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Episode Transcript:

Alexander Garbin  0:00 

Hello and welcome to the RESTORE podcast, a podcast brought to you by the RESTORE team at the University of Colorado Anschutz Medical Campus, where we discuss research related to optimizing older adult health and function and how it can impact clinical care and improve the lives of older adults. I'm your host, Alexander Garbin. And today, I'm joined by Dr. Jennifer Stevens-Lapsley.

Jennifer Stevens-Lapsley  0:21 

And two months later, the therapist came back and told us, I had no idea how much I was under dosing my patients. Not only did they tolerate the high intensity approach with the resistance training, but I got better outcomes than I could have ever achieved without it.

Alexander Garbin  0:37 

Along with being the director of the RESTORE team, she's a professor and the director in the rehabilitation science PhD program, as well as the PT section Director for Research and Development in the Physical Therapy program at the University of Colorado Anschutz Medical Campus. She's also the Associate Director for Research for the geriatrics research, education and clinical center at the eastern Colorado VA Healthcare System. Thank you for joining us today. Thank you for having me. As this is the first full episode of the RESTORE podcast and given your role as team director, would you be able to talk a little bit about the structure and the overall goal of the RESTORE team?

Jennifer Stevens-Lapsley  1:12 

Absolutely. So the RESTORE team is a collaborative team committed to optimizing older adult movement and quality of life through innovative research and education excellence. And we consist of a wide range of trainees, faculty, and collaborators. We have PhD students, DPT students, which are a Doctorate of physical therapy students, we have postdoctoral fellows, and as I mentioned, many junior faculty that are all engaged in supporting this mission to improve the quality of life of older adults. So one important aspect of the restore team is we're interdisciplinary. We do have a lot of physical therapists, but we have occupational therapists, we've had exercise scientists, we've had engineers, lots of different contributing inputs and, and perspectives in addition to our collaborators, which represent a myriad of disciplines beyond our immediate group.

Alexander Garbin  2:03 

So one area I wanted to highlight of the research team is the work related to older adults performing high intensity resistance training, what led you down this path of research?

Jennifer Stevens-Lapsley  2:12 

You know, across the board, I saw examples of underdosing and rehabilitation. And when we first started working in this area, we were predominantly focused on patients after knee and hip arthroplasty. And so we initially began our work in that population trying to address the deficits in strength that occur early after surgery. And what we found was that patients after knee replacement surgery can tolerate high intensity resistance training, and it's safe, although they still have such pronounced activation deficits in their quadriceps muscle, that that's the inability to really recruit and fully activate the muscle, that our high intensity training wasn't as effective as we thought it would be. They need other components with rehabilitation to supplement that high intensity training, but it was safe and patients tolerated it well. And so shortly after we initiated that line of research, I had a family member who was in a skilled nursing facility who had had a knee replacement. And it kind of blended and allowed me to kind of move into a whole different world of of medical complexity beyond just joint arthroplasty. I was really struck by the fact that this family member had a minor medical complication and was transferred to a SNF for care a skilled nursing facility for care. And while the medical complication resolved within a day or two, they remained at the skilled nursing facility for a much longer period of time. And that's when I started to realize that patients were being kept in skilled nursing facilities for the maximum length of time regardless of their medical needs. And when I looked a little bit closer, I realized that the rehabilitation that they were receiving wasn't necessarily allowing them to discharge earlier or discharge at a higher level of function. It was very low dose. And that was something that I felt like we could combine our previous research with, you know, the applications to this new population, medically complex, older adults, and have an even greater benefit.

Alexander Garbin  4:03 

And were you finding also that within the skilled nursing facilities, your previous research during high intensity was acceptable for these medically complex older adults?

Jennifer Stevens-Lapsley  4:12 

At first, one of the biggest hesitations was, would they tolerate it? And would we would we injure someone in the process of providing a true high intensity resistance training program? You know, we're talking about patients who are 90 years old, frail, have a history of COPD, osteoporosis, you know, many, many multiple conditions that will put them at risk for all sorts of potential injury. But over the course of working with hundreds of individuals, we found that this was incredibly safe, and patients tolerated it much better than we thought. In fact, we saw early on that our rate of refusals was less in patients implementing this particular type of program, and we started to realize that patients wanted to work harder. Not all patients, but a large majority of patients. Were on to the fact that there rehabilitation programs might not be as highly dosed or specifically targeted to really get them stronger as they might be able to tolerate and benefit from.

Alexander Garbin  5:11 

And for those that might not be aware, what is usual care right now in skilled nursing facilities?

Jennifer Stevens-Lapsley  5:17 

Yeah, so the usual care is still usual care across most of the country. It's a paradigm that we're working to try and shift. But it takes time. And what I see as I travel around to skilled nursing facilities across the country, is that when we use something like an RPE scale, rate of perceived exertion scale from one to 10, when I see patients who are exercising, and I asked them what intensity they're exercising at, from a one to 10, the large majority tell me that they're exercising at a two or three, which is light activity. It's defined as you know, something they could continue on for hours, not something that's really targeted to improve their physical function in a shorter rehabilitation episode. And so the same thing is true when I look at the ankle weights that therapists are using, you know, they'll put a two pound ankle weight on someone who's six foot 300 pounds, and ask them to extend their knee. But the force across the knee joint with that two pound ankle weight is nothing near the forces that are necessary to get up and stand up from a chair. And so there's a disconnect between how we're preparing patients with some of the strategies we're using with this underdosing paradigm, and what we really need to be doing in order to get them back to their full level of function. To give a more specific example, I've sadly seen patients literally nodding off while on the exercise bike during their rehab sessions. So there's no lower intensity than someone actually falling asleep while exercising.

Alexander Garbin  6:42 

Thank you for providing us a picture of what usual care is in many places, as well as providing that nice albeit unfortunate example. So I did want to highlight one manuscript that's looked specifically at this question of usual care versus high intensity. And that's the manuscript 'Application of high intensity functional resistance training in a skilled nursing facility: an implementation study'. To give a very general summary of this work, this was a quasi experimental study, meaning non randomized groups within a skilled nursing facility, where patients either received usual care or high intensity rehabilitation, which was termed I-stronger, or intensive therapeutic rehabilitation for older, skilled nursing home residents. What was found in this study is that there was a signal of greater effectiveness for the I-stronger group. These patients experienced statistically and clinically significant greater improvements in walking speed, which is a great indicator of physical function and health that we'll likely talk about at a later episode, and had slightly greater improvements in a test of lower extremity function, the short physical performance battery scale, and they experienced a shorter length of stay by about 3.5 days. Additionally, and one thing that I thought was important in these findings, is that fidelity was very high, meaning nearly all therapists were able to guide this intervention accurately. And patients had greater satisfaction within the I-stronger group. So in this study, you found that within a skilled nursing facility, high intensity rehabilitation was effective, therapists were able to use it, and patients enjoyed it. Is there anything else you'd like to add to that summary?

Jennifer Stevens-Lapsley  8:17 

So the study was designed to be very practical and pragmatic, it was done in a real world clinical setting a skilled nursing facility with real therapists that we trained to implement this high intensity protocol. And so that was the beauty of it. Because it was then easy to translate into other settings, we didn't require heavy equipment or specific things that weren't easy, weren't readily available in most clinical settings. And so the goal then was to take that work, and be able to practically apply it faster to variety of SNFs across the country.

Alexander Garbin  8:51 

An aspect of the study that I wanted to touch on is that it is an implementation study. For those that might not be aware of this term implementation. Can you give a brief description of what it is and why you felt this was the right type of design for this study?

Jennifer Stevens-Lapsley  9:04 

Absolutely. There's a whole field of implementation science, and it's the science of how we translate evidence into clinical practice. And so what Implementation Science allows us to do is to more rigorously evaluate the elements of what worked and what didn't work to allow for better future implementation, and the the paradigms that structure implementation science. The frameworks that are used, allow us to more quantitatively and sometimes qualitatively, evaluate what's working and what isn't working for faster translation down the road. The reality is, is it takes 17 years to translate only 14% of published findings into clinical practice. And so the goal of developing a pragmatic study and using the field of implementation science is to try and speed up that translation through rigorous frameworks and methods to fully evaluate what's working and what isn't working.

Alexander Garbin  10:03 

A key aspect of this podcast is having those take home messages for clinicians and for our older adult community. So what can a clinician or an older adult at home, take away from this study?

Jennifer Stevens-Lapsley  10:14 

Ultimately, clinicians are surprised by what patients are capable of doing our first therapist to implement this program in its entirety. When we first explained what we wanted to do said, "There's no way my patients are going to tolerate high intensity resistance training, five to six days a week on consecutive days. But I'll try it, I'll come back and let you know how it goes." And two months later, the therapists came back and told us, "I had no idea how much I was under dosing my patients. Not only did they tolerate the high intensity approach with the resistance training, but I got better outcomes than I could have ever achieved without it." I'll also say that, we're trying to understand which patients respond best to high intensity, we've shown it's safe, but we realize there may be some people that are better responders than others. And a lot of our work now and future work is designed to try and understand exactly what the targets are and who, who we need to further adapt and modify high intensity resistance training programs to achieve the intended targets. We have seen beyond just skilled nursing facilities, this high intensity approach be effective in settings like all inclusive care for the elderly. But we've seen less benefit in home health settings. And maybe the frequency of home health treatments being one to two times a week, with very limited total volume is not enough to move the dial. So we're trying to understand the dosing the settings, the patient populations to better refine what we're doing, and ultimately have an even greater impact on care.

Alexander Garbin  11:45 

Within the conclusion the manuscript mentioned potential future work, including a large multi site trial, is this something that's happening now?

Jennifer Stevens-Lapsley  11:53 

Yes, we're currently undertaking this large clinical trial on skilled nursing facilities across the country. So expanding upon the findings of a single facility, and trying to generalize those across facilities nationwide. And so there's hopefully a lot of a lot of new information that's going to be gleaned from our work in that area. And we're excited to have the opportunity to continue to build on what we've already seen to be very successful.

Alexander Garbin  12:16 

And in relation to this new large multi site trial. Were there any barriers or difficulties you encountered in the initial study that have really led to adaptations in the larger trial?

Jennifer Stevens-Lapsley  12:27 

Yes, we've had numerous iterations on our training for therapists to make it less cumbersome, to make it more engaging, to improve the patient scenarios and the clinical examples that we use in order to really help therapists truly conceptualize and apply these principles. So over many iterations, using educational design, we feel like we really improved upon the educational component in conjunction with a lot of the study design features, which include regular touch points and feedback from the therapist and tailoring, you know, the intervention to the needs of each individual, clinic or clinical team.

Alexander Garbin  13:06 

Great. Well, thanks for all this wonderful discussion in regards to high intensity rehabilitation, and just the general discussion today on this podcast. Before we go, could you touch on any current or upcoming studies within the RESTORE Team really is a teaser for potential upcoming episodes.

Jennifer Stevens-Lapsley  13:22 

Sure, you know, the high intensity rehabilitation work is, like you said, just one component of a wide variety of studies that we're undertaking to optimize mobility in older adults. One of the things that we've been invested in is measuring gait speed treating it is a sixth vital sign to monitor function since it's a strong biomarker of mortality and overall health. And so that's certainly an area that has a lot of opportunities for growth down the road. We've also done a lot of work with predictive analytics and trying to use data driven ways to anticipate how patients are going to do after surgery. And this type of information is really important for standardizing the process by which we make decisions about individualizing care. And so we're able to then tell patients where we anticipate that they're going to be two months after surgery, and that sometimes helps inform their decision to have surgery or when to have the surgery. And it also helps guide clinicians decision making about how much how often to see a patient or how much treatment to provide or what types of treatment to provide. So I think that field is wide open in terms of really being able to tap into data driven analytics to guide clinical practice decisions.

Alexander Garbin  14:31 

Well, thank you. I'm really excited to talk about those on future episodes and likely have other RESTORE Team members on to talk about that for today. Thanks for Jen for joining us today and thank you for listening.

Jennifer Stevens-Lapsley  14:42 

Thanks for having me.

Transcribed by https://otter.ai