Comparing the functional independence measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature

Combining Physical and Cognitive Functions to Discriminate Level of Gait Independence in Hospitalized Patients with Alzheimer's Disease

INTRODUCTION

Both physical and cognitive functions are required to be assessed to determine the level of gait independence in patients with Alzheimer's disease (AD); nonetheless, a method to achieve this assessment has not been established. This study aimed to investigate the accuracy of an assessment method that combined muscle strength, balance ability, and cognitive function parameters in discriminating the level of gait independence in a real-world setting in hospitalized patients with AD.

METHODS

In this cross-sectional study, 63 patients with AD (mean age: 86.1 ± 5.8 years) were classified into three groups according to their gait level: independent, modified independent (independent walking with walking aids), and dependent groups. Discrimination accuracy was calculated for single items of muscle strength, balance ability, and cognitive function tests and for combinations of each.

RESULTS

The combined accuracy of muscle strength, balance ability, and cognitive function had a positive predictive value of 100.0% and a negative predictive value of 67.7% between the independent and modified independent groups. The positive and negative predictive values were 100.0% and 72.4%, respectively, between the modified independent and dependent groups.

CONCLUSION

This study emphasizes the importance of assessing the level of gait independence in a real-world setting in patients with AD from the perspective of both physical and cognitive functions and proposes a novel method for discriminating an optimal state.

Preliminary Rasch analysis of the multidimensional assessment of interoceptive awareness in adults with stroke

PURPOSE

The Multidimensional Assessment of Interoceptive Awareness (MAIA) measures interoceptive body awareness, which includes aspects such as attention regulation, self-regulation, and body listening. Our purpose was to perform a preliminary validation of the MAIA in adults with stroke using Rasch Measurement Theory.

METHODS

The original MAIA has 32 items that measure interoceptive sensibility, which is an aspect of body awareness. We performed a preliminary analysis with Rasch Measurement Theory to evaluate the unidimensionality and structural validity of the scale. We investigated overall fit to assess unidimensionality, person and item fit, person separation reliability, targeting, local item dependence, and principal components analysis of residuals.

RESULTS

Forty-one adults with chronic stroke (average 3.8 years post-stroke, 13 women, average age 57±13 years) participated in the study. Overall fit (χ 2 = 62.26, p = 0.26) and item fit were obtained after deleting 3 items and rescoring 26 items. One participant did not fit the model (2.44%). There were no floor (0.00%) or ceiling effects (0.00%). Local item dependence was found in 42 pairs. The person separation reliability was 0.91, and the person mean location was 0.06±1.12 logits.

CONCLUSIONS

The preliminary structural validity of the MAIA demonstrated good targeting and reliability, as well as unidimensionality, and good item and person fit in adults with chronic stroke. A study with a larger sample size is needed to validate our findings.

The Korean hip fracture registry study

BACKGROUND

The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model.

METHODS

The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey.

DISCUSSION

KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants.

TRIAL REGISTRATION

Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Comprehensive rehabilitation outcome measurement scale (CROMS): development and preliminary validation of an interdisciplinary measure for rehabilitation outcomes

INTRODUCTION

Comprehensive and interdisciplinary measurement of rehabilitation outcome is an essential part of the assessment and prognosis of a patient. Thus, this requires substantial contributions from the patient, their family and the rehabilitation professional working with them. Moreover, the measurement tool should be comprehensive and must consider the cultural compatibility, cost efficiency and contextual factors of the region.

METHODS

The Comprehensive Rehabilitation Outcome Measurement Scale (CROMS) was developed through consensus and followed the Delphi process incorporating inputs from various rehabilitation professionals. The domains and items were finalized using Principal Component Analysis (PCA). The tool was validated in two native languages and back-translated considering the semantic equivalence of the scale. Intra-class correlation coefficient was performed to determine the agreement between the therapist and patient-reported scales.

RESULTS

The final CROMS carries 32 comprehensive items that can be completed by the person with disability and the professional team. CROMS compares well to similar items on FIM (l ICC of 0.93) and has good internal consistency with a Cronbach's Alpha of 0.92 for both patient and therapist reported measures.

CONCLUSIONS

The 32 item CROMS is a tool that can potentially be used to evaluate the functional independence of various patient populations, predominantly patients with neurological disabilities.

Rehabilitation of Post-COVID-19 Musculoskeletal Sequelae in Geriatric Patients: A Case Series Study

The musculoskeletal system is affected in over 40% of patients with Coronavirus disease 2019 (COVID-19). There is an increased need for post-acute rehabilitation after COVID-19, especially in elderly people with underlying health problems. The aim of this study was to evaluate the benefits of an early and goal-orientated rehabilitation program using combined approaches, robotic medical devices together with other rehabilitation techniques and therapies, in elderly people after acute COVID-19. Ninety-one patients (62.64 ± 14.21 years) previously diagnosed with severe SARS-CoV-2 infection were admitted to the Medical Rehabilitation Clinical Hospital Baile Felix, Romania, for medical rehabilitation, but only six patients (85.33 ± 3.07 years) met the inclusion criteria and participated in the study. The rehabilitation treatment was complex, performed over 4 weeks, and included combined approaches: exercise therapy, robotic gait training, occupational therapy, and massages. Activity and participation evaluation were performed using the Barthel Index and Functional Independence Measure for activities of daily living (ADLs). Assessments were performed at admission and discharge from the rehabilitation clinic. Lokomat patients' reports revealed that the patients had improved motor control (with one exception). The measurement of functional ability revealed an improvement in most cases. This study presents some of the first data on outcomes of COVID-19 patients' musculoskeletal rehabilitation in our country. Early complex medical rehabilitation improved functional independence and autonomy in ADLs in very old patients, post-COVID-19.

The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review

BACKGROUND

Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents.

METHODS

The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature.

RESULTS

Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care CONCLUSIONS: Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology.

REGISTRATION

PROSPERO registration number CRD42020171323.

Psychometrics of the observational scales of the Utrecht Scale for Evaluation of Rehabilitation (USER): Content and structural validity, internal consistency and reliability

INTRODUCTION

Establish content and structural validity, internal consistency, inter-rater reliability, and measurement error of the physical and cognitive scales of the Utrecht Scale for Evaluation clinical Rehabilitation (USER) in geriatric rehabilitation.

MATERIAL AND METHODS

First, an expert consensus-meeting (N=7) was organised for content validity wherein scale content validity index (CVI) was measured. Second, in a sample of geriatric rehabilitation patient structural validity (N=616) was assessed by confirmatory factor analyses for exploring unidimensionality. Cut-off criteria were: Root Mean Square Error of Approximation (RMSEA) ≤0.08; Comparative Fit Index (CFI) and Tucker Lewis Index (TLI) ≥0.95. Local independence (residual correlation<0.20) and monotonicity (H_i-coefficient ≥0.30 and H_s-coefficient ≥0.50) were also calculated. Cronbach alphas were calculated for internal consistency. Alpha's > 0.7 was considered adequate. Third, two nurses independently administered the USER to 37 patients. Intraclass-correlation coefficients (ICC) were calculated for inter-rater reliability (IRR), standard error of measurement (SEM) and Smallest Detectable Change (SDC).

RESULTS

The CVI for physical functioning was moderate (0.73) and excellent for cognitive functioning (0.97). Structural validity physical scale was acceptable (CFI;0.95, TLI;0.93, RMSEA;0.07, ECV;0.78, OmegaH;0.87; Monotonicity;(H_i;0.52-0.75 and H_s;0.63)). Cognitive scale was good (CFI;0.98, TLI;0.96, RMSEA;0.05, ECV;0.66 and OmegaH;0.90. Monotonicity;(H_i;0.30 -0.70 and H_s;0.61)). Cronbach's alpha were high: physical scale;0.92 and cognitive scale;0.94. Reliability physical scale ICC;0.94, SEM;5 and SDC;14 and cognitive scale ICC;0.88, SEM;5 and SDC;13.

CONCLUSION

The observational scales of the USER have shown sufficient content and structural validity, internal consistency, and interrater reliability for measuring physical and cognitive function in geriatric rehabilitation.

TRIAL REGISTRATION

N/A.

Remedial Training of the Less-Impaired Arm in Chronic Stroke Survivors With Moderate to Severe Upper-Extremity Paresis Improves Functional Independence: A Pilot Study

The ipsilesional arm of stroke patients often has functionally limiting deficits in motor control and dexterity that depend on the side of the brain that is lesioned and that increase with the severity of paretic arm impairment. However, remediation of the ipsilesional arm has yet to be integrated into the usual standard of care for upper limb rehabilitation in stroke, largely due to a lack of translational research examining the effects of ipsilesional-arm intervention. We now ask whether ipsilesional-arm training, tailored to the hemisphere-specific nature of ipsilesional-arm motor deficits in participants with moderate to severe contralesional paresis, improves ipsilesional arm performance and generalizes to improve functional independence. We assessed the effects of this intervention on ipsilesional arm unilateral performance [Jebsen–Taylor Hand Function Test (JHFT)], ipsilesional grip strength, contralesional arm impairment level [Fugl–Meyer Assessment (FM)], and functional independence [Functional independence measure (FIM)] (N = 13). Intervention occurred over a 3 week period for 1.5 h/session, three times each week. All sessions included virtual reality tasks that targeted the specific motor control deficits associated with either left or right hemisphere damage, followed by graded dexterity training in real-world tasks. We also exposed participants to 3 weeks of sham training to control for the non-specific effects of therapy visits and interactions. We conducted five test-sessions: two pre-tests and three post-tests. Our results indicate substantial improvements in the less-impaired arm performance, without detriment to the paretic arm that transferred to improved functional independence in all three posttests, indicating durability of training effects for at least 3 weeks. We provide evidence for establishing the basis of a rehabilitation approach that includes evaluation and remediation of the ipsilesional arm in moderately to severely impaired stroke survivors. This study was originally a crossover design; however, we were unable to complete the second arm of the study due to the COVID-19 pandemic. We report the results from the first arm of the planned design as a longitudinal study.

Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review

OBJECTIVE

Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs.

METHODS

PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome.

RESULTS

Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function.

CONCLUSIONS

This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions.

IMPACT

This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Action Observation Therapy for Upper Limb Recovery in Patients with Stroke: A Randomized Controlled Pilot Study

Due to the complexity of the interventions for upper limb recovery, at the moment there is a lack of evidence regarding innovative and effective rehabilitative interventions. Action Observation Training (AOT) constitutes a promising rehabilitative method to improve upper limb motor recovery in stroke patients. The aim of the present study was to evaluate the potential efficacy of AOT, both in upper limb recovery and in functional outcomes when compared to patients treated with task oriented training (TOT). Both treatments were added to traditional rehabilitative treatment. Thirty-two acute stroke patients at 15.6 days (±8.3) from onset, with moderate to severe upper limb impairment at baseline following their first-ever stroke, were enrolled and randomized into two groups: 16 in the experimental group (EG) and 16 in the control group (CG). The EG underwent 30 min sessions of AOT, and the CG underwent 30 min sessions of TOT. All participants received 20 sessions of treatment for four consecutive weeks (five days/week). The Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Box and Block Test (BBT), Functional Independence Measure (FIM) and Modified Ashworth Scale (MAS) were administered at baseline (T0) and at the end of treatment (T1). No statistical differences were found at T0 for inclusion criteria between the CG and EG, whereas both groups improved significantly at T1. After the treatment period, the rehabilitative gain was greater in the EG compared to the CG for FMA-UE and FIM (all p < 0.05). Our results suggest that AOT can contribute to increased motor recovery in subacute stroke patients with moderate to severe upper limb impairment in the early phase after stroke. The improvements presented in this article, together with the lack of adverse events, confirm that the use of AOT should be broadened out to larger pools of subacute stroke patients.

Effects of In-Hospital Physical Therapy on Activities of Daily Living in Patients with Hepatocellular Carcinoma

Activities of daily living (ADL) are frequently impaired in patients with hepatocellular carcinoma (HCC). In this retrospective study, we aimed to investigate the effects of physical therapy on ADLs in patients with HCC during hospitalization for cancer treatment. Nineteen patients with HCC were enrolled. During hospitalization, patients performed a combination of resistance training, stretching, and aerobic exercise (20–60 min/day). ADLs were assessed using the functional independence measure (FIM). Changes in FIM were evaluated by before–after analysis. No significant difference was seen in Child–Pugh class before and after physical therapy. The bilateral knee extension strength and chair stand test were significantly increased after physical therapy compared with before physical therapy (p = 0.001 and p = 0.008, respectively). The total FIM score was significantly increased after physical therapy compared with that before physical therapy (p = 0.0156). Among the 18 indexes of FIM, the stairs index was significantly improved after physical therapy compared with that before physical therapy (5.9 vs. 6.4 points, p = 0.0241). We demonstrated that physical therapy improved muscle strength without worsening liver function. Furthermore, physical therapy improved FIM, especially in the stairs index, in patients with HCC. Thus, physical therapy may be beneficial in patients with HCC during cancer treatment.

Functional Independence in the Community Dwelling Older People: a Scoping Review

Ageing potentially poses a threat to independent functioning of older adults. Although clinicians commonly focus on physical factors limiting Functional Independence (FI), it is likely that personal and environmental interactions also seem important to maintain FI. Herewith, FI exceeds several professional borders and calls for a uniform, multidisciplinary interdisciplinary supported definition of FI. This study aims to provide such a definition of FI in community dwelling older people. A scoping review was performed. Pubmed/Medline, Psychinfo and CINAHL were searched for studies describing aspects of FI. A literature-based definition of FI was discussed by experts (n = 7), resulting in a formulated final definition of FI and insight into contributing factors to FI. A multidisciplinairy focusgroup a stakeholder consultation (n = 15) ensured clinical relevance for daily practice. Data from the focusgroup stakeholder consultation were analyzed by using Atlas.ti (version 8). Based on the literature search, 25 studies were included. FI was finally defined as “Functioning physically safely and independent from another person, within one’s own context”. The contributing factors of FI comprised physical capacity combined with coping, empowerment and health literacy. Moreover, the level of FI is influenced by someone’s own context. This study confirms the relevance of the physical aspect of FI, but additionally stresses the importance of psychological factors. In addition, this study shows that one’s context may affect the level of FI as well. This underlines the importance of a holistic view and calls for multidisciplinary interdisciplinary collaboration in community-dwelling older people.

Uptake and use of a minimum data set (MDS) for older people living and dying in care homes in England: a realist review protocol

INTRODUCTION

Care homes provide nursing and social care for older people who can no longer live independently at home. In the UK, there is no consistent approach to how information about residents' medical history, care needs and preferences are collected and shared. This limits opportunities to understand the care home population, have a systematic approach to assessment and documentation of care, identifiy care home residents at risk of deterioration and review care. Countries with standardised approaches to residents' assessment, care planning and review (eg, minimum data sets (MDS)) use the data to understand the care home population, guide resource allocation, monitor services delivery and for research. The aim of this realist review is to develop a theory-driven understanding of how care home staff implement and use MDS to plan and deliver care of individual residents.

METHODS AND ANALYSIS

A realist review will be conducted in three research stages.Stage 1 will scope the literature and develop candidate programme theories of what ensures effective uptake and sustained implementation of an MDS.Stage2 will test and refine these theories through further iterative searches of the evidence from the literature to establish how effective uptake of an MDS can be achieved.Stage 3 will consult with relevant stakeholders to test or refine the programme theory (theories) of how an MDS works at the resident level of care for different stakeholders and in what circumstances. Data synthesis will use realist logic to align data from each eligible article with possible context-mechanism-outcome configurations or specific elements that answer the research questions.

ETHICS AND DISSEMINATION

The University of Hertfordshire Ethics Committee has approved this study (HSK/SF/UH/04169). Findings will be disseminated through briefings with stakeholders, conference presentations, a national consultation on the use of an MDS in UK long-term care settings, publications in peer-reviewed journals and in print and social media publications accessible to residents, relatives and care home staff.

PROSPERO REGISTRATION NUMBER

CRD42020171323; this review protocol is registered on the International Prospective Register of Systematic Reviews.

Validation of Medicare Rehabilitation Functional Assessments in Routine Care

IMPORTANCE

Assessment of functional outcomes is currently limited by a lack of large data sets. Functional assessments are included in Medicare rehabilitation assessment files, yet the validity of these measures in routine care is unknown.

OBJECTIVE

To evaluate the validity of individual-level routine care functional assessments in Medicare rehabilitation settings compared with criterion-standard National Health and Aging Trends Study (NHATS) research assessments obtained no more than 90 days later.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of individuals aged 65 years and older used the 2011 to 2015 NHATS linked with Medicare assessment files. Individuals with a discharge assessment from inpatient rehabilitation facilities, skilled nursing facilities, or home health agencies and a criterion-standard NHATS assessment were included. Data analysis was performed June 2019 to November 2019.

MAIN OUTCOMES AND MEASURES

Summary functional assessment based on independence with eating, toilet hygiene, bathing, dressing, transfers, and mobility or walking. Linear regression was used to assess agreement between the 2 scales, adjusting for time between assessments and rehabilitation setting.

RESULTS

A total of 1036 adults aged 65 years and older (671 [64.8%] aged ≥80 years; 670 [64.7%] women; 685 [66.1%] white participants) met the study criteria. The correlation of the assessments was 0.63 (95% CI, 0.59 to 0.66; mean [SD] rehabilitation score, 27.5 [7.2]; mean [SD] NHATS score, 30.5 [10.1]). The correlation increased to 0.66 (95% CI, 0.60 to 0.71) for assessments no more than 30 days apart. The linear regression model adjusting for rehabilitation setting and days between evaluations found the assessments were strongly correlated (β = 1.00 [95% CI, 0.93 to 1.08]; intercept, 0.72 [95% CI, -1.79 to 3.24]; R2 = 0.42). Differences in scores were generally small (mean [SD] of NHATS - rehabilitation score, 2.96 [7.91]), and only 59 assessments (5.7%) differed by more than 2 SDs of the mean difference. Rehabilitation service scores were typically higher than NHATS scores in individuals with lower mean scores; however, the population with lower mean scores was small (156 [15.1%]).

CONCLUSIONS AND RELEVANCE

In this large sample of older US adults, routine care rehabilitation facility functional assessments had overall moderate correlation with criterion-standard research assessments.

Validity of the Sock Test for Sitting Balance: A Functional Sitting Balance Assessment

There is a relationship between sitting balance and self-care functioning, but no occupation-based sitting balance assessment. The objective of this study was to determine whether the Sock Test for Sitting Balance (STSB) is a valid balance assessment for use by therapists in acute care. Results of the STSB were compared with those of the Adapted Functional Reach (AFR), the Functional Independence Measure (FIM™) chair transfer, and the Kansas University Sitting Balance Scale (KUSBS), in both hospitalized and healthy participants. There is a significant relationship between STSB results and AFR results for all participants (r_s = -.382, p = .012). Relationships between STSB results and score on the FIM™ Chair Transfer subscale (p = .001), and score on the KUSBS (p = .003) are significant. The STSB can differentiate between a hospitalized population and healthy population (p = .017). Criterion and known-groups validity are demonstrated, but should be confirmed with further testing.

Factors That Influence the Reintegration to Normal Living for Older Adults 2 Years Post Hip Fracture

Objectives: This study aims to identify factors that influence older adults' reintegration to normal living 2 years following a hip fracture and the association between caregiver burden and reintegration over time. Methods: This longitudinal cohort study followed 76 community-dwelling older adults and their caregivers for 2 years post-hip fracture. The primary outcome was Reintegration to Normal Living Index (RNLI), and the secondary outcome was caregiver burden. Results: Older adults scored significantly lower on RNLI at 18 to 24 months if they had few social interactions, cognitive impairment, or lower pre-fracture functional status. During follow-up, greater independence in activities of daily living and greater mobility were each positively associated with RNLI. Caregiver burden reduced if reintegration improved. Implications: Results suggest a need for targeted interventions for older adults' post-hip fracture to improve their function to enhance their reintegration to normal living and to support caregivers in decreasing their burden of care.

Measurement properties of performance-based instruments to assess mental function during activity and participation in traumatic brain injury: A systematic review

Background: Performance-based measures that focus primarily on the ability to engage in ADL are routinely used by occupational therapists to assess a client's cognitive abilities.Objective: To perform a systematic review to investigate measurement properties of performance-based instruments to assess mental function during activity and participation in individuals with traumatic brain injury.Material and methods: Pubmed, EMBASE, CINAHL, PsycINFO and OTseeker were searched. The Consensus-based Standards for the selection of health measurement instruments checklist was used to evaluate methodological quality of each included study. The quality criteria adapted by Terwee were applied to extract the results of each measurement property followed by a best evidence synthesis.Results: Twenty-eight articles, including 40 ratings of measurement properties, were included. The combination of the Functional Independence Measure and the Functional Assessment Measure showed moderate evidence of good internal consistency (Cronbach's alpha 0.99), but conflicting evidence of reliability (ICC 0.83) and poor evidence of construct validity. All other instruments showed limited or unknown evidence.Conclusions: This review provides an overview of measurement properties of performance-based instruments and contributes to such methodological considerations before choosing an instrument. Though, the results reveal a lack of high-quality evidence for any of the measurement properties, it is recommended to use tools with the highest possible evidence for positive ratings.Significance: This review contributes with psychometric evidence on instruments to use in occupational therapy practice and research.

Morphogenetic Variability as Potential Biomarker of Functional Outcome After Ischemic Stroke

The aim of our study was to evaluate the role of morphogenetic variability in functional outcome of patients with ischemic stroke. The prospective study included 140 patients with acute ischemic stroke, all of whom were tested upon: admission; discharge; one month post-discharge; and three months post-discharge. The age was analyzed, as well. The Functional Independence Measure (FIM) test and the Barthel Index (BI) were used for the evaluation of functional outcomes for the eligible participants. We analyzed the presence of 19 homozygous recessive characteristics (HRC) in the studied individuals. There was a significant change in FIM values at discharge (p = 0.033) and in BI values upon admission (p = 0.012) with regards to the presence of different HRCs. Age significantly negatively correlated for the FIM score and BI values at discharge for the group with 5 HRCs (p < 0.05), while for BI only, negative significant correlation was noticed for the group with 5 HRCs at three months post-discharge (p < 0.05), and for the group with 3 HRCs at one month post-discharge (p < 0.05) and three months post-discharge (p < 0.05). Morphogenetic variability might be one among potentially numerous factors that could have an impact on the response to defined treatment protocols for neurologically-impaired individuals who suffered an ischemic stroke.

Psychometric properties of the German Version of the Pediatric Evaluation of Disability Inventory (PEDI-G): A factor analysis

BACKGROUND

Activities of daily living (ADL) are crucial for children because they enable them to participate in everyday life. For the evaluation of children`s ADL performance, health professionals such as occupational therapists use standardized ADL assessments. To implement assessments into practice it is important that the score generated from an assessment can be viewed as a unidimensional measure.

AIM

To investigate the factor structure of the German Pediatric Evaluation of Disability Inventory (PEDI-G) in a sample of typically developing children and children with an impairment.

MATERIAL AND METHODS

An exploratory factor analysis (EFA) with factor rotation was performed to assess the factor structure for the PEDI-G domains (self-care, mobility and social function) of the Functional Skills Scale and the Caregiver Assistance Scale.

RESULTS

262 children (118 (45%) girls and 144 (55%) boys) participated in this study. Their mean age (SD) was 4 years (SD 1.91). Results suggest that the PEDI domains of the Functional Skills Scale and the Caregivers Assistance Scale can be used as unidimensional measures to evaluate child`s ability to perform activities of daily living.

CONCLUSION

The results of this study support the use of the PEDI-G for research and practice in Austria, Germany and Switzerland.

The association between effectiveness of clinical supervision of allied health professionals and improvement in patient function in an inpatient rehabilitation setting

Purpose: Clinical supervision is widely accepted as an important element of practice for allied health professionals to ensure a high quality of patient care. However, it is unknown whether effective clinical supervision of allied health professionals improves patients' outcomes. This study investigated whether effective clinical supervision of allied health professionals is associated with improved patient functional independence. Methods: A prospective longitudinal study design and multi-level regression analysis were used to explore the association between effective clinical supervision and patient functional independence. The effectiveness of clinical supervision was assessed using the Manchester Clinical Supervision Scale. Functional improvement in patients treated by allied health professionals was measured utilising the mobility and self-care subscales of the functional independence measure.Results: Physiotherapists (n = 27) and occupational therapists (n = 26) in inpatient rehabilitation were recruited and the medical records of their patients (n = 1846) audited. The effectiveness of clinical supervision of physiotherapists was positively associated with improvement in personal care. Therapist variables accounted for less than 2.5% of the variation in patient improvement in functional independence.Conclusions: Effectiveness of a reflective model of clinical supervision of physiotherapists and occupational therapists was not associated with an improvement in their patients' mobility or personal care, respectively.Implications for rehabilitationEffective clinical supervision of physiotherapists and occupational therapists using a reflective model of practice is a poor predictor of improved functional independence in rehabilitation inpatients.Patient variables, such as the intensity of therapy, were more important predictors of patient functional improvement than effective clinical supervision.Initiatives aimed at increasing intensity of therapy will likely have a greater effect on improving patient functional independence compared with initiatives aimed at improving the effectiveness of clinical supervision using a reflective model of practice.Initiatives to improve the effectiveness of clinical supervision in improving quality of care could explore the use of a direct model of practice where supervisors directly observe and support supervisees during patient treatment sessions.

Person-centred creative dance intervention for persons with dementia living in the community in Singapore

This paper examines the efficacy of the use of creative dance intervention for persons with mild to moderate dementia, living in the community. Pre- and post-intervention data were collected on the sample of 35 older people to track the impact of the intervention on the domains of function, quality of life and well-being and caregiving stress through the use of the gait speed test, CONFbal scale, Functional Independence Measure, Quality of Life-AD, Dementia Care Mapping and Zarit Burden Interview. There was an overall improvement in all the domains. Statistically significant improvement was found in the Quality of Life reports (p = 0.002) and well-being as measured by Dementia Care Mapping (p < 0.001). The findings assert the positive contributions of person-centred creative dance towards an approach and environment that promotes dementia care. Future studies on determining sustainability of such intervention are recommended.

Potential quality indicators for seriously ill home care clients: a cross-sectional analysis using Resident Assessment Instrument for Home Care (RAI-HC) data for Ontario

Background

Currently, there are no formalized measures for the quality of home based palliative care in Ontario. This study developed a set of potential quality indicators for seriously ill home care clients using a standardized assessment.

Methods

Secondary analysis of Resident Assessment Instrument for Home Care data for Ontario completed between 2006 and 2013 was used to develop quality indicators (QIs) thought to be relevant to the needs of older (65+) seriously ill clients. QIs were developed through a review of the literature and consultation with subject matter experts in palliative care. Serious illness was defined as a prognosis of less than 6 months to live or the presence of severe health instability. The rates of the QIs were stratified across Ontario’s geographic regions, and across four common life-limiting illnesses to observe variation.

Results

Within the sample, 14,312 clients were considered to be seriously ill and were more likely to experience negative health outcomes such as cognitive performance (OR = 2.77; 95% CI: 2.66–2.89) and pain (OR = 1.59; 95% CI: 1.53–1.64). Twenty subject matter experts were consulted and a list of seven QIs was developed. Indicators with the highest overall rates were prevalence of falls (50%) prevalence of daily pain (47%), and prevalence of caregiver distress (42%). The range in QI rates was largest across regions for prevalence of caregiver distress (21.5%), the prevalence of falls (16.6%), and the prevalence of social isolation (13.7%). Those with some form of dementia were most likely to have a caregiver that was distressed (52.6%) or to experience a fall (53.3%).

Conclusion

Home care clients in Ontario who are seriously ill are experiencing high rates of negative health outcomes, many of which are amenable to change. The RAI-HC can be a useful tool in identifying these clients in order to better understand their needs and abilities. These results contribute significantly to the process of creating and validating a standardized set of QIs that can be generated by organizations using the RAI-HC as part of normal clinical practice.

Pain perception of older adults in nursing home and home care settings: evidence from China

Background

In the past decade, the number of long-term care (LTC) services for older adults in China has grown annually by an average of 10%. Older adults, their family members, and policymakers in China are concerned about patient outcomes in different care settings because older adults who have a similar functional status and LTC needs may choose either nursing home care or home care. The aim of this study was to compare pain perception in nursing home care and home care settings for physically dependent older adults in China.

Methods

Multi-stage sampling method was used to recruit respondents aged 65 and older from Yichang City, China, in 2015. The researchers employed a two-step analytical strategy—zero-inflated ordered probit regression followed by propensity score matching method—to model the effect of contrasting residence types on pain perception.

Results

Zero-inflated ordered probit regression analysis with participants unmatched (n = 484) showed that compared with older adults who received home care, those who received nursing home care did not have more severe pain (β = 0.088, SE = 0.196, p = 0.655). After propensity-score matching, the research found that older adults in the home care group perceived less pain compared with the nursing home group (β = 0.489, SE = 0.169, p = 0.004).

Conclusions

The older adults who received home care perceived significantly less pain than the nursing home residents. The pain of older adults may differ based on the type of LTC services and therapy intensity they received, and home care might lead to less pain and better comfort than nursing home care.

Association between older adults’ functional performance and their scores on the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)

Purpose

The paper aims to investigate if the performance of older adults on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were associated or predictive of their functional performance in a geriatric evaluation and management (GEM) inpatient hospital setting. This will inform the occupational therapy assessment and management of older adults admitted to sub-acute GEM settings.

Design/methodology/approach

In all, 20 participants (11 men, 9 women, mean age 82 years, SD = 6.93) were recruited from a GEM ward in an Australian hospital. Participants’ cognitive abilities were assessed using the MMSE and MoCA, and their functional performance were assessed using the Functional Independence Measure (FIM). Spearman’s rho correlations and linear regression analyses were completed. Bootstrapping was applied to the regression analyses to accommodate the small study sample size.

Findings

No statistically significant correlations were obtained between the total and subscale scores of the MMSE and FIM or between the total and subscale scores of the MoCA and FIM. In other words, the cognitive and functional abilities of older adults admitted to a GEM setting were not significantly associated in this study.

Originality/value

The findings suggest that the MoCA and the MMSE were not predictive of participants’ functional performance as measure by the FIM in a sub-acute GEM setting. Occupational therapists should be cautious when interpreting participants’ MMSE, MoCA and FIM results and not depend solely on these results in the goal setting and intervention planning processes for clients on GEM wards. Further studies are recommended to confirm these findings.

Pre- and Postintervention Factor Structure of Functional Independence Measure in Patients with Spinal Cord Injury

Objective

To evaluate the factor structure of Functional Independence Measure (FIM®) scale amongst people with spinal cord injury (SCI).

Methods

This was a retrospective, register-based cohort study on 155 rehabilitants with SCI. FIM was assessed at the beginning and at the end of multidisciplinary inpatient rehabilitation. The internal consistency of the FIM was assessed with Cronbach's alpha and exploratory factor analysis was employed to approximate the construct structure of FIM.

Results

The internal consistency demonstrated high Cronbach's alpha of 0.95 to 0.96. For both pre- and postintervention assessments, the exploratory factor analysis resulted in 3-factor structures. Except for two items (“walking or using a wheelchair” and “expression”), the structures of the identified three factors remained the same from the beginning to the end of rehabilitation. The loadings of all items were sufficient, exceeding 0.3. Both pre- and postintervention chi-square tests showed significant p values < 0.0001. The “motor” domain was divided into two factors with this 2-factor structure enduring through the intervention period.

Conclusions

Amongst rehabilitants with SCI, FIM failed to demonstrate unidimensionality. Instead, it showed a 3-factor structure that fluctuated only little depending on the timing of measurement. Additionally, when measured separately, also motor score was 2-dimensional, not 1-dimensional. Using a total or subscale FIM, scores seem to be unjustified in the studied population.

The Rest of the Story: A Qualitative Study of Complementing Standardized Assessment Data with Informal Interviews with Older Patients and Families

BACKGROUND

While standardized health assessments capture valuable information on patients' demographic and diagnostic characteristics, health conditions, and physical and mental functioning, they may not capture information of most relevance to individual patients and their families. Given that patients and their informal caregivers are the experts on that patient's unique context, it is important to ensure they are able to convey all relevant personal information to formal healthcare providers so that high-quality, patient-centered care may be delivered. This study aims to identify information that older patients and families consider important but that might not be included in standardized assessments.

METHODS

Transcripts were analyzed from 29 interviews relating to eight patients with hip fractures from three sites (large urban, smaller urban, rural) in two provinces in Canada. These interviews were conducted as part of a larger ethnographic study. Each transcript was analyzed by two researchers using content analysis. Results were reviewed in two focus group interviews with older adults and family caregivers. Identified themes were compared with items from two standardized assessments used in healthcare settings.

RESULTS

Three broad themes emerged from the qualitative analysis that were not covered in the standardized assessments: informal caregiver and family considerations, insider healthcare knowledge, and patients' healthcare attitudes and experiences. The importance of these themes was confirmed through focus group interviews. Focus group participants also emphasized the importance of conducting assessments in a patient-centered way and the importance of open-ended questions.

CONCLUSIONS

A less structured interview approach may yield information that would otherwise be missed in standardized assessments. Combining both sources could yield better-informed healthcare planning and quality-improvement efforts.

A qualitative study of healthcare provider perspectives on measuring functional outcomes in geriatric rehabilitation

OBJECTIVES

To explore, from the perspective of healthcare providers, the barriers to and facilitators of using standardized outcome measures of physical function in geriatric rehabilitation settings.

METHODS

In-depth semi-structured interviews with medical doctors, nurses, physiotherapists and occupational therapists were conducted from three geriatric rehabilitation hospitals in Ontario. Qualitative content analysis through an inductive approach was used to identify barriers to and facilitators of outcome measurement in geriatric rehabilitation settings.

RESULTS

A total of 20 healthcare providers from different disciplines were interviewed. Barriers are standardized outcome measures that (1) cannot be used in isolation to inform clinical decision-making for older patients, (2) are difficult to complete and interpret in older complex patients, (3) may not be useful for all members of the clinical team and (4) are used for reasons unrelated to patient care. Facilitators are to (1) divide the standardized outcome measure into components that are useful for each team member's practice, (2) encourage standardized outcome measures as tools for improving daily communication and (3) provide adequate education and support for their daily use.

CONCLUSION

This study revealed important barriers to using standardized outcome measures in geriatric rehabilitation from the perspective of healthcare providers. However, it also identified multiple factors that may help facilitate their use.

Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence

OBJECTIVES

(1) To describe functional status, length of stay (LOS) and time to rehabilitation admission trends. (2) To identify independent predictors of motor function following rehabilitation.

STUDY DESIGN

Retrospective cohort study.

SETTING

Spinal injury rehabilitation unit at King Fahad Medical City, Riyadh, Saudi Arabia.

METHODS

From chart review of 312 traumatic and 106 nontraumatic adult patients with spinal cord injury (SCI) we extracted information on time from injury to rehabilitation admission, rehabilitation LOS, Functional Independence Measure (FIM) motor score (admission and discharge), American Spinal Injury Association Impairment Scale (AIS) grade and demographics. Hierarchical regression was employed to investigate variables associated with discharge FIM motor score for traumatic and nontraumatic SCI.

RESULTS

Mean±s.d., median days from injury to rehabilitation admission were 377±855, 150 days for traumatic SCI and 288±403, 176 days for nontraumatic SCI. For individuals with traumatic SCI, after accounting for admission FIM motor score, tetraplegia and time from injury to rehabilitation admission had a significant but small negative association with discharge FIM motor score. For individuals with nontraumatic SCI, increasing age and higher AIS grade had a significant negative association with discharge FIM motor score.

CONCLUSIONS

Shorter time from injury to rehabilitation admission may improve outcomes for those with traumatic SCI. As time spent in rehabilitation was shorter than in most other countries, a change in practice in this area may be warranted. Developing strategies to improve outcomes for older patients with nontraumatic SCI would also be beneficial.

Evaluation of complete functional status of patients with stroke by Functional Independence Measure scale on admission, discharge, and six months poststroke

Background: To evaluate the patients with stroke by Functional Independence Measure (FIM) scale, at the times of admission to hospital, discharge, and six-month poststroke, and to determine the level of improvement in patients after rehabilitative procedures. Methods: A total number of 108 patients with stroke entered the study who were admitted to neurology ward. They all received rehabilitation consultation, and occupational and physical therapies were prescribed for them. Finally, their functional status was evaluated by FIM scale. Results: The median (and range) of FIM scores were 86 (15-119), 102 (16-123) and 119 (17-126) at admission, discharge, and after six-month follow-up, respectively. Our observations showed a significant improvement in FIM scores (P < 0.001). About 13, 30, and 76 percent of the patients in individual functional tasks of motor domain and 61, 75, and 86 percent in cognitive domain got the score of 6 or 7 (complete or partial independence) on admission, discharge, and after six months, respectively. There was a reverse correlation between age and FIM improvement and also duration of hospitalization (P = 0.002). Conclusion: The study showed that the FIM is a valid tool for evaluation of patients with stroke, their follow-up and tracking the disease course. Moreover, we concluded that patients with stroke make a significant improvement in their functional status overtime. The exact effect of rehabilitative procedures and comparison with no treatment, must be assessed in separate studies.

Updating the Cognitive Performance Scale

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Effects of a safe patient handling and mobility program on patient self-care outcomes

OBJECTIVE. The aim of this study was to determine the effect of a safe patient handling and mobility (SPHM) program on patient self-care outcomes. METHOD. We used a retrospective cohort design. Data were obtained from the electronic medical records of 1,292 patients receiving inpatient rehabilitation services. Self-care scores from the FIM™ for patients who participated in rehabilitation before implementation of an SPHM program were compared with the scores of patients who participated after implementation of the program. RESULTS. Patients who received inpatient rehabilitation services with an SPHM program were as likely to achieve at least modified independence in self-care as those who received inpatient rehabilitation services without an SPHM program. CONCLUSION. SPHM programs may not affect self-care performance in adults receiving inpatient rehabilitation services. However, more work must be done to define specific and effective methods for integrating patient handling technologies into occupational therapy practice.

Affirming the Value of the Resident Assessment Instrument: Minimum Data Set Version 2.0 for Nursing Home Decision-Making and Quality Improvement

Background: We examined the agreement over time of the physical functioning domains of the Resident Assessment Instrument: Minimum Data Set Version 2.0 (RAI-MDS) and the Functional Independence Measure (FIM) in nursing home residents with dementia. Methods: We completed a secondary analysis of data from a longitudinal quasi-experimental study of residents who could transfer independently or with the assistance of one person. FIM assessments were completed at up to three time points by researchers using interviews. RAI-MDS assessments, completed by nursing home staff, were matched to the FIM assessment by nearest time. FIM and RAI-MDS assessments were correlated based on time between assessments using Pearson’s correlation. Items for activities of daily living (ADL) from the RAI-MDS were rescaled using two previously published crosswalks. Motor and ADL subscales were also used, containing eight and six items, respectively. Results: A total of 362 paired interviews and assessments were collected from 130 residents. The mean scores and standard deviations were as follows: FIM: 19.64 (7.60); William’s RAI-MDS crosswalk: 18.04 (5.25); and Velozo’s RAI-MDS crosswalk: 18.09 (6.50). Using both crosswalks, most items showed medium (r > 0.3) or large (r > 0.5) correlations, even at greater than 41 days between assessments. Subscales showed large correlations for all time intervals for both crosswalks. Conclusions: The RAI-MDS remains stable when data are collected greater than 41 days from the FIM assessment. These findings should add confidence in the RAI-MDS data and its clinical utility.

Effects of professional oral health care on elderly: randomized trial

OBJECTIVE

To better understand the role of the professional oral health care for elderly in improving geriatric oral health, the effects of short-term professional oral health care (once per week for 1 month) on oral microbiological parameters were assessed.

METHODS

Parallel, open-labelled, randomize-controlled trial was undertaken in a nursing home for elderly in Shizuoka, Japan. Thirty-four dentate elderly over 74 years were randomly assigned from ID number to the intervention (17/34) and control (17/34) groups. The outcomes were changes in oral microbiological parameters (number of bacteria in unstimulated saliva; whole bacteria, Streptococcus, Fusobacterium and Prevotella: opportunistic pathogens detection: and index of oral hygiene evaluation [Dental Plaque Index, DPI]) within the intervention period. Each parameter was evaluated at before and after intervention period. Four elderly were lost from mortality (1), bone fracture (1), refused to participate (1) and multi-antibiotics usage (1). Finally, 30 elderly were analysed (14/intervention and 16/control).

RESULTS

At baseline, no difference was found between the control and intervention groups. After the intervention period, the percentage of Streptococcus species increased significantly in the intervention group (Intervention, 86% [12/14]; Control, 50% [8/16]: Fisher's, right-tailed, P < 0.05). Moreover, DPI significantly improved in the intervention group (Intervention, 57% [8/14]; Control, 13% [2/16]: Fisher's, two-tailed, P < 0.05). The improvement in DPI extended for 3 months after intervention. None of side effects were reported.

CONCLUSION

The short-term professional oral health care can improve oral conditions in the elderly.

Scheduled analgesic regimen improves rehabilitation after hip fracture surgery

BACKGROUND

Postoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery.

QUESTIONS/PURPOSES

We compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points.

METHODS

We conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols.

RESULTS

As expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk.

CONCLUSIONS

The study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

Efficacy of a functionally-based neurorehabilitation programme: a retrospective case-matched study of rehabilitation outcomes following traumatic brain injury

OBJECTIVE

To investigate the efficacy of a functionally-based neurorehabilitation programme.

DESIGN

Retrospective, case-matched cohort design.

SETTING

An inpatient acquired brain injury (ABI) service at a post-acute rehabilitation facility. In 2001, a functionally-based rehabilitation model was introduced that streams patients into neurocognitive (NC) and neurophysical (NP) treatment groups based on predominant functional deficits.

METHODS

Sixty-nine patients with TBI admitted to the ABI service before implementation of the functionally-based programme comprised a historical control group. These patients were individually case-matched to 69 participants admitted after the functionally-based programme began. Rehabilitation outcomes were compared between matched patients treated before and after implementation of the programme.

OUTCOME MEASURES

Rehabilitation length of stay (RLOS), Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and FIM efficiency.

RESULTS

At discharge, the NP-stream had a significantly higher FIM motor efficiency compared to the historical control (0.41 vs. 0.29; p = 0.01). The NC-stream had significantly less disability, as measured by the DRS, compared to its control (3.63 vs. 5.05; p = 0.01).

CONCLUSIONS

This study presents preliminary evidence that a rehabilitation programme that targets functional needs rather than diagnosis may be useful in improving function after traumatic brain injury.

Use of the cognitive performance test for identifying deficits in hospitalized older adults

Objectives. The Cognitive Performance Test (CPT) is a functional assessment for persons with dementia. The study purpose was to evaluate the reliability, discriminant, and concurrent validity of the CPT. Method. The CPT was tested against other measures of cognition (Standardized Mini Mental Status Exam (SMMSE) and Assessment of Motor and Process Skills-Process scale (AMPS-Process)). Participants were persons 65 years and older admitted to a geriatric rehabilitation unit (n = 47). Results. The CPT correlated moderately with measures of cognition (SMMSE r = 0.47, AMPS-Process r = 0.53, P < 0.01), and ADL burden of care (FIM r = 0.32, P < 0.05). Scores were not affected by age, sex, years of education, motor skills, or comorbidities. The CPT differentiated between impaired and unimpaired individuals differently from other measures. Conclusion. While CPT appears related to other measures of cognition, test interpretation requires noting the variability between CPT scores and those measures.

Underestimating physical function gains: comparing FIM motor subscale and interRAI post acute care activities of daily living scale

OBJECTIVE

To investigate the construct validity of the activities of daily living (ADLs) sections of 2 major systems developed to measure functional ability in rehabilitation settings. Health assessment systems can inform care planning as well as policy decision-making on service effectiveness. Frailty, comorbidity, and heterogeneity make it difficult to accurately measure health outcomes for older adults. Objective investigation of the value of geriatric rehabilitation services requires assessment systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older patients.

DESIGN

Trained health care workers assessed patients with both tools at admission and discharge. We used Rasch analysis to compare the instruments' dimensionality, item difficulty, item fit, differential item function, and number of response options.

SETTING

Musculoskeletal and geriatric rehabilitation units in 2 Ontario hospitals.

PARTICIPANTS

Older adults receiving rehabilitation (N=209; mean age ± SD, 78.5±9.3; 67% women).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM and the interRAI Post Acute Care Assessment (interRAI PAC).

RESULTS

For both the FIM motor and the interRAI PAC ADLs items, the difficulty level of the items was much lower than the participant's level of ability, resulting in a large ceiling effect. Also, on both scales, less actual change in functional ability was required to move between the midlevel response options.

CONCLUSIONS

Both scales have limited ability to discriminate between subjects with higher functional ability, which indicates that they may underestimate the effectiveness of inpatient rehabilitation for this group of patients when used alone.

Mobility of Vulnerable Elders (MOVE): study protocol to evaluate the implementation and outcomes of a mobility intervention in long-term care facilities

Background

Almost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities.

Methods/Design

This longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimer's Disease.

Discussion

There are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population.

Trial Registration

This clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).