Disentangling the process of disablement.
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Biomedical subjects
A M Jette
Publications and source records attributed to A M Jette.
Are performance-based measures sufficiently reliable for use in multicenter trials? Musculoskeletal Impairment (MSI) Study Group.
BACKGROUND: The literature contains few reports of the test-retest reliability of performance-based measures. The purpose of this study was to determine the test-retest reliability of a battery of seven timed, performance-based measures used to assess the functional limitations of frail, older adults. METHODS: One hundred and five frail, elderly subjects were twice administered a battery of timed tests approximately 2 weeks apart: 8-foot walk, get-up-and-go test, stair climb, single and repetitive standing from a chair, and single and repetitive 10-pound lifts with the upper limbs. Agreement between the mean times recorded for accomplishing each task at the two administrations was assessed. RESULTS: Intraclass correlation coefficients ranged from .25 for the single chair stand to .79 for the 8-foot walk. Only the time taken for the single 10-pound lift was significantly greater at the first administration as compared with the second. CONCLUSIONS: Timed performance-based measures have a wide range of test-retest reliability. Performance-based protocols that reflect familiar tasks with discrete starting and ending points may achieve higher reliability than tasks that are unfamiliar to subjects or may have ambiguous elements in them.
Activities of Daily Living↗
Exercise--it's never too late: the strong-for-life program.
OBJECTIVES: This investigation determined whether an in-home resistance training program achieved health benefits in older adults with disabilities. METHODS: A randomized controlled trial compared the effects of assigning 215 older persons to either a home-based resistance exercise training group or a waiting list control group. Assessments were conducted at baseline and at 3 and 6 months following randomization. The program consisted of videotaped exercise routines performed with elastic bands of varying thickness. RESULTS: High rates of exercise adherence were achieved, with 89% of the recommended exercise sessions performed over 6 months. Relative to controls, subjects who participated in the program achieved statistically significant lower extremity strength improvements of 6% to 12%, a 20% improvement in tandem gait, and a 15% to 18% reduction in physical and overall disability at the 6-month follow-up. No adverse health effects were encountered. CONCLUSIONS: These findings provide important evidence that home-based resistance exercise programs designed for older persons with disabilities hold promise as an effective public health strategy.
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Moderate exercise improves gait stability in disabled elders.
BACKGROUND: Decreased muscle strength impedes elders' functional performance in daily activities such as gait. The mechanisms whereby increased strength improves gait are unknown. METHODS: A prospective, blinded, randomized trial of moderate intensity strength exercise was conducted and its impact was measured on functional mobility during gait in 132 functionally limited elders. Lower extremity strength was measured, including hip abductor, hip extensor, and knee extensor strength. Of the 132 subjects, 120 subjects (mean age, 75.1 yrs) completed 6 months of elastic band resistance training at least 3 times a week or served as no-exercise controls. RESULTS: Subjects increased their lower extremity strength in the exercise and control groups, by 17.6% and 7.3% (p < .01), respectively. Gait stability improved significantly more in the exercise group than in the control group (p < .05). Increases in forward gait velocity were not significantly different between groups. Peak mediolateral velocity and base of support improved in the exercise group, but not in the control group. Change in lower extremity strength correlated significantly but weakly with many of the gait variables. CONCLUSIONS: Gait stability, especially mediolateral steadiness, improved in the exercise group but not in the control group. These results show that even moderate strength gains benefit gait performance in elders and thus provide a sound basis for encouraging low-intensity strength training for elders with functional limitations.
Activities of Daily Living↗
Interrelationships among disablement concepts.
BACKGROUND: Understanding interrelationships among disablement concepts is critical to the design of future disability treatment and prevention interventions. METHODS: This study uses cross-sectional data to examine the relationships among physiologic impairments, functional limitations, and disability in a moderately disabled sample of 207 community-dwelling older adults. RESULTS: As hypothesized, the data revealed statistically significant curvilinear relationships of upper and lower extremity strength and balance with mobility in this older sample. Multivariate analyses further clarified the hypothesized causal mechanism among the disablement concepts by demonstrating that most of the association of muscle strength and balance with disability was through the intermediary role of mobility limitations. CONCLUSIONS: The findings from this study highlight the value of clinical trials that focus on prevention or treatment of mobility limitations as a means of preventing disability; our findings underscore the need for future research that examines the effects of other variables believed to influence disablement in late life.
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Home-based resistance training: predictors of participation and adherence.
This study identified factors associated with exercise participation and adherence in a sample of 102 sedentary, functionally limited, community-dwelling adults aged 60 to 94 years who participated in a home-based resistance training program. Stepwise regression analyses revealed that baseline physical factors (i.e., higher levels of mobility, weaker muscle strength, and fewer numbers of new medical conditions) were associated with higher rates of participation in the home program. Positive attitudes and a sense of control toward exercise, lower levels of confusion and depressive moods, and the development of fewer new medical problems during the program were related to higher levels of adherence to the program. Findings revealed that although physical health variables were the primary indicators of an older person's overall participation in the program, it was the psychological factors that were most important to adherence to this home-based program.
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Community physicians describe management issues for patients expected to live less than twelve months.
We examine management issues experienced by community physicians providing care to patients they expect to die within a year. In a case series, 61 physicians in northern New England enrolled 182 consecutive dying patients. Important management issues for these patients were recorded at enrollment and eight months later. The patients' average age was 74 years; most had cancer (48%) or cardiovascular disease (38%). Almost two-thirds of the patients died within eight months of enrollment. Major management issues for the physicians in care of these patients were deficits in basic self-care, emotional support, pain control, and nutrition. Pain control and family need for support were reported most frequently. Although demand for physician time was seldom a major management issue, when it occurred it correlated with patients' emotional needs or their desire to extend life (p < 0.01). Two barriers to optimum care commonly cited by physicians were (a) the differences in treatment expectations between family members, patients, and physicians and (b) the incurable, progressive nature of the patients' diseases. Efforts to improve care for patients who have limited life expectancy should further explore the perceptions of community physicians.
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Professional uncertainty and treatment choices by physical therapists.
OBJECTIVE: To determine patient, clinician, and practice setting characteristics associated with physical therapists' treatment choices in patients with knee, lumbar, and cervical impairments. DESIGN: Secondary analysis of data from the Focus on Therapeutic Outcomes (FOTO) database. SETTING: Data from 132 physical therapy practices owned by five United States outpatient rehabilitation companies. PATIENTS: The database contained information on 5,061 patients with knee, lumbar, or cervical impairments seen in these practices in 1993 and 1994 and agreeing to participate in data collection. Our sample consisted of 2,491 patients, treated by 462 physical therapists, who had complete data on the variables of interest. RESULTS: Physical therapists' treatment choices relied on factors other than the patient's clinical status when the impairment was likely to result in professional uncertainty as to diagnosis and consequences of treatments. For patients with spinal impairments, the clinical status of the patient was associated only with the choice of endurance exercises and modalities. Patient's clinical status was associated with every treatment type in patients with knee impairments. Educational level of the physical therapist, patient load, and payer were associated with a variety of treatment choices across the impairment types. CONCLUSION: In conditions of professional uncertainty, physical therapy practice may be influenced by many idiosyncratic factors.
Adolescent↗
Physical therapy treatment choices for musculoskeletal impairments.
BACKGROUND AND PURPOSE: The primary goal of this investigation was to describe outpatient physical therapy treatments provided to patients with lumbar, cervical, or knee impairments. SUBJECTS: Patients in this analysis received outpatient physical therapy for a primary orthopedic complaint during July 1993 through June 1994 from one of 68 practices participating in the Focus on Therapeutic Outcomes database. Data were available on 2,598 completed physical therapy episodes of care provided by 141 therapists. METHODS: At each patient's discharge, the primary physical therapist gave information on the treatments provided to each patient during the initial, middle, and final thirds of the episode of therapy as well as information on primary source of reimbursement. Patients provided information on the date of onset of their symptoms or surgery. RESULTS: These outpatient physical therapy episodes of care were characterized by a diverse array of modalities, exercises, and manual therapy treatments. Treatment choices varied by type of impairment and across thirds of the episode. Fee-for-service versus managed care payment arrangements were associated with increased use of devices, therapeutic massage, strengthening, and endurance exercises. CONCLUSION AND DISCUSSION: The study's findings revealed that although physical agents were frequently used in physical therapy episodes of care, they were applied along with exercise and manual therapy interventions. Future research should relate specific treatments to variation in patient outcomes following physical therapy.
Adult↗
Disablement outcomes in geriatric rehabilitation.
Until recently, knowledge in the field of geriatric rehabilitation has been based largely on empirical findings. There is a need for greater conceptual clarity about major disablement outcomes to provide a foundation for future theoretical research. Disablement terms promulgated by the World Health Organization's (WHO) International Classification of Impairments Disabilities and Handicaps (ICIDH) are reviewed and compared with those of an alternative model proposed by Saad Nagi in 1965. Distinctions are drawn between the disablement concepts each system includes to refer to (1) inherent attributes of patients and (2) the interaction of the patient with the social and physical environment. The importance of a disablement model reflecting this distinction between inherent and relational concepts is emphasized. Areas for fertile research opportunities in which the disablement concepts could be used are discussed. It is suggested that improved understanding of disablement outcomes could be most readily achieved by application of an epidemiologic model separating the factors affecting outcomes into three sets of variables: the host factors representing intra-individual attributes; the agent factors, which are the external event or events causing the disability; and the environmental factors, which relate to the physical or social surroundings in which the disability occurs. In future research efforts, a more theoretical approach to studying disablement outcomes is advocated as a basis for improvements in geriatric rehabilitation.
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Test-retest reliability of self-reported disability measures in older adults.
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Activities of Daily Living↗
Functional and behavioral consequences of sarcopenia.
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Disentangling the disablement process.
A model was proposed to assess the premise that functional limitations are an intermediary stage between risk factors (e.g., sex and frequency of walking a mile), pathology/impairments (e.g., musculoskeletal problems), and the onset and course of Instrumental Activities of Daily Living (IADL) disability. Analyses were based on two random subsamples (each with n = 524) of Longitudinal Study of Aging respondents who were nondisabled at baseline (1984) and reinterviewed in 1988 and 1990. The model's central premise was supported in two ways. The main influence of age, frequency of walking, and musculoskeletal problems was on the onset of functional limitations, rather than the onset of IADL disability. And, onset of lower body functional limitations influenced future disability (1990) through its relationship with disability in 1988 and functional limitations in 1990. The results underscore the value of clinical trials which focus on minimizing functional limitations as a strategy for preventing disability.
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Quality of Medicare-reimbursed home health care.
We investigated the prevalence of quality of care deficiencies in 4,324 Medicare-reimbursed episodes of care provided by 47 home health agencies. The quality of care protocol consisted of a process-oriented, systematic record review by a trained nurse reviewer. Results suggest that an estimated 14.4% of home health care episodes had quality deficiencies with the potential for or actual adverse effects on the patient. Multivariate analyses revealed that the complexity of patients' needs increased the likelihood and severity of the quality problems. Agency ownership was not related to risk of a quality problem, but regional variation in agency effects was observed. Specific problem areas were identified that suggested several ways that home health care could be improved.
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Physical therapy and health outcomes in patients with knee impairments.
BACKGROUND AND PURPOSE: Physical therapy is usually initiated with the belief that treatment will improve patients health, particularly the ability to perform daily activities and function in expected roles. The purpose of this report to describe health outcomes and related factors in patients with knee impairments receiving physical therapy. SUBJECTS: Data were obtained from a sample of 426 patients with knee impairments treated in 63 physical therapy practices across the United States. METHODS: Data were obtained during 1993 and 1994 from the Focus on Therapeutic Outcomes database. Health outcomes over an episode of physical therapy care were described using the SF-36 and the Lysholm Knee Rating Scale. Multivariate analyses were used to determine which patient and treatment characteristics were associated with these outcomes. RESULTS: The patients health improved, as measured by all but one of the SF-36 outcomes scales, with effect sizes ranging from 0.18 to 0.93 in scales in which change occurred. The patient and treatment characteristics that were studied accounted for 23% to 37% of the variability in health outcomes. CONCLUSION AND DISCUSSION: Patients who were older, had no surgery, were out of work because of their health, or were depressed were more at risk for poor health outcomes than were patients without these characteristics. These findings suggest a need for physical therapists to look for new approaches to identifying and treating patients with these characteristics.
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Physical therapy and health outcomes in patients with spinal impairments.
BACKGROUND AND PURPOSE: Little is known concerning the effects of physical therapy on health outcomes in patients with spinal impairments. This research examined the pattern of health outcomes in patients with spinal impairments and the relationship of outcomes to the physical therapy provided. SUBJECTS: Data were obtained from 1,097 patients with spinal impairments who completed an episode of care in any of 68 physical therapy practices across the United States. METHODS: Data were derived from the Focus on Therapeutic Outcomes database during 1993 and 1994. Multivariate analyses were used to determine which of the treatment variables, controlled for baseline health status and relevant patient characteristics, were related to outcomes. RESULTS: Improvement occurred in nearly all health scales. Inclusion of endurance exercise was most consistently associated with better outcomes. Inclusion of heat or cold modalities was associated with poorer outcomes. CONCLUSION AND DISCUSSION: This study suggests that physical therapists take a broader view of patient-related goals and documentation of outcomes. It also provides evidence that the type of intervention is related to outcomes.
Activities of Daily Living↗
A home-based exercise program for nondisabled older adults.
OBJECTIVES: This paper describes a videotaped, home-based, strength training program, titled Strong-for-Life and reports on its effectiveness in improving muscle strength, psychological well-being, and health status in a sample of older persons. DESIGN AND SETTING: We enrolled 102 nondisabled, community-dwelling older people aged 66 to 87, identified from the Medicare beneficiary list, into a randomized, controlled trial. MEASUREMENTS: Effectiveness was based on change in isokinetic upper and lower extremity muscle strength, psychologic well-being, and health status. RESULTS: Results revealed several statistically significant short-term benefits after 12 to 15 weeks of exercise, especially for men. Younger older adults demonstrated a 10% improvement in knee extensor strength relative to control subjects. Older male exercisers achieved significant differences relative to controls in perceived anger, tension, and overall social functioning. Male exercisers, in general, achieved significant improvement in perceived vigor. Women did not report psychological benefits following participation in the program. CONCLUSION: Study results reveal that the Strong for Life program, designed to be widely disseminated to the nondisabled older population, has many short-term positive benefits.
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Health status assessment in the occupational health setting.
This article discusses the conceptual roots of measuring health- related outcomes based on a biopsychosocial model of health. The selection and applicability of instruments for measurement of health status are discussed and suggestions are made concerning how health-status instruments may be used in the occupational- health setting. The potential value of measuring health status in the occupation-health setting is explored with a brief review of current literature and an example from one investigation in which measurements of health status were used to examine outcomes of common musculoskeletal impairments.
Health Status Indicators↗