Beatriz C. Abreu

The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis

OBJECTIVE To determine by meta-analysis whether physical exercises are beneficial for people with dementia and related cognitive impairments. DATA SOURCES Published articles and nonpublished manuscripts from 1970 to 2003 were identified by using electronic and manual searches. Key search words included exercise, rehabilitation, activities of daily living, dementia, Alzheimers disease, aged, and geriatrics. STUDY SELECTION Reviewed studies were limited to randomized trials evaluating exercise in persons 65 years of age or older with cognitive impairment. Studies included quantitative results (means, standard deviations, t tests, F tests) for physical fitness, physical functioning, cognition, or behavior outcomes. DATA EXTRACTION One reviewer extracted data on study characteristics and findings. Selected articles were evaluated for methodologic quality by 2 raters. DATA SYNTHESIS A total of 2020 subjects participated in the 30 trials that met the inclusion criteria. Summary effects were computed using a fixed effects (Hedges g(i)) model. Significant summary effect sizes (ES) were found for strength (ES=.75; 95% confidence interval [CI], .58-.92), physical fitness (ES=.69; 95% CI, .58-.80), functional performance (ES=.59; 95% CI, .43-.76), cognitive performance (ES=.57; 95% CI, 0.43-1.17), and behavior (ES=.54; 95% CI, .36-.72). The overall mean ES between exercise and nonexercise groups for all outcomes was .62 (95% CI, .55-.70). CONCLUSIONS Exercise training increases fitness, physical function, cognitive function, and positive behavior in people with dementia and related cognitive impairments.

Task performance in virtual environments used for cognitive rehabilitation after traumatic brain injury

OBJECTIVE This report describes a reliability study using a prototype computer-simulated virtual environment to assess basic daily living skills in a sample of persons with traumatic brain injury (TBI). The benefits of using virtual reality in training for situations where safety is a factor have been established in defense and industry, but have not been demonstrated in rehabilitation. SUBJECTS Thirty subjects with TBI receiving comprehensive rehabilitation services at a residential facility. METHODS An immersive virtual kitchen was developed in which a meal preparation task involving multiple steps could be performed. The prototype was tested using subjects who completed the task twice within 7 days. RESULTS The stability of performance was estimated using intraclass correlation coefficients (ICCs). The ICC value for total performance based on all steps involved in the meal preparation task was .73. When three items with low variance were removed the ICC improved to .81. Little evidence of vestibular optical side-effects was noted in the subjects tested. CONCLUSION Adequate initial reliability exists to continue development of the environment as an assessment and training prototype for persons with brain injury.

Virtual reality in the assessment of selected cognitive function after brain injury

Zhang L, Abreu BC, Masel B, Scheibel RS, Christiansen CH, Huddleston N, Ottenbacher KJ: Virtual reality in the assessment of selected cognitive function after brain injury. Am J Phys Med Rehabil 2001;80:597–604. ObjectiveTo assess selected cognitive functions of persons with traumatic brain injury using a computer-simulated virtual reality environment. Study DesignA computer-simulated virtual kitchen was used to assess the ability of 30 patients with brain injury and 30 volunteers without brain injury to process and sequence information. The overall assessment score was based on the number of correct responses and the time needed to complete daily living tasks. Identical daily living tasks were tested and scored in participants with and without brain injury. Each subject was evaluated twice within 7 to 10 days. A total of 30 tasks were categorized as follows: information processing, problem solving, logical sequencing, and speed of responding. ResultsPersons with brain injuries consistently demonstrated a significant decrease in the ability to process information (P = 0.04–0.01), identify logical sequencing (P = 0.04–0.01), and complete the overall assessment (P < 0.01), compared with volunteers without brain injury. The time needed to process tasks, representing speed of cognitive responding, was also significantly different between the two groups (P < 0.01). ConclusionA computer-generated virtual reality environment represents a reproducible tool to assess selected cognitive functions and can be used as a supplement to traditional rehabilitation assessment in persons with acquired brain injury.

Comparison of the Community Integration Questionnaire, the Craig Handicap Assessment and Reporting Technique, and the Disability Rating Scale in traumatic brain injury.

Objective:To examine the concurrent validity of the Community Integration Questionnaire (CIQ) in assessing outcomes in traumatic brain injury (TBI) by comparing it with two widely used and well-validated measurements of rehabilitation outcome. Design:A retrospective relational study of the concurrent validity of the CIQ, Craig Handicap Assessment and Reporting Technique (CHART), and Disability Rating Scale (DRS). Setting:A postacute rehabilitation facility. Participants:Seventy patients with a medical diagnosis of TBI admitted between April 1996 and October 1998 participated in the study. Results:CIQ and CHART provide ratings that are similar in several areas to those provided by the DRS. Correlation (r) among total scores and subscales for all three instruments ranged from 0.021 to 0.671 (P < .01). Correlation between CIQ and CHART is stronger than that between CIQ and DRS or between CHART and DRS, and the correlation between CHART and DRS is stronger than that between CIQ and DRS. Conclusion:The CIQ appears to be the most appropriate instrument in quantifying rehabilitation outcome in patients with TBI at the participatory (handicap) level. The findings of this study can help clinicians gain a greater understanding of the nature, redundancy, and gaps among functional outcome measures. Monitoring outcomes can also help clinicians better understand the effectiveness of interventions.

Ecological validity of the neuropsychological assessment battery screening module in post-acute brain injury rehabilitation.

Primary objective: To assess the ecological validity of the Screening Module of the Neuropsychological Assessment Battery (NAB-SM) using the Functional Independence Measure (FIM). Method: Seventy individuals with moderate-to-severe traumatic brain injury at a residential post-acute rehabilitation facility were administered the FIM instrument and the NAB-SM upon admission. Hierarchical regression analysis was used to examine the relationship between the variables from these two assessment measures. Results: Hierarchical models revealed that (1) the NAB-SM Total score was significantly associated with the FIM instrument Total score as well as the Motor and Cognition sub-scale scores, above and beyond the contribution of demographic variables, (2) the NAB-SM Language, Memory and Spatial domain scores were significantly associated with of the FIM instrument Cognition sub-scale score and (3) the NAB-SM Spatial domain score was significantly associated with of the FIM instrument Total and Motor sub-scale scores. Conclusions: The current findings support previous research and provide strong evidence for the ecological validity of the NAB-SM with regard to functional abilities as assessed by the FIM instrument.

Interdisciplinary meetings: investigating the collaboration between persons with brain injury and treatment teams.

The purpose of this study was to gain an understanding of the collaboration that occurs in interdisciplinary team meetings (ITMs) at a post-acute brain injury rehabilitation centre. A qualitative descriptive case study was chosen for its interpretative and naturalistic approach. The study included participant observation of 51 meetings, five interviews, document review of charts and memos, and inductive analyses. Four themes emerged: (1) the ITM transformation ritual (the meetings themselves); (2) the ITM shapers (the case managers); (3) the ITM collaborators (the professional interdisciplinary team members); and (4) the ritual ghosts (surprisingly, the clients). Several patterns of interactions were documented, including subservient clients, lengthy meetings, and client transformation. These findings are discussed within the context of client-centred practice. The results indicate that inclusion of the client in interdisciplinary meetings does not necessarily lead to collaboration. Clinical implications and future research are discussed.

The effects of exercise training on elderly persons with cognitive impairment and dementia

OBJECTIVE To determine by meta-analysis whether physical exercises are beneficial for people with dementia and related cognitive impairments. DATA SOURCES Published articles and nonpublished manuscripts from 1970 to 2003 were identified by using electronic and manual searches. Key search words included exercise, rehabilitation, activities of daily living, dementia, Alzheimers disease, aged, and geriatrics. STUDY SELECTION Reviewed studies were limited to randomized trials evaluating exercise in persons 65 years of age or older with cognitive impairment. Studies included quantitative results (means, standard deviations, t tests, F tests) for physical fitness, physical functioning, cognition, or behavior outcomes. DATA EXTRACTION One reviewer extracted data on study characteristics and findings. Selected articles were evaluated for methodologic quality by 2 raters. DATA SYNTHESIS A total of 2020 subjects participated in the 30 trials that met the inclusion criteria. Summary effects were computed using a fixed effects (Hedges g(i)) model. Significant summary effect sizes (ES) were found for strength (ES=.75; 95% confidence interval [CI], .58-.92), physical fitness (ES=.69; 95% CI, .58-.80), functional performance (ES=.59; 95% CI, .43-.76), cognitive performance (ES=.57; 95% CI, 0.43-1.17), and behavior (ES=.54; 95% CI, .36-.72). The overall mean ES between exercise and nonexercise groups for all outcomes was .62 (95% CI, .55-.70). CONCLUSIONS Exercise training increases fitness, physical function, cognitive function, and positive behavior in people with dementia and related cognitive impairments.

Mentoring Review and Reflections

This paper reviews mentoring definitions, mentor and protégée characteristics, and the process and outcomes of the mentoring process. In addition, the faculty provides some personal reflections about their mentoring process. Reflections of this nature may inspire us to consider further the adoption and investigation of formal and informal overt mentoring programs in our institutions in order to promote mentoring relationships that can foster personal and professional achievement and satisfaction.

Unilateral and bilateral upper extremity weight-bearing effect on upper extremity impairment and functional performance after brain injury.

The purpose of the study was to investigate the effect of upper extremity (UE) weight bearing on UE impairment functional performance of persons with acquired brain injury (BI). A quasi-experimental design was used to examine a convenience sample of 99 persons with acquired BI and 22 without BI (WBI) living in a community re-entry centre. A computerized force-sensing array pressure map system was used to determine the UE pressure during unilateral and bilateral conditions. Differences between groups were examined using t-tests. Correlations were computed between UE weight bearing and hand function, and functional performance as measured by the Fugl-Meyer scale and functional independence measure (FIM) scale. The group of people with BI exerted significantly lower UE weight bearing during unilateral conditions as compared with persons WBI [left: t (119) = 2.34, p = 0.021; right: t (119) = 4.79, p = 0.043). UE weight-bearing measures correlated strongly with FIM motor scores with bilateral UE conditions yielded the highest significant correlation (bilateral left r = 0.487, p < 0.001; bilateral right r = 0.469, p < 0.01). The results indicated that UE weight-bearing pressure differs in unilateral and bilateral conditions, between persons with and WBI and between persons with stroke and traumatic brain injury. These findings may have implications for occupational therapists that use unilateral versus bilateral motor training for rehabilitation. There is a need to replicate the study design with a randomized and stratified sample of persons with BI.

Domains of a TBI minimal data set: Community reintegration phase

Efforts to establish a minimal data set for the period of community integration after traumatic brain injury (TBI) have been the focus of a working group of leading researchers, clinicians and advocates attending the Galveston Brain Injury Symposium in 2001 and 2002. The purpose of the data set is to increase the consistency and interpretability of TBI research and programme evaluation by providing a common set of measures to document key aspects of community integration. It is intended to be sensitive to intervention, comprehensive, reflect satisfaction and outcome and promote future treatment/therapy. In deciding on the components of a minimal data set, the tri-partite model of outcomes was adopted (initially employed in psychotherapy, adapted to TBI) which focuses on the needs of the individual, society and the health provider. Scales are recommended for the respective components of the model.