Meaningful Change Estimates for the Late-Life Function and Disability Instrument in Older Adults

Trajectories of Physical Function and Disability Over 12 Months in Older Adults With Chronic Low Back Pain

BACKGROUND AND PURPOSE

Understanding prognosis is critical for clinical care and health policy initiatives. The purpose of this study was to determine whether distinct prognostic trajectories of physical function and disability exist in a cohort of 245 community-dwelling older adults with chronic low back pain (LBP), and to characterize the demographic, health, and pain-related profiles of each trajectory subgroup.

METHODS

All participants underwent standard clinic examinations at baseline, 3 months, 6 months, and 12 months. At each time point, the Late Life Function & Disability Instrument (LLFDI) was used to measure general physical function (LLFDI Function) and disability (LLFDI Disability-Limitation); the Quebec LBP Disability Questionnaire was used to measure disability due to pain. Growth mixture modeling (GMM) was performed on each outcome to identify distinct trajectory classes/subgroups; baseline demographic (eg, age and sex), health (eg, comorbidities, depressive symptoms, and physical activity level), and pain-related (eg, LBP intensity, pain-related fear, and pain catastrophizing) characteristic profiles were compared across subgroups.

RESULTS

GMM statistics revealed an optimal number of 3 to 4 trajectory subgroups, depending on the outcome examined. Subgroups differed across demographic, health, and pain-related characteristics; the classes with the most favorable prognoses had consistent profile patterns: fewer depressive symptoms, fewer comorbidities, higher physical activity levels, lower LBP intensities, less pain-related fear, and less pain catastrophizing.

CONCLUSION

Our findings indicate that several distinct trajectory subgroups exist that would have been masked by observing mean cohort change alone. Furthermore, subgroup characteristic profiles may help clinicians identify likely prognostic trajectories for their patients. Future research should focus on identifying modifiable risk factors that best predict group membership, and tailoring interventions to mitigate the risk of poor prognosis.

Measures of perceived mobility ability in community-dwelling older adults: a systematic review of psychometric properties

OBJECTIVES

The objective of this systematic review was to synthesise the psychometric properties of measures of perceived mobility ability and related frameworks used to define and operationalise mobility in community-dwelling older adults.

METHODS

We registered the review protocol with PROSPERO (CRD42022306689) and included studies that examined the psychometric properties of perceived mobility measures in community-dwelling older adults. Five databases were searched to identify potentially relevant primary studies. We qualitatively summarised psychometric property estimates and related operational frameworks. We conducted risk of bias and overall quality assessments, and meta-analyses when at least three studies were included for a particular outcome. The synthesised results were compared against the Consensus-based Standards for the Selection of Health Measurement Instruments criteria for good measurement properties.

RESULTS

A total of 36 studies and 17 measures were included in the review. The Late-Life Function and Disability Index: function component (LLFDI-FC), lower extremity functional scale (LEFS), Mobility Assessment Tool (MAT)-short form (MAT-SF) or MAT-Walking, and Perceived Driving Abilities (PDA) Scale were identified with three or more eligible studies. Most measures showed sufficient test-retest reliability (moderate or high), while the PDA scale showed insufficient reliability (low). Most measures had sufficient or inconsistent convergent validity (low or moderate) or known-groups validity (low or very low), but their predictive validity and responsiveness were insufficient or inconsistent (low or very low). Few studies used a conceptual model.

CONCLUSION

The LLFDI-FC, LEFS, PDA and MAT-SF/Walking can be used in community-dwelling older adults by considering the summarised psychometric properties. No available comprehensive mobility measure was identified that covered all mobility domains.

An innovative rehabilitation program for the veterans affairs post-acute skilled nursing setting: Preliminary results

BACKGROUND

Skilled nursing rehabilitative care plays a critical role in older adults' functional recovery impacting post-discharge outcomes. Variations across post-acute rehabilitative care services and patient outcomes indicate a need to improve rehabilitative care in this setting. We adapted a successful outpatient care program (Live Long Walk Strong-LLWS) to address this need in post-acute care settings within the Veterans Health Administration. LLWS differs from standard PT care by treating impairments linked to functional decline that are not traditionally targeted by standard care, providing formalized coaching to optimize behavior change, and providing post-discharge case management to optimize long-term outcomes. The purpose was to adapt, refine and implement the LLWS program for the Community Living Center (CLC), determine its acceptability and feasibility, and evaluate its preliminary effectiveness among older adults.

METHODS

The design of the program was adapted from the original outpatient LLWS program to the CLC setting through quality improvement methods and the Replicating Effective Programs (REP) framework. Primary outcomes included measures of feasibility and acceptability of >80% enrollment and completion of sessions as well as preliminary effectiveness using performance-based and patient-reported measures of function including the Short Physical Performance Battery (SPPB), AM-PAC, a Global Rating of Change questionnaire, and a satisfaction survey.

RESULTS

After 18 months, 51 Veterans had enrolled in the LLWS program, with 94.1% maintaining enrollment. We observed >80% completion of the inpatient and home follow-up sessions. Most patients were highly satisfied with care. Improvements in the SPPB (2.3 (SD 2.2) points), gait speed (0.17 (0.14) m/s) and the AM-PAC (6.5 (SD 5.7)) surpassed clinically meaningful thresholds.

CONCLUSIONS

This novel care program is feasible and acceptable to Veterans, demonstrating preliminary effectiveness with improving functional outcomes. Future research is needed to further examine the program's impact on other important outcomes relative to standard modes of care.

Connecting real-world digital mobility assessment to clinical outcomes for regulatory and clinical endorsement-the Mobilise-D study protocol

BACKGROUND

The development of optimal strategies to treat impaired mobility related to ageing and chronic disease requires better ways to detect and measure it. Digital health technology, including body worn sensors, has the potential to directly and accurately capture real-world mobility. Mobilise-D consists of 34 partners from 13 countries who are working together to jointly develop and implement a digital mobility assessment solution to demonstrate that real-world digital mobility outcomes have the potential to provide a better, safer, and quicker way to assess, monitor, and predict the efficacy of new interventions on impaired mobility. The overarching objective of the study is to establish the clinical validity of digital outcomes in patient populations impacted by mobility challenges, and to support engagement with regulatory and health technology agencies towards acceptance of digital mobility assessment in regulatory and health technology assessment decisions.

METHODS/DESIGN

The Mobilise-D clinical validation study is a longitudinal observational cohort study that will recruit 2400 participants from four clinical cohorts. The populations of the Innovative Medicine Initiative-Joint Undertaking represent neurodegenerative conditions (Parkinson's Disease), respiratory disease (Chronic Obstructive Pulmonary Disease), neuro-inflammatory disorder (Multiple Sclerosis), fall-related injuries, osteoporosis, sarcopenia, and frailty (Proximal Femoral Fracture). In total, 17 clinical sites in ten countries will recruit participants who will be evaluated every six months over a period of two years. A wide range of core and cohort specific outcome measures will be collected, spanning patient-reported, observer-reported, and clinician-reported outcomes as well as performance-based outcomes (physical measures and cognitive/mental measures). Daily-living mobility and physical capacity will be assessed directly using a wearable device. These four clinical cohorts were chosen to obtain generalizable clinical findings, including diverse clinical, cultural, geographical, and age representation. The disease cohorts include a broad and heterogeneous range of subject characteristics with varying chronic care needs, and represent different trajectories of mobility disability.

DISCUSSION

The results of Mobilise-D will provide longitudinal data on the use of digital mobility outcomes to identify, stratify, and monitor disability. This will support the development of widespread, cost-effective access to optimal clinical mobility management through personalised healthcare. Further, Mobilise-D will provide evidence-based, direct measures which can be endorsed by regulatory agencies and health technology assessment bodies to quantify the impact of disease-modifying interventions on mobility.

TRIAL REGISTRATION

ISRCTN12051706.

The ongoing effects of the COVID-19 pandemic on perceived physical activity, physical function and mood of older adults in the U.K: A follow-up study (March 2020-June 2021)

Coronavirus (COVID-19) and its variants, continue to spread globally more than two years after the discovery of the wild-type virus in Wuhan, China. Following the onset of COVID-19, fluctuating restrictions have likely impacted the daily lives of older adults living in the United Kingdom (UK). Subsequently, the longer term effects of COVID-19 on physical activity levels, perceived physical function and mood of older adults are unclear. Therefore, the present study aimed to follow a group of older adult's living in the UK for one year, to monitor physical activity levels, perceived physical function and mood. A longitudinal, mixed-methods, observational study was conducted using self-administered, online surveys at 3-month intervals between March 2020 and June 2021. A total of 100 participants (46 males [age: 76 ± 5 years] and 54 females [age:74 ± 4 years]) completed all surveys. Bayesian analysis allowed calculation of direct probabilities whilst incorporating our prior knowledge. Throughout this period, older adults maintained or increased their pre-lockdown physical activity levels despite a decrease in intensity of effort of physical activity tasks, whilst sitting time increased at two of the follow-up time-points. Furthermore, perceived physical function decreased (ps = 91.78%;>1.21 AU) and mood undulated in a pattern that reflected the tightening and easing of restrictions. Despite total physical activity being maintained, perceived physical function decreased by a small but clinically meaningful margin.

Description and Functional Benefits of Meeting Frequency, Intensity, and Time of Resistance and Cardiovascular Exercises: A Study of Older Adults in a Community-Based, Slow-Stream Rehabilitation, Hospital-to-Home Transition Program

This prospective cohort study described cardiovascular and resistance exercises completed by older adults in a community-based, slow-stream rehabilitation, hospital-to-home transition program; compared exercises completed to the American College of Sports Medicine (ACSM) exercise guidelines; and, assessed differences in Late Life Function and Disability Index (LLFDI)-Function Component (FC) between older adults who met and did not meet the ACSM guidelines. Descriptive statistics and Factorial ANCOVA were conducted. For cardiovascular exercise 59.3% of participants met frequency, 73.4% met intensity, and 35.9% met time. For resistance exercise, 67.2% of participants met frequency, 42.2% met intensity, and 76.6% number of repetitions. Participants who met both frequency and time for cardiovascular exercise had higher LLFDI-FC scores, as did those who met intensity and/or number of repetitions for resistance exercise. The findings provide support that older adults engaged in a slow-stream rehabilitation program can meet the ACSM exercise guidelines for community-dwelling older adults, and that meeting the guidelines improves function.

A randomized-controlled trial comparing supervised aerobic training to resistance training followed by unsupervised exercise on physical functioning in older breast cancer survivors

INTRODUCTION

This study compared the relative efficacy of aerobic training to resistance training on physical functioning in older breast cancer survivors and determined whether benefits could be maintained by transitioning to unsupervised home-based training.

MATERIALS AND METHODS

Early-stage, post-treatment, older (≥65 years) breast cancer survivors (n = 114; mean age 72 years) were randomized to 12 months of supervised aerobic (n = 37), resistance (n = 39) or stretching (active control; n = 38) training followed by 6 months of unsupervised home-based training. Outcomes included aerobic capacity by 6-min walk distance (6MWD; m), maximal upper and lower body strength (1-repetition maximum; kg); physical function by short physical performance battery (SPPB), SF-36 and Late Life Function and Disability Instruments.

RESULTS

Over 12-months of supervised exercise, all groups improved in muscle strength and SPPB scores, but resistance trained women also improved 6MWD. Improvements in upper and lower body strength in the resistance group were significantly greater than those in the stretching control (+2.5 kg vs. +1.8 kg; p = 0.05) and aerobic groups (+8.3 kg vs +2.7 kg; p = 0.047), respectively, with trends for greater improvements in 6MWD (+57.9 m vs. +22.5 m; p = 0.057) and self-report physical function (+4.8 vs. -4.4; 0.066) in resistance trained women versus controls. Compared to values at 12 months, there were no changes during unsupervised training in any measure within or between groups, except for self-reported advanced lower extremity function which improved in the resistance group and fell in the aerobic group (+1.3 vs. -3.1; p = 0.043).

DISCUSSION

Supervised exercise can improve strength and physical functioning among older breast cancer survivors. Resistance training may lead to better improvements compared to aerobic or flexibility training, whether in a supervised or unsupervised setting. Clinicaltrials.govNCT00662103.

Feasibility of performance-based and self-reported outcomes in self-managed falls prevention exercise interventions for independent older adults living in the community

Background

Little is known about associations between performance-based measurements and self-reported scales, nor about ceiling effects or sensitivity to change to evaluate effects in the target population for self-managed exercise interventions. This study aimed to explore the feasibility of using performance-based outcomes for gait speed, functional leg strength and balance, and self-reported outcomes of falls-efficacy and functional ability in two self-managed falls prevention exercise interventions for community dwelling older adults.

Methods

Independent living, community-dwelling older adults (n = 67) exercised with one of two self-managed falls prevention exercise programmes, a digital programme (DP) or a paper booklet (PB) in a 4-month participant preference trial. Pre- and post-assessments, by blinded assessors, included Short Physical Performance Battery (SPPB) and 30s Chair stand test (30s CST). Participants completed self-reported questionnaires: Activities-specific and Balance Confidence scale (ABC), Iconographical Falls Efficacy Scale (Icon-FES), Late-Life Function and Disability Instrument Function Component (LLFDI-FC). In addition, improvement in balance and leg strength was also self-rated at post-assessment. Participants’ mean age was 76 ± 4 years and 72% were women.

Results

Ceiling effects were evident for the balance sub-component of the SPPB, and also indicated for ABC and Icon-FES in this high functioning population. In SPPB, gait speed, 30s CST, and LLFDI-FC, 21–56% of participants did not change their scores beyond the Minimal Clinically Important Difference (MCID). At pre-assessment all performance-based tests correlated significantly with the self-reported scales, however, no such significant correlations were seen with change-scores. Improvement of performance-based functional leg strength with substantial effect sizes and significant correlations with self-reported exercise time was shown. There were no differences in outcomes between the exercise programmes except that DP users reported improved change of leg strength to a higher degree than PB users.

Conclusion

The LLFDI-FC and sit-to-stand tests were feasible and sensitive to change in this specific population. The balance sub-component of SPPB and self-reported measures ABC and Icon-FES indicated ceiling effects and might not be suitable as outcome measures for use in a high functioning older population. Development and evaluation of new outcome measures are needed for self-managed fall-preventive interventions with high functioning community-dwelling older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02851-9.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

BACKGROUND

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

METHODS

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

DISCUSSION

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

TRIAL REGISTRATION

German Clinical Trials Register, . Registered on March 11, 2021.

Understanding Clinical Significance in Rehabilitation: A Primer for Researchers and Clinicians

ABSTRACT

The objective of this review was to summarize the concept of clinical significance and associated methods focusing on the area of rehabilitation to provide a resource to rehabilitation researchers and clinicians. Studies were searched on electronic databases from inception until July 28, 2020, with no date or language limits. Manual searches as well as Scopus forward citation for relevant references were performed. Narrative synthesis of study results was performed. Definitions of the concepts related to clinical significance, ways of calculating, and interpreting each method were provided using rehabilitation examples. An explanation of methods to evaluate clinical significance (distribution, anchor, and opinion-based methods) and their advantages and disadvantages were also provided. Considering the limitations of statistical significance in assuring meaningfulness of results, clinical interpretation of research outcomes and the report of clinical significance in intervention trials should be a priority in rehabilitation research. When possible, the use of multiple methods (distribution, anchor, and opinion based) is recommended. Thus, clinical researchers are encouraged to present results in a manner that allow the rehabilitation professionals to easily interpret and implement those results in their clinical practice.

Impact of COVID-19 on mobility and participation of older adults living in Hamilton, Ontario, Canada: a multimethod cohort design protocol

INTRODUCTION

The novel COVID-19 required many countries to impose public health measures that likely impacted the participation and mobility of community-dwelling older adults. This protocol details a multimethod cohort design undertaken to describe short-term and medium-term changes to the mobility and participation of older Canadians living in the community rather than retirement facilities during the COVID-19 pandemic.

METHODS AND ANALYSIS

A longitudinal telephone (or online)-administered survey is being conducted with a random sample of older adults living within 20 km of McMaster University, Hamilton, Ontario, Canada, identified from census dissemination areas. Baseline data collection of community-dwelling older adults aged 65 years and over began in May 2020 with follow-ups at 3, 6, 9 and 12 months. The Late-Life Function and Disability Instrument and global rating of change anchors are the primary outcomes of interest. A subsample of respondents will participate in open-ended, semistructured interviews conducted over the telephone or through video-conference, to explore participants' lived experiences with respect to their mobility and participation during the pandemic. Descriptive statistics and quantitative approaches will be used to determine changes in mobility and social and personal participation, and associated personal and environmental factors. For the interviews, qualitative data will be analysed using descriptive phenomenology.

ETHICS AND DISSEMINATION

Approval was obtained from the Hamilton Integrated Research Ethics Board of McMaster University (2020-10814-GRA). This study may inform the design of programmes that can support community-dwelling older adults during and after the COVID-19 pandemic. Findings will be disseminated through peer-reviewed publications and conferences focused on ageing.

Hip Range of Motion and Strength Predict 12-Month Physical Function Outcomes in Older Adults With Chronic Low Back Pain: The Delaware Spine Studies

Objective

The objective of this study was to investigate whether poor hip range of motion (ROM) and strength predict 12‐month physical function decline among older adults with chronic low back pain (LBP) and whether hip osteoarthritis modifies those relationships.

Methods

At baseline, passive ROM and strength measurements were taken for hip flexion, extension, abduction, adduction, internal rotation, and external rotation; ultrasound images and self‐reported symptoms were used to evaluate hip osteoarthritis presence (eg, osteophytes and hip pain). At baseline and 12 months, performance‐based (repeated chair rise, self‐selected gait speed, 6‐minute walk test [6MWT]) and self‐reported (Quebec LBP Disability Questionnaire, Late‐Life Function & Disability Instrument [LLFDI] basic and advanced lower extremity scales) physical function outcomes were assessed. Regression models were constructed for each outcome predicted by baseline hip ROM and strength measures, with adjustment for potential covariates. To avoid collinearity, hip ROM and strength measures with the strongest unadjusted correlations were included in final models. The hip osteoarthritis presence by hip ROM/strength interaction was also explored.

Results

Hip abduction strength predicted repeated chair rise (β = −0.297, P < 0.001), gait speed (β = 0.160, P = 0.003), 6MWT (β = 0.159, P ≤ 0.001), Quebec LBP Disability Questionnaire (β = −0.152, P = 0.003), and LLFDI basic lower extremity scale (β = 0.171, P = 0.005) outcomes. Regarding hip ROM, extension predicted repeated chair rise (β = −0.110, P = 0.043) and LLFDI advanced lower extremity scale (β = 0.090, P = 0.007) outcomes, external rotation predicted gait speed (β = 0.122, P = 0.004) outcomes, and abduction predicted LLFDI basic lower extremity scale (β = 0.114, P = 0.026) outcomes. The hip osteoarthritis interaction was not significant for any model.

Conclusion

Reduced hip strength and ROM predict physical function decline; hip osteoarthritis presence may not modify these relationships.

Home-based rehabilitation programme compared with traditional physiotherapy for patients at risk of poor outcome after knee arthroplasty: the CORKA randomised controlled trial

OBJECTIVES

To evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy.

DESIGN

A prospective, single-blind, two-arm randomised controlled superiority trial.

SETTING

14 National Health Service physiotherapy departments in the UK.

PARTICIPANTS

621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool.

INTERVENTIONS

A multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance.

RESULTS

621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4-7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2-6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI -0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions.

CONCLUSIONS

The CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group.

TRIAL REGISTRATION NUMBER

ISRCTN13517704.

A prospective study to establish the minimal clinically important difference of the Mini-BESTest in individuals with stroke

OBJECTIVE

To determine the minimal clinically important difference of the Mini-BESTest in individuals' post-stroke.

DESIGN

Prospective cohort study.

SETTING

Outpatient stroke rehabilitation.

SUBJECTS

Fifty outpatients with stroke with a mean (SD) age of 60.8 (9.4).

INTERVENTION

Outpatients with stroke were assessed with the Mini-BESTest before and after a course of conventional rehabilitation. Rehabilitation sessions occurred one to two times/week for one hour and treatment duration was 1.3-42 weeks (mean (SD) = 17.4(10.6)).

MAIN MEASURES

We used a combination of anchor- and distribution-based approaches including a global rating of change in balance scale completed by physiotherapists and patients, the minimal detectable change with 95% confidence, and the optimal cut-point from receiver operating characteristic curves.

RESULTS

The average (SD) Mini-BESTest score at admission was 18.2 (6.5) and 22.4 (5.2) at discharge (effect size: 0.7) (P = 0.001). Mean change scores on the Mini-BESTest for patient and physiotherapist ratings of small change were 4.2 and 4.3 points, and 4.7 and 5.3 points for substantial change, respectively. The minimal detectable change with 95% confidence for the Mini-BESTest was 3.2 points. The minimally clinical importance difference was determined to be 4 points for detecting small changes and 5 points for detecting substantial changes.

CONCLUSIONS

A change of 4-5 points on the Mini-BEST is required to be perceptible to clinicians and patients, and beyond measurement error. These values can be used to interpret changes in balance in stroke rehabilitation research and practice.

Frequency of But Not Capacity for Participation in Everyday Activities Is Associated With Cognitive Impairment in Late Life

We examined features of everyday activities (capacity and frequency) between older adults with and without cognitive impairment over 12 months. Participants aged ≥60 years and at risk for depression were included (n = 260); 26% (n = 69) had an acquired cognitive impairment at baseline. Cognitive impairment was defined as one standard deviation below norms on the Repeatable Battery for the Assessment of Neuropsychological Status. Features of everyday activities were measured by a computerized adaptive test version of Late-Life Function and Disability Instrument (LLFDI) at six time points (baseline, 6 weeks, 3, 6, 9, 12 months). There were significant between-group differences in activity frequency (p = .04), but not activity capacity (p = .05). The group difference in activity frequency exceeded minimal detectable changes (MDC₉₀ = 3.7) and reached moderate clinical meaningfulness (∆ at six time points = 3.7-4.7). Generalized linear mixed models revealed no Group × Time interactions on activity capacity and frequency (p = .65 and p = .98). Practitioners may assess changes in activity frequency to monitor cognitive status of clients even when there is no loss of activity capacity.

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

The Rehabilitation Enhancing Aging Through Connected Health Prehabilitation Trial

OBJECTIVE

To evaluate the proof of concept of an innovative model of physical therapy Rehabilitation Enhancing Aging through Connected Health (REACH) and evaluated its feasibility and effect on physical function and health care utilization.

DESIGN

Quasi-experimental 12-month clinical trial.

SETTING

Two outpatient rehabilitation centers.

PARTICIPANTS

Community-dwelling older primary care patients with a treatment arm undergoing the intervention (n=75; mean age=77±5.9y; 54% women) and propensity matched controls derived from a longitudinal cohort study (n=430; mean age=71±7.0y; 68% women) using identical recruitment criteria (N=505).

INTERVENTION

Combined outpatient and home PT augmented with a commercially available app and computer tablet.

MEASUREMENTS

Primary outcomes included a feasibility questionnaire, exercise adherence, self-reported function, and the Short Physical Performance Battery (SPPB). Secondary outcomes included the rates of emergency department (ED) visits and hospitalizations.

RESULTS

Among REACH participants, we observed a 9% dropout rate. After accounting for dropouts, with propensity matching, n=68 treatments and n=100 controls were analyzed. Over the 12-month study duration, 85% of participants adhered to the exercise program an average of 2 times a week and evaluated the treatment experience favorably. In comparison to controls, after 1 year of treatment and within multivariable regression models, REACH participants did not manifest a significant difference in patient reported function (group x time effect 1.67 units, P=.10) but did manifest significant differences in SPPB (group x time effect 0.69 units, P=.03) and gait speed (group x time effect .08m/s, P=.02). In comparison to controls, after 1 year, the rate of ED visits (group x time treatment rate=0.27, P<.004) were significantly reduced, but a significant reduction in hospitalizations was not observed.

CONCLUSION

The REACH intervention is feasible and has proof of concept in preventing functional decline and favorably affecting health care utilization. Evaluation on a larger scale is warranted.

Evaluating the Influence of Social Engagement on Cognitive Impairment and Mobility Outcomes Within the Boston RISE Cohort Study

OBJECTIVE

We investigated the associations between mild cognitive impairment (MCI), social engagement (SE), and mobility.

DESIGN

We evaluated data from a cohort study of older adult primary care patients (N = 430). Outcomes included self-reported function (Late-Life Function Instrument [LLFI]) and performance-based mobility (Short Physical Performance Battery score [SPPB]). Linear regression models evaluated the association between MCI and mobility, MCI and SE, mobility measures and SE, and whether SE mediated the association between MCI status and mobility.

RESULTS

Participants with MCI had significantly lower mobility and lower SE as compared with those without MCI (LLFI: 53.5 vs. 56.9, P < 0.001; SPPB: 7.9 vs. 9.3, P < 0.001; SE score: 44.9 vs. 49.0, P < 0.001). Mild cognitive impairment was significantly associated with both LLFI and SPPB (LLFI β = -2.93, P < 0.001; SPPB β = -1.26, P < 0.001) and SE (β = -3.20, P < 0.001). Social engagement was significantly associated with both LLFI and SPPB (LLFI β = 0.22; P < 0.001; SPPB β = 0.08; P < 0.001). There was a positive association between SE and mobility (P< 0.05). A mediator effect of SE was supported when evaluating the association between MCI and mobility.

CONCLUSIONS

Among older adult primary care patients at risk for mobility decline, higher levels of SE mitigate the association between MCI and mobility.