FOTO - Focus on Therapeutic Outcomes | Geriatrics Archives

Physical Therapy in Emergency Department and ER Revisits for Older Adult Fallers

Selena Horner — Mon, 29 Oct 2018 10:00:00 +0000

In 2009 the Physician Quality Reporting Initiative included assessing for falls and creating plans to reduce falls. This research looking at claims data from 2012-2013 provides insight into clinical practice.

I am not always in agreement with how Centers for Medicare and Medicaid Services has proposed to improve care. I can see from history that reporting isn’t the same as actually implementing changes into practice.

Many in the medical world know that once an older adult falls, it is very highly likely that a another fall is probable. I can see from the below study that when an older adult is seen in the emergency room with injuries or complications from a fall, the care is only focused on the immediate situation and is not forward thinking to reduce additional injuries down the road due to another fall.

As I look at the numbers, only 3% of the patients received services from a physical therapist. I don’t believe that having a physical therapist in the emergency department after an injurious fall would provide much tangible benefit with regard to providing lasting procedures during that emergency visit. What I believe would be better would be to have the physical therapist educate and provide information on why outpatient services would be helpful, when to initiate the services and assist with locating an outpatient option for the patient. It would actually probably be cheaper to have the person performing the emergency room visit discharge be responsible for ensuring a referral to a physical therapist… and it might even be really helpful to have a clinical decision guideline within the electronic health record propose a follow-up with a physical therapist.

It is very surprising to me that this study looked at data after PRQI was implemented when PQRI had a targeted measure focused on assessing for falls and creating a plan of care for falls. There was a big disconnect in ensuring that a future fall could be substantially reduced.

You’ll find the abstract to the recent study below.

Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis.

Lesser A¹, Israni J¹, Kent T¹, Ko KJ¹.

Abstract

OBJECTIVES:

To determine whether providing physical therapy (PT) services in the emergency department (ED) improves outcomes for older adults who fall.

DESIGN:

We used Medicare claims data to examine differences in recurrent fall-related ED revisit rates of older adults who presented to the ED for a ground-level fall and whether they received PT services in the ED. Our logistic regression model controlled for age, sex, Medicaid eligibility, acute injury, and certain known chronic comorbidities associated with risk of falling.

SETTING:

We analyzed national 2012-13 Medicare claims data for individuals aged 65 and older.

PARTICIPANTS:

This was a claims-based analysis. We defined an index visit as any ED claim that included an International Classification of Diseases, Ninth Revision, Clinical Modification E-Code indicating a ground-level fall. Visits resulting in admission were excluded, as were claims associated with an individual who died during follow-up; 17,975 of the 560,277 claims for eligible outpatient index visits included revenue center codes for PT services.

MEASUREMENTS:

We calculated the proportion of index visits associated with a fall-related ED revisit within 30 and 60 days and assessed differences in these proportions between individuals who did and did not receive PT services in the ED.

RESULTS:

Receiving PT services in the ED during an index visit for a ground-level fall was associated with a significantly lower likelihood of a fall-related ED revisit within 30 days (odds ratio (OR)=0.655, p<.001) and 60 days (OR=0.684, p<.001).

CONCLUSION:

Expanding PT services in the ED may reduce future fall-related ED use of older adults. Additional analyses could assess characteristics of individuals receiving PT in the ED and follow-up PT use after discharge.

J Am Geriatr Soc. 2018 Aug 21. doi: 10.1111/jgs.15469. [Epub ahead of print]

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Should We Rethink How We Help Reduce Falls?

Selena Horner — Mon, 22 Oct 2018 10:00:00 +0000

We know that when an older adult falls, there is a high likelihood of injury. Could we address reducing the rate of falls a bit differently in the clinic?

If you sit back and think of what you would typically observe in a treatment session focused on improving balance, you would typically see activities that seem more anticipatory in nature. For lack of a better description, you’d notice postural sway with the movement revolving around the ankle joint. Usually the person is in a static position.

I took liberty to snag the image from the research study. I had to do this because this image is far better than any words I could use to describe reactive balance training. Conventional balance training, in my opinion, typically heavily relies on anticipatory activities. This study begins to look at reactive balance training. Reactive balance training is different because something is done to the patient and the patient has to provide a reflexive response to eliminate experiencing a fall.

In this particular study, the reactive balance training would be considered dynamic. The subjects were exposed to a “slip” situation. The platform below the foot was moved forward or backward or in various directions to capture the response. In other words, these subjects were able to experience a fall situation and respond.

You’ll find the abstract to the recent study below.

Neuromuscular and Kinematic Adaptation in Response to Reactive Balance Training – a Randomized Controlled Study Regarding Fall Prevention.

Krause A^1,², Freyler K¹, Gollhofer A¹, Stocker T³, Brüderlin U³, Colin R³, Töpfer H³, Ritzmann R¹.

Abstract

Slips and stumbles are main causes of falls and result in serious injuries. Balance training is widely applied for preventing falls across the lifespan. Subdivided into two main intervention types, biomechanical characteristics differ amongst balance interventions tailored to counteract falls: conventional balance training (CBT) referring to a balance task with a static ledger pivoting around the ankle joint versus reactive balance training (RBT) using externally applied perturbations to deteriorate body equilibrium. This study aimed to evaluate the efficacy of reactive, slip-simulating RBT compared to CBT in regard to fall prevention and to detect neuromuscular and kinematic dependencies.

In a randomized controlled trial, 38 participants were randomly allocated either to CBT or RBT. To simulate stumbling scenarios, postural responses were assessed to posterior translations in gait and stance perturbation before and after 4 weeks of training. Surface electromyography during short- (SLR), medium- (MLR), and long-latency response of shank and thigh muscles as well as ankle, knee, and hip joint kinematics (amplitudes and velocities) were recorded.

Both training modalities revealed reduced angular velocity in the ankle joint (P < 0.05) accompanied by increased shank muscle activity in SLR (P < 0.05) during marching in place perturbation. During stance perturbation and marching in place perturbation, hip angular velocity was decreased after RBT (P from TTEST, P_t < 0.05) accompanied by enhanced thigh muscle activity (SLR, MLR) after both trainings (P < 0.05). Effect sizes were larger for the RBT-group during stance perturbation. Thus, both interventions revealed modified stabilization strategies for reactive balance recovery after surface translations.

Characterized by enhanced reflex activity in the leg muscles antagonizing the surface translations, balance training is associated with improved neuromuscular timing and accuracy being relevant for postural control. This may result in more efficient segmental stabilization during fall risk situations, independent of the intervention modality. More pronounced modulations and higher effect sizes after RBT in stance perturbation point toward specificity of training adaptations, with an emphasis on the proximal body segment for RBT. Outcomes underline the benefits of balance training with a clear distinction between RBT and CBT being relevant for training application over the lifespan.

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Motor-Cognitive Dual-Task Training in Patients with Dementia

Selena Horner — Mon, 17 Sep 2018 10:00:00 +0000

If your patient happens to have mild to moderate dementia, is it possible to have an effect on the motor and cognitive functional ability?

Clinically, I specialize in working with older adults. Quite a few of them have some level of dementia. I always wonder if there is a way to impact the dementia aspect because cognition is so important for safe function in daily life.

What I really need to truly address this study is full text access. How helpful is walking and counting with regard to transferability? Transfering to what?

From my perspective, I like to incorporate dual task activities with a cognitive component because it challenges the motor performance. If the patient is thinking about X while doing Y and nailing Y with pretty good performance, then I know their body has learned the motor activity.

Other times, there seem to be patients who have little ability to perform a motor-cognitive dual task without totally falling apart with their motor performance.

I thought this study could have some relevance to clinical practice. It seems that the majority of our treatments may be focused on impairments and not necessarily incorporating the level of complexity that a patient may need – especially if the patient exhibits a bit of dementia.

You’ll find the abstract to the recent study below.

Transferability and Sustainability of Motor-Cognitive Dual-Task Training in Patients with Dementia: A Randomized Controlled Trial.

Lemke NC^1,², Werner C^2,³, Wiloth S^2,⁴, Oster P², Bauer JM^2,³, Hauer K².

Abstract

BACKGROUND:

Specific dual-task (DT) training is effective to improve DT performance in trained tasks in patients with dementia (PwD). However, it remains an open research question whether successfully trained DTs show a transfer effect to untrained DT performances.

OBJECTIVE:

To examine transfer effects and the sustainability of a specific DT training in PwD.

METHODS:

One hundred and five patients with mild-to-moderate dementia (Mini-Mental State Examination: 21.9 ± 2.8 points) participated in a 10-week randomized, controlled trial. The intervention group (IG) underwent a specific DT training (“walking and counting”). The control group (CG) performed unspecific low-intensity exercise. DT performance was measured under three conditions: (1) “walking and counting” (trained); (2) “walking and verbal fluency” (semi-trained), and (3) “strength and verbal fluency” (untrained). Outcomes evaluated at baseline, after training, and 3 months after the intervention period included absolute values for the motor and cognitive performance under DT conditions, and relative DT costs (DTCs) in motor, cognitive and combined motor-cognitive performance.

RESULTS:

The IG significantly improved DT performances in the trained condition for absolute motor and cognitive performance and for motor, cognitive, and combined motor-cognitive DTCs compared to the CG (p ≤ 0.001-0.047; ηp2 = 0.044-0.249). Significant transfer effects were found in the semi-trained condition for absolute motor and partly cognitive performance, and for motor but not for cognitive DTCs, and only partly for combined DTCs (p ≤ 0.001-0.041; ηp2 = 0.049-0.150). No significant transfer effects were found in the untrained condition. Three months after training cessation, DT performance in the trained condition was still elevated for most of the outcomes (p ≤ 0.001-0.038; ηp2 = 0.058-0.187). Training gains in the DT performance in the semi-trained condition were, however, not sustained, and no significant group differences were found in the DT performance in the untrained condition after the follow-up.

CONCLUSION:

This study confirmed that specific DT training is effective in improving specifically trained DT performances in PwD and demonstrated sustainability of training-induced effects for at least 3 months. Effects were partially transferable to semi-trained DTs but not to untrained DTs. With increasing distance between trained and untrained DTs, transferability of training effects decreased.

Gerontology. 2018 Jul 24:1-16. doi: 10.1159/000490852. [Epub ahead of print

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Measures of Physical Performance and Muscle Strength as Predictors of Fracture Risk

Selena Horner — Mon, 10 Sep 2018 10:00:00 +0000

For some reason, when I think of fracture risk, I immediately think of bone density. My thoughts are being challenged with this recent study.

The FRAX seems to be the predictive tool of choice for predicting 10 year risk of osteoporetic fracture. The self-report tool focuses on familial history of hip fracture and patient previous history of hip fracture. It considers glucocorticoids, smoking and alcohol consumption. It also considers secondary osteoporosis and bone mineral density. When you think the aspects of this predictive tool, the focus is very targeted toward bones.

I have been seeing more and more studies looking at physical performance and the ability to predict various adverse events. I’m seeing a pattern of physical performance tests that seem to have value in predicting adverse events: the timed chair stands test, gait speed and grip strength. For older adults, it seems that these 3 physical function measures have quite a bit of value and insight into the direction the patient’s health is heading.

Often times, our evaluations are laser focused a the specific condition being treated. It seems the above three tests provide important insight into the patient’s health. This is another study that highlights the predictive value of physical performance tests: this particular study focuses on fractures.

You’ll find the abstract to the recent study below.

Measures of physical performance and muscle strength as predictors of fracture risk independent of FRAX, falls and BMD: A meta-analysis of the Osteoporotic Fractures in Men (MrOS) Study.

Harvey NC^1,², Odén A^3,⁴, Orwoll E⁵, Lapidus J⁶, Kwok T⁷, Karlsson MK⁸, Rosengren BE⁸, Ribom E⁹, Cooper C^1,^2,¹⁰, Cawthon PM^11,¹², Kanis JA^4,¹³, Ohlsson C³, Mellström D³, Johansson H^3,^4,¹³, McCloskey E^4,¹⁴.

Abstract

Measures of muscle mass, strength and function predict risk of incident fractures, but it is not known whether this risk information is additive to that from FRAX® probability.

We investigated, in the Osteoporotic Fractures in Men (MrOS) Study cohorts (Sweden, Hong Kong, USA), whether measures of physical performance/ appendicular lean mass by DXA predicted incident fractures in older men, independently of FRAX probability.

Baseline information included falls history, clinical risk factors for falls and fractures, femoral neck BMD, and calculated FRAX probabilities. An extension of Poisson regression was used to investigate the relationship between time for 5 chair stands, walking speed over 6m, grip strength, appendicular lean mass (ALM) adjusted for body size (ALM/height² ), FRAX probability [major osteoporotic fracture (MOF) with or without femoral neck BMD, available in a subset of n = 7531], and incident MOF (hip, clinical vertebral, wrist or proximal humerus). Associations were adjusted for age, time since baseline, and are reported as hazard ratio (HR) for first incident fracture per SD increment in predictor, using meta-analysis.

5660 men in USA (mean age 73.5 years); 2764 in Sweden (75.4 years); and 1987 in Hong Kong (72.4 years) were studied. Mean follow-up time was 8.7-10.9 years.

Greater time for 5 chair stands was associated with greater risk of MOF [HR:1.26(95%CI:1.19,1.34)], whereas greater walking speed [HR:0.85(95%CI:0.79,0.90), grip strength [HR:0.77(95%CI:0.72,0.82)] and ALM/height² [HR:0.85(95%CI:0.80,0.90)] were associated with lower risk of incident MOF. Associations remained largely similar after adjustment for FRAX, but that between ALM/height² and MOF was weakened [HR:0.92(95%CI:0.85,0.99]. Inclusion of femoral neck BMD markedly attenuated the association between ALM/height² and MOF [HR:1.02(95%CI:0.96,1.10)].

Measures of physical performance predict incident fractures independently of FRAX probability. Whilst the predictive value of ALM/height² being substantially reduced by inclusion of BMD requires further study, these findings support the consideration of physical performance in fracture risk assessment.

J Bone Miner Res. 2018 Jul 16. doi: 10.1002/jbmr.3556. [Epub ahead of print]

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Wearable Sensors and the Assessment of Frailty

Selena Horner — Mon, 02 Jul 2018 10:00:00 +0000

Do the majority of the older adults we treat have an accurate perception of their physical activity level?

The most recent experience I can recall about a patient’s perception about physical activity happened a few months ago. I had an older adult who was noting an increase in her normal amount of strength and also was feeling deconditioned. She had been ill multiple times over the past year with pneumonia.

As we were talking about her typical activity level, she insinuated that she walked with her granddaughter, walked at the senior center and spent time walking in her home. I should have picked up on her daughter’s nonverbal body language. The following week, the patient had a pedometer. The daughter got her a pedometer and wanted her to use it to show me her activity level. I asked my patient how her day had been and about her walking. The patient mentioned a significant amount of walking prior to attending her visit. I told her I was curious about how many steps that would be and had her show me her pedometer recordings.

Let’s just say that 500 steps was far, far less than the patient described. From the experience with that particular patient, I learned that a patient’s perceptions may not necessarily reflect true judgment of activity level. This particular patient would definitely be considered frail and really wasn’t achieving the required amount of physical activity to begin to change her status to pre-frail.

I do believe that wearable sensors may definitely help in providing information to help us guide patients through their rehabilitation. The sensors can provide both more accurate information for us while at the same time motivating patients.

You’ll find the abstract to the recent study below.

Wearable Sensors and the Assessment of Frailty among Vulnerable Older Adults: An Observational Cohort Study.

Razjouyan J^1,², Naik AD^3,^4,⁵, Horstman MJ^6,⁷, Kunik ME^8,^9,¹⁰, Amirmazaheri M¹¹, Zhou H¹², Sharafkhaneh A¹³, Najafi B^14,¹⁵.

Abstract

Background: The geriatric syndrome of frailty is one of the greatest challenges facing the U.S. aging population. Frailty in older adults is associated with higher adverse outcomes, such as mortality and hospitalization. Identifying precise early indicators of pre-frailty and measures of specific frailty components are of key importance to enable targeted interventions and remediation. We hypothesize that sensor-derived parameters, measured by a pendant accelerometer device in the home setting, are sensitive to identifying pre-frailty.

Methods: Using the Fried frailty phenotype criteria, 153 community-dwelling, ambulatory older adults were classified as pre-frail (51%), frail (22%), or non-frail (27%). A pendant sensor was used to monitor the at home physical activity, using a chest acceleration over 48 h. An algorithm was developed to quantify physical activity pattern (PAP), physical activity behavior (PAB), and sleep quality parameters. Statistically significant parameters were selected to discriminate the pre-frail from frail and non-frail adults.

Results: The stepping parameters, walking parameters, PAB parameters (sedentary and moderate-to-vigorous activity), and the combined parameters reached and area under the curve of 0.87, 0.85, 0.85, and 0.88, respectively, for identifying pre-frail adults. No sleep parameters discriminated the pre-frail from the rest of the adults.

Conclusions: This study demonstrates that a pendant sensor can identify pre-frailty via daily home monitoring. These findings may open new opportunities in order to remotely measure and track frailty via telehealth technologies.

Sensors (Basel). 2018 Apr 26;18(5). pii: E1336. doi: 10.3390/s18051336.

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