Transcript Maryland OAIC Overview - Claude D Pepper Older Americans

University of Maryland
Older Americans Independence Center
OAIC Overview
July 19,2013
PIs: Andrew Goldberg, MD
Jay Magaziner, PhD, MS Hyg
University of Maryland Claude D. Pepper
Older Americans Independence Center
Mission:
Cardiovascular and neuromotor deconditioning are
fundamental to the functional impairments and
disabilities observed in older people with chronic
disease. The goals of the UM-OAIC are to determine the
mechanisms and efficacy of motor learning-based
exercise rehabilitation programs designed to restore and
maintain function and the prevent the functional declines
that put older adults with chronic disease at risk for
disability.
Partnerships
Division of Gerontology &
Geriatric Medicine
VA Geriatric Research,
Education, & Clinical
Center (GRECC)
Kernan Orthopedics and
Rehabilitation Hospital
VA Geriatrics Service
Division of Endocrinology,
Diabetes & Nutrition
VA Rehabilitation & Development
Center of Excellence in Exercise &
Robotics for Neurological
Disorders (MERCE)
Department of Neurology
Geriatrics & Gerontology,
Education & Research Program
Center for Research on Aging
Multiple Sclerosis Center of Excellence
University of
Maryland,
Baltimore
Baltimore
VA Medical
Center
Loch Raven Community
Living Center
Nutrition Obesity Research Center
Department of Physical Therapy
and Rehabilitation Science
Department of Epidemiology &
Public Health
Mental Health Service MIRECC
University of Maryland
Claude D. Pepper
Older American
Independence Center
Regional Medical Education Center
(RMEC)
Chesapeake Health
Education Program (CHEP)
UNIVERSITY OF MARYLAND CLAUDE D. PEPPER OLDER AMERICANS
INDEPENDENCE CENTER
Principal Investigator: Andrew P. Goldberg, MD
External Advisory Board
Leadership/Administration Core
A. Goldberg, MD, Leader / J. Magaziner, PhD, MS Hyg, Co-Leader
Data Safety Monitoring Boards
· Full Committee · Subcommittee
Administration and Program Management
K. Longo, MS
A. Sullens, MA
Publications Committee
Research Cores
RC-1: Biostatistics, Informatics
and Translational Research
Core Leaders:
J. Sorkin, MD, PhD
J. Magaziner, PhD, MSHyg
RC-2: Applied
Physiology and Tissue
Mechanisms
Core Leaders:
A. Ryan, PhD
L. Katzel, MD, PhD
RC-3: Mobility Function and
Neuromotor Plasticity
Core Leaders:
R. Macko, MD
M. Rogers, PhD, PT
Research Career
Development Core
Core Leaders:
A. Goldberg, MD
J. Magaziner, PhD, MSHyg
Pilot/Exploratory
Studies Core
Core Leaders:
M. Rodgers, PhD, PT
A. Goldberg, MD
Conceptual Model of the UM-OAIC
Aging
Chronic
Disease
Preventive and Restorative Research in Chronic Diseases
of Aging Interdisciplinary Conceptual Model
Clinical
Phenotypes
Pathophysiology
& Mechanisms of
Functional
Impairments
Exercise &
Neuromotor
Learning
Rehabilitation
Functional
Outcomes and
Translation into
the Community
Acute
Event
Research
Working Groups
(RC-1)
Functional
Recovery
Improved
Quality
of Life
“Free-Living”
Independence
Clinical Evaluation
(RC-2)
Mechanisms
(RC-2,3)
Interventions
(RC-2,3)
Preventive
& Restorative
Lifestyle Habits
• Community Trials
• “Real World” Outcomes
• Medical Practice
RC1: Biostatistics, Informatics & Translational Research
Specific Aims:
• To provide biostatistical and informatics support to
investigators,
• Foster the design of motor learning-based exercise
rehabilitation interventions
• Facilitate the translation of interventions from the
laboratory to the clinic and the community
• Organize Research Working Groups (RWGs) that will
assist OAIC investigators in the design and conduct
of research studies
RC-1 Research
RO1: Community Ambulation Following Hip Fracture
(3 clinical sites)
• Primary Aim: To determine if a “specific” 16-week
multi-modal intervention based on aerobic
conditioning, specificity of training, and muscle
overload initiated 2-3 months post fracture is more
successful in producing community ambulators than a
“non-specific” multi-modal control intervention of
transcutaneous electrical nerve stimulation, flexibility
activities, and active range of motion exercises.
R37: Effects of Multi-Modal Exercise Intervention
Post Hip Fracture
• This is an ancillary study to the Phase III RO1
randomized clinical trial, with specific aims to
evaluate mechanisms underlying community
ambulation: body composition, bone turnover,
hormone regulation, aerobic capacity, balance, gait,
inflammation, affect, and cognition.
RC 2: Applied Physiology and Tissue Mechanisms
Specific Aims:
• Facilitate the conduct of musculoskeletal and tissue mechanistic
exercise rehabilitation and preventive medical research in aging and
disability across the UM-OAIC projects
– Perform medical assessments and cardiovascular screening of
research volunteers to ensure patient safety and eligibility for
research protocols.
– Develop and test of novel exercise-based interventions in older
volunteers in UM-OAIC research.
• Conduct clinical applied training in translational research and the
assessment of cardiovascular and physiological outcomes of exercise
rehabilitation in aging and laboratory training of standardized core
methodologies to facilitate translational research.
• Provide study support, mentor and train UM-OAIC researchers in the
performance of applied exercise physiology and tissue mechanisms
research relevant to exercise–based rehabilitation in older people with
chronic disabling diseases
Stroke. 2013: In Press
Subjects
•Men and women (n=10)
•50-76 years
Lower Body RT
•3x/week
•12 weeks
1RM Strength
•22% ↑ Leg press
•45% ↑ Leg extension
Insulin Sensitivity
•No change in M
•M/I ↑31%
Stroke. 2011: 42(2):416-420
RT Reduces Muscle Myostatin mRNA
Muscle Hypertrophy after RT
M u scle V o lu m e
2100
Myostatin
16%
250
* 40%
*
3
V o lu m e (c m )
1700
14%
†
1500
Pre
1300
Pos t
1100
900
700
Arbitrary Units (au)
1900
200
150
49%
*
27%
100
Post
50
500
P a re tic
N o n -P a re tic
Pre
0
Paretic
Non-Paretic
RC 3: Mobility and Neuromotor Plasticity
Specific Aims
• Provide expertise and investigator resources to assess
the multi-system neuromotor, biomechanical, motor
learning and behavioral factors affecting mobility
performance.
• Design and conduct of novel motor learning based
exercise interventions:
– Determine the quantitative measures of whole-body
multi-segmental neuromotor control
– Understanding the mechanisms of exercise-mediated
neuroplasticity of balance, locomotion, and upper
limb activities in older people with chronic diseases.
• Mentor junior faculty and train UM-OAIC investigators in
the mechanistic study of neuromotor control, exercisemediated neuroplasticity and motor learning.
RO1: Intervention to Enhance Lateral Balance Function
& Prevent Falls in Aging
Specific Aims
• To determine the effects of (a) step training, (b) hip abductoradductor (AB-AD) muscle strengthening, and (c) a combined step
training & muscle strengthening program compared to (d) a
standard flexibility & relaxation program (control) on the stepping
response characteristics to an external balance perturbation.
•
To determine the effect of step training, with and without the
strengthening intervention, compared to the control group on
maximum hip AB-AD joint torque and power.
Secondary aim is to determine the prospective fall frequency of the
different intervention groups during monthly follow-up for 1-year
post-training.
Robotics Training after Stroke
Mission and Long-term Objectives:
Develop and deploy state-of-the-art modular lower
extremity robotic technology to improve walking and
balance function and promote durable benefits
toward mobility independence in older individuals
with stroke and other neurologic diseases.
Deficit-adjusted Robotics Training after Stroke
 Deficit-adjusted robotic assistance
 Terminal stance: push-off for propulsion
 Swing: drop foot and safe landing
 Level of robotic assistance
 Biomechanical models specific to deficit
 Capacity to predict optimal robotic support
Can a deficit-adjusted approach
reduce drop foot and/or
increase push off propulsion in
chronic hemiparetic stroke?
Robotics Training Eliminates Foot Drop in Chronic Stroke
FREE WALKING TRIALS
Peak Swing Angle
(deg)
13
PRE: 2.5
deg
10
8
RETN: 8
deg
5
3
0
0
5
10
15
6
weeks 20
Training visit
Gait Speed (cm/s)
100
82
76
80
COMMUNITY
AMBULATOR
60
47
40
20
0
PRE
POST
RETN
Patient reported discarding
use of her assistive ankle
brace at home-community at
6-week follow-up and beyond
Improvement in Standing Balance: Better Dynamic
Inter-limb Weight Transfer -> Reduced Fall Risk
PRE
DORSAL VIEW OF
POSTURAL SWAY
POST
Anterior-Posterior Center of Pressure (m)
95% confidence
ellipse
Raw time series
Δ Variability of Sway = -50%
Medial-Lateral Center of Pressure (m)
Medial-Lateral Center of Pressure (m)
Selected On-going Trials
PI
Trial
Population
J. Magaziner, PhD, MS Hyg/ R. Craik, PhD, PT
Community Ambulation Following Hip Fracture
(RC 1, 2, 3)
Hip Fracture
M. Stuart, PhD/ R. Macko, MD
Adaptive Physical Activity for Chronic Stroke
(RC 1)
Chronic Stroke Survivors
A. Ryan, PhD/ C. Hafer- Macko, MD
Aging, Inflammation and Exercise in Chronic
Stroke (RC 1, 2, 3,)
Chronic Stroke Survivors
M. Rogers, PhD, PT, FAPTA
Intervention to Enhance Lateral Balance
Function and Prevent Falls in Aging (RC 2,3)
Older Adults with and without a
Recent Fall
L. Forrester, PhD
Ankle Robotic Training after Stroke: Effects on
Gait and Balance (RC 2, 3)
Chronic Stroke Survivors
S. Prior, PhD
Aerobic Exercise (AEX) to Improve Regulation
of Endothelial Progenitor Cells (EPCs) and
Vascular Function in Older Adults with T2DM
(RC 1, 2)
Type 2 Diabetes Mellitus
R. Macko, MD; T. Forrester, MD
Early Exercise to Improve Muscle and
Cardiometabolic Health After Stroke (RC 3)
Acute Stroke Survivors
S. Seliger, MD, MS; D. Weiner, MD, MS, co-PI
Randomized Trial of Exercise Training on
Cognitive and Physical Function in CKD (RC 1,
2, 3)
Chronic Kidney Disease
Recently Funded Trials
Investigator
Grant Title
S. Prior
Paul B. Beeson Patient-Oriented Research CDA in Aging (K23):
Effects of Aerobic Exercise on EPCs and Vascular Dysfunction
in Aging and T2DM
K. Oursler/
A. Ryan
VA Merit: Effect of Exercise Training on Inflammation and
Function in HIV infected Veterans
M. Serra
CDA: Treadmill Rehabilitation, Energy Utilization, and Oxidative
Stress in Stroke
J. Russell
VA RR&D Merit: Improving Autonomic Function and Balance in
Diabetic Neuropathy
UM-OAIC Research Career Development Core
Goals:
Provide an enriched, mentor-based research training and
educational environment to:
• Promote the career development of junior faculty
toward independence as investigators in aging-related
research related to the UM-OAIC themes.
• Train future leaders in academic gerontology and
geriatric medicine.
• Support the training of trainees and junior faculty
pursuing research careers in aging by emphasizing
multidisciplinary training to learn novel approaches to
improving function and independence in older people.
Current RCDC Jr. Scholars
•
Douglas Savin, PhD, PT (mentors - Drs. Rogers, Wittenberg and Whitall)
3rd year RCDC Jr. Scholar
“Comparison of Reactive Step Training and Voluntary Task-Oriented
Training to Induce Neuromotor Changes for Improving Balance and
Preventing Falls”
Pilot Funding 07/2012
•
Avellino Verceles MD (mentors - Drs. Goldberg, Terrin, and Hasday)
3rd year RCDC Jr. Scholar
“Development of a Multimodality Strengthening and Mobility Program
for Ventilator Dependent Older Patients”
Pilot Funding 07/2012
•
Michael Dimyan, M.D. (mentors - Drs. Wittenberg, Macko)
2nd year RCDC Jr. Scholar
“Investigating Brain Network Interactions in Stroke and Aging Using
Concurrent Transcranial Magnetic Stimulation and Functional Magnetic
Resonance Imaging (TMS-fMRI). Goal is to investigate key brain motor
network determinants of movement using concurrent TMS-fMRI”
RCDC Jr. Scholars in the Pipeline
Junior faculty at UMB and JHU interested in RCDC
Scholar positions:
• Laura Buchanan, MD
(Trauma Surgery UM – Acute rehabilitation post
abdominal surgery)
• Sandra Quezada, MD, MS
(Gastroenterologist UM- inflammatory bowel disease)
• Gautam Ramani, MD
(Cardiologist UM-rehabilitation in heart failure patients)
• Monica Serra, PhD, RD
(Exercise physiologist UM- exercise-rehabilitation,
metabolism and nutrition in obesity, breast cancer and
stroke survivors)
Pilot/Exploratory Studies Core (PESC)
Goal of the PESC:
To provide start-up support for high quality pilot and
exploratory research to acquire information needed to
select or design future crucial studies of the
mechanisms underlying disability, recovery and
prevention in older persons and the functional and
clinical responses to rehabilitation.
2012 Pilots
• Robert Creath, PhD (mentor – Dr. Rogers)
“Using Self-triggered, Sensory-enhanced Gaze Shift to
Improve Axial Turning Deficits in Persons with Parkinson’s
disease.”
• Avelino Verceles, MD & Chris Wells, PhD, PT, CCS, ATC
(mentor – Dr. Goldberg)
“Development of a Rehabilitation Strengthening and Mobility
Program for Ventilator Dependent Older Patients.”
• Douglas Savin, PhD, PT (mentor – Dr. Rogers)
“Comparison of Reactive Step Training & Voluntary TaskOriented Training to Induce Neuromotor Changes for
Improving Balance & Preventing Falls.”
• Kelly Westlake, PhD, PT (mentor – Dr. Rogers)
“Probing the Neural Basis & Influence of Cognitive Changes
on Impaired Balance in Older Adults.”
2013 Pilots
• L. Buchanan, MD (mentor – Dr. Magaziner)
“Using Rehabilitation and Exercise to Improve Outcome of
Older Amercians in the Setting of Emergency Surgical
Disease.”
• S. Kesmodel, MD & M. Serra PhD (mentor – Dr. Goldberg)
“Effects of a Structured Exercise Program on Functional
and Metabolic Declines in Postmenopausal Breast Cancer
Patients Taking Aromatase Inhibitors.”
• D. Loane, PhD (mentor – Dr. Faden)
“The Effect of Voluntary Exercise on Microglial Activation
Phenotypes and Repair Processes in the Aged Injured
Brain.”
• N. Steinle, MDH. & Resnick, PhD , MPH (mentor – Dr.
Goldberg) “YMCA-Veterans Wellness Program: Pilot Study
of a Novel Approach to Weight Loss and Disability
Prevention in Older, Overweight Veterans.”
Selected Community-Based Programs/Dissemination
• Exercise rehabilitation programs for stroke survivors are now
based at the Baltimore VA, three senior centers in Howard
County, the Loch Raven VA and Kernan Hospital. A
collaboration is developing with the Baltimore City Department of
Aging senior centers.(Richard Macko, MD)
• Myerberg Senior Center is the site of a growing, multi-faceted
collaboration with the Center for Research on Aging and a falls
prevention research project. (Mark W. Rogers, Ph.D., P.T.)
• Weinberg Place is the site of an exercise research and nutrition
study, a collaboration between Weinberg Senior Living and
School of Nursing investigators. (Barbara Resnick, Ph.D.,
Kathleen Michael, Ph.D., RN).
• The Program in Aging, Trauma, and Emergency Care (PATEC) is
collaborating with clinical researchers in the OAIC to develop
programs for early rehabilitation of older trauma patients and
investigate neural mechanisms underlying brain injury to
improve outcomes in older trauma patients. (Jay Magaziner,
PhD, MS Hyg)