Poster 12: Stay well and healthy! An in-home preventive health care program for persons aging with developmental disability

Objective: To pilot an intervention to prevent functional decline and health problems among persons with intellectual and developmental disability aging in the community. Design: Pilot for a large randomized trial. Setting: Private residences and group homes. Participants: 201 adults with intellectual and developmental disability, aged 32 years and older, were randomly assigned to an advance practice nurse (APN) intervention (n=101) or health-risk appraisal and feedback only (HRA) intervention (n=100). Interventions: The APN group received in-home multidimensional assessment, targeted recommendations, and quarterly follow-up visits for up to 1 year. The HRA group received an in-home interview with written feedback. Main Outcome Measures: Health, functional status, and risks; use of acute medical services; and feasibility assessment. Results: Assessment tools and interventions were demonstrated to be feasible in a population with mild to moderate intellectual and developmental disability. Recruitment and randomization were successful (avg age, 41y; 52% men). High levels of health risks were identified (mean, 7.6; range, 1-20y); 23.4% reported “fair” or “poor” general health; 16.4% reported probable depression; 34.5% reported recent falls; 36.8% reported fair or poor oral health; and 32.7% reported pain moderate or worse. Conclusion: Interventions are feasible for trials in this population and have broad applicability to other populations aging with disability.     

Study of the Independence IBOT 3000 Mobility System: an innovative power mobility device, during use in community environments

OBJECTIVE: To test the safe and effective use of a new mobility device, the Independence IBOT 3000 Mobility System, by people with a disability. DESIGN: A prospective, balanced, open-label evaluation that used participants as their own controls. SETTING: Home and community environments. PARTICIPANTS: Twenty subjects who use a mobility device. INTERVENTIONS: Subjects used the test device for up to 2 weeks in their home and community environments. MAIN OUTCOME MEASURE: Safety was determined by comparing the number of reported adverse events, including falls, in the test device compared with their own device. Effectiveness was measured by comparing scores from the Community Drive Test in the test device versus their own chair. RESULTS: No adverse event requiring medical attention was reported for either device and a similar number of device falls were reported for each device. The scored driving test results found that the test device was shown to statistically improve (P <.001) the subjects independent functional mobility skills in a community environment. Ten of 20 subjects were able climb stairs independently; the remaining 10 subjects were able to climb stairs with the assistance of only 1 person. CONCLUSIONS: People who are properly assessed, and participate and successfully complete the training, will benefit through increased independence in community mobility activities.     

Association of mobility limitations with health care satisfaction and use of preventive care: a survey of Medicare beneficiaries

OBJECTIVE: To examine the association between satisfaction with health care, the use of preventive health care, and mobility limitation. DESIGN: Cross-sectional analysis of survey data. SETTING: Community. PARTICIPANTS: A total of 12,769 people, age greater than 65, who participated in the 2001 Medicare Current Beneficiary Survey. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-report of mobility limitation, satisfaction, and use of preventive health care (immunizations, cancer screening). Sampling weights were used in all analyses, including logistic regression for survey data, to calculate estimates for a Medicare population of 31 million. RESULTS: After controlling for sociodemographic characteristics, Medicare beneficiaries with mobility limitations were significantly more dissatisfied with their health care compared with beneficiaries without mobility limitations. Receipt of preventive care did not differ for those with and without mobility limitation on some preventive services. CONCLUSIONS: Mobility limitation is highly associated with dissatisfaction with health care among older adult beneficiaries. Although Medicare beneficiaries may receive similar rates of preventive care, those with mobility limitation may have more difficulty accessing services and be more dissatisfied with their health care in general.     

Consumer,advocate, provider: a paradox requiring a new identity paradigm

The best measure of a society is how well it cares for its weakest members. Over the past 60 years, I have had to merge the roles of consumer, advocate, and provider into a new identity paradigm. This address shares my experiences-the best and the worst of what I have seen. On reflection, I offer the following words of advice to both persons who have disabilities and those who are able-bodied: "if there is no wind, row!"     

The segway personal transporter as an alternative mobility device for people with disabilities: a pilot study

Sawatzky B, Denison I, Langrish S, Richardson S, Hiller K, Slobogean B. The Segway Personal Transporter as an alternative mobility device for people with disabilities: a pilot study.

Objectives

To determine the functional measures that best correlate with the skill levels of people with disabilities who operate a Segway Personal Transporter, and—using a qualitative analysis—to explore subjects’ experience with the Segway.

Design

A prospective study encompassing 3 training sessions with the Segway to correlate subjects’ functional ability (eg, cognition, balance, mobility, muscle strength) with their skill level on the device.

Setting

A provincial adult rehabilitation center.

Participants

Twenty-three subjects (age range, 19−65y) with a wide range of disabilities (eg, multiple sclerosis, spinal cord injury, amputation) who could walk at least 6m with or without assistance.

Interventions

Not applicable.

Main Outcome Measures

Segway Task Assessment, Berg Balance Scale, and Timed Up & Go test.

Results

No correlation was found because all participants successfully completed the final Segway Task Assessment, regardless of scores on functional assessments.

Conclusions

The Segway is a useful device for a broad range of populations with functional disabilities. Subjects found the Segway easy to use and were excited about its potential as an assistive device for use in their communities.     

Promoting physical activity among women with mobility impairments: a randomized controlled trial to assess a home- and community-based intervention

OBJECTIVE: To assess the effectiveness of an intervention to promote physical activity and fitness in physically disabled women. DESIGN: Randomized controlled trial. SETTING: Home or community. PARTICIPANTS: Seventy-five adult women with mobility limitations. INTERVENTION: Incorporated behavioral techniques, social support, and education to promote exercise. MAIN OUTCOME MEASURES: Fitness measures included weight, body mass index, resting blood pressure and heart rate, time to complete a mobility course, and heart rate during and blood pressure after navigating the course. Also collected self-reported experience of secondary conditions and weekly self-reports of physical activity. RESULTS: We found no significant fitness differences between groups, except for peak heart rate. However, paired t tests of the physical activity data revealed the experimental group significantly increased its total weekly physical activity minutes (P=.04), and the increase in weekly cardiovascular activity approached significance (P=.06). CONCLUSIONS: The experimental group did not experience better fitness or fewer secondary conditions than the controls. However, the experimental group's physical activity data indicate that this group significantly increased its activity over 6 months. Thus, although this study did not detect health changes, it showed that mobility-impaired women can adopt and maintain a physical activity program.     

Quantifying environmental factors: a measure of physical, attitudinal, service, productivity, and policy barriers

OBJECTIVE: To develop and test a new instrument to assess environmental barriers encountered by people with and without disabilities by using a questionnaire format. DESIGN: New instrument development. SETTING: A rehabilitation hospital and community. PARTICIPANTS: Two convenience samples: (1) 97 subjects, 50 with disabilities and 47 without disability, and (2) 409 subjects with disabilities from spinal cord injury, traumatic brain injury, multiple sclerosis, amputation, or auditory or visual impairments. In addition, a population-based sample in Colorado of 2269 people (mean age, 44 y; 57% men) with and without disabilities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item development; factor structure; test-retest, subject-proxy and internal consistency reliability; content, construct, and discriminant validity; and subscale and abbreviated version development. RESULTS: Panels of experts on disability developed items for the Craig Hospital Inventory of Environmental Factors (CHIEF). The instrument measured the frequency and magnitude of environmental barriers reported by individuals. Five subscales were derived from factor analysis measuring (1) attitudes and support, (2) services and assistance, (3) physical and structural, (4) policy, and (5) work and school environmental barriers. The CHIEF total score had high test-retest reliability (intraclass correlation coefficient [ICC]=.93) and high internal consistency (Cronbach alpha=.93), but lower participant-proxy agreement (ICC=.62). Significant differences were found in CHIEF scores among groups of people with known differences in disability levels and disability categories. CONCLUSIONS: The CHIEF has good test-retest and internal consistency reliability with evidence of content, construct, and discriminant validity resulting from its development strategy and psychometric assessments in samples of the general population and among people with a variety of disabilities.     

Lower extremity physical performance, self-reported mobility difficulty, and use of compensatory strategies for mobility by elderly women

Ganesh SP, Fried LP, Taylor DH Jr, Pieper CF, Hoenig HM. Lower extremity physical performance, self-reported mobility difficulty, and use of compensatory strategies for mobility by elderly women.

Objective

To describe the relationship between lower extremity physical performance, self-reported mobility difficulty, and self-reported use of compensatory strategies (CSs) for mobility inside the home.

Design

Cross-sectional exploratory study.

Setting

Community-dwelling elders.

Participants

Disabled, cognitively intact women 65 years or older (N=1002), from the Women's Health and Aging Study I.

Interventions

Not applicable.

Main Outcome Measures

CS scale: no CS, behavioral modifications (BMs) only, durable medical equipment (DME) with or without use of BMs, and any use of human help (HH); and 3 dichotomous CS measures: any CS (vs none); DME+HH (vs BMs only, among users of any CS); any HH (vs DME only, among users of any DME/HH).

Results

Self-reported mobility difficulty and physical performance were significantly correlated with one another (r=−.57, P<.0001) and with the CS scale ([r=.51, P<.001] and [r=−.54, P<.0001], respectively). Sequential logistic regressions showed self-reported difficulty and physical performance were significant independent predictors of each category of CS. For the any CS and DME+HH models, the odds ratio for self-reported difficulty decreased by approximately 50% when physical performance was included in the model, compared with difficulty alone ([18.0 to 8.6] and [7.3 to 3.8], respectively), but both physical performance and difficulty remained significant predictors (P<.0001). The effects of covariates differed for the various CS categories, with some covariates having independent relationships to CS, and others appearing to have moderating or mediating effects on the relationship of self-reported difficulty or physical performance to CS.

Conclusions

Physical performance, self-reported difficulty, health conditions, and contextual factors have complex effects on the way elders carry out mobility inside the home.     

Presentation 3: Assessing disability in older adults: the effects of asking questions with and without health attribution

Objective: To determine the effects of using questions with and without health attribution on a self-reported disability instrument developed for use with older adults. Design: Cross-sectional. Setting: Community-based. Participants: 75 community-dwelling older adults from central and eastern Massachusetts. Interventions: Not applicable. Main Outcome Measures: We administered the disability component of the Late Life Function and Disability Instrument. To test whether altering attribution influenced scores, we administered the same 16 questions with attribution to specific health conditions. Results: A higher prevalence of disability was reported in the nonattributed compared with the health attribution (t=5.76, P<.001; 95% CI, 3.8-7.8). Item analyses indicated that participants were significantly more likely to report disability on the nonattributed version of 4 of the 16 disability items that required out-of-home travel. Conclusions: In this sample of older adults, estimates of disability were underestimated by questions that included specific attribution to health conditions. Factors other than health appear to influence self-report of disability related to participation in travel outside of the home.     

Concurrent and predictive validity of a self-reported measure of medication adherence

Adherence to the medical regimen continues to rank as a major clinical problem in the management of patients with essential hypertension, as in other conditions treated with drugs and life-style modification. This article reviews the psychometric properties and tests the concurrent and predictive validity of a structured four-item self-reported adherence measure (alpha reliability = 0.61), which can be easily integrated into the medical visit. Items in the scale address barriers to medication-taking and permit the health care provider to reinforce positive adherence behaviors. Data on patient adherence to the medical regimen were collected at the end of a formalized 18-month educational program. Blood pressure measurements were recorded throughout a 3-year follow-up period. Results showed the scale to demonstrate both concurrent and predictive validity with regard to blood pressure control at 2 years and 5 years, respectively. Seventy-five percent of the patients who scored high on the four-item scale at year 2 had their blood pressure under adequate control at year 5, compared with 47% under control at year 5 for those patients scoring low (P less than 0.01).     

Leg extension power asymmetry and mobility limitation in healthy older women

OBJECTIVE: To investigate the association of asymmetry in leg extension power (LEP) with walking and standing balance. DESIGN: Cross-sectional analysis. SETTING: Research laboratory. PARTICIPANTS: Healthy female twins (N=419), ages 63 to 75 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The LEP difference between the stronger and the weaker leg, measured with the Nottingham power rig, was calculated. Ten-meter maximal walking velocity was assessed in a laboratory corridor on a wide (170 cm) and narrow (35 cm) track, and the ability to maintain tandem stance for 20 seconds was recorded. RESULTS: The mean LEP difference +/- standard deviation between the legs was 15%+/-9% (P<.001). Those with large LEP difference had lower walking velocity and poorer standing balance than those with small LEP difference, in particular when the LEP of the stronger leg was below the median. CONCLUSIONS: Even in healthy older women, substantial LEP asymmetry between the lower limbs was present, encumbering walking and standing balance. Lower-limb muscle power asymmetry warrants further study in order to develop well-targeted strategies for preventing mobility limitation in older people.     

Managing activity difficulties at home: a survey of Medicare beneficiaries

Dudgeon BJ, Hoffman JM, Ciol MA, Shumway-Cook A, Yorkston KM, Chan L. Managing activity difficulties at home: a survey of Medicare beneficiaries.

Objective

To describe assistance from helpers and use of assistive technology and environmental modification by community-dwelling people with difficulties in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Design

Cross-sectional study using the 2004 Medicare Current Beneficiary Survey.

Setting

Community.

Participants

Nationally representative sample of 14,500 Medicare beneficiaries (mean age, 71.5y; 55% female; 49% currently married; 68% living with others; 84% white).

Interventions

Not applicable.

Main Outcome Measures

Self-reported difficulty with ADLs and IADLs; uses of help, assistive technology, and/or environmental modification.

Results

Difficulties were reported most frequently for heavy housework, walking, and shopping; money management, shopping, and light housework were reported as activities most often needing a helper. Walking, bathing, and toileting were activities most often needing uses of assistive technology. Bathroom modifications were the most commonly reported environmental modification. Results from a logistic regression showed that advancing age was the primary factor associated with increasing use of helpers and assistive technology or both for difficult activities.

Conclusions

Uses of helpers, assistive technology, and environmental modification are common but vary by type of ADL and/or IADL and age. Focused studies regarding uses of help and access to assistive technology and environmental modification appear needed to support community living. Public education about methods and types of accommodations appears needed and may substitute for or augment guidance from care providers.     

Validation of the Reintegration to Normal Living Index in a population of community-dwelling people with mobility limitations

OBJECTIVE: To validate the Reintegration to Normal Living Index (RNLI) in a population of community-dwelling adults with mobility limitations. DESIGN: Cross-sectional survey. SETTING: Community. PARTICIPANTS: Six hundred four people between the ages of 18 and 80 years who had a mobility limitation, lived in the community, and had been discharged from rehabilitation for at least 1 year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The RNLI. RESULTS: The RNLI is a reliable measure of community reintegration. A 2-factor structure emerged from a principal components analysis that indicates there are 2 subscales of the RNLI in a population with mobility impairments. CONCLUSIONS: The RNLI is a reliable and valid measure for studies of community integration among people living with long-term consequences of a chronic health condition.     

Obesity prevalence among a group of Chicago residents with disabilities

OBJECTIVE: To examine the prevalence of overweight, obesity, and extreme obesity in a predominantly minority group of adults with disabilities. DESIGN: Cross-sectional study using secondary data analysis. SETTING: Major university medical center. PARTICIPANTS: Adults with physical and cognitive disabilities (N = 306). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Direct measures of height and weight to classify subjects into 3 obesity categories: overweight (body mass index [BMI] range, 25-29.9 kg/m2), obese (BMI range, 30-39.9 kg/m2), and extreme obesity (BMI, > or = 40 kg/m2). RESULTS: People with disabilities, regardless of sex, race and ethnicity, or age, had significantly higher rates of overweight, obesity, and extreme obesity compared with people without disabilities. Extreme obesity (BMI, > or = 40 kg/m2) was approximately 4 times higher among people with disabilities than in the general population (odds ratio = 4.08; 95% confidence interval, 3.50-4.66). There were also substantial differences in obesity prevalence among people with disabilities, using actual measurement data, compared with self-reported data from previously published data sets. CONCLUSIONS: The disparity in excess body weight between people with and without disabilities, particularly in the category of extreme obesity, along with substantial differences in obesity prevalence between actual and self-reported data, show a critical need to better understand why these differences exist.     

Estimating transition probabilities in mobility and total costs for medicare beneficiaries

Hoffman JM, Ciol MA, Huynh M, Chan L. Estimating transition probabilities in mobility and total costs for Medicare beneficiaries.

Objective

To examine how persons move back and forth along levels of mobility disability.

Design

Self-reported mobility limitations were used to create categories of annual transition states. The total cost to Medicare associated with each year was calculated for each participant. In addition, we examined cost relative to transition state, adjusting for demographic and other health status variables.

Setting

National survey.

Participants

Participants in the longitudinal Medicare Current Beneficiary Survey from 1992 to 2005.

Interventions

Not applicable.

Main Outcome Measures

Annual self-reported mobility limitations and total Medi costs.

Results

Most participants remained without mobility limitations or improved over time. Reported average costs were 10 times higher for those who transitioned to severe limitations, unable to walk, or death compared with persons who reported no mobility limitation. Estimated costs were highest for those transitioning to increased states of disability and to death.

Conclusions

Mobility limitations in older adults are dynamic, and improvement (as measured by annual transitions) occurred for a large number of Medicare beneficiaries. High total annual costs were observed in groups that transitioned to worsening mobility states, suggesting a link between mobility limitation transitions and cost. Prevention and treatment of mobility limitation may be an important factor to consider in health care reform.     

The Patient-Specific Functional Scale: validity in workers' compensation claimants

Gross DP, Battié MC, Asante AK. The Patient-Specific Functional Scale: validity in workers' compensation claimants.

Objective

To examine the construct and predictive validity of the Patient-Specific Functional Scale (PSFS) in workers' compensation claimants.

Design

Prospective cohort study with 1-year follow-up.

Setting

A workers' compensation rehabilitation facility.

Participants

Subjects included 294 claimants with a variety of musculoskeletal disorders. The sample was predominantly male (70%), with a mean age of 44 years. Subjects completed a battery of measures at baseline including the PSFS, the Pain Disability Index (PDI), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).

Interventions

Not applicable.

Main Outcome Measures

Outcomes for determining predictive validity included administrative indicators of timely return to work and recovery during the 1-year follow-up. Analysis included Pearson correlation and multivariable Cox and logistic regression.

Results

At baseline, the PSFS correlated moderately (r range, 0.3−0.5) with other indicators of functional limitation (PDI, SF-36 role−physical subscale) but negligibly with the SF-36 mental health and role−emotional subscales. The PSFS was associated with timely recovery (adjusted hazard ratio, 1.16; 95% confidence interval, 1.07-1.27) with increasing functional limitation related to delayed recovery.

Conclusions

Results provide construct and predictive validity evidence for the PSFS as an indicator of functional limitation in workers' compensation claimants.     

Poster 7: Shoulder impingement syndrome: clinical indicators and short-term predictors of disability

Objective: To identify the best indicators of the current disability of patients with shoulder impingement syndrome (SIS) and the strongest predictors of 3-month SIS-related disability. Design: Prospective cohort study. Setting: Movement analysis laboratory. Participants: 41 subjects with SIS. Interventions: Evaluations at baseline and at 3 months. Main Outcome Measures: Personal, occupational, and impairment variables and the Shoulder Pain and Disability Index (SPADI). Cross-sectional explicative and 3-month predictive regression models of the level of disability (SPADI score) were developed using multivariate analyses. Results: Strength deficits in shoulder abduction-lateral rotation, pain during muscle strength testing, painful arc in abduction, scapular anterior tilting asymmetry, gender, and age explained 91% of the variance of the SPADI at baseline. The SPADI score at baseline, perceived work capacity, acromiohumeral distance at 90° of abduction, acromiohumeral distance difference between shoulders at 110° of flexion, difference between active and passive range of motion in abduction, and the presence of SIS on the dominant side predicted 86% of the variance of the SPADI at 3 months. Conclusions: Variables that best explain the current disability level and predictors of short-term level of disability should be considered in SIS treatment planning as well as for establishing prognosis.     

Raised paraspinal muscle activity reduces rate of stature recovery after loaded exercise in individuals with chronic low back pain

OBJECTIVES: To further the understanding of stature recovery in subjects with and without chronic low back pain (CLBP) and to determine the relations among stature recovery, paraspinal muscle activity, and perceived pain and disability. DESIGN: A case-control study in which stature loss and recovery were assessed in subjects with and without CLBP after a 20-minute loaded walking task (10% of body mass). Group differences in pain, disability, and paraspinal muscle activity were also assessed. SETTING: A university laboratory. PARTICIPANTS: Twenty subjects with CLBP were matched (age, sex, body mass, physical activity level) with 20 controls who were recruited through notices in the university, general community, and local Primary Care Trust. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stature changes and integrated electromyograms of the paraspinal muscles during a loading and unloading period were assessed. RESULTS: Stature changes after loading did not differ between groups ( P <.05). Subjects with CLBP recovered significantly less stature during unloading than did the controls ( P <.05). Paraspinal muscle activity correlated negatively with stature recovery ( P <.05). Relations among stature recovery, pain, and disability were shown ( P <.05). CONCLUSIONS: The elevated paraspinal muscle activity exhibited by the CLBP group increased compression on the intervertebral disks and diminished their ability to recover the height lost through loaded exercise. Further research is required to establish whether a change in paraspinal muscle activity is associated with corresponding changes in stature recovery, and if this has any clinical implications by reducing pain and disability.