Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial.
ABSTRACT: The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate.We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ?4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score.Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4-29.8) points lower (p?
Project description:<h4>Rationale</h4>Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown.<h4>Objectives</h4>To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program.<h4>Methods</h4>Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month.<h4>Measurements and main results</h4>A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71).<h4>Conclusions</h4>An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421).
Project description:BACKGROUND:The Continuous-Scale Physical Functional Performance 10 Test (CS-PFP 10) quantitatively assesses physical functional performance in older adults who have a broad range of physical functional ability. This study assessed the validity and reliability of the CS-PFP 10 German version. METHODS:Forward-translations and backtranslations as well as cultural adaptions of the test were conducted. Participants were German-speaking Swiss community-dwelling adults aged 64 and older. Concurrent validity was assessed using Pearson correlation coefficients between CS-PFP 10 and gait velocity, Timed Up and Go Test, hand grip strength, SF-36 physical function domain, and Freiburger Physical Activity Questionnaire. Internal consistency was calculated by Cronbach's alpha. RESULTS:Backtranslation and cultural adaptions were accepted by the CS-PFP 10 developer. CS-PFP 10 total score and subscores (upper body strength, upper body flexibility, lower body strength, balance and coordination, and endurance) correlated significantly with all measures of physical function tested. Internal consistency was high (Cronbach's alpha 0.95-0.98). CONCLUSION:The CS-PFP 10 German version is valid and reliable for measuring physical functional performance in German-speaking Swiss community-dwelling older adults. Quantifying physical function is essential for clinical practice and research and provides meaningful insight into physical functional performance of older adults. This trial is registered with ClinicalTrials.gov NCT01539200.
Project description:Exercise confers short-term benefits for individuals with Parkinson disease (PD).The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program.The 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control).This study was conducted in outpatient clinics.The participants were 121 individuals with PD (Hoehn & Yahr stages 1-3).The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month.Outcomes, obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous Scale-Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinson's Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinson's Disease Quality of Life Scale [PDQ-39]).Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), 10 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), and 16 months (mean difference=-1.7, 95% CI=-2.5 to -1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=-1.47, 95% CI=-2.79 to -0.15) and 16 months (mean difference=-1.95, 95% CI=-3.84 to -0.08).Absence of a non-exercise control group was a limitation of the study.Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.
Project description:<h4>Background</h4>Overall functional ability declines over time in people with Parkinson disease (PD). Established benchmarks are needed to allow clinicians and researchers to facilitate meaningful interpretation of data.<h4>Objective</h4>The purposes of this study were: (1) to report typical values for standard measures of functional ability commonly used in intervention studies and clinical practice with individuals in the early and middle stages of PD and (2) to describe the profile of functional limitations using the Hoehn and Yahr (H&Y) stages of disease and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores.<h4>Design</h4>Cross-sectional data were obtained from 5 different studies.<h4>Methods</h4>Three hundred thirty-nine patients were evaluated for disease severity (UPDRS motor score); functional capacity (Continuous Scale Physical Functional Performance Test [CS-PFP]); balance and gait (Functional Reach Test [FRT], Timed "Up & Go" Test [TUG], 360-degree turn, Six-Minute Walk Test [6MWT], and Two-Minute Walk Test); and basic functional activities (supine-to-stand task, stand-to-supine task, and functional axial rotation [FAR]).<h4>Results</h4>The mean UPDRS motor score for the sample was 39.2 (SD=12.93). At each stage of PD (from least to most involved), scores on functional measures indicated a significant and progressively reduced functional status. Limitations began early in the disease for the CS-PFP and FAR. Losses in performance were consistent across all stages of disease for the CS-PFP, FRT, 6MWT, and FAR. Several measures demonstrated meaningful losses of function only in later stages of disease. Findings extend current appreciation of functional limitations that begin early in PD and can guide the choice of functional outcome measures at different stages of disease severity.<h4>Limitations</h4>Data were obtained only from participants in H&Y stages 1 through 3 and only for some of the performance measures typically used.<h4>Conclusions</h4>The findings demonstrate that functional loss occurs at different points in the disease process, depending on the task under consideration. The resulting profile of functional limitations provides benchmarks that clinicians and researchers can use to interpret and monitor status of patients.
Project description:<h4>Background</h4>Pediatric patients admitted for acute lung disease are treated and monitored in the hospital, after which full recovery is achieved at home. Many studies report in-hospital recovery, but little is known regarding the time to full recovery after hospital discharge. Technological innovations have led to increased interest in home-monitoring and digital biomarkers. The aim of this study was to describe at-home recovery of 3 common pediatric respiratory diseases using a questionnaire and wearable device.<h4>Methods</h4>In this study, patients admitted due to pneumonia (n = 30), preschool wheezing (n = 30), and asthma exacerbation (AE; n = 11) were included. Patients were monitored with a smartwatch and a questionnaire during admission, with a 14-day recovery period and a 10-day "healthy" period. Median compliance was calculated, and a mixed-effects model was fitted for physical activity and heart rate (HR) to describe the recovery period, and the physical activity recovery trajectory was correlated to respiratory symptom scores.<h4>Results</h4>Median compliance was 47% (interquartile range [IQR] 33-81%) during the entire study period, 68% (IQR 54-91%) during the recovery period, and 28% (IQR 0-74%) during the healthy period. Patients with pneumonia reached normal physical activity 12 days postdischarge, while subjects with wheezing and AE reached this level after 5 and 6 days, respectively. Estimated mean physical activity was closely correlated with the estimated mean symptom score. HR measured by the smartwatch showed a similar recovery trajectory for subjects with wheezing and asthma, but not for subjects with pneumonia.<h4>Conclusions</h4>The digital biomarkers, physical activity, and HR obtained via smartwatch show promise for quantifying postdischarge recovery in a noninvasive manner, which can be useful in pediatric clinical trials and clinical care.
Project description:<h4>Background</h4>Acute geriatric treatment is a type of early rehabilitation for hospitalized seniors to maintain personal autonomy and to avoid nursing home placement.<h4>Objective</h4>The aim of the study was to describe the changes of mobility and functional independence of older trauma patients during acute geriatric treatment.<h4>Material and methods</h4>This study analyzed admission and discharge assessment data from 164 patients in the geriatric department with fall-related injuries. Mobility and performance in activities of daily living were assessed using the short physical performance battery (SPPB), gait speed and Barthel index. We analyzed changes in mobility from admission to discharge (t-test) and examined differences in mobility between patients returning home and those admitted to long-term care (age-adjusted and gender-adjusted linear regression model).<h4>Results</h4>Patients improved their mobility measured by the SPPB by 1.8 points ± 2.1 points, gait speed by 0.10 ± 0.14 m/s and the Barthel index by 13 ± 16 points, all p < 0.001). The number of patients not able to walk decreased from 43% to 14% (p = 0.003). Of the community-dwelling patients 73% were discharged either directly back home or after rehabilitation outside the hospital as a transitional solution.<h4>Conclusion</h4>In the context of acute geriatric treatment older trauma patients significantly improved their mobility and performance. The majority of patients could return home.
Project description:<h4>Introduction</h4>A compartment syndrome (CS) occurs when increased pressure within an anatomic compartment leads to inadequate perfusion. Although rare, gluteal CS can be encountered when an unconscious person has a prolonged period of immobilization.<h4>Presentation of case</h4>A 20-year-old male with history of polysubstance abuse leading to passing out, presented with right buttock and lower extremity pain, increased creatinine phosphokinase (CPK), and acute renal failure. Physical examination and MRI confirmation supported gluteal CS. Patient was taken to the OR for gluteal fasciotomy. Afterwards, the pain improved, the CPK and creatinine trended to normal. He was discharged home on day 7.<h4>Discussion</h4>CS can occur in any part of the body with fascial compartments. Increased compartmental pressure causes compression of vessels and nerves in the area that can lead to ischemia and necrosis. CS can occur after trauma, excessive fluid resuscitation, or surgery. It is also reported due to the prolonged periods of immobilization and increasing pressure on dependent areas. Often, intra-compartmental pressure is measured to confirm the diagnosis. The mainstay of treatment is fasciotomy.<h4>Conclusion</h4>Due to the rarity of gluteal compartment syndrome, the diagnosis is often delayed. If the affected area is ischemic for a significant amount of time, it can lead to sciatic nerve palsy, paresthesias, paralysis and muscle necrosis. Patients may experience irreversible damage after the syndrome and as such providers should be cognizant of this clinical entity to make an early diagnosis of gluteal compartment syndrome.
Project description:OBJECTIVES:Body composition alterations occur during aging. The purpose of the present analysis was to explore the functional consequences of the overlap of sarcopenia and osteoporosis, and the potential role of insulin-like growth factor 1 (IGF1) in their development in the oldest old. SETTING AND PARTICIPANTS:Eighty-seven nonagenarians from the Louisiana Healthy Aging Study were included. MEASURES:The definition of sarcopenia was based on appendicular lean mass (ALM). Osteoporosis was diagnosed based on bone mineral density (BMD) T score. Four phenotypes were compared: (1) healthy body composition, that is, nonosteoporotic nonsarcopenic (CO, control group), (2) osteoporotic (O, low BMD T score), (3) sarcopenic (S, low ALM), and (4) osteosarcopenic (OS, low BMD T score and low ALM). Sex- and age-specific IGF1-Standard Deviation Scores (SDS) were calculated. The Continuous Scale-Physical Functional Performance (CS-PFP) test was performed. RESULTS:In OS men, IGF1-SDS values (-0.61 ±0.37 vs -0.04 ± 0.52, P = .02) were lower than those in CO males (control group), whereas IGF1-SDS were similar in the 4 body composition phenotypes in women. In men only, ALM was positively associated with IGF1-SDS values (P = .01) independent of age and C-reactive protein concentration. Regarding bone health, we found no association between IGF1-SDS values and BMD. IGF1-SDS was not associated with functional performance (CS-PFP) in men and women. CONCLUSIONS/IMPLICATIONS:IGF1 sensitivity in skeletal muscle and bone may differ by sex in the oldest old. IGF1 status did not appear to affect physical functionality. Determinants and clinical and functional characteristics of osteosarcopenia need to be further investigated in order to define conclusive diagnostic criteria.
Project description:<h4>Background</h4>Severe sepsis is a common cause for admission to the general medical ward. Previous work has demonstrated substantial new long-term disability in patients with severe sepsis, but the short-term functional outcomes of patients admitted to the general medical floor -- where the majority of severe sepsis is treated -- are largely unknown.<h4>Methods</h4>A retrospective cohort study was performed of patients initially admitted to non-ICU medical wards at a tertiary care academic medical center. Severe sepsis was confirmed by three physician reviewers, using the International Consensus Conference definition of sepsis. Baseline functional status, disposition location, and receipt of post-acute skilled care were recorded using a structured abstraction instrument.<h4>Results</h4>3,146 discharges had severe sepsis by coding algorithm; from a random sample of 111 patients, 64 had the diagnosis of severe sepsis confirmed by reviewers. The mean age of the 64 patients was 63.5 years +/- 18.0. Prior to admission, 80% of patients lived at home and 50.8% of patients were functionally independent. Inpatient mortality was 12.5% and 37.5% of patients were discharged to a nursing facility. Of all patients in the cohort, 50.0% were discharged home, and 66.7% of patients who were functionally independent at baseline were discharged to home.<h4>Conclusions</h4>New physical debility is a common feature of severe sepsis in patients initially cared for on the general medical floor. Debility occurs even in those with good baseline physical function. Interventions to improve the poor functional outcomes of this population are urgently needed.
Project description:BACKGROUND:Geriatric assessment upon admission may reveal factors that contribute to adverse outcomes in hospitalized older patients. The purposes of this study were to derive a Frailty Index (FI-PAC) from the interRAI Post-Acute Care instrument (interRAI-PAC) and to analyse the predictive ability of the FI-PAC and interRAI scales for hospital outcomes. METHODS:This retrospective cohort study was conducted by combining patient data from interRAI-PAC with discharge records from two post-acute care hospitals. The FI-PAC was derived from 57 variables that fulfilled the Frailty Index criteria. Associations of the FI-PAC and interRAI-PAC scales (ADLH for activities of daily living, CPS for cognition, DRS for mood, and CHESS for stability of health status) with hospital outcomes (prolonged hospital stay ?90?days, emergency department admission during the stay, and in-hospital mortality) were analysed using logistic regression and ROC curves. RESULTS:The cohort included 2188 patients (mean age (SD) 84.7 (6.3) years) who were hospitalized in two post-acute care hospitals. Most patients (n =?1691, 77%) were discharged and sent home. Their median length of stay was 35?days (interquartile range 18-87?days), and 409 patients (24%) had a prolonged hospital stay. During their stay, 204 patients (9%) were admitted to the emergency department and 231 patients (11%) died. The FI-PAC was normally distributed (mean (SD) 0.34 (0.15)). Each increase of 0.1 point in the FI-PAC increased the likelihood of prolonged hospital stay (odds ratio [95% CI] 1.91 [1.73?2.09]), emergency admission (1.24 [1.11?1.37]), and in-hospital death (1.82 [1.63?2.03]). The best instruments for predicting prolonged hospital stay and in-hospital mortality were the FI-PAC and the ADLH scale (AUC 0.75 vs 0.72 and 0.73 vs 0.73, respectively). There were no differences in the predictive abilities of interRAI scales and the FI-PAC for emergency department admission. CONCLUSIONS:The Frailty Index derived from interRAI-PAC predicts adverse hospital outcomes. Its predictive ability was similar to that of the ADLH scale, whereas other interRAI-PAC scales had less predictive value. In clinical practice, assessment of functional ability is a simple way to assess a patient's prognosis.