1 EFFEC T S OF LINE DANCING ON PHYSICAL FUNCTION AND DISABILITY IN OLDER ADULTS WITH MOBILITY DIFFICULTY By CRYSTAL G. BENNETT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMEN T OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014
2 Â© 2014 Crystal G. Bennett
3 To my husband, Peter and my children, Alyssa, Preston, Trenton and Carissa, thank you for your hugs and support during this journey. To my parents, John and Helen, who never allowed me to give up and inspired me to finish strong.
4 ACKNOWLEDGMENTS I thank my family, friends and colleagues for helping me on this journey. I thank my com mittee members, Dr. Chris Hass, Dr. Ann Horgas, and Dr. Bryan Weber for their time and expertise. I would especially like to thank my mentor, Beverly L. Roberts for her dedication and encouragement. I thank Jeanelle and Harvey Kingr y , my line dancing instr uctors, who made this project possible. I thank all the participants in the dance classes for their willingness to try something new. I dedicate this dissertation to the person that started me on this journey, Dr. Marilyn L. Lamborn, she inspired me to pur sue my dreams and if she was still with us today would have been proud of what I have accomplished.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 10 ABSTRACT ................................ ................................ ................................ ................... 11 CHAPTER 1 BACKGROUND AND S IGNIFICANCE ................................ ................................ ... 13 Significance ................................ ................................ ................................ ............ 13 Theoretical Framework ................................ ................................ ........................... 14 Disablem ent Model ................................ ................................ ........................... 15 Preclinical Disability Model ................................ ................................ ............... 15 Theoretical Model ................................ ................................ ................................ ... 16 Background ................................ ................................ ................................ ............. 17 Exercise and Impairments ................................ ................................ ...................... 19 Exercise and Functional Limitations ................................ ................................ ........ 20 Exercise and Preclinical Disability ................................ ................................ .......... 21 Exercise and Disability ................................ ................................ ............................ 21 Covariates ................................ ................................ ................................ ............... 21 Rationale for Line Dancing ................................ ................................ ...................... 22 Summary ................................ ................................ ................................ ................ 23 Specific Aims and Hypotheses ................................ ................................ ............... 23 2 LITERATURE REVIEW ................................ ................................ .......................... 25 Impairments ................................ ................................ ................................ ............ 25 Balance ................................ ................................ ................................ ............ 25 Muscle Strength ................................ ................................ ............................... 27 Functional Limitations ................................ ................................ ............................. 28 Physical Performance ................................ ................................ ....................... 28 Endurance ................................ ................................ ................................ ........ 29 Gait ................................ ................................ ................................ ................... 30 Disability ................................ ................................ ................................ ................. 31 Mobility Disability ................................ ................................ .............................. 31 Preclinical Disability ................................ ................................ .......................... 31 Potential Covariates ................................ ................................ ................................ 32 Depressive Symptoms ................................ ................................ ...................... 32 Balance confidence ................................ ................................ .......................... 32
6 3 METHODS ................................ ................................ ................................ .............. 34 Design ................................ ................................ ................................ ..................... 34 Sample Selection ................................ ................................ ................................ .... 34 Setting ................................ ................................ ................................ ..................... 35 Line Dancing ................................ ................................ ................................ ........... 37 Safety Monitoring of Dance ................................ ................................ ..................... 40 Adherence ................................ ................................ ................................ .............. 41 Control Group ................................ ................................ ................................ ......... 41 Measurements ................................ ................................ ................................ ........ 41 Impairments ................................ ................................ ................................ ............ 42 Balance ................................ ................................ ................................ ............ 42 Muscle strength ................................ ................................ ................................ 42 Functional limitations ................................ ................................ .............................. 43 Physical Performance ................................ ................................ ....................... 43 Endurance ................................ ................................ ................................ ........ 44 Gait ................................ ................................ ................................ ................... 44 Preclinical Disability ................................ ................................ ................................ 45 Task frequency ................................ ................................ ................................ . 45 Task modification ................................ ................................ ............................. 45 Disability ................................ ................................ ................................ ................. 46 Covariates ................................ ................................ ................................ ............... 47 Depressive symptoms ................................ ................................ ...................... 47 Daily log of activity ................................ ................................ ............................ 47 Balance confidence ................................ ................................ .......................... 47 Perceived Benefit of Dance ................................ ................................ .................... 48 Data Analysis ................................ ................................ ................................ .......... 48 Human Subject Protection ................................ ................................ ...................... 49 Data Storage and Management ................................ ................................ .............. 51 4 RESULTS ................................ ................................ ................................ ............... 53 Sample and Setting ................................ ................................ ................................ . 53 Hypothesis Testing ................................ ................................ ................................ . 54 Hypothesis 1 ................................ ................................ ................................ ........... 55 Hypothesis 2 ................................ ................................ ................................ ........... 56 Hypothesis 3 ................................ ................................ ................................ ........... 56 Hypothesis 4 ................................ ................................ ................................ ........... 56 Hypothesis 5 ................................ ................................ ................................ ........... 57 Summary ................................ ................................ ................................ ................ 57 5 DISCUSSION ................................ ................................ ................................ ......... 65 Dance and Impa irments ................................ ................................ .......................... 65 Dance and Functional Limitations ................................ ................................ ........... 66 Dance and Preclinical Disability ................................ ................................ .............. 67 Dance and Disability ................................ ................................ ............................... 67
7 Limitations ................................ ................................ ................................ ............... 68 Clinical Implications ................................ ................................ ................................ 68 Future Research ................................ ................................ ................................ ..... 70 Summary ................................ ................................ ................................ ................ 71 APPENDIX A ................................ ................................ .................. 72 B THE DISABLEMENT MODEL ................................ ................................ ................. 73 C SUBSTRUCTION OF SELECTION, OPTIMIZATION, AND COMPENSATION (SOC) MODEL ................................ ................................ ................................ ........ 74 D THEORY SYNTHESIS OF DISABLEMENT MODEL AND PRECLINICAL DISABILITY ................................ ................................ ................................ ............ 75 E LINE DANCE CHOREOGRAPHY ................................ ................................ ........... 76 F OUTCOMES AND MEASUREMENTS ................................ ................................ ... 84 G INSTRUMENTS ................................ ................................ ................................ ...... 85 LIST OF REFERENCES ................................ ................................ ............................. 112 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 125
8 LIST OF TABLES Table page 4 1 Demographic characteristics ................................ ................................ .............. 59 4 2 Heal th conditions ................................ ................................ ................................ 60 4 3 Tests of normality ................................ ................................ ............................... 61 4 4 Differences between line dancing and control groups ................................ ........ 62 4 5 Differences between the controls and line dancing groups for nominal outcome variables ................................ ................................ .............................. 63 4 6 Pearson correlations matrix ................................ ................................ ................ 64 A 1 Outcomes and measurements ................................ ................................ ............ 84 A 2 Borg rating of perceived exertion scale ................................ .............................. 86
9 LIST OF FIGURES Figure page 1 1 Proposed Theoretical Model ................................ ................................ ............... 17
10 LIST OF ABBREVIATIONS ADL Activities of daily living BBS Berg Balance Sca le FES Falls Efficacy Scale GDS Geriatric Depression Scale IADL Instrumental activities of daily living MOD Task modification Scale PCD Preclinical disability SOC Selection, Optimization, Compensation SPPB Short Physical Performance Battery
11 Abstract of Di ssertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EFFECTS OF LINE DANCING ON PHYSICAL FUNCTION AND DISABILITY IN OLDER ADULTS WITH MO BILITY DIFFICULTY By Crystal G. Bennett August 2014 Chair: Beverly L. Roberts Major: Nursing Sciences Older adults with mobility difficulty experience loss of independence that affects daily life. Those wi th mobility difficu lty have a higher risk o f having chronic disease and shorter survival than those without disability (Balzi et al., 2010; Keeler, Guralnik, Tian, Wallace & Reuben, 2010 ) . Given the older adult population is expected to nearly double in size by 2050, the number of those with mobili ty difficulty may increase (Ortman, Velkoff, & Hogan , 2014). Exercise delays progression of disability, but many older adults do not exercise. Alternative forms of exercise such as dance, is needed to reduce the number of sedentary older adults. Dance i s a fun and enjoyable exercise that has the potential to improve the daily lives of older adults. The effects of line dancing on physical function and disability had yet to be investigated. Thus, the purpose of this study was to evaluate an intervention by examining the effects of line dancing on impairments, functional limitations, preclinical disability and disability in older adults with mobility difficulty . T his study fills an important gap in knowledge about the effects of dance on preclinical and clin ical disability.
12 Results of this study revealed that eight weeks of line dancing improved some impairments, reduced functional limitations, and reduced mobility disability. This study was the first to examine line dancing as an exercise intervention for o lder a d ults with mobility difficulty. The findings from this study contribute to exis ting knowledge of dance effects on physical function and disability. Future studies with larger samples are needed to confirm and extend the present study results.
13 CH APTER 1 BACKGROUND AND SIGNIFICANCE Significance Mobility tasks become increasingly difficult for the older adult and may result in disability and loss of independence in daily lives. The prevalence of disability of 22% among adults in 2005 remained the sa me as in 1999 (21.8%) but will likely increase in coming years due to the aging of the baby boomer population (Centers for Disease Control and Prevention [CDC], 2009). The prevalence of mobility disability is increasing among older adults (Brault, Hootman, Hellmick, & Theis, 2009; Seeman , Merkin, Crimmins, & Karlamangia , 2010). Mobility disability is the most common disability (39.4%) reported among community dwelling older adults aged 65 years and older and affect s over 15,000 older adults (Brault, 2012). From the National Health and Nutrition E xamination Survey, functional limitations increased significantly only among those age d 60 to 69 years of age (Seeman et al. , 2010). In the 2005 United States Census, difficulty walking three blocks and climbing a fl ight of stairs, aspects of mobility disability, were the most common limitation reported among older adults (CDC, 2009). Exercise has been found to delay progression of disability (Berk, Hubert, & Fries, 2006) and decrease the risk for mobility disability (Boyle, Buchman, Wilson, Bienias, & Bennett, 2007; L ife Study Investigators , 2006) in community dwelling older adults. M obility disability contribute s to morbidity and mortality (Balzi et al., 2010; Hui & Rubenstein, 2006). Compared to older adults witho ut disability, those with mobility disability live about one year less (Keeler, Guralnik, Tian, Wallace & Reuben, 2010). In addition, mobility disability is the strongest predictor of developing a new chronic disease within two ye ars (CDC, 2013 ).
14 In the U .S., the cost of disability in 2006 was over 390 billion dollars (Anderson, Armour, Finkelstein & Wiener, 2010). Disability is one of the primary factors contributing to economic insecurity with persons age 85 and older at the greatest risk of poverty (Joh nson & Wilson, 2010 ; Pope & Tarlov, 1991). As the fastest growing segment of older Americans (Hobbs, 2010; Purcell, 2009) , those 85 and older have higher rates of disability requiring long term care that cost s on average $68,000 per year (Fuller Th omson e t al., 2009; U.S. Department of Health and Human Services [U.S.DHHS], 2008). Despite efforts of Healthy People 2010 (U.S. DHHS, 2010), disability remains a major public health problem. The economic and personal burden of disability related to healthcare e xpenditures and quality of life make it a significant public health concern. Healthcare providers must be concerned about disability and its impact in older adults. Exercise can delay disability and improve physical and psychological function (Gerst, Micha els Obregon & Wong, 2011; Life Study Investigators, 2006; U.S. Department of Health and Human Services, 2008). Yet, 28% of adults aged 65 years and older lead sedentary lifestyles that place them at high risk for disability (Balzi et al., 2010; Umstattd et al., 2006). Theoretical Framework The theoretical underpinnings for this study were based on the Disablement model (Verbrugge & Jette, 1994) and the Preclinical Disability model ( Fried, Her dman, Kuhn, Rubin & Turano, 1991 ) . The Disablement model (Appendi x B ) is an expansion of impairment s , functional limitation s A ).
15 Disablement Model The Disablement model (Verbrugge & Je tte, 1994) describes the sequential pathway of pathology, impairment s , functional limitations and disability. Pathology is s that are an abnormality or loss of physiological, emotional, o r structural functions. Functional limitations may follow and is the ability of the body to function as a whole. According to Nagi (1991), disability is difficulty in performance of physical and social tasks within the and Jette (1994) added intra individual, extra individual, and risk factors to the model that affect pathology, impairment s , functional limitations, and disability. Intra individual factors are internal to the individual such as lifestyle changes, activity mo difications and psychosocial characteristics. Extra individual factors are external to the individual that pertain to the physical and social environment and include exercise. Risk factors are characteristics of an individual that are present at or before onset of disablement. These factors can speed up or slow down the process of disablement. Preclinical Disability Model isability describes two constructs (preclinical disability and disability) and their relationship . Preclin ical disability is a transitional stage that precedes disability (Fried et al., 1991) , and is based on the Selection, Optimization and Compensation (SOC) model (Baltes & Baltes, 1990) . The SOC model is comprised of three adaptive processes of selection, o ptimization and compensation. Fried uses these processes to describe the transition from preclinical disability to disability . Preclinical disability includes reduced task frequency, maximizing capability, and task modification (Appendix C) .
16 Persons us e s election in determining the tasks performed and their frequency. For example, an older adult may change the amount of time spent walking around the house or avoid climbing stairs . Optimization focuses on maximizing capability with available resources. F or example, an older adult may walk on a treadmill to maximize their ability to walk outside their home. Compensation refers to modifications in how a task is performed in order to complete the task. For instance, an older adult may use a cane to walk dow n the street. Older adults use compensatory strategies in response to functional limitation by changing the way they perform a task to maintain independent functioning (Fried et al., 1991). There are many types of compensatory strategies may be physical, e nvironmental, psychosocial, behavioral and physiological in nature . The use of these strategies may minimize the impact of a functional limitation and prevent disability. Theoretical Model The theoretical model used for this study was a synthesi s of the Di sablement model (Verbrugge & Jette, 1994) and the Preclinical Disability model (Fried et al., 1991) (Appendix D) . I mpairment s i nclude d balance and muscle strength that are known to predict disability. F unctional limitations include d physical performance, endurance, and gait thought to be the result of impairment. Preclinical disability was a transition state that was expected to mediate the influence of functional limitations on disability . Selection and compensation were assessed in the study. Optimizat ion was not included because line danc ing was not expected to affect aspect of preclinical disability . Although there are many types of disability, mobility disability was selected because of its importance in independent living . Line dancing was considere d an extra individual factor and was ex pected to have a direct e ffect on impairment, functional limitations,
17 preclinical disability, and disability. Depressive symptoms and balance confidence were intra individual factors that may influence functional limi tations and disability independent of line dancing . Figure 1 1. Proposed Theoretical Model Background Exercise is planned, repetitive physical activity that works to improve one or more components of physical fitness such as strength, balance, and endurance (Chodzko Zajko et al., 2009). Exercise improves impairments and reduces functional limitations subsequently preventing disability (C DC, 2013 ). Aerobic and muscle strengthening exercises are recommended for older adults because these exercises imp rove health and may reduce disability (CDC, 2008). Balance exercise is also recommended because it incorporates different stances to improve overall postural control that is
18 important to reduce falls (CDC, 2013 ). Often aerobic, muscle strengthening, flexib ility or balance exercises may be combined . I nterventions with aerobic and muscle strengthening components have significantly reduc ed the risk for disability (Life Study Investigators , 2006). Dance is a complex motor activity that involves cognitive cont rol and the use of the large muscle s of the lower extremities (Brown, Martinez, & Parsons, 2006). Dance is similar to walking, balance training, and strength training as it requires the integration of sensory, motor control and musculoskeletal systems and the use of lower extremity large muscle groups. In contrast, dance involves multi directional changes, attention to music, and the need to remember a complex motor pattern (Blasing et al., 2012; Brown, Martinez, & Parsons, 2006; Hackney, Hall, Echt & Wolf, 2012 ). While walking and some balance training involve dynamic balance control, dance involves dynamic balance control while coordinating a movement in response to music and other dance participants (Hackney & Earhart, 2010). Although some types of streng th training involve weight bearing exercises, most training is done in a seated position and does not involve weight bearing of the large muscle groups. D ance, walking, and balance training are weight bearing and involve these muscle groups. Dance and oth er types of aerobic exercise use large muscle groups for a sustained period of time that involve aerobic metabolism, while strength and balance training involve shorter periods of training that are anaerobic in nature. Strength training, balance training, and walking stimulate the primary motor cortex and spinal cord areas of the neural axis (Adkins, Boychuk, Remple, & Kleim, 2006). Strength training increases motor neuron excitability and synaptogenesis within
19 the spinal cord, while balance training stimu lates synaptogenesis and cortical reorganization in the primary motor corte x. In contrast, walking, a type of endurance training , does not induce changes in neuronal circuitry within the primary motor cortex, but does stimulate the spinal reflexes within t he spinal cord. Since dance involves complex motor movements, it would be expected to stimulate the primary motor cortex, corticospinal pathway, and the spinal cord. Although strength training, balance training and walking involve the visual, auditory, a nd somatosensory systems, dance involves greater use of these systems. Dance involves the visual system more than other types of training. Dance requires constant feedback from the visual system to guide body movements in relation to visual objects such as other dancers (Brown, Martinez, & Parsons, 2006). Dance also uses the auditory system more than other types of training to synchroniz e movement to music and verbal commands from the instructor (Hackney, Kantorovich, Levin & Earhart, 2007); while other typ es of training primarily do not include continuo us external auditory cues. Although balance training may use the somatosensory system, dance changing to the demands of the e nvironment (Blasing et al., 2012; Hackney & Earhart, 2010). Exercise and Impairments Exercise has been found to improve balance and muscle strength that are impairments. Aerobic and muscle strengthening exercise improved balance (Lord et al., 1995; Jette et al., 1999; Barnett et al., 2003) but balance exercise had greater effects because this type of training is specific to balance (Howe et al., 2012). Dance has also
20 been found to improve balance (Duncan & Earhart, 2012; Eyigor et al., 2009; Hackney & Earh art, 2009; Shigematsu et al., 2002; Sofianidis, Hatzitaki, Douka & Grouios, 2009). Knee extensor and flexor strength are of particular importance to older adults because these muscle groups are important for mobility (Guralnik et al., 2000; Manty et al., 2011). Aerobic and balance training exercise has improved knee extensor muscle strength (Goodpaster et al., 2008; Lu, Hui Chan, & Tsang, 2013; Kalapotharkos et al. , 2006; Talbot, Gaines, Huynh & Metter, 2003 , Wu, Zhao, Zhou, & Wei, 2002 ), but greater impro vements were found with muscle strengthening exercise (Lui & Latham, 2009). Improvements in muscle strength have been limited to only one type of dance, Korean dance (Jeon, Choe & Chae, 2000). Exercise and Functional Limitations Exercise has a significan t impact on physical performance, gait and endurance that are predictors of subsequent disability (Cress et al., 1999; Ka lapotharkos et al., 2006; Life Study Investigators , 2006; Sung, 2009). Physical performance has been found to be improved by aerobic ex ercise (Kalapotharkos et al., 2006; Kolbe Alexander, Lambert, & Charlton, 2006; Moore Harrison, Speer, Johnson & Cress, 2008) and combined muscle strengthening and aerobic exercise (Life Study Investigators , 2006). Interventions of combined aerobic and mus cle strengthening exercise improved gait (Life Study Investigators , 2006; VanSwearingen, Perera, Brach, Wert & Studenski, 2011) and endurance (Duncan et al., 2003; Pang, Eng, Dawson, McKay & Harris, 2005). Very small studies of aerobic, Turkish, and Tango dances suggest that dance may have similar beneficial effects among mobility impaired and healthy adults (Eyigor et al., 2009; Hackney & Earhart, 2010; Hackney et al. , 2012; Hui, Chui & Woo, 2009 , Shigematsu et al., 2002). In a very small preliminary stud y, eight weeks of line dancing
21 improved physical performance among older adults with mobility difficulty (Bennett & Roberts, 2011). Exercise and Preclinical Disability Although preclinical disability is a transitional stage from functional limitations to d isability, little is known about the effects of exercise on this transition. A study of task specific exercise suggests exercise may have a beneficial effect on preclinical disability, but, unlike aerobic and muscle strengthening interventions, the exercis e was directed on specific motor tasks (Manini et al., 2006). Whether an exercise such as dance would have similar effects is unknown. Exercise and Disability Combined aerobic with muscle strengthening exercise has been effective at reducing mobility dis ability (Life Study Investigators , 2006, Luukinen et al., 2006). One small study of contemporary dance revealed significant reductions in mobility difficulty (Keogh, Kilding, Pidgeon, Ashley & Gillis, 2012). Whether other types of dance would have similar effects is uncertain. Covariates Depressive symptoms are a psychosocial characteristic associated with increased disability burden in older adults (Barry, Allore, Bruce & Gill, 2009; Gool et al., 2005) and increased likelihood of developing a mild or seve re disability (Barry et al., 2009). Depressive symptoms may influence the disablement process by affecting the transition from functional limitations to disability in older adults (Gool et al., 2005). Balance confidence also may influence the pathway to di sablement. Low balance confidence is associated with declines in physical performance, gait speed, and a higher risk for preclinical disability (Higgins et al., 2012 ; Maly, Costigan &Olney, 2006;
22 Mendes de Leon, Seeman, Baker, Richardson & Tinetti, 1996). While having greater balance confidence is associated with an increased ability to perform activities of daily living (Schepens, Sen, Painter & Murphy, 2012). Thus, depressive symptoms and balance confidence must be taken into consideration when assessing the effects of exercise. Rationale for Line Dancing Similar to other types of aerobic exercise, dance has important health benefits that include improved balance, physical performance, gait, endurance, cardiovascular health and aerobic capacity (Howe et a l., 2012; Hui, Chui, & Woo, 2009 ; Kim et al., 2003, Murrock & Gary, 2010). The Centers for Disease Control recommends that older adults participate in aerobic exercise at least 10 minutes per day building up to 150 minutes per week and perform muscle stre ngthening exercises at least two days per week (CDC, 2008). However, many older adults do not meet these recommendations (United States Department of Health and Human Services, 2008). Reasons for not meeting the recommendations may be related to health pro blems or other limitations that make it difficult to exercise. Fear of falling or injury, lack of time and enjoyment, and lack of social support are also significant barriers (Forkan et al., 2006). Dance is an aerobic exercise that may be acceptable to ol der adults and involves socialization that may increase enjoyment not found with individual exercise (Lima & Viveira, 2007 ). Dance is popular and accessible to older adults in their own community and can be offered where they already congregate such as sen ior centers and community programs (Verghese, 2006). Group dance, such as line dancing, increases social interaction and exercise adherence among participants (Cress et al., 1999; Lima
23 & Vivera, 2007). Further, older adults prefer line dancing because it d oes not require a partner (Gavin & Myers, 2003). Summary Exercise is known to improve impairments, reduce functional limitations and prevent disability. Dance has limited evidence to support its beneficial effects on impairments, functional limitations an d mobility. Yet, the effects of dance on preclinical disability and disability are unknown. Hence, the purpose of this study is to evaluate an intervention by examining the effects of line dancing on impairments, functional limitations, preclinical disabil ity and disability in older adults with mobility difficulty. Specific Aims and Hypotheses Specific Aim 1: To assess the effects of 8 week line dancing on impairments (balance and muscle strength), functional limitations (physical performance, endurance, and gait ), preclinical disability (task frequency and task modification ), and disability (mobility). Hypothesis 1: Eight weeks of line dancing will reduce impairment s (balance and muscle strength) when compared with wait listed control group. Hypothesis 2: Eight weeks of line dancing will improve functional limitations (physical performance, endurance, and gait) when compared with wait listed control group. Hypothesis 3: Eight weeks of line dancing will reduce preclinical disability (task frequency an d task modification) when compared with wait listed control group. Hypothesis 4: Eight weeks of line dancing will reduce disability (mobility) when compared with wait listed control group. Specific Aim 2: To examine the relationships between depressive s ymptoms and balance confidence with impairments (balance and muscle strength), functional limitations (physical performance, endurance, and gait), preclinical disability (task frequency and task modification), and disability (mobility). Hypothesis 5 : Dep ressive symptoms and balance confidence will be related to impairments (balance and muscle strength), functional limitations (physical
24 performance, endurance, and gait), preclinical disability (task frequency and task modification), and disability (mobilit y).
25 CHAPTER 2 LITERATURE REVIEW Th e review of literature is organized by the concepts in the theoretical model for this study (see Figure 1 1 in Chapter 1 ). Strength training, balance training, and aerobic exercise are known to affect physical function. Dance has characteristics that are similar to these types of exercise that are expected to affect the study outcomes. This review includes studies of dance and randomized control studies of aerobic exercise because much more is known about the beneficial impact of this exercise than dance. Impairments Balance Balance is needed to safely perform activities of daily living that can reduce disability (Rantanen et al., 2001). Balance training is known to include specific movements that improve balance. In a m eta analysis of randomized control studies (Howe et al., 2012), combined exercise that included balance, strength, and aerobic components had the greatest effect on improving static and dynamic balance. S tudies of aerobic exercise such as walking and cycli ng, were not to have a significant effect . Since dance involves multi directional changes and dynamic balance control, improvements in static and dynamic balance were expected (Brown, Martinez, & Parsons, 2006; H ackney, Hall, Echt, & Wolf, 2012 ). In studi es of different types of dance, significant improvements in balance were found in healthy community dwelling older adults, 12 weeks of modified aerobic dance (Shigemat su et al., 2002) and 10 weeks of Greek dance (Sofianidis, Hatzitaki, Douka & Grouios, 2009) significantly improved static balance measured by single leg stance. Improvement in static balance is not un expected because the dances in these studies require d si ngle leg standing.
26 Five weeks of line dancing with foot stomps or muscle strengthening and foot stomps (Young, Weeks & Beck, 2007) improved balance more than line dancing that continued throughout the study period and plateaued at 15 and 32 weeks. Line dan cing may not account for these findings because there was no control group to evaluate the natural course of balance over time. Although Salsa (Granacher et al., 2012,) aero bic dance (Hui, Chui & Woo, 2009 ) and jazz dance (Alpert et al., 2009; Wallman et al., 2009) incorporate movements that challenged balance, no significant improvements in static balance were associated with these dances. In studies of Jazz dance (Alpert et al., 2009; Wallman et al., 2009), there were no controls to compare the changes i n balance . In the Salsa study (Granacher et al., 2012), little change in balance would be expecte d because all subjects were exercising over four times the recommended 150 minutes of physical activity per week prior to the intervention . In the aerobic danc e study (Hui, Chui & Woo, 2009 ) the control group was more physically active than those in the dance group. Improvements in dynamic balance were found with dance in healthy and mobility impaired older adults. In a randomized control trial, significant im provements in dynamic balance were found in physically active healthy community dwelling elders following 8 weeks of Turkish dance (Eyigor et al., 2009). Even in severely mobility impaired older adults, dance has significantly improved balance. In a single subject design without a control group, 10 weeks (Hackney et al., 2012) and 12 weeks of adapted Tango dance (Hackney & Earhart, 2010) improved static and dynamic balance. Similar findings were found in randomized control trials of Tango among those with Thirteen weeks of adapted Tango and ballroom dance (Hackney & Earhart, 2009) significantly increased static and dynamic balance that changed little in the control
27 group. Similar findings were found with the same population in a longer study (12 months) of adapted tango (Duncan & Earhart, 2012) with significant improvements in static and dynamic balance at 3, 6, and 12 months, but balance declined during this time period in the control group. Muscle Strength Lower extremity muscle stren gth, specifically knee extensor and flexor strength, is an important determinant of balance (Karinkanta et al., 2005) and mobility (Guralnik et al., 2000) . While strength training is known to improve muscle strength, aerobic exercise such as walking has be en found to improve lower body muscle strength. Dance is similar to walking because it involves the large muscle groups of the lower extremity for a sustained period of time. In studies of aerobic exercise, walking has consistently been found to improve kn ee extensor and flexor muscle strength (Kalapotharkos et al., 2006; Talbot, Gaines, Huynh & Metter, 2003). Similar improvements in knee flexor muscle strength were found in studies of combined walking and muscle strengthening exercise (Ettinger et al., 199 7; Goodpaster et al. , 2008). Similar to walking, dance has been found to improve knee extensor muscle strength. Korean dance three times a week for 12 weeks (Jeon, Choe & Chae, 2000), increased knee extensor strength (34%) compared to a loss in the contro l group (10%). In contrast, 12 weeks of aerobic dance did not significantly increase knee extensor strength in community dwelling old er adults (Hui, Chui & Woo, 2009 ), however participants were already physically active and improvements in strength from da nce may have been limited. Similar to other dance interventions, line dancing involves the large muscle groups of the lower extremities (Young, Weeks and Beck, 2007) and may also improve knee extensor and flexor strength.
28 Functional Limitations Physical Performance Physical performance of certain motor tasks is required for independence in daily activities (Guralnik et al., 1989). Lower extremity function is often examined in aging research and is an important predictor of mobility disability (Guralnik et al., 1995; Life Study Investigators, 2006). Weight bearing exercises such as walking, balance training and dance would be expected to improve lower extremity function because they improve balance and muscle strength . In randomized control studies of 12 mo nths of combined muscle strengthening, walking , flexibility and balance training (Life Study Investigators , 2006) and 16 weeks of walking exercise (Moore Harrison, Speer, Johnson & Cress, 2008) in sedentary community dwelling elders, improvements in lower extremity physical performance were found for the experimental groups while it worsened for the controls. Similar findings were found following 12 weeks of walking (Kalapotharkos et al., 2006) and 20 weeks of aerobic exercise (Kolbe Alexander, Lambert & Ch arlton, 2006). Balance training has also been found to improve physical performance. In randomized control trials of Tai Chi , significant improvements in physical performance were found following 12 weeks of Tai Chi in mobility impaired subjects (Wolf et al., 2006), but not for 24 weeks of Tai Chi in healthy elders (Chyu et al., 2010). In the 24 week study, subjects had higher functioning and may have achieved maximum gains in physical performance than those with mobility impairments in the 12 week study. The effects of dance on physical performance have been inconsistent. Although improvements in lower extremity function were found following 8 weeks of tango (McKinley et al., 2008) and 10 to 13 weeks of adapted tango (Hackney et al., 2012; Hackney & Earha rt, 2010), these studies did not include a control group. Twelve months
29 of line dancing (Young, Weeks & Beck, 2007) had similar effects on improvements in physical performance as the line dancing and strength training group. In randomized control trials of 8 weeks of Turkish dance (Eyigor et al., 2009) and 12 weeks of a ero bic dance (Hui, Chui & Woo, 2009 ) in physically active elders , significantly greater improvements in physical performance than in controls who had little improvement. Other randomized cont rol studies of 12 weeks of modern dance (Keogh et al., 2012) and 13 weeks of adapted tango and ballroom dancing (Hackney & Earhart, 2009) revealed no significant improvements in physical performance. Although there were no improvements in physical performa nce in the adapted tango and ballroom study (Hackney & Earhart, 2009), the control group experienced declines. Endurance Endurance is the ability to perform an activity for sustained periods (American College of Sports Medicine, 2009 ) , and walking enduranc e is an important predictor of mobility disability (Chang et al., 2004; Espeland et al. , 2007; Vestergaard et al. , 2009) . In randomized control studies of combined exercise training in older adults with mobility impairments (Duncan et al. , 2003; Pang, Eng , Dawson, McKay & Harris, 2005), improvements in walking endurance have been found. Similar to walking, dance is aerobic in nature. I mprovements in endurance were found following 12 weeks of aerobic dance (Shigematsu et al. , 2002) , 13 weeks of ballroom an d tango dancing (Hackney & Earhart, 2009) and 24 weeks of tango dance (Duncan & Earhart, 2012) while declines in endurance were found for the control group s in these studies . In mobility impaired individuals , 10 and 12 weeks of Tango dance (Hackney & Earha rt, 2010; Hackney et al. , 2012) improved walking endurance. Despite involving physically active adults,
30 improvements in walking endurance were found for those in control and 8 week Turkish dance group s (Eyigor et al., 2009). Gait M any aspects of gait hav e been studied (e.g. cadence, stride length). Of these gait speed is considered the most important because it is an important vital sign of aging (Fritz & Lusardi, 2009; Hardy, Perera, Roumani, Chandler & Studenski, 2007) and a significant predictor of mor tality (Studenski et al. , 2011), hospitalization (Hornyak, Vanswearingen & Brach, 2012), and IADL disability (Seidel, Brayne, & Jagger, 2011). Usual gait speed is used more often in studies because exercise has been f ound to only affect this and not fast g ait speed (Daley & Spinks, 2000; Lopopolo, Greco, Sullivan, Craik & Mangione, 2006). In a meta analysis of combin ed exercise and strength training (Lopopolo et al., 2006), usual gait speed was 1.83 times more likely to improve than in controls. Improvemen ts in usual gait speed have been found with moderate intensity multi component exercise in mobility limited older adults following 12 weeks of walking , muscle strengthening, balance and gait training exercise (VanSwearingen, Perera, Brach, Wert, & Studensk i, 2011); and 6 months of walking, muscle strengthening, flexibility and balance training exercise (Life Study Investigators , 2006). Since dance incorporates complex motor movements using large muscle groups, improvements in gait speed would be expected. In physically active adults and those , usual gait speed significantly increased following 8 weeks of Turkish dance (Eyigor et al. , 2009) and 12 months of Tango dance (Duncan & Earhart, 2012) while declines were found for the contr ol groups. While 12 weeks of Tango dance
31 (McKinley et al., 2008) did not significantly improve gait speed, both the Tango and walking group had similar improvements. Disability Mobility Disability Mobility disability is often the first type of disability to occur in older adults (Fried, Bandeen Riche, Chaves & Johnson, 2004). Although systematic reviews of randomized control trials (Keysor & Jette, 2001; Latham, Bennett, Stretton & Anderson, 2004) found that exercise did not significantly reduce overall di sability, reductions in mobility disability were found. In randomized control trials, 6 months of muscle strengthening, walking, flexibility and balance training (Life Study Investigators , 2006) reduced the incidence of mobility disability. Similarly, a s tudy of muscle strengthening, walking, and flexibility exercise (Luukinen et al., 2006) and 12 weeks of contemporary dance (Keogh, Kilding, Pidgeon, Ashley & Gillis, 2012) found reductions in difficulty in performing mobility tasks. Preclinical Disability Preclinical disability is a transitional stage from functional limitations to disability (Fried, Herdman, Kuhn, Rubin & Turano, 1991). Since functional limitations and disability have been found to be affected by exercise, similar effects would be expected in preclinical disability (see above sections for summary of this research). Only one study of exercise (Manini et al. , 2007) has examined the effects of exercise on preclinical disability . Task modification was the only aspect of preclinical disability a ssessed. The task specific exercise was designed to target specific functional tasks and reduce task modification and performance time. T he resistance exercise group and the combined resistance and task specific exercise group all had reduc tions in task
32 mo dification but not performance time. Task frequency, another component of preclinical disability, was not assessed in this study. Potential Covariates Depressive Symptoms Depressive symptoms are manifestations of sadness that are an important predictor o f disability ( Barry, Allore, Bruce & Gill, 2009; Penninx et al., 1999). In a prospective study, those with depressive symptoms were found to have greater declines in gait speed and physical performance compared to those without symptoms (Ruo et al., 2007). In a randomized control study (Life Study ) of combined aerobic and muscle strengthening exercise, depressive symptoms were not found to significantly influence physical performance (Matthews et al., 2011). However, the importance of depression in disabili ty and functional limitations suggests the effects of depression should be considered in exercise studies. Balance confidence Balance confidence is the belief that an individual has the capability to perform an activity without losing balance (Miller, Sp eechley & Deathe, 2002). In a meta analysis of community dwelling elders, higher balance confidence was associated with a greater ability to perform tasks of daily living (Schepens, Sen, Painter & Murphy, 2012). Low confidence defined as self efficacy has been associated with lower physical performance and gait speed (Maly, Costigan, & Olney, 2006; Mendes de Leon, Seeman, Baker, Richardson & Tinetti, 1996) and an increased risk of preclinical disability (Higgins et al., 2012). Balance confidence should be c onsidered in exercise studies because it may independently influence physical performance and disability.
33 Summary Dance is a multi component exercise that involves dynamic balance, cognitive control and complex motor movements. Dance is a fun and enjoyab le exercise that can be performed in the home or community. Unlike other types of exercise, dance does not require special equipment. Dance is performed to music that often motivates the person to participate in dance. Group dance such as line dancing has been found to improve participation, increase adherence, and encourage socialization in older adults. Among older adults, line dancing is often preferred over other types of dance because line dancing does not require a partner (Gavin & Myers, 2003). Anoth er important feature of line dancing is that it can be modified to meet the individual needs of the participant. Although studies of dance found improvements in impairments and functional limitations, no studies of dance examined preclinical and clinical d isability.
34 CHAPTER 3 METHODS Design An experimental design was used with randomly assigned older adults to either an 8 week line dancing or wait listed control group. In a preliminary study, eight weeks of line dancing was sufficient time to observe sig nificant improvements in balance and physical performance in 10 older adults (Bennett & Roberts, 2011). At prete st and 8 weeks, measures were collected for impairment s (balance and muscle strength), functional limitations (physical performance, endurance and gait), preclinical disability (task frequency and task modification), disability (mobility), depressive symptoms and balance confidence. Depressive symptom s and balance confidence were covariates. Pe rceived benefit of dance was measured at pretest onl y for the line dance group. Sample Selection The sample was sedentary community dwelling adults 65 years and older with mobility difficulty defined as self report ed difficulty walking Â¼ mile or climbing a flight of stairs. These individuals wer e selected b ecause they are at high risk of IADL disability (Balzi et al. , 2010). To be included in the study, they had to be exercising less than 30 minutes three times a week, able to follow and understand directions and willing to be randomized. Excluded due to saf ety concerns were thos e using an assistive device or with severe neurological condition s d portable oxygen, have an internal cardiac defibrillator, or experienced a myocardial infarction within the past 6 mo n ths were excluded as they are high risk of having an acute cardiovascular event during exercise (American College of Sports Medicine, 2009 ). In previous studies of dance, older adults with physical limitations and chronic illness were safely able to parti cipate in dance (Duncan & Earhart, 2012; Hackney, Hall,
35 Echt, & Wolf, 2012 ; Borges et al., 2012). Hence, no other exclusions for morbidity were used. Since there were no dance intervention studies that examined preclinical disability and disab ility, estim ations for sample were based on other outcomes. Other dance studies have used the Berg Balance Scale and single leg stance for balance and effect sizes from these were used for power analysis. In a study of 13 weeks of Tango dance, an effect size of .90 wa s found for the Berg Balance Scale (Hackney & Earhart, 2009). In a preliminary line dancing study, a large effect size of 1.17 was found for one leg standing balance in older adults with mobility difficulty (Bennett & Roberts, 2011). Using the POWER proced ure in SAS software (version 9.2, Cary, N.C.) and a ssuming a level of significance of .05, a two sided test, and power of .80, the detectable effect size was .9 1 for 20 subjects that also allowed for 20 % attrition. Setting Te sting and line dancing took p lace at a comm unity center located in a rural community in Northwest Florida. There are 151,372 people living in these communities with 12.9% over 65 years of age (United States Census Bureau, 2010). Whites (87.8%) are the largest racial group with Blacks (5.4%) and Hispanics and Latinos (4.3%) a very small percentage of the population (United States Census Bureau, 2010). The community center is centrally located and easily accessible to residents of North and Central Escambia County, Florida. Whites are t he most prevalent racial group to access the community center. L ow cost public transportation was available within a fifty mile radius of the community center making it accessible to those without private transportation. Approximately 30 to 50 older adults participate weekly at the center in recreational activities or congregate meals provided by the Council on Aging of West
36 Florida. Recreational activities offered include yo ga, bingo, and bridge. There were no line dance classes offered at the center, but the center had adequate space and flooring suitable for line dancing and testing. Sample Recruitment A convenience sample was recruited from community dwelling adults 65 years and older. Flyers provide d information about the study and how to contact the i nvestig ator. Recruitment flyers were placed in local senior community centers, retirement homes, senior health fairs, healthcare provider offices, local businesses, public libraries, churches, and civic organizations. Before making flyers available to an a gency for pos ting, the investigator met with the contact persons or administra tors of the agency. They were given written and verbal instructions to only use the IRB approve d flyer. In addition, it was emphasized that study information must come from the i nvestigator who is responsible for the information given to potential subjects. Emails were sent to designated contacts at the University of West Florida Center on Aging , Council on Aging of West Florida and West Florida Area Health Education Center reques ting that they email the flyer in electronic format with information about the study to their contacts. A script was used for presentations to inform interested persons about th e study. The script included a description of the study and how participants wi ll be randomly assigned to dance or be asked to maintain their usual daily activities. A contact person at the Council on Aging of West Florida and the Escambia County Parks a nd Recreation Department were asked to advertise the study using the IRB approve d flyer. In addition, the line dance instructor is well kn own in the community and was asked to help promote the study. To ensure adequate representatio n of minorities, efforts were made to recruit blacks as this is the largest (4%) minority group in the
37 c ommunity. Specific strategies to recruit blacks consisted of contacting a prominent community leader to promote the study to the black co mmunity. The leader was identified by the Council on Aging of West Florida. Interested adults contacted the investigat or by phone. The investigator co ntacted interested adults by telephone to screen for eligibility usi ng a script. The interview end ed if the individual declined to continue or did not meet the inclusion criteria. Those individuals not interested or ineligib le for the study were acknowledged for their participation in the interview. For eligible and interested persons, an appointment was made to obtain written consent and collect baseline data. At the baseline visit, subjects were screened again for el i gibili ty and information about health history to be used for description of sample characteristics of subjects. Line Dancing The 8 week line dancing intervention wa s a low impact dance routine where one fo ot wa s always in contact with the floor and is appropri ate for older adults with mobility difficulty (Bennett & Roberts , 2011). Participants began the one hour line dance class twice a week for 8 weeks because positive effects in balance and muscle strength have been found for this time period (Eyigor, Karapol at, Durmaz, Ibisoglu & Cakir, 2009) and in a preliminary study (Bennett & Roberts) of this same intervention . The cl asses were taught by a dance instructor with over 15 years of experience teaching line dancing to older adults in the communit y. The line d ance instructor had experience with the population of interest as she taught the line dance classes in the pilot study and assisted in the design of the dance intervention. Although other types of dance exist, older adults were found to prefer line dancing because they do not need a dance partner (Gavin & Myers, 2003). Tango and ballroom dance are commonly partner
38 dances, while Jazz, Salsa and line dancing do not require partners. Despite Jazz and Salsa dances being non partnered, these dances often use com plex movements that require leaping and jumping with both feet off the floor and are not safe for those with mobility limitations. L ine dancing is a simple aerobic exercise that can be modified specifically for those with mobility limitations. Thus, line d ancing may be a better alternative for older adults than other types of dance such as Jazz, Tango or Salsa. The line dance intervention used simple routines that are used in novice line dance class es. The dance routines varied with each class and new movem ents were added with each routine. Line dancing involve d continuous integrated movements of the legs and trunk, weight transfers and postural control . Choreographed movements included walking forward/backward, side to side, turns, pivots, grapevine pattern of feet, shuffle, knee flexion, stepping and stomping that are expected to improve dynamic balance, gait, physical performance, and mobility. The line dancing session include d specific choreographed dances performed to music selected by the line dance ins tructor (list of dances with associated movements in Appendix E ). The d ances were taught in a specific order each week with a progression from easy to more complex danc e movements. Then dances were repeated the following week to reinforce learning the danc e steps. When learning a new danc e, the tempo of the music was slow so that participants could learn and perform the new dance at a slower pace prior to performing at a moderate pace. Modifications . Since the participants had mobility difficulty , some ne eded modifications to the dance steps in order to participate in the line dancing (Hackney & Earhart, 2010; Emory, Silva, Christopher, Edwards, & Wahl, 2011). The instructor and the researcher observe d participants for difficulty with the movements and int roduce d a
39 similar but less challenging movement as a replacement . For example one participant had difficulty performing the grapevine pattern of the feet (step across and then behind other foot) and the movement was changed to side to side steps to allow the participant to safely continue dancin g . Although some participants need ed modifications, others were able to perform the steps without difficulty. Modifications were documented each session on a participant log. Line Dancing Procedures Line dancing cl asses met 1 hour twice a week for 8 weeks. The structure of th e classes each week included 10 minutes of warm up, 40 minutes of dancing and 10 minutes of cool down. A warm up session prior to the line dancing and co ol down session afterwards include d 10 mi nutes of seated stretching for arms, legs and shoulder rolls. The 40 minute line dancing class included time to learn the new dance introduced each week, time to practice the new dance, break times, and time to review and perform dances learned in previous classe s. Line dance classes occurred in a group setting because dancing in a group has been found to increase attendance and participation (Lima & Vivera, 2007). Participants were instructed to dance at a pace where they can easily talk with others to mai ntain a moderate intensity level. During dancing the Borg Rating of Perceived Exertion Scale (RPE) (Borg, 1998) was used to monitor safety o f dance and participants were instructed to stop dancing with a Borg rating of 1 5 or higher that indicates heavy to maximal exertion (Appendix F ) . Participants were instructed to self monitor and taught to rate exertion of line dancing on a scale range of 6 (no exertion) to 20 (maximum exertion). The line dance instructor gave verbal instructions and visual cues ( e.g ., points finger to left) while demonstra ting the movements. This assisted participants with various
40 learning styles such as auditory or visual in learning the movements. When teachin g new steps the instructor demonstrate d facing the participants at first before facing the opposite direction. The instructor or her assistant was always visible to the participant during the dancing. Dance classes took place in a community center with handicap accessibility, adequate space and lighting, and without carpet to p romote a safe e nvironment. Participants were asked to wear supportive and comfortable shoes for the classes to allow movement. Participants were also instructed to complete a daily activity log and submit it each week. Safety Monitoring of Dance Prior to starting the study, th e line dancing participant obtain ed written approval from their healthcare provider to participate in the dan ce classes. Participants were given a form for the healthcare provider to sign that the participant is able to safely partici pate in line dancing. Prior to the start of the line dancing program the participants were instructed to stop dancing and sit in a chair to rest for 5 minutes if at any time they felt light headed, dizzy, weak or tired, short of breath or h ave chest pains. Chairs were available in the room during the dancing. The investiga tor, a registered nurse, was on site and an AED (automatic external defibrillator) was available for each dance class. The investigator and line dance instruct or had cell phones for immed iate access to emergency services (911) if needed during the c lasses. The participants were asked to provide to the investigator emergency contact information and numbers will be accessible during class. If a participan t experienced an accident or i njury d uring the class and needed immediate medical attention then the emergency contact will be notified. Prior to resuming the inter vention, the participant was assessed by the vention. The participan t
41 was allowed to continue if their signs and symptoms had resolved following a 5 to 10 minute rest perio d. If the participant complained of tiredness or was unsteady with standing then the participant was not allowed to resume dancing for that session. A dherence Adherence to the line dancing was essential to ensure the participant receive d an adequate amount of the intervention. In studies of line dancing, participation rates were at 70% for the 12 month study (Young, Weeks & Beck) and 100% for an 8 week preliminary study (Bennett & Ro berts, 2011). Attendance was monitored and recorded for each dan ce class. The investigator greet ed the participants at each dance session and offer ed an opportunity for ques tions. This was done to show the p articipants the investigator had a vested interest in them and their participation in the study. Those participants who did not inform the investigator of their abs ence were contacted by telephone to let them know they were missed at class and to ascertain if barriers to participation can be addressed. Participa nts in the control group were called a t start of intervention and every 2 weeks to provide an opportunity to ask questions and be acknowledged for their continued participation in the study. Control Group Partici pa nts in the control group were instructed to continue their normal daily activities during the study period but not begin regular exercise program while in the study. Participants were instructed to complete a daily activity log. The control group was off ered the line dance classes free of charg e for 8 weeks once the study had ended. Measurements M easurements of primary outcomes were impairment s (balance and muscle strength), functional limitations (physical performance, endurance, and gait), preclinical
42 disability (task frequency and task modification), and disability (mobility). C ovariates included depressive symptoms and balance confidence . O ther measures of interest were perceived be nefit of dance, daily activity log . The outcomes, measurements, and in formation about the number of items and time to complete the test are included in Appendix F and t he instru ments are included in Appendix G . Impairment s Balance Balance was measured by the 14 item Berg Balance Scale (Berg et al. , 1989) that evaluates per formance on common balance tasks. The BBS is considered the gold standard and is often used to validate other functional balance measures in community dwelling older adults (Whitney, Wrisley & Fu rman, 2003). Participants were rated on a 5 point scale for t he ability to perform the task. These r atings were summed for a total score ranging from 0 to 56 with higher scores indicating better performance. The BBS has been found to have high inter (ICC=.98) and intra rater reliability (ICC=.98) in a community dwel ling elderly population (Berg et al., 1992). The BBS also is significantly related to balance and mobility tests such as the Timed get up and go (TUG) (r= .76) and Tinetti Mobility Index (r= .91) ( Berg et al., 1992). The BBS has shown to be an independent predictor of falls among healthy community dwelling older adults (Muir et al., 2010). Muscle strength Muscle strength of knee extensors and knee flexors of dominant side was measured using a Nicholas Manual hand held dynamometer (Model: BK 7454). These muscle groups were measured because adequate knee strength is essential for mobility tasks (Manty et al. , 2011). The dynamometer was zeroed prior to each measurement following manufacturer instructions. Calibration of the device will have been performed
43 by the man ufacturer. Participants sa t in a chair with hips and knees at a 90 degree angle for flexion, lower leg vertical to the floor and feet not touchin g floor. The participant was tested with knee at an 80 degree flexion for assessing knee extensors and at 90 degree flexion for knee flexors. The dynamometer was placed at front lower leg proximal to ankle for knee extensors and to the posterior of lower leg proximal to ankle for kne e flexors. Participants were shown a demonstration of the movements pri or to testing. Participants were instructed to increase their effort gradually using maximum effort to move their lower ex tremity while the dynamometer was held in place for 5 seconds as this has shown to be adequate to achieve maximum effort (Bohannon , 1990) . Each muscle group was measured twice and the mean of the tests (kilograms) were used. Muscle strength was muscle strength is divided by their weight in kilograms. Test retest reliability was high for k nee extensor s (.99 1.00) and knee flexors (.98 .99) in community dwelling older adults with a history of falls (Wang, Olson, & Protas, 2002). Functional limitations Physical Performance Physical performance was measured by the Short Physical Performan ce Battery (SPPB) that assesses lowe r extremity function . The tasks rated include d time to get up from chair, three balance stances, and walking 4 meters. Scores of 1 to 4 for each test were assigned based on time (quartiles) of performance (National Insti tute on Aging, 2011) . A summary score (0 12) was calculated by adding the scores of each test. Test retest correlations were .97 for balance, .89 for gait speed, and .73 for time to get up from chair (Guralnik, Ferruci, Simonsick, Salive, & Wallace, 1995). A low SPPB score has been associated with a greater risk of disability, morbidity and mortality (Guralnik et al., 1995; Life Study Investigators , 2006). In hospitalized older
44 adults, the SPPB predicted length of hospital stay and was associated with comor bidity and diseas e severity (Volpato et al., 2011 ). The SPPB has been used as a standard measure of physical performance in multi center randomized control studies of older adults. It is also recommended for use in exercise intervention studies to prevent mobility disability (Vasunilashorn et al., 2009). Endurance Endurance was assessed using the time to complete a 400 meter walk that is associated with an increased risk for mobility disability and death (Life Study Investigators, 2006). Test test reliabil ity for inability to complete the 400 meter walk was high (.91 .93). The 400 meter walk has been used as an objective measure of major mobility disability in large studies such as the LIFE study with community dwelling older adults. Older adults who stoppe d to rest during the 400 meter walk were five times more likely to develop mobility disability over those who did not stop (Vestergaard et a l., 2009). Rest periods were recorded since stops during walk are strongly correlated with subsequent mobility disa bility (Vestergaard et al., 2009). Participants were o bserved and rest periods were rec orded. If the participant could not complete the 400 meter walk in 15 minutes the participant stop ped walking . T ime to complete the 400 meter walk and ability to complet e the walk were also recorded. Gait Gait was assessed using gait speed as it has shown to predict mobility disability (Guralnik et al., 2000; Fried et al., 2001 ) and to be associated with survival rates (Studenski et al ., 2011). Gait speed was computed u sing data (seconds) from the 400 meter walk. Inability to complete the 400 meter walk within 15 minute time period or inability to complete it without rest periods or assistance is considered having major
45 mobility disability (Rejeski et al., 2005) . Gait sp eed was assigned a time of 15 minutes if unable to complete walk. Preclinical Disability Task frequency Selection is task frequency that is a change in frequency in performing a task and was measured using the Fried Preclinical Disability (PCD) screening (Fried et al., 1996) . The PCD screening assesses risk for disability on tasks of daily living based on frequency, modification, and difficulty. For this study only the 5 mobility tasks were of importance because the participants had mobility disability an d dance is expected to only affect these tasks. The following mobility tasks were Participants were asked if they have changed how often they her scores indicating greater preclinical disability. The test retest reliability was good at .74 for walking one half mile Study II (Fried, Young, Rubin, Bandeen Roche, 20 01), the self reported function ratings predicted differences in balance, knee muscle strength, and gait speed. Task modification Compensation is task modification that is changing the way the task is performed to complete the task and will be measured us ing the Fried Preclinical Disability (PCD) Screening (Fried et al., 1996) and Task Modification Scale (MOD) (Manini et al. , 2006). Modification of tasks was assessed by self report of task modification for the mobility tasks previously described for task f requency and performance on selected mobility
46 tasks from the Task Modification instrument. Using the Fried PCD Screening , participants were asked if they have changed the method of performing each mobility task as compared to how they did it before. Partic summed with higher scores indicating greater preclinical disability. The reliability and validity of the Fried PCD screening has previously been discussed. The MOD scale (Appendix F ) is an objective measure and tasks rated will include chair rises from three different chair heights, kneeling to standing, and lying to standing. Ascending and descending flight of stairs will not be rated because the re are no stairs at the testing location. Scores of 0 modification used to perform the task. The sco res were summed with higher scores indicating greater task modificati on. Test retest reliability was high (.55 .88) for individual tasks and for the summed MOD score (.92). Inter rater reliability was high (.76 .95) for the individual tasks and (.98) for the MOD score. Disability Mobil ity was assessed atings of difficulty in performing mobility tasks identified for preclinical disability and difficulty walking a quarter of a mile or climbing a flight of stairs (Gill, Allore, Hardy & Guo, 2006). Participants were asked if they have difficulty performing each of the mobility tasks. Participants will rate difficulty summed for mobility tasks from the Fried PCD Screening. A rating of difficulty for either difficulty walking a quarter of a mile of cli mbing a flight of stairs was considered having mobility disability. Thus, the individual ratings for these tasks were used to determine mobility disability.
47 Covariates Depressive symptoms Depressive symptoms were assessed using the 15 item Geriatric Depression Scale Short Form (GDS S) (Shei kh & Yesavage, 1986) . The original GDS had 30 items but the GDS S has been found to be more feasible to complete than the original scale. The GDS long form and the GDS S have been found to be highly correlated (r= .89) in assessing depressive symptoms supporting the use of the GDS S (Lesher & Berryhill, 1994). Respondents provide d answe in the past week. Those with a score of greater than 5 were referred to their healthcare provider as this indicates clinical depression ( Greenberg, 2012). ). Daily log of act ivity A daily activity log was used to monitor physical activity during the study . Pa rticipants were instructed to track daily activity on a log and submit their log weekly. Co ntrol group participants were instructed to mail their log weekly using a prov ided postage paid envelope. The activity log include d 12 common everyday activities such as housework and gardening, other types of activity and exercise, minutes spent doing activity, and date of activity. Balance confidence Balance confidence was asses sed using the Falls Efficacy Scale (FES) (Tinetti, 1990) that is based on self effi cacy theory. The FES has 10 items that asks subjects to in and out of b rate d confidence
48 highly correlated with self reported IADL status in community dwelling populations (Tinetti et al., 1994). Higher scores indicate low balance confidence that has been associated with higher risk of preclinical disability (Higgins et al., 2012). Test retest reliability was good at .71. Reliability and validity has been established in community dwelling older ad ults (Tinetti, 1990). Perceived Benefit of Dance In the proposed study, the perceived benefit of dance was not included in th e theoretical model, but was assessed at pretest for the dance group. The perceived benefit of dance has not been examined, but h as been in other studies of exercise. In studies of exercise, perceived benefit of exercise has been found to predict exercise adherence. In this study, a participant who expect ed that line dancing w ould not be beneficial may not have attend ed the sessions or participate d in other types of exercise affecting adherence and validity of the results. Pe rceived benefit of dance was used to as sess expectations using a scale to rate the be nefit of the dance intervention , Participants were beneficial d o you using none to very beneficial. Higher score indicate s higher expectations for the line dance intervention. Data Analysis Data was entered into the Statistical Package fo r the Social Sciences (SPSS) for analysis. Descriptive statistics were used to describe the characteristics of the sample. Analysis of co variance (AN C OVA) with the pretest as a covariate was used to assess the effects of line dance intervention. T he indepe ndent variables were line dance intervention or control group . AN C OVA was used for each outcome: impairment s (balance and muscle strength), functional limitations (physical performance, endurance
49 and gait), preclinical disability (task frequency and task m odification) and disability (mobility). Significance was determined using an alpha of .05. Assumptions for AN C OVA were tested and included normal distribution of data, homogeneity of variance, and sphericity. Assumption of homogeneity of variance was dete rmined by a non Assumptions of normal distribution and sphericity were determined by a non statistically significant Shapiro An evaluation of the utility of the covariates (depressive s ymptoms and balance confidence) and the dependent variables were tested by correlation coefficient s between the covariates and the dependent variables at posttest. If the correla tion coefficient wa s significant between the covariate and the dependent var ia ble then the covariate was included as a control in the analysis. Intention to treat analysis was used for those participants who had pre and post test data . A limitation of this analysi s is that a participant who attend ed one session wa s treated similar to those who attend ed all sessions. As a result, the dose of the intervention wa s not considered . H ence a subsequent analysis compare d those who participate d in at least 75% of the dance sessions to those in the control group . This is a minimum dose of th e intervention as effects f rom line dancing have been found at 5 weeks (Young , Weeks, & Beck , 2007 ). Human Subject Protection Institutional Rev iew Board (IRB) approval was obtained from the University of Florida to conduct the study . Potential participant s were interviewed over the phone to screen for eligibility and telephone consent was obtained. Information ob tained during the interview include d questions to assess for inclusion and exclusion criteria and
50 whether the individual can understand the questi ons and be easily understood during the interview. If participant met study inclusion criteria, an appointment was made with the investigator to review and sign the inform ed consent. Participants were given the opportunity to take consent form home and rev iew and return within 1 3 days to sign consent. The investigator r ecognized that providing informed consent is an important decision and wanted the participant to have ample time to complete the p rocess. All participants were given a copy of the informed c onsent form. Tracking of the informed consent process was done for eac h participant. The process include d documentation of date, time, d uration, and notes about what was discussed with the participant. Pot ential risks to participants include d falls and fa tigue associated with the testing or line dance intervention. Participants may experience slight muscle soreness lasting two to three days which is common with any exer cise intervention. Risks were minimized by (1) obtaining healthcare provider approval fo r line dance participation, (2) monitoring participants during testing and interventions, (3) instructing participants to dance at their own pace, and (4) providing warm up and cool down sessions at each dan ce session. Participants were informed they may w ithdrawal from the study at any time and their participation in the study is voluntary. Benefits of the study may include improvements in overall health and function. All testing was conducted at the community center. Written informed consent was obtained from the participant prior to any testing. The investigator assisted each participant with completion of questionnaires in a private location to maintain conf identiality. Questionnaires measure d preclinical disability, disability, depressive symptoms, bal ance confidence and perceived benefit of dance (line dance group only). Those with a score of greater than 5 on the Geriatric Depression Scale were referred for
51 a clinical evaluation and were not excluded from participation in the study. In addition, all p art icipants complete d a medical health history and were asked demographic informatio n. Demographic information include d age, gender, race, socioeconomic status, work status, marital status, and educational sta tus. Performance testing was done in the commun ity center. The investigat or was near the participant while performing the tests of impairment s (balance and muscle strength) and functional limitations (physical performance, endurance and gait) to ensure safety. The estima ted time to complete all tests w as 70 minutes. Testing was performed at pretest and posttest at completion of 8 weeks of line dancing or 8 weeks after pretest for control group and this data collection point wa s appropriate as only the intermediate effect of dance is being examined . To e nsure safety of participants during performance testing, the investigat or was beside or near the participant at all times. The investiga tor, a registered nurse, was on site and an AED (automatic external defibrillator) was available fo r the testing. The in vestigator had cell phones for immediate access to emergency services (911) if needed d uring testing. Testing stopped if at any time p articipants felt light headed, dizzy, weak o r tired, short of breath or had chest pain. Data Storage and Management Data storage, coding and entering of data, verification, transformat ions, and data retrieval was the responsibility of the investigator. A ll data collection forms were reviewed for missing data at pre and pos t test sessions. Efforts were made to obtain missing data when needed. Paper files were used to collect data and data was entered by hand into electronic database and verified for ac curacy. Electronic files were placed on the security protected UF server and encrypted digital media. All paper file inc luding
52 informed consents were ffice. Informed consents were stored separately from data files.
53 CHAPTER 4 RESULTS A convenience sample of community dwelling older adults with mobility difficulty was randomly assi gned to either an 8 week line dancing or wait listed control group . Primary outcomes were impairments (balance and muscle strength), functional limitations (physical performance, endurance and gait), preclinical disability (task frequency and observed and perceived task modification), and disability (mobility). Potential covariates, depressive symptoms and balance confidence were assessed at baseline and at post test. Perceived benefit of dance was assessed at baseline only for dance group. Sample and Set ting Forty five older adults were screened for eligibili ty to participate but twenty two were excluded because they reported use of assistive devices, having a pacemaker or MI within p ast six months, or exercising more than 30 minutes three times per week. Twenty three community dwelling older adults who met inclusion criteria, and signed a consent form were enrolled in the study and randomized to either the wait listed control group (n = 11) or the dance group (n = 12). The sample consisted of 3 males and 20 female whose age ranged from 65 to 93 years (M = 73.4, SD =8.4). Although the majority of participants were Caucasian (n = 21), two were Black. There were no significant differences in the demographic and health status characteristics between groups at baseline (see Table 4 1 and Table 4 2). All participants reported that they were currently taking over the counter or prescription medications. The five most commonly reported medications were fish oil (48%), ace inhibitors (30%), cholesterol lowering agen ts (30%), aspirin (30%), and Vitamin C (30%). The majority of participants (n = 19) reported seeing their healthcare provider on a regular basis for a
54 health problem. Perceived benefit of dance was assessed at baseline for those in the dance group. Two pa There was 100% adherence to the study and none of the dance participants missed more than two dance sessions. Thus, all dance participants recei ved an adequate dose of the intervention by attending at least 75% of the dance sessions. Daily activity was recorded by each participant. The type of activity and minutes spent in each activity was recorded. The sample reported participating in daily act ivities average of 28 minutes per week. The dance group had reported greater total time spent in daily activity that was expected since they were engaged in the dance intervention twice per week. Hypothesis Testing Analysis of variance with pretest as a covariate was used to assess the effects of 8 week line dancing on impairments (balance and muscle strength), functional limitations (physical performance, endurance, and gait), preclinical disability (task frequency and observed and perceived task modific ation), and disability (mobility). Prior to this analysis, assumptions of normality and homoscedasticity were assessed. The the assumption of h omoscedasticity was met . Normality was assessed by examining the dependent variable s for skewness, kurtosis, and a non significant Kolmogorov Smirnov (K S) test. The K S tests were significant for the Berg balance scale, observed and perceived task modification (See Table 4.3). Thus, transformations were used to attempt to correct the non normal distributions of the Berg Balance Scale, observed and perceived task modification. The frequency distribution of the Berg Balance Scale had two peaks, one at each of the low and high ends of the range of possible scores. This
55 scale was dichotomized into low for scores below 54 and high for 54 and higher. The frequency distribution of the perceived task modification score had two peaks, one at each of the low and high ends of the range of p ossible scores. This instrument was dichotomized into low for scores below 4 and high for 4 and higher. The frequency distribution of the observed Task Modification Scale had two peaks, one at each of the low and high ends of the range of possible scores. This scale was dichotomized into low for scores below 15 and high for 15 and higher. covariates (depressive symptoms and balance confidence) with impairments (balance and muscle strength), functional limitations (physical performance, endurance, and gait), preclinical disability (task frequency and observed and perceived task modification), and disability (mobility). Five hypotheses were tested during data analysis. In s pite of violations of normality, AN C OVA was used to assess the effects of the line dance intervention because this statistic is robust against violations of normality. ANCOVA was used to assess the effects of dance while controlling for the effects of depr essive symptoms and balance confidence. Kruskal Wallis for repeated measures of dichotomous variables was used to compare the dance and control groups. Hypothesis 1 Eight weeks of line dancing will reduce impairments (balance and muscle strength) when c ompared with the wait listed control group. There was no significant difference between groups for balance. One participant in the dance group improved from having low to high balance at post test , while two participants in the control group also improved . In contrast, the line dancing group had
56 significantly greater knee extensor strength but not for knee muscle flexor strength (See Table 4.4). Body weight was not significantly different from pre to post test , thus the gains in knee extensor strength were not influenced by decreased body weight. Inter rater reliability was determined by examining the intraclass correlation s for knee flexor strength at pretest was (.790), knee flexor strength at posttest (.903), knee extensor strength at pretest (. 822) and at posttest (.758). The dichotomized Berg Balance Scale was not significant between the groups (See Table 4 5). Hypothesis 2 Eight weeks of line dancing will reduce functional limitations (physical performance, endurance, and gait) when compared with wa it listed control group. The line dancing group had significantly greater physical performance, endurance, and gait speed (See Table 4 4). In contrast, there was no significant difference in ability to complete the 400 meter walk (see Table 4 5). Gait sp eed could be from the 400 meter walk and the timed 4 meter walk from the SPPB. Irrespective of the calculations used for gait speed, the line dancing group had significantly greater gait speed. Hypothesis 3 Eight weeks of line dancing will reduce precli nical disability (task frequency and observed and perceived task modification) when compared with wait listed control group. There were no significant differences between the control and line danc e groups for task frequency and observed and perceived tas k modification (see Table 4.4). Hypothesis 4 Eight weeks of line dancing will reduce mobility disability when compared with the wait listed control group.
57 ANCOVA was done to assess the effects of the intervention while controlling for balance confidence on perceived mobility disability because it was significantly related to percei ved mobility difficulty (p= .012 ) . W hen b alance confidence was controlled, the line dancing group had significantly lower mobility disability . Since difficulty climbing a flight of stairs and walking Â¼ mile were used to select older adults with mobility difficulty, the effects of line dancing on these were also examined. The line dancing group had significantly reduced difficulty climbing a flight of stairs but no t a significant difference for difficu lty walking a quarter of mile . (See Table 4.5) Hypothesis 5 Depressive symptoms and balance confidence will be related to impairments (balance and muscle strength), functional limitations (physical performance, endurance, and gait), preclinical disability (task frequency and observed and perceived task modification), and disability (mobility). symptoms and balance confidence post test are displayed in Table 4 6. Greater depressive symptoms were significantly associated with lower endurance, task frequency, perceived mobility disability , and difficulty climbing a flight of stairs . Balance confidence had a significant positive relati onship with endurance, task fr equency, perceived and observed task modification, per ceived mobility disability, difficulty walking Â¼ mile , and difficulty climbing a flight of stairs, but had a negative relationship with physical performance and gait speed. Summary In summary, five hyp otheses were tested and line dancing significant ly improved muscle strength, physical performance, endurance, gait speed perceived mobility disability , and difficulty climbing a flight of stairs . When controlling for balance
58 confidence, dance had a signifi cant effect on mobility disability. There were no significant differences in demographic, health, and daily activity between the groups.
59 Table 4 1. Demographic characterist ics Total Frequency (n = 23) Total % (n = 23) Control Frequency (n = 11) Control % (n = 11) Intervention Frequency (n = 12) Intervention % (n = 12) Chi Square Gender Female Male 20 3 87.0 13.0 10 1 90.9 9.1 12 0 100 0 .590 Race Caucasian Black 21 2 91.3 8.7 11 0 100 0 10 2 83.3 16.7 .156 Marital Status Married Widowed Divorced Ne ver Married 9 7 5 1 39.1 30.4 21.7 4.3 4 3 4 0 36.4 27.2 36.4 0 5 4 1 1 41.7 33.3 8.3 8.3 .404 Education Grade 8 Grade 9 Grade 11 Grade 12 Post HS Grad Associate degree College grad degree Doctoral degree 1 1 1 9 5 1 1 3 1 4.3 4.3 4.3 39.1 21.7 4.3 4.3 13.0 4.3 0 1 0 4 3 1 1 1 0 0 9.1 0 36.4 27.3 9.1 9.1 9.1 0 1 0 1 5 2 0 0 2 1 8.3 0 8.3 41.7 16.7 0 0 16.7 8.3 .579 Living Status Lives alone Lives with someone 13 10 56.5 43.5 5 6 45.5 54.5 8 4 66.7 33.3 .305
60 Table 4 2. Health c onditions Total Frequency (n = 23) Total % (n = 23) Control Frequency (n = 11) Control % (n = 11) Intervention Frequency (n = 12) Intervention % (n = 12) Chi Square High Blood Pressure 17 73.9 8 72.3 9 75 .901 Peripheral Vascul ar Disease 5 21.7 4 36.4 1 8.3 .104 Diabetes 7 30.4 5 45.4 2 16.7 .134 Neuropathies 7 30.4 4 36.4 3 25 .554 Respiratory disease 4 17.4 3 27.3 1 8.3 .231 Osteoporosis 6 26.1 3 27.3 3 25 .901 Arthritis 15 65.2 8 72.3 7 58.3 .469 Depression 6 26.1 2 18 4 33.3 .408 Joint replacement 6 26.1 4 36.4 2 16.7 .283 Other conditions not listed 15 65.2 7 63.4 8 66.7 .879
61 Table 4 3 . Tests of n ormality Kolmogorov Smirnov Shapiro Wilk Statistic df Sig. Statistic Df Sig. Physical Perfo rmance post Balance post Endurance post .120 .218 .124 23 23 23 .200 .006* .200 .956 .889 .917 23 23 23 .379 .015 .059 Gait Speed post .228 23 .003* .903 23 .030 Muscle strength knee extensor post .124 23 .200 .948 23 .262 Muscle strength knee flexor po st .167 23 .095 .868 23 .006 Task frequency post .104 23 .200 .952 23 .326 Perceived task modification post .218 23 .006* .858 23 .004 Observed task modification post .244 23 .001* .879 23 .009 Perceived mobility difficulty post .150 23 .195 .925 23 .0 85 Difficulty walking Â¼ mile post .444 23 .000* .590 23 .000 Difficulty climbing a flight of stairs .163 23 .116 .925 23 .085 *. Distribution p < .05
62 Table 4 4 . Differences between l ine dancing and control g roups Pretest Post Test Controls Mean (SD) Dance Mean (SD) Controls Mean (SD) Dance Mean (SD) F test Balance 48.64 (5.62) 48.08 (7.93) 47.00 (6.18) 50.42 (4.56) 1.30 Strength Knee extensor .09 (.03) .11 ( .03) .09 ( .03) .14 ( .04) 6.92* Knee flexor .07 (.03) .09 ( .04) .08 ( .03) . 11 ( .06) 1.42 Physical Performance 7.73 (1.90) 6.75 (2.37) 7.18 (2.08) 9.17 (2.32) 20.50** * Gait speed (meters/sec) .75 (.19) .86 (.27) .72 (.13) 1.00 (.25) 18.57*** Endurance (Minutes) 9.53 (2.57) 8.63 (3.17) 9.64 (2.09) 7.05 (1.96) 12.61** Perceive d Task Frequency 8.27 (3.72) 6.42 (3.31) 8.00 (3.63) 4.75 (2.70) 2.67 Perceived Task Modification 3.36 (1.91) 3.42 (1.67) 2.72 (1.62) 2.42 (1.31) .0 2 Observed 11.82 (6.61) 10.75 (7.04) 12.18 (7.81) 9.17 (7.30) 1.07 Perceived Disability 10.64 (6.00) 8.25 (6.67) 9.27 (5.31) 4.17 (4.43) 4.89 * Difficulty walking Â¼ mile 1.00 (1.18) .58 (.79) .55 (.82) .17 (.39) . 51 Difficulty climbing stairs 3.64 (1.12) 3.08 (1.93) 3.27 (1.00) 1.75 (1.42) 7.72 * Note: ANCOVA results * p < .05, ** p < .01, *** p < . 001
63 Table 4 5. Differences between the controls and line dancing groups for n ominal o utcome v ariables Total Frequency (%) (n = 23) Controls Frequency (%) (n = 11) Dance Frequency (%) (n = 12) Chi Square Balance Low 14 (60.1) 8 (72.7) 6 (50) . 27 High 9 (39.1) 3 (27.2) 6 (50) 400 meter walk Unable to complete 400m walk within 15 minutes 1 (4.3) 1 (9.1) 0 .29 Completes the 400m walk without stopping within 15 min 22 (95.6) 10 (91) 12 (100) Note : none of the differences were significant
64 Table 4 6. Pearson correlations m atrix Dependent Variables Depressive Symptoms Balance Confidence Balance .086 .285 Muscle strength K nee extensor .158 .104 K nee flexor .172 .007 Physical Performance .378 .623** Enduran ce .433* .565** Gait Speed .362 .441* Preclinical disability Task Frequency .692** .688** Perceived Task Modification .060 .560** Observed Task Modification .257 .532** Disability Mobility disability .627* * .691** Difficulty walking Â¼ mile . 342 .715 ** Difficulty climbing a flight of stairs . 557** . 529** * p < .05, ** p < .01, *** p < .001
65 CHAPTER 5 DISCUSSION Older adults with mobility disability are at risk of losing their independence and having subsequent worsening disability. Although exercise has been found to delay the progression of disability, many older adults with mobility difficulty do not exercise (Berk, Hubert, & Fries, 2006; Life Study Investigators, 2006 ). Line dancing is an exercise that may improve physical function and reduce disability. The purpose of this study was to assess the effects of an eight week line dancing intervention on impairments, functional limitations, preclinical disability, and dis ability. Dance and Impairments Some, not all, impairments benefited from line dancing. Balance was expected to improve because line dancing had required dynamic movements that challenge postural control (Brown, Martinez, & Parsons, 2006). Yet, the l ine dancing and control groups were not significantly different unlike in previous studies (Duncan & Earhart, 2012; Hackney & Earhart, 2009), even with dance as short as the 8 weeks used in the present study (Eyigor et al., 2009). Although there was not a significant difference, those in the line dance group experienced a 2 point increase in the Berg Balance Scale that approached the 4 points required for cl inical meaningfulness (Donoghue & Stokes, 200 9). I n a previous study of tango and ballroom dance wit participants, a greater increase of 4 points was achieved in that 13 week study (Hackney & Earhart, 2009). Interestingly, dance improved knee extensor but not knee flexor strength. The knee extensors were more involved in the line d ancing movements than the knee flexors and may account for differences in strength of the muscle groups (Young, Weeks, & Beck, 2007). I n a 12 week study of Korean dance , significantly greater
66 strength in the knee extensors also was found but not knee flex or strength (Jeon, Choe, & Chae, 2000). Similar patterns in muscle strength have been found for aerobic and balance training where knee extensors and knee flexors were likewise involved (Goodpaster et al., 2008; Lu, Hui Chan, & Tsang, 2013; Kalapotharkos et al., 2006; Talbot, Gaines, Huynh & Metter, 2003; Wu, Zhao, Zhou, & Wei, 2002). Dance and Functional Limitations Since functional limitations are the result of impairments and line dancing improved some impairments, reductions in functi onal limitations were expected. Line dancing significantly improved physical performance and was consistent with findings of a pilot study that also used the Short Physical Performance Battery (SPPB) (Bennett & Roberts, 2011). In previous dance studies, the effects of d ance on physical performance have been inconsist ent, but different measures (i.e. timed up and go, chair stands) of physical performance were used (Eyigor et al., 2006; Hackney & Earha rt, 2009; Hui, Chui, & Woo, 2009 ; Ke ogh et al., 2012). V ariance in the m easurements of performance may account for the inconsistencies of findings. Since line dancing is aerobic in nature, i mprovements in end urance were expected. Line dancing significantly improved endurance. In fact, those in the line dancing group had imp roved endurance while it declined for controls. Similar findings were found when the distance in the six minute walk was used to assess endurance (Duncan & Earhart, 2012; Hackney & Earhart, 2009; Hackney & Earhart, 2010; Hackney et al., 2012), in contrast to the 400 meter walk used in the present study. The finding of improved endurance is of clinical importance, as those with greater endurance may lower their risk of having a new mobility limitation (Life Study Investigators, 2006; Simonsick et al., 2008 ; Vestergaard et al., 2009 ).
67 Since line dancing increased knee extensor muscle strength, improvements in usual gait speed were expected. As was found in a previous study of 8 weeks of dance (Eyigor et al., 2009), the eight weeks of line dancing significantl y increased usual gait speed that worsened for controls and improved in the dance group. A gait speed of 1.18 meters/second indicates risk for mobility disability (Deshpande, Metter, Guralnik, Bandinelli, & Ferruci, 2013). The mean gait speed of the dance group was 1.00 meters/second still placing them at risk of having mobility disability, yet they were above the major disability threshold of .6 meters/second (Cummings, Studenski & Ferruci, 2014). In contrast, the controls had a lower mean gait speed of .72 meters/second that placed them at a higher risk of mobility disability. Dance and Preclinical Disability O bserved and perceived task modifications and frequencies for doing tasks were not significantly affected by line dancing. Although line dancing s ignificantly improved functional limitations, the effects on physical function may not have been large enough to affect precli nical disability . R eductions in preclinical disability happen over time and verity of the limitation. Older adults may perceive modifying tasks and changing frequency of tasks as normal for their age. Hence, they may not report a modification or a change of frequency. Dance and Disability Line dancing significantly reduced diffic ulty with mobility disability tasks and remained so when controlling for depressive symptoms and balance confidence. Similar improvements in disability were found in a 12 week dance study that included a greater number of mobility tasks (Keogh et al., 2012 ). Difficulty walking Â¼ mile and climbing a flight of stairs were used to identify older adults with mobility difficulty for the present study. Despite, faster times to complete the 400 meter walk (1/4 mile), line dancing did
68 not significantly reduce perc eived di fficulty walking this distance. In contrast, line dancing did signifi cantly reduce the difficulty in climbing a flight of stairs. Since line dancing improved impairments and reduced functional limitations that precede disability, improvements in m obility disability would be expected. However, preclinical disability is theoriz ed to precede disabilit y . This inconsistency may be attributed to the sample already having mobility disability and have already transitioned from preclinical disability to cli nical disability. In addition, a n individual may have difficulty performing certain tasks and not others. So it is possible that those in dance may have improved in certain tasks of mobility while other tasks declined, but the sample size was too small to explore this possibility . In addition, perceptions of d ifficulty can change over time and o lder adults may not perceive difficulty until it has reached a significant level interfering with daily activities (Fried et al., 1991). Limitations The small samp le size limits the generalizability of these findings to other older adults with mobility difficulty. T hose who chose to parti cipate may be hea lthier and may perceive line dancing to be more beneficial compared with those who did not participate. Since th e data collector was not blinded to group a subject was randomized to, there may be potential bias in the assessments of study outcomes. Two hours per week for eight weeks was the minimum dose of dance where significant effects in previous studies were fou nd. A greater weekly frequency or number of weeks for line dancing would increase t he dose and may potentially significantly increase the effects on outcomes that were not significant in this study . Clinical Implications Regular exercise is beneficial fo r older adults as it improves physical function and may reduce disability. Current recommendations are for older adults to participate in at
69 least 150 minutes per week of moderate intensity aerobic exercise (CDC, 2013). In spite of this recommendation, man y older adults do not achieve the minimum recommended amount of exercise . Line dancing is recommended as an aerobic exercise for older adults with mobility difficulty. Although other types of dance may be recommended for older adults, the classes do not a lways include modifications in the dance steps to accommodate the limitation of the older adult . Hence, some individuals would have to stop the dance or not attempt the dance due to their inability to perfo rm the movements. Line dancing is feasible and mo difications to the movements e nable the older adult with mobility difficulty to perform the dance. The line dance instructor must plan for modifications as part of the line dance choreography and observe participants for difficulty during the line dance cl asses so that another movement can be substituted. In this study, the line dance instructor was experienced at monitoring participants for difficulty and introduced a new movement when indicated. Many of the dance participants in this study continued on w ith the line dance instructor paying for 8 weeks of line dance classes. K nee extensor muscle strength is integral to balance and mobility required for independence in activities of daily living (Guralnik et al., 2000; Hasegawa et al., 2008; Karinkanta et a l., 2005). Line dancing significantly improved knee extensor strength and may be a n enjoyable intervention for those who requiring strengthening of these muscle groups. Although a limited number of mobility tasks were assessed in the present study, the re ductions in the difficulty in climbing stairs suggests that line dancing may improve other mobility tasks and minimize disability.
70 Implications for Theory The theoretical framework used to design this study was the disablement model with preclinical disa bility inserted as a transitional stage that precedes disability. The findings from this study provide some support for the theoretical framework. Findings for impairments were inconsistent. Knee strength but not balance was improved with line dancing on certain impairments . The ceiling effects of the measure for balance may have accounted for the lack of significant findings. All measures of functional limitations were reduced with line dancing. Findings were also inconsistent for disability. Since pr eclinical disability was theorized to precede disability, line dancing would have been expected to reduce preclinical disability. Since the study population had mobility disability , they may have already transitioned from preclinical disability . This is the first study to use this framework, and refinements to the model require additional rese arch and theory testing. Future Research A larger sample should be used in future research to increase the g eneralizability of the findings. T he oldest old may bene fit from line dancing and are the fastest growing age group that is at greater risk for loss of independence (Hobbs, 2010). A lthough there were significant changes on most study outcomes at 8 weeks, a longer intervention period or greater weekly frequenc y would increase the dose effect. Measurements during the intervention period would provide information about whether changes in outcomes continue or reach a plateau at some point. Future studies should also assess the long term effects after the completi on a community based line dancing program. Many older adults have chronic pain, often from arthritis, that has known to adversely affect mobility and functional limitations. Exercise has been shown to
7 1 improve pain, and line dancing may have had similar e ffects and account for the changes seen in the physical and functional changes found in the present study. Including pain as an outcome in future studies may provide information about its role in similar outcomes and provide information about the importan t clinical benefit of line dancing on pain. Future research is to disentangle the effects of line dancing from other factors inherent in this intervention. The aerobic intensity of line dancing was not measured and whether the changes in the outcomes can be attributed to the aerobic aspects of line dancing or other factors is unknown. Music is an external cue that may facilitate movement or have unknown effects on the physical and psychological response to line dancing. Research is needed to determine whe ther the effects of line dancing are independent of the effects of musi c. Comparison studies are needed with three arms to disentangle the effects of line dancing from music: line dancing alone, without music or with the same music throughout the study pe riod. In addition, an examination of the role social support has during line dancing is needed. Older adults who remain home and dance to an instructional video may have different outcomes than those who dance as part of a group program. Summary This st udy was the first to examine line dancing as an exercise intervention for older adults with mobility difficulty. Eight weeks of line dancing improved muscle strength, physical pe rformance, gait, and mobility disability. Line d ancing involves socialization that may increase enjoyment and promote adherence while incorporating dynamic balance control and the use of lower extremity large muscle group s to improve physical function, and reduce disability that threatens the independence of older adults.
72 APPEND IX A Active Pathology Impairment Functional Limitation Disability The schematic above shows the sequential pathway of pathology, impairment, functional limitation and disability. Active pathology is disruption of th state. Impairment is an abnormality or loss of physiological, emotional, or structural functions. Functional limitation is the ability of the body to function as a whole. Disability is difficulty in performance of physical and social tasks
73 APPENDIX B THE DISABLEMENT MODEL Extra Individual Factors The Main Pathway PATHOLOGY IMPAIRMENTS FUNCTIONAL LIMITATIONS DISABILITY Intra Individual Factors Risk Factors The main pathway constructs o f pathology, impairments, functional limitations, and disability are defined in Appendix A. Extra individual factors are external to the individual and include medical care and rehabilitation (e.g. surgery or physical therapy), medications and other thera peutic regimens (e.g. recreational therapy or exercise), external supports (e.g. special equipment or respite care), and the physical and social environment (e.g. public transportation or access to healthcare). Intra individual factors are internal to th e individual and include lifestyle and behavior changes, psychosocial attributes and coping, and activity accommodations. RISK FACTORS ARE CHA RACTERISTICS OF AN I NDIVIDUAL THAT ARE PRESENT AT OR BEFORE ONSET OF DISABLEMENT .
74 APPENDIX C SUBSTRUCTION OF S ELECTION , OPTIMIZATION , AND COMPENSATION (SOC) MODEL The Preclinical Disability Model (Fried, 1991) is derived from the Selection, Optimization, and Compensation (SOC) Model. Fried (1991) used the SOC model in a new way by applying it to physical function . Selection is task frequency, optimization is maximizing capability, and compensation is task modification. Selection Optimiza tion Compensation Task Frequency Task Modification Maximizing capability
75 APPENDIX D T HEORY SYNTHESIS OF DISABLEMENT MODEL AND PRECLINICAL DISABILITY Extra Individual Factors Line Dancing Impairments Balance Muscle strength Functional Limitations Physical Performance Endurance Gait Disability Mobility Preclinical Disability Task frequency Task Modification Intra Individual Factors Depressive symptoms Balance confide nce
76 APPENDIX E L INE DANCE CHOREOGRA PHY Appendix E includes a description of each dance taught during the 8 week line dance intervention. The description includes the step count and associated movement performed for each dance. Dance s are listed in the order introduced during the intervent ion period . Dance Introduction of Dance Repeated performances Texas Barefoot Week One Week Two Week Five Locomotion Week One Week Two Week Eight No Problem Week Two Week Three Week Eight Cowboy Charleston Week Three Week Four Week Eight Canadian Stro ll Week Four Week Five Week Eight Week Five Week Six Week Eight The New York Stroll Week Six Week Seven Week Eight Uh huh Week Seven Week Seven Week Eight TEXAS BAREFOOT (Fast music half time steps) 1 2 Touch Right foot to right; hold 3 4 Step Right foot beside left; hold 5 6 Touch Left foot to left; hold 7 8 Step Left foot beside right; hold 9 16 Repeat Steps 1 8 17 18 Step forward right; hold
77 19 20 Step forward left; hold 21 22 Step forward right; hold 23 24 Step forward left; hold 25 3 2 JAZZ BOX WITH Â¼ TURN RIGHT 25 26 Step right foot across left; hold 27 28 Step left foot slightly back as you turn Â¼ to right; hold 29 30 Step right foot by left foot; hold 31 32 Step left foot by right foot, hold LOCOMOTION 28 count (7 set s of 4 count beats) 4 wall line dance Count Steps (Steps to the right and left) 1 4 Step right; close with left Step left; close with right (Step to right side with right foot; bring left foot to right to close. Step to left side with left foot; Bring r ight foot to left to close.) 5 8 Repeat above 4 counts 9 12 Right foot forward and close twice (Step forward and slightly to the right with right foot. Drag left foot together to close. Repeat.) 13 16 Left foot forward and close twice. (Step forward and sl ightly to the left with left foot. Drag right foot together to close. Repeat.)
78 17 20 Walk forward 3 steps and kick. (With right foot, walk forward three steps [right, left, right] and kick with left foot as you clap Once [left foot does not take weight]) 2 1 24 Walk back 2 steps and touch (With left foot, walk backwards 3 steps [left, right, left] and step on right foot by left [weight should be on both feet]) 25 28 Scoots forward, back and turn (With feet together, scoot forward, clap once; scoot back, clap once; scoot forward, clap once, and then shuffle as you turn to the right Â¼ turn, clap once) YOU ARE READY TO START OVER AT STEP 1 NO PROBLEM 4 Wall line dance Shuffle forward twice, Â¼ left turn, stomp 1 2 Step right forward, step left alongside right, step right forward 3 4 Step left forward, step right alongside left, step left forward 5 6 Step right forward, turning Â¼ left step left 7 8 Stomp right, stomp left Jazz Box 9 10 Cross right over left, step back left 11 12 Step right next to left, step left in place Vine right, vine left 13 14 Step right to right side, step left behind right 15 16 Step right to right side, touch left next to right
79 17 18 Step left to left side, step right behind left 19 20 Step left to left side, touch right next to left Begi n again COWBOY CHARLESTON 1 & Touch forward with ball of right 2 & Step back on right 3 & Touch back with ball of left 4 & Step forward on left 5 8 Repeat last 4 counts 1&2& Tap right toe out to the right twice 1&2& Step behind left foot with right foot , step to the left with the left foot, step in front of left foot with right foot 1&2& Tap left toe out to the left twice 1&2& Step behind right foot with left foot, step right with the right foot, making Â¼ turn right step forward with the left foot Start again CANADIAN STROLL Count Steps 1 4 Right side, together, side, touch 1 Step right to right side
80 2 Slide/step left beside right 3 Step right to right side 4 Touch left toes beside right 5 8 Left side, together, side touch 5 Step left to left side 6 Sl ide/step right beside left 7 Step left to left side 8 Touch right toe beside left 9 12 Touch right heel forward, touch right toe back, step right forward turning Â¼ right, point left 9 Touch right heel forward 10 Touch right toe back 11 Step right forward t urning Â¼ right 12 Touch left toe to left side 13 16 Forward stroll: forward, drag, forward, touch 13 Step left forward 14 Lock step right forward behind left (modified: step drag) 15 Step left forward 16 Touch right toe beside left End of pattern, Begin ag ain facing the 3:00 wall Forward left together right, in place left, back right together left, in place right
81 1 3 Left foot step forward, right step beside left. Left step in place. 4 6 Right foot step back. Left step beside right. Right ste p in place. Forward left together right, in place left, back right together left, in place right 7 9 Left foot step forward, right step beside left. Left step in place. 10 12 Right foot step back. Left step beside right. Right step in place.Left spiral. Ri ght spiral. 13 Left cross on the diagonal over right Turn body slightly right, 14 Right step side right. Turn body slightly left. 15 Left foot replace weight, body facing slightly left. 16 Right cross on the diagonal over left. Turn body slightly left, 17 Left step side left. Turn body slightly right. 18 Right foot replace weight, body facing slightly right.Left spiral. Right spiral with Â¼ turn left. 19 Left cross on the diagonal over right. Turn body slightly left. 20 Right step side right. Turn body sligh tly left. 21 Left foot replace weight, body facing slightly left. 22 Right cross on the diagonal over left. Turn body slightly left. 23 Left step back and Wm Â¼ right. 24 Right step forward making Â½ turn to right. (End facing side wall Â¼ left from original starting position.) THE NEW YORK STROLL RIGHT HEEL, LEFT HEEL
82 1 Touch right heel forward 2 Bring right beside left 3 Touch left heel forward 4 Bring left beside right RIGHT HEEL, LEFT HEEL 5 Touch right heel forward 6 Bring right beside left 7 Touch lef t heel forward 8 Bring left beside right 4 POLKAS DIAGONALLY 9&10 Shuffle forward diagonally right, left, right 11&12 Shuffle forward diagonally left, right, left 13&14 Shuffle forward diagonally right, left, right 15&16 Shuffle forward diagonally left, ri ght, left VINE RIGHT, TURN Â½, VINE LEFT 17 Step right on right 18 Cross left behind right 19 Step right while turning Â½ 20 Brush left 21 Step left on left 22 Cross right behind left 23 Step left on left 24 Touch right beside left
83 UH HUH! 32 count 4 wall line dance HEEL, TOGETHER 4 TIMES 1 2 Tap right heel forward (1), Step right foot beside left (2). 3 4 Tap left heel forward (3), Step left foot beside right (4). 5 6 Tap right heel forward (5), Step right foot beside left (6). 7 8 Tap left heel forward ( 7), Step left foot beside right (8). SIDE, TOGETHER, SIDE , TOUCH, SIDE, TOGETHER, SIDE TOUCH 1 2 Step right foot to right side (1), Step left beside right (2). 3 4 Step right foot to right side (3), Touch left foot beside right (4). 5 6 Step left foot to left side (5), Step right foot beside left (6). 7 8 Step left foot to left side (7), Touch right foot beside left (8). HEEL, TOGETHER 4 TIMES 1 2 Tap right heel forward (1), Step right foot beside left (2). 3 4 Tap left heel forward (3), Step left foot bes ide right (4). 5 6 Tap right heel forward (5), Step right foot beside left (6). 7 8 Tap left heel forward (7), Step left foot beside right (8). STEP KICK, BACK TOUCH, STEP, Â¼ TURN LEFT, STOMP, CLAPS 1 2 Step forward with right foot (1), Kick forward with l eft foot (2). 3 4 Step back with left foot (3), Touch right toe back (4). 5 6 Step forward with right foot (5), Turn Â¼ Left, put weight onto left foot (6). 7 8 Stomp right foot beside left, weight on left foot (7), Clap hands twice (8). Start again from be ginning.
84 APPENDIX F O UTCOMES AND MEASUREMENTS Table A 1 . Outcomes and measurements Outcome Measurement Number of Items Time Balance Berg balance scale 14 15 minutes Muscle Strength Handheld dynamometer N/A 5 minutes Endurance 400 meter walk N/A 5 10 minutes Physical Performance Short Physical Performance Battery N/A 8 minutes Gait 400 meter walk N/A N/A Preclinical Disability Fried Preclinical Disability screening tool 5 10 minutes Preclinical Disability Task Modification Scale (MOD) 5 10 m inutes Mobility disability Ratings of difficulty walking Â¼ mile and climbing a flight of stairs 2 < 1 minute Depressive symptoms Geriatric Depression Scale Short Form 15 10 minutes Balance confidence Falls Efficacy Scale 10 5 minutes Perceived benefit of dance Rating of dance benefit 1 < 1 minute Activity Log Daily activity N/A < 1 minute per day
85 APPENDIX G INSTRUMENTS Borg Rating of Perceived Exertion Scale Berg Balance Scale Short Physical Performance Battery Preclinical and Disability Screening To ol Task Modification Scale Daily Log of Activity Geriatric Depression Scale Falls Efficacy Scale Perceived Benefit of Dance Scale
86 Table A 2 . Borg rating of perceived exertion scale Borg Scale (6 20) Intensity 6 No exertion at all 7 8 Extremely light 9 Very light 10 11 Light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion
87 BERG BALANCE SCALE SITTING TO STANDING INSTRUCTIONS: Please stand up. Try not to use your hand for support. ( ) 4 able to stand without using hands and stabilize independently ( ) 3 able to stand independently using hands ( ) 2 able to stand using hands after several tries ( ) 1 needs minimal aid to stand or stabilize ( ) 0 needs moderate or maximal assist to stand ST ANDING UNSUPPORTED INSTRUCTIONS: Please stand for two minutes without holding on. ( ) 4 able to stand safely for 2 minutes ( ) 3 able to stand 2 minutes with supervision ( ) 2 able to stand 30 seconds unsupported ( ) 1 needs several tries to stand 30 secon ds unsupported ( ) 0 unable to stand 30 seconds unsupported If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL INSTRUCT IONS: Please sit with arms folded for 2 minutes. ( ) 4 able to sit safely and securely for 2 minutes ( ) 3 able to sit 2 minutes under supervision ( ) 2 able to able to sit 30 seconds ( ) 1 able to sit 10 seconds
88 ( ) 0 unable to sit without support 10 seco nds STANDING TO SITTING INSTRUCTIONS: Please sit down. ( ) 4 sits safely with minimal use of hands ( ) 3 controls descent by using hands ( ) 2 uses back of legs against chair to control descent ( ) 1 sits independently but has uncontrolled descent ( ) 0 ne eds assist to sit TRANSFERS INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair. ( ) 4 able to transfer safely with minor use of hands ( ) 3 able to transfer safely definite need of hands ( ) 2 able to transfer with verbal cuing and/or supervision ( ) 1 needs one person to assist ( ) 0 needs two people to assist or supervise to be safe STANDING UNSUPPORTED WITH EYES CLOSED INSTRUCTIONS: Please close your eyes and stand still for 10 seconds. ( ) 4 able to stand 10 seconds safely ( ) 3 able to stand 10 seconds with supervision ( ) 2 able to stand 3 seconds ( ) 1 unable to keep eye s closed 3 seconds but stays safely
89 ( ) 0 needs help to keep from falling STANDING UNSUPPORTED WITH FEET TOGETHER INSTRUCTIONS: Place your feet together and stand without holding on. ( ) 4 able to place feet together independently and stand 1 minute safely ( ) 3 able to place feet together independently and stand 1 minute with supervision ( ) 2 able to place feet together independently but unable to hold for 30 seconds ( ) 1 needs help to attain position but able to stand 15 seconds feet together ( ) 0 need s help to attain position and unable to hold for 15 seconds REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fin gertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.) ( ) 4 can reach forward confidently 25 cm (10 inches) ( ) 3 can reach forward 12 cm (5 inches) ( ) 2 can reach forward 5 cm (2 inches) ( ) 1 reaches forward but needs supervision ( ) 0 loses balance whil e trying/requires external support PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION INSTRUCTIONS: Pick up the shoe/slipper, which is in front of your feet. ( ) 4 able to pick up slipper safely and easily ( ) 3 able to pick up slipper but needs superv ision
90 ( ) 2 unable to pick up but reaches 2 5 cm(1 2 inches) from slipper and keeps balance independently ( ) 1 unable to pick up and needs supervision while trying ( ) 0 unable to try/needs assist to keep from losing balance or falling TURNING TO LOOK BEH IND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. (Examiner may pick an object to look at directly behind the subject to encourage a better twist turn.) ( ) 4 looks behind from both sides and weight shifts well ( ) 3 looks behind one side only other side shows less weight shift ( ) 2 turns sideways only but maintains balance ( ) 1 needs supervision when turning ( ) 0 needs assist to keep from losing balance or falling TURN 360 DEGREES INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction. ( ) 4 able to turn 360 degrees safely in 4 seconds or less ( ) 3 able to turn 360 degrees safely one side only 4 seconds or less ( ) 2 able to turn 360 degrees safely but slowly ( ) 1 needs close supervision or verbal cuing ( ) 0 needs assistance while turning PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
91 INSTRUCTIONS: Place each foot alternately on the st ep/stool. Continue until each foot has touched the step/stool four times. ( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds ( ) 3 able to stand independently and complete 8 steps in > 20 seconds ( ) 2 able to complete 4 steps without aid with supervision ( ) 1 able to complete > 2 steps needs minimal assist ( ) 0 needs assistance to keep from falling/unable to try STANDING UNSUPPORTED ONE FOOT IN FRONT INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of t he other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the othe r foot and ( ) 4 able to place foot tandem independently and hold 30 seconds ( ) 3 able to place foot ahead independently and hold 30 seconds ( ) 2 able to take small step indep endently and hold 30 seconds ( ) 1 needs help to step but can hold 15 seconds ( ) 0 loses balance while stepping or standing STANDING ON ONE LEG INSTRUCTIONS: Stand on one leg as long as you can without holding on. ( ) 4 able to lift leg independently and hold > 10 seconds ( ) 3 able to lift leg independently and hold 5 10 seconds ( ) 2 able to lift leg independently and hold L 3 seconds ( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.
92 ( ) 0 unable to try of needs assist to prevent fall ( ) TOTAL SCORE (Maximum = 56 )
93 SHORT PHYSICAL PERFORMANCE BATTERY All of the tests should be performed in the same order as they are presented in this protocol. Instructions to the participants are shown in bold italic and should be give n exactly as they are written in this script. 1. BALANCE TESTS The participant must be able to stand unassisted without the use of a cane or walker. You may help the participant to get up. ove your body in different movements. I will first describe and show each movement to you. Then ne. Let me emphasize that I do not want you to try to do any exercise that you feel might be unsafe. Do you have any questions before we begin? A. Side by Side Stand Now I will show you the first movement . (Demonstrate) I want you to try to stand with your feet together, side by side, for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Stand next to the participant t o help him/her into the side by side position.
94 When the participant has his/her feet together, ask Then let go and begin timing as you say, Stop the stopwatch and say after 10 seconds or when the participant steps out of position or grabs your arm. If participant is unable to hold the position for 10 seconds, record result and go to the gait speed test. Number of seconds held: __.__ __ sec B. Semi Tandem Stand Now I will show you the second movement . (Demonstrate) Now I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whic hever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Stand next to the participant to help him/her into t he semi tandem position When the participant has his/her feet together, ask Then let go and begin timing as you say Stop the stopwatch and say after 10 seconds or when the participant steps out of position or grabs your arm.
95 If participant is unable to hold the position for 10 seconds, record result and go to the gait speed test. Number of seconds held: __.__ __ sec C. Tandem Stand Now I will show you the third movement . (Demonstrate) Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Stand next to the participant to help him/her into the tandem position. Supply ju When the participant has his/her feet together, ask Then let go and begin timing as you say, Stop the stopwatch and say after 10 seconds or wh en the participant steps out of position or grabs your arm. Number of seconds held: __.__ __ sec
96 2. GAIT SPEED TEST Now I am going to observe how you normally walk. If you use a cane or other walking aid and you feel you need it to walk a short distance, then you may use it. A. First Gait Speed Test This is our walking course. I want you to walk to the other end of the course at your usual speed, just as if you were walking down the street to go to the store. Demonstrate the walk for the participant. Walk all the way past the other end of the tape before you stop. I will walk with you. Do you feel this would be safe? Have the participant stand with both feet touching the starting line. When the pa rticipant acknowledges this instruction say: Press the start/stop button to start the stopwatch as the participant begins walking. Walk behind and to the side of the participant. ly across the end line. B. Second Gait Speed Test Now I want you to repeat the walk. Remember to walk at your usual pace, and go all the way past the other end of the course. Have the participant stand with both feet touching the starting line. When I When the participant acknowledges this instruction say: Press the start/stop button to start the stopwatch as the participant begins walking. Walk behind and to the side of the participant.
97 GAIT SPEED TEST SCORING: Length of walk test course: Four meters A. Time for First Gait Speed Test (sec) Time for 4 meters : __ . __ __ sec B. Time for Second Gait Sp eed Test (sec) Time for 4 meters : __ . __ __ sec What is the time for the faster of the two walks? Record the shorter of the two times : __ . __ __ sec If only one walk done, then record that time.
98 3.CHAI R STAND TEST Single Chair Stand movement test. Do you think it would be safe for you to try to stand up from a chair without using your arms? The next test measures the strength in your legs. (Demonstrate and explain the procedure.) First, fold your arms across your chest and sit so t hat your feet are on the floor; then stand up keeping your arms folded across your chest. Please stand up keeping your arms folded across your chest. (Record result). If participant cannot rise without using arms, say ar This is the e nd of their test. Record result as > 60 seconds and go to the scoring page. Time in seconds: __. __ __ Repeated Chair Stands 1. Do you think it would be safe for you to try to stand up from a chair five times without using your arms? 2 . (Demonstrate and explain the procedure): Please stand up straight as QUICKLY as you can five times, without stopping in between. After standing up each time, sit timing you with a stopwatch. 3. When the participant is properly seated, say: and begin timing. 4. Count out loud as the participant arises each time, up to five times. 5. Stop if participant becomes tired or short of breath during repeated chair st ands. 6. Stop the stopwatch when he/she has straightened up completely for the fifth time. 7. Also stop: If participant uses his/her arms After 1 minute, if participant has not completed rises 8. If the participant stops and appears to be fatigued before completing the five stands, confirm this by asking stopwatch. Time to complete 5 Chair Stands in seconds: __.__ __
99 Scoring for Complete Short Physical Performance Battery Statistical package software will be used to assign scores for the times recorded for each test. The scoring for each test is described below. Scoring for Bal ance Tests: A. Side by side stand Held for 10 sec 1 point Not held for 10 sec 0 points Not attempted 0 points (circle reason below) If participant did not attempt test or failed, circle why: Tried but unable ( 1), Participant could not h old position unassisted ( 2),Not attempted, you felt unsafe (3 ), Not attempted, participant felt unsafe (4), Participant unable to understand instructions (5), Other (specify) _____________________________ (6), Participant refused (7) Scoring: B. Semi Tandem stand Held for 10 sec 1 point Not held for 10 sec 0 points Not attempted 0 points (circle reason below) If participant did not attempt test or failed, circle why: Tried but unable (1), Participant could not hold position unassist ed (2),Not attempted, you felt unsafe (3), Not attempted, participant felt unsafe (4), Participant unable to understand instructions (5), Other (specify) _____________________________ (6), Participant refused (7) Scoring: C. Tandem stand Held for 10 sec 2 point Held for 3 to 9.99 sec 1 point Not attempted 0 points If participant did not attempt test or failed, circle why: Tried but unable (1), Participant could not hold position unassisted (2),Not attempted, you felt unsafe (3), Not attempted, participant felt unsafe (4), Participant unable to understand instructions ( 5), Other (specify) _____________________________ (6), Participant refused (7)
100 Total Balance Test score _____ points Scoring for Gait Speed (4 meter walk): If time is more than 8.70 sec: 1 point If time is 6.21 to 8.70 sec: 2 points If time is 4.82 to 6.20 sec: 3 points If time is less than 4.82 sec: 4 points If participant did not attempt test or failed, circle why: Tried but unable (1), Participant could not walk unassisted (2),Not attempted, you felt unsafe (3), Not attempted, participant felt unsa fe (4), Participant unable to understand instructions (5), Other (specify) _____________________________ (6), Participant refused (7) Gait Speed Test score _____ points Scoring for Chair Stand: Participant unable to complete 5 chair stands or complet es stands in > 60 seconds: 0 points If chair stand time is 16.70 sec or more: 1 point If chair stand time is 13.70 to 16.69 sec: 2 points If chair stand time is 11.20 to 13.69 sec: 3 points If chair stand time is 11.19 sec or less: 4 points Chair Stan d Test score _____ points Total SPPB Score _____ points (sum of balance test, gait speed and chair stand points )
101 PRECLINICAL AND DISABILITY SCREENING TOOL Instructions Below are some questions about everyday activities that you may do in a normal week. Question 1 asks if you have difficulty with the activity. If yes , please rate how much difficulty you have on a scale from 1 (some difficulty) to 5 (extreme difficulty) Question 2 asks if you have changed how often you do the activity. Question 3 asks if you have changed how you do the task. This can mean that you do it differently (slower, move your body differently, hold onto something), use special equipment (for example, a cane or grip bar) or assistance from another person. Please answ er questions 1 3 for each of the activities. 1. Do you have any difficulty with this activity? 2. Have you changed how frequently you do this activity? 3. Have you changed how you do this activity compared to how you did it before? Activity No Yes If yes , please rate how much difficulty you have on a scale from 1 (some difficulty) to 5 (extreme difficulty) Could do for non health reasons No Yes, do it more frequently Yes, do it less frequently it any more No Yes, changed the way I do it
102 1. Do you have any difficulty with this activity? 2. Have you changed how frequently you do this activity? 3. Have you changed how you do this activity compared to how you did it before? Activity No Yes If yes , please rate how much difficulty you have on a scale from 1 (some difficulty) to 5 (extreme difficulty) Could do for non health reasons No Yes, do it more frequently Yes, do it less frequently it any more No Yes, changed the way I do it Get out of car Get out of bed Walk down flight of stairs (10 steps) Walk around home
103 1. Do you have any difficulty with this activity? 2. Have you changed how frequently you do this activity? 3. Have you changed how you do this activity compared to how you did it before? Activity No Yes If yes , please rate how much difficulty you have on a scale from 1 (some difficulty) to 5 (extreme difficulty) Could do for non health reasons No Yes, do it more frequently Yes, do it less frequently it any more No Yes, changed the way I do it Walk Â½ mile Walk Â¼ mile Climb flight of stairs (10 steps)
104 TASK MODIFICATI ON SCALE On the task modification scale (MOD) you will identify a compensatory strategy subjects use to complete a chair rise, stair ascent/descent, kneel to stand, supine to stand. The MOD scale is hierarchically arranged from No Difficulty (a score of zero) to subtle and severe compensatory modifications (score one to five). If a subject uses multiple modifications, record one with highest score. MOD: CHAIR RISE Describe: Demonstrate and say: across your chest. Test: Examiner note: If the participant is unsuccessful with their hands across their chest. Notes:______________________________________________________________________ ______________ ___________________________________________________________ _______________________________ _____________________________________________________________________________________________ __________ Examiner note: Adjust the chair to the middle height setting (38 cm seat pan) Describe Demonstrate and say: across your chest. Test: _____ Rises in a steady and controlled action _____ Stomps feet, rocks body, extends arms or elbows to thighs _____ scoots to the front of the ch air or makes multiple attempts _____ uses hands on any part of chair for assistance _____ needs investigator assistance _____ refuses to attempt the task Time to complete the task: (e.g. 5.01) _____________
105 Examiner note: If the participant is unsuccessful with their hands across their chest. Notes:_____________________________________________________________________________________ _____________________ _____________________________________________________________________ _ __ _____________________________________________________________________________________________ __________________ Examiner note: Adjust the chair to the lowest height setting (30 cm seat pan) Describe Demonstrate and say: across your chest. Test: Notes:______________________________________________________________________________ _______ _________________________________________________________________________________________ ____ ___ ___________________________________ _______________________________________________________ ______________ MOD: kneel to stand Describe Demonstrate and say e as quickly as possible with your hands _____ Rises in a steady and controlled a ction _____ Stomps feet, rocks body, extends arms or elbows to thighs _____ scoots to the front of the chair or makes multiple attempts _____ uses hands on any part of chair for assistance _____ needs investigator assistance _____ refuses to attempt the task _____ Rises in a steady and controlled action _____ Stomps feet, rocks body, extends arms or elbows to thighs _____ scoots to the front of the chair or makes mul tiple attempts _____ uses hands on any part of chair for assistance _____ needs investigator assistance _____ refuses to attempt the task Time to complete the task: (e.g. 5.01) _____________ Time to complete the task: (e.g. 5.01) _____________
106 Say If NO. Record why and move to the ne xt test. Say cannot _________________________________________________________________ If YES. Now proceed and ask the participant to kneel on their left knee. Say Te st Notes:____________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________ _________________________________________________________ ____________________________________________ Repeat on while kneeling on the right knee. Notes:_____________________________________________________________________________________ ___ _____________________________________________________________________________________________ _____ Rises from a kneeling position without the use o f hands _____ Light use of hand/s on chair or knee (no shift in body weight) _____ Forcefully uses one or two hands on the chair causing a shifting of body weight _____ Kneels to the floor but requires assistance to rise _____ Cannot kneel to the floor _____ Refuses to attempt the task Time to complete the task: (e.g. 5.01) _____________ _____ Rises from a kneeling position without the use of hands _____ Light use of hand/s on chair or knee (no shift in body weight) _____ Forcefully uses one or two hands on the chair causing a shifting of body weight _____ Kneels to the floor but requires assistance to rise _____ Cannot kneel to the floor _____ Refuses to attempt the task Time to complete the task: (e.g. 5.01) _____________
107 _____________________________________________________________________________________________ ____________________________________________ MOD: Supine to st and Describe Demonstrate and say ise from the floor to a standing position as quickly as possible. Please do not use your hands on your knee or chair unless absolutely necessary If NO. Record why and move to the next test. _________________________________________________________________ Say Test Notes:_____________________________________________________________________________________ ___________________________________________________________________________________ __________ _____________________________________________________________________________________________ ____________________________________________ ____ _ Rise in a steady and controlled action (with or without rolling to a prone position) _____ Uses one or two hands on top of thigh or lightly touches chair _____ Bear crawl two hands on floor, crawl s into upright position _____ Forcefully uses one or two hands on the chair causing a shifting of body weight; _____ Needs investigator assistance _____ Refuses to attempt the task Time to complete the task: (e.g. 5.01) _____________
108 Log of daily activity: P lease record in minutes approximately how long you did the following activities: Date Mon / / Tues / / Wed / / Thurs / / Fri / / Sat / / Sun / / Light housework (ironing, cooking or sweeping) Heavy housework (scrubbing floor, wall, or window) Vacuuming/ Mopping Climbing stairs Walking outside Walking in mall Gardening Mowing the lawn Lifting (child, packages or groceries) Taking out the trash Exercise: Walking, jogging, or running Line Dancing Other exercise? Please specify Any other activities? Please specify
109 GERIATRIC DEPRESSION SCALE SHORT FORM Instructions: Circle the answer that best describes how you felt over the past week. 1. Are you basically satisfied with your life? y es n o 2. Have you dropped many of your activities and interests? y es no 3. Do y ou feel that your life is empty? y es no 4. Do you often get bored? y es no 5. Are you in good spirits most of the time? y es no 6. Are you afraid that somethi ng bad is going to happen to you? y es no 7. Do you feel happy most of the time? y es no 8. Do you often feel helpless? y es no 9. Do you prefer to stay at home, rather than going out and doing things? y es no 10. Do you feel that you have mo re problems with memory than most? y es no 11. Do you think it is wonderful to be alive now? y es no 12. Do you feel worthless the way you are now? yes no 13. Do you feel full of energy? y es no 14. Do you feel that your situation is hopel ess? y es no 15. Do you think that most people are better off than you are? y es no
110 FALLS EFFICACY SCALE On a scale from 1 to 10, with 1 being very confident and 10 being not confident at all, how confident are you that you do the following activities without falling? Activity Score (1 10) 1. Take a bath or shower 2. Reach into cabinets or closets 3. Walk around the house 4. Prepare meals not requiring carrying heavy or hot objects 5. Get in and out of bed 6. Answer the door or telephone 7. Get in and out of a chair 8. Getting dressed and undressed 9. Personal groo ming (i.e. washing your face) 10. Getting on and off the toilet
111 PERCEIVED BENEFIT OF DANCE SCALE Scale Benefit 0 No benefit 1 Very little benefit 2 3 Beneficial 4 5 Very beneficial
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125 BIOGRAPHICAL SKETCH Crystal Gail Bennett earned he in nursing from Pensacola Junior Colle in nursing from the University of West Florida in 1997. Her initial experience was in medical surgical nursing and then critical c are nursing in Pensacola, Flor ida. She continued her educa tion and graduated with her m from the University of South Alabama in 2003 . She received her Ph.D. from the University of Florida in the summer of 2014. She began her career as a n ursing fac ulty member in 2004 teaching in the baccalaureate program at the University of West Florida in Pensacola, Florida. She currently still teaches at the University of West Florida and plans to teach undergraduate and graduate nursing courses in the future .
CLINICALSCHOLARSHIP TheEffectofPostinjuryDepressiononQualityofLifefollowing MinorInjury ThereseS.Richmond,PhD,CRNP,FAAN 1 ,WenshengGuo,PhD 2 ,TheimannAckerson,MSSW 3 , JuddHollander,MD 4 ,VicenteGracias,MD 5 ,KeithRobinson,MD 6 ,&JayAmsterdam,MD 7 1 Xi, AndreaB.LaporteProfessorofNursing,UniversityofPennsylvaniaSchoolofNursing,Philadelphia,PA,USA 2ProfessorofBiostatistics,UniversityofPennsylvaniaPerelmanSchoolofMedicine,Philadelphia,PA,USA 3ProgramAdministrator,CentreforExecutive&ProfessionalEducation,UniversityofWindsor,Windsor,Ontario,Canada 4ProfessorofEmergencyMedicine,UniversityofPennsylvaniaPerelmanSchoolofMedicine,Philadelphia,PA,USA 5ProfessorofSurgery,RobertWoodJohnsonUniversityHospital,NewBrunswick,NJ,USA 6AssociateProfessorofPhysicalMedicine&Rehabilitation,UniversityofPennsylvaniaPerelmanSchoolofMedicine,Philadelphia,PA,USA 7ProfessorofPsychiatry,UniversityofPennsylvaniaPerelmanSchoolofMedicine,Philadelphia,PA,USA Keywords Cohortstudy,depression,injuries,qualityof life,trauma Correspondence Dr.ThereseS.Richmond,Universityof Pennsylvania,SchoolofNursing,FaginHall330, 418CurieBlvd.,Philadelphia,PA19104. E-mail:firstname.lastname@example.org Accepted:November14,2013 doi:10.1111/jnu.12064 Abstract Purpose: Todescribequalityoflife(QoL)intheyearfollowingminorinjury andtotestthehypothesisthatindividualswithdepressioninthepostinjury yearexperiencelowerQoLthandoindividualswithnodepression. Design: Prospective,longitudinal,cohortdesign.Atotalof275adultswere randomlyselectedfrominjuredpatientspresentingtoanurbanemergency department. Methods: Allparticipantsunderwentstructuredpsychiatricdiagnosticinterviewsimmediatelyafterinjuryandat3,6,and12months.Theprimary outcome,QoL,wasmeasuredusingtheQualityofLifeIndex.Covariatesincludeddemographics,injurystatus,preinjuryfunctionalstatus,preinjurysocialsupport,andanticipationofproblemspostdischarge.TheGeneralEstimatingEquationwasusedtocomparechangesinQoLbetweenparticipantswith andwithoutdepressionover3,6,and12months,adjustingforcovariates. Results: An18.1%proportion(95%conÃždenceinterval[CI]13.3,22.9%) ofthesamplemetcriteriaforamooddisorderinthepostinjuryyear.The depressedgroupreportedaQoLthatwas4.2points(95%CI2.8Ã5.6)lowerin theyearpostinjurycomparedwiththatofthenondepressedgroup. Conclusions: DepressionafterminorinjurynegativelyaffectsQoLevenafull yearpostinjury. ClinicalRelevance: TheÃžndingsofthisstudyshowthatpatientswhohave injuriesthataretreatedanddischargedfromanemergencydepartmentcan havesigniÃžcantlylowerQoLintheyearafterthatinjurythatisattributed,in part,topostinjurydepression.Nursesshouldprovideanticipatoryguidanceto patientsthattheymayexperiencefeelingsofsadnessorbeing"blue,"andthat iftheydo,theyshouldseekcare. Traumaticinjuryaccountsfor1ofevery10deaths globallyandposesagrowinghealthburdeninlowandmiddle-incomecountries(Hofman,Primack,Keusch, &Hrynkow,2005;Norton&Kobusingye,2013). Mortalityalone,however,underestimatesthetremendousburdenofinjurysincethevastmajorityofinjuries arenotlifethreatening.IntheUnitedStatesin2010there were180,911deathsfrominjury,andinthesameyear therewere31,575,978nonfatalinjuries(CentersforDiseaseControl,NationalCenterforInjuryPreventionand Control,2013). Threestrategiescanreducetheglobalburdenofinjury:(a)preventinjury,(b)improvesurvival,and(c)optimizerecovery.Inroadshavebeenmadeinpreventing 116 JournalofNursingScholarship,2014;46:2,116Â…124. C 2013SigmaThetaTauInternational
Richmondetal. EffectofPost-injuryDepressiononQoL injury;forexample,reductionofdeathsfrommotorvehiclecrashesintheUnitedStatesisconsideredoneofthe top10publichealthpreventionsuccessesofthe20thcentury(CentersforDiseaseControl,1999).Advanceshave alsobeenachievedinimprovinginjurysurvival.Arobust bodyofresearchhasdemonstratedthattraumacenters andregionaltraumasystemsimprovesurvivalofthemost seriouslyinjured(MacKenzieetal.,2006).Whilethese successesareadmirable,lessprogresshasbeenmadein optimizingrecovery. Thegoalofinjuryrecoveryistohelppatientsreturntotheirpreinjurystateofhealthandqualityof life(QoL).Thisdoesnotoccur.Healthstatus,functionalstatus,andQoLhavebeenshowntofallbelowpopulationnormsfollowingmoderatetosevere injuries(Aitken,Chaboyer,Kendall,&Burmeister,2012; Ringburgetal.,2011;Ringdal,Plos,Ortenwall,&Bergbom,2010).Yetthevastmajorityofinjuriesareminor (Polinder,Haagsma,Toet,&vanBeeck,2011).Labeling aninjuryas"minor"mayverywellbeamisnomerifwe considertheimpactofinjury.Lyonsetal.(2011)found thatnonadmittedemergencydepartment(ED)injuries (e.g.,minorinjuries)accountformorethantwothirds (67%)ofyearslivedwithdisabilityafterinjury.Given thispublichealthburden,itisimportanttoexaminewhy therearesuboptimaloutcomes. Nursesandtheentirehealthcareteamarewellpositionedtooptimizerecoverybutarehamperedbythe factthattraumacareisprimarilyacutecareorientedand focusespredominatelyonthephysicalinjury.Indeed,patientsseenintheEDaretypically"treatedandstreeted," withlimitedfollow-upandpoorunderstandingofhow thesepatientsrecoveraftertheseinjuries.Recognizing thelimitationsofthesefoci,RichmondandAitken(2011) developedtheTraumaOutcomesModelasatheoretical foundationtoguideresearchandpractice.Thismodel purportsthatimportantlong-termoutcomesarephysical,functional,psychological,andQoLandemphasizes theneedtoexamineoutcomesacrosssettings.Theseoutcomesareimportanttopatientsandfamiliesandresonate withtheincreasingfocusonpatient-reportedoutcomes. Inthisstudy,wefocusonQoLasasalientoutcome intheyearafterminorinjury.MinorinjuriesaredeÃžned asinjuriesthathavenocentralnervoussysteminvolvementanddonotthreatenlossoflifeorlimb,butare ofsufÃžcientimportthatindividualsseekurgentmedical careinanED.Arecentsystematicreviewdemonstrates thatpostinjuryhealth-relatedQoLimprovedoverthe postinjuryyearbutremainedlowerthanbeforeinjury (Polinderetal.,2010).WhatislesscleariswhyQoLisreducedevenafterminorinjury,wherethephysicalnature oftheinjuryisunlikelytoaccountforthisreductionbeyondtheimmediateacuterecoveryphase.Therefore,itis importanttoexaminepossiblefactorsthatcouldaccount forreducedpostinjuryQoL. Between20%and35%ofpatientsdevelopanew psychiatricdisorderintheyearaftermoderatetosevere injury(Bryantetal.,2010),andthesedisordersnegativelyaffectreturntopreinjuryfunction(Sutherland, Suttie,Alexander,&Hutchison,2011)andreduce health-relatedQoL(Toien,Bredal,Skogstad,Myhren,& Ekeberg,2011).Thepreponderanceofresearchshows littleassociationbetweentheseverityofphysicalinjuryandtheseverityofpsychologicaldistress(Brasel, deRoon-Cassini,&Bradley,2010;Richmond,Kauder, Hinkle,&Shults,2003).Previousworkfromourteam showedthat18%ofpatientswithminorinjurydevelopedsigniÃžcantdepressioninthepostinjuryyear (Richmondetal.,2009).Thepurposeofthisstudywas todeterminethecontributionofpostinjurydepressionto QoLintheyearfollowingminortraumaticinjury. Methods Thiswasaprospective,longitudinalcohortstudyof 275adultswithminorinjurywhosoughtcareforthe injuryinanED.Thestudywasapprovedbytheuniversity'sinstitutionalreviewboard.Abriefsummary ofmethodsispresented,andadetaileddescriptionof thestudymethodologyhasbeenpreviouslypublished (Richmondetal.,2009). EligibilityCriteriaandSetting Theprimaryinclusioncriteriawereadults(age18 yearsandolder)whosustainedanacutetraumaticinjuryandwhosoughtcareinanED.AninjurywasdeÃžnedasminorbyaninjuryseverityscore(ISS)of2to 8(possiblerange1Ã75,where75isincompatiblewith life)andnormalphysiologyfollowinginjury,deÃžnedby atriage-RevisedTraumaScore(t-RTS)of12(Baker& O'Neill,1976;Championetal.,1989).TheinternationallyacceptedTraumaandInjurySeverityScore(TRISS) methodology,whichcalculatestheprobabilityofsurvival (Ps)basedonamathematicalequationofthet-RTS,ISS, andageindicatethatthePsofa35-year-oldwithatRTSof12andanISSof8wouldbe99.5%.Exclusion criteriaincludedinjuryduetosuicideattempt,intimate partnerviolenceoramedicalcondition(e.g.,pathologicalfracture),currentpsychosisormajordepression,traumaticbraininjury,orcognitivedeÃžcitthatprecludedinformedconsent.ThesettingwasanurbanEDinanacademicmedicalcenterwithalevel1traumacenterinthe northeasternUnitedStates. Instruments Primaryoutcome. TheprimaryoutcomeofQoL wasmeasuredusingtheQualityofLifeIndex-Generic JournalofNursingScholarship,2014;46:2,116Â…124. 117 C 2013SigmaThetaTauInternational
EffectofPost-injuryDepressiononQoL Richmondetal. VersionIII(QLI),aself-reportmeasureofaperson'ssatisfactionwithkeydomainsofhisorherlifeandthe self-reportedrelativeimportanceofeachofthesedomains(Ferrans&Powers,1985,1992).Thetotalscore canrangefrom0to30,withhigherscoresindicating higherQoL.Foursubscalescorescanbecalculated,and thesearehealth/functioning,social/economic,psychological/spiritual,andfamily.Internalconsistencyforthe totalQLIscorerangesfrom0.73to0.99(Universityof IllinoisatChicago,n.d.).Contentandconstructvalidity havebeenestablished(Ferrans&Powers,1985,1992). TheQLIwascompletedat3,6,and12monthsafter injury. Psychiatricdiagnosticassessment. Depressionis theprimarypredictorvariableofinterest.Depression wasdiagnosedusingacomprehensiveresearchdiagnosticinterview,theStructuredClinicalInterviewforAxis IDSM-IVDisordersÃ‘PatientEdition(SCID-I/P;AmericanPsychiatricAssociation,1994;First,Spitzer,Gibbon, &Williams,1994).Thissemi-structuredinterviewprovidedadetailedpsychiatrichistoryanddiagnosesatthe 3-monthinterview.ItwassupplementedbytheLongitudinalIntervalFollow-upEvaluation(LIFE;Kelleretal., 1987)atthe6-and12-monthinterviews.WhenparticipantsscreenedpositiveintheLIFEsemi-structuredinterview,thefulldepressionmoduleoftheSCIDwasused fordiagnosticveriÃžcation. Covariates. Demographics,injurymechanism,body systeminjured,ISS,andothersalientvariableswereadjustedinthemultivariateanalysis.Preinjuryfunctional statuswasmeasuredusingtheFunctionalStatusQuestionnaire(FSQ),whichassessedactivitiesofdailyliving, instrumentalactivitiesofdailyliving,mentalwell-being, socialactivity,andqualityofinteractionpriortoinjury (Jetteetal.,1986).Internalconsistencyrangesfrom0.77 to0.92,andcriterionandconstructvalidityhavebeen established(Cleary&Jette,2000).Eachsubscalescore istransformedto0to100.Allsubscaleswiththeexceptionofmentalwell-being(becauseofoverlapwith depression)wereincludedascovariates.Socialsupport wasmeasuredatintakebythebriefversionoftheSocial SupportQuestionnaire,ashort,reliable,andpsychometricallysoundinstrumenttomeasuresocialnetworkand satisfactionwiththesupportreceived(Sarason,Sarason, Shearin,&Pierce,1987).Socialnetworkscorescanrange from0to54andsupportscoresfrom1to6,withhigher scoresindicatingalargernetworkandhighersatisfaction. Wecollectedself-reportofthedaysaffectedbyhealth inthemonthbeforeinjury(Jetteetal.,1986).Specifically,participantswereaskedthenumberofdayslost fromwork(includingschoolandhomemanagement), numberofdaysspentinbedmorethanone-halfday, andnumberofdayswhereactivitieswerecutdownmore thanone-halfdaybecauseofhealthinthemonthbeforetheinjury.Participantswereaskedtoratesatisfactionwiththeirhealthpriortotheinjuryandwereasked iftheyanticipatedproblemsafterdischargeduetotheir injury(yes-noresponse). Procedure WhenpatientsweremedicallystableintheED,they wereaskedtoprovideverbalconsenttoreleasetheir namestotheresearchteamandtocompletetheFSQ. PatientswereaskedtorespondtotheFSQbasedon theweekpriortoinjury,providingapreinjurymeasureoffunctionalstatus,andtook10to15mintocompletethequestionnaire.Individualsweredrawnfromthis poolofeligiblepatientsusingalistofrandomnumbers thatwereweightedtoreÃŸecttheÃŸowofpatientsinthe EDandwerebasedontreatmentroomadmissiontime. Randomlyselectedpatientswerecontacted,provided studyinformation,andhadallquestionsanswered.Ifinterested,anappointmentforanin-personintakeinterviewwasmade,atwhichtimewritteninformedconsent wasobtained. Interviewswereconductedintheparticipant'shome, studyofÃžces,oramutuallyagreeablepublicplacewitha privatespace.Theintakeinterviewwasconductedwithin daystoapproximatelyaweekaftertheEDvisitand includeddemographic,injury,andcovariatedata,the psychiatricinterview(viaSCID),andtheQLItoassess theimmediatepostinjuryQoL.Thepsychiatricdiagnosticinterviewtook1to2hrtocompleteandwasconductedbyamaster's-preparedsocialworkerwhohad beentrainedindiagnosticinterviewsunderthedirection ofthestudypsychiatrist(J.A.).Atfollow-up,theQoLwas measuredaskingparticipantstoconsidertheirQoLduringthemonthimmediatelypriortothestudyvisitand took5to10mintocomplete.Patientswereprovided thankyouincentivesof$30,$30,$30,and$60forthe intake,3-,6-,and12-monthvisits,respectively. StatisticalMethods Studypowerwasbasedontheassumptionthat15% ofparticipantswouldhavepostinjurydepression.This wasaconservativeassumptionbasedonastudyofsurvivorstreatedforinjuryinEDsinIsrael(Shalevetal., 1998).FortheGeneralEstimatingEquation(GEE)analysestherewas80%power,with a = 0.05todetectan effectsizeof0.49standarddeviation( SD )inQoLby12 monthsbetweenparticipantswithandwithoutdepression(Diggle,Liang,&Zeger,1994). t tests,analysisof variance,chisquare,andFisher'sexacttestswereused tocompareparticipantswhocompletedthestudyand thosewhowerelosttofollow-up.Frequencieswith95% 118 JournalofNursingScholarship,2014;46:2,116Â…124. C 2013SigmaThetaTauInternational
Richmondetal. EffectofPost-injuryDepressiononQoL conÃždenceintervals(95%CIs)describedtheproportion ofparticipantsdiagnosedwithadepression.Meansand SDsforQLIwerecalculatedforthedepressedandnondepressedgroupsandwerecomparedusing t tests.The QLIscoresweresufÃžcientlynormallydistributedtouse therawscoreasthedependentvariable. WetestedthehypothesisthatindividualswithdepressioninthepostinjuryyearwouldhavelowerQoLthan thosewithoutdepression.Individualswerecodedinthe depressedgroupifthediagnosiswasmadepostinjury.Regardlessofwhetherthedepressionresolved,theindividualremainedcodedasdepressedfortheremainderof theanalyses.Injuryisanunexpectedevent;hence,we didnothaveapreinjurymeasureofQoLandusedthe rawQLItotalscoreasthedependentvariable.Because theQLIsubscalescoresreÃŸectthesamepatternsand magnitudesofdifferencebetweendepressedandnondepressedindividuals,wereportonlytheQLItotalscore. TheGEEwasusedtocomparechangesinQLItotalscores betweenparticipantswithandwithoutdepressionacross time(3,6,and12months),whileadjustingforcovariates (demographics,injuryintent,injurymechanism,satisfactionwithsocialnetwork,preinjuryfunctionalstatus,and preinjuryworkstatus). Results SampleDescription Thesamplehasbeenpreviouslydescribed(Richmond etal.,2009),andweprovideabriefsummaryofthe275 individualswhoconsentedtoparticipate.Fifty-twopercentofthesampleweremen.Themeanagewas40.4 years(SD16.8)and25.8%weremarried.Blackscomprised57%ofthesample,withtheremainderWhites (40%)andAsians(3%).Themajoritygraduatedhigh school(averageof13.7yearsofeducation).Seventy-one percentwereemployed.Themajority(45.1%)reported anannualincomebetween$20,000and$59,999,with 32.1%reportinglessthan$20,000andtheremainderreportinganincomeexceeding$60,000. Injurieswerepredominatelyunintentional(91%)and duetoslipsorfalls(48%),motorvehicle-pedestrian-bike crashes(28.7%),sports(8.4%),andassaults(8%).The majorityofparticipantshadanextremityfracture(63%). ThemeanISSfortheentiresamplewas4.1( SD 1.12), reÃŸectingminorinjury.Preinjuryfunctionasmeasured bytheFSQrangedfromalowscoreof79.4( SD 17.1) formentalwell-beingtoahighscoreof96.8( SD 10.5) foractivitiesofdailyliving.Themeansocialnetwork scorewas22.1( SD 12.4),withthescoreforhighlevels ofsatisfaction5.73( SD 0.56).Preinjurysatisfactionwith healthrangedfrom verydissatisÃžed (2.9%)to verysatisÃžed (33.2%).Participantsreportedanaverageof1.13days ( SD 3.2)ofreducedactivitiesduetohealthinthemonth beforetheinjury.Immediatelyafterinjury,44%ofparticipantsreportedtheyanticipatedproblemsreturningto theirnormalactivities. Twohundredandforty-eightparticipants(90%)were retained,althoughsomemissedoneofthethreefollowupvisits(240at3months,235at6months,and238 at12months).Participantslosttofollow-upweremore likelytobemen,tobeinjuredviamotorvehiclecrashes, tohavealesssevereinjury,andtohaveameanof1.5 yearslesseducationthanthosewhocompletedthestudy ( p < .05).Forty-Ãžveparticipants(18%;95%CI13.3, 22.9%)werediagnosedwithamooddisorderinthe postinjuryyear(Richmondetal.,2009). MajorFindings Thedepressedandnondepressedgroupswerecomparedateachtimepoint(3,6,and12months)without controllingforanycovariates.Atalltimepoints,theQLI scorewas3.4to5.5pointslowerinthedepressedgroup thaninthenondepressedgroup( Table1 ).DepressionaffectedallsubscalesoftheQLIsimilarly( Figure1 ).Thus, ourmultivariateanalysisusedthetotalQLIscoreasthe primaryoutcome. Inthemultivariatemodel( Table2 ),controllingforall othercovariates,theQLIwas4.2pointslowerinparticipantswithpostinjurydepression(95%CI2.79Ã5.62)as comparedtothosewithoutdepression.Othercovariates signiÃžcantlycontributingtolowerQoLweredissatisfactionwithpreinjuryhealth,fewerpeopleinthesocialnetwork,anticipatingproblemsafterhospitaldischarge,and havingmoredaysofactivitiesreducedduetohealthin themonthbeforeinjury.Theoveralltimetrendispositive,attherateof0.16permonth,indicatingthatthe QoLimprovedovertime,butQoLforthedepressedgroup andnondepressedgroupneverequalized,evenafullyear post-injury.Wetestedtheinteractionbetweendepressionandtime,andthisinteractionwasnotsigniÃžcant. Table1. ComparisonofDepressedandNondepressedPatientsonQualityofLifeIndex(QLI)Scoresat3,6,and12MonthsPostinjury DepressedNondepressed Variablemean( SD )mean( SD ) 3mo, n = 303mo, n = 210 6mo, n = 426mo, n = 189 12mo, n = 4512mo, n = 190 TotalQLIscore 3mo17.2(5.44) 23.4(4.41) 6mo16.8(5.97) 24.7(6.31) 12mo18.1(5.35) 24.1(4.13) HigherQLIscoresreÂ”ecthigherlevelsofqualityoflife.SigniÂ“cance: p < .001. JournalofNursingScholarship,2014;46:2,116Â…124. 119 C 2013SigmaThetaTauInternational
EffectofPost-injuryDepressiononQoL Richmondetal. QLI Health & Functioning 0 5 10 15 20 25 30 2 Weeks3 Months6 Months12 Months p<.001p<.001p<.001p<.001 QLI Psychological/Spiritual 0 5 10 15 20 25 30 2 Weeks3 Months6 Months12 Months p<.001p<.001p<.001p<.001 QLI Family 0 5 10 15 20 25 30 2 Weeks3 Months6 Months12 Months p<.001p<.001p<.001p<.001 QLI Total 0 5 10 15 20 25 30 2 Weeks3 Months6 Months12 Months p<.001 p<.001 p<.001p<.001 Figure1. MeanQualityofLifeIndex(QLI)scoresinthepostinjuryyear.Thedepressedgroupisrepresentedbythesolidlineandnondepressedgroupis representedbythedashedline.(Errorbarsshowtwotimesthestandarderror.) Discussion OurÃžndingsindicatethatdepressionisthemajorcontributortoreducedQoLintheyearfollowingminorinjury.QoLscoresofthedepressedgroupslowlyincreased inthepostinjuryyear;however,atalltimepoints,the meanQoLscorewassigniÃžcantlylowerinparticipants withdepressionthaninthosewithoutdepression.Importantly,type,mechanism,andseverityofphysicalinjury werenotsigniÃžcantlyassociatedwithQoLinthepostinjuryyear.ThisÃžndingisconsistentwitharecentreport ofmoreseriouslyinjuredpatients,whichshowedposttraumaticstressanddepressionnegativelyaffectsQoLbut severityofphysicalinjurydoesnot(Moergeli,Wittmann, &Schnyder,2012).Giventhat1in10adultsinthe UnitedStatesseekscareinanEDforinjuryandthat18% ofoursamplewerediagnosedwithdepressionafterinjury,thisÃžndinghassigniÃžcantimplicationsforthepublic'shealth. Inthisstudy,ourprimaryoutcomewaspatientreportedQoL.TherearevaryingwaysofmeasuringQoL, andmanystudieshaveusedmeasuresthatfocusonphysicalandmentaldimensionsofhealth(e.g.,Wang,Tsay,& Bond,2005).Inparticular,somestudiesmeasureQoLusingtheSR-36,whichisvalid,reliable,andwidelyused. However,theSF-36couldarguablybesaidtomoredirectlymeasurehealthstatusorfunctionalstatusrather thanQoL.Inthisstudy,weapproachQoLasamultidimensionalconcept.Severalresearchersrecommend takingintoaccountnotonlythedegreetowhicheach dimensionofQoLismet,butalsohowimportanteach dimensionistotheindividual(e.g.,weightingofthe contributiontowell-being;Costanzaetal.,2007).Our approachtoassessingQoLinawaythatmeasuressatisfactionwithkeydimensionsofone'slifeandtakesinto accounttheimportanceofeachtotheindividualcontributestoourunderstandingofQoLafterminorinjury (Ferrans&Powers,1985,1992). QoLisreducedaftermoderatetosevereinjury(Gross, Attenberger,Huegli,&Amsler,2010;Overgaard,Hoyer, &Christensen,2011)andafterspeciÃžcinjurytypessuch asbraininjury(Gross,Schuepp,Attenberger,Pargger, &Amsler,2012;Steeletal.,2010),pelvicringinjuries (Borg,Berg,Fugi-Meyer,&Larsson,2010),orinjuries 120 JournalofNursingScholarship,2014;46:2,116Â…124. C 2013SigmaThetaTauInternational
Richmondetal. EffectofPost-injuryDepressiononQoL Table2. MultivariateGeneralEstimatingEquationModelofQualityofLife IndexScoresintheYearFollowingInjury BetaStandard95%ConÂ“dence Variableestimateerrorinterval Depression Yes ÂŠ 4.20720.7225 ÂŠ 2.7910, ÂŠ 5.6234 c No(ref) Time0.01610.00610.0041,0.0280 a Anticipateproblems afterdischarge No1.73770.44590.8638,2.6117 c Yes(ref) Satisfactionwith pre-injuryhealth VerydissatisÂ“ed ÂŠ 4.45531.4493 ÂŠ 7.2960, ÂŠ 1.6147 a DissatisÂ“ed ÂŠ 6.10671.1183 ÂŠ 8.2986, ÂŠ 3.9148 c Notsure ÂŠ 4.1250.8662 ÂŠ 5.8262, ÂŠ 2.4308 c VerysatisÂ“ed(ref) No.ofdayswhere activitieswerecut downbecauseof healthinthemonth beforeinjury 0.26500.08390.1005,0.4295 b Socialnetwork1.67390.46840.7559,2.5919 b Note. ReferentGroup = . a p < .01, b p < .001, c p < .0001. requiringadelayedabdominalclosure(Zarzauretal., 2011).However,ourÃžndingssuggestthatindividuals experienceproblemsevenafterminorinjury(Langley, Derrett,Davie,Ameratunga,&Wyeth,2011;Richmond etal.,2009).Thequestioniswhy.TheÃžndingsofthis studyaddtotheunderstandingoftheinteractionofphysicalinjuryandpsychologicalconsequencesonanimportantpatient-centeredoutcomesuchasQoL. TherehasbeensigniÃžcantgrowthinresearchdocumentingthepsychologicalconsequencesofinjury,and studieshavepredominatelyfocusedonposttraumatic stressdisorder(Aitken,Chaboyer,Shuetz,Joyce,& Macfarlane,2012)althoughincreasinglyondepression (Orweliusetal.,2012).Linkingthesepsychologicalconsequencestolong-termchangesinQoLhasbeenless forthcoming.Severalstudiesreportinverseassociations betweenposttraumaticstresssymptomsandQoLacross allseveritiesofphysicalinjury(Haagsmaetal.,2012) andafterminortraumaticbraininjury(vanVeldhoven etal.,2011).Thesestudies,however,donotexaminethe contributionofpostinjurydepressiontoQoLafterminor injury.Ourstudyilluminatesboththeprevalenceofdepressionafterevenminorphysicalinjuryanditsimpact onpostinjuryQoLcontrollingformanyothervariables thatcouldpotentiallyaffectQoL. Depressionusuallydoesnotemergeuntilpatientsare dischargedfromthehospital,atwhichpointsymptoms canbeignored,notrecognizedordiagnosed,andnot treated(Richmond,etal.,2000).Individualswithminor injurywhoareseenanddischargedfromtheEDwiththe expectationofrapidresumptionofpreinjuryrolesand responsibilitiesmaybeatparticularriskforhavingdepressiongounrecognized.Severalscreenersdesignedto predictthefuturedevelopmentofdepressionorposttraumaticstressdisorderbasedonashortassessmentpriorto dischargehavebeendevelopedwithgoodsensitivityand speciÃžcity(Masonetal.,2009;O'Donnelletal.,2008; Richmondetal.,2011).Couplingtheuseofpredictive screeningtonarrowthegroupatriskforpsychological consequenceswiththeuseofearlytreatment(Zatzick etal.,2013)hasthepotentialtosigniÃžcantlyimprove QoLafterinjury. Themajorstrengthofthisstudyistheprospective,cohort,longitudinaldesign,whichallowedustoexamine theemergenceofdepressioninthepostinjuryyear.The useofarandomselectionprocesstoidentifypotential participantsfromthepopulationofminorinjurypatients seenintheEDandtheexcellentretentionrateoverthe 12monthsaddstothecredibilityofthestudy. SeveralcaveatsshouldalsobeconsideredwheninterpretingtheÃžndings.TheunexpectednatureoftraumaticinjuryprecludedourabilitytoobtainpreinjuryQoL measures.Nonetheless,theconsistentreductioninQoL inthedepressedgroupovertimesupportstheimportanceofaddressingthepsychologicalaswellasphysicalaspectsofinjury.ItispossibletherecouldbealternativeexplanationsforthereducedQoL.Wedidnotassess paininourstudy.Painhasbeenshowntobepresentin asubsetoftraumapatientspostinjury(Black,Herbison, Lyons,Polinder,&Derrett,2011;Gross&Amsler,2011; Treviono,Essig,deRoon-Cassini,&Brasel,2012)and couldcontributetoreducedQoLandwarrantsexaminationinfuturestudies. ConclusionsandClinicalImplications DepressionafterminorinjurynegativelyaffectsQoL evenafullyearpostinjury.Depressionhasbeenshown toemergeaftermoderatetosevereinjuriesandaftercentralnervoussysteminjuriesandhasbeenshowntoreducepostinjuryQoL.TheÃžndingsfromthisstudyshow thatevenafterminorinjury,depressionemergestothe detrimentofQoL.Itisthereforeprudentforcliniciansto provideanticipatoryguidancetopatientsthattheymay experiencefeelingsofsadnessorbeing"blue,"andthat iftheydo,theyshouldseekcare.AspredictivescreenersbecomemorereÃžned,systemsofcarecouldbedevelopedthatallowsimplefollow-upphonecallstopatients inhigh-riskcategoriestoperformascreenwithintheÃžrst monthortwoafterinjurytodetermineifdepressionhas emergedandtoreferpatientsforfollow-upcare. JournalofNursingScholarship,2014;46:2,116Â…124. 121 C 2013SigmaThetaTauInternational
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