Implementation of a rehabilitation model in a Program of All-Inclusive Care for the Elderly (PACE): Preliminary data.

BACKGROUND: Nursing home eligible participants in the Program of All-inclusive Care for the Elderly (PACE) are at high risk for falls. Physical function is a modifiable predictor of falls and an important target for prevention. We engaged a PACE site to explore feasibility of implementing progressive intensive rehabilitation to improve physical function and preliminary patient-level improvements. METHODS: The research involved a mixed-methods, pre-post implementation study with longitudinal patient follow-up at one Denver PACE site. Older adults at risk for institutionalization (N = 28) took part in Screening and high-intensity interventions to Improve Falls risk and Transform expectations in age and aging (SHIFT) rehabilitation program over six weeks. Outcomes included the short physical performance battery (SPPB); 4-meter gait speed at baseline, discharge, and 6 and 12 months postdischarge from SHIFT. A focus group with staff explored facilitators and barriers to program implementation in the PACE setting and with complex patients and perceived effectiveness. RESULTS: The rehabilitation team demonstrated high treatment fidelity to SHIFT (>80%). No treatment-specific adverse events were reported. SPPB scores and gait speeds improved significantly over time (p < 0.005). The average SPPB score at evaluation was 4.6 ± 0.24 compared to 7.7 ± 0.38 points at discharge. The average gait speed at evaluation was 0.58 ± 0.03 meters/second (m/s) compared to 0.79 ± 0.04 m/s at discharge. Common barriers to program completion included changes in health status and environmental factors (e.g., transportation). CONCLUSIONS: Rehabilitation therapists incorporated a high-intensity resistance training program into routine care of complex older adults in PACE and improved pre-post physical function to levels above independence thresholds (SPPB ≥6; gait speed ≥0.65 m/s). Our pilot implementation study informed refinement of eligibility criteria, number of visits, and strategies to address long-term adherence to enhance scalability and optimize impact.

Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice.

OBJECTIVE: Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients. METHODS: Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models. RESULTS: 2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts. CONCLUSIONS: Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes. This suggests that both clinical and research populations may recover similarly from TKA.

Characteristics of young and lower functioning patients following total knee arthroplasty: a retrospective study.

BACKGROUND: Rates of total knee arthroplasty (TKA) procedures in younger, more medically complex patients have dramatically increased over the last several decades. No study has examined categorization of lower and higher functioning subgroups within the TKA patient population. Our study aimed to determine preoperative characteristics of younger patients who are lower functioning following TKA. METHODS: Patients were categorized into higher and lower functioning subgroups defined using a median split of 1) postoperative Timed Up and Go (TUG) test times and 2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale scores. A split in age (65 years) was used to further classify patients into four categories: younger lower functioning, younger higher functioning, older lower functioning and older higher functioning. Measures from preoperative domains of health, psychological, physical performance and pain severity were examined for between-group differences. RESULTS: Comparing mean values, the younger lower functioning subgroup using the TUG had significantly weaker knee extensor, slower gait speed, higher body mass index and greater pain compared to other subgroups. The younger lower functioning subgroup using the WOMAC physical function subscale demonstrated higher pain levels and Coping Strategies Questionnaire-Catastrophizing Subscale scores compared to the older lower functioning subgroup. CONCLUSIONS: Poorer preoperative physical performance and pain severity appear to have the largest influence on early postoperative TKA recovery in younger lower functioning patients relative to both younger and older higher functioning patients.