Pilot Study for Implementing an Osteoporosis Education and Exercise Program in an Assisted Living Facility and Senior Community

Abstract

Background: Project Healthy Bones (PHB) is a 24-week, peer-led exercise and education program for older adults at risk of osteoporosis. Method: Residents from an assisted living and senior community program were enrolled after medical clearance. Participant demographics, geriatric fitness assessments, exercise logs, quizzes, and surveys were collected at baseline and 24 weeks. Data were analyzed using paired t tests and ANOVA of change scores for the pooled data within the R statistical environment. Results: Forty of the 53 enrolled participants completed the program. Participants improved their strength, balance, posture, and flexibility, resulting in a reduced risk of falls and fractures. In addition, their knowledge of bone health, nutrition, and fall prevention increased. Conclusion: Offering low-cost disease-specific programs such as PHB helps minimize the complications of osteoporosis and improve the overall health of participants. Implementing disease-specific public health programs in assisted living centers can increase access to programs.

Keywords

osteoporosis exercise balance falls geriatric assisted living facility public health evaluation evidence-based interventions community based health promotion

Introduction

Osteoporosis reduces bone mass and causes structural deterioration of bone tissue, increasing the risk of fractures (Cosman et al., 2014). People above the age of 50 are at a greater risk of osteoporosis, and approximately 53.6 million Americans have either osteoporosis or low bone density (Wright et al., 2014). The estimated annual cost in the United States of medical care for osteoporosis-related fractures will increase to 25.3 billion dollars by 2025 (Cosman et al., 2014).

Proper screening (Cosman et al., 2014; Kanis et al., 2010), diet (Perry & Downey, 2012; Sahni, Mangano, McLean, Hannan, & Kiel, 2015), education, and exercise contribute to improved outcomes by slowing osteoporosis progression and reducing the incidence of fracture. Exercises that include weight-bearing activities (Bolam, Uffelen, & Taaffe, 2013; Cumming & Wallace, 2000), balance training (Perry & Downey, 2012), posture training (Sinaki & Brey, 2005), and stretching (Gehlsen & Whaley, 1990) have the greatest impact on bone density and reduction in falls and fractures.

To minimize the complications of osteoporosis, the New Jersey Department of Human Services (NJDHS), Division of Aging Services established the New Jersey Interagency Council on Osteoporosis (ICO) in 1997. The ICO is a multidisciplinary coalition comprised of members from the public, state government, health care, academic, and corporate communities. With a mission to promote the development, implementation, and evaluation of comprehensive osteoporosis prevention and education programs, the ICO developed Project Healthy Bones (PHB). This 24-week program is designed for older adults with or at risk of osteoporosis. It consists of weekly 80-min exercise and education classes led by certified peer-leaders. More than 2,000 New Jersey residents have participated in PHB, and waiting lists exist in most counties (State of New Jersey Department of Health, 2013). Thus, new settings for the program need to be created to meet the demand.

The exercises in PHB are organized into four categories: posture, balance, strength, and flexibility. In the strength-training portion, weight-bearing and resistance exercises focus on the spine and hip to help stimulate bones. The education section covers osteoporosis-related topics such as safety while exercising, falls prevention, nutrition, risk factors, screening, and medications. PHB classes are conducted by trained volunteers who serve as class leaders. This has the benefit of decreasing costs and expanding availability. A previous study of PHB showed that 57 participants who completed 12 to 23 weeks of the program were able to lift heavier weights and increased their dietary calcium intake (Shimomura, 2001). A case series report of five patients with epilepsy found that all participants improved balance, minimized fall risk, and increased osteoporosis-related knowledge following participation in a PHB program (Girgis et al., 2015).

PHB is a program that is currently offered in the community setting. An assisted living home includes people who are extremely frail and at a high risk of fractures, and an exercise and education program focusing specifically on bone health could have great benefits in that population.

The objectives of this study were (a) to evaluate the benefits of PHB for older adults using various geriatric fitness tests that assess balance, posture, flexibility, strength, and fall risk; (b) to evaluate the benefits of the educational component of PHB by using quizzes that test knowledge on osteoporosis, nutrition, and falls prevention; and (c) to assess the feasibility of integrating PHB into a privately funded assisted living facility.

Method

Study Design and Participants

During a 2-year study period, participants in the pilot program included members of three different Francis E. Parker Memorial Home programs: the assisted living residence, the adult day care, and the community wellness program. The participants were recruited through investigator presentations to the facility residents, posted advertisements at the facility, and referral of potential participants by Parker Home staff. Participants were excluded if they did not have a medical clearance from their doctor or exhibited a Mini Mental Status Exam (MMSE) score of lower than 20 during screening.

Procedures

The PHB program is disseminated by the NJDHS through master trainers who train lead coordinators. The lead coordinators in turn train and supervise peer-leaders who conduct the individual PHB classes. One lead coordinator trained and supervised the 12 leaders in this study. Three 24-week classes were conducted from June 2012 to March 2014, meeting weekly for 60 min of exercise and 20 min of education. These classes followed the ICO-approved PHB exercise and education manual.

The Rutgers Institutional Review Board approved the study (IRB Protocol Number: 12-646), and all participants signed a consent form prior to any study-related activity. Before the first class, participant demographics, medical history, MMSE score, FRAX (fracture risk assessment tool) score, and apathy score were collected at the Parker Home (Kanis et al., 2010; Martin, Beidrzycki, & Firinciogullari, 1991). During each class, attendance and exercise logs recording the amount of weight used were completed for each participant. Pre- and post-measurements included geriatric fitness assessments, a nutrition log to measure calcium intake, measures of fear of falling with the Falls Efficacy Scale (FES) and a scale of fear from 1 to 10, and questionnaires to measure the participants’ knowledge of bone health, nutrition, and falls prevention (Greenberg, 2012). Fitness assessments were also completed at midpoint for the assisted living and day care participants to ascertain progress and facilitate tracking the data for those unable to complete the entire program. Surveys of the participants’ progress were taken at the end of the program and 3 months later.

The geriatric fitness assessments were selected with consultation from a physical therapist. They included the occiput-to-wall, functional reach, 30-s chair stand, timed up and go, single-leg stand (eyes open, eyes closed, and on a balance pad), tandem stand, and four-step square assessments (Antonelli-Incali et al., 2007; Bohannon, 2006; Briggs, Weiner, Duncan, Chandler, & Studenski, 1992; Gossman, Birch, Drews, & Shaddeau, 1989; Dite & Viviene, 2002; Duncan, Weiner, Chandler, & Studenski, 1990; Jones & Rikli, 1999; Papaioannou et al., 2010; Rikli & Jones, 1999; Shumway-Cook, Brauer, & Woollacott, 2000; Springer, Marin, Cyhan, Roberts, & Gill, 2007). Due to time constraints, the single-leg stands and tandem stand were stopped after 3 minutes. These tests assessed strength, balance, flexibility, posture, overall function, and risk of falling. In addition, the functional reach and four-step square tests measured dynamic balance; the 30-second chair stand assessed for lower body strength and mobility problems; the occiput-to-wall test determined risk for vertebral fractures; and the timed up and go test measured gait and lower body strength.

Throughout the program, the Parker Home staff evaluated the participants during their normal daily activities to ensure that they were physically and mentally capable of participating in the study. Staff members at the Parker Home were trained as PHB leaders to enable them to continue the program after the study was completed.

Outcomes

The primary end points included changes in means from baseline on the questionnaires and geriatric fitness assessments. Secondary outcomes included changes in the number of participants meeting age-matched norms for each fitness test, and the number of participants at risk for falls for each fitness test. Other outcomes included identifying the number of medications that could increase the risk of falls or bone loss, and the Parker Home’s ability to continue offering PHB.

Data Analysis

Paired t tests were used for analyses within the participants’ programs. ANOVA was used for pooled comparisons, with the program group (assisted living vs. community) as a blocking factor. The R statistical environment was used for analyses (R Core Team). All p values shown are nominal.

Results

Study Population

Fifty-three participants enrolled in the study; 40 (75%) completed the program. Six program completers were men, 34 were women, and the average age was 80.3 ± 9.0 years. Two participants dropped out after midpoint testing due to health problems (dementia and cancer); three did not complete baseline testing; and eight dropped out within the first few weeks due to health problems or prior commitments. For the 40 who completed the program, community and assisted living/day care participants attended an average of 21 classes (88% attendance) and 20 classes (83% attendance), respectively. Twenty-five (62%) of the completing participants were community members, and 15 (38%) were from the assisted living residence. Participants from the assisted living facility were generally older, took more medications, and had fewer prior screenings for osteoporosis compared with the community participants (Table 1).

Table 1.

Baseline Demographics and Characteristics.

	Total^a	Community	Assisted living/day care
	n = 42	n = 25	n = 17
Age (M ± SD; years)	80.6 ± 9.0	76.4 ± 8.5	86.6 ± 5.7***
Sex (M/F)	9/33	2/23	7/10**
Ethnicity
White (%)	36 (85.7)	23 (92.0)	13 (76.5)
Black (%)	3 (7.1)	1 (4.0)	2 (11.8)
Asian (%)	2 (4.8)	1 (4.0)	1 (5.9)
Hispanic (%)	1 (2.4)	0 (0)	1 (5.9)
MMSE score (M ± SD)	28.1 ± 2.4	29.0 ± 1.3	26.9 ± 3.0*
Apathy score (M ± SD)^b	25.0 ± 4.4	24.6 ± 4.0	26.7 ± 4.9
Medication use
Number per participant (M ± SD)	5.3 ± 3.8	4.3 ± 3.4	6.8 ± 4.1*
Number associated with falls (M ± SD)	2.4 ± 1.7	1.1 ± 1.0	2.8 ± 1.5
Number associated with bone loss (M ± SD)	0.8 ± 0.9	0.6 ± 0.8	1.1 ± 1.7
Polypharmacy (%)^c	26 (62)	12 (48)	14 (82)***
Health status score (M ± SD)^d	1.7 ± 0.8	1.5 ± 0.8	2.0 ± 0.7
Number of participants with a DXA (%)	22 (52)	19 (76)	3 (18)***
Osteopenia or osteoporosis (%)^e	18 (84.2)	15 (83.3)	3 (100.0)***
FRAX, major osteoporotic fracture risk (%)	19.2 ± 13.8	20.2 ± 16.0	17.4 ± 8.5^f
FRAX, hip fracture risk (%)	9.7 ± 12.2	9.8 ± 14.6	8.5 ± 6.4^f
Participants with a prior vitamin D concentration (%)	19 (45)	11 (44)	8 (47)
Exercise regularly (%)^g	27 (64)	20 (80)	7 (41)**

Note. MMSE = Mini Mental Status Exam, DXA = Dual-energy X-ray absorptiometry

Includes all participants up to midpoint.

Higher score = more apathy, 28 is the norm.

Four or more drugs per day.

Values are self-reported, 0 = excellent, 1 = very good, 3 = good, 4 = fair, 5 = poor.

Includes only participants with a DXA scan.

An age of 90 was used if the participant was older than 90, and therefore, the true risk is slightly greater.

Three times a week for 30 min.

p < .05. **p < .01. ***p < .001.

Education

After completing the program, the community participants had less fear of falling (p = .051); more knowledge about osteoporosis, nutrition, and falls prevention (p < .001); and improved calcium intake. The participants taking too much calcium reduced their calcium intake (p < .05), and those taking too little calcium increased their intake (p < .01). The assisted living/day care participants gained knowledge on osteoporosis, nutrition, and falls prevention (p < .001). The educational component of the program also included information on vitamin D. This prompted eight participants from the assisted living facility to have their serum vitamin D concentrations checked by the Parker Home doctor. As a result, seven of these participants were treated for low vitamin D concentrations. In addition, all participants learned which of their medications increased bone loss or fall risk (Tables 2 and 3).

Table 2.

Community Questionnaire Results and Fitness Results.

Survey	Baseline score	24-week score	Change from baseline
Total body weight (M ± SD; lbs)	157 ± 29 (n = 25)	154 ± 27 (n = 25)	3.0
Falls Efficacy Scale score (M ± SD)	27 ± 8 (n = 25)	26 ± 8 (n = 24)	1.0
Falls Concern Scale Score (M ± SD)^a	5.4 ± 2.3 (n = 25)	4.5 ± 2.8 (n = 25)	0.5
Percent correct quiz scores (M ± SD)^b	68.4 ± 9.1 (n = 25)	88.2 ± 7.5 (n = 24)	19.8***
Calcium intake
>Goal (M ± SD; mg)	2,028 ± 410 (n = 10)	1	598*
<Goal (M ± SD; mg)	800 ± 144 (n = 10)	1	317**
Weight lifted by participants
Arm (M ± SD; lbs)	0 (n = 25)	3.2 ± 1.3 (n = 25)	3.2***
Leg (M ± SD; lbs)	0 (n = 25)	3.2 ± 1.2 (n = 25)	3.2***

Scale from 1 to 10, 1 is low concern about falling, 10 is high concern about falling.

Covers bone health, nutrition, and fall prevention.

p < .05. **p < .01. ***p < .001.

Table 3.

Assisted Living/Adult Day Care Questionnaire Results and Fitness Results.

Survey	Baseline score	24-week score	Change from baseline
Total body weight (M ± SD; lbs)	147 ± 28 (n = 17)	147 ± 30 (n = 15)	0
Falls Efficacy Scale score (M ± SD)	30 ± 8 (n = 17)	30 ± 9 (n = 10)	0
Falls Concern Scale score (M ± SD)^a	4.7 ± 2.6 (n = 17)	3.5 ± 2.3 (n = 15)	1.2
Percent correct quiz scores (M ± SD; %)^b	72.1 ± 9.2 (n = 16)	84.4 ± 9.1 (n = 15)	12.3***
Calcium intake
>Goal (M ± SD; mg)	2,063 (n = 1)	1,636 (n = 1)	427
<Goal (M ± SD; mg)	715 ± 198 (n = 5)	726 ± 119 (n = 5)	11
Weight lifted by participants
Arm (M ± SD; lbs)	0 (n = 17)	2.7 ± 1.4 (n = 15)	2.7***
Leg (M ± SD; lbs)	0 (n = 17)	2.4 ± 1.2 (n = 15)	2.4***

Scale from 1 to 10, 1 is low concern about falling, 10 is high concern about falling.

Covers bone health, nutrition, and fall prevention.

p < .05. **p < .01. ***p < .001.

Geriatric Fitness Assessment Results

All participants increased the amount of weight that they could lift in the arm and leg exercises (p < .001; Tables 2 and 3). Community participants showed improvements in the geriatric assessments (functional reach [p < .001], timed up and go [p < .001], chair stand [p < .01], and four-step square [p < .001]) with a greater number of participants meeting age-matched normal values and fewer participants with scores indicative of a risk of falling or poor mobility. The occiput-to-wall test, a screening tool for vertebral fracture, indicated that community participants had improved posture after the program, but this improvement was not statistically significant unless the community and assisted living data sets were pooled. In addition, community participants showed improved balance. Many were able to stand at least twice as long as their baseline measurement in the single-leg stand (p < .01) and tandem stand (p < .001; Table 4).

Table 4.

Community Geriatric Assessment Results.

Test	Baseline score (n = 25)	Number meeting age-matched norm	Number at risk	24-week score (n = 25)	Number meeting age-matched norm	Number at risk	Change from baseline
Functional reach (M ± SD)^a	9.6 ± 2.3	7	4	14.0 ± 2.6	22	0	4.4***
Occiput to wall (M ± SD; cm)^b	4.3 ± 3.6	—	11	3.1 ± 3.1	—	4	1.1
Timed up and go (M ± SD; s)^c	10.8 ± 4.2	12	5	8.5 ± 3.4	19	2	2.3***
Four-step square (M ± SD; s)^d	12.8 ± 5.8	—	7	9.4 ± 5.9	—	2	3.4***
30-s chair stand (M ± SD; number stands)^e	8 ± 5	5	11	12 ± 6	12	3	4***
Tandem stand (M ± SD; s)	65.3 ± 61.8	—	—	120.9 ± 74.0	—	—	55.6***
Single-leg stand, eyes open (M ± SD; s)	22.4 ± 25.8	14	—	36.9 ± 43.2	17	—	14.5**

At risk of mobility problems and decreased activities of daily living.

At risk of vertebral fracture, >5 cm.

At risk of falling, >13.5 s.

At risk of falling, >15.0 s.

At risk of mobility problems and falls, <8 stands.

p < .05. **p < .01. ***p < .001.

Assisted living/day care participants showed improvement in the timed up and go (p < .05), four-step square (p < .01), tandem stand (p < .05), and single-leg stand (p = .051) tests after 12 weeks of the class. In addition, they had a greater number of participants meeting age-matched normal values and fewer participants with scores indicative of a risk of falling. At 24 weeks, two participants withdrew and the improvement was not statistically significant (Table 5). Given the effect sizes (mean change from baseline divided by standard deviation) of the tests that reached significance in the pooled sample, which ranged from .33 to 1.0, to reach 80% power in the assisted living/day care population would require sample sizes ranging from 68 (occiput to wall) to 11 (four-step square).

Table 5.

Assisted Living/Adult Day Care Geriatric Assessment Results.

Test	Baseline score	Number meet norm	Number at risk	Midpoint score	Number meet norm	Number at risk	Change from baseline	24-week score	Number meet norm	Number at risk	Change from baseline
Functional reach (M ± SD)^a	7.7 ± 3.9 (n = 17)	3	7	9.8 ± 3.6 (n = 16)	7	4	2.1	10.7 ± 5.2 (n = 15)	8	3	3.0
Occiput to wall (M ± SD; cm)^b	6.2 ± 3.4 (n = 17)	—	8	5.5 ± 3.6 (n = 16)	—	8	0.7	4.7 ± 3.0 (n = 15)	—	3	1.4
Timed up and go (M ± SD; s)^c	16.5 ± 7.4 (n = 17)	4	9	14.8 ± 6.1 (n = 16)	5	7	1.7*	14.9 ± 8.6 (n = 15)	6	7	1.6
Four-step square (M ± SD; s)^d	18.8 ± 5.5 (n = 8)	—	6	15.2 ± 4.8 (n = 7)	—	4	3.6**	13.7 ± 5.2 (n = 6)	—	1	5.2
30-s chair stand (M ± SD; number stands)^e	8 ± 5 (n = 17)	5	8	8 ± 5 (n = 16)	5	7	0	10 ± 6 (n = 15)	8	5	2
Tandem stand (M ± SD; s)	15.5 ± 18.4 (n = 16)	—	—	34.5 ± 38.3 (n = 15)	—	—	19.0*	31.9 ± 46.3 (n = 14)	—	—	16.4
Single-leg stand, eyes open (M ± SD; s)	4.5 ± 5.7 (n = 17)	3	—	7.2 ± 7.6 (n = 16)	6	—	2.7	6.8 ± 6.6 (n = 15)	5	—	2.3

At risk of mobility problems and decreased activities of daily living.

At risk of vertebral fracture, >5 cm.

At risk of falling, >13.5 s.

At risk of falling, >15.0 s.

At risk of mobility problems and falls, <8 stands.

p < .05. **p < .01. ***p < .001.

Neither group improved their balance on the single-leg stand test with closed eyes or their balance on the balance pad test. When combining groups, improvement was significantly greater in younger participants on the chair stand (p < .05). Comparison of the total of number of tests in which participants improved showed that participants with a higher MMSE score had the greater improvement in number of tests (p < .05).

Survey Results

During the last class, all the participants who completed the program said that PHB improved their overall health (40, 100%), physical strength (32, 80%), flexibility (35, 88%), balance (34, 85%), and energy levels (30, 75%). They felt the program enabled them to increase exercise duration (32, 80%), promoted healthier eating habits (30, 75%), and fostered an increased awareness concerning the importance of posture in the prevention of falls (40, 100%). Thirty-seven (92%) of 40 participants wanted to continue the program.

Three months after the pilot program, 16 (47%) of the 34 participants surveyed were continuing PHB exercises, either by themselves or in another program. Twenty-seven (79%) of 34 participants were still eating a calcium-rich diet. Reasons for not continuing PHB included conflict with work, lack of time, difficulty finding a class near them, or inconvenient class times.

Sustainability

Six months after the pilot program, the staff at the Francis E. Parker Memorial Home included PHB in their health programs. Two assisted living/day care and seven community participants from the study continued PHB with these classes. Four assisted living facility staff members were trained as leaders, and the program expanded to a new location owned by the assisted living facility. A collaboration of academic investigators, the NJDHS, and a privately funded assisted living facility led to the expansion of the program in this new setting. The investigators recommended that the ICO, managing PHB with the NJDHS, add the functional reach or four-step square test as an additional outcome measurement to the program. The ICO chose to add the single-leg stand balance test as a treatment outcome because they felt it was easy to collect. The addition of balance training on uneven surfaces and limited light situations will be reserved for more advanced programs that could follow the PHB program.

Discussion

The PHB program was successfully implemented at the Parker Home. Strength, balance, flexibility, posture, and overall function improved, and the risk of falling was reduced through the exercise portion of the program. Participants were able to improve their strength, even with only small increases in weights. One possible explanation for the lack of improvement on the single-leg stand with eyes closed or on the balance pad was that there were no exercises in the program to improve balance on uneven surfaces or in the dark. Knowledge, fear of falling, vitamin D screening, and calcium intake improved due to the education portion. The community group additionally benefited from the education because many were taking more than 500-mg calcium at a time, impairing absorption (Nieves, 2003), or more than 1,500 mg in supplements daily, increasing cardiovascular risk (Bolland et al., 2010). With reduced fear of falling and improved balance, participants regained some independence and better performed ADLs (activities of daily living) (Greenberg, 2012). With the resistance exercises focusing on the hip and spine, the participants worked on building and maintaining bone integrity (Cumming & Wallace, 2000). Improvement was found after only 12 weeks in people participating only once a week. These results indicate that a program designed and monitored by the state, such as PHB, could significantly benefit older adults.

Twelve-week data were collected for the assisted living/day care group to facilitate inclusion of the data for those unable to complete the entire program. These midpoint results showed a significant improvement on tests indicating an increase in balance and decrease in fall risk. Twenty-four-week data for the assisted living/day care group again showed improvement in fitness, but these results were not statistically significant possibly due to low statistical power. Nevertheless, the results support the benefits of PHB in an assisted living home because the program helped maintain physical fitness in a population that is usually functionally declining. Assisted living/day care participants improved similarly to the community group on the quizzes and were also able to significantly increase the amount of weight they could lift. The education component was especially important in the assisted living population because most participants were unaware of osteoporosis risk factors and vitamin D screening. Aiming to maintining vitamin D conscentrations around 30 ng/mL in high risk patients will likely improve bone health and fall risk (Cosman et al., 2014; Judge et al., 2014).

Differences in results between the two groups are evident when comparing the fitness assessment outcomes and baseline demographics. The assisted living/day care group was older and frailer compared with the community participants. This may have caused them not to increase their arm and leg weights as much as the community participants, and may have led to less improvement in other fitness tests. Moreover, the assisted living group had a lower average MMSE score, which indicated a reduced cognitive function compared with the community group. Many of these participants needed extra help during the first few weeks of the program to learn the exercises, and may have resulted in their doing less than 24 weeks of each exercise. Another potential reason for the difference in results is that there were not enough participants in the assisted living group to compare statistically with the community group. The frail nature of the assisted living residents made it harder to recruit them, and several were hospitalized during the study due to acute conditions. In addition, many of the assisted living participants appeared to plateau as time progressed, possibly attributable to their declining health. Overall, the results demonstrate that this program holds promise for the assisted living population. More research needs to be done to optimize the exercise program for the more frail participants.

Previous studies found that inadequate social support systems contribute to a decrease in the quality and quantity of physical activity in senior citizens, and that community-based programs are beneficial in creating an environment that encourages these individuals to stay socially connected (Benjamin et al., 2011; Deforche & Bourdeaudhuij, 2000; Drewnowski & Evans, 2001). The sociability of an organized group can provide a strong sense of support (Bjornsdottir, Arnadottir, & Halldorsdottir, 2012), and the fact that many participants continue in PHB classes for years is a testimony to the sense of community that develops in this program. This study saw an increased sense of community among the participants with 92% of participants wanting to continue PHB after the completion of the study.

One evidence-based program similar to PHB is the Highmark Osteoporosis Prevention and Education (HOPE) program which was developed by an insurance company; however, this program is not peer-led and was deemed too expensive to sustain (Pearson, Burkhart, Pifalo, Palaggo-Toy, & Krohn, 2005). Programs such as PHB that draw on trained volunteers enable participants to gain similar benefits at a lower cost.

Other peer-led community-based exercise programs have published results similar to this study such as the StrongWomen Program (Seguin, Heidkamp-Yound, Kuder, & Nelson, 2012), EnhanceFitness (Belza et al., 2006), A Matter of Balance: Managing Concerns About Falls (Healy el al., 2008), Active Choices (Wilcox et al., 2008), and Stepping On (Clemson et al., 2004). These programs primarily focus on either education or exercise and are not specific to osteoporosis. The inclusion of exercise and educational components in a program is likely to result in a positive impact on lifestyle changes and outcomes, and, in particular, fewer and less injurious falls (Campbell et al., 1997; Patil et al., 2015; Sherrington et al., 2008; Stubbs, Brefka, & Denkinger, 2015).

PHB offers multiple advantages. It incorporates both health education and exercises specifically designed for older adults with or at risk of osteoporosis. It is under the auspices of the NJDHS and includes oversight by the ICO. One limitation to this study was the inability to randomize the patients to a control group. A randomized trial was not feasible due to the limited sample size and the fact that it was difficult to exclude Parker Home clients from programs held within their facility. Further research with a larger population could add to the demonstrated benefits of PHB. Other limitations include the inability to control the participant’s participation in other types of exercise throughout the duration of the program and practice effects on the physical assessments.

Results from the PHB study and other evidence-based programs demonstrate the benefits of affordable, accessible, and peer-led public health programs. Training staff from assisted living facilities to become class leaders and lead coordinators can expand access to public health programs, and increased quality of community-based programs may be achieved by partnering with local, county, and state public health departments. Offering low-cost bone-strengthening programs can minimize the complications of osteoporosis. This program is unique in that it represents a collaborative development effort between state government, health care, academic, and corporate communities committed to the management of osteoporosis. This program can serve as a model for implementing and expanding other public health programs across a wide range of therapeutic areas.

Footnotes

Acknowledgements

The authors acknowledge the following persons: Margie Bissinger, DPT, who helped select the appropriate geriatric fitness assessments to utilize and trained the staff to perform the measurements. Peer-leaders under lead coordinator Sally Fullman included Mary Kao, Richard Sherman, Donna Drew, Adrienne Kay, Lorraine Walkiewicz, Annabeth Watkins, Mary L. Wagner, and Aparna P. Nanduri. Paige Meade and Annabeth Watkins assisted with classes, lectures, data management, and manuscript editing. Hee Nam Park, DC, provided patient assessments for posture. Niyati Shaw, Dahea You, Shannon Kaminski, Philip Lu, Caitlin McCarthy, and Laura Wagner helped participant’s complete paperwork and measurements during the testing dates. Lisa Slater helped provide oversight of the study logistics at the Francis E. Parker Memorial Home. Lori Morell, Julie Madsen, Kristin West, and Anne Ang were trained as Project Healthy Bones (PHB) peer-leaders to continue the program after the study ended. The Interagency Council on Osteoporosis with the State of New Jersey Department of Human Services reviewed and edited the study protocol, presentations, and manuscript.

Authors’ Note

The results of this study were presented as a poster at the American Geriatrics Society Annual Scientific Meeting on May15-17, 2015, in National Harbor, MD.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was provided by the Francis E. Parker Memorial Home grant program.

Author Biographies

Aparna P. Nanduri, PharmD, conducted research in osteoporosis, nutrition, and exercise as a part of her graduate honors thesis at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey. She is working as a clinical pharmacy resident at the VA Maryland Health Care System.

Sally Fullman, PhD, is a Project Healthy Bones (PHB) lead coordinator with the New Jersey Department of Human Services, Division of Aging Services. She has developed many educational and community awareness projects, and is an advocate for osteoporosis awareness on the state and national levels.

Lori Morell, CMP, PT, works as a senior manager for the Center for Healthy Aging at the Francis E. Parker Memorial Home. She is an exercise enthusiast and advocate for the disabled, and holds several wellness certifications.

Steve Buyske, PhD, is an associate research professor in the Department of Statistics and Biostatistics at Rutgers, The State University of New Jersey. His research interests include statistical genetics, psychometrics, and biostatistics.

Mary L. Wagner, PharmD, MS, is an associate professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey. Her research interests include osteoporosis prevention, neurology, and inter-professional care models for chronic conditions.

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