Daniel K. White

Trajectories of Gait Speed Predict Mortality in Well-Functioning Older Adults: The Health, Aging and Body Composition Study

BACKGROUND Although gait speed slows with age, the rate of slowing varies greatly. To date, little is known about the trajectories of gait speed, their correlates, and their risk for mortality in older adults. METHODS Gait speed during a 20-m walk was measured for a period of 8 years in initially well-functioning men and women aged 70-79 years participating in the Health, Aging and Body Composition study. We described the trajectories of gait speed and examined their correlates using a group-based mixture model. Also risk associated with different gait speed trajectories on all-cause mortality was estimated using a Cox-proportional hazard model. RESULTS Of 2,364 participants (mean age, 73.5 ± 2.9 years; 52% women), we identified three gait speed trajectories: slow (n = 637), moderate (n = 1,209), and fast decline (n = 518). Those with fast decline slowed 0.030 m/s per year or 2.4% per year from baseline to the last follow-up visit. Women, blacks, and participants who were obese, had limited knee extensor strength, and had low physical activity were more likely to have fast decline than their counterparts. Participants with fast decline in gait speed had a 90% greater risk of mortality than those with slow decline. CONCLUSION Despite being well-functioning at baseline, a quarter of older adults experienced fast decline in gait speed, which was associated with an increased risk of mortality.

Auditory and visual impairments in patients with blast-related traumatic brain injury: Effect of dual sensory impairment on Functional Independence Measure.

The frequencies of hearing impairment (HI), vision impairment (VI), or dual (hearing and vision) sensory impairment (DSI) in patients with blast-related traumatic brain injury (TBI) and their effects on functional recovery are not well documented. In this preliminary study of 175 patients admitted to a Polytrauma Rehabilitation Center, we completed hearing and vision examinations and obtained Functional Independence Measure (FIM) scores at admission and discharge for 62 patients with blast-related TBI. We diagnosed HI only, VI only, and DSI in 19%, 34%, and 32% of patients, respectively. Only 15% of the patients had no sensory impairment in either auditory or visual modality. An analysis of variance showed a group difference for the total and motor FIM scores at discharge (p < 0.04). Regression model analyses demonstrated that DSI significantly contributed to reduced gain in total ( t = -2.25) and motor ( t = -2.50) FIM scores ( p < 0.05). Understanding the long-term consequences of sensory impairments in the functional recovery of patients with blast-related TBI requires further research.

Effectiveness of an Inpatient Multidisciplinary Rehabilitation Program for People With Parkinson Disease

Background and Purpose: In the outpatient setting, it can be difficult to effectively manage the complex medical and rehabilitation needs of people with Parkinson disease (PD). A multidisciplinary approach in the inpatient rehabilitation environment may be a viable alternative. The purposes of this study were: (1) to investigate the effectiveness of an inpatient rehabilitation program for people with a primary diagnosis of PD, (2) to determine whether gains made were clinically meaningful, and (3) to identify predictors of rehabilitation outcome. Subjects: Sixty-eight subjects with a diagnosis of PD were admitted to an inpatient rehabilitation hospital with a multidisciplinary movement disorders program. Methods: Subjects participated in a rehabilitation program consisting of a combination of physical therapy, occupational therapy, and speech therapy for a total of 3 hours per day, 5 to 7 days per week, in addition to pharmacological adjustments based on data collected daily. A pretest-posttest design was implemented. The differences between admission and discharge scores on the Functional Independence Measure (FIM) (total, motor, and cognitive scores), Timed “Up & Go” Test, 2-Minute Walk Test, and Finger Tapping Test were analyzed. Results: An analysis of data obtained for the 68 subjects admitted with a diagnosis of PD revealed significant improvements across all outcome measures from admission to discharge. Subjects with PD whose medications were not adjusted during their admission (rehabilitation only) (n=10) showed significant improvements in FIM total, motor, and cognitive scores. Improvements exceeded the minimal clinically important difference in 71% of the subjects. Prior level of function at admission accounted for 20% of the variance in the FIM total change score. Discussion and Conclusion: The results suggest that subjects with a diagnosis of PD as a primary condition benefited from an inpatient rehabilitation program designed to improve functional status.

Are features of the neighborhood environment associated with disability in older adults

Purpose. To explore the association of features of a persons neighborhood environment with disability in daily activities. Method. We recruited 436 people aged 65 years and over (mean 70.4 years (SD = 3.9)) with functional limitations from the Multicenter Osteoarthritis Study (MOST). Features of the neighborhood environment were assessed using the Home and Community Environment (HACE) survey. The Late-Life Disability Instrument (LLDI) was used to assess disability in daily activities. We used logistic regression to examine the association of individual environmental features with disability. Results. Older adults whose neighborhoods did not have parks and walking areas less frequently engaged in a regular fitness program (OR = 0.4, 95% CI (0.2, 0.7)), and in social activities (OR = 0.5, 95% CI (0.3, 1.0)). Those whose neighborhoods had adequate handicap parking had 1.5–1.8 higher odds of engagement in several social and work role activities. The presence of public transportation was associated with 1.5–2.9 higher odds of not feeling limited in social, leisure, and work role activities, and instrumental activities of daily living. Conclusion. Our exploratory study suggests that parks and walking areas, adequate handicap parking, and public transportation are associated with disability in older adults.

Do radiographic disease and pain account for why people with or at high risk of knee osteoarthritis do not meet physical activity guidelines

OBJECTIVE Knee osteoarthritis (OA) and pain are assumed to be barriers to meeting physical activity guidelines, but this has not been formally evaluated. The purpose of this study was to determine the proportions of people with and those without knee OA and knee pain who meet recommended physical activity levels through walking. METHODS We performed a cross-sectional analysis of community-dwelling adults from the Multicenter Osteoarthritis Study who had or who were at high risk of knee OA. Participants wore a StepWatch activity monitor to record steps per day for 7 days. The proportion of participants who met the recommended physical activity levels was defined as those accumulating≥150 minutes per week at ≥100 steps per minute in bouts lasting ≥10 minutes. These proportions were also determined for those with and those without knee OA, as classified by radiography and by severity of knee pain. RESULTS Of the 1,788 study participants (mean±SD age 67.2±7.7 years, mean±SD body mass index 30.7±6.0 kg/m2, 60% women), lower overall percentages of participants with radiographic knee OA and knee pain met recommended physical activity levels. However, these differences were not statistically significant between those with and those without knee OA; 7.3% and 10.1% of men (P=0.34) and 6.3% and 7.8% of women (P=0.51), respectively, met recommended physical activity levels. Similarly, for those with moderate/severe knee pain and those with no knee pain, 12.9% and 10.9% of men (P=0.74) and 6.7% and 11.0% of women (P=0.40), respectively, met recommended physical activity levels. CONCLUSION Disease and pain have little impact on achieving recommended physical activity levels among people with or at high risk of knee OA.

Measures of adult general functional status: SF‐36 Physical Functioning Subscale (PF‐10), Health Assessment Questionnaire (HAQ), Modified Health Assessment Questionnaire (MHAQ), Katz Index of Independence in Activities of Daily Living, Functional Independence Measure (FIM), and Osteoarthritis‐Function‐Computer Adaptive Test (OA‐Function‐CAT)

Self-reported measures to assess and quantify functional status are important tools for clinicians and investigators. These measures qualify limitation with different types of functional activities and quantify the extent of limitation. We are particularly interested in measures of general functional status. Although these “generic” measures of function were originally developed in other patient populations, they are relevant to the field of rheumatology. In particular, these instruments have been found to be valid and reliable measures of function, sensitive to changes in function, and have distinct thresholds for important change in people with rheumatologic disease. Some notable studies have been added to the literature for general functional status measures in the last decade. Most of these additions are in the area of identifying thresholds for minimum clinically important difference, i.e., the smallest amount of change associated with a minimally important decline or improvement in function. To reflect changes in clinical practice over the last decade, we chose to review the Functional Independence Measure, which is a commonly used measure in practice to assess function. Also, Computer Adaptive Testing has developed over the past decade, which represents an innovative and exciting change to how self-reported tests of function are administered. Therefore, the purpose of this report is to provide an update to measures of general functional status commonly employed for people with rheumatologic diseases and provide a review of a Computer Adaptive Testing measure of functioning for people with osteoarthritis.

Changes in Walking Activity and Endurance Following Rehabilitation for People With Parkinson Disease

OBJECTIVE To investigate changes in walking activity and endurance after interdisciplinary rehabilitation in people with Parkinson disease (PD). DESIGN Randomized controlled trial. SETTING Clinic, home, and community. PARTICIPANTS Mild to moderate PD (Hoehn and Yahr stage 2-3). INTERVENTIONS Three experimental conditions lasting 6 weeks in duration: (1) no active rehabilitation; (2) 3.0 hours of interdisciplinary rehabilitation a week; or (3) 4.5 hours of interdisciplinary rehabilitation a week. Participants had stable medication regimes during the study. MAIN OUTCOME MEASURES Walking activity was estimated with an activity monitor (AM) (time spent walking and number of 10-second walking periods) in the home and community settings over a 24-hour period. Walking endurance was measured in the clinic with the two-minute walk test (2MWT). Linear contrast analyses were applied to examine changes in walking activity and endurance after higher doses of rehabilitation, and 2-way analysis of variance models with interaction were applied to examine the effect of high and low baseline walking levels on changes. RESULTS The 2MWT was completed by 108 people with PD (mean age, 66.53y; with PD, 6.59y), and AM data were used from 74 of these people (mean age, 66.7y; with PD, 5.8y). Improvement in AM measures and the 2MWT did not significantly change across increasing dosages of interdisciplinary rehabilitation. Higher doses of rehabilitation resulted in significant improvements in the 2MWT for subjects with low baseline walking endurance (P=.001), and in AM measures for subjects with high baseline walking activity (P<.02). CONCLUSIONS Interdisciplinary rehabilitation can improve walking activity and endurance depending on baseline walking levels.

Do worsening knee radiographs mean greater chances of severe functional limitation

Development of functional limitation is thought to be unrelated to changes in severity of radiographic osteoarthritis (OA) of the knee. We evaluated the relationship of change in radiographic OA to the incidence of severe functional limitation.

Is symptomatic knee osteoarthritis a risk factor for a trajectory of fast decline in gait speed? Results from a longitudinal cohort study†

Gait speed is an important marker of health in adults and slows with aging. While knee osteoarthritis (OA) can result in difficulty walking, it is not known if radiographic knee OA (ROA) and/or knee pain are associated with a fast decline trajectory of gait speed over time.

Clinically Important Improvement in Function Is Common in People with or at High Risk of Knee OA: The MOST Study

Objective. To calculate the frequency of clinically important improvement in function over 30 months and identify risk factors in people who have or are at risk of knee osteoarthritis (OA). Methods. Subjects were from the Multicenter Osteoarthritis (MOST), a longitudinal study of persons with or at high risk of knee OA. We defined minimal clinically important improvement (MCII) with the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) physical function using 3 different methods. Baseline risk factors tested for improvement included age, sex, educational attainment, presence of radiographic knee OA (ROA), the number of comorbidities, body mass index (BMI), knee pain, walking speed, isokinetic knee extensor strength, depressive symptoms, physical activity, and medication usage. We used logistic regression to evaluate the association of baseline risk factors with MCII. Results. Of the 1801 subjects (mean age 63 yrs, BMI = 31, 63% women), most had mild limitations in baseline function (WOMAC = 19 ± 11). Regardless of how defined, a substantial percentage of subjects (24%–39%) reached MCII at 30 months. Compared to their counterparts, people with MCII were less likely to have ROA and to use medications, and were more likely to have a lower BMI, less knee pain, a faster walking speed, more knee strength, and fewer depressive symptoms. After adjustment, MCII was 40% to 50% less likely in those with ROA, and 1.9 to 2.0 times more likely in those walking 1.0 meters/second faster than counterparts. Conclusion. Clinically important improvement is frequent in people with or at high risk of knee OA. The absence of ROA and a faster walking speed appear to be associated with clinically important improvements.