Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke

OBJECTIVES: To determine the effect of two different community-based group exercise programs on functional balance, mobility, postural reflexes, and falls in older adults with chronic stroke. DESIGN: A randomized, clinical trial. SETTING: Community center. PARTICIPANTS: Sixty-one community-dwelling older adults with chronic stroke. INTERVENTION: Participants were randomly assigned to an agility (n=30) or stretching/weight-shifting (n=31) exercise group. Both groups exercised three times a week for 10 weeks. MEASUREMENTS: Participants were assessed before, immediately after, and 1 month after the intervention for Berg Balance, Timed Up and Go, step reaction time, Activities-specific Balance Confidence, and Nottingham Health Profile. Testing of standing postural reflexes and induced falls evoked by a translating platform was also performed. In addition, falls in the community were tracked for 1 year from the start of the interventions. RESULTS: Although exercise led to improvements in all clinical outcome measures for both groups, the agility group demonstrated greater improvement in step reaction time and paretic rectus femoris postural reflex onset latency than the stretching/weight-shifting group. In addition, the agility group experienced fewer induced falls on the platform. CONCLUSION: Group exercise programs that include agility or stretching/weight shifting exercises improve postural reflexes, functional balance, and mobility and may lead to a reduction of falls in older adults with stroke.     

Prompting primary providers to increase community exercise referrals for older adults: a randomized trial

OBJECTIVES: To determine whether a clinic-based physical activity promotion intervention can lead to more community-based exercise referrals by providers and higher exercise motivation in patients. DESIGN: Cluster randomized, controlled trial. SETTING: Seattle Veterans Affairs General Internal Medicine Clinic. PARTICIPANTS: Thirty-one physicians and nurse practitioners were randomized to a physical activity counseling intervention or control condition (counseling about tobacco cessation). Three hundred thirty-six patients aged 50 and older and visiting a study provider were enrolled. INTERVENTION: Intervention providers were trained to offer referrals to community exercise programs for patients who reported before their clinic visit that they were "contemplative" about regular exercise. MEASUREMENTS: Process measures of health behavior assessment and provider advice, exercise stage-of-change, proportion of participants reporting regular physical activity. RESULTS: At baseline, 172 intervention patients and 164 controls were similar with respect to sex, age, comorbidity score, and exercise motivation level. Forty-five percent of all intervention patients and 35% of controls reported receiving exercise advice (P=.07). Intervention patients who were contemplative about exercise were even more likely to receive exercise advice than contemplative controls (59% vs 38%; P=.02). After 4 months, 35% of all intervention patients reported regular exercise, compared with 28% of controls (P=.06). CONCLUSION: Primary providers are more likely to offer exercise advice when informed whether patients are contemplative about exercise. Patients may be more likely to start regular exercise as a result of this advice.     

A randomized controlled clinical trial of the Seattle Protocol for Activity in older adults

OBJECTIVES: To compare the efficacy of a physical activity program (Seattle Protocol for Activity (SPA)) for low‐exercising older adults with that of an educational health promotion program (HP), combination treatment (SPA+HP), and routine medical care control conditions (RMC). DESIGN: Single‐blind, randomized controlled trial with two‐by‐two factorial design. SETTING: Community centers in King County, Washington, from November 2001 to September 2004. PARTICIPANTS: Two hundred seventy‐three community‐residing, cognitively intact older adults (mean age 79.2; 62% women). INTERVENTIONS: SPA (in‐class exercises with assistance setting weekly home exercise goals) and HP (information about age‐appropriate topics relevant to enhancing health), with randomization to four conditions: SPA only (n=69), HP only (n=73), SPA+HP (n=67), and RMC control (n=64). Active‐treatment participants attended nine group classes over 3 months followed by five booster sessions over 1 year. MEASUREMENTS: Self‐rated health (Medical Outcomes Study 36‐item Short‐Form Survey) and depression (Geriatric Depression Scale). Secondary ratings of physical performance, treatment adherence, and self‐rated health and affective function were also collected. RESULTS: At 3 months, participants in SPA exercised more and had significantly better self‐reported health, strength, and general well‐being (P<.05) than participants in HP or RMC. Over 18 months, SPA participants maintained health and physical function benefits and had continued to exercise more than non‐SPA participants. SPA+HP was not significantly better than SPA alone. Better adherence was associated with better outcomes. CONCLUSION: Older adults participating in low levels of regular exercise can establish and maintain a home‐based exercise program that yields immediate and long‐term physical and affective benefits.     

Graded motor imagery training as a home exercise program for upper limb motor function in patients with chronic stroke: A randomized controlled trial

Purpose:Although several types of occupational therapy for motor recovery of the upper limb in patients with chronic stroke have been investigated, most treatments are performed in a hospital or clinic setting. We investigated the effect of graded motor imagery (GMI) training, as a home exercise program, on upper limb motor recovery and activities of daily living (ADL) in patients with stroke.Methods:This prospective randomized controlled trial recruited 42 subjects with chronic stroke. The intervention group received instruction regarding the GMI program and performed it at home over 8 weeks (30 minutes a day). The primary outcome measure was the change in motor function between baseline and 8 weeks, assessed the Manual Function Test (MFT) and Fugl-Meyer Assessment (FMA). The secondary outcome measure was the change in ADL, assessed with the Modified Barthel Index (MBI).Results:Of the 42 subjects, 37 completed the 8-week program (17 in the GMI group and 20 controls). All subjects showed significant improvements in the MFT, FMA, and MBI over time (P < .05). However, the improvements in the total scores for the MFT, FMA, and MBI did not differ between the GMI and control groups. The MFT arm motion score for the GMI group was significantly better than that of the controls (P < .05).Conclusions:The GMI program may be useful for improving upper extremity function as an adjunct to conventional rehabilitation for patients with chronic stroke.     

Multiple-modality exercise and mind-motor training to improve cardiovascular health and fitness in older adults at risk for cognitive impairment: A randomized controlled trial

BackgroundThe effects of multiple-modality exercise on arterial stiffening and cardiovascular fitness has not been fully explored.ObjectivesTo explore the influence of a 24-week multiple-modality exercise program associated with a mind-motor training in cardiovascular health and fitness in community-dwelling older adults, compared to multiple-modality exercise (M2) alone.MethodsParticipants (n = 127, aged 67.5 [7.3] years, 71% females) were randomized to either M4 or M2 groups. Both groups received multiple-modality exercise intervention (60 min/day, 3 days/week for 24-weeks); however, the M4 group underwent additional 15 min of mind-motor training, whereas the M2 group received 15 min of balance training. Participants were assessed at 24-weeks and after a 28-week non-contact follow-up (52-weeks).Resultsat 52-weeks, the M4 group demonstrated a greater VO2max (ml/kg/min) compared to the M2 group (mean difference: 2.39, 95% CI: 0. 61 to 4.16, p = 0.009). Within-group analysis indicated that the M4 group demonstrated a positive change in VO2max at 24-weeks (mean change: 1.93, 95% CI: 0.82 to 3.05, p = 0.001) and 52-weeks (4.02, 95% CI: 2.71 to 5.32, p = 0.001). Similarly, the M2 group increased VO2max at 24-weeks (2.28, 95% CI: 1.23 to 3.32, p < 0.001) and 52-weeks (1.63, 95% CI: 0.43 to 2.83, p = 0.008). Additionally, the M2 group decreased 24 h SBP (mmHg) at 24-weeks (−2.31, 95% CI: −4.61 to −0.01, p = 0.049); whereas the M4 group improved 24 h DBP (−1.6, 95% CI: −3.03 to −0.17, p = 0.028) at 52-weeks.ConclusionMind-motor training associated with multiple-modality exercise can positively impact cardiovascular fitness to the same extent as multiple-modality exercise alone.     

Square-stepping exercise and fall risk factors in older adults: a single-blind, randomized controlled trial

BACKGROUND: Decreased fitness of the lower extremities is a potentially modifiable fall risk factor. This study aimed to compare two exercise programs--square-stepping exercise (SSE), which is a low-cost indoor program, and walking--for improving the fitness of the lower extremities. METHODS: We randomly allocated 68 community-dwelling older adults (age 65-74 years) to either the SSE or walking group (W group). During the 12-week regimen, the SSE group participated in 70-minute exercise sessions conducted twice a week at a local health center, and the W group participated in outdoor supervised walking sessions conducted weekly. The W group was instructed to increase the number of daily steps. Prior to and after the program, we obtained information on 11 physical performance tests for known fall risk factors and 3 self-reported scales. The fall incidence was followed-up for 8 months. RESULTS: At 12 weeks postregimen, significant differences were observed between the two exercise groups with respect to leg power (1 item), balance (2 items), agility (2 items), reaction time (2 items), and a self-reported scale (1 item); the SSE group demonstrated a marked improvement in the above-mentioned items with Group x Time interactions. Significant time effects were observed in the tests involving chair stands, functional reach, and standing up from a lying-down position without Group x Time interactions. During the follow-up period, the fall rates per person-year in the SSE and W groups were 23.4% and 33.3%, respectively (p =.31). CONCLUSION: Although further studies are required, SSE is apparently more effective than walking in reducing fall risk factors, and it appears that it may be recommended as a health promotion exercise in older adults.     

规范康复治疗对前循环脑卒中偏瘫患者肢体运动功能的影响

目的研究规范的康复治疗对前循环脑卒中偏瘫患者肢体运动功能的影响。方法80例前循环脑卒中偏瘫患者随机分为康复组(30例)和对照组(50例),康复组患者给予6个月规范的康复治疗,对照组患者住院期间接受1个月的康复治疗,出院后定期随访。结果康复组和对照组在治疗前、治疗1个月时肢体运动功能差异无统计学意义,但在3、6个月时肢体功能恢复与对照组比较差异有统计学意义(P<0.01)。结论规范康复治疗对于前循环脑卒中偏瘫患者肢体运动功能的恢复有明显的促进作用。     

Yoga to prevent mobility limitations in older adults: feasibility of a randomized controlled trial

Background

The loss of mobility during aging impacts independence and leads to further disability, morbidity, and reduced life expectancy. Our objective was to examine the feasibility and safety of conducting a randomized controlled trial of yoga for older adults at risk for mobility limitations.

Methods

Sedentary older adults (n?=?46; age 60–89) were recruited and randomized to either yoga or a health education comparison group. Yoga sessions (60-min) occurred 2x weekly, and 90-min health education sessions occurred weekly, for 10?weeks. The primary outcomes were recruitment rate, intervention attendance, and retention at assessments. Adverse event rates and participant satisfaction were also measured. Physical performance measures of gait, balance, and strength and self-report outcome measures were administered at baseline and 10-weeks.

Results

Recruitment lasted 6?months. Retention of participants at the 10-week follow-up was high (89% - performance measures; 98% - self-report questionnaires). Attendance was good with 82% of yoga and 74% of health education participants attending at least 50% of the sessions. No serious adverse events were reported. Patient satisfaction with the interventions was high. The mean effect size for the physical performance measures was 0.35 with some over 0.50. The mean effect size for self-report outcome measures was 0.36.

Conclusions

Results indicate that it is feasible to conduct a larger RCT of yoga for sedentary older adults at risk for mobility problems. The yoga and comparison interventions were safe, well accepted, and well attended. Effect sizes suggest yoga may have important benefits for this population and should be studied further.

Trial Registration

ClinicalTrials # NCT03544879; Retrospectively registered 4 June, 2018.

     

Clinical effectiveness of a rehabilitation program integrating exercise,self‐management,and active coping strategies for chronic knee pain: A cluster randomized trial

Objective

Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self‐management, and active coping strategies (Enabling Self‐management and Coping with Arthritic Knee Pain through Exercise [ESCAPE‐knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.

Methods

We conducted a single‐blind, pragmatic, cluster randomized controlled trial. Participants age ≥50 years, reporting knee pain for >6 months, were recruited from 54 inner‐city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self‐reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC‐func]) 6 months after completing rehabilitation.

Results

A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (?3.33 difference in WOMAC‐func score; 95% confidence interval [95% CI] ?5.88, ?0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (?3.53; 95% CI ?6.52, ?0.55) or group rehabilitation (?3.16; 95% CI ?6.55, ?0.12).

Conclusion

ESCAPE‐knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

     

Recruitment of older adults for a randomized, controlled trial of exercise advice in a general practice setting

OBJECTIVES: The success of any clinical trial depends strongly on recruiting enough participants in a reasonable time period. This paper aims to identify the obstacles, as well as the successful aspects, of recruiting of older participants into an exercise study. DESIGN: This describes the recruitment of 299 older adults into a randomized, controlled trial of exercise advice in a general practice setting. Letters of invitation were sent from two general practices inviting the patients to attend a 15-minute screening appointment. Patients considered eligible for enrollment were then scheduled for a baseline appointment and randomized into the trial. SETTING: Two general practices in Adelaide, South Australia. PARTICIPANTS: Healthy, sedentary, community-dwelling patients aged 60 years or older. RESULTS: A total of 2878 letters of invitation were sent, and 913 patients attended a screening appointment. Of these, 351 (38.4%) were initially eligible, with one-third excluded because they were already too physically active. Two hundred ninety-nine participants, approximately 1 of every 10 patients sent letters, were enrolled in the project at the end of a 15-week period. DISCUSSION: A general practice approach was effective in recruiting 299 older adults to an exercise project within an acceptable time frame. Factors promoting the success of recruitment through general practice included choosing large, well established practices, computerized age-sex registers, and placing minimal demands on the general practitioners and practice staff. A continuing problem with recruiting participants for a project involving exercise is that the volunteer population tends to be healthy and interested in physical activity.     

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.
DESIGN: Randomized, controlled trial.
SETTING: Seven community hospitals and five general hospitals in the midlands and north of England.
PARTICIPANTS: Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness.
INTERVENTION: Multidisciplinary team care for older people in community hospitals.
MEASUREMENTS: The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services.
RESULTS: Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26–6.28; P =.03). The results for the secondary outcome measures were similar for the two groups.
CONCLUSION: Postacute community hospital rehabilitation care for older people is associated with greater independence.     

The effect of a task-oriented walking intervention on improving balance self-efficacy poststroke: a randomized, controlled trial

OBJECTIVES: To evaluate the efficacy of a task-oriented walking intervention in improving balance self-efficacy in persons with stroke and to determine whether effects were task-specific, influenced by baseline level of self-efficacy and associated with changes in walking and balance capacity. DESIGN: Secondary analysis of a two-center, observer-blinded, randomized, controlled trial. SETTING: General community. PARTICIPANTS: Ninety-one individuals with a residual walking deficit within 1 year of a first or recurrent stroke. INTERVENTION: Task-oriented interventions targeting walking or upper extremity (UE) function were provided three times a week for 6 weeks. MEASUREMENTS: Activities-specific Balance Confidence Scale, Six-Minute Walk Test, 5-m walk, Berg Balance Scale, and Timed "Up and Go" administered at baseline and postintervention. RESULTS: The walking intervention was associated with a significantly greater average proportional change in balance self-efficacy than the UE intervention. Treatment effects were largest in persons with low self-efficacy at baseline and for activities relating to tasks practiced. In the walking group, change in balance self-efficacy correlated with change in functional walking capacity (correlation coefficient=0.45, 95% confidence interval=0.16-0.68). Results of multivariable modeling suggested effect modification by the baseline level of depressive symptoms and a prognostic influence of age, sex, comorbidity, time poststroke, and functional mobility on change in self-efficacy. CONCLUSION: Task-oriented walking retraining enhances balance self-efficacy in community-dwelling individuals with chronic stroke. Benefits may be partially the result of improvement in walking capacity. The influence of baseline level of self-efficacy, depressive symptoms, and prognostic variables on treatment effects are of clinical importance and must be verified in future studies.