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Cognitive vulnerability, that is, clinically significant symptoms of dementia, depression, or delirium, puts older adults at high risk for physical inactivity and falls. Programs addressing activity and falls are needed. The purpose was to determine feasibility of an in-home, modified, Otago Exercise Program (OEP) for those with cognitive vulnerability, based on acceptability (retention and adherence), safety (pain intensity and falls), and potential positive effects (change in short physical performance battery (SPPB)). This secondary analysis of a randomized controlled trial included 80 participants who received the OEP; 64 completed it, 48% had depression, 22% had dementia, and 30% had a combination dementia/depression/delirium. Adherence to home exercise was low to moderate; pain was stable over 16 weeks; 31% of participants reported falls unrelated to OEP. SPPB increased from 6.95 to 7.74 (p < .01); age by time and diagnosis by time interactions were not significant. The modified OEP shows promising feasibility for older adults with cognitive vulnerability.

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OBJECTIVES: Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (∆6MWD). METHODS: This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was ∆6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed. RESULTS: Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to ∆6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31-93 m) more than those who did not get on the floor. CONCLUSIONS: Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture. IMPACT: This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor.

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Heart rate (HR) by time curves could be useful as a measure of treatment fidelity. The purposes were to describe the frequency of common recording irregularities (e.g. errors) observed during exercise, validate a process to correct those errors, and determine whether there is a clinically meaningful benefit to data correction. 1895 exercise sessions from 69 older adults with hip fracture were inspected for errors in the placement of event markers (duration of exercise) and signal artifacts. Marker errors occurred in 33% of the participants, and corrected in 324 sessions. Signal artifacts occurred in 96% of the participants, and eliminated in 702 sessions. Computer code was 85% accurate in detecting signal artifacts, compared to 97% for investigators. HR was significantly higher after correction, but the average change was only 0.69 + 1.20 beats per minute. A HR monitor showing HR by time curves can be used to evaluate treatment fidelity during exercise.

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The objective of this paper is to describe our experience as patient advisors as we work on a Patient-Centered Outcomes Research Institute-funded project, CHoosing Options for Insomnia in Cancer Effectively (CHOICE). The CHOICE Study is a comparative effectiveness trial comparing acupuncture with cognitive behavioral therapy for insomnia in cancer survivors. We describe the composition of the patient advisory panel, the patient engagement process, and our contributions throughout the study, and we highlight some of our successes so far. Our motivation to contribute to the research process and our hopes for the future of patient-centered outcomes research are discussed.

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BACKGROUND: Stiffness is a common complaint in individuals with knee osteoarthritis and is a component of the osteoarthritis diagnosis. Yet the relationship between stiffness and function is poorly understood and methods to quantify stiffness are limited. METHODS: Using a cross-sectional observational design with 66 subjects with knee osteoarthritis, stiffness and damping coefficients were calculated from a relaxed knee oscillation procedure. Gait parameters were measured using an electronic walkway. Self-reported pain, stiffness, and function were measured with the Western Ontario and McMaster Osteoarthritis Index. Correlation and Alexander's normalized-t approximation analyses were used to assess associations among the variables. Subset analysis was performed on subjects with and without tibiofemoral joint crepitus. FINDINGS: Slight to moderate correlations existed between stiffness and damping coefficients and most gait parameters ((| r |=0.30-0.56; P<.05) and between Western Ontario and McMaster Osteoarthritis Index scores and all gait parameters (| r |=0.35-0.62; P<.05). The damping coefficient was only slightly associated with patient-rated Western Ontario and McMaster Osteoarthritis Index stiffness subscale scores. Subset analysis revealed significant correlations that differed between those with and without crepitus. INTERPRETATION: These findings suggest that laboratory measured stiffness and damping coefficients, Western Ontario and McMaster Osteoarthritis Index scores and gait-related measurements assess different aspects related to movement in individuals with knee osteoarthritis. Stiffness and damping coefficients may offer the ability to explain gait changes in the knee that are independent of a person's perceptions particularly in the early stages of the disease.

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STUDY DESIGN: Descriptive, case-matched comparison. OBJECTIVES: To compare the knee joint stiffness and damping coefficients of individuals with knee osteoarthritis (KOA) to those of age- and gender-matched individuals without KOA. A secondary purpose was to investigate relationships between these coefficients and complaints of stiffness in individuals with KOA. BACKGROUND: KOA is a leading cause of disability, and stiffness is a common complaint in individuals with KOA. Yet the most common method of assessing knee joint stiffness is through a self-report questionnaire. METHODS AND MEASURES: Stiffness and damping coefficients at the knee were calculated in 10 volunteers (mean age +/- SD, 64.1+/-15.5 years) with KOA and compared to coefficients from age-and gender-matched individuals without KOA, collected in a previous study (mean age +/- SD, 62.1+/-13.9 years). Stiffness and damping coefficients were calculated from the angular motion of the knee during a relaxed oscillation. Spearman correlation coefficients were calculated between stiffness and damping coefficients and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores for subjects with KOA. RESULTS: Independent 2-tailed t tests revealed significantly larger damping coefficients (P = .035) among those with KOA (95% CI, 0.10-2.32 Nm s/rad). Spearman rank correlations revealed a significant positive relationship (r = .85, P = .003) between the damping coefficient and the stiffness subscore of the WOMAC. CONCLUSION: This study offers preliminary data demonstrating the feasibility of measuring stiffness and damping coefficients in individuals with KOA. Additionally, the damping coefficient is increased in people with KOA when compared to age- and gender-matched individuals without KOA. The damping coefficient appears to be associated with the complaints of stiffness reported by the WOMAC.

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