Maintaining function in persons with

chronic disabilities by adapted

physical activity programs

Francesco Benvenuti

Dipartimento Territorio Fragilità

AUSL11 Empoli

Società della Salute Valdarno Inferiore

Giornata CPPS di messa in rete

Promozione della salute e prevenzione

nelle persone anziane:

quali sfide per i Cantoni Latini?

Castello Sasso Corbaro

7 febbraio 2014

APAs

Physical activity programs, carried out in group, adapted to chronic alterations of

functional status for tertiary prevention of disability

Fucecchio

S. Croce S.A.

Castelfranco

Montopoli

S. Miniato

Gambassi

Montaione

Montelupo

Empoli

Montespertoli

Certaldo

Capraia e Limite

Cerreto Guidi Vinci

Castelfiorentino

Low disability classes High disability classes

AUSL11:

Residents: 231.000, 22% >65 years

Inserted (nov. 2003 – gen. 2014): 20127

Participants (gen. 2014): 4700

0

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

High disability

Low disability

APA Classes n

um

ber

USL1

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2008 2009 2010 2011 2012N

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O

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USL11

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USL12

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2008 2009 2010 2011 2012

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Lo

w a

nd

hig

h d

isa

bil

ity A

PA

cla

sse

s

Alta disabilità

Bassa disabilità

Tuscany: APA Classes

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2008 2009 2010 2011 2012

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N. Classi alta disabilità

N. Classi bassa disabilità

Tuscany: Gyms & Pools

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2008 2009 2010 2011 2012

NU

ME

RO

Implementation of physical activity

for persons with chronic disabilities

Policy steps

• Bridge theory and practice by creating exercise

opportunities (APA classes)

• Remove barriers

• Promote an organization for easy and safe

access to APA classes

• Promote collaborative environment

Implementation of physical activity

for persons with chronic disabilities

Policy steps

• Bridge theory and practice by creating

exercise opportunities (APA classes)

• Remove barriers

• Promote an organization for easy and safe

access to APA classes

• Promote collaborative environment

Disease or Syndrome Treatment

or

Primary Prevention

Tertiary Prevention

Cancer (breast, colon, prostate) Yes No

Coronary artery disease Yes Yes

Chronic obstructive pulmonary disease No Yes

Dementia (different from multiinfarct dementia) No No

Depression Yes Yes

Diabetes type 2 Yes Yes

Mobility impairment, falls Yes Yes

Chronic renal failure Yes Yes

Peripheral vascular disease Yes Yes

Hypertension Yes Yes

Back pain No Yes

Congestive hearth failure No Yes

Obesity Yes Yes

Arthritis No Yes

Osteoporosis Yes Yes

Parkinson’s dis., CNS degenerative disorders No Yes

Stroke Yes Yes

Venous stasis disease Yes Yes

Fiatarone Singh MA, J Gerontol Med Sci 57A, M262-82, 2002

The exercise is:

Safe

Effective

Not disease-specific

Impairments

Functional limitations

Disability

Sedentary life style

Depression,

lack of vocational pursuits,

higher family and social

support, etc.

Sarcopenia, altered joint

flexibility, cardiovascular

deconditioning,

osteoporosis, etc.

Worse gait, endurance,

balance, manual dexterity,

etc.

Decrements of AADLs,

IADLs, BADLs…

Independent

Disable

Sedentary life style

Impairments

Functional limitations

Disability

Chronic diseases converge towards common pathways!!

\

Moderate Hypomobility

Severe Hypomobility

Mild Hypomobility

Impairments

Functional limitations

Disability

Active life-style

Better integration in the

community, preservation of

vocational pursuits, less

need of family and social

support, etc.

Better muscle and joint

function, endurance,

increased BMD, etc. Better gait, balance, manual

dexterity, etc.

Less disability for AADLs,

IADLs, BADLs…

Life style

Fre

quency

Health Low high

Low

High

Fu

nc

tio

na

l s

tatu

s

Duration of exercise

Life style

Fre

quency

Health Low High

Low

High

Ph

ys

ica

l a

cti

vit

y f

or

he

alt

h p

uro

po

se

s

LR 35/03

Am

ato

ria

l s

po

rt a

cti

vit

y

co

mp

eti

tive

sp

ort

s a

cti

vit

ies

Life style

Fre

quency

Health Low High

High

Low

AP

A h

igh

dis

ab

ilit

y

Ph

ys

ica

l a

cti

vit

y f

or

he

alt

h p

uro

po

se

s

LR 35/03

DGR 595/05

DGR 459/09

AP

A l

ow

dis

ab

ilit

y

Am

ato

ria

l s

po

rt a

cti

vit

y

co

mp

eti

tive

sp

ort

s a

cti

vit

ies

Implementation of physical activity

for persons with chronic disabilities

Policy steps

• Bridge theory and practice by creating exercise

opportunities (APA classes)

• Remove barriers

• Promote an organization for easy and safe

access to APA classes

• Promote collaborative environment

Medical clearance (certification) for low intensity

leisure physical activity programs: - Useless

- Expensive

- Schizophrenic

Remove alibi (for citizens and clinicians): - follow EBM

- redirect inappropriate rehab programs to APA

FOR HYPOMOBILITY SYNDROMES AND

OSTEOPOROSIS AND CHRONIC SYNDROMES

WITH STABILIZED OUTCOMES APA

PROGRAMS ARE APPROPRIATE…..

Recovery plateau

what we observe

Reh

ab

ilit

ati

on

Reh

ab

ilit

ati

on

Re

ha

bil

ita

tio

n

Reh

ab

ilit

ati

on

Time from acute event

Acute &

Subacute

Chronic

Physically active lifestyle

Recovery plateau

Time from acute event

Acute &

Subacute

Chronic

Evidence for community–based APA programs

“…benefits of physical activity and exercise with regard

to morbidity, mortality, and disability in… arthritis, heart

disease, diabetes, stroke, pulmonary disease, and

osteoporosis”.

Bean et al. Arch Phys Med Rehabil, 2004

Implementation of physical activity

for persons with chronic disabilities

Policy steps

• Bridge theory and practice by creating exercise

opportunities (APA classes)

• Remove barriers

• Promote an organization for easy and safe

access to APA classes

• Promote collaborative environment

Easy and safe access: - easy access procedures (for citizens & clinicians)

- effective and clearly defined exercise programs adapted

to participants’ functional status

- widespread geographic distribution

- low cost AND economically sustainable for trainers and

participants

High disability APA

Low disability APA

High disability APA

Hypomobility

Syndrome

Clinicians

Red flags? Further evaluation

& treatment

APA Coordination

Center

Inclusion criteria?

APA

YES

NO

YES

NO

REHABILITATION

PLATEAU

IMPAIRMENTS

CORRECTABLE?

HOSPITAL

REHABILITATION

COMMUNITY

REHABILITATION

REHABILITATION

NURSING HOME

EXTRAHOSPITAL

SEMI-RESIDENTIAL

REHABILITATION

YES

NO

END

NO

YES

END

APA

FOLLOW

UP

Low disability APA Programs High disability APA Programs

ACCESS PROCEDURES

Master Libri

Via Morgagni, 39/R

50134 Firenze

tel. 055/4368577

fax 055/4249446

masterlibri@libero.it

www.usl11.toscana.it

EXERCISE PROGRAM

Sinaki M, 1998

Exercise program

A&E Service contacts Fracture 5° finger left hand (2004)

*Fracture left right humerus (2005)

Fratture right wrist (2006)

Head injury (2008)

*Head injury (2010)

*Fracture D12 (2011)

*Accidents occurred during APA classes

Gym inspections

Telephone interviews

SAFETY CONTROL

40 organizations; 84 gyms/pools

Median Home-gym distance 1.1 km

GEOGRAPHIC DISTRIBUTION

≈2.20 € for 1 hour session

27 € per month for classes 3 times/week

20 € per month for classes 2 times/week

10 € / year for insurance

( ) + = 2.30 €

LOW COST AND SUSTAINABLE

Implementation of physical activity

for persons with chronic disabilities

Policy steps

• Bridge theory and practice by creating exercise

opportunities (APA classes)

• Remove barriers

• Promote an organization for easy and safe

access to APA classes

• Promote collaborative environment

Stakeholders

GPs and AUSL clinicians

Education

Reward system

Research

Clinical pathways for Chronic Care

WHAT IS YOUR OPINION?

CONTINUING (n=117)

INTERRUPTED (n=90)

Test di Wilcoxon: P<0.001

Test di Wilcoxon: NS

Test di Wilcoxon: NS

TRAINERS

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100

VERY WELL WELL SO AND SO BAD

Perc

en

t

GYMNASIUM

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80

100

VERY WELL WELL SO AND SO BAD

pe

rce

nt

TIME SCHEDULE

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60

80

100

VERY WELL WELL SO AND SO BAD

Pe

rce

nt

How is your ….

compared to one year ago?

Better or cured

Same

Worse

Chi2

always P<0.00001

BACK PAIN

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250

Not adherent to APA Adherent to APA

Part

icip

ants

HEALTH

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250

Not adherent to APA Adherent to APA

Part

icip

ants

MOOD

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Not adherent to APA Adherent to APA

Part

icip

ants

Insulin

0,0

40,0

80,0

120,0

160,0

0 +30 +60 +90 +120

mU

/L

Before

After 6 months

minutes

1mU/L =7,217 pMol/L

Mean Glucose and Insulin Curves in individuals without IGT or DM (n=21) Baseline and Post 6 month APA Intervention

* * *

*Paired sample

t-test: P<0.05

Glucose

0,0

40,0

80,0

120,0

160,0

0 +30 +60 +90 +120

mg

/dl

Before

After 6 months

minutes

FEMORE PROSSIMALE

RACHIDE LOMBARE

-0,05 -0,04 -0,03 -0,02 -0,01

0 0,01 0,02 0,03 0,04 0,05

Bassa Media Alta

PARTECIPAZIONE AL PROGRAMMA DI ESERCIZIO

g/c

m2 *

-4,0

-3,0

-2,0

-1,0

0,0

1,0

2,0

3,0

4,0

Bassa Media Alta

PARTECIPAZIONE AL PROGRAMMA DI ESERCIZIO

perc

ento

*

-5,0

-3,0

-1,0

1,0

3,0

5,0

Bassa Media Alta

PARTECIPAZIONE AL PROGRAMMA DI ESERCIZIO

perc

ento

*

-0,05

-0,03

-0,01

0,01

0,03

0,05

Bassa Media Alta

PARTECIPAZIONE AL PROGRAMMA DI ESERCIZIO

g/c

m2

*

DIFFERENZA ASSOLUTA DIFFERENZA NORMALIZZATA

* P<0,05 rispetto ai valori basali (test di Wilcoxon per campioni appaiati).

Bone Mineral Density

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10

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70

80

Gait Vel

(statures/s x200)

Motricity Index SPPB (x10) Berg Balance

Score

Hamillon (x5) SIS Participation

APA Functional ∆ > Control Functional ∆

APA Baseline

APA Post 6 months

Control Baseline

Control Post 6 months

Group x time

P < .005 for all

Chronic

Stroke

Survivors

GOALS GIVEN TO THE GENERAL DIRECTORS OF

THE 12 LOCAL HEALTH AUTHORITIES

BY TUSCANY REGION

Bersaglio USL 11 Empoli 2012

Conferenza Stato Regioni ed Unificata

Citizens Conferences

APA dinners

Media

AFA day

T-shirt

Integrazione con altri programmi di salute

Punti della salute

Fare la spesa…e guadagnare salute

Integrazione con altri programmi di salute

BENESSERE DONNA

GRAZIE! f.benvenuti@usl11.toscana.it