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I'm really happy to be part of
this panel and in this symposium trained to be able
to share our research teams
experience with implementing a virtual
for fractured prevention exercise program
that really wasn't the midst of the pandemic.
I'll talk to you about some of the challenges.
There were several and
some of the surprises that we had,
positive, overall, really positive.
Let's then move on.
The program I'm going to talk
about is named Strong Foundations,
but it evolved from
this large clinical trial carbon medics study
since concluded.
I wouldn't be surprised that
several people in our audience
today were participants in this study.
It was a two site trials,
UC San Diego and
Washington University School of Medicine in St. Louis.
There were a total about 600 participants.
Then a fairly long intervention trial that looked at
mindfulness training and exercise
in the main outcome measure in this study,
it was actually cognitive function.
I was brought in as a co-investigator to help develop
the exercise program and then evaluate it, et cetera.
The program was six months,
twice weekly, in-person exercise classes.
Some of the pictures here
are taken directly from the program.
This was held at a local YMCA.
Then after the six months of intensive,
it went to a once weekly maintenance program for a year.
We had recruited participants in groups or
cohorts of 15 and they were enrolled,
started the program and this was ongoing.
We were literally down to the end in
our our last two cohorts of
20 from San Diego Washington,
you have the same thing going on there in St. Louis.
It was the last 6-8 weeks
of the structured phase of the program.
Then along came COVID-19.
Now as my little cartoon suggest
here the possibilities of
what could go wrong out there are stressing me out.
Certainly there was a lot of
anxiety and stress all around.
For us, it was what are we going to do?
Of course, the gyms were closed,
people didn't want to go out in anywhere at way point.
We had to make a decision whether to just cancel
the last two groups that would have been
about 10 percent of our sample.
We didn't want to do that, our participants
didn't want to do that.
We scrambled and we decided to attempt to
use the Zoom platform to do virtual exercise.
Mind you I had never done anything like this myself.
We went ahead and did that.
The first couple of weeks
we're a lot of trials and tribulations there.
But it went on and we finished.
Those participants, then went into
their maintenance and the virtual maintenance
continued until the trial ended just shortly ago.
We decided eight weeks into it that we would collect
some data on how people felt about it.
Because when we started thinking,
once we got near the end,
that'll make because it will work.
Maybe we can go further with
a different population that I
wasn't really interested in.
That was actually saying
older adults but different topic.
We use this tool called the System Usability Scale.
It's one that was developed and
quite certainly more for industry then for academia.
But it was getting at how people felt
about and how well they accepted virtual learning.
We applied this.
What you're looking at here is each participant
in one of our 20 cohorts indices right at the end,
after eight weeks in
the lockdown phase of virtual training.
According to the authors of the scale,
scores of 70 percent or higher are consistent
with a program or whatever tool is being studied,
consistent with it being usable and acceptable.
We had an average score of
82 all the two people
actually reached that 70 percent threshold.
That gave us a little bit up.
Maybe this could work.
Then we start some responses from individuals.
I've just put four different participants
here in quotes from them.
But what I want to point out on this is
that attendance and this isn't
a fair comparison because the Zoom base was eight weeks
versus 4.5-5 months of their in-person.
But attendance, even though
a couple of these people really
didn't prefer Zoom, was an imperfect.
Actually for the 13 people who stayed
in the trial in this particular cohort,
it was close to a 100 percent.
We started to have meetings,
talk more, thinking about, again,
the population that is of
most interests in most of my experiences
in bone health and fall and fracture prevention.
Here we thinking, well,
who can reach with this and for all in-person programs.
Great problem in exercise community programs
is trying to reach homebound individuals.
Whether they're home-bound because illness or frailty,
or just lack of transportation to a community center.
We thought that would be a target for us.
Then we started thinking beyond
San Diego County because of course,
we're not limited by geography.
We made some inquiries and
certainly didn't study there's any degree,
but we suspect that in rural communities is very few,
if any, targeted programs
for fall and fracture prevention.
Then also our regular exercisers who may benefit from
more guided instruction specific
to fall and fracture prevention.
We decided we can do this, let's do this.
We named this program Strong Foundations,
and few minutes I'll tell you how that
got its name when you see the components of the program.
We're also right at about that time,
we were fortunate to secure some funding from UCSD,
that clinical and translational research institute CTRI.
This was led by our Medical Director,
Dr. Ryan Moran, who also
has a strong interest in fall prevention.
The program was part of a larger effort to
integrate within the UC Health System
of fall prevention clinic
to improve screening and assessment and
referral for follow-up care to individual patients needs.
That has begun and
I have a flowchart here
which you'll go through in detail.
But essentially participants 65 and older when
they're in the clinic for
a medicare annual wellness visit or seeing
their primary care physician
are going to be screened and this partners already
been going on short survey
yes or no responses to have you fallen in the past year,
fear of falling, et cetera.
Then that leads to group visit.
These are being administered by nursing staff.
Probably going to expand this to
have more interns from our lab involved in this.
Then eventually folks that dissipates or patients
are then referred depending on their individual needs,
and that might be to orthopedics and physical therapy
or say how you're performing participants,
at least at the outset,
then could get referred for community programs
such as, the Strong Foundations.
This isn't just in a nutshell what the program is.
It's going to be administered fully virtually one day a
week plus a home exercise
with video components in detailed instruction manual.
We just know nailing down the whole curriculum.
It's going to be a 12 week program.
But we did, do too short four week cohorts to pilot test.
We've learned from that and I'll
share some of that with you in a moment.
But the distinctive feature that we
believe will set us apart from some of the many,
there's terrific online programs,
terrific of YouTube videos for all different exercise,
probably thousands of them.
We have vetted a lot of those user than
a resource manual and some are excellent,
but what they're lacking is individualized in real time.
Really the model we're
using this to have a lead exercise instructor,
a highly specialized person
that has done geriatric exercise.
He or she, we have one of
each sex that we'll be doing this with us.
They'll have 2-3 assistants providing semi
individualized training using
the breakout room function of Zoom.
We think that's what sets us apart.
After the first pilot in this is,
we have 13 people in that first four week pilot.
We use that system usability scale again,
how did they like it?
Mind you this is only four weeks.
After people have been in programs for
12 weeks or six months or two years,
maybe their interests starts to wane little bit,
but certainly for four weeks,
these participants usually like the program,
so 90 percent said that they
indeed would be redoing this and would want to continue.
We wanted to get some information about class structure.
Using this color code,
green and purple for strongly
agreeing that the instructor wasn't effective,
that the format was relatively easy to follow.
This really pleased us, it pleased me,
that participants indeed did feel
safe at home doing these exercises,
even though we weren't giving them
challenges to their balance,
which of course carries some risk of falling.
We try to minimize that fall risk,
but maximize the challenge and they felt safe doing it.
Then we asked the participants awareness of
the assistant instructors who were
watching as the lead instructor led the class.
We didn't do such a good job of that and I think what
happens here is the assistant instructors
will look for folks
that doing something technically not quite right,
and they'll focus on trying to help them and some of
the other participants then fall by the wayside.
We need to do a better job of that.
Also, if you take a look here
about their interest in or
would they be willing to use a breakout room?
We also didn't do a really good job of
addressing that as we were working through
the kinks of how do we make that work.
But two-thirds of them said yes,
they would use it and then a few not so sure,
I think some weren't even quite sure what it was because
not all participants in
the four-week class got to go into a breakout room.
An important factor here is home exercise practice.
There's really a structured program at
home where they have all the materials,
written and in video of the exercises.
We asked how many times a week did they practice
this and over 90 percent responded,
they did it at least 1-2 times a week
and a full 50 percent said 3-5.
Once more, this was only a four week,
would that decrease over time?
Perhaps. But we're happy that at
least at this point they are doing it.
In the time remaining here,
let me just give you a visual sampler,
if you will, of what this program looks like.
The name Strong Foundations comes from,
these are the three key features.
I think these are
the pillars that are going to lead to reduce
falls and fractures based on
the science that has been published.
A heavy emphasis on posture and spinal stability,
balance of course, and functional strength.
The National Osteoporosis Foundation
has this very good poster that
participants will have a great urge them
to print it and post it at home.
We will be training them on how to do the mechanics of
these movements of everyday activities
so that it's protecting the spines.
Some call these spine sparing,
I call them spine friendly movements.
This can go a long way to protecting the back from pain.
There's also evidence that it can
decrease the hyperkyphotic posture,
the bent over posture that eventually just
becomes normal and it can lead to vertebral fractures.
Heavy emphasis there,
heavy emphasis on balance and mobility.
These are pictures mostly from our medics
trial where we gave a lot of different challenges.
When people think of balance,
sometimes they think of standing on one foot,
but falls occur mostly when we're moving, not standing.
A lot of different gait practice,
movement, challenged in the surface we are on,
they challenge the sensory systems so that they adapt to
uneven surfaces or sub surfaces, etc.
Then lastly, strength exercises.
The pictures can see heavy emphasis on lower body
and leg strength and also on back, because once more,
the literature tells us if you do
resistance training for the back muscles,
in older adults, can slow the loss
of bone in the vertebral bodies,
so heavy emphasis there.
Then I will just finish
with this page of community resources.
The agent and independent services
through County Health Department
has had a program for
22 years now called the Feeling Fit Club.
Participants named their group,
their club is a picture from one of the sites.
They are pre-COVID there in
28 community sites spread across the whole county.
Currently most of the classes are still virtual,
but I was told just several days ago that
some sites are starting to reopen for the in-person.
Then scripts, trauma department sponsors, workshops.
Those also went to virtual
and they were likely open backup to in-person
and they also co-sponsored volunteer instructor trainings
for another balanced program called a matter of balance.
Lastly, the link to
our strong foundation program
for anyone who's interested,
wants to find out more about it,
happy to have you contact us and we will get back to you.
With that, I'll leave you with this beautiful look
at Torrey Pines trails
and I thank you for your attention.
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