Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease

OBJECTIVE: To study the activity level and heart rate response, objectively measured during normal daily life, of persons with a unilateral transtibial amputation for vascular disease. DESIGN: Case comparison. SETTING: General community, daily life in the Netherlands. PARTICIPANTS: Nine subjects with a unilateral transtibial amputation for vascular disease (convenience sample) and 9 control subjects without known impairments (matched for sex, age, social situation, employment). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Duration of dynamic activities, body motility (the intensity of body movement, measured with accelerometry), and heart rate (on 2 consecutive days). RESULTS: Persons with an amputation were less active than the comparison subjects (4.3% vs 11.4% of a 48-h period, P=.007). Body motility during walking was lower in the amputee group (.111 g vs.147 g, P=.003). No differences between groups were found in normalized heart rate during walking. In the amputee group, a strong relationship was found between body motility during walking and the percentage of the day that the subject walked (r=.88, P=.002). No relationship was found between the percentage of the day that persons with an amputation were active and data from disability questionnaires. CONCLUSION: Persons with a unilateral transtibial amputation for vascular disease were considerably less active than persons without known impairments. Heart rate response during walking of the amputee group did not differ from the response in the comparison group.     

Life Habits and Prosthetic Profile of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up

Zidarov D, Swaine B, Gauthier-Gagnon C. Life habits and prosthetic profile of persons with lower-limb amputation during rehabilitation and at 3-month follow-up.

Objective

To assess performance of life habits among persons with lower-limb amputation at admission, at discharge, and 3 months after rehabilitation discharge and describe their prosthetic profile at discharge and follow-up.

Design

Case series.

Setting

Inpatient rehabilitation.

Participants

Unilateral persons with lower-limb amputation (N=19; 14 men; mean age, 53.4±14.6y).

Intervention

Interdisciplinary rehabilitation.

Main Outcome Measures

Life habits performance and prosthetic profile.

Results

In the daily activities subdomain, the lowest performances were observed for mobility and housing at all evaluation times. Within the social role subdomain, employment, recreation, and community life scores were the lowest for the 3 evaluations. Mean scores for all activities of daily living subdomain categories significantly increased (P<.05) during rehabilitation except for personal care and communication. Only community life (social roles subdomain) significantly increased during rehabilitation; life habits remained unchanged after discharge. Fifty-eight percent of patients at discharge versus 68.4% at follow-up used their prosthesis for more than 9 hours a day, and this increased significantly postdischarge (P=.017). Locomotor capability with prosthesis was similarly high at discharge and follow-up.

Conclusions

Among persons with lower-limb amputation, social role life habits appear to be more disturbed than those associated with activities of daily living. At discharge, prosthetic wear and locomotor capabilities with prosthesis were high and tended to improve on return to the community.     

Accelerometry-based activity spectrum in persons with chronic physical conditions

van den Berg-Emons RJ, Bussmann JB, Stam HJ. Accelerometry-based activity spectrum in persons with chronic physical conditions.

Objectives

(1) To give an overview of the impact of a variety of chronic physical conditions on accelerometry-based levels of everyday physical activity and to identify high-risk conditions; and (2) to compare these objectively assessed activity levels with the levels estimated by rehabilitation physicians.

Interventions

Not applicable.

Design

Cross-sectional study.

Setting

Participant's home environment.

Participants

Patients (n=461) with 18 chronic physical (sub)conditions and able-bodied subjects (n=96).

Main Outcome Measures

We summarized data on the level of everyday physical activity as objectively measured with an accelerometry-based activity monitor. Thirty-one rehabilitation physicians filled in a questionnaire designed to obtain their estimates of the level of physical activity in patients with the various conditions.

Results

Only 4 of the studied conditions had normal activity levels (≥90% of the able-bodied level). Persons with transtibial amputation (vascular), spinal cord injury, and myelomeningocele (wheelchair dependent) had the lowest levels of activity, less than 40% of the able-bodied level. In general, rehabilitation physicians were aware of the inactive lifestyles, but considerably underestimated the magnitude of inactivity in the high-risk conditions.

Conclusions

This is the first study to provide an objectively assessed activity spectrum in a variety of chronic physical conditions. We hope this study will increase the awareness of health professionals as to which chronic physical conditions are at increased risk for an inactive lifestyle, and will contribute to adaptation of patient management accordingly.     

Association of activity limitations and lower-limb explosive extensor power in ambulatory people with stroke

Saunders DH, Greig CA, Young A, Mead GE. Association of activity limitations and lower-limb explosive extensor power in ambulatory people with stroke.

Objective

To determine whether the explosive lower-limb extensor power of the affected and unaffected sides, and any asymmetry, are associated with activity limitations after stroke.

Design

Cross-sectional observational study of baseline data from a randomized controlled trial.

Setting

Measurements made in a hospital clinical research facility.

Participants

Community-dwelling (N=66) subjects with stroke who were independently ambulatory. Subjects’ mean age was 72±10 years.

Interventions

Not applicable.

Main Outcome Measures

The lower-limb extensor power of each lower limb (in W/kg), performance of specific functional activities (comfortable walking velocity, Functional Reach Test, chair-rise time, Timed Up & Go test), and global indices of activity limitation (FIM instrument, Rivermead Mobility Index, Nottingham Extended Activities of Daily Living).

Results

Low lower-limb extensor power in either lower limb was the principal factor from among the confounders we recorded that significantly (R² range, .21-.46) predicted the limitation of specific functional activities, and low lower-limb extensor power in either lower limb was the principal predictive factor for global indices of activity limitation (R² range, .13-.38). The degree of asymmetry of lower-limb extensor power between legs was low and had little or no predictive value.

Conclusions

In ambulatory persons with stroke, activity limitations are associated with deficits in lower-limb extensor power of both lower limbs, and not the severity of any residual asymmetry. These findings suggest that interventions to increase lower-limb extensor power in both lower limbs might reduce activity limitations after stroke.     

The effects of prosthetic foot design on physiologic measurements, self-selected walking velocity, and physical activity in people with transtibial amputation

OBJECTIVE: To investigate the physiologic differences during multispeed treadmill walking and physical activity profiles for the Otto Bock C-Walk foot (C-Walk), Flex-Foot, and solid ankle cushion heel (SACH) foot in people with transtibial amputation. DESIGN: A repeated-measures design with 3 prostheses. SETTING: Research laboratory. PARTICIPANTS: Eight men with unilateral transtibial amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physiologic responses (energy expenditure, gait efficiency, exercise intensity, rating of perceived exertion [RPE]) during multispeed treadmill walking (53.64, 67.05, 80.46, 93.87, 107.28 m/min) test were analyzed with 2-way repeated-measures analysis of variance (ANOVA). One-way ANOVA was employed to analyze foot-type differences for self-selected walking velocity (SSWV), and steps per day (daily activity). Analysis of covariance was used to analyze foot-type differences with SSWV as the covariable for the physiologic measurements. RESULTS: The C-Walk had a trend of improved physiologic responses compared with the SACH; however, no foot-type differences were statistically significant. Compared with the C-Walk and SACH, the Flex-Foot showed no significant differences in energy expenditure and gait efficiency, but significantly lower percentage of age-predicted maximum heart rate and RPE values. CONCLUSIONS: The energy storing-releasing feet appeared to have certain trends of improved gait performance compared with the SACH; however, not many objective foot-type differences were significantly noted. Further studies with a larger sample size are suggested.     

A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge

van den Berg-Emons RJ, Bussmann JB, Haisma JA, Sluis TA, van der Woude LH, Bergen MP, Stam HJ. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge.

Objectives

To assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons.

Design

Prospective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge.

Setting

Rehabilitation center in The Netherlands and the participant's home.

Participants

Persons (n=40) with SCI.

Interventions

Not applicable.

Main Outcome Measures

The physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays.

Results

Random coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge.

Conclusions

The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge.     

Relationship between models of care and key rehabilitation milestones following unilateral transtibial amputation: a national cross-sectional study

ObjectivesTo identify different models of care (MOC) post transtibial amputation (TTA) and relate these to achievement of rehabilitation milestones.DesignRetrospective analysis of rehabilitation milestone data and a survey of MOC in 10 vascular centres.SettingNHS Scotland vascular centres.ParticipantsAll unilateral TTA between January 2011 and December 2014 (n = 643).Main outcome measuresTime (in days) to achieve the following rehabilitation milestones: compression therapy, early walking aid, casting for a prosthetic limb, prosthetic delivery, inpatient discharge and final discharge from rehabilitation. MOC were scored according to seven key aspects of service provision.ResultsThe mean age of the cohort was 67 [standard deviation (SD) 13] years, 76% were male and 63% had peripheral arterial disease and diabetes. The median number of days to achieve rehabilitation milestones varied between centres {compression therapy six [interquartile range (IQR) 0–12], early walking aid 14 (IQR 10–27), prosthetic casting 39 (IQR 27–71), prosthetic delivery 53 (IQR 36–87), inpatient discharge 53 (IQR 29–85) and final discharge from rehabilitation 141 (IQR 92–209)}. Only two centres included all seven key aspects of service provision within their MOC. Vascular centres that achieved the optimal MOC achieved the rehabilitation milestones more quickly than other vascular centres.ConclusionsA positive association was found between optimal MOC and early achievement of rehabilitation milestones post TTA. Key aspects of service provision associated with a quicker time to achieve rehabilitation milestones included: use of a postoperative rigid dressing, specialist physiotherapy input in the early postoperative period, daily inpatient gym sessions and inpatient prosthetic provision. To the authors’ knowledge, this is the first study to document MOC following TTA and to relate these to the achievement of rehabilitation milestones.     

Article 7: Categorization, deductive reasoning, and self-awareness: association to everyday competence in persons with acute brain injury

Objective: To examine the contribution of self-awareness and executive function to the performance of instrumental activities of daily living (IADLs) among adults with acute brain injury. Design: Correlational research design. Setting: Acute neurosurgery unit. Participants: 40 men and women between the ages of 21 to 84 years. Interventions: Not applicable. Main Outcome Measures: Performance on the Toglia Category Assessment (TCA), the Deductive Reasoning Test (DRT), and the Revised Observed Tasks of Daily Living served as dependent variables of interest. Self-awareness was measured using subtests of the TCA and DRT. Results: Categorization and deductive reasoning contributed significantly to IADL performance, suggesting that both executive measures can serve as predictors of IADL in persons with brain injuries. Self-awareness contributed significantly to IADL performance, but its contribution was mediated through categorization ability. Executive function correlated significantly with posttest IADL performance estimation, but not with IADL performance predictions. Conclusions: Executive functions, as well as self-awareness, predicted ADL performance in persons with brain injury. The results are discussed within the framework of a conceptual model that illustrates the multifaceted nature of executive function and its relationship to self-awareness and everyday functional competence.     

Score comparability of short forms and computerized adaptive testing: Simulation study with the activity measure for post-acute care

OBJECTIVE: To compare simulated short-form and computerized adaptive testing (CAT) scores to scores obtained from complete item sets for each of the 3 domains of the Activity Measure for Post-Acute Care (AM-PAC). DESIGN: Prospective study. SETTING: Six postacute health care networks in the greater Boston metropolitan area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services. PARTICIPANTS: A convenience sample of 485 adult volunteers who were receiving skilled rehabilitation services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inpatient and community-based short forms and CAT applications were developed for each of 3 activity domains (physical & mobility, personal care & instrumental, applied cognition) using item pools constructed from new items and items from existing postacute care instruments. RESULTS: Simulated CAT scores correlated highly with score estimates from the total item pool in each domain (4- and 6-item CAT r range,.90-.95; 10-item CAT r range,.96-.98). Scores on the 10-item short forms constructed for inpatient and community settings also provided good estimates of the AM-PAC item pool scores for the physical & movement and personal care & instrumental domains, but were less consistent in the applied cognition domain. Confidence intervals around individual scores were greater in the short forms than for the CATs. CONCLUSIONS: Accurate scoring estimates for AM-PAC domains can be obtained with either the setting-specific short forms or the CATs. The strong relationship between CAT and item pool scores can be attributed to the CAT's ability to select specific items to match individual responses. The CAT may have additional advantages over short forms in practicality, efficiency, and the potential for providing more precise scoring estimates for individuals.     

Responsiveness of Mobility, Daily Living, and Instrumental Activities of Daily Living Outcome Measures for Geriatric Rehabilitation

Demers L, Desrosiers J, Nikolova R, Robichaud L, Bravo G. Responsiveness of mobility, daily living, and instrumental activities of daily living outcome measures for geriatric rehabilitation.

Objectives

To assess and compare the ability of the Timed Up & Go (TUG) and subscales of the Functional Autonomy Measurement System (SMAF) to detect change in people undergoing geriatric rehabilitation in inpatient geriatric rehabilitation units (GRUs) and day hospitals.

Design

Longitudinal design with repeated measures obtained at admission and discharge from rehabilitation and at 2 follow-up interviews.

Setting

Inpatient and outpatient hospital-based settings.

Participants

Subjects (N=237, age 80±7y) had data at admission and discharge from rehabilitation (changing time frame), and of these, 160 had data at 2 subsequent follow-ups (stable time frame).

Interventions

Not applicable.

Main Outcome Measures

The TUG was used to estimate basic mobility, and subscales of the SMAF were used to estimate general mobility (SMAF-mobility), basic activities of daily living (SMAF-ADL), and instrumental activities of daily living (SMAF-IADL). Professionals' perception of change was used as a criterion.

Results

The TUG generated large values for the standardized response mean (SRM) and Guyatt's responsiveness index in GRUs (.98 and 1.12) and day hospitals (.89 and 1.85). Professionals' perception of change in mobility was explained by a perceptible change in the TUG in day hospitals (15%) but not in GRUs. The SMAF-mobility, SMAF-ADL, and SMAF-IADL were associated with large values of SRM and Guyatt's responsiveness index in GRUs (.97-2.17) and with small to moderate values in day hospitals (.29-.54). Moderate to large portions in the professionals' perceptions of change for mobility (20%, 17%), basic ADLs (10% and 14%), and IADLs (23% and 19%) were associated with the respective change scores of the subscales of the SMAF in both GRUs and day hospitals.

Conclusions

Progress of older adults in the areas of mobility, basic ADLs, and IADLs can be captured using the TUG, SMAF-mobility, SMAF-ADL, and SMAF-IADL in both GRUs and day hospitals. The results support their use in settings of high- and low-intensity rehabilitation, thus suggesting their adequacy for use in these 2 settings.     

Short-form activity measure for post-acute care

OBJECTIVE: To develop a comprehensive set of short forms using item response theory (IRT) and item pooling procedures for the purpose of monitoring postacute care functional recovery. DESIGN: Prospective study. SETTING: Six postacute health care networks in the greater Boston area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services. PARTICIPANTS: A convenience sample of 485 adult volunteers who were currently receiving skilled rehabilitation services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We developed a set of 6 short forms across 3 activity domains from new items and items from existing postacute care instruments. RESULTS: Inpatient- and community-based short forms were developed for each of 3 activity domains: physical & movement, applied cognition, and personal care & instrumental. Items were selected for inclusion on the short forms to maximize content coverage and information value of items across the range of content and to minimize ceiling and floor effects. We were able to match the distribution of sample scores with very good item precision for 1 of the constructs (physical & movement); the other 2 domains (personal care & instrumental, applied cognition) were more challenging because of the variability in patient recovery and ceiling effects. CONCLUSIONS: ITR methods and item pooling procedures were valuable in developing paired sets of short-form instruments for inpatient and community rehabilitation that provided estimates of functioning along a common metric for use across postacute care settings.     

Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke

Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke.

Objective

To investigate the relationship between severity of unilateral spatial neglect (USN) and functional recovery in activities of daily living after a right-hemisphere stroke.

Design

Observational study.

Setting

Rehabilitation hospital in Italy.

Participants

We investigated 107 of 131 inpatients with right-hemisphere stroke who were consecutively admitted to our rehabilitation hospital.

Interventions

Not applicable.

Main Outcome Measures

To assess USN severity, conventional and nonconventional Behavioral Inattention Tests (BITs) were performed at admission to inpatient rehabilitation at a median of 19 days after stroke occurrence. FIM was performed both on admission to and discharge from inpatient rehabilitation to assess functional autonomy. FIM efficiency (improvement of FIM score per day of stay length) and FIM effectiveness (proportion of potential improvement achieved) were calculated.

Results

Fifty-four (50.5%) of the 107 patients were affected by USN. In these 54 patients, both conventional and nonconventional BIT scores were significantly correlated with FIM scores assessed at discharge from rehabilitation: ρ values were .385 (P=.004) and .396 (P=.003), respectively. After adjustment for 7 potential confounders, including FIM scores before rehabilitation, we found a significant positive association between either conventional or nonconventional BIT scores and FIM scores after rehabilitation (r=.276, P=.047 and r=.296, P=.033, respectively), FIM efficiency (r=.315, P=.022 and r=.307, P=.025, respectively), and FIM effectiveness (r=.371, P=.006 and r=.306, P=.026, respectively).

Conclusions

Data support the independent prognostic role of USN severity assessed at admission to inpatient rehabilitation after a right-hemisphere stroke. Models aimed at predicting the functional outcome in stroke survivors may benefit from inclusion of USN severity.     

Stair negotiation time in community-dwelling older adults: normative values and association with functional decline

Oh-Park M, Wang C, Verghese J. Stair negotiation time in community-dwelling older adults: normative values and association with functional decline.

Objectives

To establish reference values for stair ascent and descent times in community-dwelling, ambulatory older adults, and to examine their predictive validity for functional decline.

Design

Longitudinal cohort study. Mean follow-up time was 1.8 years (maximum, 3.2y; total, 857.9 person-years).

Setting

Community sample.

Participants

Adults 70 years and older (N=513; mean age, 80.8±5.1y) without disability or dementia.

Interventions

Not applicable.

Main Outcome Measures

Time to ascend and descend 3 steps measured at baseline. A 14-point disability scale assessed functional status at baseline and at follow-up interviews every 2 to 3 months. Functional decline was defined as an increase in the disability score by 1 point during the follow-up period.

Results

The mean±SD stair ascent and descent times for 3 steps were 2.78±1.49 and 2.83±1.61 seconds, respectively. The proportion of self-reported and objective difficulty was higher with longer stair ascent and descent times (P<.001 for trend for both stair ascent and descent). Of the 472 participants with at least 1 follow-up interview, 315 developed functional decline, with a 12-month cumulative incidence of 56.6% (95% confidence interval [CI], 52.1%–61.3%). The stair negotiation time was a significant predictor of functional decline after adjusting for covariates including gait velocity (adjusted hazard ratio [aHR] per 1-s increase: aHR=1.12 [95% CI, 1.04–1.21] for stair ascent time; aHR=1.15 [95% CI, 1.07–1.24] for stair descent time). Stair descent time was a significant predictor of functional decline among relatively high functioning older adults reporting no difficulty in stair negotiation (P=.001).

Conclusions

The stair ascent and descent times are simple, quick, and valid clinical measures for assessing the risk of functional decline in community-dwelling older adults including high-functioning individuals.     

Poster 34: Cognitive impairment and everyday competence among 3 groups of persons: an empirical study

Objective: To compare problem-solving skills and everyday competency across clinical groups. Design: Between-groups design. Setting: Acute neurosurgery unit, community for the elderly, assisted living facilities for elderly and people diagnosed with schizophrenia, and nursing homes for the elderly. Participants: 60 older adults (age, ≥65y), 40 adults diagnosed with schizophrenia, and 40 adults with brain injuries. Interventions: Not applicable. Main Outcome Measures: Everyday competency was assessed using the Revised Observed Tasks of Daily Living (OTDL-R). Results: OTDL-R performance was significantly worse for participants diagnosed with schizophrenia than for participants with brain injury or older adults. Performance of the latter 2 groups did not differ. Higher educated persons in each of the 3 groups performed at a significantly higher level than less educated persons. Furthermore, older persons in each group performed worse than younger persons. Conclusions: The OTDL-R is a sensitive performance-based tool of potential importance for occupational therapists in the assessment of instrumental activities of daily living and problem-solving skills. However, education level and age should be taken into consideration during assessment. Additional research is needed to characterize more fully the psychometric properties of the OTDL-R for appropriate use by clinicians and researchers.     

The Trinity Amputation and Prosthesis Experience Scales and quality of life in people with lower-limb amputation

OBJECTIVES: To undertake preliminary research into quality of life (QOL) for a group of people with a lower-limb amputation and to investigate what aspects of the "prosthetic experience" are most strongly associated with QOL using the Trinity Amputation and Prosthesis Experience Scales (TAPES). DESIGN: Cross-sectional survey. SETTING: Prosthetic limb fitting center. PARTICIPANTS: Sixty-three people older than 18 years with unilateral lower-limb amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The TAPES and the World Health Organization Quality of Life Questionnaire-Brief Version. RESULTS: There were no significant differences in any of the QOL domain scores (physical health, psychological, social relationships, environmental) arising from age, gender, level of amputation, or cause of amputation. However, there were significant differences depending on the length of time living with the prosthesis and the degree of prosthetic use. Stepwise regression identified different significant predictors for each domain of QOL. CONCLUSIONS: These findings support the claim that the TAPES can be used to evaluate QOL for this patient group. Further research is warranted to learn how sensitive the scale and its items are to change in clinical status.     

Repeatability and validity of a modified Activities of Daily Living (ADL) index in studies of chronic disability

In order to measure disability in a randomised controlled trial of different intensities of rehabilitation following stroke, a modification of existing methods has been developed; it makes use of 17 items of activities of daily living (ADL) which are rated on a three-point scale, and it has been subjected to tests of repeatability and validity. While some activities (e.g. use of taps, ascending or descending stairs) are either redundant or repetitive, others provide independent measures of disability. There was no significant inter-observer variability; the assessors disagreed on 78 (3.7%) out of a total of 2,125 paired observations. In a study of short-term within-patient variability, different scores were assigned on 49 (14.4%) out of a total of 340 observations made on two separate occasions. Minor differences (mainly in activities involving equipment e.g. cookers) emerged when scores obtained in hospital were compared with those obtained at home, but the two sets of scores were still highly correlated (r = 0.962). There was, however, considerable discrepancy between the hospital scores and those derived from the patients' own estimates of their activities at home, the latter falling below actual capabilities as indicated by the hospital scores. A clinical validation of the index showed a significant association between the hospital ADL scores and the extent of cerebral lesions determined by the number of neurological deficits. This modified ADL index is sufficiently repeatable and valid for the assessment of patients with moderate disability as a result of stroke and other chronic diseases; in most circumstances, it can probably be simplified to include only five or six items.