Susan Hughes, DSW Susan Hughes, DSW Minnesota Gerontological Minnesota Gerontological

SocietySocietyApril 24, 2009April 24, 2009

Briiiiiidging the Briiiiiidging the Translation Gap and Translation Gap and

Surviving!Surviving!

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OverviewOverview

Importance of translationImportance of translation Review development and testing of Review development and testing of

Fit and Strong! (EB program)Fit and Strong! (EB program) Current status translating Fit and Current status translating Fit and

Strong! – RE-AIM and lessons Strong! – RE-AIM and lessons learnedlearned

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Need for translationNeed for translation

Number of EB programs in pipeline Number of EB programs in pipeline growing growing

Result of substantial investment by NIHResult of substantial investment by NIH In comparison, minimal support for In comparison, minimal support for

translationtranslation Major public health challenge right nowMajor public health challenge right now AoA and CDC stepping up to plate but AoA and CDC stepping up to plate but

$ limited$ limited

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FutureFuture

Despite limits in funding, practice Despite limits in funding, practice will have to change to incorporate will have to change to incorporate EB programs that are out thereEB programs that are out there

$1 billion sitting in DHHS for this $1 billion sitting in DHHS for this purpose= down payment purpose= down payment

Title indicates, surviving current Title indicates, surviving current challenges tricky but doable- challenges tricky but doable-

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Future cont’dFuture cont’d

fundamentally – translation/diffusion fundamentally – translation/diffusion totally necessary- hope you will agree- totally necessary- hope you will agree-

when times are tough, $ limited, even when times are tough, $ limited, even more important that programs offered more important that programs offered have greatest impact possiblehave greatest impact possible

Now, move on, describe Fit and Strong! Now, move on, describe Fit and Strong!

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First, acknowledgeFirst, acknowledge

Greater Chicago Chapter, Arthritis FoundationGreater Chicago Chapter, Arthritis Foundation NIAMSNIAMS National Institute on Aging Roybal Center National Institute on Aging Roybal Center

(P50 AG15890)(P50 AG15890) National Institute on Aging (R01 AG23424)National Institute on Aging (R01 AG23424) Centers for Disease Control and Prevention Centers for Disease Control and Prevention

(R18 DP001140)(R18 DP001140) Arthritis FoundationArthritis Foundation Chicago Department on AgingChicago Department on Aging

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In what sense, In what sense, evidence-based????evidence-based????

Builds on earlier longitudinal study of Builds on earlier longitudinal study of 600 older adults in Chicago (GeriMAC)600 older adults in Chicago (GeriMAC)

Supported by Arthritis Foundation and Supported by Arthritis Foundation and NIAMSNIAMS

Found:Found: Arthritis is number one cause of disabilityArthritis is number one cause of disability Lower extremity joint impairment, in Lower extremity joint impairment, in

particular, is a risk factor for future particular, is a risk factor for future disabilitydisability

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Converging Evidence-LE Converging Evidence-LE Impairment and DisabilityImpairment and Disability

• 1990: Jette, Branch, and Berlin 1990: Jette, Branch, and Berlin LE LE performanceperformance predicts IADL disability at 2 years predicts IADL disability at 2 years

• 1995: Guralnik, et al. 1995: Guralnik, et al. LE LE performanceperformance at baseline predicts Year 4 ADL at baseline predicts Year 4 ADL

disability and institutionalizationdisability and institutionalization• 1998: Dunlop and Hughes1998: Dunlop and Hughes

LE joint impairment at baseline predicts disability LE joint impairment at baseline predicts disability levels at year 4 consistent with institutional use levels at year 4 consistent with institutional use

First to pin-point role of joint impairment due to First to pin-point role of joint impairment due to arthritis as causal mechanismarthritis as causal mechanism

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LE Joint Impairment LE Joint Impairment and Disabilityand Disability

Link makes sense when consider Link makes sense when consider role of large, weight bearing LE role of large, weight bearing LE joints in performing joints in performing ADLsADLs ToiletingToileting Transferring in/out of bedTransferring in/out of bed Climbing stairs, etc. Climbing stairs, etc.

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Purpose of Longitudinal Purpose of Longitudinal StudyStudy

Identify modifiable risk factors Identify modifiable risk factors related to disabilityrelated to disability

Finding re LE joint impairment Finding re LE joint impairment indicates urgent need develop indicates urgent need develop intervention to interrupt intervention to interrupt progression of impairment to progression of impairment to disabilitydisability

Physical activity a likely candidate Physical activity a likely candidate

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OA Exercise OA Exercise LiteratureLiterature

• People with OA have poor aerobic People with OA have poor aerobic functioning functioning and and decreased muscle strength decreased muscle strength vs controlsvs controls

• Pain decreases activity; Pain decreases activity; • Decreased activity leads to de-conditioning:Decreased activity leads to de-conditioning:

• Frozen jointsFrozen joints• Wasted musclesWasted muscles• Decreased lung and heart capacity= vicious Decreased lung and heart capacity= vicious

cyclecycle

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OA lit cont’d.OA lit cont’d.

Most studies targeted increased muscle Most studies targeted increased muscle strength or aerobic capacitystrength or aerobic capacity

Recent consensus that mulitple component Recent consensus that mulitple component programs neededprograms needed

TargetTarget Flexibility/balanceFlexibility/balance Aerobic capacityAerobic capacity StrengthStrength

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OA exercise literature, OA exercise literature, cont’dcont’d

Most studies found benefits at Most studies found benefits at conclusion of 8 or 12 week conclusion of 8 or 12 week interventionsinterventions

Almost no information on longer term Almost no information on longer term impact or maintenance of PA after impact or maintenance of PA after programs endedprograms ended

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Adherence Literature Adherence Literature suggests:suggests:

include education component geared to include education component geared to increasing self-efficacy (SE)increasing self-efficacy (SE)

What is self-efficacy?What is self-efficacy? Confidence can perform a taskConfidence can perform a task Belief that if you perform it, you will achieve Belief that if you perform it, you will achieve

a desired outcomea desired outcome 3 types of SE important in this case:3 types of SE important in this case:

arthritis disease managementarthritis disease management exerciseexercise exercise adherenceexercise adherence

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Adherence Literature Adherence Literature suggests:suggests:

make exercise as easy to do as make exercise as easy to do as possiblepossible

help participants develop help participants develop individualized routinesindividualized routines

provide structured reinforcement provide structured reinforcement re: progressre: progress

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Combines Exercise with Combines Exercise with Education for Lifestyle Education for Lifestyle ChangeChange

Can’t just tell people to exercise and Can’t just tell people to exercise and teach them howteach them how

Need to review what exercise means Need to review what exercise means to them in context of their livesto them in context of their lives

prior experienceprior experienceconcerns about safetyconcerns about safetyfacilitators and barriersfacilitators and barriersproblem solvingproblem solving

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Fit and Strong! Fit and Strong! ComponentsComponents

Multiple-component exercise Multiple-component exercise plusplus education for lifestyle changeeducation for lifestyle change

3 sessions/week for 8 weeks = 24 3 sessions/week for 8 weeks = 24 sessionssessions

60-minutes exercise, 30 minutes 60-minutes exercise, 30 minutes educationeducation

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General class General class scheduleschedule

5 minute warm-up5 minute warm-up 20 minutes of aerobic exercise20 minutes of aerobic exercise 20 minutes of strength training20 minutes of strength training 10 minutes of flexibility/balance10 minutes of flexibility/balance 5 minutes of cool-down5 minutes of cool-down 30 minutes-Education, group 30 minutes-Education, group

problem solving problem solving

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Individualized Individualized Contract for Exercise Contract for Exercise MaintenanceMaintenance

Important feature: Week 7, instructor Important feature: Week 7, instructor develops an individualized plan with each develops an individualized plan with each participant to follow after Fit and Strong! participant to follow after Fit and Strong! endsends

Develops individualized plan incorporating Develops individualized plan incorporating preferences for time, place, form of: preferences for time, place, form of:

flexibilityflexibilityaerobicaerobicstrength exercisesstrength exercises

Plan is a Plan is a contract for post Fit and Strong! contract for post Fit and Strong! maintenance which each participant signs maintenance which each participant signs

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Efficacy StudyEfficacy StudyDesign/MethodsDesign/Methods

RCT, will an exercise/education intervention RCT, will an exercise/education intervention targeted to people with lower-extremity OA:targeted to people with lower-extremity OA: lower extremity disability lower extremity disability 6-minute distance walk (aerobic capacity) 6-minute distance walk (aerobic capacity) time to rise unassisted from seated position time to rise unassisted from seated position

(lower-extremity muscle strength) (lower-extremity muscle strength) exercise, exercise adherence, and arthritis exercise, exercise adherence, and arthritis

management SEmanagement SE

over short term (8 weeks)? over short term (8 weeks)?

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Design/Methods (cont’d)Design/Methods (cont’d)

And, will sustained adherence to PA And, will sustained adherence to PA after Fit and Strong! ends affect after Fit and Strong! ends affect outcomes at 6 and 12 months?outcomes at 6 and 12 months?

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Pre-Posttest MeasuresPre-Posttest Measures

• Baseline; 2, 6, and 12 monthsBaseline; 2, 6, and 12 months

• called participants in both groups called participants in both groups quarterlyquarterly

still exercising?still exercising? what doing?what doing? how long, how often?how long, how often?

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Individuals Screened

(n = 704)

Treatment (n = 115)

Control (n = 100)

Followed at 8 weeks (n = 83)

Followed at 8 weeks (n = 55)

Followed at 6 months (n = 74)

Followed at 6 months (n = 44)

Enrolled (n = 215) Requested Deferment (n = 40)

Patient Refused (n = 84) Did not meet inclusion criteria (n = 365)

Followed at 12 mos. (n = 58)

Followed at 12 months (n = 32)

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Baseline Demographic Baseline Demographic Characteristics*Characteristics*

*No statistically significant differences between treatment and control groups

  Treatment Group Control Group

  (N=115) (N=110)

  % or Mean % or Mean

Age 73.3 73.4

Female 80.6 85.9

Education    

>High School 66.4 72.7

Income    

<$20,000 32.4 33.7

ARA Class    

I 22.6 22.2

II 64.5 64.2

III 12.9 13.6

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Other Self-Reported Other Self-Reported ConditionsConditions

TreatmentTreatment ControlControl (N = 115)(N = 115) (N = (N =

100)100) %% % %

CardiovascularCardiovascular 36.8 36.8 33.0 33.0 Disease Disease

AsthmaAsthma 6.8 6.8 5.8 5.8 EmphysemaEmphysema 3.9 3.9 5.8 5.8 DiabetesDiabetes 14.6 14.6 12.8 12.8 CancerCancer 6.8 6.8 2.3 2.3

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AnalysesAnalyses Used Random EffectsUsed Random Effects

One covariate:One covariate: Arthritis Functional ClassArthritis Functional Class

– Found in attrition analyses to discriminate between Found in attrition analyses to discriminate between groupsgroups

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Significant Outcomes Favoring Significant Outcomes Favoring Treatment Group Treatment Group

2 Months2 Months 6 Months6 Months 12 months12 monthsAdherenceAdherence AdherenceAdherence AdherenceAdherence

SE for ExerciseSE for Exercise SE for ExerciseSE for Exercise SE for ExerciseSE for Exercise

Time Adherence Time Adherence EfficacyEfficacy

Time Adherence Time Adherence EfficacyEfficacy

SE for Arthritis SE for Arthritis Pain Management Pain Management

(borderline)(borderline)WOMAC StiffnessWOMAC Stiffness WOMAC Stiffness WOMAC Stiffness WOMAC Stiffness WOMAC Stiffness

(borderline)(borderline)

WOMAC PainWOMAC Pain

Geri-AIMS PainGeri-AIMS Pain Geri-AIMS PainGeri-AIMS Pain

(borderline)(borderline)

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Effect SizesEffect SizesTreatment Group

2 months 6 months 12 months

Self Efficacy

Exercise 0.78 0.80 0.91

Time Adherence 0.76 0.71

Pain Management 0.65

Geri-AIMS

Pain 0.25 0.19

WOMAC

Pain -0.47

Stiffness -0.33 -0.35 -0.21

Adherence

Total Exercise Minutes 0.86 0.71 0.67

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ConclusionsConclusions

Benefits observed at 2, 6, and 12 Benefits observed at 2, 6, and 12 months; no untoward results (rheum months; no untoward results (rheum fellow) fellow)

Efficacy trial preliminary baseline, 2 and Efficacy trial preliminary baseline, 2 and 6 months findings published April 2004 6 months findings published April 2004 GerontologistGerontologist

Efficacy trial final baseline, 6 and 12 Efficacy trial final baseline, 6 and 12 month findings published December month findings published December 2006 2006 GerontologistGerontologist

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Effectiveness R01: Long-Term Effectiveness R01: Long-Term Maintenance of Exercise Among Maintenance of Exercise Among Older Adults with OAOlder Adults with OA

Funded by NIA through cross-institute Funded by NIA through cross-institute initiative to examine strategies to initiative to examine strategies to support long-term maintenance of support long-term maintenance of behavior changebehavior change

Opportunity to expand REACH of Fit Opportunity to expand REACH of Fit and Strong!and Strong!

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Design and MethodsDesign and Methods

Recruit 600 older adultsRecruit 600 older adults Replicate Fit and Strong! in 5 Replicate Fit and Strong! in 5

Chicago Department on Aging Chicago Department on Aging regional senior centers with all regional senior centers with all participantsparticipants

Following 8-week Fit and Strong!, Following 8-week Fit and Strong!, participants were randomized to participants were randomized to “mainstreamed” vs. “negotiated” “mainstreamed” vs. “negotiated” treatment groups; half in each group treatment groups; half in each group received telephone reinforcementreceived telephone reinforcement

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Design and Methods Design and Methods cont’d.cont’d.

Outcomes assessed in person at Outcomes assessed in person at baseline, 2, 6, 12, and 18 monthsbaseline, 2, 6, 12, and 18 months

Quarterly telephone calls assess Quarterly telephone calls assess maintenance of multiple component maintenance of multiple component physical activity program over timephysical activity program over time

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Demographic Characteristics: Demographic Characteristics: Participants (N=536)Participants (N=536)

Mean AgeMean Age 7171 FemaleFemale 86%86% > High School> High School 66% 66% Race/EthnicRace/Ethnic

CaucasianCaucasian

African African AmericanAmerican

HispanicHispanic

OtherOther

37%37%

49%49%

9%9%

5%5%

ARA Class IIARA Class II 58% 58% Income <$20,000Income <$20,000 37%37%

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% Other Self-Reported % Other Self-Reported ConditionsConditions

  N=536

High Blood Pressure 65

Diabetes 24

Heart Disease 15

Lung Disease 6

Cancer 3

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Changed InstructorsChanged Instructors

Prior goal: err on side of safety- Prior goal: err on side of safety- designed and tested using Physical designed and tested using Physical Therapist instructorsTherapist instructors

Current goal: maximize Current goal: maximize REACH/reduce costREACH/reduce cost Trained certified exercise instructors Trained certified exercise instructors

in Fit and Strong!in Fit and Strong! 161 161 participants trained by PTs; participants trained by PTs; 375 375

participants trained by CEIs.participants trained by CEIs.

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Results of Change Results of Change Compared outcomes under two instruction modesCompared outcomes under two instruction modes Hypothesis: no difference in outcomesHypothesis: no difference in outcomes Found no significant differences between PT and Found no significant differences between PT and

CEI-led participants on:CEI-led participants on: AttendanceAttendance Maintenance of physical activityMaintenance of physical activity Class evaluation (overwhelmingly positive for both)Class evaluation (overwhelmingly positive for both) Performance measuresPerformance measures LE Pain, stiffness, and functioningLE Pain, stiffness, and functioning

Superior results in PT-led group on two of five SE Superior results in PT-led group on two of five SE measures: measures: SE for exercise and barriers adherence SE (Seymour, Hughes at al, in SE for exercise and barriers adherence SE (Seymour, Hughes at al, in

press, press, Arthritis Care andArthritis Care and Research)Research)

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Findings 2, 6, and 12 months: Findings 2, 6, and 12 months: Exercise Participation (N = Exercise Participation (N = 486)486)

 

Caloric expenditure (all)

Caloric expenditure (moderate)

Frequency of exercise (all)

Frequency of exercise (mod)

  b p b p b p b p

2 mos 0.288 0.000 0.332 0.000 0.970 0.432 2.154 0.001

6 mos 0.125 0.009 0.132 0.041 -0.725 0.595 0.480 0.492

12 mos 0.098 0.044 0.096 0.142 0.120 0.931 0.745 0.294

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Findings at 2, 6, and 12 Findings at 2, 6, and 12 months: LE Functionmonths: LE Function

 WOMAC Pain 

WOMAC Stiffness 

WOMAC Physical Function

  b p b p b p

2 mos -0.355 0.018 -0.347 0.000 -1.770 0.000

6 mos -0.181 0.281 -0.308 0.000 -1.783 0.001

12 mos -0.458 0.006 -0.417 0.000 -1.722 0.001

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Findings 2, 6, and 12 Findings 2, 6, and 12 months: Performance months: Performance MeasuresMeasures

 6 minute walk 

Timed sit-stand 

Body Mass Index 

  b p b p b p

2 mos 0.039 0.039 2.517 0.000 -0.185 0.331

6 mos 0.077 0.000 2.243 0.000 -0.201 0.300

12 mos 0.055 0.014 1.849 0.000 -0.378 0.057

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Significant Outcomes (N=486)Significant Outcomes (N=486)2 Months2 Months 6 Months6 Months 12 months12 months

Caloric Caloric Expenditure (all)Expenditure (all)

Caloric Expenditure Caloric Expenditure (all)(all)

Caloric Expenditure Caloric Expenditure (all)(all)

Caloric Caloric Expenditure Expenditure (moderate)(moderate)

Caloric ExpenditureCaloric Expenditure

(moderate)(moderate)

WOMAC StiffnessWOMAC Stiffness WOMAC Stiffness WOMAC Stiffness WOMAC Stiffness WOMAC Stiffness

WOMAC PainWOMAC Pain WOMAC PainWOMAC Pain

WOMAC Physical WOMAC Physical FunctionFunction

WOMAC Physical WOMAC Physical FunctionFunction

WOMAC Physical WOMAC Physical FunctionFunction

Lower-extremity Lower-extremity strengthstrength

Lower-extremity Lower-extremity strengthstrength

Lower-extremity Lower-extremity strengthstrength

Aerobic capacityAerobic capacity Aerobic capacityAerobic capacity Aerobic capacityAerobic capacity

Body Mass Index Body Mass Index (borderline)(borderline)

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Conclusions Conclusions

Fit and Strong! is safe, low cost, Fit and Strong! is safe, low cost, easily replicable EB program easily replicable EB program

Has been demonstrated to impact:Has been demonstrated to impact: Exercise maintenanceExercise maintenance Lower-extremity stiffness, pain, physical Lower-extremity stiffness, pain, physical

functionfunction Lower-extremity strength (timed sit-Lower-extremity strength (timed sit-

stand)stand) Aerobic capacity (6 minute distance walk)Aerobic capacity (6 minute distance walk)

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Conclusions cont’d.Conclusions cont’d. Benefits observed at 2, 6, and 12 Benefits observed at 2, 6, and 12

months-consistent over timemonths-consistent over time

Benefits Benefits consistentconsistent across increasingly across increasingly diverse participants, settings, and diverse participants, settings, and geographic areasgeographic areas

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Current translation Current translation effortsefforts

R18 from CDC to disseminate in IL R18 from CDC to disseminate in IL and NC- working with AAAsand NC- working with AAAs

Contract from National Arthritis Contract from National Arthritis Foundation to disseminate in 4 Foundation to disseminate in 4 additional states (NH, MI, KS, CA)additional states (NH, MI, KS, CA)

Active at multiple sites in WVA- Active at multiple sites in WVA- mayor’s reaction!mayor’s reaction!

Describe more in breakoutDescribe more in breakout

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Bottom Line- Just Do Bottom Line- Just Do It!It!

Do evidence based programming! It Do evidence based programming! It matters and can help your bottom line matters and can help your bottom line in addition to your clients over timein addition to your clients over time

Researchers –hang in there- Researchers –hang in there- intervention-translation a long road but intervention-translation a long road but doable and incredibly rewarding doable and incredibly rewarding

If we stick together- as a community of If we stick together- as a community of committed gerontologists, produce the committed gerontologists, produce the evidence, send the same message -the evidence, send the same message -the $ will follow!$ will follow!

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Thanks!