Faculty Research Fellowship Abstracts
- Rawan AlHeresh, PhD
- Susan E. Fasoli, ScD, OTR/L
- Shweta Gore, PhD, DPT, GCS, CLT
- Sara Knox, PT, DPT, GCS, CEEAA
- Andrew B. Phillips, PhD, RN
- John Wong, PhD
- Lauryn Zipse, PhD, CCC-SLP
“Impact of physical activity and strength training on long term health outcomes in community-dwelling older adults with cardiovascular multimorbidity.” by Shweta Gore, PhD, DPT, GCS, CLT
The prevalence of multimorbidity or multiple chronic conditions (MCC) is rising exponentially in older adults and accounts for a huge burden of health care costs. Cardiovascular related MCCs in older adults represent the largest cause of morbidity and mortality both within the US and globally. Regular physical activity is associated with optimal health outcomes in the healthy population and prevents the risk of cardiovascular disease. Additionally, strength training is associated with improved functional outcomes and quality of life in individuals with cardiovascular disease; however, little is known about the impact of physical activity and participation in strengthening exercise on long-term prognostic health outcomes in community-dwelling older adults with cardiovascular MCC.
This study aims to determine the associations of physical activity and of time spent in strengthening exercise with all-cause and cardiovascular-related hospitalizations and mortality in community-dwelling older adults with cardiovascular MCCs.
To answer these questions, the National Health and Nutrition Examination Survey (NHANES) data linked to Medicare claims data and National Death Index will be utilized to prospectively follow older adults with cardiovascular MCC for a period of five-years or until they die. Activity level measurement will be collected using the Actigraph 7164 accelerometer. Separate multivariable logistic regression models with all-cause and cardiovascular-related hospitalization as categorical dependent variables will be constructed to determine the associations between physical activity and strengthening exercise and hospitalization after controlling for covariates. Cox proportional hazard models will be utilized to determine the association of physical activity and strengthening exercise with all-cause and cardiovascular-related hospitalizations and mortality after adjusting for covariates. Receiver-Operating Curves (ROC) will be plotted to determine the optimal physical activity cut-points with the best sensitivity-specificity combination in identifying a hospital admission from cardiovascular causes and from all causes.
"Factors Impacting Discharge to Community from Home Health Care for Individuals with Alzheimer’s Disease and Related Dementias." by Sara Knox, PT, DPT, GCS, CEEAA.
Post-acute care is a prominent and costly component of the health care continuum. Interest in post-acute care health outcomes and strategies to minimize health care expenditures is widespread among stakeholders in the health care system. Recent legislation has highlighted the importance of discharge to community as a priority healthcare outcome for payers and patients. Home health agencies provide care to more beneficiaries than any other post-acute setting. A significant portion of individuals receiving home health care have a diagnosis of Alzheimer’s disease or related dementias (ADRD). Individuals with ADRD are known to have poor health outcomes associated with care transitions, including discharges. Yet, there is a paucity of research addressing factors associated with negative outcomes after discharge from post-acute care settings, and little information regarding effective strategies to optimize positive outcomes after discharge.
Objective: The objective of this proposed study is to determine factors associated with successful discharge to community (DTC) for individuals with ADRD. Methods: This proposed study will be a retrospective cohort study of Medicare fee-for-service beneficiaries, with and without ADRD, who had a home health episode between June 30, 2013 and July 1, 2015. The outcome variable of interest will be successful DTC as defined by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). Predictor variables will include the types of services provided, length of care, number of visits, early discharge, and low utilization. The predictive value of these factors on successful DTC will be examined using logistic regression.
Expected Results: It is expected that factors associated with successful DTC will differ in the presence of an ADRD diagnosis. Importance: DTC is an actionable health care outcome that home health care agencies and clinicians can positively impact. Improving our understanding of factors associated with successful DTC for individuals with ADRD can better inform allocation of resources, development of discipline specific plans of care, and discharge planning during home health care. This is a critical first step in improving successful DTC after home health care for individuals with ADRD.
Arthritis and rheumatological conditions has a profound impact on employment, with estimates showing approximately one-third of people with arthritis and rheumatological conditions becoming unemployed within 10 years of being diagnosed, of those who are still employed work function is lower compared to those who do not have arthritis. The high prevalence of arthritis-related work loss in the working aged population makes this disease group a strategic population to test interventions to prevent or minimize work loss. Work loss -or unemployment- is a rare outcome requiring very large samples and long follow-up time periods necessitating high study costs. Targeting intermediate outcomes such as work function, defined as work-related task performance, could be fruitful. Responsive and sensitive work function assessment tools, however, do not exist. Additionally, the field is lacking assessments that are person-centered and cover the breadth of work function as a construct, where modern statistical methods like Item-Response (IRT) Theory could be utilized.
The objective of this study is to develop a comprehensive question bank for assessing work function in two major domains; physical work demands, and mental/behavioral work demands to be used as a foundation for IRT testing and ultimately develop a Computer Adaptive Test (CAT).
The methods will begin by completing a thorough literature review to identify the existing assessments pertaining to work function using scientific databases such as PubMed, CINAHL, Medline, EBSCO, and hand searches if necessary. All literature pertaining to work-related assessment such as health, economics and occupational medicine will be searched and examined for content. The ICF taxonomy will be used as a conceptual foundation to characterize the aspects of interactions between the persons abilities, work-related activity demands, and the environment of the workplace when developing the physical and metal/behavioral content models. We will then use focus groups compromised of clinicians to identify new test items that were not covered in the literature review process. We aim to generate 100 items for each of the work function domains. Next, we will seek feedback from national and international experts to review the items we generated in the previous step. The feedback will pertain to domain fit, actual content of items, item response options, clarity of item and importance of inclusion in item bank. Final step in this proposal will be to complete cognitive testing to find out if the respondents understood the questions consistently as intended with ease.
This proposed project will generate a new and refined item pool to assess function in the workplace for people with arthritis and rheumatological conditions and allow for the application of IRT and CAT methodologies. This will ready the item pools for feasibility and distributional characteristics and ultimately for calibration and subsequent inclusion in a CAT platform.
"Speaking Along: The Effects of Speech Entrainment in People with Aphasia," by Lauryn Zipse, PhD, CCC-SLP
People with some sub-types of aphasia produce halting, nonfluent spoken output that may be agrammatic. Many people with aphasia (PWA) also have concomitant apraxia of speech (AOS), a motor speech disorder that further affects speech fluency. Speaking or singing in unison is a component of many aphasia therapies designed to promote increased spoken output or improve fluency. However, the conditions under which unison production is effective, whom this technique works for, and why it works, remain poorly understood. The proposed study will test whether the prosodic structure of the utterance affects the degree to which PWA benefit from speaking along to speech. Metrical prosody will be compared to conversational prosody; the former is based on musical structure, with timing governed by regularly occurring intervals and integer sub-divisions of these intervals, while the latter is dictated by syntactic and prosodic rules, i.e, is dependent on linguistic knowledge.
This study will also investigate whether PWA are truly entraining their speech to the spoken model, such that their speech coincides with, rather than closely follows, the stimulus. Entrainment requires prediction of what is coming next in the signal. Although it has been assumed that PWA entrain their speech to a model in unison conditions, this has never been confirmed. The proposed study will time-lock the speech output measures to the stimulus signal, evaluating whether entrainment is occurring when the prosody is metrical vs. conversational, under conditions of either high or low phonological and motor speech demands. The results from this study will be used to evaluate a two-route model of speech planning, in which speech can be organized according to a metrical or a prosodic framework, and in which these frameworks can be damaged or preserved independently.
"Piloting an Adaptive Agent Based Model to evaluate Frailty in the pre-elderly and elderly populations" by Andrew B. Phillips, PhD, RN
The elderly population is the United States places an increasing demand on both our economic and healthcare resources. Those over age 65 account for approximately 34% of healthcare spending, but only 14% of the population1. This disproportionate cost is reflective of the increasing number of chronic conditions we experience as we age. Changing this dynamic is important to improving the quality of life of our aging population and reducing the demand on our economic and healthcare resources. Advances in technology nutrition, medication, and genomics have served to improve our management and understanding of these disease processes. Other influencers of health such as our environment, social well-being, cognitive health, physical activities, and access to care represent further influencers of the aging process and health. Less understood are the ways in which these influencers interact and contribute to aging. How much does our environment contribute our health later in life? Are there “points of no return” during middle age where behavioral, medical, or other interventions become less effective? How do our behaviors and choices interact with physical, mental, and other health indicators to predict future health?
Frailty has been identified as a key measure of the decreased “physiologic reserve” that results in cumulative declines and increased vulnerability to chronic illness. While there are several proposed measures of frailty that have been validated against specific data sets, there are minimal studies on the influence to be given to the criteria that assess overall frailty risk. The result is a need for a more dynamic rather than static model of frailty that reflects the interrelationships among the current five frailty criteria (Shrinking, Weakness, Poor endurance and energy, Slowness, and Low physical activity) as well as the many potential physiological, cognitive, environmental and other factors that in combination contribute to frailty.
The science of Adaptive Agent Models (AAMs) are one method of dynamic evaluation using complex systems science. AAM is a bottom-up methodology that considers individual agent attributes such as age, sex, socioeconomic status, physical and mental health, etc., and the multiple interactions that take place among multiple agents, the environment, and the other “agents” within a complex system. An AAM has the ability to examine both individual behaviors and environmental characteristics that contribute to frailty and identify those that have the greatest influence. Our growing understanding of aging, combined with an increasing availability of large data sets and new computational methods, create an ideal opportunity to develop an AAM at this time.
The first step in achieving this goal is development of a Pilot AAM utilizing the method through replication of well documented frailty measures and outcomes. Validation of a simple Pilot AAM is a critical starting point for future models that have the capability to improve or replace existing frailty instruments and identify opportunities for early intervention in the aging process at the primary care level. The results from this Pilot should provide initial data on the relative influence of each of the five frailty criteria on frailty prevalence and mortality.
1. National Health Expenditures Fact Sheet. 2016.
Interleukin-1 beta (IL-1β) is a cytokine involved in the immune response to microbial infection and the development of many human diseases. IL-1β is synthesized as a precursor in immune cells. The precursor is processed by a multimeric protein complex called the NLRP3 inflammasome to yield mature IL-1β that is secreted from the cell. Different kinds of danger signals (microbes, DNA damaging agents, toxins, etc.) stimulate immune cells to produce IL-1β by activating the NLRP3-inflammasome, yet how these danger signals cause inflammasome activation is not known. I hypothesize that Mcl-1 regulates the NLRP3-mediated activation of IL-1β production in mammalian cells by acting as an inhibitor. Mcl-1 fits the criteria of such a candidate because it has a short half-life, plays a role in cell survival, and belongs to a family that binds NLRP3-like members. In addition, my preliminary data demonstrated that Mcl-1 is degraded in response to stimuli that activates NLRP3. To test whether the hypothesis of Mcl-1 being the regulatory protein of the NLRP3-inflammasome is true, I will artificially increase and decrease the expression of Mcl-1 in mouse bone marrow-derived macrophages using lentivirus and siRNA, respectively. Understanding how the production of IL-1β is regulated may lead to effective treatments to block IL-1β production in many diseases.
"Infusing Robot-Assisted Therapy with Motor Learning Principles: An Active Learning Program for Stroke (ALPS)" by Susan E. Fasoli, ScD, OTR/L
Rehabilitation robots and passive gravity-assist orthoses provide clinicians with new treatment options to improve upper extremity (UE) motor capacity and performance after stroke. Systematic reviews of robot assisted therapy for the paretic UE confirm gains in motor capacity as measured by clinical assessments, but provide little evidence of improved UE performance during daily tasks and occupations.1,2,3 These findings may be attributed to the limited availability of rehabilitation robots to train the paretic hand and a primary focus on intensity of practice with little regard for other principles of motor learning and experience-dependent neuroplasticity.4,5 These principles, including the salience of training tasks, transfer of acquired skills to similar activities, and active engagement and problem solving, are key to task-oriented training paradigms in stroke (e.g. constraint-induced movement therapy) but have not been well integrated into robot-assisted therapy protocols. The transfer of robot-trained movements to UE activities within the home and community needs further exploration before widespread use in rehabilitation practice is expected.
The objectives of this pilot project are to 1) generate and test a feasible and reproducible protocol in which motor learning principles are more fully infused into robot-assisted therapy and 2) examine participant outcomes via measures across domains of the International Classification of Functioning (ICF).6 Specifically, we will develop a structured Active Learning Program for Stroke (ALPS) that promotes identification of interfering and changeable UE impairments; establishes clear patient-centered goals; encourages active problem solving and UE self-management; and facilitates self-efficacy and confidence in UE use via challenging and meaningful practice. We will provide participants with a home action plan that will combine ALPS training with patient-targeted treatment activities to encourage the transfer of acquired skills to activities in the home and community. Persons with moderate UE impairments more than six months post stroke will be randomly assigned to one of two intervention groups in which they receive ALPS training with either 1) robot assisted therapy (RT) alone, or 2) robot-assisted therapy plus therapist-guided task-oriented training (RTTOT).