- Email: [email protected]
Poster 47
A14
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
muscles of the aged rats showed significantly greater numbers of developmental MHC positive cells when compared with the soleus of the 12-month-old rats. The EDL of the 36-month-old rats exhibited noticeably greater numbers of developmental MHC positive cells than in the young animals in half of the muscles studied. Conclusions: There is evidence of skeletal muscle regeneration occurring in the soleus of the aged rats in the midst of the fiber atrophy that accompanies aging. Such changes in the EDL also occur, but appear to be less common. The muscle specific differences observed in the expression of developmental MHC with age may be influenced by the fiber type and function differences of this muscle as compared with the soleus. Evaluation of the coexpression of the developmental MHC with the mature MHCs (slow, fast) is currently under investigation. Key Words: Aging; Rehabilitation; Skeletal muscle. Poster 47 Does Use of Bedrails in a Subacute Rehabilitation Facility Benefit the Patient? Stephanie Clop, MD (San Juan VA Medical Center, San Juan, PR); Maricarmen Cruz-Jimenez, MD, e-mail: [email protected]. Disclosure: None. Objective: To analyze the number and severity of falls in a subacute rehabilitation facility before and after the implementation of the “no-restraint policy” of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Design: Retrospective study. Setting: Subacute rehabilitation facility. Participants: All residents at the facility between January 1, 1996, and July 1, 1999. Interventions: Not applicable. Main Outcome Measure: The number of falls were quantified. Severity of injuries was qualified: level 0 is no injury, level 1 is a minor injury, level 2 is a major injury, and level 3 is death. Results: There was a significant increase in falls (207 before, 227 after) when the no-restraint policy started (P⫽.0005), with a relative risk (RR) of 1.4 (restraints were defined as bedrails). There was no significant difference in the severity of injuries between the groups. In the bedrail group, significantly more injuries were found in those who were confused (P⫽.0595). In oriented patients, a significant decrease in the number of falls (P⫽.0624) and risk of injuries were found with bedrail use (RR⫽.54). Conclusions: After the implementation of the JCAHO no-restraint policy, a significant increase in the number of falls was found in our long-term care facility. There was an observable tendency of a subgroup of patients to benefit from bedrails (oriented patients). Key Words: Accidental falls; Orientation; Rehabilitation; Restraint, physical. Poster 48 Aging-Related Changes in Achilles’ Tendon Reflexes.Sun G. Chung, MD, PhD (Rehabilitation Institute of Chicago, Chicago, IL); Elton van Rey, PT; Elliot J. Roth, MD; Li-Qun Zhang, PhD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the aging-related changes of Achilles’ tendon reflex activities. Design: Case-control study. Setting: Institutional research center. Participants: 14 elderly subjects (8 women, 6 men; mean age, 69.4⫾7.1y) and 18 young subjects (9 women, 9 men; mean age, 30.0⫾6.6y). Intervention: Subjects were seated in a custom-designed chair with the trunk, thigh, and lower leg immobilized. The foot was fixed firmly on a footplate connected to a torque sensor. The Achilles’ tendon was tapped using a force transducer–mounted plastic hammer. Tendon-tapping force and the resulting reflex torque generated by the ankle joint were measured simultaneously at neutral ankle position in the isometric condition to minimize nonreflex viscoelastic contribution of muscle. Main Outcome Measures: Peak reflex-mediated torque, peak electromyography, and tendon reflex gain calculated from the relationship between the tapping force and joint torque were compared as parameters for reflex magnitude. Reflex loop delay and contraction time were analyzed as parameters for reflex timing. Results: The elderly subjects showed lower peak torque (2.33⫾1.29Nm) and tendon reflex gain (332.69⫾226.32cm) than the young subjects (3.75⫾1.92Nm, 657.62⫾401.37cm; P⫽.024, P⫽.009, respectively). Longer reflex loop delay was noticed in the elderly group (47.0⫾10.89ms) as compared with the young group (40.19⫾5ms) (P⫽.028). The peak electromyographic activity was lower (.13⫾.12mV vs .17⫾.15mV, P⫽.43) and contraction time was longer (144.43⫾30.02ms vs 131.0⫾31.7ms, P⫽.24) in the elderly group, but neither was significant. Conclusions: Not only was the magnitude of Achilles’ tendon reflex decreasing but also the reflex loop latency was delayed along with the neuromuscular aging process. Relatively longer contraction time with lower peak reflex torque in elderly subjects may be considered as less synchronized reflex excitation with aging. Key Words: Aging; Reflex, stretch; Rehabilitation.
Poster 49 Acute Rehabilitation of the Geriatric Patient: Sociocultural, Clinical, and Functional Characteristics With Implications. Yee Sien Ng, MD (Singapore General Hospital, Singapore, Singapore); Swee Long Chong, MD, e-mail: [email protected]. Disclosure: None. Objectives: To define the sociodemographics, clinical, and functional characteristics of the Singapore population and to discuss the implications. Design: A database review of patients defined as geriatric (age ⬎64y) compared with the nongeriatric patients. Setting: Rehabilitation unit. Participants: 172 (46%) of 374 consecutively admitted patients. Interventions: Not applicable. Main Outcome Measure: FIM™ instrument. Results: 87 (51%) of the geriatric group were men and stroke (64.5%) was the most common primary diagnosis. 39 patients (22.6%) had depression, and urinary tract infection (UTI) was the most common (n⫽36, 20.1%) medical complication. Comparing the geriatric and nongeriatric groups, no significant differences were found in the rehabilitation length of stay (P⫽.41). In the geriatric group, the mean admission FIM score was 65 while the final FIM score was 84.1 and these were lower than the corresponding scores for the nongeriatric group (admission FIM⫽70.2, P⫽.03; discharge FIM⫽90.4, P⫽.008). However, there were no differences in the quantum of improvement of the FIM scores (P⫽.45) between the 2 groups. 24 geriatric patients (14%) had no ready caregiver. Most geriatric patients (90.1%) were discharged home and outpatient therapies were arranged for most (80%). Conclusions: About half of our patients were geriatric, and good functional gains were achieved compared with the nongeriatric patients. Depression and UTI are common and vigilance should be maintained in
Arch Phys Med Rehabil Vol 84, September 2003
detecting and treating these. A home disposition is an achievable goal and discharge planning should consider options if no caregiver is available. Outpatient therapies should remain affordable and accessible. Key Words: Complications; Geriatrics; Rehabilitation.
Poster 50 A Meta-Analysis on the Effects of Different Intervention Programs in Decreasing the Incidence of Falls in the Elderly.Maria Luisa P. Santos, MD (Univesity of Santo Tomas, Manila, Philippines); Consuelo G. Suarez, MD, e-mail: [email protected]. Disclosure: None. Objective: To review the evidence of the effect of fall prevention programs in decreasing the rate of falls and fractures in older persons. Design: Meta-analysis. Setting: Household and community centers. Participants: Elderly persons 60 years and older. Interventions: Balance and strength training, education and environmental modifications. Main Outcome Measures: Decreased incidence of falls. Results: 16 studies met the eligibility criteria. 13 trials were rated high and only 3 studies did poorly with a score of 3/6. The summary of the overall magnitude of the effect of the dataset was beneficial, favoring the intervention group (odds ratio [OR]⫽.56). Only trials with comprehensive risk assessment intervention demonstrated an effect size favoring the control group (OR⫽1.17). Stratified analysis revealed a homogenous population with trials done in established institutions. Conclusion: Fall prevention programs decrease the occurrence of falls by an OR of .56 (95% CI, .49 –.63) while fracture had an overall OR of .52 (95% CI, .35–.78). Fall prevention programs are therefore beneficial for elderly patients in decreasing incidence of falls and fall-related fractures. Key Words: Accidental falls; Elderly; Exercise; Rehabilitation.
Poster 51 Effects of the Proprioceptive Feedback Intervention With SENSERite and Circumferential Ankle Pressure on Proprioception and Balance Performance in Community-Dwelling Older Adults With Diminished Ankle Perception. Joshua H. You, PT, PhD (University of Virginia, Charlottesville, VA); Linda Bunker, PhD; Bruce Gansneder, PhD; Joe Gieck, PT, ATC, EdD; Ethan Saliba, PT, PhD; Susan Saliba, PT, PhD, e-mail: sung.you@hampton. Disclosure: None. Objective: To investigate the effects of proprioceptive feedback intervention (PFI) with the SENSERite system and circumferential ankle pressure on ankle proprioceptive acuity and balance performance. Design: Repeated measure with double-blinded assessments of outcomes at 3 points. Setting: A university laboratory. Participants: 40 community-dwelling older adults with either lower (diminished) entering proprioceptive acuity (LEPA) or higher entering proprioceptive acuity (HEPA). Intervention: The control group received PFI alone and used perceptual error feedback presented in the SENSERite system’s screen in terms of knowledge of results to match a selfselected target position as accurately as possible. The experimental group received concurrent PFI and circumferential ankle pressure. Main Outcome Measures: Electromechanically measured absolute constant error, variable error, and equilibrium score. Results: LEPA participants in the experimental group demonstrated significantly reduced absolute constant error across time (P⬍.05). No statistical significances for variable error and equilibrium score were observed. Conclusions: LEPA participants enhanced proprioceptive accuracy more from a combination of PFI and circumferential ankle pressure than from PFI alone via a mechanism known as peripheral control. In contrast, HEPA participants did not show significant improvement across time and may have relied on central control mechanisms to maintain accuracy. Balance performance was essentially unaffected by either intervention, perhaps due to lack of practice specificity. Key Words: Balance; Pressure; Proprioception; Rehabilitation.
Poster 52 Phase Advanced Circadian Sleep Disorder in an Elderly Institutionalized Patient: A Case Report. Alvin K. Antony, MD (University of North Carolina, Chapel Hill, NC); Bradley Vaughn, MD; John Oh, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university rehabilitation center. Patient: An 85-year-old female resident of a geriatric care facility where she fell and sustained a right hip fracture. Case Description: The patient required a right total hip arthroplasty and was admitted to the rehabilitation center. During inpatient rehabilitation, the patient was noted to have the daily onset of somnolence in the early afternoon, poor nocturnal sleep, and poor daytime performance and alertness. Nighttime administration of sedative hypnotics failed to induce sleep and instead caused agitation and confusion. Assessment/Results: Magnetic resonance imaging and magnetic resonance angiography of the brain and serum electrolytes were normal. The sleep referral service was consulted and after quantitative and qualitative studies the patient was noted to have a phase advanced circadian sleep disorder. Because of polypharmacy issues, nonpharmacologic recommendations were instituted to delay sleep onset. The patient was transferred to a room with a southern exposure and more sunlight. When not in therapy, she was kept at the nurses’ station to increase her social interaction. The patient’s therapy sessions were shifted to the early afternoon when she was most prone to sleep. After 2 weeks, the patient had improved daytime performance, had more normal sleep onset, and slept throughout the night. Discussion: The circadian system via the hypothalamic suprachiasmatic nucleus governs the sleep-wake cycle in mammals. Zeitgebers, or modulators, of the circadian system include light, exercise, and social interaction. The circadian system can become phase advanced in elderly institutionalized patients due to poor sunlight exposure, limited social interaction in the evening hours, and limited exercise resulting in early sleep onset and poor daytime performance and alertness. Conclusion: Nonpharmacologic measures, such as increasing bright sunlight exposure, increasing social interaction, and timing of therapy sessions, can prevent early sleep onset and improve nighttime sleep in elderly rehabilitation patients. Key Words: Circadian rhythm; Rehabilitation; Sleep disorders.
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
muscles of the aged rats showed significantly greater numbers of developmental MHC positive cells when compared with the soleus of the 12-month-old rats. The EDL of the 36-month-old rats exhibited noticeably greater numbers of developmental MHC positive cells than in the young animals in half of the muscles studied. Conclusions: There is evidence of skeletal muscle regeneration occurring in the soleus of the aged rats in the midst of the fiber atrophy that accompanies aging. Such changes in the EDL also occur, but appear to be less common. The muscle specific differences observed in the expression of developmental MHC with age may be influenced by the fiber type and function differences of this muscle as compared with the soleus. Evaluation of the coexpression of the developmental MHC with the mature MHCs (slow, fast) is currently under investigation. Key Words: Aging; Rehabilitation; Skeletal muscle. Poster 47 Does Use of Bedrails in a Subacute Rehabilitation Facility Benefit the Patient? Stephanie Clop, MD (San Juan VA Medical Center, San Juan, PR); Maricarmen Cruz-Jimenez, MD, e-mail: [email protected]. Disclosure: None. Objective: To analyze the number and severity of falls in a subacute rehabilitation facility before and after the implementation of the “no-restraint policy” of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Design: Retrospective study. Setting: Subacute rehabilitation facility. Participants: All residents at the facility between January 1, 1996, and July 1, 1999. Interventions: Not applicable. Main Outcome Measure: The number of falls were quantified. Severity of injuries was qualified: level 0 is no injury, level 1 is a minor injury, level 2 is a major injury, and level 3 is death. Results: There was a significant increase in falls (207 before, 227 after) when the no-restraint policy started (P⫽.0005), with a relative risk (RR) of 1.4 (restraints were defined as bedrails). There was no significant difference in the severity of injuries between the groups. In the bedrail group, significantly more injuries were found in those who were confused (P⫽.0595). In oriented patients, a significant decrease in the number of falls (P⫽.0624) and risk of injuries were found with bedrail use (RR⫽.54). Conclusions: After the implementation of the JCAHO no-restraint policy, a significant increase in the number of falls was found in our long-term care facility. There was an observable tendency of a subgroup of patients to benefit from bedrails (oriented patients). Key Words: Accidental falls; Orientation; Rehabilitation; Restraint, physical. Poster 48 Aging-Related Changes in Achilles’ Tendon Reflexes.Sun G. Chung, MD, PhD (Rehabilitation Institute of Chicago, Chicago, IL); Elton van Rey, PT; Elliot J. Roth, MD; Li-Qun Zhang, PhD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the aging-related changes of Achilles’ tendon reflex activities. Design: Case-control study. Setting: Institutional research center. Participants: 14 elderly subjects (8 women, 6 men; mean age, 69.4⫾7.1y) and 18 young subjects (9 women, 9 men; mean age, 30.0⫾6.6y). Intervention: Subjects were seated in a custom-designed chair with the trunk, thigh, and lower leg immobilized. The foot was fixed firmly on a footplate connected to a torque sensor. The Achilles’ tendon was tapped using a force transducer–mounted plastic hammer. Tendon-tapping force and the resulting reflex torque generated by the ankle joint were measured simultaneously at neutral ankle position in the isometric condition to minimize nonreflex viscoelastic contribution of muscle. Main Outcome Measures: Peak reflex-mediated torque, peak electromyography, and tendon reflex gain calculated from the relationship between the tapping force and joint torque were compared as parameters for reflex magnitude. Reflex loop delay and contraction time were analyzed as parameters for reflex timing. Results: The elderly subjects showed lower peak torque (2.33⫾1.29Nm) and tendon reflex gain (332.69⫾226.32cm) than the young subjects (3.75⫾1.92Nm, 657.62⫾401.37cm; P⫽.024, P⫽.009, respectively). Longer reflex loop delay was noticed in the elderly group (47.0⫾10.89ms) as compared with the young group (40.19⫾5ms) (P⫽.028). The peak electromyographic activity was lower (.13⫾.12mV vs .17⫾.15mV, P⫽.43) and contraction time was longer (144.43⫾30.02ms vs 131.0⫾31.7ms, P⫽.24) in the elderly group, but neither was significant. Conclusions: Not only was the magnitude of Achilles’ tendon reflex decreasing but also the reflex loop latency was delayed along with the neuromuscular aging process. Relatively longer contraction time with lower peak reflex torque in elderly subjects may be considered as less synchronized reflex excitation with aging. Key Words: Aging; Reflex, stretch; Rehabilitation.
Poster 49 Acute Rehabilitation of the Geriatric Patient: Sociocultural, Clinical, and Functional Characteristics With Implications. Yee Sien Ng, MD (Singapore General Hospital, Singapore, Singapore); Swee Long Chong, MD, e-mail: [email protected]. Disclosure: None. Objectives: To define the sociodemographics, clinical, and functional characteristics of the Singapore population and to discuss the implications. Design: A database review of patients defined as geriatric (age ⬎64y) compared with the nongeriatric patients. Setting: Rehabilitation unit. Participants: 172 (46%) of 374 consecutively admitted patients. Interventions: Not applicable. Main Outcome Measure: FIM™ instrument. Results: 87 (51%) of the geriatric group were men and stroke (64.5%) was the most common primary diagnosis. 39 patients (22.6%) had depression, and urinary tract infection (UTI) was the most common (n⫽36, 20.1%) medical complication. Comparing the geriatric and nongeriatric groups, no significant differences were found in the rehabilitation length of stay (P⫽.41). In the geriatric group, the mean admission FIM score was 65 while the final FIM score was 84.1 and these were lower than the corresponding scores for the nongeriatric group (admission FIM⫽70.2, P⫽.03; discharge FIM⫽90.4, P⫽.008). However, there were no differences in the quantum of improvement of the FIM scores (P⫽.45) between the 2 groups. 24 geriatric patients (14%) had no ready caregiver. Most geriatric patients (90.1%) were discharged home and outpatient therapies were arranged for most (80%). Conclusions: About half of our patients were geriatric, and good functional gains were achieved compared with the nongeriatric patients. Depression and UTI are common and vigilance should be maintained in
Arch Phys Med Rehabil Vol 84, September 2003
detecting and treating these. A home disposition is an achievable goal and discharge planning should consider options if no caregiver is available. Outpatient therapies should remain affordable and accessible. Key Words: Complications; Geriatrics; Rehabilitation.
Poster 50 A Meta-Analysis on the Effects of Different Intervention Programs in Decreasing the Incidence of Falls in the Elderly.Maria Luisa P. Santos, MD (Univesity of Santo Tomas, Manila, Philippines); Consuelo G. Suarez, MD, e-mail: [email protected]. Disclosure: None. Objective: To review the evidence of the effect of fall prevention programs in decreasing the rate of falls and fractures in older persons. Design: Meta-analysis. Setting: Household and community centers. Participants: Elderly persons 60 years and older. Interventions: Balance and strength training, education and environmental modifications. Main Outcome Measures: Decreased incidence of falls. Results: 16 studies met the eligibility criteria. 13 trials were rated high and only 3 studies did poorly with a score of 3/6. The summary of the overall magnitude of the effect of the dataset was beneficial, favoring the intervention group (odds ratio [OR]⫽.56). Only trials with comprehensive risk assessment intervention demonstrated an effect size favoring the control group (OR⫽1.17). Stratified analysis revealed a homogenous population with trials done in established institutions. Conclusion: Fall prevention programs decrease the occurrence of falls by an OR of .56 (95% CI, .49 –.63) while fracture had an overall OR of .52 (95% CI, .35–.78). Fall prevention programs are therefore beneficial for elderly patients in decreasing incidence of falls and fall-related fractures. Key Words: Accidental falls; Elderly; Exercise; Rehabilitation.
Poster 51 Effects of the Proprioceptive Feedback Intervention With SENSERite and Circumferential Ankle Pressure on Proprioception and Balance Performance in Community-Dwelling Older Adults With Diminished Ankle Perception. Joshua H. You, PT, PhD (University of Virginia, Charlottesville, VA); Linda Bunker, PhD; Bruce Gansneder, PhD; Joe Gieck, PT, ATC, EdD; Ethan Saliba, PT, PhD; Susan Saliba, PT, PhD, e-mail: sung.you@hampton. Disclosure: None. Objective: To investigate the effects of proprioceptive feedback intervention (PFI) with the SENSERite system and circumferential ankle pressure on ankle proprioceptive acuity and balance performance. Design: Repeated measure with double-blinded assessments of outcomes at 3 points. Setting: A university laboratory. Participants: 40 community-dwelling older adults with either lower (diminished) entering proprioceptive acuity (LEPA) or higher entering proprioceptive acuity (HEPA). Intervention: The control group received PFI alone and used perceptual error feedback presented in the SENSERite system’s screen in terms of knowledge of results to match a selfselected target position as accurately as possible. The experimental group received concurrent PFI and circumferential ankle pressure. Main Outcome Measures: Electromechanically measured absolute constant error, variable error, and equilibrium score. Results: LEPA participants in the experimental group demonstrated significantly reduced absolute constant error across time (P⬍.05). No statistical significances for variable error and equilibrium score were observed. Conclusions: LEPA participants enhanced proprioceptive accuracy more from a combination of PFI and circumferential ankle pressure than from PFI alone via a mechanism known as peripheral control. In contrast, HEPA participants did not show significant improvement across time and may have relied on central control mechanisms to maintain accuracy. Balance performance was essentially unaffected by either intervention, perhaps due to lack of practice specificity. Key Words: Balance; Pressure; Proprioception; Rehabilitation.
Poster 52 Phase Advanced Circadian Sleep Disorder in an Elderly Institutionalized Patient: A Case Report. Alvin K. Antony, MD (University of North Carolina, Chapel Hill, NC); Bradley Vaughn, MD; John Oh, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university rehabilitation center. Patient: An 85-year-old female resident of a geriatric care facility where she fell and sustained a right hip fracture. Case Description: The patient required a right total hip arthroplasty and was admitted to the rehabilitation center. During inpatient rehabilitation, the patient was noted to have the daily onset of somnolence in the early afternoon, poor nocturnal sleep, and poor daytime performance and alertness. Nighttime administration of sedative hypnotics failed to induce sleep and instead caused agitation and confusion. Assessment/Results: Magnetic resonance imaging and magnetic resonance angiography of the brain and serum electrolytes were normal. The sleep referral service was consulted and after quantitative and qualitative studies the patient was noted to have a phase advanced circadian sleep disorder. Because of polypharmacy issues, nonpharmacologic recommendations were instituted to delay sleep onset. The patient was transferred to a room with a southern exposure and more sunlight. When not in therapy, she was kept at the nurses’ station to increase her social interaction. The patient’s therapy sessions were shifted to the early afternoon when she was most prone to sleep. After 2 weeks, the patient had improved daytime performance, had more normal sleep onset, and slept throughout the night. Discussion: The circadian system via the hypothalamic suprachiasmatic nucleus governs the sleep-wake cycle in mammals. Zeitgebers, or modulators, of the circadian system include light, exercise, and social interaction. The circadian system can become phase advanced in elderly institutionalized patients due to poor sunlight exposure, limited social interaction in the evening hours, and limited exercise resulting in early sleep onset and poor daytime performance and alertness. Conclusion: Nonpharmacologic measures, such as increasing bright sunlight exposure, increasing social interaction, and timing of therapy sessions, can prevent early sleep onset and improve nighttime sleep in elderly rehabilitation patients. Key Words: Circadian rhythm; Rehabilitation; Sleep disorders.