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Monthly Archives: February 2011

The Texas Legislative Budget Board published a report (find it here: http://www.lbb.state.tx.us/Health_Services/State_Supported_Living_Centers.pdf) on what used to be known as the State Schools, now known as the State Supported Living Centers (SSLCs). It’s a report essentially calling for two things: first, a closing of some of the SSLCs especially as resident populations are decreasing and second, a rethinking of how those SSLCs provide services.

Closing Selected SSLCs:
The report makes a number of strong arguments for closing some of the SSLCs:
• First, Texas essentially operates two systems for care of the intellectually and developmentally disabled. The first is the SSLC, the second is a community placement option. Other states primarily operate the community model. By operating two systems, Texas is unable to see any cost-savings from the community model.
• Second, the SSLC makes up almost 35% of the costs while serving less than 15% of the clients.
• SSLC facilities range in age from being almost 100 years old to being 33 years old. This means that they have enormous maintenance and operational costs associated with them. In fact, some of the facilities have needs that exceed the values of the buildings.
• Third, the census of the SSLCs has been in sharp decline over the past 30 years, but the SSLCs have not been downsized to reflect this, as a result there has been little cost savings from the decline.
• Fourth, despite significant investments in facilities, safety, training, and staffing DADS has not been able to address the deficiencies in the SSLCs that were cited by the Department of Justice. All the monitoring reports that have been published have mentioned that the staff have good intentions, but the deficiencies are still present. The LBB report states that the incidents of abuse, neglect, and exploitation have increased from 427 in 2006 to 705 in 2010 (which is the highest number of incidents since 2006).
• Fifth, despite investments and training the average turnover rate of staff in the SSLCs is still increasing, which affects the quality of care.

The LBB’s recommendation is to close on or more, these are reflected as riders in both HB1 (http://www.lbb.state.tx.us/Bill_82/1_Recommend/Bill-82-1_House_Recommend.pdf) and SB1 (http://www.lbb.state.tx.us/Bill_82/1_Recommend/Bill-82-1_Senate_Recommend.pdf). The LBB recommends setting up a process for closing the SSLCs both now and in the future.

Rethinking SSLC Provided Services:
Essentially, the LBB is arguing that DADS is using an outdated approach to operating the SSLCs and providing care to residents. They use the example of the state of Kansas as an example of how to modernize these services. In summary, the recommendations are:
• Flatten the organizational chart in the SSLCs
• Decentralize the running of the SSLCs to provide more choices to residents and to the SSLCs
• Make programs and services less medically-oriented and more person-oriented so that the residents are part of the decision-making process
• Seek better employment for the residents than is the current practice

HB1 and SB1 have a rider for DADS to hire a consultant that would change the culture of how DADS operates the SSLCs.

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Tanskanen et al had an interesting study in the March issue of the Journal of Strength and Conditioning Research looking at the impact of eight weeks of basic training for military recruits. It’s looking at Finnish military recruits, but it’s interesting for several reasons. First, they are having an obesity epidemic as well which has an impact on military preparedness. Second, in Finland they have compulsory military service – so it’s not like recruits are spending time getting into shape before entering basic training. Third, they are looking at how training, overreaching, and hormonal markers interact.

The study looked at the impact of basic training on 57 subjects. The highlights of the results are:
• After the first five weeks of training, maximal oxygen consumption improved by 11% (mean). It did not improve after that point.
• Maximum heart rate and postexercise lactate were both lower after both week five and week eight of training.
• Subjects lost almost 4% of their fat mass after four weeks of training and almost 8% after seven weeks of training.
• Hormone levels changed as a result of basic training; cortisol and IGF-1 decreased between week four and seven; testosterone increased during the first four week s of training and then decreased from weeks four to seven. Having said that, almost a quarter of the subjects showed an increase in testosterone throughout the study.
• Those subjects with a “high incidence of sick absences” had a lower serum testosterone and lower maximal oxygen consumption than other subjects.
• Those subjects that felt physically and mentally overloaded during the training had a lower maximal oxygen consumption, lower fat free mass, and higher submaximal test heart rate prior to the start of basic training than other subjects.

It’s a very limited subject pool, but there are some interesting things to think about as a result of this study. First, being more fit before entering basic training seems to make it less physically and mentally stressful. This should be an obvious statement, but given how unfit and obese the population is today it is not. Second, gains in physical fitness (at least in this study) peaked halfway through the study. Now, one has to keep in perspective that military recruits aren’t being trained to be athletes, they need enough fitness to perform in their roles so this might be adequate. It’s also possible that this is not intentional (i.e. it is not intentional that fitness peaks halfway through), in which case this is great feedback to modify the basic training conditioning programs. Third, the authors are really concerned about overtraining and military recruits. This is curious because I would think that we’d want to adapt military recruits to be able to function in a physically and mentally stressful environment. One in which they get little sleep, little food, suffer privations, and are constantly in danger.

Tanskanen, M.M., et al. (2011). Serum sex hormone-binding globulin and cortisol concentrations are associated with overreaching during strenuous military training. Journal of Strength and Conditioning Research, 25(3), 787-797.

Cormie, et al.  have a two-part article in Sports Medicine looking at the literature on training for power.  This is a great publication which always has some of the best literature reviews.

In the first part of their article, they look at the science behind power production.  They touch on all the things you’d need to see, force-velocity, length-tension, elastic energy, stretch reflex, etc.  But it is when they begin to get into the muscular- and neural physiology that this article gets very interesting.

I’m not going to cover obvious things like larger muscles can produce more force, rather I’ll touch on the interesting ones:

1.     Muscle fascicle length: Larger fascicles shorten more quickly than shorter ones. However, it is unclear if this can be trained (i.e. can fascicle length be shortened or lengthened as a result of training?).  Essentially they report that the literature is mixed on this topic, some studies find an increase some do not.

2.     Neural physiology: To increase force production you’d (in theory) need to increase the recruitment of motor units, bypass the size principle, recruit motor units more frequently or synchronize those motor units better.  Basically they found:

a.     Current research cannot establish that we recruit more motor units as a result of training.

b.     It does not appear that we preferently recruit Type II muscle fibers as a result of training

c.      Increases in maximal motor unit firing frequency may contribute to improved force and power generation (i.e. training may change the patterns of motor unit firing frequency)

d.     Synchronization seems to be a theory right now, not something supported by evidence.

A lot of this duplicates things I’ve been saying in this blog (see: http://wp.me/pZf7K-2C and  http://wp.me/pZf7K-N) about what we “know” versus what we think we know.

Cormie, P. McGuigan, M.R., and Newton, R.U. (2011).  “Developing maximal neuromuscular power: Part 1, biological basis of maximal power production.”  Sports Medicine, 41(1), 17-38.

State Senator Nelson filed SB 571 (see it here: http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=82R&Bill=SB571) , which deals with efficiencies and cost-savings in the Texas health and human services agencies. In many ways it is a strange bill, it isn’t connected to any part of statutes and it is very loose and nonspecific, i.e. significantly open to interpretation. The idea of identifying cost savings and efficiencies is a laudable one, but for this to be dictated by the Legislature is concerning as they don’t understand how everything works on anything more than a superficial level.

The first thing to understand is that this bill (as of 2/11/11) is only filed. It will need to go to committee, be heard in committee, passed in committee, go to the Senate, be heard in the Senate, passed in the Senate, the whole process repeats in the House, then the Governor would need to sign. All this would need to be done before this bill becomes law.

With that said, it’s worth looking at this bill in some detail. The first part of the bill is part philosophical statement. In it, the Senator affirms the Legislature’s right to determine appropriations and to reduce or eliminate appropriations if it is necessary to achieve a balanced budget. Should this bill pass, it will trump any other statute to the contrary.

The second part of the bill is addressed to all health and human services agencies, though these aren’t identified. One would assume this means all Article II agencies, but since this isn’t specified it could be more broadly applied if desired. This part of the bill states that all these agencies “shall” identify efficiencies and reduce expenditures, and then includes manners in which this will be accomplished. To me this implies a need to report these things back to the Legislature. The means for accomplishing this include:
• Eliminating or modifying programs not funded or funded at a reduced level as a result of the FY12 and 13 budgets.
• Streamling functions, consolidating administrative and service functions
• Evaluating the fees for current programs and (my assumption) raising them if necessary to cover costs
• Maximize co-payment opportunities
• Renegotiate contracts
• Evaluate regulatory requirements (goes back to streamilining)
• Get Federal permission to streamline when necessary
• Shift the onus to primary care
• Evaluate the state medical assistance and children as well as the child health plan program (I’m assuming this refers to all the Medicaid and CHIP programs)
• Implement additional initiatives identified by the agencies

In addition, there are instructions to each of the Article II agencies.

For the Health and Human Services Commission:
• Streamline the eligibility determination process
• Evaluate the elimination of Temporary Assistance for Needy Families exemptions not required by Federal law (this is a Federal block grant): This is about $63 million a year for FY12 and 13.

For Department of Aging and Disabilities Services:
• Evaluate forensic commitment requirements to ensure that alleged offenders with intellectual disabilities are being served in the most appropriate and cost-effective setting (goes back to closing state supported living centers)
• Ensure clients are in the most cost-effective wavier program appropriate
• Streamline the waiver programs
• Perform utilization management and review for all community entitlement and wavier programs (in other words, eliminate the ones that do not have many people enrolled)
• Increase community based long-term care services while containing costs (this is interesting as both the Senate and House bills cut funding for this)
• Outsource waiver services to the community when possible

Both the Senate and House budgets are going to seriously decrease the services received to Texans. The long term implications will be abuse for elderly and disabled Texans at the hands of poorly paid, overworked providers. Lack of state assistance in the care of the elderly and disabled will burden families and insurance companies.

For the Department of State Health Services:
• Evaluate forensic commitment requirements to ensure that alleged offenders with a mental illness are being served in the most appropriate and cost-effective setting
• Streamline public health efforts
• Utilize residential units in state hospitals to provide cost-effective care and to maintain bed capacity
• Require hospitals which accept the state medical assistance program to charge state mental hospitals no more than the state medical assistance program fee for services
• Expand cost-effective models of care for mental illness
• Manage expenditures for drugs provided through the state mental hospitals
• Privatize a state mental hospital

There are pro’s and con’s to privatizing a hospital. Certainly outsourcing is a good way to reduce costs. The major cons are that you have a lack of accountability, a lack of control, and (of course) the hospital will be run with the idea of making a profit.

The assumption that anything having to do with the state can be made cost-effective is naïve and reflects a lack of understanding of how the state does business.

For the Department of Assistive and Rehabilitative Services:
• Evaluate the feasibility and cost-effectiveness of providing early childhood intervention services through the state medical assistance and child health plan program (i.e. Medicaid).

This would certainly shift the expenses involved with this program, it would also limit the people that would be served by it as Medicaid has eligibility requirements. Those people who would not be covered by these programs would be on their own. In addition, this shift is being evaluated at a time when the Senator has instructed HHSC to evaluate “… the state medical assistance and children as well as the child health plan program…”

For the Department of Family and Protective Services:
• Maximize use of the Department of State Health Services to provide mental health and substance abuse services that are purchased through CPS and adult protective services program.
• Make child care regulation more efficient.
• Redesign the foster care system so that it improves outcomes for children and families.
The first bullet directs DFPS to rely on DSHS during a time when DSHS is being told (in this bill) to privatize a hospital, make care more cost-effective, make drugs cost less, and pay providers less money. It seems a bit contradictory.

The second bullet probably isn’t possible given how the state of Texas operates, but it’s nice to say.

I think there’s a good intent behind this bill, but the bill is largely ignorant of how the state operates, it’s written in a way that it contradicts itself in several areas, and if it happened the way that it is written would have a serious impact on the services that Texans receive.

I think there needs to be a real serious dialog about what services Texas should provide to which citizens. Then there needs to be a real serious dialog about what state agencies are critical to providing those services, what can be eliminated, and what can be merged/streamlined. The Legislature also needs to realize that every one of the bills they file (almost) has a reporting requirement attached to it, which means that staff has to be hired/focused on generating those reports. This also needs to be prioritized so that the important information that the Legislature actually reads is delivered and the rest is dropped.

In February the Texas Comptroller released a report entitled “Gaining Costs, Losing Time: The Obesity Crisis in Texas.” The report can be found at: http://www.window.state.tx.us/specialrpt/obesitycost/ . It’s an important document because it provides a great deal of statistical and financial information for lawmakers in Texas.

First the big-picture statistics. According to the Comptroller’s report:
• Two thirds of Texas adults are overweight or obese.
• Almost 30% of Texas adults are obese.
• Both these are higher than the national averages, though not by much.
• More than 20% of Texas children aged 10-17 are obese (not overweight, they are obese), which is higher than the national average.
• Obese individuals spend $1429 per year on health care, which is 41.5% higher than normal-weight persons.
• In Texas, the Comptroller reports that obesity cost Texas businesses $9.5 billion in 2009.

Drilling down into the statistics, the information isn’t surprising but it bears repeating (keep in mind, these numbers are for Texans):
• Older individuals are more likely to be obese.
• Black and Hispanic adults are more likely to be obese. Child obesity is also more common among these populations.
• Education and income impact obesity:
o 22.2% of college graduates were obese vs. 37.4% of individuals without a high school diploma
o 38.1% of Texans earning $15,000-24,999 annually were obese vs. 26.3% of individuals earning more than $50,000 per year
• Obesity directly cost insurance companies (in Texas) $4 billion in 2009. This translates into increased insurance premiums and co-pays for everyone.
• The fitness level of Texas children is terrible. Using the Fitnessgram test results, the following is the percentage of students (by grade) who tested in the healthy fitness zone in 2009-2010:
o 3rd grade: 37.3% of girls, 31% of boys
o 4th grade: 34.2% of girls, 25.3% of boys
o 5th grade: 30.1% of girls, 21.8% of boys
o 12th grade: 8.1% of girls, 8.5% of boys
o Notice a trend as children get older?

So there is a problem. More Texans are obese or overweight, this leads to rising health care costs, disease, early death, and rising insurance costs. The Comptroller’s report has a number of recommendations.

A lot of these are things that should be done, but they won’t help (printing the number of calories in restaurants, education, etc.). I don’t say this to be negative, but the fact is that people understand how they should eat – they just chose not to eat that way.

The recommendations that I like from the report are:
• Study the link between fitness and academic performance. If there is one, this allows one to build a powerful case on why this is important. Performance on the TAKS test means money and prestige to school districts, if one can make the case that improving fitness would improve results…
• Restore the high school PE graduation requirement to 1.5 credits.
• Increase middle-school PE requirements to six semesters.
• The last two bullets at least provide the opportunity to make physical activity a habit and provide some physical activity to Texas’ children.

Bellar et al had a study published in the February issue of the Journal of Strength and Conditioning Research showing that band training is superior to increasing bench press strength than free weight tension alone. On the one hand, this is a valuable study because there is still a paucity of published research on band training. On the other hand, this study serves as a good object lessons as it has a number of shortcomings.

The study looked at eleven untrained college students (males) and put them on a 13-week training program for the bench press. The program was organized as follows:
Baseline 1-RM test
3 weeks of familiarization training
1-RM test
3 weeks of either band training (5x5x70% 1-RM + 15% in bands) or standard training (5x5x85%)
1-RM test
3 weeks of either band or standard training (whichever was not performed before)
1-RM test

The idea was to use the first 3 week phase to wash out the learning effect and to have each subject train on both protocols randomly.

The authors report that band training resulted in almost 10 kg of improvement in the bench press, standard training in over 7.5 kg. The band improvement was statistically different than the standard improvement.

There are a number of things that we don’t know from this study:
• Baseline strength levels: Due to the way the training is organized, we’re never given the week one bench press test. We’re only shown that band and standard training result in “x” improvement, but not the improvement over the entire 13 weeks.
• Strength levels at each 1-RM test

As I mentioned above, on the one hand its good to get more research on the effectiveness of band training. On the other, there are some shortcomings and cautions:
• Band training is probably going to be most effective with national-caliber and elite athletes, those who have exhausted the effectiveness of standard training.
• The training has extremely limited variety (i.e. 5x5x85% or 5x5x70+15%), this can limit the effectiveness of both protocols.
• Reporting that in the middle of a 13-week program, either band or standard training results in a given improvement seeks to disassociate parts of the training from the whole of the training process, which cannot be done. While one may use statistical tests to look at the effect of three weeks of training out of 13, in reality those three weeks are part of the 13 and heavily influenced by what came before and what comes after.
• I’m going to argue that there is still a major learning effect over the first 13 weeks and it’s difficult to argue that is not occurring.

When looking at the effectiveness of band training in the future, a few things would really make this a more powerful study (in case anyone is looking for a dissertation topic):
• Use national-caliber, experienced powerlifters.
• Longer study which is periodized, maybe 6-12 months.
• Include a number of assistance exercises.
• Have a band only group and a standard training only group, with volume, intensity, and load equivalent between the groups.

Bellar, D.M., Muller, M.D., Barkley, J.E., Kim, C-H., Ida, K., Ryan, E.J., Bliss, M.V., and Glickman, E.L. (2011). “The effects of combined elastic- and free-weight tension vs. free-weight tension on 1-RM strength in the bench press.” Journal of Strength and Conditioning Research, 25(2), 459-463.

Izquierdo et al had a study published in the February Medicine and Science in Sports and Exercise attempting to link EMG, strength, hypertrophy, and metabolite changes over a seven week period of training.

It’s an interesting study because it reinforces some of the things that challenge what we “know” about the neural adaptations to strength training.

The study looked at twelve active males and had them complete seven weeks of twice per week progressive total body strength training. Subjects were tested on the 10-RM leg press both pre- and post-training.

At the end of seven weeks of training, quadriceps cross-sectional area increased by over 4% and peak power output on the leg press increased by almost 11%. Beyond that, there are some interesting results:
• There seems to be less electrical activation at the quadriceps after the seven weeks of training.
• Blood lactate levels (during the 10-RM test) were significantly higher after the seven weeks of training.

There are a few important things to note about this study:
• First, the electrical activity results are interesting. Prior to training, as the subjects became fatigued the electrical activity in the quadriceps increased (perhaps increased recruitment to compensate for fatigue?). This did not occur post-training, suggesting some type of neural adaptation.
• Second, the fact that the blood lactate levels were higher during the 10-RM after seven weeks of training suggests that with training the subjects could tolerate greater levels of blood lactate than pre-training.
• Third, it’s a small subject size. It’s difficult to draw conclusions to a larger population after studying twelve subjects.
• Fourth, the subjects were relatively untrained. Again, it’s difficult to say how training impacts athletes and it’s impossible to apply these results to athletes.
• Fifth, seven weeks is a short time period. It’s difficult to apply these results to a longer period of training. Seven weeks was long enough to see a pretty significant increase in cross-sectional area and peak power

One of the big things to take home about this study is that despite what we think we “know” about neural adaptations to strength training, much of our knowledge is unsubstantiated by research. We know that strength and power increase faster than cross-sectional area, but we don’t know why as it is extremely challenging to measure muscle activation accurately. This is another study that reinforces how confusing and contradictory this information is.

Izuierdo, M., Gonzalez-Izal, M., Navarro-Amezqueta, I., Calbet, J.A.L., Ibanez, J., Malanda, A., Mallor, F., Hakkinen, K., Kraemer, W., Gorgostiage, E. (2010). “Effects of strength training on muscle fatigue mapping from surface EMG and blood metabolites.” Medicine and Science in Sports and Exercise, 43(2), 303-311.

Earp, et al. had an interesting article in the February issue of the Journal of Strength and Conditioning Research that reinforced something that I had written in an earlier post about plyometrics (http://wp.me/pZf7K-P) which is that different jumps may be applicable to different types of athletic events.  This is something that is really logical, but we rarely practice it with plyometrics.

The authors studied 25 “trained” individuals and looked at how characteristics like muscle fascicle length and pennation angle influences rate of force development on various jumps.  This is an interesting approach because there has been some work showing that pennation angle increases as a result of strength training and that length and angle both impact sprinting speed, but nothing looking at jumping.

Subjects performed 2-3 squat jumps (2 second pause at the bottom), countermovement jumps, and depth jumps (from a 30 cm box) on a force platform, the jumps were also videotaped.

There are some interesting results from this study:

  • Depth jump height > counter movement jump height > squat jump height, like you’d expect.
  • Peak vertical ground reaction force is greatest in depth jumps, then countermovement jumps, then squat jumps.
  • The depth jump had the greatest rate of force development at the 0-10, 10-30, and 30-50 millisecond time periods.
  • No anatomical variable predicted propulsion time for any jump type.
  • For the squat jump a longer Achilles tendon meant a faster rate of force production at the later stages of the jump.
  • For the countermovement jump, gastrocnemius fascicle length predicted rate of force development at the early stages of the jump (i.e. greater fascicle length meant greater rate of force development).
  • There is an intensity-dependent effect of Achilles tendon length on early force production.  Restated, higher intensity jumps requiring a faster rate of force production are more dependent upon Achilles tendon length than lower intensity jumps requiring a slower rate of force development.
  • Length of the muscle fascicles and the Achilles tendon is probably more important because of the “stretch” in the stretch shortening cycle.  Greater length means more stretch which means the ability to store and recover more elastic energy, in theory.

 

Things we don’t know from this study:

  • The “trained” status basically refers to recreational weight training.  Some subjects were former football players.  This means that it is challenging to carry these results over to an athletic population, which means that the usefulness of these results is limited.
  • We do not know how experienced these subjects were with these jumps.  Subjects with more experience (i.e. elite athletes) may have performed very differently.
  • We do not know basic things about these subjects like fast twitch fiber percentage, fiber area, or strength levels.  These are critical variables to successful performance of the jumps and may have impacted the results.  It also limits the applicability of the results to a larger population.

 

Interesting things that we can determine from this study:

  • The different jump types have different rate of force development profiles, which makes them more or less applicable to different athletic events.  For example, an athletic event that requires a RFD over a 0-50 millisecond time period is going to benefit more from a depth jump, one that requires it over 200-300 milliseconds is going to benefit more from a squat jump.
  • Fascicle length and Achilles tendon length may be things to look at for athlete selection, but this requires a great deal more research.

 

Earp. J.E., Kraemer, W.J., Cormie, P., Volek, J.S., Maresh, C.M., Joseph, M., and Newton, R.U. “Influence of muscle-tendon unit structure on rate of force development during the squat, countermovement, and drop jumps.”  Journal of Strength and Conditioning Research, 25(2), 340-347.