Developing Rehabilitative Strategies for Disability Prevention in Primary Care

描述（由主要研究者提供）：70岁或以上的美国人中，有1/4的人受到行动不便的影响。基于初级保健的活动能力测试一直被提倡作为一种重要的临床测试，用于识别那些有随后活动能力下降和残疾风险的人。理想情况下，对那些有风险的人进行康复治疗，应该解决那些导致行动能力下降的最主要原因。我们将这些定义为康复性障碍，并确定了9种康复性障碍，包括当代康复项目中最常见的焦点。在认识到许多这些因素是相互关联的，我们以前的工作和经验表明，康复障碍包括在四个不同的类别（力量，速度，稳定性和能力），我们称之为康复障碍域（RID）。我们假设，最常见的医疗条件和活动能力下降之间的最终共同途径将以RID表现的不同模式为特征。令人惊讶的是，鉴于活动能力受限的高患病率及其临床重要性，目前还没有关于活动能力危险因素筛查和干预的既定活动能力护理指南，作为预防老年初级保健患者残疾的一种手段。对于易患疲劳和虚弱的老年患者，最佳的活动能力康复应针对那些少数RID和RID组合最负责活动能力下降。然而，如果没有更好的证据来确定哪些损伤和非物理因素在康复中优先考虑，康复护理将不可避免地更像是“一门艺术而不是一门科学”——依赖于个体从业者的主观观点和经验。相比之下，随着对目标风险因素的更清晰理解，康复护理可以成为成功的基于初级保健的残疾预防战略的重要组成部分。我们建议对420名65岁及以上表现出临床前残疾的初级保健患者进行前瞻性队列研究。在2年的随访中，我们计划评估这9种康复障碍，确定导致衰退和残疾的独特RID模式。初步研究表明，RID的强度、速度、稳定性和容量特征可能是最重要的原因。本研究将解决三个具体目标：(1)在基线上，我们将检查这9种康复性损伤所代表的RID，并评估RID的哪些模式与通过晚年功能和残疾工具（LLFDI）的功能组件测量的当前活动能力限制相关；(2)我们将测试在基线时呈现的RID和RID组合预测未来两年内由LLFDI的功能成分测量的流动性功能的下降；(3)我们将测试在基线时出现的RID和RID组合可以预测两年内LLFDI的残疾成分所衡量的残疾进展。填补这一知识空白将有助于制定以初级保健为基础的康复战略，以预防残疾。

DESCRIPTION (provided by principal investigator): Mobility problems affect 1/4 of all Americans aged 70 years or older. Primary care--based mobility testing has been advocated as an important clinical test for identifying those at risk for subsequent mobility decline and disability. Ideally, rehabilitation for those at risk should address the impairments that are most responsible for mobility decline. We define these as Rehabilitative Impairments and have identified 9 rehabilitative impairments as encompassing the most common foci of contemporary rehabilitation programs. In recognizing that many of these factors are interrelated, our previous work and experience suggests that rehabilitative impairments are encompassed within four distinct categories (Strength, Speed, Stability and Capacity), which we refer to as Rehabilitative Impairment Domains (RID). We hypothesize that the final common pathway between the most common medical conditions and mobility decline will be characterized by differing patterns of RID presentation. Surprisingly, given the high prevalence of mobility limitations and their clinical importance, there are no established mobility care guidelines concerning mobility risk factor screening and intervention as a means of preventing disability among older primary care patients. For older patients vulnerable to fatigue and frailty, optimal mobility rehabilitation should be directed toward those few RID and RID combinations most responsible for mobility decline. However, without better evidence determining which impairments and nonphysical factors to prioritize through rehabilitation, rehabilitative care will inevitably be more "an art than a science" - dependent on the subjective views and experiences of individual practitioners. In contrast, with a clearer understanding of the risk factors to target, rehabilitative care can be a vital component of a successful primary-care based disability prevention strategy. We propose to conduct a prospective cohort study among 420 primary care patients, aged 65 years and older that manifest preclinical disability. Over 2 years of follow up, we plan to evaluate these 9 rehabilitative impairments identifying the distinct RID patterns most responsible for decline and disability. Preliminary work suggests that RID characteristic of Strength, Speed, Stability and Capacity may be most responsible. This investigation will address three specific aims: (1) At baseline, we will examine the RID represented by these 9 rehabilitative impairments and evaluate what patterns of RID are associated with current mobility limitation as measured by the Function component of the Late Life Function and Disability Instrument (LLFDI); (2) We will test which RID and RID combinations presenting at baseline predict future decline in mobility function as measured by the Function component of the LLFDI over two years; (3) We will test which RID and RID combinations present at baseline predict the progression of disability as measured by the Disability components of the LLFDI over two years. Filling this knowledge gap will allow for the development of primary care-based rehabilitative strategies to prevent disability.