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Pre-habilitation: Effective Preventative Medicine for Rehabilitation

If an apple a day keeps the doctor away, what can a knee bend do? The American Academy of Orthopedic Surgeons recently answered this question with the results of a new study of the impact of physical therapy on surgical outcomes for hip replacement. The answer: “Prehabilitation reduces the need for perioperative care by 30%.” Amazing results, especially considering that total joint replacements will increase by 400% by 2030 according to the academy. Considering that post-acute care costs are the fastest rising and most variable, an investment in pre-habilitation can pay off huge dividends. Based on data from the AMA and CDC we’ve estimated that a 10% decrease in post-acute care costs could help realize $4.3B in savings over this same period. The AAOS study showed that patients who received pre-habilitation saw a decline in up to $1,215 per patient in perioperative care, due to a decrease in costs for skilled nursing and home care. Given that total joint replacement costs vary from a low of $6000 to a high of $30,000, providing pre-habilitation and a means for patients to be adherent is a very easy way to get to this 10% decrease. If you’d like more information on how we calculated these costs contact us.

The theme of pre-habilitation was also prevalent at the recent ACRM annual congress in Toronto, consider it the preventative health of rehabilitation, which literally means the act of restoring something to it’s original state. If you can decrease the amount of damage done in the first place, restoring it to the original state becomes easier or at least if you don’t see complete recovery, you see better outcomes. Two sessions at the conference explored this concept where there was known risk of damage: one focused on pre-habilitation for cancer patients that would need to undergo surgery, and the other a focused study on adults with lower back pain who were at risk of declining.

Effect of Diet on Outcomes for Cancer Surgery PatientsOne session focused on pre-habilitation for patients undergoing cancer surgery, and was striking both for the outcomes and for the collaborative and interdisciplinary team. The session, “Improving Outcomes With Multimodal Prehabilitation in Surgical Cancer Patients” was notable both for the outcomes presented and for the strength of the collaborative and inter-disciplinary team that included led by Dr. Carli from McGill University that included physicians, dieticians, and physical therapists. The team presented the results of their randomized clinical study that showed that a prehab program including strength training, exercise, diet, and nutrition counseling could decrease hospital stays by ½ a day and that the strength training helped patients compensate for surgery-related weakness perioperatively.

Patients were given either just nutrition counseling or nutrition counseling plus a whey supplement or a placebo. Patients with nutrition counseling sustained their levels in the 6 minute walk test before and after surgery. Patients with both nutrition counseling and the whey supplement improved their distances in the 6-minute walk test after surgery.

Together the strength training, nutritional counseling, and protein supplements improved patient surgical outcomes. Ideally, nutrition counseling was recommended to begin at cancer diagnosis, but at the very least pre-surgery. This study proved that there are modifiable patient risk factors before surgery that can improve outcomes.

Exercise for Lower Back Pain in SeniorsA second study outlined by Dr. Gregory Hicks from the University of Delaware  in the session “Novel Ways to Improve Mobility and Physical Function in Older Adults: A Targeted Intervention Approach”, looked at whether stabilizing trunk exercises could prevent decline in high-risk seniors. Interestingly, the presenter X pointed out, any studies involving trunk muscle stabilization had purposely excluded adults over 65 so there was no evidence of the impact. In this study, the control group was given the usual care condition of heat, ultrasound, massage, and stretching. The second group was given trunk muscle training and Neuromuscular Electromagnetic Stimulation. Unfortunately, the second group had low adherence to their programs, and were not happy to miss out on heat and massage. This probably says more about the need for patient education and engagement than anything. In many studies strengthening exercises have proven helpful, but not if you can’t get patients to do them. Regardless, patients in the trunk muscle group had a 17% higher rating on the top 3 functional limitations that they had reported as being most important to them at the outset of the study and their exercise self-efficacy was expected to continue to improve over time.

While the results were positive, Hicks outlined some of the limitations of the study, including the exercise adherence but also pointed out that patients had different outcomes based on the physical therapist delivering the treatment and based on how closely they identified with the pre-defined outcome measures that were used in the standard tools (OSWESTRY). This brings up an interesting point about how to deliver care.

While research has proven that proactive activities, like improving diet or exercise, can improve outcomes, patients, and by that I mean humans, are subject to human nature, which is not always doing what’s in our own best interest.

There are ways to change this within the care delivery system to help patients adhere to their treatment plans:

  • Making sure patients understand what they are being asked to do
  • Making it easy to follow instructions
  • Fostering a positive relationship between patient and healthcare provider

Adapted from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/pdf/tcrm0103-189.pdf

These principles are fundamental to our Wellpepper patient engagement solutions and help us get over 70% patient engagement. We’re pretty excited to see the opportunities for these types of solutions to be used in pre-habilitation scenarios that are proven to improve outcomes.

Posted in: Prehabilitation

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My Life with Trackers

My Facebook and Twitter feeds are full of people talking about the new gadgets they got for Christmas. Tracking has gone mainstream as many of those gadgets are fitness and activity tracker devices. I thought I’d share a bit about what I’ve learned as an avid tracker for some of these newbies.

I have been using apps and devices to track my activities for over 7 years. When Nike in-shoe sensors came on the market in 2006, I was an early adopter and since then have upgraded to various GPS watches and apps like RunKeeper on my phone. I love tracking my runs and hikes. It adds an extra sense of accomplishment seeing exactly how far you’ve gone, elevation climbed and how fast you’ve traveled. Seeing my progress overtime was especially motivating and helpful when training for upcoming races.  It led me to want to track more. I definitely felt myself getting caught up in the quantified self movement.

flex

Fitbit Flex

So when we decided to get Fitbit trackers at Wellpepper, I was all over it. I was very excited to start tracking activities outside of runs.  I chose the wristband format while Mike and Anne chose the Fitibt Zips that clip onto your pocket or waistband. I liked the idea wearing the Fitbit at all times tracking all activities (including sleep) and thought I would have a better chance of not losing it. We found this to be true right away as Mike lost his first two Fitbits.  (Protip: Clip your Fitbit with your Fitbit inside your pocket.) Anne wasn’t too keen on the look of the sporty black wristband so chose the smaller out of sight zip and also appreciated that the Zip didn’t need to be charged. (However, both Anne and Mike had over a week of no activity recorded when their batteries actually died.)

Fitbit Zip

Fitbit Zip

Initial findings were very fun and intriguing: an Ultimate Frisbee game is about 8,000 steps and a good round of golf about 18,000 steps with up to 20,000 steps if that happened to be a bad round of golf. The most lucrative activity turned out to be dancing, it’s surprising how many steps you can take while dancing at a wedding! (23k)  Step counts varied between the different Fitbit types. As my steps were tracked by the movement of my arm, I definitely got credit for additional steps including a few 1000 from petting an upset dog during a thunderstorm. This caused some debates over the accuracy and fairness of the Wellpepper Fitbit leaderboard, which is definitely a fun and motivating feature of the Fitbit app. 

Fitbit 3Definitely the most surprising findings were how many steps could add up with regular day to day activities.   I found that I generally took around 1000 steps just walking around the house and getting ready in the morning.  A walk to the store to grab a few groceries could garner up to 2000 steps. Turn that trip into a walk to the farmer’s market and you could easily generate 4k steps! It was surprising how a few small decisions could turn a relatively normal day into highly productive and active day.  I found this infographic: The Exercise Experiment: A Tale of Two Days does a great job of showing the difference small choices can make.

Even more surprising, or even shocking, was how many steps I didn’t take on an inactive day.  I work from home and it’s not uncommon for me to grab a cup of coffee in the morning, jump on my laptop and get to work. Some days, the time can slip by and before you know it, the day is gone.  I never used to worry about it because when I am not working, I am highly active. However, after I came across The Truth about Sitting, I decided I needed to be more aware of my overall activity. I think this has been the greatest impact of the Fitbit. I thought that I might dive deeper into analyzing my runs or hikes, but it has actually created this awareness to keep me moving all the time. It reminded me of something John Mattison (CIMO of Kaiser Permanente) said at FutureMed:

It’s not about wearing a million sensors, we don’t need digital nannies, it’s about becoming more mindful.

Posted in: Healthcare Technology, M-health

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Breaking the Barriers to Exercise

Last Friday, May 3rd I attended the IDEA Personal Trainer Institute Conference in Seattle.  IDEA is a conference for personal trainers to come together and get comprehensive, in-depth training from some of the top fitness professionals in the world. Sessions ranged from full-on workout sessions (TRX, Kettle Bell training) to lectures on motivating clients, and running a successful fitness business.  I had the opportunity to attend a session presented by Rodney Corn from PTA Global entitled “Breaking the Barriers to Exercise” in which he discussed how to motivate non-exercisers to get active.

1gf4g Rodney started off the session by asking: “What do you consider exercise?” Now in a room full of personal trainers you can imagine that there were visions of some pretty intense and vigorous exercise. To be fair, the morning sessions looked something like the video you see on the left.  He then asked the room to go through a series of movements. He had us pick up a medicine ball and carry it to the other end of the conference room. Then he had us roll an exercise ball to the other end of the conference room. Pretty easy and non-strenuous movements.  “Was this exercise?” From the expressions of the majority of the people in the room I would say most thought NO.

Exercise is movement.  It is generally defined as movement that is planned, structured, and repetitive for the purpose of conditioning any part of the body. The industry’s  standard for exercise is a minimum of 150 minutes of moderate exercise or 75 minutes of intense exercise per week.  For increased benefits the recommendation is 300 minutes of moderate exercise or 150 minutes of intense exercise per week.

In the following video Dr. Joan Vernikos, looks to simplify the idea of exercise stating:

“The key to lifelong health is more than just traditional gym exercise. The answer is to rediscover a lifestyle of constant, natural, low intensity, non-exercise movement that uses the gravity vector throughout the day.”

So if exercise is so simple, then why aren’t more people doing it? The situation today is pretty dire:

  •  1.6 billion people are overweight or obese in the world
  • 60% of people worldwide don’t get sufficient exercise
  • 70% of the US population is overweight or obese
  • Less than 20% of people get the recommended amount of physical activity
  • 25% of US population does ZERO physical activity

There are more fitness facilities, personal trainers and education than ever, yet there is also less participation in exercise and more disease than ever before. What are the barriers to exercise? Why are so many people remaining inactive? Rodney suggested there are two major obstacles: Pre-existing level of activity and the suggested time required to exercise.

Dr. Roy Sugarman, Neuropsychologist states: “People need the reward of micro-goal successes to avoid ambivalence about the big goals”.   So breaking down daily activities into smaller, shorter bouts and intervals would be much easier for the sedentary populace to digest. Protocols for non-exercisers and beginners should be just 5 to 10 minutes in length. It has been scientifically proven even short intervals (5-10 min) of activity can have a physical and mental benefit.

At this point of the lecture you could hear the collective sigh of the trainers in the room.  Really? Only 5-10 minutes? Personal trainers are used to pushing people to their limits. They turn even the average Joe into an athlete. How can 10 minutes be enough? Rodney hammered home the point by saying:

“People are more likely to change when they have a sense of control, can manage the process and see some quick micro results.”

Trainers should match exercises and programs specifically to the client by knowing their personality, behavior patterns and motivation. They should ensure that the program gives the client a sense of control and that the length of exercise is short enough to facilitate change. The fact is, the more often you can get someone to do an activity, the more likely you are able to help them establish a new habit. If the program is overwhelming for an individual, they just won’t do the exercises. Training programs need to be appealing, nonthreatening and most of all – achievable.

The fitness industry is not designed to meet the needs of the sedentary population because the fitness industry’s idea of exercise is too high. The reality is that any movement is exercise and for some just doing simple movements around the house is where they need to start. As Dr Joan Vernikos says: “Sitting kills, movement heals”. Helping someone get in the habit of performing even the simplest of movements can move them towards a more healthy and active lifestyle.

At Wellpepper, we motivate behavior change by giving clients detailed instructions, reminders, and motivational prompts to remember to do their exercises. Many professionals we have worked with recognize that when it comes to motivation, sometimes less is more.  However, some have asked how many exercises can you prescribe to clients with Wellpepper? The answer is as many as you like,  but the trick is to find that magic amount for the end customer. What will drive them to change?

Posted in: Exercise Physiology, Healthcare motivation

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