), greater AP and V predictability (r=.19, .22), smoothness (r=.14-.20) and V power (r=.23); all p<0.05. Adjusted for gait speed, LSA scores were negatively related to V decay (rp =-.13) and AP-ML symmetry (rp =-.13) and positively related to V predictability (rp =.16), total smoothness (rp =.13) and V power(rp =.16); all p<.05.

Conclusions: Independent of gait speed, community mobility is associated with measures of gait quality, particularly smoothness of walking with adaptability in V and ML directions.

Clinical Relevance: Gait quality explains community mobility and highlights the importance for physical therapists to assess how well a person walks. The measures and processing to achieve gait quality description require specialized equipment and analytics. Advances in technology and processing are necessary to enable such measures in clinical practice. Clinical measures of gait quality may be useful for PTs to recognize walking problems that may restrict community mobility.

TITLE: Optimizing Fall Risk Reduction in Older Adults With Fear of Falling Requires a Multifactorial Approach

CURRENT SECTION: Geriatrics

AUTHORS: Joseph Abdulmasih, Michael Hyun Chung, Alexander Jeffrey Garbin, Beth E. Fisher

ABSTRACT BODY:

Purpose/Hypothesis: Fear of falling (FOF), an exaggerated concern of falling, affects approximately 36% of older adults and increases one's likelihood of falls.1,2 Potential contributors to this increased fall risk include physiologic (e.g. flexibility, strength, proprioception) and non-physiologic variables (e.g. environmental, psychological) associated with FOF.3-5 Many intervention studies aim to reduce fall risk in this population by improving the physiologic variables; however, these studies have limited success likely due to an underemphasis on manipulating the non-physiologic variables.6 Importantly, prior to recommending the utilization of non-physiologic variables for fall risk reduction in this population, it is essential to understand their impact on fall risk. Therefore, we aim to determine the influence of non-physiologic variables on fall risk in older adults with a FOF by controlling for common physiologic variables. We hypothesize that FOF will be associated with increased likelihood of future falls, independent of these physiologic variables.

Number of Subjects: 5508 older adults (aged 65-105, 3196 female, 1546 with FOF) from the National Health and Aging Trends Study database.

Materials and Methods: Using binary logistic regression, we assessed whether FOF (probed by asking if participants have had a FOF in the past month) predicted future falls (assessed by asking participants during a 1-year follow-up if they have fallen in the past year). Determination of whether the effect of FOF on fall risk was, in part, due to non-physiologic variables was made by subsequently creating a stepwise binary logistic regression model that included physiologic variables. Physiologic variables that were placed into the model for possible selection include age, sex, grip strength, vision, presence of pain, self-reported lower extremity weakness, upper extremity weakness, prior fall, 5 times sit to stand, and peak expiratory flow. These models output odds ratios with 95% confidence intervals (CI).

Results: Without adjusting for physiologic variables, the presence of FOF resulted in 2.44 (CI 2.15-2.81) greater odds of a future fall. The stepwise model selected physiologic variables of age, pain, lower extremity weakness, prior fall, and 5 times sit to stand. When adjusting for these variables, the presence of FOF resulted in 1.52 (CI 1.29-1.77) greater odds of a future fall.

Conclusions: FOF is a predictor of future falls in older adults. When controlling for physiologic variables, the effects of FOF persisted but were reduced.

Clinical Relevance: These results suggest that both physiologic and non-physiologic variables increase fall risk in older adults with a FOF. As such, clinicians aiming to reduce falls in this population should employ a multifactorial approach. In addition to exercise, successful strategies for fall risk reduction in older adults with a FOF should include: psychological interventions, cognitive-behavioral therapy, and home hazard assessment.7

TITLE: A Telehealth Video-Analysis Method to Assess Quality and Quantity of Movement in Persons With Dementia

CURRENT SECTION: Geriatrics

AUTHORS: Eva Barth, Jennifer Tritz, Ellen L. McGough

ABSTRACT BODY:

Purpose: To describe an innovative protocol for evaluating the quality and quantity of movement in response to an exercise program for individuals with dementia and their caregivers delivered via telehealth.

Description: Individuals with dementia are more sedentary than their age-matched peers. They face several barriers to mobility including impaired motor learning and decreased ability to participate in fitness classes. This telehealth application was developed, in response to COVID-19, to evaluate the quality and quantity of exercise movement during EM-STAR (Exercise for Mobility and Staff Training in Assisted Living), a moderate-intensity program for people with dementia. We applied best practices for telehealth as recommended by Medicare such as using audio and video equipment allowing two-way, real-time interaction between the clinician and patient. To extend our ability to remotely evaluate movement and physical activity levels, we utilized a motion analysis app.

Telehealth methods were developed for recording five EM-STAR exercises, viewed from the lateral perspective, for real-time and post-program assessment. Hudl Technique iOS application (UberSense Inc) is a free video analysis application with features including slow-motion playback and goniometry for measurement of body segment and joint angles. The Hudl video analysis tool was applied to quantify: (1) four major joint excursion angles (shoulder flexion, elbow extension, hip flexion, knee extension), (2) sitting and standing angle relative to vertical, (3) client response time from receiving instructions to initiating movement, and (4) number of exercise repetitions per session. The Hudl video analysis protocols developed for EM-STAR can be used with HIPAA compliant video calling platform applications, including Zoom, eVisit, or SimplePractice. This video-based application facilitates both real-time and post-session assessment of movement as well as therapist-patient/caregiver interaction.

Summary of Use: Application of Hudl Technique post telehealth patient/caregiver exercise sessions provides a novel method to assess the quality and quantity of movement in adults with dementia. This protocol can be carried out via remote methods by providing easy-to-follow instructions for the patient's caregiver. This application has the capacity to track movement, using a smartphone/tablet camera, during telehealth exercise programs allowing for real-time and post-session analysis of movement.

Importance to Members: It is increasingly important for physical therapists to be able to remotely assess movement in response to Covid-19 and the expansion of telehealth services. Although this program is designed for individuals with dementia, the parameters of analysis can be applied to a range of patient populations.

KEYWORDS: Dementia, Telehealth, Video Analysis

TITLE: Cardiovascular Health Markers in Older Adults With and Without Chronic Low Back Pain and Radiculopathy

CURRENT SECTION: Geriatrics

AUTHORS: Peter C. Coyle, Victoria O'Brien, David G Edwards, Ryan T. Pohlig, Gregory Evan Hicks

ABSTRACT BODY:

Purpose/Hypothesis: There is considerable overlap in risk profiles between chronic low back pain with radiculopathy (CLBPR) and cardiovascular health among older adults; obesity and smoking are related to both conditions, and may largely drive the potential relationship. We sought to explore the impact of CLBPR on cardiovascular health outcomes (i.e. cholesterol, pro-inflammatory markers, and vascular endothelial function), independent of body mass index (BMI) and current smoking status.

Number of Subjects: Age- and sex-matched community-dwelling older adults (60-85 years old) with (n=21) and without (n=21) CLBPR were recruited. Current smokers were excluded.

Materials and Methods: Blood samples were collected to measure cholesterol levels and pro-inflammatory markers (i.e. C-reactive Protein [CRP] and interleukin-6 [IL-6]). Vascular endothelial function, a marker of cardiovascular health, was evaluated using brachial artery flow-mediated dilation (FMD). Unadjusted between-group comparisons were made between those with and without CLBPR on descriptive characteristics and cardiovascular health outcomes. General linear models with multifactorial designs were evaluated; group membership, body mass index (BMI), education, and their respective two-way interaction terms were included as independent variables.

Results: Older adults with CLBPR had a significantly higher BMI (p=.004), lower education (p=.013), higher IL-6 concentration (i.e. more systemic inflammation; p=.016), and lower FMD (i.e. lower endothelial function; p=.009) compared to those without pain. After controlling for BMI and education differences, the between-group differences for IL-6 attenuated, and no interaction effect was present. However, there was a significant group by education interaction effect (p=.049) for endothelial function. Older adults without pain who were highly educated had higher FMD values, indicating better endothelial function (9.2%); while the following combinations all had lower FMD values in comparison: no pain plus low education, CLBPR plus high education, and CLBPR plus low education (5.9%, 6.1%, and 6.6%, respectively).

Conclusions: Among older adults, CLBPR is linked with worse endothelial function regardless of education level, and comparable to those without pain and low education. These findings suggest that all older adults with CLBPR may be at a higher risk of cardiovascular disease in the future.

Clinical Relevance: Screening for cardiovascular health risk factors is a critical aspect in patient management. Clinicians should be aware that CLBPR may be a unique risk factor for poor cardiovascular health, independent of traditional risk factors, such as age, sex, obesity, and tobacco-use.

© 2021 APTA Geriatrics, An Academy of the American Physical Therapy Association.