A Longitudinal Theory-Based Investigation of how Environmental Aesthetics predicts Home-based Exercise

INTRODUCTION

Environmental aesthetics is a recognized macro environmental correlate of physical activity participation. Extrapolating this effect, we hypothesize this variable to also function as a determinant of exercise participation in the microenvironment, such as the home. Specifically, we predict that the environmental aesthetics of the location of cardio and resistance training equipment will predict determinants of exercise participation within the Integrated Behavior Change (IBC) model.

METHODS

Adult owners of exercise equipment (N = 231) completed measures on the environmental aesthetics of their cardio and resistance training equipment, exercise time, and constructs from the IBC model across three consecutive monthly surveys. Study hypotheses were tested using multilevel structural equation modeling with participants (level 2) nested within time (level 1).

RESULTS

The model revealed predictive effects of intention, habit, and planning on exercise participation over time. The findings indicated a total effect of autonomous motivation on intention and habit. In addition, environmental aesthetics of cardio and strength training equipment predicted autonomous motivation, along with habit and intention when accounting for indirect effects. Finally, planning moderated the intention-behavior relationship, indicating that participants who scored higher on planning were more likely to translate their intentions to behavior.

CONCLUSIONS

These findings provide informative notes for designing effective home-based exercise programs, which have increased in popularity over the past recent years. Specifically, experimental studies that provide exercise equipment should ensure that the location of the equipment is appealing to the participant to increase the likelihood equipment use and exercise engagement.

Massage Therapy as a Self-Management Strategy for Musculoskeletal Pain and Chronic Conditions: A Systematic Review of Feasibility and Scope

Background: Musculoskeletal pain and chronic conditions are associated with deteriorating pain, stress, anxiety, and health-related quality of life (HR-QOL). There is emerging evidence that performing massage therapy as self-management (MTSM) is a viable approach to alleviate these symptoms across various clinical populations. However, a significant gap remains on the effectiveness and limitation of MTSM usage as no systematic review has been conducted to comprehensively evaluate and synthesize the scope, feasibility, and efficacy of MTSM. This systematic review aimed to investigate the effect of MTSM on common symptoms of musculoskeletal and chronic conditions, followed by identifying characteristics of MTSM dosage, setting, and adherence for formulating themes. Methods: A systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, which involved searching seven electronic databases, including Medline (OVID), CINAHL (EBSCO), PEDro, Web of Science (Clarivate), PsycINFO (EBSCO), Google Scholar, and EMBASE (Elsevier) from inception to January 2023. Clinical studies were eligible if they included MTSM, and massage treatment was more than 50% of the intervention. The quality of studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. Target variables were extracted, including study design, participants' characteristics, outcome measures, massage dosage (duration, frequency, and timing), training setting, provider of massage training, adherence to the MTSM intervention, comparator, and key findings. Results: A total of 17 studies were evaluated and included 770 participants (female: N = 606) with musculoskeletal pain or chronic conditions. The emerged themes for MTSM utilization consisted of arthritis pain (knee, n = 3; neck, n = 1, hand, n = 2), neck and back pain (n = 4), and stress and anxiety (n = 3). Prescribed self-administered massage duration ranged from a single session to a maximum of 8-12 weeks, where 4 weeks (n = 8) was the most commonly prescribed duration. Out of 11 studies that used MTSM as a solo modality, 7 studies (41.2%) showed significant improvement in the outcome measures such as chronic neck and back pain, stress or anxiety, fatigue, quality of sleep, and HR-QOL. In addition, health benefits, including anxiety, depression, pain intensity, and pain threshold, were observed in six studies (35.3%) where MTSM was applied as a coadjuvant modality, which was combined with therapist-applied massage and physiotherapy. Conclusions: These findings support that MTSM is a viable approach to enhance the benefit of therapist-applied massage or as a solo modality for symptom management of musculoskeletal pain and chronic conditions. The review provides suggestions for design improvement, such as reporting participants' adherence to the prescribed massage regimen, that would be informative for providing a robust understanding of the magnitude or the extent to which MTSM is effective. Future studies on MTSM intervention are encouraged to use a theoretical framework and validated measures for determining and facilitating treatment fidelity.

Identifying behavioral determinants and stage of readiness for performing knee massage among individuals with knee osteoarthritis: An observational study

OBJECTIVE

Patients who experience knee osteoarthritis or chronic knee pain can alleviate their symptoms by performing self-knee massage. Understanding the readiness and types of determinants needed to facilitate self-knee massage is needed to design effective, theory-informed interventions. The primary objective of this study was to apply the transtheoretical model of behavior change to identify how factors, which include the type of knee condition and pain level, predict an individual's readiness to adopt self-knee massage. The secondary objective employed the capability, opportunity and motivation-behavior (COM-B) model to identify relevant determinants that are predictive of an individual's readiness to undertake self-knee massage.

METHODS

An observational study design was used to recruit individuals with knee osteoarthritis (n = 270) and chronic knee pain (n = 130). Participants completed an online survey that assessed the transtheoretical model of behavior change stages, COM-B determinants (capability, opportunity and motivation), along with self-administered massage behavior. Multivariate analysis of covariance and structural equation modeling were used to test the primary and secondary objective, respectively.

RESULTS

Participants who had knee osteoarthritis scored higher on the action stage compared to those with chronic pain (P = 0.003), and those who experienced greater level of pain scored higher in the contemplation (P < 0.001) and action phases (P < 0.001) of performing knee massage compared to those with milder pain. The COM-B structural equation model revealed self-administered knee massage to be predicted by capability (β = 0.31, P = 0.004) and motivation (β = 0.29, P < 0.001), but not opportunity (β = -0.10, P = 0.39). Pain level predicted motivation (β = 0.27, P < 0.001), but not capability (β = 0.09, P = 0.07) or opportunity (β = 0.01, P = 0.83). Tests for mediating effects found that determinants of COM-B (motivation and capability) mediate between pain level and self-administered massage behavior (β = 0.10, P = 0.002).

CONCLUSION

Clinicians and researchers can expect that patients diagnosed with knee osteoarthritis or who have chronic knee pain are ready (action stage) or are considering the behavior (contemplation stage) of self-knee massage. Individuals who report having knee osteoarthritis or chronic knee pain should be coached to develop the skills to perform self-knee massage and helped to develop the motivation to carry out the therapy. Please cite this article as: Nemati D, Munk N, Kaushal N. Identifying behavioral determinants and stage of readiness for performing knee massage among individuals with knee osteoarthritis: an observational study. J Integr Med. 2024; 22(1): 54-63.

Predicting Exercise Behavior among Caregivers of Persons with Dementia- A Longitudinal Investigation Using an Extended Health Belief Model

BACKGROUND AND OBJECTIVES

Family caregivers of persons with dementia face an elevated risk of several chronic illnesses compared to their non-caregiver counterparts. While exercise is a strong preventive measure for several debilitating health conditions, longitudinal research guided by theoretical frameworks has not identified how behavioral determinants predict exercise among caregivers. This study aimed to investigate how intrapersonal exercise determinants contribute to caregivers' exercise participation while accounting for social-contextual factors, including perceived caregiving burden and pandemic-related distress, by employing an extended Health Belief Model.

RESEARCH DESIGN AND METHODS

The study was a longitudinal observational design. Community-dwelling older adult family caregivers of individuals with dementia (n=127) were recruited with the support of a nonprofit organization. Participants completed measures of the Health Belief Model that also included dual process constructs (intention and habit), along with caregiving burden, pandemic-related distress, and exercise behavior across three consecutive months. Data were analyzed using a multilevel structural equation model with participants (level 2) nested within time (level 1).

RESULTS

The model revealed direct effects of caregiving burden that debilitate perceived behavioral control, attitudes, threats, and worsen burden, in addition to hampering intention and habit when accounting for total effects. Pandemic-related distress exacerbated caregiving burden and weakened Health Belief Model constructs via total effects.

DISCUSSION AND IMPLICATIONS

These findings inform constructs to develop a community-based education program for family caregivers to successfully adopt and maintain exercise behavior. Incorporating supportive resources and coping strategies for caregivers of persons with dementia are needed to address the effects of behavioral deterrents.

Comparing exercise determinants between Black and White older adults with heart failure

BACKGROUND

Heart Failure is a leading cause of mortality among older adults. Engaging in regular exercise at moderate-to-vigorous intensity has been shown to improve survival rates. Theory-informed methodologies have been recommended to promote exercise, but limited application of theoretical framework has been conducted for understanding racial disparities among older adults with heart failure. This study aimed to use the Health Belief Model to compare exercise behavior determinants between Black and White older adults diagnosed with heart failure.

METHODS

The HF-ACTION Trial is a multi-site study designed to promote exercise among individuals with heart failure that randomized participants to an experimental (three months of group exercise sessions followed by home-based training) or control arm. The present study used structural equation modeling to test the change in Health Belief Model constructs and exercise behavior across 12 months among older adults.

RESULTS

Participants (n = 671) were older adults, 72.28 (SD = 5.41) years old, (Black: n = 230; White, n = 441) diagnosed with heart failure and reduced ejection fraction. The model found perceived benefits, self-efficacy, perceived threats, and perceived barriers to predict exercise behavior among Black and White older adults. However, among these constructs, only perceived benefits and self-efficacy were facilitated via intervention for both races. Additionally, the intervention was effective for addressing perceived barriers to exercise only among White participants. Finally, the intervention did not result in a change of perceived threats for both races.

CONCLUSIONS

Among health belief model constructs, perceived threats and barriers were not facilitated for both races in the experimental arm, and the intervention did not resolve barriers among Black older adults. Racial differences need to be considered when designing interventions for clinical populations as future studies are warranted to address barriers to exercise among Black older adults with heart failure.

Investigating the association between knee osteoarthritis symptoms with pain catastrophizing domains between Hispanics and non-Hispanic Whites

Knee osteoarthritis (KOA) is a chronic disease accompanied by debilitating symptoms including pain, stiffness, and limited physical functionality, which have been shown to be associated with pain catastrophizing. Previous studies have revealed racial discrepancies in pain catastrophizing, notably between Hispanics and non-Hispanics while pointing to potential health disparities. Using a conceptual model, this study aimed to investigate racial differences in associations between KOA symptoms with specific pain catastrophizing domains (rumination, magnification, and helplessness). Patients with KOA (n = 253; 147 Hispanics, 106 non-Hispanic Whites) completed a survey that included measures of knee symptoms, pain catastrophizing, and demographic variables. Structural equation modeling revealed that among Hispanics, each pain catastrophizing domain (rumination, magnification, and helplessness) was associated with at least two symptomatic experiences, including pain severity and difficulty in physical function. Specifically, pain severity was associated with (a) rumination: β = 0.48, p < 0.001, (b) magnification: β = 0.31, p = 0.003; and (c) helplessness: β = 0.39, p < 0.001). Additionally, a lower score in physical function was associated with higher magnification (β = 0.26, p = 0.01), and helplessness (β = 0.25, p = 0.01). Among non-Hispanic White patients, pain severity was further associated with two domains of pain catastrophizing, including rumination (β = 0.39, p < 0.001) and helplessness (β = 0.35, p = 0.01). In addition, association pathways for demographic variables revealed that older Hispanics experienced greater challenges with higher pain severity (β = 0.26, p = 0.01) and greater difficulty with physical function (β = 0.31, p < 0.001) while Hispanics females experienced higher pain (β = 0.19, p = 0.03). These findings highlight the importance of designing tailored interventions that consider key demographic factors such as age, and gender, to improve physical function that might alleviate pain catastrophizing among Hispanics with KOA.

Investigating the Relationship Between Physical Activity Disparities and Health-Related Quality of Life Among Black People With Knee Osteoarthritis

INTRODUCTION

Knee osteoarthritis (OA) is the most common form of arthritis, which is a leading cause of disability. Although no cure exists for knee OA, physical activity has been shown to improve functionality, which can improve an individual's health-related quality of life (HR-QOL). However, racial disparities exist in participating in physical activity, which can result in Black people with knee OA experiencing lower HR-QOL compared with their White counterparts. The purpose of this study was to investigate disparities of physical activity and related determinants, specifically pain and depression, and how these constructs explain why Black people with knee OA experience low HR-QOL.

METHODS

Data were from the Osteoarthritis Initiative, a multicenter longitudinal study that collected data from people with knee OA. The study used a serial mediation model to test whether a change in scores for pain, depression, and physical activity over 96 months mediated the effects between race and HR-QOL.

RESULTS

Analysis of variance models found Black race to be associated with high pain, depression, and lower physical activity and HR-QOL at baseline and month 96. The findings supported the prospective multi-mediation model, which found pain, depression, and physical activity to mediate between race and HR-QOL (β = -0.11, SE = 0.047; 95% CI, -0.203 to -0.016).

CONCLUSION

Disparities in pain, depression, and physical activity could explain why Black people with knee OA experience lower HR-QOL compared with their White counterparts. Future interventions should address sources of pain and depression disparities by improving health care delivery. Additionally, designing race- and culture-appropriate community physical activity programs would help to achieve physical activity equity.

Massage Therapy for Hospitalized Patients Receiving Palliative Care: A Randomized Clinical Trial

CONTEXT

Massage therapy is increasingly used in palliative settings to improve quality of life (QoL) and symptom burden; however, the optimal massage "dosage" remains unclear.

OBJECTIVES

To compare three massage dosing strategies among inpatients receiving palliative care consultation.

METHODS

At an urban academic hospital, we conducted a three-armed randomized trial examining three different doses of therapist-applied massage to test change in overall QoL and symptoms among hospitalized adult patients receiving palliative care consultation for any indication (Arm I: 10-min massage daily × 3 days; Arm II: 20-min massage daily × 3 days; Arm III: single 20-min massage). Primary outcome measure was single-item McGill QoL question. Secondary outcomes measured pain/symptoms, rating of peacefulness, and satisfaction with intervention. Data were collected at baseline, pre- and post-treatment, and one-day postlast treatment (follow-up). Repeated measure analysis of variance and paired t-test were used to determine significant differences.

RESULTS

Total n = 387 patients were 55.7 (±15.49) years old, mostly women (61.2%) and African-American (65.6%). All three arms demonstrated within-group improvement at follow-up for McGill QoL (all P < 0.05). No significant between-group differences were found. Finally, repeated measure analyses demonstrated time to predict immediate improvement in distress (P ≤ 0.003) and pain (P ≤ 0.02) for all study arms; however, only improvement in distress sustained at follow-up measurement in arms with three consecutive daily massages of 10 or 20 minutes.

CONCLUSION

Massage therapy in complex patients with advanced illness was beneficial beyond dosage. Findings support session length (10 or 20 minutes) was predictive of short-term improvements while treatment frequency (once or three consecutive days) predicted sustained improvement at follow-up.

National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses

Background

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice.

Methods

A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs).

Results

Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs.

Conclusions

One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

COMPARING EXERCISE DETERMINANTS BETWEEN BLACK AND WHITE OLDER ADULTS WITH HEART FAILURE

Heart Failure (HF) is a leading cause of mortality among older-adults (OA); however, engaging in moderate-to-vigorous intensity of physical activity (MVPA) improves survival rates. Limited research has applied behavior theory to understand determinants of MVPA among OA with HF and compared the effects between races. This study aimed to use the Health Belief Model (HBM) to compare MVPA determinants between Black and White OA diagnosed with HF.

Methods: The HF-ACTION Trial is a multi-site trial that helped facilitate physical activity among individuals with HF. The present study used structural equation modeling to test the change in HBM determinants and MVPA across 12 months among OA.

Results: Participants were OA 72.28 (SD= 5.41) years old, (Black: n= 230; White, n= 441). The model found MVPA to be facilitated by perceived benefits (Black: β=.27, p=.001; White: β=.28; p<.001), self-efficacy (Black: β=.20, p=.003; White: β=.24; p<.001) and deterred by perceived barriers (Black: β=-.25, p=.001; White β=-.24; p<.001). Perceived threats deterred Black OA (β=-.23; p=.002) but not White OA (β=-.07; p=.278) from MVPA. Experimental arm predicted the development of self-efficacy (Black: β=.21. p=.001; White: β=.23; p=.001), and perceived benefits (Black: β=.21. p=.001; White: β=.23; p=.001) but not barriers (p>.05) for both races.

Conclusions: Perceived barriers was a strong determinant to MVPA, and it was not resolved in the experimental arm for either race. The experimental arm did not resolve perceived threat, which was a deterrent for Black OA. Individual characteristics need to be considered when designing programs for HF patients to reduce health disparity.

EXERCISE BEHAVIOR IS DETERMINED BY PANDEMIC DISTRESS AND TASK BURDEN AMONG CAREGIVERS OF OLDER ADULTS

Background

Caregivers who have dependents with dementia are at a much higher risk of heart disease and mental illnesses compared with non-dementia caregivers. Consequently, these outcomes have been exacerbated by societal barriers that resulted from the pandemic. Engaging in regular physical activity at a moderate-to-vigorous level (MVPA) is beneficial for caregivers has it has been shown to prevent several adverse health outcomes. However, pandemic-related (COVID-19) distress likely worsened caregiver burden which in turn compromised their MVPA levels. The purpose of this study was to understand how caregiving burden impacts MVPA when accounting for physical activity determinants from an augmented Theory of Planned Behavior (TPB) model.

Methods

Participants (n=127) were caregivers for older adults (65+) who have dementia. Participants completed measures of MVPA (behavior), TPB, pandemic-related distress (COVID Caregiver Risk Index) and burden scale for family caregivers. The study was investigated using a structural equation model.

Results

Participants were 45.5 (SD=3.4) years old, 76.4% female. Attitudes (β=.22, p=.012) and perceived behavioral control (β=.19, p<.001) predicted intention. Attitudes and perceived behavioral control mediated the relationship between past behavior and intention (β=.17, p=.02). Covid distress predicted caregiver burden (β=.35, p<.001), and caregiver burden mediated the effects between distress and behavior (β=-.12, p=.01).

Conclusions

Caregiver burden findings suggest that societal changes and demographic-specific burdens related to caregivers need to be considered for caregivers with dependents who have dementia. Taken together, exercise programs that focus on traditional behavioral determinants also need to include specific approaches to buffer caregiving burden experienced in this demographic.

Abstract P167: Inconsistency in the Application of National Institutes of Health Stroke Scale Scores (NIHSS) Between Neurologist and Emergency Room Nurses During Acute Ischemic Stroke

Background: The National Institutes of Health Stroke Scale (NIHSS) score is the gold standard for assessing stroke severity. One 2006 study demonstrated research nurses had better interrater reliability in clinical trials than neurologists, but little is known about NIHSS score consistency between neurologists and registered nurses in clinical practice. Consistent baseline NIHSS scoring by neurologists and nurses is crucial to determine stroke acuity, deliver evidence-based treatment, and optimize patient outcomes. The purpose of this study was to determine whether a difference existed between healthcare providers’ NIHSS scores and determine factors affecting inconsistencies in scores.

Methods: A retrospective chart review of patients treated at a single Comprehensive Stroke Center safety net hospital compared the initial NIHSS scores given to the same patient by neurologists and emergency department nurses from January 2018 to December 2019. Of the 588 charts reviewed, 438 met inclusion criteria. Patients were divided into two cohorts based on score differences between neurologists and nurses: clinically meaningful score difference ≥2 (n= 152, 34.70%) and non-meaningful score difference <2 (n= 286, 65.30%,).

Results: Only two variables were significantly associated with greater score inconsistencies: higher NIHSS score (p = <.01) and patients presenting with aphasia (p =<.01). Clinically meaningful score inconsistencies were 44% more likely to occur in aphasic stroke patients.

Conclusions: Although overall NIHSS scores are similar between physicians and nurses, patients with aphasia and more severe strokes were more likely to be scored inconsistently. Neurologists and nurses have different training and certification requirements with nurses required to certify annually while neurologists are not. Implementing a policy that requires all providers to undergo the same training in specific areas of the NIHSS may eliminate disparity and ensure patients are given the interventions needed for best outcomes.

Abstract P834: Inconsistency in the Application of National Institutes of Health Stroke Scale Scores (NIHSS) Between Neurologist and Emergency Room Nurses During Acute Ischemic Stroke

Background: The National Institutes of Health Stroke Scale (NIHSS) score is the gold standard for assessing stroke severity. One 2006 study demonstrated research nurses had better interrater reliability in clinical trials than neurologists, but little is known about NIHSS score consistency between neurologists and registered nurses in clinical practice. Consistent baseline NIHSS scoring by neurologists and nurses is crucial to determine stroke acuity, deliver evidence-based treatment, and optimize patient outcomes. The purpose of this study was to determine whether a difference existed between healthcare providers’ NIHSS scores and determine factors affecting inconsistencies in scores.

Methods: A retrospective chart review of patients treated at a single Comprehensive Stroke Center safety net hospital compared the initial NIHSS scores given to the same patient by neurologists and emergency department nurses from January 2018 to December 2019. Of the 588 charts reviewed, 438 met inclusion criteria. Patients were divided into two cohorts based on score differences between neurologists and nurses: clinically meaningful score difference ≥2 (n= 152, 34.70%) and non-meaningful score difference <2 (n= 286, 65.30%,).

Results: Only two variables were significantly associated with greater score inconsistencies: higher NIHSS score (p = <.01) and patients presenting with aphasia (p =<.01). Clinically meaningful score inconsistencies were 44% more likely to occur in aphasic stroke patients.

Conclusions: Although overall NIHSS scores are similar between physicians and nurses, patients with aphasia and more severe strokes were more likely to be scored inconsistently. Neurologists and nurses have different training and certification requirements with nurses required to certify annually while neurologists are not. Implementing a policy that requires all providers to undergo the same training in specific areas of the NIHSS may eliminate disparity and ensure patients are given the interventions needed for best outcomes.

Massage perceptions and attitudes of undergraduate pre-professional health sciences students: a cross-sectional survey in one U.S. university

BACKGROUND

Attitudes and beliefs about massage therapy have been explored among health professionals and health profession students, but not for undergraduate preprofessional health sciences students.

METHODS

This cross-sectional survey sought to determine pre-professional health students' attitudes and perceptions toward massage therapy and determine the extent demographic variables such as age, gender, race, along with lifetime massage experience are associated with neutral/negative perceptions.

RESULTS

N = 129 undergraduate students completed the Attitudes Toward Massage scale and 7 supplemental items pertaining to sexuality and therapist gender preference along with questions regarding lifetime massage utilization. Prevalence of massage therapy utilization was 35.6% (lifetime) and 18.6% (last 12-months). Overall, positive attitudes towards massage therapy was observed with participants reporting massage experience expressing more positive massage attitudes (lifetime; p = 0.0081, the past 12 months; p = 0.0311). Participants with no massage experience were more likely to report neutral/negative attitudes toward massage (p = 0.04). Men were more likely to prefer their massage therapist to be of the opposite sex (38.9%) compared to women (2.1%) (p = < 0.0001). Men were less confident than women in their concern of becoming sexually aroused during massage (p = 0.0001) and in the belief that massage is sexually arousing (p = 0.048). Both genders expressed comfort with female and/or male massage therapists, but if given a choice, both prefer a female massage therapist.

CONCLUSIONS

Undergraduate pre-professional health sciences students have generally positive attitudes towards massage therapy however more research is needed regarding implicit gender bias and/or preferences. This work should inform future research designs examining the impact of attitudes and beliefs on patient referrals to massage therapy.