Hip-focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial.

BACKGROUND: Previously, we identified a population of older adults with chronic low back pain, hip pain, and hip muscle weakness who had worse 12-month low back pain and functional outcomes than age-matched adults with only low back pain, indicating an increased risk for future mobility decline. We sought to determine whether tailored, hip-focused physical therapy reduced pain and functional limitations in this high-risk population compared with non-tailored, spine-focused physical therapy. METHODS: We did a multicentre, single-masked, randomised controlled trial at three research-based sites in the USA. We recruited older adults (aged 60-85 years) with hip pain and weakness who reported moderate low back pain intensity at least half the days in the last 6 months. Patients were randomly assigned to hip-focused physical therapy or spine-focused physical therapy using permuted blocks with random block size, stratified by site and sex (ie, male or female). The primary outcomes were self-reported disability using the Quebec Back Pain Disability Scale (QBPDS) and performance-based 10-Meter Walk Test (10MWT) at 8 weeks. All analyses were done in the intention-to-treat population. Adverse events were collected by study staff via a possible adverse event reporting form and then adjudicated by site investigators. This trial was registered with ClinicalTrials.gov, NCT04009837. FINDINGS: Between Nov 1, 2019, and April 30, 2022, 184 participants were randomly assigned to receive hip-focused (n=91) or spine-focused physical therapy (n=93) interventions. The mean age was 70·7 (SD 6·2) years. 121 (66%) of 184 participants were women, 63 (34%) were men, and 149 (81%) were White. At 8 weeks, the mean between-group difference on the QBPDS was 4·0 (95% CI 0·5 to 7·5), favouring hip-focused physical therapy. Both groups had similar, clinically meaningful gait speed improvements (10MWT) at 8 weeks (mean difference 0·004 m/s [95% CI -0·044 to 0·052]). No serious adverse events were related to study participation. INTERPRETATION: Tailored hip-focused physical therapy demonstrated greater improvements in low back pain-related disability at 8 weeks. However, both hip-focused physical therapy and spine-focused physical therapy produced clinically meaningful improvements in disability and function for this high-risk population at 6 months. These findings warrant further investigation before clinical implementation. FUNDING: US National Institute on Aging of the National Institutes of Health.

A Clinical Measure of Trunk Neuromuscular Function Predicts Falling in Older Adults With Chronic Low Back Pain.

BACKGROUND AND PURPOSE: Older adults with low back pain (LBP) are at risk for falling, but condition-specific mechanisms are unknown. Trunk neuromuscular function is critical for maintaining balance during mobility tasks and is often impaired in older adults with LBP. The purpose of this study was to assess whether aberrant lumbopelvic movements (or aberrant movements), a clinical index of trunk neuromuscular function, were associated with increased fall risk among older adults with chronic LBP over a 12-month follow-up period. METHODS: This study analyzed data from a prospective cohort study of 250 community-dwelling older adults with chronic LBP. Participants were screened for 4 aberrant movements during 3 trials of forward flexion from a standing position: instability catch, painful arc, altered lumbopelvic rhythm, and Gower's sign. Aberrant movements were totaled to yield a summary score (ie, 0-4). Prospective falls were monitored via monthly fall calendars for 12 months. A generalized linear model with Poisson distribution and log link function was used to evaluate the association between aberrant movements and prospective fall risk. Age, sex, body mass index, LBP intensity, dynamic balance performance, prior falls, anxiolytic medication usage, and hip osteoarthritis characteristics were included as covariates in the model. RESULTS: Baseline aberrant movements were independently associated with greater fall risk (risk ratio = 1.249, 95% CI = 1.047-1.491, P = .014); each 1-unit increase in aberrant movement score imparted a 24.9% increase in the risk of falling. CONCLUSIONS: Aberrant movements increased the risk of falling among older adults with chronic LBP over a 1-year span.

Examining Psychological Factors as Contributors to Pain, Disability, and Physical Function in Geriatric Chronic Low Back Pain: A Prospective Analysis of the Delaware Spine Studies Cohort.

In younger populations, risk factors from psychologically-focused theoretical models have become accepted as primary drivers behind the persistence of low back pain (LBP), but these risk factors have not been thoroughly assessed in older adult populations (60-85 years). To address this knowledge gap, we sought to examine longitudinal associations between both general and pain-related psychological risk factors and future pain intensity, LBP-related disability, and physical function (gait speed) outcomes in older adults with chronic LBP (n = 250). Questionnaires for general (ie, depressive symptoms) and pain-related psychological risk factors (ie, fear-avoidance beliefs, pain catastrophizing, and kinesiophobia) were collected at baseline. Questionnaire values were entered into principal component analysis to yield a combined psychological component score. LBP intensity (pain thermometers), LBP-related disability (Quebec Back Pain Disability Scale), and gait speed were measured at baseline and 12-month follow-up. Multiple linear regression was used to examine adjusted associations between baseline psychological component scores and each prospective outcome. The baseline psychological component score failed to independently predict 12-month LBP-related disability and gait speed after adjustment for baseline outcomes. Though the psychological component score was associated with 12-month LBP intensity after adjusting for baseline LBP intensity, this association diminished with full adjustment for other baseline characteristics. Cumulatively, general and pain-related psychological risk factors did not independently predict longitudinal pain, disability, and physical function outcomes in this cohort. Compared to younger populations with this condition, general and pain-related psychological risk factors may have less influence on the maintenance of chronic LBP in older adults. PERSPECTIVE: This article failed to establish consistent independent relationships between psychological factors and worse longitudinal pain, disability, and physical function outcomes in older adults with chronic LBP. The findings highlight a need to determine other age-specific biopsychosocial risk factors that may impact the maintenance of chronic pain in this patient population.

Construct validity of movement-evoked pain operational definitions in older adults with chronic low back pain.

OBJECTIVE: Movement-evoked pain (MeP) may predispose the geriatric chronic low back pain (LBP) population to health decline. As there are differing operational definitions for MeP, the question remains as to whether these different definitions have similar associations with health outcomes in older adults with chronic LBP. DESIGN: Cross-sectional analysis of an observational study. SETTING: Clinical research laboratory. SUBJECTS: 226 older adults with chronic LBP. METHODS: This secondary analysis used baseline data from a prospective cohort study (n = 250). LBP intensity was collected before and after the repeated chair rise test, stair climbing test, and 6-minute walk test; MeP change scores (ie, sum of pretest pain subtracted from posttest pain) and aggregated posttest pain (ie, sum of posttest pain) variables were calculated. LBP-related disability and self-efficacy were measured by the Quebec Back Pain Disability Scale (QBPDS) and Low Back Activity Confidence Scale (LOBACS), respectively. Physical function was measured with the Health ABC Performance Battery. Robust regression with HC3 standard errors was used to evaluate adjusted associations between both MeP variables and disability, self-efficacy, and physical function. RESULTS: Greater aggregated posttest MeP was independently associated with worse disability (b = 0.593, t = 2.913, P = .004), self-efficacy (b = -0.870, t = -3.110, P = .002), and physical function (b = -0.017, t = -2.007, P = .039). MeP change scores were not associated with any outcome (all P > .050). CONCLUSIONS: Aggregate posttest MeP was linked to poorer health outcomes in older adults with chronic LBP, but MeP change scores were not. Future studies should consider that the construct validity of MeP paradigms partially depends on the chosen operational definition.

Movement-Evoked Pain Versus Widespread Pain: A Longitudinal Comparison in Older Adults With Chronic Low Back Pain From the Delaware Spine Studies.

It is currently unknown which pain-related factors contribute to long-term disability and poorer perceived health among older adults with chronic low back pain (LBP). This investigation sought to examine the unique influence of movement-evoked pain (MeP) and widespread pain (WP) on longitudinal health outcomes (ie, gait speed, perceived disability, and self-efficacy) in 250 older adults with chronic LBP. MeP was elicited with 3 standardized functional tests, while presence of WP was derived from the McGill Pain Map. Robust regression with HC3 standard errors was used to examine associations between these baseline pain variables and health outcomes at 12-month follow-up. Covariates for these models included age, sex, body mass index, resting and recall LBP intensity, LBP duration, depression, pain catastrophizing, and baseline outcome (eg, baseline gait speed). Greater MeP was independently associated with worse 12-month LBP-related disability (b = .384, t = 2.013, P = .046) and poorer self-efficacy (b = -.562, t = -2.074, P = .039); but not gait speed (P > .05). In contrast, WP and resting and recall LBP intensity were not associated with any prospective health outcome after adjustment (all P > .05). Compared to WP and resting and recall LBP intensity, MeP is most strongly related to longitudinal health outcomes in older adults with chronic LBP. PERSPECTIVE: This article establishes novel independent associations between MeP and worse perceived disability and self-efficacy at 12-months in older adults with chronic LBP. MeP likely has biopsychosocial underpinnings and consequences and may therefore be an important determinant of health outcomes in LBP and other geriatric chronic pain populations.

Trajectories of Physical Function and Disability Over 12 Months in Older Adults With Chronic Low Back Pain.

BACKGROUND AND PURPOSE: Understanding prognosis is critical for clinical care and health policy initiatives. The purpose of this study was to determine whether distinct prognostic trajectories of physical function and disability exist in a cohort of 245 community-dwelling older adults with chronic low back pain (LBP), and to characterize the demographic, health, and pain-related profiles of each trajectory subgroup. METHODS: All participants underwent standard clinic examinations at baseline, 3 months, 6 months, and 12 months. At each time point, the Late Life Function & Disability Instrument (LLFDI) was used to measure general physical function (LLFDI Function) and disability (LLFDI Disability-Limitation); the Quebec LBP Disability Questionnaire was used to measure disability due to pain. Growth mixture modeling (GMM) was performed on each outcome to identify distinct trajectory classes/subgroups; baseline demographic (eg, age and sex), health (eg, comorbidities, depressive symptoms, and physical activity level), and pain-related (eg, LBP intensity, pain-related fear, and pain catastrophizing) characteristic profiles were compared across subgroups. RESULTS: GMM statistics revealed an optimal number of 3 to 4 trajectory subgroups, depending on the outcome examined. Subgroups differed across demographic, health, and pain-related characteristics; the classes with the most favorable prognoses had consistent profile patterns: fewer depressive symptoms, fewer comorbidities, higher physical activity levels, lower LBP intensities, less pain-related fear, and less pain catastrophizing. CONCLUSION: Our findings indicate that several distinct trajectory subgroups exist that would have been masked by observing mean cohort change alone. Furthermore, subgroup characteristic profiles may help clinicians identify likely prognostic trajectories for their patients. Future research should focus on identifying modifiable risk factors that best predict group membership, and tailoring interventions to mitigate the risk of poor prognosis.

Gait asymmetry is associated with performance-based physical function among adults with lower-limb amputation.

BACKGROUND: Adults with lower-limb amputation walk with an asymmetrical gait and exhibit poor functional outcomes, which may negatively impact quality-of-life. OBJECTIVE: To evaluate associations between gait asymmetry and performance-based physical function among adults with lower-limb amputation. METHODS: A cross-sectional study involving 38 adults with a unilateral transtibial (N = 24; 62.5 ± 10.5 years) or transfemoral amputation (N = 14; 59.9 ± 9.5 years) was conducted. Following gait analysis (capturing step length and stance time asymmetry at self-selected (SSWS) and fast walking speeds (FWS)), participants completed performance-based measures (i.e. Timed Up and Go (TUG), the 10-Meter Walk Test (10mwt), and the 6-Minute Walk Test (6MWT)). RESULTS: Step length and stance time asymmetry (at SSWS and FWS) were significantly correlated with each performance-based measure (p < .001 to p = .035). Overall, models with gait measures obtained at SSWS explained 40.1%, 46.8% and 40.1% of the variance in TUG-time (p = .022), 10mwt-speed (p = .003) and 6MWT-distance (p = .010), respectively. Models with gait measures obtained at FWS explained 70.0%, 59.8% and 51.8% of the variance in TUG-time (p < .001), 10mwt-speed (p < .001), and 6MWT-distance (p < .001), respectively. CONCLUSIONS: Increases in step length or stance time asymmetry are associated with increased TUG-time, slower 10mwt-speed, and reduced 6MWT-distance. Findings suggest gait asymmetry may be a factor in poor functional outcomes following lower-limb amputation.

Aberrant Lumbopelvic Movements Predict Prospective Functional Decline in Older Adults with Chronic Low Back Pain.

OBJECTIVE: To investigate if clinically observable aberrant lumbopelvic movements are associated with physical function at 12-month follow-up in older adults with chronic low back pain (CLBP), both directly and indirectly through baseline physical function. DESIGN: Secondary analysis of a yearlong prospective cohort study. SETTING: Clinical Research Laboratory. PARTICIPANTS: Community-dwelling older adults with CLBP (N=250). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Data from 239 participants were analyzed. Participants were screened at baseline for aberrant lumbopelvic movements during active trunk flexion; total observable aberrant movements were recorded and summed (range 0-4). Latent constructs of physical function were developed from an array of perception-based and performance-based outcome measures at baseline and 12 months, respectively. Structural Equation Modeling was used to assess the direct effect of baseline aberrant movement score on the latent construct of 12-month physical function, and its indirect effect through baseline physical function. RESULTS: Aberrant movements were present in most participants (64.7%) and had a significant negative total effect on 12-month physical function (γ= -0.278, P<.001). Aberrant movement score's direct effect and indirect effect, through baseline functioning, were significantly negatively associated with physical function at 12-months, after adjusting for covariates (γ=-0.068, P=.038; γ= -0.210, P<.001, respectively). CONCLUSIONS: Aberrant lumbopelvic movements are associated with decreased physical function at 12-month follow-up in older adults with CLBP, independent of baseline physical function and covariates. Future studies should evaluate if screening for aberrant movements may inform prognostic and interventional efforts in this patient population.

The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain.

OBJECTIVE: Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment. METHODS: This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively. IMPACT: This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.

A Standardized Assessment of Movement-evoked Pain Ratings Is Associated With Functional Outcomes in Older Adults With Chronic Low Back Pain.

OBJECTIVE: Despite high prevalence estimates, chronic low back pain (CLBP) remains poorly understood among older adults. Movement-evoked pain (MeP) is an understudied factor in this population that may importantly contribute to disability. This study investigated whether a novel MeP paradigm contributed to self-reported and performance-based function in older adults with CLBP. MATERIALS AND METHODS: This secondary analysis includes baseline data from 230 older adults with CLBP in the context of a prospective cohort study. The Repeated Chair Rise Test, Six Minute Walk Test, and Stair Climbing Test were used to elicit pain posttest LBP ratings were aggregated to yield the MeP variable. Self-reported and performance-based function were measured by the Late Life Function and Disability Index (LLFDI) scaled function score and Timed Up-and-Go Test (TUG), respectively. Robust regression with HC3 standard errors was used to model adjusted associations between MeP and both functional outcomes; age, sex, body mass index, and pain characteristics (ie, intensity, quality, and duration) were utilized as covariates. RESULTS: MeP was present in 81.3% of participants, with an average rating of 5.09 (SD=5.4). Greater aggregated posttest MeP was associated with decreased LLFDI scores (b=-0.30, t=-2.81, P=0.005) and poorer TUG performance (b=0.081, t=2.35, P=0.020), independent of covariates. LBP intensity, quality and duration were not associated with the LLFDI or TUG, (all P>0.05). DISCUSSION: Aggregated posttest MeP independently contributed to worse self-reported and performance-based function among older adults with CLBP. To understand long-term consequences of MeP, future studies should examine longitudinal associations between MeP and function in this population.

Classification of Geriatric Low Back Pain Based on Hip Characteristics With a 12-Month Longitudinal Exploration of Clinical Outcomes: Findings From Delaware Spine Studies.

OBJECTIVE: The purpose of this study is to identify geriatric chronic low back pain (LBP) subgroups based on the presence of potentially modifiable hip impairments, using Latent Variable Mixture Modeling (LVMM), and to examine the prospective relationship between these subgroups and key outcomes over time. METHODS: Baseline, 3-month, 6-month, and 12-month data were collected from a prospective cohort of 250 community-dwelling older adults with chronic LBP. Comprehensive hip (symptoms, strength, range of motion, and flexibility), LBP (intensity and disability), and mobility function (gait speed and 6-Minute Walk Test) examinations were performed at each timepoint. Baseline hip measures were included in LVMM; observed classes/subgroups were compared longitudinally on LBP and mobility function outcomes using mixed models. RESULTS: Regarding LVMM, a model with 3 classes/subgroup fit best. Broadly speaking, subgroups were differentiated best by hip strength and symptom presence: subgroup 1 = strong and nonsymptomatic, subgroup 2 = weak and nonsymptomatic, and subgroup 3 = weak and symptomatic (WS). Regarding longitudinal mixed models, all subgroups improved in most outcomes over time. Specifically, over 12 months, the nonsymptomatic subgroups had lower LBP intensity and disability levels compared with the WS subgroup, whereas the strong and nonsymptomatic subgroup had better mobility function than the 2 "weak" subgroups. CONCLUSION: These subgroup classifications may help in tailoring specific interventions in future trials. Special attention should be given to the WS subgroup given their consistently poor LBP and mobility function outcomes. IMPACT: Among older adults with chronic low back pain, there are 3 hip subgroups: "strong and nonsymptomatic," "weak and nonsymptomatic," and "weak and symptomatic." People in these subgroups demonstrate different outcomes and require different treatment; proper identification will result in tailored interventions designed to benefit individual patients. In particular, people in the WS subgroup deserve special attention, because their outcomes are consistently poorer than those in the other subgroups.

Hip Range of Motion and Strength Predict 12-Month Physical Function Outcomes in Older Adults With Chronic Low Back Pain: The Delaware Spine Studies.

OBJECTIVE: The objective of this study was to investigate whether poor hip range of motion (ROM) and strength predict 12-month physical function decline among older adults with chronic low back pain (LBP) and whether hip osteoarthritis modifies those relationships. METHODS: At baseline, passive ROM and strength measurements were taken for hip flexion, extension, abduction, adduction, internal rotation, and external rotation; ultrasound images and self-reported symptoms were used to evaluate hip osteoarthritis presence (eg, osteophytes and hip pain). At baseline and 12 months, performance-based (repeated chair rise, self-selected gait speed, 6-minute walk test [6MWT]) and self-reported (Quebec LBP Disability Questionnaire, Late-Life Function & Disability Instrument [LLFDI] basic and advanced lower extremity scales) physical function outcomes were assessed. Regression models were constructed for each outcome predicted by baseline hip ROM and strength measures, with adjustment for potential covariates. To avoid collinearity, hip ROM and strength measures with the strongest unadjusted correlations were included in final models. The hip osteoarthritis presence by hip ROM/strength interaction was also explored. RESULTS: Hip abduction strength predicted repeated chair rise (ß = -0.297, P < 0.001), gait speed (ß = 0.160, P = 0.003), 6MWT (ß = 0.159, P ≤ 0.001), Quebec LBP Disability Questionnaire (ß = -0.152, P = 0.003), and LLFDI basic lower extremity scale (ß = 0.171, P = 0.005) outcomes. Regarding hip ROM, extension predicted repeated chair rise (ß = -0.110, P = 0.043) and LLFDI advanced lower extremity scale (ß = 0.090, P = 0.007) outcomes, external rotation predicted gait speed (ß = 0.122, P = 0.004) outcomes, and abduction predicted LLFDI basic lower extremity scale (ß = 0.114, P = 0.026) outcomes. The hip osteoarthritis interaction was not significant for any model. CONCLUSION: Reduced hip strength and ROM predict physical function decline; hip osteoarthritis presence may not modify these relationships.

Hip osteoarthritis signs and symptoms are associated with increased fall risk among community-dwelling older adults with chronic low back pain: a prospective study.

BACKGROUND: Older adults with concurrent low back and hip pain are predisposed to reductions in physical performance and health-related quality of life. Yet no study to date has assessed whether or not coexisting hip impairments increase fall risk in older adults with chronic low back pain (CLBP). The objective of this study was to determine if hip osteoarthritis (OA) signs and symptoms per American College of Rheumatology (ACR) criteria are associated with fall risk over a 1-year span. METHODS: Falls were prospectively monitored for 1 year via fall calendars. Age, sex, body mass index (BMI), anxiolytic use, balance confidence, LBP-related disability, and prior fall history were identified as covariates. Hip pain, pain with hip internal rotation (IR), hip IR range of motion (ROM) ≥ 15°, and morning stiffness lasting ≤ 60 min were evaluated at baseline and summed to represent hip OA impairment burden. A generalized linear model with a Poisson distribution and log link function assessed the association between ACR criteria and fall risk beyond established covariates. As a secondary analysis, binary logistic regression assessed ACR criteria and the odds of falling two or more times within a year. RESULTS: Data from two-hundred and ten participants were analyzed. Hip OA signs and symptoms were present in 97.1% of the participants, and hip OA impairment burden was significantly greater (p < 0.050) in participants who fell ≥ 2 times compared to single and non-fallers. Higher hip OA impairment burden was associated with significantly increased fall risk (p = 0.001, risk ratio = 1.23, 95% CI 1.09-1.38) and odds of falling multiple times (p < 0.05, odds ratio = 1.41, 95% CI 1.01-1.95) after adjustment for covariates. CONCLUSIONS: Older adults with CLBP and concomitant hip impairments are an at-risk group for falling. Healthcare professionals should employ falls screening and preventive measures to avoid negative sequelae in this vulnerable population.

Markers of Cardiovascular Health in Older Adults with and Without Chronic Low Back and Radicular Leg Pain: A Comparative Analysis.

OBJECTIVES: 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, independent of body mass index (BMI) and current smoking status. METHODS: Age- and sex-matched older adults (60-85 years of age) with (n = 21) and without (n = 21) CLBPR were recruited. Current smokers were excluded. Blood samples were collected to measure cholesterol levels and pro-inflammatory markers (i.e., C-reactive protein and interleukin-6). Vascular endothelial function, a marker of cardiovascular health, was evaluated by measuring brachial artery flow-mediated dilation (FMD). General linear models with multifactorial designs were evaluated; group membership, BMI, education, and their respective two-way interaction terms were included as independent variables. RESULTS: Older adults with CLBPR had significantly higher BMIs (P = 0.004) and lower educational levels (P = 0.013) than did those without pain. There was a significant group-by-education interaction effect (P = 0.049) for endothelial function. Older adults without pain who were highly educated had higher FMD values, indicating better endothelial function (9.2%), whereas the following combinations all had lower FMD values: 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 educational level and independent of BMI and smoking. These findings suggest that older adults with CLBPR may be at a higher risk of cardiovascular disease.

Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study.

The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.

Association Between Improved Mobility and Distal Health Outcomes.

BACKGROUND: We examined the association between improved mobility and distal health outcomes in older adults using secondary analysis of data from a cluster-randomized controlled group exercise trial. METHODS: Participants were 303 men and women aged ≥65 and older in 32 independent living facilities, senior apartments, and community centers who participated in 12-week group exercise interventions. Included were those who completed ≥1 follow-up phone call regarding outcomes assessment in the following year. Gait speed and 6-minute walk distance (6MWD) were assessed at baseline and immediately after 12-week interventions to determine mobility performance change status. Falls, emergency department (ED) visits, and hospitalizations were assessed monthly for 12 months following the end of interventions via interactive voice response phone calls. Incident rate ratios (IRRs) were calculated to quantify incidence of adverse outcomes with respect to mobility performance change. RESULTS: Each 0.05 m/s increase in gait speed resulted in an 11% reduction in falls (IRR = 0.89; 95% confidence interval [CI], 0.84-0.94; p < .0001); a similar decrease was seen for each 20 m increase in 6MWD (IRR = 0.89; 95% CI, 0.83-0.93; p = .0003). Those who improved gait speed had 61 falls per 1,000 person-months versus 135 in those who had no change/a decline. Those who improved 6MWD had 67 falls per 1,000 person-months versus 110 per 1,000 person-months in those who had no change/a decline. Differences in ED visits and hospitalizations were not statistically significant. CONCLUSION: Improvements in mobility performance are associated with lower incidence of future falls. Given the exploratory nature of the findings, further investigation is warranted.

Potential long-term impact of "On The Move" group-exercise program on falls and healthcare utilization in older adults: an exploratory analysis of a randomized controlled trial.

BACKGROUND: Wellness program participation may reduce the risk of falling, emergency department-use, and hospitalization among older adults. "On the Move" (OTM), a community-based group exercise program focused on the timing and coordination of walking, improved mobility in older adults, but its impact on falls, emergency department-use, and hospitalizations remains unclear. The aim of this preliminary study was to investigate the potential long-term effects that OTM may have on downstream, tertiary outcomes. METHODS: We conducted a secondary analysis of a cluster-randomized, single-blind intervention trial, which compared two community-based, group exercise programs: OTM and a seated exercise program on strength, endurance, and flexibility (i.e. 'usual-care'). Program classes met for 50 min/session, 2 sessions/week, for 12 weeks. Older adults (≥65 years), with the ability to ambulate independently at ≥0.60 m/s were recruited. Self-reported incidence of falls, emergency department visitation, and hospitalization were assessed using automated monthly phone calls for the year following intervention completion. Participants with ≥1 completed phone call were included in the analyses. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated (reference = usual-care). RESULTS: Participants (n = 248) were similar on baseline characteristics and number of monthly phone calls completed. Participants in the seated exercise program attended an average of 2.9 more classes (p = .017). Of note, all results were not statistically significant (i.e. 95% CI overlapped a null value of 1.0). However, point estimates suggest OTM participation resulted in a decreased incidence rate of hospitalization compared to usual-care (IRR = 0.88; 95% CI = 0.59-1.32), and the estimates strengthened when controlling for between-group differences in attendance (adjusted IRR = 0.82; 95% CI = 0.56-1.21). Falls and emergency department visit incidence rates were initially greater for OTM participants, but decreased after controlling for attendance (adjusted IRR = 1.08; 95% CI = 0.72-1.62 and adjusted IRR = 0.96; 95% CI = 0.55-1.66, respectively). CONCLUSION: Compared to a community-based seated group exercise program, participation in OTM may result in a reduced risk of hospitalization. When OTM is adhered to, the risk for falling and hospitalizations are attenuated. However, definitive conclusions cannot be made. Nevertheless, it appears that a larger randomized trial, designed to specifically evaluate the impact of OTM on these downstream health outcomes is warranted. TRIAL REGISTRATION: Clinical trials.gov (NCT01986647; prospectively registered on November 18, 2013).

Development and Validation of Person-Centered Cut-Points for the Figure-of-8-Walk Test of Mobility in Community-Dwelling Older Adults.

BACKGROUND: The Figure-of-8-Walk test (F8WT) is a performance measure of the motor skill of walking. Unlike walking speed over a straight path, it captures curved path walking, which is essential to real-world activity, but meaningful cut-points have yet to be developed for the F8WT. METHODS: A secondary analysis of 421 community-dwelling older adults (mean age 80.7 ± 7.8), who participated in a community-based exercise clinical trial, was performed. Area under receiver operating characteristic curves (AUROCC) were calculated using baseline data, with F8WT performance discriminating different self-reported global mobility and balance dichotomies. Cut-points for the F8WT were chosen to optimize sensitivity and specificity. For validation, F8WT cut-points were applied to postintervention F8WT data. Participants were called monthly for 12 months after intervention completion to record self-reported incident falls, emergency department visits, and hospitalizations; risks of the outcomes were compared between those who performed well and poorly on the F8WT. RESULTS: F8WT performance times of ≤9.09 seconds and ≤9.27 seconds can discriminate those with excellent (sensitivity = 0.647; specificity = 0.654) and excellent/very good global mobility (sensitivity = 0.649; specificity = 0.648), respectively. A total number of steps ≤17 on the F8WT can discriminate those with excellent/very good/good global balance (sensitivity = 0.646; specificity = 0.608). Compared to those who performed poorly, those who performed well had a lower incidence of negative outcomes: F8WT time ≤9.09 seconds = 46%-59% lower; F8WT time ≤9.27 seconds = 46%-56% lower; F8WT steps ≤17 = 44%-50% lower. CONCLUSIONS: Clinicians may consider these preliminary cut-points to aid in their clinical decision making, but further study is needed for definitive recommendations.

Pain Provocation and the Energy Cost of Walking: A Matched Comparison Study of Older Adults With and Without Chronic Low Back Pain With Radiculopathy.

BACKGROUND AND PURPOSE: Chronic low back pain with radiculopathy (CLBPR) is common among older adults and can lead to walking difficulty. Energy cost of walking strongly predicts changes in walking speed, which is predictive of mortality in older adults. The purposes of this study were to examine (1) the impact of pain provocation on the energy cost of walking and (2) the relationship between pain intensity and change in energy cost of walking. METHODS: Older adults (60-85 years) with (n = 20) and without (n = 20) CLBPR were matched on age, sex, and diabetes presence/absence. Energy cost of walking was measured with a portable metabolic gas analyzer, as participants walked for 20 minutes or less. Energy cost and pain measurements occurred during early and late stages of walking. Percent change in energy cost was calculated. Participants were grouped by their pain response during walking: increased pain (n = 13); consistent pain (n = 7); no pain, matched to individuals with increased pain (n = 13); and no pain, matched to individuals with consistent pain (n = 7). We examined the within-groups change in energy cost for all groups, as well as the relationship between late-stage pain intensity and percent change of energy cost for individuals whose pain increased. RESULTS AND DISCUSSION: Within the increased pain group, energy cost of walking significantly increased from early to late stages (median change = 0.003 mL/kg/m, P = .006), and late-stage pain intensity explained 41.2% (p = 0.040) of the variance in percent change. Since pain appears to be linked to energy cost, effective pain management with walking may be an important factor in preventing mobility decline. CONCLUSIONS: Among older adults with CLBPR, pain provocation drives increases in the energy cost of walking. Because high energy cost of walking is predictive of mobility decline, clinicians may focus on effective pain management strategies during walking, which may potentially decrease the risk of mobility decline.

Energy Impairments in Older Adults With Low Back Pain and Radiculopathy: A Matched Case-Control Study.

OBJECTIVES: To investigate the impact that the presence of chronic low back pain with radiculopathy (CLBPR) may have on (1) energy efficiency and (2) energy capacity among community-dwelling older adults. DESIGN: Matched case-control study. SETTING: Clinical research laboratory. PARTICIPANTS: Included in the analysis were community-dwelling older adults (N=38, 60-85 years) with and without CLBPR. Participants were matched between-groups on age (±5 years), sex, and diabetic status. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Energy cost of walking at self-selected speed (ie, energy efficiency) and peak volume of oxygen consumed (ie, energy capacity). RESULTS: Older adults with CLBPR had a higher energy cost of walking at self-selected speed (P=.009) and lower peak volume of oxygen consumed while walking (P=.050), compared to those without pain. CONCLUSIONS: Older adults with CLBPR may benefit from specific rehabilitative interventions that target these potentially modifiable energetic outcomes, thereby reducing the risk of mobility decline. Future studies should identify which mechanisms specifically contribute to diminished energy efficiency and capacity among older adults with CLBPR.