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National Institute on Disability and Rehabilitation Research Presentations Presentation 1 A Systematic Review of the Effectiveness of Exercise Rehabilitation for People With Dementia. Patricia Heyn, PhD (School of Allied Health Sciences/Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX); Beatriz C. Abreu, OTR, PhD; Kenneth J. Ottenbacher, OTR, PhD. Disclosure: None declared. Objective: To determine on the basis of a critical review and meta-analysis of the published literature whether physical exercises are beneficial for people with dementia and related cognitive disorders. Data Sources: A database of published and unpublished manuscripts from 1975 to October 2002 was compiled using MEDLINE, PubMed, CINAHL, AGELINE, Psyc-Lit, Educational Resources Information Center (ERIC), Sport Discuss (SIRC/CDC), Dissertation Abstracts, and a manual search. Key search words included physical activity, physical therapy, exercise, fitness, movement therapy, exercise rehabilitation, endurance, strength, aerobic training, flexibility, balance, aged, frail elderly, Alzheimer’s disease, dementia, cognitive impairment, and disability. Articles not written in English were excluded. Study Selection: To be included, reports had to meet the following criteria: (1) they had to evaluate the effects of intervention (exercise rehabilitation, program, or activities based on physical training), (2) they had to include older adults with cognitive impairments, (3) they had to evaluate outcome measures of physical fitness or health-related physical fitness components, cognitive and physical functioning, and behavior, (4) they had to include a control condition lacking exercise training, and (5) they had to use random assignment. Data Extraction: Two reviewers independently assessed the methodologic quality of the data of each included study. One reviewer extracted relevant meta-analysis data. Data Synthesis: Twentyone randomized trials met the inclusion criteria and were analyzed. For each selected outcome, summary effects were computed by pooling standardized mean differences as well as raw mean differences. Significant improvements were found for all outcomes. The meta-analysis resulted in a significant homogenous standardized effect sizes with regard to strength (.78; 95% CI, .63–.93) and behavior (.67; 95% CI, .46 –.87). The overall effect size (physical fitness, behavior, cognitive and functional performance), weighted by sample size, was dw equal to .67. This effect size index was converted to a U3 value of .75, indicating that the average patient receiving a program of focused exercise rehabilitation performed better than approximately 75% of those patients in comparison groups. Conclusions: The results show promising evidence of the benefits of physical activity and exercise training on strength, behavior, functional performance, cognition, and physical health of older persons affected by dementia syndrome and related cognitive impairments. Key Words: Cognition disorders; Dementia; Exercise; Rehabilitation.
Presentation 2 Outcomes and Reimbursement of Inpatient Rehabilitation Services for Medicare Beneficiaries With Stroke and Hip Fracture. Anne Deutsch, MS, RN (Northwestern University, Institute for Health Service Research and Policy Studies, Chicago, IL); Carl V. Granger, MD; Roger C. Fiedler, PhD; Gerben DeJong, PhD; Robert L. Kane, MD; Kenneth J. Ottenbacher, PhD; Allen W. Heinemann, PhD; Maurizio Trevisan, MD; John Naughton, MD. Disclosure: None declared. Objective: To assess whether outcomes and reimbursement differ for Medicare beneficiaries with a stroke or hip fracture when beneficiaries are treated in an inpatient rehabilitation facility (IRF)– versus a skilled nursing facility (SNF)– based rehabilitation program. Design: Retrospective cohort study in which patients’ clinical outcome data and Medicare payment data were linked. Setting: Inpatient rehabilitation facilities and skilled nursing facility-based rehabilitation programs from across the United States. Participants: 29,793 Medicare beneficiaries with hip fracture and 58,724 beneficiaries with stroke who were treated in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. Interventions: Not applicable. Main Outcomes Measures: Discharge destination after the rehabilitation stay and discharge FIM™ instrument motor ratings after adjustment for various patient- and facility-level characteristics; Medicare Part A reimbursement stratified by case-mix group (CMG). Results: Among older patients with hip fracture in CMGs 701 to 703 (age range, 83–102y) and all patients in CMGs 704 and 705, those treated in IRFs were less likely to return to the community. Adjusted odds ratios ranged from .73 (95% CI, .63–.84) to .82 (95% CI, .68 –.98). For younger patients in CMGs 701 to 703 (age range, 24 – 82y), the proportion of patients discharged to the community was equivalent. Discharge functional status for patients with hip fracture did not differ clinically. Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 54% to 73%. For all patients with stroke in CMGs 101 to 107, and younger patients in CMGs 108 to 114 (age range, 26 –77y), those treated in IRFs were more likely to return to the community. Adjusted odds ratios ranged from 1.42 (95% CI, 1.15–1.74) to 1.61 (95% CI, 1.22–2.11). The functional status of patients in CMGs 101 to 107 did not differ clinically, but for patients in CMGs 108 to 114, those treated in IRFs achieved more independence by discharge (raw FIM motor ratings were higher by 4.9 and 2.3 units for patients ⬍78y and ⬎77y, respectively). Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 79% to 117%. Conclusion: Patients with hip fracture achieved equal or better outcomes in SNF-based rehabilitation programs at a lower cost. Patients with stroke achieved better outcomes when treated in IRFs at a higher cost. Key Words: Medicare Part A; Rehabilitation.
Arch Phys Med Rehabil Vol 84, October 2003
Presentation 3 Assessing Disability in Older Adults: The Effects of Asking Questions With and Without Health Attribution. Nicole Dubuc, PhD (Boston University, Boston, MA); Stephen M. Haley, PhD; Jill T. Kooyoomjian, BA; Alan M. Jette, PhD. Disclosure: None declared. Objective: To determine the effects of using questions with and without health attribution on a self-reported disability instrument developed for use with older adults. Design: Cross-sectional. Setting: Community-based. Participants: 75 community-dwelling older adults from central and eastern Massachusetts. Interventions: Not applicable. Main Outcome Measures: We administered the disability component of the Late Life Function and Disability Instrument. To test whether altering attribution influenced scores, we administered the same 16 questions with attribution to specific health conditions. Results: A higher prevalence of disability was reported in the nonattributed compared with the health attribution (t⫽5.76, P⬍.001; 95% CI, 3.8 –7.8). Item analyses indicated that participants were significantly more likely to report disability on the nonattributed version of 4 of the 16 disability items that required out-of-home travel. Conclusions: In this sample of older adults, estimates of disability were underestimated by questions that included specific attribution to health conditions. Factors other than health appear to influence self-report of disability related to participation in travel outside of the home. Key Words: Disabled persons; Rehabilitation. Presentation 4 Intensive Medical Intervention and Pulmonary Rehabilitation of Patients With Advanced Restrictive Lung Disease. Isaac J. Kreizman, MD (Mount Sinai Medical Center, New York, NY). Disclosure: None declared. Objective: To examine the benefits of an inpatient pulmonary rehabilitation program on patients with advanced interstitial lung disease (ILD). Design: Prospective cohort study. Repeated measures with experimental interventions and control group over a 2-year period. Setting: In- and outpatient pulmonary rehabilitation program in a hospital-based academic center. Participants: A total of 80 patients with the diagnosis of advanced ILD— 40 consecutive patients (mean age, 45.7y) admitted for inpatient pulmonary rehabilitation with the diagnosis of advanced ILD and 40 patients (mean age, 48.1y) with the diagnosis of advanced ILD who did not receive inpatient rehabilitation services. Intervention: Patients with advanced ILD were offered inpatient pulmonary rehabilitation. Patients admitted for inpatient pulmonary rehabilitation received services as defined by the American Association of Cardiovascular and Pulmonary Rehabilitation. Main Outcome Measures: Pulmonary vital capacity, diffusion capacity, FIM™ instrument, 6-minute walk, and St. George’s Questionnaire. All measures were collected at the time of eligibility for admission to rehabilitation. Subsequent measures were collected in the inpatient program (experimental group) on discharge. The same measures were collected from patients (control group) who were not admitted for rehabilitation at the same time interval. Results: Analysis of covariance was used to test for group differences in mean change after adjusting for initial status. Improvements in all outcome measures were found in patients with ILD who received inpatient pulmonary rehabilitation services. These patients had improved vital capacity (Pⱕ.001), FIM score (Pⱕ.001), St. George’s Questionnaire score (Pⱕ.001), 6-minute walk score (Pⱕ.001), and diffusion capacity (P⫽.009). Conclusion: Pulmonary rehabilitation of patients with advanced ILD results in statistically significant improvement in pulmonary physiology, physical functioning, and quality of life. Key Words: Lung diseases, interstitial; Rehabilitation. Presentation 5 An Investigation of Foot Alignment and Support in Ankle Foot Orthoses. Stefania Fatone, PhD (Northwestern University Prosthetics Research Laboratory & Rehabilitation Engineering Research Program, Chicago, IL); Steven A. Gard, PhD; Dudley S. Childress, PhD; Bryan S. Malas, PhD. Disclosure: Supported by the Department of Veteran Affairs, Veterans Health Administration, Rehabilitation Research and Development Service (grant no. A2676I) and the National Institute on Disability and Rehabilitation Research, US Department of Education (training grant no. H133P990006.) Objective: To investigate the effect that ankle-foot alignment and foot support in ankle-foot orthoses (AFOs) may have on the gait of subjects with hemiplegia after stroke. Design: Test-retest. Setting: Motion analysis research laboratory. Participants: 20 participants with hemiplegia. Intervention: Subjects underwent 3 gait analyses, each 2 weeks apart. The first tested walking with a conventionally aligned AFO; the second tested walking with a heel-height compensated AFO with full-length footplate; and the third tested walking with a heel-height compensated AFO with three-quarter length footplate. Main Outcome Measures: We acquired bilateral kinematic, kinetic, electromyographic, and plantar pressure data, as well as subjective information from the subjects using a questionnaire. Results: Preliminary data from 7 subjects suggests that, compared with a shoes-only condition, all AFO conditions improved ankle position at initial contact and in swing, and, where knee hyperextension was present, reduced the onset and magnitude of the hyperextension. All AFO conditions also changed the internal knee moment from flexor to extensor, decreased the heel strike transient present in the vertical ground reaction force, and improved roll-over shape. Conclusions: Compared with the full length AFOs, the three-quarter length AFO provided the shortest roll-over shape and had the highest peak pressures in the midfoot. We believe that this study
National Institute on Disability and Rehabilitation Research Presentations Presentation 1 A Systematic Review of the Effectiveness of Exercise Rehabilitation for People With Dementia. Patricia Heyn, PhD (School of Allied Health Sciences/Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX); Beatriz C. Abreu, OTR, PhD; Kenneth J. Ottenbacher, OTR, PhD. Disclosure: None declared. Objective: To determine on the basis of a critical review and meta-analysis of the published literature whether physical exercises are beneficial for people with dementia and related cognitive disorders. Data Sources: A database of published and unpublished manuscripts from 1975 to October 2002 was compiled using MEDLINE, PubMed, CINAHL, AGELINE, Psyc-Lit, Educational Resources Information Center (ERIC), Sport Discuss (SIRC/CDC), Dissertation Abstracts, and a manual search. Key search words included physical activity, physical therapy, exercise, fitness, movement therapy, exercise rehabilitation, endurance, strength, aerobic training, flexibility, balance, aged, frail elderly, Alzheimer’s disease, dementia, cognitive impairment, and disability. Articles not written in English were excluded. Study Selection: To be included, reports had to meet the following criteria: (1) they had to evaluate the effects of intervention (exercise rehabilitation, program, or activities based on physical training), (2) they had to include older adults with cognitive impairments, (3) they had to evaluate outcome measures of physical fitness or health-related physical fitness components, cognitive and physical functioning, and behavior, (4) they had to include a control condition lacking exercise training, and (5) they had to use random assignment. Data Extraction: Two reviewers independently assessed the methodologic quality of the data of each included study. One reviewer extracted relevant meta-analysis data. Data Synthesis: Twentyone randomized trials met the inclusion criteria and were analyzed. For each selected outcome, summary effects were computed by pooling standardized mean differences as well as raw mean differences. Significant improvements were found for all outcomes. The meta-analysis resulted in a significant homogenous standardized effect sizes with regard to strength (.78; 95% CI, .63–.93) and behavior (.67; 95% CI, .46 –.87). The overall effect size (physical fitness, behavior, cognitive and functional performance), weighted by sample size, was dw equal to .67. This effect size index was converted to a U3 value of .75, indicating that the average patient receiving a program of focused exercise rehabilitation performed better than approximately 75% of those patients in comparison groups. Conclusions: The results show promising evidence of the benefits of physical activity and exercise training on strength, behavior, functional performance, cognition, and physical health of older persons affected by dementia syndrome and related cognitive impairments. Key Words: Cognition disorders; Dementia; Exercise; Rehabilitation.
Presentation 2 Outcomes and Reimbursement of Inpatient Rehabilitation Services for Medicare Beneficiaries With Stroke and Hip Fracture. Anne Deutsch, MS, RN (Northwestern University, Institute for Health Service Research and Policy Studies, Chicago, IL); Carl V. Granger, MD; Roger C. Fiedler, PhD; Gerben DeJong, PhD; Robert L. Kane, MD; Kenneth J. Ottenbacher, PhD; Allen W. Heinemann, PhD; Maurizio Trevisan, MD; John Naughton, MD. Disclosure: None declared. Objective: To assess whether outcomes and reimbursement differ for Medicare beneficiaries with a stroke or hip fracture when beneficiaries are treated in an inpatient rehabilitation facility (IRF)– versus a skilled nursing facility (SNF)– based rehabilitation program. Design: Retrospective cohort study in which patients’ clinical outcome data and Medicare payment data were linked. Setting: Inpatient rehabilitation facilities and skilled nursing facility-based rehabilitation programs from across the United States. Participants: 29,793 Medicare beneficiaries with hip fracture and 58,724 beneficiaries with stroke who were treated in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. Interventions: Not applicable. Main Outcomes Measures: Discharge destination after the rehabilitation stay and discharge FIM™ instrument motor ratings after adjustment for various patient- and facility-level characteristics; Medicare Part A reimbursement stratified by case-mix group (CMG). Results: Among older patients with hip fracture in CMGs 701 to 703 (age range, 83–102y) and all patients in CMGs 704 and 705, those treated in IRFs were less likely to return to the community. Adjusted odds ratios ranged from .73 (95% CI, .63–.84) to .82 (95% CI, .68 –.98). For younger patients in CMGs 701 to 703 (age range, 24 – 82y), the proportion of patients discharged to the community was equivalent. Discharge functional status for patients with hip fracture did not differ clinically. Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 54% to 73%. For all patients with stroke in CMGs 101 to 107, and younger patients in CMGs 108 to 114 (age range, 26 –77y), those treated in IRFs were more likely to return to the community. Adjusted odds ratios ranged from 1.42 (95% CI, 1.15–1.74) to 1.61 (95% CI, 1.22–2.11). The functional status of patients in CMGs 101 to 107 did not differ clinically, but for patients in CMGs 108 to 114, those treated in IRFs achieved more independence by discharge (raw FIM motor ratings were higher by 4.9 and 2.3 units for patients ⬍78y and ⬎77y, respectively). Across all CMGs, the IRF Medicare Part A payments were higher than SNF payments by 79% to 117%. Conclusion: Patients with hip fracture achieved equal or better outcomes in SNF-based rehabilitation programs at a lower cost. Patients with stroke achieved better outcomes when treated in IRFs at a higher cost. Key Words: Medicare Part A; Rehabilitation.
Arch Phys Med Rehabil Vol 84, October 2003
Presentation 3 Assessing Disability in Older Adults: The Effects of Asking Questions With and Without Health Attribution. Nicole Dubuc, PhD (Boston University, Boston, MA); Stephen M. Haley, PhD; Jill T. Kooyoomjian, BA; Alan M. Jette, PhD. Disclosure: None declared. Objective: To determine the effects of using questions with and without health attribution on a self-reported disability instrument developed for use with older adults. Design: Cross-sectional. Setting: Community-based. Participants: 75 community-dwelling older adults from central and eastern Massachusetts. Interventions: Not applicable. Main Outcome Measures: We administered the disability component of the Late Life Function and Disability Instrument. To test whether altering attribution influenced scores, we administered the same 16 questions with attribution to specific health conditions. Results: A higher prevalence of disability was reported in the nonattributed compared with the health attribution (t⫽5.76, P⬍.001; 95% CI, 3.8 –7.8). Item analyses indicated that participants were significantly more likely to report disability on the nonattributed version of 4 of the 16 disability items that required out-of-home travel. Conclusions: In this sample of older adults, estimates of disability were underestimated by questions that included specific attribution to health conditions. Factors other than health appear to influence self-report of disability related to participation in travel outside of the home. Key Words: Disabled persons; Rehabilitation. Presentation 4 Intensive Medical Intervention and Pulmonary Rehabilitation of Patients With Advanced Restrictive Lung Disease. Isaac J. Kreizman, MD (Mount Sinai Medical Center, New York, NY). Disclosure: None declared. Objective: To examine the benefits of an inpatient pulmonary rehabilitation program on patients with advanced interstitial lung disease (ILD). Design: Prospective cohort study. Repeated measures with experimental interventions and control group over a 2-year period. Setting: In- and outpatient pulmonary rehabilitation program in a hospital-based academic center. Participants: A total of 80 patients with the diagnosis of advanced ILD— 40 consecutive patients (mean age, 45.7y) admitted for inpatient pulmonary rehabilitation with the diagnosis of advanced ILD and 40 patients (mean age, 48.1y) with the diagnosis of advanced ILD who did not receive inpatient rehabilitation services. Intervention: Patients with advanced ILD were offered inpatient pulmonary rehabilitation. Patients admitted for inpatient pulmonary rehabilitation received services as defined by the American Association of Cardiovascular and Pulmonary Rehabilitation. Main Outcome Measures: Pulmonary vital capacity, diffusion capacity, FIM™ instrument, 6-minute walk, and St. George’s Questionnaire. All measures were collected at the time of eligibility for admission to rehabilitation. Subsequent measures were collected in the inpatient program (experimental group) on discharge. The same measures were collected from patients (control group) who were not admitted for rehabilitation at the same time interval. Results: Analysis of covariance was used to test for group differences in mean change after adjusting for initial status. Improvements in all outcome measures were found in patients with ILD who received inpatient pulmonary rehabilitation services. These patients had improved vital capacity (Pⱕ.001), FIM score (Pⱕ.001), St. George’s Questionnaire score (Pⱕ.001), 6-minute walk score (Pⱕ.001), and diffusion capacity (P⫽.009). Conclusion: Pulmonary rehabilitation of patients with advanced ILD results in statistically significant improvement in pulmonary physiology, physical functioning, and quality of life. Key Words: Lung diseases, interstitial; Rehabilitation. Presentation 5 An Investigation of Foot Alignment and Support in Ankle Foot Orthoses. Stefania Fatone, PhD (Northwestern University Prosthetics Research Laboratory & Rehabilitation Engineering Research Program, Chicago, IL); Steven A. Gard, PhD; Dudley S. Childress, PhD; Bryan S. Malas, PhD. Disclosure: Supported by the Department of Veteran Affairs, Veterans Health Administration, Rehabilitation Research and Development Service (grant no. A2676I) and the National Institute on Disability and Rehabilitation Research, US Department of Education (training grant no. H133P990006.) Objective: To investigate the effect that ankle-foot alignment and foot support in ankle-foot orthoses (AFOs) may have on the gait of subjects with hemiplegia after stroke. Design: Test-retest. Setting: Motion analysis research laboratory. Participants: 20 participants with hemiplegia. Intervention: Subjects underwent 3 gait analyses, each 2 weeks apart. The first tested walking with a conventionally aligned AFO; the second tested walking with a heel-height compensated AFO with full-length footplate; and the third tested walking with a heel-height compensated AFO with three-quarter length footplate. Main Outcome Measures: We acquired bilateral kinematic, kinetic, electromyographic, and plantar pressure data, as well as subjective information from the subjects using a questionnaire. Results: Preliminary data from 7 subjects suggests that, compared with a shoes-only condition, all AFO conditions improved ankle position at initial contact and in swing, and, where knee hyperextension was present, reduced the onset and magnitude of the hyperextension. All AFO conditions also changed the internal knee moment from flexor to extensor, decreased the heel strike transient present in the vertical ground reaction force, and improved roll-over shape. Conclusions: Compared with the full length AFOs, the three-quarter length AFO provided the shortest roll-over shape and had the highest peak pressures in the midfoot. We believe that this study