James H. Rimmer, PhD Lakeshore Foundation Endowed Chair in Health Promotion and Rehabilitation Sciences Professor, Department of Occupational Therapy University of Alabama at Birmingham Virtual Day of Allied Health & Rehabilitation ICHPO December 3, 2015 From Therapist to Trainer: Transforming the Lives of People with Disabilities

Outline 1.Overview and consequences of Post-Rehab Health Decline (PHD) Some Data Models of Deconditioning and Secondary Conditions 2.Calibrating Activity to Need: Four levels of Transformative Exercise

Transforming Patients into Participants Tethered to the medical and pharmaceutical industries Primary focus is on disease care rather than health care ‘What drug can we prescribe today for this patient’s new ailment?’ Virtually no discussion of health promotion in ‘health’ care settings.

Understanding and Preventing Acute and Chronic Post-Rehabilitation Health Decline (PHD)

Conceptual Model of Deconditioning in People with Disabilities Disability Associated Low Energy Expenditure Deconditioning Syndrome (DALEEDS)

Antecedents Physiologic Effects of DALEEDS Personal Disability Environmental Associated Conditions -paralysis -spasticity -balance Secondary Conditions - pain -fatigue -depression --weight gain Employment Status -unemployed -underemployed -not employed Other -medications -aging with a disability -overprotection Inaccessible Facilities Lack of accessible fitness equipment Poorly designed communities Policy Physical Inactivity Pathway 1 ` Pathway 2 Outcomes Immobilization Strength Aerobic Fitness Flexibility Insulin Sensitivity Hypertension Dyslipidemia Falls and Injuries Impaired Balance Osteopenia Total Energy Expenditure Resting Energy Expenditure Sarcopenia Obesity Physical Function including ADLs Cardiovascular Morbidity Sedentary Behavior Personal Care Assistance Health Care Utilization Community Participation Quality of Life

Low Levels of Physical Activity 47% 26% Source National Health Interview Survey (NHIS); Source: Centers for Disease Control and Prevention, Vital Signs: Disability and Physical Activity- U.S. Inactive adults with disabilities

CALIBRATING ACTIVITY TO NEED, INTEREST & MOTIVATION

Health & Function Target threshold of health/function Recovery (months) Rehab Post-rehab Health Decline (PHD) PHD: Getting Beyond the Plateau: Importance of Exercise Transformative Exercise Shorter LOS in rehab 1,2 LOS = Length of stay 3,4 Physical Inactivity Case 1 Case 2 1,2: Condition-specific Training/Fitness 3,4: Recreation/Sport, Lifetime PA

Exercise/PA Dose-Response

Transformative Exercise Continuum

Transformative Exercise Framework A Continuum of Health Services That Targets Underperforming Systems to Improve Health & Function Rehabilitation Condition Specific Exercise 12 Fitness 3 Physical Activity 4 Rimmer & Lai, 2015

Neuroscience and Dance  January 2015: “Dance may be able to aid with both physical and cognitive impairments, particularly due to the combined nature of including both physical and cognitive stimulation.”  Future directions: “Evaluate the potential of dance as an alternative therapy in neurorehabilitation.”

Movement-2-Music (M2M)  Created by three dance instructors, accompanist and postdoc

M2M Elements MAPPETT  M odality  A daptation  P osition  P attern  E quipment  T echnique  T ime

Sample M2M Segment  Modality - Cardiorespiratory  Adaptation- Slower tempo (2-count vs. 4-count) for less conditioned participants; nonambulatory participants use arms to simulate legs (eg, elbow flexion for knee flexion)  Position – Standing for higher functioning and sitting for nonambulatory or less conditioned participants  Pattern – (a) 5 min. sitting (UB), (b) 15 min. standing holding ballet bar (LB), Sliding (side-to-side), walking/stepping (forward/backward)  Equipment – 2-lb hand-held weights for seated participants  Technique – Theater dance forms  Time – 20 min segment (5 seated/15 standing) with 1-2-min rest interval between seated/standing activity

Rehabilitation Family/Caregivers Students/Volunteers ExerciseProfessionals Researchers Inclusive Health Community