The HealtheSteps™ lifestyle prescription program to improve physical activity and modifiable risk factors for chronic disease: a pragmatic randomized controlled trial.

BACKGROUND: Our objective was to determine the influence of the HealtheSteps™ lifestyle prescription program on physical activity and modifiable risk factors for chronic disease in individuals at risk. METHODS: One hundred eighteen participants were recruited from 5 sites in Southwestern Ontario, Canada and randomized to either the intervention (HealtheSteps™ program, n = 59) or a wait-list control group (n = 59). The study comprised three phases: an Active Phase (0 to 6 months) consisted of bi-monthly in-person lifestyle coaching with access to a suite of eHealth technology supports (Heathesteps app, telephone coaching and a private HealtheSteps™ social network) followed by a Minimally-Supported Phase I (6 to 12 months), in which in-person coaching was removed, but participants still had access to the full suite of eHealth technology supports. In the final stage, Minimally-Supported Phase II (12 to 18 months), access to the eHealth technology supports was restricted to the HealtheSteps™ app. Assessments were conducted at baseline, 6, 12 and 18 months. The study primary outcome was the 6-month change in average number of steps per day. Secondary outcomes included: self-reported physical activity and sedentary time; self-reported eating habits; weight and body composition measures; blood pressure and health-related quality of life. Data from all participants were analyzed using an intent-to-treat approach. We applied mixed effects models for repeated measurements and adjusted for age, sex, and site in the statistical analyses. RESULTS: Participants in HealtheSteps™ increased step counts (between-group [95% confidence interval]: 3132 [1969 to 4294], p < 0.001), decreased their sitting time (- 0.08 [- 0.16 to - 0.006], p = 0.03), and improved their overall healthful eating (- 1.5 [- 2.42 to - 0.58], p = 0.002) to a greater extent compared to control at 6 months. Furthermore, exploratory results showed that these individuals maintained these outcomes 12 months later, after a minimally-supported phase; and retained improvements in sedentary time and improved healthful eating after 18 months. No differences in self-reported physical activity, health-related quality of life, weight, waist circumference or blood pressure were observed between groups at 6 months. CONCLUSIONS: Our findings suggest that HealtheSteps™ is effective at increasing physical activity (i.e., step counts per day), decreasing weekday sitting time, and improving healthful eating in adults at increased risk for chronic disease after 6 months; however, we did not see change in other risk factors. Nonetheless, the maintenance of these behaviours with minimal support after 12 and even 18 months indicates the promise of HealtheSteps™ for long-term sustainability. TRIAL REGISTRATION: The trial was registered on April 6, 2015 with ClinicalTrials.gov (identifier: NCT02413385 ).

It Is the Time to Think About a Treat-to-Target Strategy for Knee Osteoarthritis.

Osteoarthritis (OA) is a rheumatic disease that affects the well-being of the patient, compromises physical and mental function, and affects other quality of life aspects. In the literature, several evidence-based guidelines and recommendations for the management of knee osteoarthritis (KOA) are available. These recommendations list the different therapeutic options rather than addressing a hierarchy between the treatments and defining the real target. Therefore, a question arises: are patients and physicians satisfied with the current management of KOA? Actually, the answer may be negative, thus suggesting a change in our therapeutic strategies. In this article, we address this challenge by suggesting that it is time to develop a "treat to target strategy" for KOA.

Evaluating the use of intra-articular injections as a treatment for painful hip osteoarthritis: a randomized, double-blind, multicenter, parallel-group study comparing a single 6-mL injection of hylan G-F 20 with saline.

OBJECTIVE: Hip osteoarthritis (OA) is difficult to treat. Steroid injections reduce pain with short duration. With widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to-date, we compared safety/efficacy of a single, 6-mL image-guided injection of hylan G-F 20 to saline in painful hip OA. METHOD: 357 patients were enrolled in a multicenter, double-blind, randomized saline placebo- controlled trial. Subjects were ≥35 years of age, with painful (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]-A1:5.0-8.0; numeric rating scale [NRS]: 0-10) mild-to-moderate hip OA (Kellgren-Lawrence grade II/III) and minimal contralateral hip pain (WOMAC-A1 < 4). Outcome measures included "pain on walking" (WOMAC-A1 and -A), Patient Global Self-Assessment (PTGA), WOMAC-A1 responder rate (+≥2 points on NRS), and adverse events (AEs) over 26 weeks. RESULTS: 357 patients (hylan G-F 20 single:182; saline:175) were enrolled. Both groups demonstrated significant pain improvement from baseline over 26 weeks (P < 0.0001); saline-induced pain reduction was a remarkable 35%. WOMAC-A and PTGA scores also significantly improved (P < 0.0001). No statistically significant difference was observed between groups in WOMAC-A1 scores (hylan G-F 20 single:-2.19 ± 0.16; saline:-2.26 ± 0.17) or WOMAC-A1 responders (41-52%). Treatment-related AE rates at target hip were similar (hylan G-F 20 single:23 patients [12.8%]; saline:12 [7.0%]). Posthoc analysis found, despite protocol requirements, many patients had psychological (31%) or potential neuropathic pain (27.5%) conditions. CONCLUSION: A single 6-mL hylan G-F 20 injection or saline for painful hip OA resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between hylan G-F 20 and saline placebo were observed.

The discrepancy between recommendations and clinical practice for viscosupplementation in osteoarthritis: mind the gap!

Recently AAOS, ACR and OARSI revised their recommendations for the management of knee osteoarthritis (OA) and for hand, knee and hip joints. During ISIAT (International Symposium on Intra-Articular Treatments) 2013 round table on recommendations about the use of intra-articular Hyaluronic Acid (IAHA) in OA, several considerations were elaborated by the ISIAT Technical Expert Panel (TEP) regarding discrepancy between recommendations and clinical practice. The ISIAT TEP gathered the following eight suggestions regarding the drawing of recommendations on the use of IAHA in OA and its comparison with other treatments. It is necessary to merge data coming from both RCTs and registers. Only studies with a strong level of evidence should be taken into account. A common threshold of efficacy should be assessed for comparing treatments. Evaluation of hard outcomes is essential. The effect size of placebo as comparator should be attentively considered in RCTs. Particular attention should be given to different phenotypes of OA that may possibly respond differently to each treatment. Compliance and long-term side effects of different therapeutic approaches should be evaluated. Pharmacoeconomic evaluation should be performed on the long term.

Non-alpha-adrenergic effects on systemic vascular conductance during lower-body negative pressure, static exercise and muscle metaboreflex activation.

AIM: This study tested the hypothesis that non-α-adrenergic mechanisms contribute to systemic vascular conductance (SVC) in a reflex-specific manner during the sympathoexcitatory manoeuvres. METHODS: Twelve healthy subjects underwent lower-body negative pressure (LBNP, -40 mmHg) as well as static handgrip exercise (HG, 20% of maximal force) followed by post-exercise forearm circulatory occlusion (PECO, 5 min each) with and without α-adrenergic blockade induced by phentolamine (PHE). Aortic blood flow, finger blood pressure and superficial femoral artery blood flow were measured to calculate cardiac output, SVC and leg vascular conductance (LVC) during the last minute of each intervention. RESULTS: Mean arterial pressure (MAP) decreased more during LBNP with PHE compared with saline (-7 ± 7 vs. -2 ± 5%, P = 0.016). PHE did not alter the MAP response to HG (+20 ± 12 and +24 ± 16%, respectively, for PHE and saline) but decreased the change in MAP during PECO (+12 ± 7 vs. +21 ± 14%, P = 0.005). The decrease in SVC and LVC with LBNP did not differ between saline and PHE trials (-13 ± 10 vs. -17 ± 10%, respectively, for SVC, P = 0.379). In contrast, the SVC response to HG increased from -9 ± 12 with saline to + 5 ± 15% with PHE (P = 0.002) and from -16 ± 15 with saline to +1 ± 16% with PHE during PECO (P = 0.003). LVC responses to HG or PECO were not different from saline with PHE. CONCLUSIONS: Non-α-adrenergic vasoconstriction was present during LBNP. The systemic vasoconstriction during static exercise and isolated muscle metaboreflex activation, in the absence of leg vasoconstriction, was explained by an α-adrenergic mechanism. Therefore, non-α-adrenergic vasoconstriction is more emphasized during baroreflex, but not metaboreflex-mediated sympathetic activation.

Scoping review report: obesity in older adults.

Obesity is associated with an increased risk for early death, heart disease and stroke, disability and several other comorbidities. Although there is concern about the potential burden on health-care services with the aging demographic and the increasing trend of obesity prevalence in older adults, evidence on which to base management strategies is conflicting for various reasons. The analytic framework for this review is based on a scoping review methodology, and was conducted to examine what is known about the diagnosis, treatment and management of obesity in older adults. A total of 492 relevant research articles were identified using PubMed, Scirus, EBSCO, Clinicaltrials.gov, Cochrane Reviews and Google Scholar. The findings of this review indicate that the current WHO (World Health Organization)-recommended body mass index, waist circumference and waist-to-hip ratio obesity thresholds for the general adult population may not be appropriate for older adults. Alternatively, weight change or physical fitness may be more useful measures of mortality and health risk in obese older adults. Furthermore, although obesity in older adults is associated with several disorders that increase functional disability, epidemiological evidence suggests that obesity is protective against mortality in seniors. Consequently, the trend toward increasing prevalence of obesity in older adults will lead to an increase in unhealthy life years and health-care costs. The findings from this review also suggest that treatment strategies for obese older adults should focus on maintaining body weight and improving physical fitness and function rather than weight loss, and that a combination of aerobic and resistance exercise appears to be the most effective strategy. In conclusion, this review demonstrates the need for more research to clarify the definition of obesity in older adults, to establish criteria for evaluating when to treat older adults for obesity, and to develop effective treatment strategies focused on functional outcomes in obese older adults.

Central versus peripheral cardiovascular risk in metabolic syndrome.

Individuals with metabolic syndrome (MetS; i.e., three of five of the following risk factors (RFs): elevated blood pressure, waist circumference, triglycerides, blood glucose, or reduced HDL) are thought to be prone to serious cardiovascular disease and there is debate as to whether the disease begins in the peripheral vasculature or centrally. This study investigates hemodynamics, cardiac function/morphology, and mechanical properties of the central (heart, carotid artery) or peripheral [total peripheral resistance (TPR), forearm vascular bed] vasculature in individuals without (1-2 RFs: n = 28), or with (≥3 RFs: n = 46) MetS. After adjustments for statin and blood pressure medication use, those with MetS had lower mitral valve E/A ratios (<3 RFs: 1.24 ± 0.07; ≥3 RFs: 1.01 ± 0.04; P = 0.025), and higher TPR index (<3 RFs: 48 ± 2 mmHg/L/min/m(2); ≥3 RFs: 53 ± 2 mmHg/L/min/m(2); P = 0.04). There were no differences in heart size, carotid artery measurements, cardiovagal baroreflex, pulse-wave velocity, stroke volume index, or cardiac output index due to MetS after adjustments for statin and blood pressure medication use. The use of statins was associated with increased inertia in the brachial vascular bed, increased HbA1c and decreased LDL cholesterol. The independent use of anti-hypertensive medication was associated with decreased predicted [Formula: see text] triglycerides, diastolic blood pressure, interventricular septum thickness, calculated left ventricle mass, left ventricle posterior wall thickness, and left ventricle pre-ejection period, but increased carotid stiffness, HDL cholesterol, and heart rate. These data imply that both a central cardiac effect and a peripheral effect of vascular resistance are expressed in MetS. These data also indicate that variance in between-group responses due to pharmacological treatments are important factors to consider in studying cardiovascular changes in these individuals.

CHARMM: the biomolecular simulation program.

CHARMM (Chemistry at HARvard Molecular Mechanics) is a highly versatile and widely used molecular simulation program. It has been developed over the last three decades with a primary focus on molecules of biological interest, including proteins, peptides, lipids, nucleic acids, carbohydrates, and small molecule ligands, as they occur in solution, crystals, and membrane environments. For the study of such systems, the program provides a large suite of computational tools that include numerous conformational and path sampling methods, free energy estimators, molecular minimization, dynamics, and analysis techniques, and model-building capabilities. The CHARMM program is applicable to problems involving a much broader class of many-particle systems. Calculations with CHARMM can be performed using a number of different energy functions and models, from mixed quantum mechanical-molecular mechanical force fields, to all-atom classical potential energy functions with explicit solvent and various boundary conditions, to implicit solvent and membrane models. The program has been ported to numerous platforms in both serial and parallel architectures. This article provides an overview of the program as it exists today with an emphasis on developments since the publication of the original CHARMM article in 1983.

FIM after hip fracture: is telephone administration valid and sensitive to change?

OBJECTIVES: It has been reported recently that follow-up FIM trade mark scores have been obtained from stroke patients via telephone interviews with either the former patient or proxy caregivers. We studied the validity and sensitivity of change of a "phone FIM" score in a sample of hip fracture patients after rehabilitation. DESIGN: We compared FIM scores among hip fracture patients in a specialized musculoskeletal rehabilitation program. Sample size estimate of 27 was determined before the study. Patients included those with hip fracture returning to independent living in their own home. RESULTS: Twenty-nine patients were identified as a convenience sample of admitted patients. The phone FIM score at 8 wk was a valid predictor of the discharge FIM score and the observed FIM and phone FIM scores at 8 wk were similar. The sensitivity to change over 8 wk was similar between observed and phone FIM scores compared with the discharge FIM score. CONCLUSIONS: The phone FIM instrument presents a useful clinical instrument to monitor patient functional status in the community, showing excellent psychometric properties. Ease of use and low cost should encourage greater use in clinical management of these patients.

The energetics of off-rotamer protein side-chain conformations.

Non-rotameric ("off-rotamer") conformations are commonly observed for the side-chains of protein crystal structures. This study examines whether such conformations are real or artifactual by comparing the energetics of on and off-rotamer side-chain conformations calculated with the CHARMM energy function. Energy-based predictions of side-chain orientation are carried out by rigid-geometry mapping in the presence of the fixed protein environment for 1709 non-polar side-chains in 24 proteins for which high-resolution (2.0 A or better) structures are available. For on-rotamer conformations, 97.6 % are correctly predicted; i.e. they correspond to the absolute minima of their local side-chain energy maps (generally to within 10 degrees or less). By contrast, for the observed off-rotamer side-chain conformations, 63.8 % are predicted correctly. This difference is statistically significant (P<0.001) and suggests that while most of the observed off-rotamer conformations are real, many of the erroneously predicted ones are likely to be artifacts of the X-ray refinements. Probabilities for off-rotamer conformations of the non-polar side-chains are calculated to be 5.0-6.1 % by adaptive umbrella-sampled molecular dynamics trajectories of individual amino acid residues in vacuum and in the presence of an average protein or aqueous dielectric environment. These results correspond closely to the 5.7 % off-rotamer fraction predicted by the rigid-geometry mapping studies. Since these values are about one-half of the 10.2 % off-rotamer fraction observed in the X-ray structures, they support the conclusion that many of the latter are artifacts. In both the rigid-geometry mapping and the molecular dynamics studies, the discrepancies between the predicted and observed fractions of off-rotamer conformations are largest for leucine residues (approximately 6 % versus 16.6 %). The simulations for the isolated amino acid residues indicate that the real off-rotamer frequency of 5-6 % is consistent with the internal side-chain and local side-chain-backbone energetics and does not originate from shifts due to the protein. The present results suggest that energy-based rotation maps can be used to find side-chain positional artifacts that appear in crystal structures based on refinements in the 2 A resolution range.

A self-paced step test to predict aerobic fitness in older adults in the primary care clinic.

OBJECTIVES: To study the potential usefulness of a submaximal self-paced step test as a prediction of maximal aerobic capacity (VO2max) in older adults in the primary care setting. DESIGN: Data were collected during a prospective randomized study of an exercise program. SETTING: Four university family medical clinics in London, Ontario, Canada. PARTICIPANTS: A random sample of 240 healthy older (> or =65) men (n = 118) and women (n = 122) from four family medical clinics underwent self-paced step testing in the clinic with a family physician (n = 16), and step testing and a maximal exercise treadmill test with measurement of respired gases in an exercise laboratory. Testing was done in random order (clinic/laboratory) separated by 2 weeks and then repeated at 52 weeks, following introduction of an exercise program. Relationships between outcome variables were examined by Pearson correlation coefficients while prediction of VO2max was examined using multivariate regression analysis. Cross-validation with 30 age-matched hypertensive and 40 age-matched post-hip arthroplasty patients was used to test the accuracy of the predictive models. MEASUREMENTS: Measured VO2max, predicted VO2max, step test time, step test heart rate, body mass index (BMI), and O2 pulse. RESULTS: Two hundred women (n = 108) and men (n = 92) completed both the initial and 52-week assessments. Stepping time, heart rate, age, BMI, and O2 pulse were strongly associated with VO2max for both a normal and a fast step pace and were chosen to develop the predictive model. Normal step-pace correlation with VO2max (ml/kg/min) was no different (female 0.93: male 0.91) from fast pace (0.95:0.90) with no difference between clinic and laboratory measurement at baseline or 52 weeks. Cross-validation showed no significant difference from the main group using the predictive model. CONCLUSIONS: The self-paced step test is a safe and simple clinical instrument that strongly and reliably predicts VO2max, is sensitive to change, and is generalizable in the family practice setting among community-dwelling older adults differing in fitness and health status.

In-line skating injuries: patterns and protective equipment use.

The incidence of in-line skating injuries has increased with the rapid growth in the sport's popularity, but few studies have examined patterns of injuries.

Determination of prefracture physical function in community-dwelling people who fracture their hip.

BACKGROUND: Prefracture physical function must be accurately determined to set appropriate and attainable goals for rehabilitation following hip fracture. This is especially important for people who were living independently prior to their fracture. This study determines reliability and internal consistency of a prefracture physical function questionnaire (PFPFQ) completed by both patients and knowledgeable informants (KIs). METHODS: A 20-item PFPFQ, including ambulation, transfers, balance, and self-care domains, was developed using focus groups. Community-dwelling patients with a hip fracture (N = 40, 77.9 +/- 8 years) completed the PFPFQ on two occasions during postoperative acute care. Forty KIs were identified by the patients and also completed the PFPFQ on two occasions via telephone interview. Day-to-day reliability of the patients and KIs [intraclass correlation coefficients (ICC)], and internal consistency [Kuder-Richardson coefficient (KR)] of the PFPFQ were determined. RESULTS: Intrarater reliability was high with ICCs (95% confidence interval) of 0.94 (0.89, 0.96) for patients and 0.96 (0.93, 0.98) for KIs. Interrater reliability on occasion 1 had an ICC of 0.81 (0.69, 0.88). Internal consistency of the patient responses on the first occasion was high (KR coefficient = 0.896). CONCLUSIONS: The PFPFQ is a reliable and internally consistent instrument for determining prefracture physical function in community-dwelling people who fracture their hip. In situations where patients with a hip fracture are unable to provide this necessary information, KIs can provide reliable estimates of prefracture function to assist in setting appropriate rehabilitation goals.

Is exercise effective treatment for osteoarthritis of the knee?

OBJECTIVE: To review and determine the effectiveness of exercise treatment in osteoarthritis of the knee. METHODS: A computerised literature search of Medline was carried out searching between June 1966 and January 2000. RESULTS: Twenty three randomised controlled trials were identified from the literature. Only three trials were sufficiently powered. Small to moderate beneficial effects of exercise treatment were found for pain, small beneficial effects on disability outcome measures, and moderate to great beneficial effects were observed according to patient global assessment of effect. It was not possible to obtain evidence on the content of exercise interventions, as studies were hampered by lack of attention to proper concealment, reporting of adverse effects, and long term effects of exercise treatment. The lack of standard outcomes measures is also noted. CONCLUSIONS: The available evidence indicates beneficial short term effects of exercise treatment in patients with osteoarthritis of the knee. However, the number of available studies is limited, and more research is needed to expand this recommendation. Specifically, additional trials should provide information on adherence, home based interventions, interaction with pharmacological treatments, functional outcomes measures relevant to exercise treatment in these patients, and long term effects. At present, doctors should recommend exercise to all patients with mild/moderate disease. Further study should be encouraged and exercise should be continued to be recommended as a mainstay of non-pharmacological treatment of osteoarthritis of the knee.

Left ventricular diastolic filling and cardiovascular functional capacity in older men.

We investigated anaerobic threshold (< theta(L)) gas exchange kinetics and maximal oxygen uptake (VO2,max) among older men with reduced left ventricular end-diastolic filling (LVDF). Ten men (mean age, 73 years) with LVDF impairment and low fitness, but without other cardiovascular dysfunction were studied. Treatments compared to control included: 5 days, high intensity exercise training protocol; 5 days, calcium channel blockade (240 mg verapamil); 21 days, detraining/washout; and 5 days, combined treatments. Results indicated no changes in resting left ventricular systolic function with any treatment. Significant resting diastolic function changes included increased early:late flow velocity (control, 0.87; training, 1.28; verapamil, 1.32), and a decreased isovolumic relaxation time (control, 0.10 s; training, 0.08 s; verapamil, 0.08 s). The combined treatments were not additive. Sub-threshold oxygen uptake kinetics (tauVO2, s) were significantly faster following either training or verapamil (tauVO2,control, 62+/-12; tauVO2,training, 44+/-9; tauVO2,verapamil, 48+/-10) and combined treatments (tauVO2, 41+/- 8). V O2,max (ml kg(-1) min(-1)) was significantly increased (control, 21.8+/-2.2; training, 27.3+/-2.2; verapamil, 25.2+/-3.4; combined treatments, 26.9+/-2.3). Increasing ventricular preload with either exercise training or calcium channel blockade was coincident with faster tauVO2 and increased VO2,max.

Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial.

OBJECTIVE: This 8 week randomized, double blind clinical trial compared the effect of a combined home based progressive exercise program and treatment with the nonsteroidal medication oxaprozin to treatment with oxaprozin alone on pain and physical functioning in older community dwelling patients with unilateral knee osteoarthritis (OA). METHODS: Efficacy variables measured before and after 8 weeks included (1) pain using the Western Ontario McMaster (WOMAC) pain, physical disability, and stiffness subscales and a 10 point visual analog scale (VAS) before and after self-paced walking (SPW) and stepping (SPS) functional tasks; (2) physical function using the time to complete a self-paced 40 m walk (SPW) and 20 cycles of 2 steps (SPS): (3) physical activity level using the Physical Activity Scale for Elderly (PASE); (4) clinical measures of knee functioning (range of motion). One hundred seventy-nine men and women (mean age 74 +/- 6 yrs) with radiographic evidence of mild/moderate medial compartment OA were randomized to either a progressive home based knee exercise program (n = 88) or a control program (n = 89). All patients were given oxaprozin 1,200 mg per os daily. RESULTS: We observed significant reduction from baseline in activity related pain (VAS); and improvement in SPW and SPS test time, passive range of motion, and PASE after 8 weeks in both groups. These changes were significantly greater (p < 0.05) in the exercise versus sham group. CONCLUSION: Addition of a progressive exercise program to nonsteroidal antiinflammatory therapy in patients with knee OA can improve measures of activity and activity related pain more than medication alone.