overview

Exercise Intervention Research on Persons with Disabilities - What We Know and Where We Need to Go. Professor James H. Rimmer, PhD; Director, National Center on Physical Activity and Disability, Department of Disability and Human Development, University of Illinois at Chicago, Chicago, IL, USA December 1, 2010Olle Höök LectureSwedish Society of Medicine Annual MeetingGoteborg, Sweden

Overview

• Part 1: What we know 1. Evidence on exercise interventions and

health outcomes 2. Characteristics of the exercise intervention

• Part 2: Where we need to go1. Identifying the problem2. Finding ways to address it3. Framing Future Research

Part 1: Point 1

What we know ~The evidence on exercise interventions and health outcomes in persons with disabilities

Methods –Scoping Review at Abstract Level

Disability and Health Promotion Scoping Review Matrix (N=330)

With Exercise Studies (N=135)

MEDLINE PsycInfo CINAHL

•Subject headings related to disability population, health promotion interventions and health outcomes

Searc

hin

g

Str

ate

gie

s •1986~June 2006•English language•Peer-reviewed journal•Adults with disabilities (18-65 yrs)

•Not health promotion related•Medically oriented treatment E

xcl

usi

on

Cri

teri

a

•Not disability related •Not peer reviewed•Outside age range•Outside publication year

N=3987

Excluded

3657

Exercise studies included in this review (N=80)

•Rehab modality involved •Rehab techniques involved

•Nonspecific disability type•Non-health-related outcomes

Excl

usi

on

Cri

teri

a

Rimmer et al. (2010). Am J Phy Med & Rehab 89: 249-63

No. of Trials by Disability and Research Design(Total N=80)

Non-RCT included pre- and post-trial (N=22), non-randomized controlled trial (N=16), case study (N=4), qualitative study (N=3), single subject design (N=2), and unavailable (N=1).


Alz. Dis., Alzheimer’s disease; ; ALS, amyotrophic lateral sclerosis ;Mus. Dys., Muscular dystrophy; Parki. Dis., Parkinson’s disease

Physical Activity Guidelines for Americans-cont’d

6

• Health Outcomes Areas– All-cause mortality– Cardiorespiratory health– Musculoskeletal health– Metabolic health– Energy balance & maintenance of healthy

weight– Cancer – Functional health– Mental health

7

Number of Studies by Disability Group and Subcategories in Functional Health

Vocational,1

Pain,5

Motor Funct.,10

Balance,14

QOL,11

Funct. Ind.,12

Walking Cap.,18

0

2

4

6

8

AD ALS CPCross ID MD MS PD PolioSCI STK TBI

1

12 21

21

1

1

3

1

1

1

32

52

2 23

1 121

2 2

7

1 1 1

6

1

8

# o

f tr

ials

Subc

ateg

ory

(N)

AD, Alzheimer’s disease; ALS, amyotrophic lateral sclerosis; CP, cerebral palsy; Cross, cross disability; ID, intellectual disability; MD, muscular dystrophy; MS, multiple sclerosis; PD, Parkinson’s disease;STK, stroke; TBI, traumatic brain injury; QOL, quality of life

8

Number of Studies by Disability Group and Subcategories in Cardiorespiratory Health

Lipis, 2

CR fitness,21

0

2

4

AD ALS CPCross ID MD MS PD PolioSCI STK TBI

21

2

1

3

2

3

1

2

4

2

# o

f tr

ials

AD, Alzheimer’s disease; ALS, amyotrophic lateral sclerosis; CP, cerebral palsy; Cross, cross disability; ID, intellectual disability; MD, muscular dystrophy; MS, multiple sclerosis; PD, Parkinson’s disease;STK, stroke; TBI, traumatic brain injury; CR fitness, cardiorespiratory fitness

Subca

tegor

y (N

)

9

Number of Studies by Disability Group and Subcategories in Musculoskeletal Health

AD, Alzheimer’s disease; ALS, amyotrophic lateral sclerosis; CP, cerebral palsy; Cross, cross disability; ID, intellectual disability; MD, muscular dystrophy; MS, multiple sclerosis; PD, Parkinson’s disease;STK, stroke; TBI, traumatic brain injury; BMD, bone mineral density; M. Strength, muscle strength

13 2

42

4 3

5

3

1 1 1 11 1 1 2

1 10

2

4

6

8

# o

f tr

ial

AD ALS CP Cross ID MD MS PD Polio SCI STK TBI

BMD,2

Flexibility,5

M. Endurance,4

M. Strength,27

Subc

ateg

ory

(N)

10

Number of Studies by Disability Group and Subcategories in Metabolic Health

AD, Alzheimer’s disease; ALS, amyotrophic lateral sclerosis; CP, cerebral palsy; Cross, cross disability; ID, intellectual disability; MD, muscular dystrophy; MS, multiple sclerosis; PD, Parkinson’s disease;STK, stroke; TBI, traumatic brain injury; BMI, body mass index

1

4

1 1

12

0

2

4

# o

f tr

ial


Body Fat,3

Weight/BMI,7

Subc

ateg

ory

(N)

11

Number of Studies by Disability Group and Subcategories in Mental Health

AD, Alzheimer’s disease; ALS, amyotrophic lateral sclerosis; CP, cerebral palsy; Cross, cross disability; ID, intellectual disability; MD, muscular dystrophy; MS, multiple sclerosis; PD, Parkinson’s disease;STK, stroke; TBI, traumatic brain injury; Social Int., social interaction

1

6

12

1 12

1

12

1 1

1 1 1

1 1 1 10

2

4

6

# o

f tr

ial


Other,4

Cognition,3

Social Int.,5

Depression,7

Fatigue,8

Subc

ateg

ory

(N)

Other: quality of sleep (AD); self-perception (CP); maladaptive behavior (ID); self-esteem (TBI)

12

Effects of Exercise on Health Outcomes by Evidence and Disability

No Limited Moderate Strong

LEVEL OF EVIDENCE

% o

f trials w

ith sig

. fin

din

gs

Strong: > 85% of reviewed trials were significant; Moderate: 50-84% of reviewed trials were significant; Limited: <49% of reviewed trials with significant findings.

CRHCRHMBHMBHFHFHMSHMSHMHMH

CRHCRH

MBHMBH

FHFH

MSHMSHMHMH

CRHCRH

MBHMBH

FHFH

MSHMSH

MHMHNon-Progressive physical disabilities: Stroke, TBI, SCI, CPProgressive physical disabilities: MS, Polio, Muscular Dystrophy, Parkinson’s, ALSCognitive disabilities: ID/DS, Alz. Dis.

FH, Functional Health CRH, Cardiorespiratory Health MSH, Musculoskeletal Health MBH, Metabolic Health MH, Mental Health

Prevalence of Adverse Events

98.2%

1.8%

99.4%

0.6%0%

20%

40%

60%

80%

100%

Participants not experiencingadverse events

Participants experiencingadverse events

Pre

vale

nce

(N, %

) Exercise Group (N=2961)

Control Group (N=1832)

2908 1821

53, 11,

Less than 2% of prevalence of adverse events relating to exercise in the exercise group

U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report 2008

Prevalence of Adverse Events-cont’d

Prevalence of Events in the Execise and Control Group

1.15%

0.60%

0.00%

0.50%

1.00%

1.50%

2.00%

Exercise Group Control Group

Ad

vers

e E

ven

ts Serious Adverse Events (N=45)

Non-Serious Adverse Events(N=19)

0.64%

(N=1832)(N=2961)

14

Type of Adverse Events:• Serious: withdrew from the study• Non-Serious: completed the study

N=34

N=19 N=11


15

Prevalence of 4 Major Adverse Events

0.00% 0.50% 1.00% 1.50% 2.00%

Total

Increased fatigueSoreness or Pain

Falls

Cardiovascular

OthersElevated spasticity

MS exacerbationRecurrent stroke

Control Group (N=1832)

Exercise Group (N=2961) Symptom-Associated

Cardiovascular Problems

Fall

Musculoskeletal Problems


Part 1: Point 2Characteristics of exercise interventions in persons with disabilities

No. of Studies by Exercise Type


18

Exercise Regimen

• Type – Aerobic exercise: walking on ground,

treadmill, using cycle ergometer, stepping ergometer, rowing, arm ergometer (SCI), and wheelchair ergometer (SCI)

– Strengthening: progressive resistance mode with weight machines, free weights and elastic bands.

– Aquatic exercise: (stroke, MS, traumatic brain injury, Polio)

– Alternative: Yoga (MS), Tai-Chi (MS, Parkinson’s), Qigong (Muscular Dystrophy)

19

Exercise Regimen-cont’d

• Intensity– Moderate or higher (50% HRmax or

VO2peak)

• Frequency– 3-5 times/week

• Duration– 30-60 minutes per session

• Length– 12-20 weeks

20

Summary• Level of evidence

– Relatively strong evidence for musculoskeletal health, functional health and mental health.

– More studies needed on metabolic health, healthy weight and decreasing secondary conditions.

• Strong need for more RCTs. • Safety

– Exercise can be implemented safely without inducing significant adverse events.

Part 2: Point 1Identifying the Problem from a Public Health Perspective

•Problem: Low Physical Activity Levels in People with Disabilities Create Enormous Health Problems•Conceptual model of deconditioning in people with disabilities

Leisure-Time Physical Activity Participation

Altman et al. (2008). Disability and Health in the U.S., 2001-2005

%

Relationship Between Leisure-Time Physical Activity & Health Status by Disability

Altman et al. (2008). Disability and Health in the U.S., 2001-2005

Leisure-Time Physical Activity Health Status

Without Disability

Disability

Condition

Rate in Total Sample, % (n=2075)

Rate in Disability Group,

% (n=545)

Rate in No Disability Group,

% (n=1530)

Chronic pain in muscles, joints 23.8 55.6 14.2Sleep problems 22.4 41.8 16.3Extreme fatique 20.7 44.8 13.2Weight or eating problems 19.8 39 13.7Periods of depression 17.2 33.5 12.1Skin problems 14.2 22 9Muscle spasms 11.4 25.5 7Respiratory infections (not colds) 10.9 20.9 7.8Falls or other injuries 10.2 20.6 6.9Bowel/bladder problems 9.8 22.8 5.7Serious episodes of anxiety 9.6 19.9 6.3Lack of romantic relationships 8.4 14.9 6.3Problems getting out/getting around 8.3 22.4 3.9Problems making/seeing friends 7.4 12.7 5.7Feelings of being isolated 5.6 14.8 5.3Asthma 5.3 12.2 3.4Deconditioning

Rate of Secondary Conditions in Adults with and without Disability (Kinne et al., 2004)

Part 2: Point 2Identifying the Core Problem:Deconditioning

Environmental

Pathway 2

Pathway 1

Decon

dit

ion

ing

C

ycle

Environmental

Pathway 2

Pathway 1

Decon

dit

ion

ing

C

ycle

How do we break this deconditioning cycle?

Environmental

Pathway 2

Pathway 1

Decon

dit

ion

ing

C

ycle

Case Study 1

• A 30-yr old man with a upper level SCI visits his doctor for a Stage II pressure ulcer. He’s gained 30 lbs since his injury and had a 30 percent reduction in lean body mass. He’s lost a significant amount of strength 10 years post-injury and is no longer able to perform independent transfers or pressure relief. He sits in his wheelchair most of the day with little movement or activity. His personal assistance services are increased to assist with transfers and ADLs.

Case Study 3

• A 35-year old woman with multiple sclerosis has high levels of fatigue and is taking a corticosteroid that has caused her to gain 25 lbs. She now feels more fatigued and is concerned that exercise will make her more tired, so she stops going to her local health club. The increased weight gain and reduced muscle strength impair her balance resulting in a serious fall. She decides to purchase a scooter to prevent further falls.

Fitness-Enhancing

Activity

Leisure Activity

Task-Specific Activity

Residual Activity & Movement

<3 METs

3 -4 METs

4 -6 METs

>6 METs

Lower I ntensity

Higher I ntensity Characteristics Examples

•Cardiopulmonary•Strength

•Exercise machines•Exercise classes•Jogging, swimming, fast walking/rolling, cycling

•Enjoyable •Seasonable •Social

•Leisure sports (golf, tennis , bowling)•Walking dog•Biking •Skiing

•Indoor/outdoor household

•Employment•Community

•Yard work•Errands•Stairs•Shopping •Rehabilitation

•Cumulative •Moving body•Gesture•Shifting •Fidgeting

Physical Activity Pyramid of Energy Expenditure (PAPEE)

Rimmer & Schiller (2010). Second State of the Science Conference, Interactive Exercise Technologies and Exercise Physiology for People with Disabilities, RECTECH

Part 2 Point 3

Where we need to go ~

Systems Change•Transitional model from rehabilitation to community-based physical activity•How to make it happen

Overall Length of Stay (LOS) following Medical Rehabilitation Has Been Decreasing

Ottenbacher et al. (2004). JAMA 292, p. 1687-95

Day , Median (interquartile range)

N=148,807

Length of Stay and Hospital Readmission in People with Disabilities

Re-hospitalization

Length of Stay

Ottenbacher et al. (2000). A J Public Health 90, 1920-3

N=96,473, pertaining 8 impairment categories

0 2 4 6 8 10 12 14 16 18 20

He

alt

h &

Fu

nc

tio

n

Minimum level of function

Recovery (months)

Rehab

Physical activity

Getting Beyond the Plateau

Exercise/PA

Shorter LOS in rehab

Transi

tio

nal P

A

LOS, Length of stay; PA, Physical activity

How to Make It Happen

• Fitness professionals must strengthen their skills in health promotion and disability.

• Rehabilitation professionals must embrace the concept of extending its services into community-based fitness centers.

• The third party must be willing to pay for the membership and the consultative services.

Health Promotion Model for People with Disabilities

Rehabilitation

Community Exercise

Transitional SettingUniversity-Based Clinic

Hospital Wellness FacilityPrivate Clinic

Community SettingHome ProgramFitness Center

Recreation FacilitySenior Center

Rehabilitation SettingHospital

Rehabilitation CenterLong-Term Care Facility

Outpatient Medical Center

Rehab Med- RCEP

RCEP - CIFT

Rehab Med, Rehabilitation Medicine;RCEP, Registered Clinical Exercise Physiologist;CIFT, Certified Inclusive Fitness Trainer

Rehab - RCEP

RCEP - CIFT

Certified Inclusive Fitness Trainer –CIFT(ACSM/NCPAD)

Competency Area %

Exercise Prescription and Programming 20

Exercise Physiology and Related Exercise Science 18

Health Appraisal, Fitness and Clinical Exercise Testing

15

Safety, Injury Prevention, and Emergency Procedures

11

Clinical and Medical Considerations 11

Human Behavior and Counseling 10

Disability Awareness 10

Americans with Disabilities Act (ADA) & Facility Design

5

http://www.vue.com/acsm/cift/

http://www.vue.com/acsm/cift/

Key Abilities of a CIFT

• demonstrates and leads safe, effective and adapted methods of exercise

• writes adapted exercise recommendations• understands precautions and contraindications to exercise

for people with disabilities• is aware of current ADA policy specific to recreation

facilities (U.S. Access Board Guidelines) and standards for accessible facility design

• can utilize motivational techniques and provide appropriate instruction to individuals with disabilities to enable them begin and continue healthy lifestyles

Part 2: Point 3Framing Future Research

Empower the Person

Enable the Environment

Provide Access

Increase Participation

Barriers to Physical Activity Make it More Difficult for

Youths with Disabilities to Reach the Goal

Physical Activity Conceptual Model

Healthy, Active

LifestylesFOR ALL

Improve Physiological and Psychological Health

Promote Sustainability

Access

Participation

Sustainability Environ

mental

Pathway 2

Pathway 1

Decon

dit

ion

ing

C

ycle

Deconditioning Cycle

Slowdown or Break

Physical Activity

Rehabilitation

Searchable Electronic LibrarySearchable Electronic Library – – Conceptual Framework Conceptual Framework

Intensity

Frequency

Duration

Length

Type

Intervention

Cardiorespiratory Health

Metabolic Health

Musculoskeletal Health

Functional Health

Mental Health

Healthy Weight

Secondary Conditions-

pain, fatigue, othersAdverse events

Health OutcomesStudy Info

Author

Year

Title

Keyword

Design

Methodo- logical quality

SettingCancer

All-Cause Mortality

Participant

Disability Type

Age

Study Characterist

ic

Pattern

Example of Summary Table

Study Information

ParticipantDemographics

Study Characteristics

Abstract

Intervention Characteristics

Health Outcomes

Webshop• NCPAD has a variety

of instructional adapted exercise programs and products available for purchase such as:– Exercise Program

for Stroke Survivors

– Core and Stability Exercises for Stroke Survivors and People with Multiple Sclerosis

James H. Rimmer Director, National Center on Physical Activity

and Disability www.ncpad.org

Professor, Dep. of Disability and Human Development,

University of Illinois at Chicago (M/C 626)1640 W. Roosevelt Rd., Room 711

Chicago, IL 60608Phone: 312-413-9651 Fax: 312-355-4058

TTY: 800-900-8086 Email: [email protected]

Thank you

overview

Documents

review n

exercise studies n

unavailable n

sheet1rct n

review matrix n

posttrial n

qualitative study n

case study n