Spotlight on Physical Activity : How to measure and promote in your patients. Disclosure. Session Learning Objectives

Transcription

1 Spotlight on Physical Activity : How to measure and promote in your patients Rogelio A. Coronado, PT, PhD, FAAOMPT Jennifer S. Brach, PT, PhD Steven R. Fisher, PT, PhD, GCS Daniel K. White, PT, ScD, MSc Disclosure No relevant financial relationship exists Session Learning Objectives 1. Distinguish physical activity from health-related constructs such as physical function and capacity 2. Recognize the value of objectively-measured physical activity for predicting health-related outcomes and assessing intervention response within post-acute, postoperative, and community settings 3. Identify successful evidence-based strategies for improving physical activity 1

2 Session Outline Defining physical activity and establishing its value (Coronado) Methodological challenges and measurement limitations of physical activity (Brach) Value of physical activity measures during and after acute hospitalization (Fisher) Physical activity interventions: practical advice for the PT (White) Defining Physical Activity and Establishing its Value Rogelio A. Coronado, PT, PhD, FAAOMPT Department of Physical Therapy Department of Orthopaedic Surgery and Rehabilitation The University of Texas Medical Branch Constructs of What Patients Can Do Physical Capacity/Fitness Physical Performance Physical Function 2

3 Physical Capacity/Fitness Latimer, Spine, 1999 Physical Performance Strand, Phys Ther, 2002 Physical Function Binkley, Phys Ther, 1999 Denehy, Phys Ther,

4 Commonalities Across Measures Measure complimentary constructs related to physical well-being Often targeted by PT interventions Clinically feasible Assume relation to patient s actual engagement in healthpromoting behaviors (i.e., physical activity) Physical Activity: What Patients Actually Do any body movement that works your muscles and requires more energy than resting. Walking, running, dancing, swimming, yoga, and gardening are a few examples of physical activity. Physical Activity and Health Higher levels of physical activity associated with: Improved physical well-being Less morbidity and mortality Lower healthcare utilization/expenditures Higher cognitive function Findings across a range of conditions 4

5 Hallal, Lancet, 2012 Hallal, Lancet, 2012 Holden, Rheumatology,

6 Dunlop, Arthritis Rheum, 2011 Physical Activity and Disability Lin, Pain, 2011 Comparative Change in Outcomes De Groot, Clin Orthop Relat Res,

7 Physical Activity as a Treatment Target? Lee, Lancet, 2012 Comparison to Smoking and Obesity Eliminate: Smoking Obesity Physical Inactivity Improve life expectancy in US by: years years years Lee, Lancet, 2012 Darlow, Arch Phys Med Rehabil,

8 Veldhuijzen van Zanten, Sports Med, 2015 Facilitators in Older Adults Time to bond: social interaction Bona fide friendships Freedom from being isolated I want to be healthy: chronic disease management New lease on life Capalb, Aust J Prim Health, 2014 Thematic schema illustrating conceptual interactions among valuing interaction with peers and improved health and mental well-being, personal benefits of exercise and apathy, physical limitations and environmental barriers, and access difficulties and social influences. Franco et al. Br J Sports Med,

9 BIOMEDICAL BIOPSYCHOSOCIAL Houben, Eur J Pain, 2005 Therapists treatment orientation and physical activity recommendation Independent Variable St. Beta P-value Biomedical 0.28 < Biopsychosocial < 0.01 Chiropractors 0.29 < 0.05 Houben, Eur J Pain, 2005 Berra, JAMA,

10 Methodological Challenges and Measurement Limitations of Physical Activity Jennifer S. Brach, PT, PhD Department of Physical Therapy University of Pittsburgh Self-report Measurement Journals, questionnaires, etc. Include many different types of activities (occupation, leisure, transportation) Timeframe (past week, month, year) Must be able to recall activity Difficulty capturing low or even moderate activity Performance-based Measurement Pedometers, accelerometers, etc. Research grade and commercially available devices Range of costs Most focus on walking behavior Some provide immediate feedback Accuracy varies device, central obesity, gait deviations, assistive devices 10

11 Sample Devices Sample Devices Commercially available Sample Devices Research Grade 11

12 Factors to Consider When Selecting a Device Accuracy Placement Cost Type of data obtained (steps, light/ moderate/ vigorous, energy expenditure) How data are obtained immediate or must download Commercially available Need for computer interface Examples of Data Output StepWatch 3 (formerly SAM) 12

13 Actigraph ACTIVPAL PROFESSIONAL Fitbit 13

14 Fitbit Pedometers Garmin Vivofit 14

15 Accuracy Percent Error for 100 Step Accuracy Test by Gait Speed Category 10 Percent Error DigiWalker ActiGraph SAM -40 < >1.0 Gait Speed (m/s) Storti KL et al, MSSE SCORE study 44 Residents of Independent Living Facilities Mean age 87±5.7 years; range Mean gait speed 0.73 m/s Assistive device use 22 (50%) used no device 17 (39%) - used wheeled walker or rollator 4 (9%) cane 1 (2%) - hand held assist 15

16 Methods 3 research devices 6 commercially available devices Walked 100 steps Counted by 2 researchers Measured gait speed and assistive device use Compared recorded to actual steps Accuracy = Steps recorded by device Steps counted by researcher X 100 Accuracy - % steps recorded for total sample and by walker use Device Total sample N=44 No device N=22 Walker N=17 Gait speed 0.73 m/s 0.94 m/s 0.68 m/s Actigraph Step Watch Activpal Fitbit charge Garmin vivo Zip shirt Zip on hip Digiwalker Accusplit Accuracy of ActiGraph by Gait Speed % steps recorded Gait Speed (m/s) 16

17 Accuracy of Stepwatch by Gait Speed 120 % steps recorded Gait Speed (m/s) Accuracy of Activpal by Gait Speed % steps recorded Gait Speed (m/s) Accuracy of Fitbit Charge by Gait Speed % steps recorded Gait Speed (m/s) 17

18 Accuracy of Garmin vivo by Gait Speed % steps recorded Gait Speed (m/s) Accuracy of Zip on shirt by Gait Speed % steps recorded Gait Speed (m/s) Accuracy of Zip on Hip by Gait Speed % steps recorded Gait Speed (m/s) 18

19 Accuracy of Digiwalker by Gait Speed % steps recorded Gait Speed (m/s) Accuracy of Accusplit by Gait Speed % steps recorded Gait Speed (m/s) Preferences 19

20 Preferred Wear Location (n=42) 24% 38% 38% wrist waist shirt Device Characteristics Very important Readability of display, ease of putting it on and off, comfort, and accuracy Important Ease of accessing data, minimal need to charge, and cost Somewhat important Wear location, appearance, and size Not that important Connection to smart device Percentage of People Having Difficulty Putting on the Device Yamax Accusplit Zip Charge Garmin vivo 20

21 Summary No one perfect device Not an excuse to not measure activity Many factors need to be considered Accuracy Type of data needed Cost Personal preferences Ever changing and evolving field new devices available daily Test accuracy of device on each patient 100 step test Value of physical activity measures during and after acute hospitalization Steve R. Fisher, PT, PhD, GCS Department of Physical Therapy The University of Texas Medical Branch associations between physical activity and health: 1) at the population level; 2) at the bedside.. 21

22 Case Description 74 year old retired welder admitted to the hospital with CHF (NYHA class II) exacerbation. Moderate OA bilateral knees: Kellgren Lawrence grade 2-3 Hx: HTN, lumbar sx, smoker 40+ years Lives alone in single story home Widowed 5 years ago; children live out of state Transfer SNF Admit CLH dc home Transfer ACE Readmit ICU dc home Admitted to ACE 22

23 Older Patient Activity During Acute Hospitalization What is the natural history of older patient activity? What are the most important factors influencing in-hospital activity? What relevant proximal outcomes are linked with activity around the time of acute hospitalization? Are there clinically meaningful levels of activity for those outcomes? StepWatch Activity Monitor Uses a combination of acceleration, position, and timing to detect strides taken by the leg of attachment. Records step activity in 1-minute intervals synchronized to a 24-hour clock - resulting in a temporal series of 1,440 observations per day. Activity Metrics Daily activity level Average daily activity Total number of steps taken per complete 24 hour (midnightto-midnight) day. The average overall level of ambulation across days: (total daily steps / number of days the accelerometer is worn). Time spent walking Activity bouts Defined as the number of 1-minute intervals with stride count greater than 0. A measure of the number of times per day patients engaged in ambulatory activity: defined as the number of 1-minute intervals in which the subject switches from inactivity (stride count=0) to activity (stride count > 0) per day. Change A change score representing the absolute difference in total daily steps from day X to day Y: values can be zero (no change); negative (less active time Y); or positive (more active time Y). 23

24 Cumulative percentage distributions of daily mobility levels: 24hr day is the unit of analysis Older Patient Activity During Acute Hospitalization What is the natural history of older patient activity? What are the most important factors influencing in-hospital activity? What relevant proximal outcomes are linked with activity around the time of acute hospitalization? Are there clinically meaningful levels of activity for those outcomes? Older Patient Activity During Acute Hospitalization 1 Objective: describe the amount and patterns of ambulatory activity in hospitalized older adults over consecutive hospital days. 239 men and women 65 years and older admitted for acute medical illness. All patients wore an accelerometer (step activity monitor) from admission to discharge. 24

25 Step Activity According to Number of Complete 24 Days Spent in Hospital Older Patient Activity During Acute Hospitalization Implications: While some inactivity during acute hospitalization may not be avoidable or inappropriate, evidence is accumulating that prolonged levels of very low activity may be the underlying final common pathway to functional decline among many geriatric patients. Study Activity in hospital % of each 24 hour day active Fisher et. al. walking 4.1% Brown et. al. standing or 3.7% walking Pederson et al. standing or walking 4.5% 25

26 Older Patient Activity During Acute Hospitalization What is the natural history of older patient activity? What are the most important factors influencing in-hospital activity? What relevant proximal outcomes are linked with activity around the time of acute hospitalization? Are there clinically meaningful levels of activity for those outcomes? Mean Daily Steps Mean IQR Characteristic % p Age 0.05 < Gender 0.81 Women Men Race 0.73 White Nonwhite BMI, kg/m² Prior Mobility <0.01 Independent Cane - Walker Dependent History of Falls <0.01 Yes No Restricted by 0.99 tubing Yes No Physician 0.05 Activity Orders As tolerated Amb w Assist Bed Rest Mean Daily Steps Mean IQR Characteristic % p PT Consult <0.01 Yes No Confusion or Delirium 0.02 Yes No Prior ADL Limitations <0.01 Yes No Reason for Admission 0.24 Cardiopulmonary Infectious Gastrointestinal Neurological Other Charlson Comorbidity 0.65 Index Illness Severity & & LOS (days) & & JAGS, 2010 Factors that influence in-hospital activity 2 All variables entered into regression model with average daily activity as outcome. Non-significant variables were removed via backwards elimination to achieve a parsimonious model. CART analysis performed to establish a hierarchical order of variables 26

27 Significantly associated with the mean daily steps in hospital: diagnostic category ethnicity illness severity prior mobility status 585 ± 738 (N = 198) Cane or Walker / Dependent 338 ± 459 (N = 97) Prior Mobility R² change = 10.8% Independent 822 ± 869 (N = 101) Orthopedic / Neurologic 313 ± 520 (N = 18) Admission Diagnosis R² change = 5.3% All Other Medicine Categories 932 ± 892 (N = 83) Minority 661 ± 428 (N = 23) Ethnicity R² change = 2.2% White 1036 ± 999 (N = 60) Major / Extreme Mild / Moderate Classification and regression tree (CART) analysis results 794 ± 717 (N = 28) APR-DRG R² change = 2.9% 1249 ± 1163 (N = 32) Factors that influence in-hospital activity Older patient ambulation varied significantly according to identifiable and clinically relevant characteristics On the acute floor, illness severity is likely not the predominant limiting factor for all patients. Patients with a history of AD use require increased attention in regard to mobility status. Patients with different acute medical illnesses share a similar walking profile. Age Ageing,

28 Older Patient Activity During Acute Hospitalization What is the natural history of older patient activity? What are the most important factors influencing in-hospital activity? What relevant proximal outcomes are linked with activity around the time of acute hospitalization? Are there clinically meaningful levels of activity for those outcomes? Early Ambulation and LOS 3 Patients who spent at least 2, 24hr days in hospital. Step change score: total steps on 2 nd day total steps on 1 st day. Regression models were used to compare different functional forms of step change score on LOS. The best fitting model was the one in which LOS was discontinuous with a large drop at a change score of 600 steps or more. Arch Int. Med Length of Stay Step total change score by length of stay Step Total Change from First to Second Complete Day of Hospitalization 28

29 Early Ambulation and LOS Clinically meaningful thresholds for ambulation in hospital may not be excessively high or time prohibitive. Potential for ambulation as an intermediate measure to important health health outcomes like functional status, service utilization, and LOS. Ambulatory Activity and Falls in Hospitalized Older Adults 4 Information on the ambulatory activity of older patients who fall is lacking. Objective: Compare the mean daily steps, time spent walking, and number of activity episodes of patients who had a documented fall during their hospital stay (cases) to matched controls who didn t fall. Fisher, et al. Arch Phys Med & Rehab. 29

30 Cases Controls p-value N = 10 N = 25 Mean Daily Steps (432.2) (876.0) 0.87 Daily Minutes of Activity 53.8 (36.9) 50.1 (58.6) 0.18 Daily Activity Episodes 25.8 (16.9) 21.6 (23.8) 0.16 Sensitivity analysis: compared number of steps in the 24 hours prior to the fall for cases to that of controls matched to a comparable day in their hospital stay. On average, cases took 512 steps on the day prior to the fall and controls steps (p=1.00). Ambulatory Activity and Falls in Hospitalized Older Adults Patient falls were more likely to be associated with cognitive and hospital environmental factors than actual amount of walking. Ambulatory activity of patients who fell and matched controls that didn t fall was very similar and alone may be a poor predictor of falls. Fisher, et al. Arch Phys Med & Rehab. In press. In-Hospital Activity and 30-day Readmission 5 Objective: determine the strengths of association of walking activity and activities of daily living (ADL) during acute hospitalization on risk of 30-day readmission. identify preliminary walking activity thresholds that would support the targeting of interventions to minimize rehospitalizations. 30

31 Regression models predicting 30-day readmission by mean daily steps and ADL disability. Steps Model ADL Disability Model Combined Steps and ADL Model OR 95% CI OR 95% CI OR 95% CI Steps Any difficulty with ADL AUC Adjustment for age and gender ROC curve of steps on readmission status. In-Hospital Activity and 30-day Readmission Walking activity was a stronger predictor of readmission than ADLs. The use of sensor technology to monitor patient activity during hospitalization may provide clinicians with valuable information on early readmission risk not captured by measures of ADLs. 31

32 Post Discharge activity as a marker for 30-day readmission ambulatory older patients received an accelerometer during their hospital stay and wore it home for up to 1 week. Assessed readmission status back to our hospital after 30 days. Post Discharge activity as a marker for 30-day readmission Activity was significantly less, on average, for readmitted patients during their first week home: 2280 vs. 4058, respectively; p<0.01 Those patients who were least active in hospital were also more likely to be less active post discharge. 32

33 Summary Simple measures of physical activity can provide valuable information to inform clinical decision making for individual patients. Advances in wearable sensor technology will make collection of and access to this information easier. More consensus is needed regarding safe and therapeutic levels of activity in older patient populations. Physical Activity Interventions: Practical Advice for the PT Daniel K. White, PT, ScD, MSc Department of Physical Therapy University of Delaware Case Study 55 year old plumber with new onset of knee pain. BMI 35, pain 2/10 on most days, difficulty walking 10 city blocks. 33

34 PTs are ideal to deliver a physical activity intervention PCP One visit 15 minutes/visit Non-expert in exercise PT Multiple visits 20 to 45 minutes/visit Expert in exercise Critical parameters for a physical activity intervention Fitness trackers Step Goal Recommendation to exercise Critical parameters for a physical activity intervention Fitness trackers Step Goal Recommendation to exercise 34

35 Bravata et al. JAMA Critical parameters for a physical activity intervention Fitness trackers Step Goal Recommendation to exercise Have a step goal Bravata et al. JAMA

36 Step goal ranges 6,000 steps/day for people with knee OA (White et al 2014). 3,000 steps/day as a preliminary goal Tudor-Locke s step based indices for the general population Step Goals How to evaluate if step goals are achieved? Good days and bad days Monday Tuesday Wednesday ,000 4,000 36

37 Critical parameters for a physical activity intervention Fitness trackers Step Goal Recommendation to exercise Recommendation to exercise 4,500 people from Canada with arthritis reported a clinical recommendation as the most important factor for exercise (O Donnell et al 2013) Same finding in the US (Fontaine et al 2006) Few recommend activity to their patients 1/3 Primary Care Physicians for knee OA (Maserejian et al 2014) Patients believe PT s should recommend exercise 90% of patients agree PTs should talk about activity PTs should champion physical activity Expertise in exercise Repeated visits over time with patients Major advantages over physician-delivered care Where and When to recommend In the context of the PT session Beginning, Middle of exercise, or at the end 5 minute intervention Recommend monitor Review progress towards step goals Set new step goal 37

38 1. Select monitor 2. Observe steps 3. Set step goal 4. Repeat 2 and 3 How to recommend Case Study 55 year old plumber with new onset of knee pain. BMI 35, pain 2/10 on most days, difficulty walking 10 city blocks. Monitor Steps/day goal Summary PTs are ideal for a physical activity recommendation Help recommend an appropriate fitness tracker Set a step goal Review steps and set a new goal 38