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  • USPSTF Recommends Physical Therapy to Reduce Falls in Community-dwelling Adults

    Based on new evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls in community-dwelling older adults, the US Preventive Services Task Force (USPSTF) recommends physical therapy or exercise and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.

    USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older, because it says the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values.

    In extensive comments to USPSTF, APTA commended the task force for "its focus on physical therapy and the role that it plays in reducing the societal burden that falls present as the number one cause of injury among adults ages 65 and older." APTA also stated that it was "deeply concerned with the statement that 'the benefit is small' for multifactorial risk assessments in Recommendation 2." The association added, "… we feel that the approach to quantifying the effect of the risk assessment is misrepresentative given the unique considerations for falls prevention evaluation. A risk assessment may, in fact, not be appropriate for every member of the population, but a falls screening as outlined by the American Geriatrics Society and British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons is an important consideration to justify those individuals for which a multifactorial risk assessment is very impactful."

    The recommendations and supporting documents are posted on USPSTF's website.A summary for patients is available in Annals of Internal Medicine.  

    APTA recently revised its Balance and Falls webpage, which includes a variety of patient care resources, consumer education materials, and links to CEU courses.

    New in the Literature: Predicting Functional Performance After TKA (J Orthop Res. 2012 Apr 26. [Epub ahead of print])

    Poorer performance preoperatively on the Six-Minute Walk Test (6MW), Stair Climbing Test (SCT), and Timed Up and Go Test (TUG) was related to poorer performance in the same measure after total knee arthroplasty (TKA), say authors of a study designed to develop a preliminary decision algorithm predicting functional performance outcomes to aid in the decision of when to undergo TKA. Age and decreased mental health were secondary predictors of poorer performance at 6 months on the TUG and SCT, respectively. These measures may help further develop models that predict thresholds for poor outcomes after TKA, the authors add.

    One hundred and nineteen patients undergoing primary unilateral TKA were evaluated before and 6 months after TKA. A regression tree analysis using a recursive partitioning function was performed with TUG time, 6MW distance, and SCT time as measured 6 months after TKA as the primary outcomes. Preoperative measures of functional performance, joint performance, anthropometrics, demographics, and self-reported status were evaluated as predictors of the primary outcomes 6 months after surgery.  

    Individuals taking 10.1 or more seconds on TUG and aged 72 years or older before surgery had the poorest performance on TUG 6 months after surgery. Individuals walking less than 314 meters on 6MW before surgery had the poorest performance on 6MW 6 months after surgery. Individuals taking 17 or more seconds to complete SCT and scoring less than 40 on the SF-36 mental component score before surgery had the poorest performance on SCT 6 months after surgery.

    APTA member Michael J. Bade, PT, is lead author of the article, which is published in Journal of Orthopaedic Research. APTA members Joseph A. Zeni, PT, PhD, Jennifer E. Stevens-Lapsley, PT, MPT, PhD, and Lynn Snyder-Mackler, PT, ScD, SCS, FAPTA, are coauthors.

    Mobile Technology, Coaching Linked to Multiple Behavior Changes in Diet and Activity

    A combination of mobile technology and remote coaching holds promise in encouraging healthier eating and physical activity, say researchers at the National Institutes of Health who examined the best way to change multiple health behaviors in adults. Free, full text of the article is available in Archives of Internal Medicine

    The scientists studied 204 adults who were overweight or obese and had a diet high in saturated fat and low in fruits and vegetables. The participants also engaged in little daily physical activity and had high amounts of sedentary leisure time.

    Each participant was assigned to 1 of 4 groups:

    • increase fruit and vegetable intake and increase time in moderate/vigorous physical activity
    • increase fruit and vegetable intake and reduce time in sedentary leisure activities
    • decrease fat intake and increase time in moderate/vigorous physical activity
    • decrease fat intake and decrease time in sedentary leisure activities

    Participants received mobile devices and were trained on entering information about their daily activities and eating patterns. Coaches studied the data received and then phoned or e-mailed participants to encourage and support healthy changes during the 3-week study. Participants also were asked to continue to track and submit their data over a 20-week follow-up period. Financial incentives for reaching study goals during the study and continuing participation during the follow-up period were offered.

    All 4 groups showed improvements in reaching the assigned health goals, with the most striking results occurring in the group asked to increase fruit and vegetable intake and reduce sedentary leisure activities. After 20 weeks, this group's average daily servings of fruits and vegetables increased from 1.2 to 2.9. The group's average minutes per day of sedentary leisure activity dropped from 219.2 to 125.7, and the percentage of saturated fat in daily calories went from 12 to 9.9.

    "Via technology, we will soon be able to deliver fully automated and configurable multiple risk factor interventions that monitor progress continuously and can be delivered throughout the day every day," William T. Riley, PhD, says in accompanying commentary on the study. "It remains an empirical question, however, whether these technological advances improve outcomes, reduce costs, or both."

    Hospital-at-Home Model Gains Attention as Health Reform Evolves

    A model of care adopted in Australia, England, Israel, and Canada that allows patients who are chronically ill with acute medical problems to receive hospital services in their homes is gaining attention in the United States, says a Kaiser Health News article. 

    Hospital-at-home programs fundamentally refashion care by "testing traditional notions of how services should be delivered when people become seriously ill." In most programs, physicians examine the patient daily, and nurses and aides visit up to 3 times a day, often for an extended period. Programs currently are offered by Presbyterian Healthcare Services in Albuquerque, New Mexico, and through the Veterans Health Administration in Portland, Oregon; Honolulu; Boise, Idaho; and New Orleans.

    In a study of 3 hospital-at-home programs published in 2005 in Annals of Internal Medicine, researchers demonstrated that patient outcomes were similar or better, satisfaction was higher, and costs were 32% less than traditional hospitalizations. The programs in the study focused on people with 4 conditions—chronic obstructive pulmonary disease, congestive heart failure, pneumonia, and cellulitis.

    Resistance from Medicare and private insurers is the biggest problem these programs face, the article says. Traditional fee-for-service Medicare does not pay for hospital-at-home services, although individual private Medicare Advantage plans may do so. 

    In addition, physicians may find the new model of care intimidating. Starting a program requires a considerable up-front investment of time and money. Furthermore, "keeping beds full is a financial mandate for most hospitals." However, that may change as hospitals and physicians form accountable care organizations that call for providers to restructure how health care is delivered while participating in the financial rewards and risks of those changes, says the article.