Developing Rehabilitative Strategies for Disability Prevention in Primary Care

描述（由主要研究者提供）：行动不便问题影响1/4的70岁或以上的美国人。以初级保健为基础的活动能力测试一直被认为是一项重要的临床测试，用于识别那些有随后活动能力下降和残疾风险的人。理想的情况是，对那些有风险的人进行康复应该解决造成行动能力下降的最主要原因。我们将这些定义为康复性损伤，并确定了9种康复性损伤，包括当代康复计划中最常见的焦点。在认识到这些因素中的许多因素是相互关联的，我们以前的工作和经验表明，康复性损伤包括在四个不同的类别（力量，速度，稳定性和能力），我们称之为反射性损伤领域（RID）。我们假设，最常见的医疗条件和流动性下降之间的最终共同途径将以不同的RID表现模式为特征。令人惊讶的是，考虑到行动不便的高患病率及其临床重要性，目前还没有关于行动不便风险因素筛查和干预作为预防老年初级保健患者残疾的一种手段的既定行动不便护理指南。对于容易疲劳和虚弱的老年患者，最佳的活动康复应该针对那些最容易导致活动能力下降的少数RID和RID组合。然而，如果没有更好的证据来确定哪些损伤和非身体因素优先通过康复，康复护理将不可避免地更多地是“一门艺术而不是科学”-依赖于个人从业者的主观观点和经验。相比之下，更清楚地了解目标风险因素，康复护理可以成为成功的初级保健残疾预防战略的重要组成部分。我们建议在420名年龄在65岁及以上的初级保健患者中进行一项前瞻性队列研究，这些患者表现出临床前残疾。在2年的随访中，我们计划评估这9种康复障碍，确定最可能导致衰退和残疾的不同RID模式。初步工作表明，力量，速度，稳定性和能力的RID特征可能是最负责任的。本研究将解决三个具体目标：（1）在基线时，我们将检查由这9种康复障碍所代表的RID，并评估RID的模式与当前活动受限相关，这些活动受限由晚期生活功能和残疾工具（LLFDI）的功能组成部分测量;（2）我们将测试在基线时呈现的RID和RID组合预测未来移动功能的下降，如通过LLFDI的功能成分测量的，超过两年;（3）我们将测试在基线时存在的RID和RID组合预测两年内LLFDI的残疾组成部分测量的残疾进展。填补这一知识空白将有助于制定以初级保健为基础的预防残疾的康复战略。公共卫生相关性行走、爬楼梯和其他基本活动困难影响了近1/4的65岁以上的成年人，并预示着福尔斯、住院甚至死亡等问题。我们的研究将确定哪些身体因素，通过康复可以纠正，是最负责老年初级保健患者的流动性恶化。结果将导致研究评估使用康复作为预防老年人残疾的一种手段。

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. PUBLIC HEALTH RELEVANCE Difficulty with walking, climbing stairs and other basic mobility tasks affect almost 1/4 of adults over the age of 65 years and are predictive of such problems as falls, hospitalizations and even death. Our study will identify which physical factors, correctable through rehabilitation, are most responsible for worsening mobility among older primary care patients. The results will lead to studies evaluating the use of rehabilitation as a means of preventing disability among older adults.