Kenneth J. Ottenbacher

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.

The reliability of the functional independence measure: A quantitative review

OBJECTIVE The reliability of the Functional Independence Measure (FIMSM) for adults was examined using procedures of meta-analysis. DATA SOURCES Eleven published studies reporting estimates of reliability for the FIM were located using computer searches of Index Medicus, Psychological Abstracts, the Functional Assessment Information Service, and citation tracking. STUDY SELECTION Studies were identified and coded based on type of reliability (interrater, test-retest, or equivalence), method of data analysis, size of sample, and training or experience of raters. DATA EXTRACTION Information from the articles was coded by two independent raters. Interrater reliability for coding all elements included in the analysis ranged from .89 to 1.00. DATA SYNTHESIS The 11 investigations included a total of 1,568 patients and produced 221 reliability coefficients. The majority of the reliability values (81%) were from interrater reliability studies, and the intraclass correlation coefficient (ICC) was the most commonly used statistical procedure to compute reliability. The reported reliability values were converted to a common correlation metric and aggregated across the 11 studies. The results revealed a median interrater reliability for the total FIM of .95 and median test-retest and equivalence reliability values of .95 and .92, respectively. The median reliability values for the six FIM subscales ranged from .95 for Self-Care to .78 for Social Cognition. For the individual FIM items, median reliability values varied from .90 for Toilet Transfer to .61 for Comprehension. Median and mean reliability coefficients for FIM motor items were generally higher than for items in the cognitive or communication subscales. CONCLUSIONS Based on the 11 studies examined in this review the FIM demonstrated acceptable reliability across a wide variety of settings, raters, and patients.

The Functional Independence Measure: Tests of Scaling Assumptions, Structure, and Reliability Across 20 Diverse Impairment Categories

OBJECTIVE The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system. DESIGN This study involved a cross-sectional analysis of patient records, utilizing factor analysis and techniques of multitrait scaling to verify the summative properties of the motor and cognitive dimensions of the FIM and to study the statistical properties of admission FIM scores. PATIENTS Included were a total of 93.829 patients discharged from 252 freestanding rehabilitation hospitals and units during calendar year 1992. Cases were excluded that had missing or out-of-range values or atypical lengths of stay. These criteria were developed previously in conjunction with an expert clinical panel and confirmed through statistical analyses. RESULTS Factor analyses supported the motor and cognitive dimensions across all 20 impairment categories. The resulting subscales exceeded minimum criteria for item internal consistency in 96.9% of tests and item discriminant validity in 100% of tests. Reliability coefficients for each impairment category for both subscales ranged from .86 to .97. There were no major ceiling effects, but patients in certain impairment categories were unable to climb stairs at admission. CONCLUSION The psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice. Findings provide support for the motor and cognitive subscales as used in the FIM-FRGs. As a unidimensional scale, the FIM quantifies care burden. Split into the motor and cognitive (as used in the FIM-FRGs) it distinguishes physical disabilities from those arising from communication or cognitive difficulties.

The community integration questionnaire: A comparative examination

ABSTRACT The community integration questionnaire (CIQ) was designed to assess home integration, social integration and productive activity in persons with acquired brain injury. The instrument consists of 15 items and can be completed by self report or with the assistance of a family member or caregiver familiar with the persons health status and social activities. Previous research has demonstrated adequate test-retest reliability and internal consistency. This study was designed to examine further, the psychometric characteristics of the CIQ and begin the process of establishing the instruments validity. The CIQ was administered to 341 persons with traumatic brain injury (TBI) and 210 persons without TBI or any other apparent disabilities. The results indicate that the total scores are normally distributed for both persons with and without TBI. A statistically significant difference (P < 0.01) was found between subjects with TBI and those without TBI for all three subscales of the CIQ and for total scores. Data analysis also revealed that the total CIQ scores statistically differentiated among subjects with TBI living in three different settings: (1) living independently; (2) living in a supported community situation and (3) living in an institution. Intercorrelations among the three subscales (home, social and productivity) demonstrated that the CIQ provides unique information in the assessment of community integration for persons with TBI. Areas of future research necessary to expand the research and program evaluation usefulness of the CIQ are identified.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Purpose— The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. Conclusions— As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.)

Trends in Androgen Prescribing in the United States, 2001 to 2011

Although commercial sales of androgen replacement therapy (ART) have increased substantially in recent years,1,2 to our knowledge, no national population-based studies of this treatment have been reported. In view of the conflicting evidence on the risks and benefits of ART,3-7 understanding androgen prescribing patterns in the United States is important from both a clinical and a public health perspective. We used data from Clinformatics DataMart (CDM), one of the nations largest commercial health insurance populations, to examine androgen prescribing patterns in the United States over the past decade.

Assessing walking speed in clinical research: a systematic review

OBJECTIVE To provide a systematic review and describe how assessments of walking speed are reported in the health care literature. METHODS MEDLINE electronic database and bibliographies of select articles were searched for terms describing walking speed and distances walked. The search was limited to English language journals from 1996 to 2006. The initial title search yielded 793 articles. A review of the abstracts reduced the number to 154 articles. Of these, 108 provided sufficient information for inclusion in the current review. RESULTS Of the 108 studies included in the review 61 were descriptive, 39 intervention and 8 randomized controlled trials. Neurological (n=55) and geriatric (n=27) were the two most frequent participant groups in the studies reviewed. Instruction to walk at a usual or normal speed was reported in 55 of the studies, while 31 studies did not describe speed instructions. A static (standing) start was slightly more common than a dynamic (rolling) start (30 vs 26 studies); however, half of the studies did not describe the starting protocol. Walking 10, 6 and 4 m was the most common distances used, and reported in 37, 20 and 11 studies respectively. Only four studies included information on whether verbal encouragement was given during the walking task. CONCLUSIONS Tests of walking speed have been used in a wide range of populations. However, methodologies and descriptions of walking tests vary widely from study to study, which makes comparison difficult. There is a need to find consensus for a standardized walking test methodology.

Onset of Frailty in Older Adults and the Protective Role of Positive Affect

The aim of this study was to examine the longitudinal association between positive affect and onset of frailty for 1,558 initially nonfrail older Mexican Americans from the Hispanic Established Populations for Epidemiological Studies of the Elderly database. The incidence of frailty increased 7.9% during the 7-year follow-up period. High positive affect was found to significantly lower the risk of frailty. Each unit increase in baseline positive affect score was associated with a 3% decreased risk of frailty after adjusting for relevant risk factors. Findings add to a growing positive psychology literature by showing that positive affect is protective against the functional and physical decline associated with frailty.

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.

Hand grip strength and incident ADL disability in elderly Mexican Americans over a seven-year period

Background and aims: Little is known about muscle strength as a predictor of disability among older Mexican Americans. The aim of this study was to examine the association between hand grip strength and 7-year incidence of ADL disability in older Mexican American men and women. Methods: A 7-year prospective cohort study of 2493 non-institutionalized Mexican American men and women aged 65 or older residing in five south-western states. Maximal hand grip strength test, body mass index, cognitive function, activities of daily living, self-reports of medical conditions (arthritis, diabetes, heart attack, stroke, cancer, hip fracture), and depressive symptoms were obtained. Results: In a Cox proportional regression analysis, there was a linear relationship between hand grip strength at baseline and risk of incident ADL disability over a 7-year follow-up. Among non-disabled men at baseline, the hazard ratio of any new ADL limitation was 1.90(95% CI 1.14–3.17) for those in the lowest quartile, when compared with men in the highest hand grip strength quartile, after controlling for age, marital status, medical conditions, high depressive symptoms, MMSE score, and BMI at baseline. Among non-disabled women at baseline, the hazard ratio of any new ADL limitation was 2.28 (95% CI 1.59–3.27) for those in the lowest quartile, when compared with women in the highest hand grip strength quartile. Conclusions: Hand grip strength is an independent predictor of ADL disability among older Mexican American men and women. The hand grip strength test is an easy, reliable, valid, inexpensive method of screening to identify older adults at risk of disability.