Home versus center based physical activity programs in older adults.

BACKGROUND: Physical inactivity is a leading cause of preventable death and morbidity in developed countries. In addition physical activity can potentially be an effective treatment for various medical conditions (e.g. cardiovascular disease, osteoarthritis). Many types of physical activity programs exist ranging from simple home exercise programs to intense highly supervised hospital (center) based programs. OBJECTIVES: To assess the effectiveness of 'home based' versus 'center based' physical activity programs on the health of older adults. SEARCH STRATEGY: The reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL) (1991-present), MEDLINE (1966-Sept 2002), EMBASE (1988 to Sept 2002), CINAHL (1982-Sept 2002), Health Star (1975-Sept 2002), Dissertation Abstracts (1980 to Sept 2002), Sport Discus (1975-Sept 2002) and Science Citation Index (1975-Sept 2002), reference lists of relevant articles and contacted principal authors where possible. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of different physical activity interventions in older adults (50 years or older) comparing a 'home based' to a 'center based' exercise program. Study participants had to have either a recognised cardiovascular risk factor, or existing cardiovascular disease, or chronic obstructive airways disease (COPD) or osteoarthritis. Cardiac and post-operative programs within one year of the event were excluded. DATA COLLECTION AND ANALYSIS: Three reviewers selected and appraised the identified studies independently. Data from studies that then met the inclusion/exclusion criteria were extracted by two additional reviewers. MAIN RESULTS: Six trials including 224 participants who received a 'home based' exercise program and 148 who received a 'center based' exercise program were included in this review. Five studies were of medium quality and one poor. A meta-analysis was not undertaken given the heterogeneity of these studies. CARDIOVASCULAR. The largest trial (accounting for approximately 60% of the participants) looked at sedentary older adults. Three trials looked at patients with peripheral vascular disease (intermittent claudication). In patients with peripheral vascular disease center based programs were superior to home at improving distance walked and time to claudication pain at up to 6 months. However the risk of a training effect may be high. There are no longer term studies in this population. Notably home based programs appeared to have a significantly higher adherence rate than center based programs. However this was based primarily on the one study (with the highest quality rating of the studies found) of sedentary older adults. This showed an adherence rate of 68% in the home based program at two year follow-up compared with a 36% adherence in the center based group. There was essentially no difference in terms of treadmill performance or cardiovascular risk factors between groups. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). Two trials looked at older adults with COPD. In patients with COPD the evidence is conflicting. One study showed similar changes in various physiological measures at 3 months that persisted in the home based group up to 18 months but not in the center based group. The other study showed significantly better improvements in physiological measures in the center based group after 8 weeks but again the possibility of a training effect is high. OSTEOARTHRITIS. No studies were found. None of the studies dealt with measures of cost, or health service utilization. AUTHORS' CONCLUSIONS: In the short-term, center based programs are superior to home based programs in patients with PVD. There is a high possibility of a training effect however as the center based groups were trained primarily on treadmills (and the home based were not) and the outcome measures were treadmill based. There is conflicting evidence which is better in patients with COPD. Home based programs appear to be superior to center based programs in terms of the adherence to exercise (especially in the long-term).

Evaluation of motor vehicle driving performance in patients with chronic diplopia.

BACKGROUND: Uncorrected diplopia is a condition that may make it unsafe for a person to operate a motor vehicle. In some jurisdictions, physicians are required by law to report the person with diplopia to the appropriate authority. METHODS: In this masked study, 10 patients of varying ages with stable diplopia of greater than 6 months' duration and 10 age-matched control subjects were placed in a driving simulator and evaluated on their performance. Various cues and threats, including near-accident situations, were presented; stimulus recognition and reaction times were recorded. RESULTS: No significant difference was found between the groups for either cue or threat recognition responses or reaction times. Increasing age was the factor most associated with poor response performance on all test measures (P < .001). Slowed response time in patients with poor binocular single vision was the only other significant association. CONCLUSION: Although response times were slower in subjects with poor binocular single vision scores, stimulus recognition responses were not significantly different; in our opinion, stimulus recognition is more relevant to driving performance and therefore chronic diplopia does not appear to be a contraindication for driving a motor vehicle.

Development of psychometrically matched English and Spanish language neuropsychological tests for older persons.

Item response theory (IRT) methods were used to develop a neuropsychological test battery with matched English and Spanish language forms. Candidate items for 12 scales measuring core neuropsychological abilities were generated and administered to 200 community-dwelling elderly participants tested in Spanish and 208 tested in English. IRT methods were used to eliminate linguistically biased items and refine scales to assess broad ability ranges. Reasonably good psychometric matching of scales was achieved within and across English and Spanish language forms. All scales were sensitive to cognitive impairment as measured by the Mini-Mental State Examination (MMSE), with highly similar relationships between scale scores and MMSE across English and Spanish groups. The outcome supports the use of IRT methods in cross-cultural and multilingual test development and indicates that this strategy has potential for future neuropsychological test development.

Validity of the PULSES profile compared with the Functional Independence Measure for measuring disability in a stroke rehabilitation setting.

OBJECTIVES: To test the validity of the PULSES profile for measuring the disability of stroke rehabilitation patients and to compare it with the Functional Independence Measure (FIM); and to determine the ability of the PULSES score to predict discharge home from a stroke rehabilitation setting. STUDY DESIGN: Retrospective cohort. SETTING: A tertiary stroke rehabilitation unit. PATIENTS: One hundred ninety-seven patients admitted consecutively to a stroke rehabilitation unit from September 1992 to April 1995. METHODS: The PULSES profile was tested for internal consistency. Criterion validity was evaluated by comparing with the FIM. Construct validity was tested using the multimethod-multitrait matrix method and by performing logistic regression to determine if admission PULSES score was predictive of discharge home. RESULTS: Internal consistency of the PULSES profile was supported with a Cronbach's alpha of .74. There was a high correlation between the PULSES and FIM admission and discharge scores of -.82 and -.88, respectively. The multimethod-multitrait matrix correlations demonstrated good convergent and divergent validity for the correlation of the PULSES profile items and the FIM subcategories. Multivariate logistic regression determined the admission PULSES total score to be an independent variable in the model to predict discharge home. CONCLUSIONS: The PULSES profile is a valid measure for assessing disability in the stroke rehabilitation setting. The PULSES profile correlates highly with the FIM. The admission PULSES total score is predictive of discharge home from a stroke rehabilitation program.

Saskatchewan physicians' attitudes and knowledge regarding assessment of medical fitness to drive.

BACKGROUND: Although legislation has been introduced in Saskatchewan for mandatory reporting by physicians of patients considered medically unfit to drive, little is known about physicians' attitudes, knowledge or resources with regard to evaluating medical fitness to drive. METHODS: The objective of this study was to determine Saskatchewan physicians' attitudes, knowledge, training, resources and current educational needs with regard to evaluating medical fitness to drive. A questionnaire survey of all physicians in the province who were identified as likely to be involved in determining medical fitness to drive was conducted between October and December 1996. RESULTS: Of the 1102 physicians who received a questionnaire, 690 (62.6%) responded, of whom 167 were excluded because they were not involved in assessing fitness to drive. Thus, 523 (55.9%) of the 935 eligible physicians surveyed completed the questionnaire. Most (57.6% [298/517]) of the respondents indicated that they do not hesitate to report patients medically unfit to drive; however, 59.5% (307/516) felt that the physician-patient relationship is negatively affected by reporting. Overall, 85.5% (444/519) of the respondents felt that restricted licensing is a fair alternative for people who might otherwise be denied a full licence. The availability of restricted licensing positively influenced the decision to report for 60.3% (313/519) of the respondents. Significantly more rural physicians than urban physicians believed that the need to drive was greater for rural residents than for urban dwellers (81.2% [95/117] v. 64.2% [257/400], p < 0.001). Physician knowledge regarding specific medical conditions and fitness to drive was generally poor. The resource most commonly used in determining medical fitness to drive was the Physicians' Guide to Driver Examination (71.1% [361/508] of respondents). The most useful continuing medical education methods indicated by physicians for assessing medical fitness to drive included conference presentations, workshops and journal articles. INTERPRETATION: Most of the Saskatchewan physicians surveyed supported restricted licensing, and the availability of restricted licensing made them more likely to report patients considered medically unfit to drive. The physician-patient relationship was felt to be negatively affected by reporting.

A comparison of traumatic brain injury in the Saskatchewan native North American and non-native North American populations.

OBJECTIVE: To compare native North American and non-native North American patients admitted for inpatient rehabilitation following traumatic brain injury in order to identify pertinent differences between the two groups with regards to the initial injury, medical management and allocated resources. DESIGN: A retrospective chart review was performed on all patients admitted to the unit between July 1994 and March 1997 with the diagnosis of traumatic brain injury. RESULTS: Significant differences were found between the two groups in the areas of alcohol and drug involvement with the initial injury (p < 0.0001), geographical location of the injury (p < 0.0001), initial treatment received (p = 0.0102), discharge planning (p < 0.0001), and post-discharge follow-up (p = 0.0052). CONCLUSIONS: The results indicate that native North Americans are more likely to suffer a head injury than non-native North Americans, that alcohol is more likely to be involved, and that native North American patients are less likely to be offered post-discharge resources. Further prospective study to explore these areas is required.

The effect of temperature on nerve conduction parameters in carpal tunnel syndrome.

Correction factors exist to allow for the dramatic effect that temperature has on nerve conduction study parameters. However, these are based on normal nerves in normal individuals and may not be appropriate in the diseased nerve setting. Our clinical study showed that in carpal tunnel syndrome, the median nerve reacts differently to temperature changes compared with normal ulnar controls. Furthermore, statistically significant differences exist between the rates of change with increasing temperature in motor and sensory nerves.

Anterior interosseous nerve syndrome presenting with pronator teres weakness: a case report.

Anterior interosseous nerve syndrome (AINS) has been well described. A key muscle to examine clinically and on electromyography is the pronator teres, as this can differentiate between forearm and more proximal entrapment sites. We present a case of AINS with marked weakness and denervation of pronator teres. At operation the anterior interosseous nerve gave rise to the nerve to pronator teres and was entrapped by a fibrous band from the deep head of pronator teres.

Attentional deficits in stroke patients: a visual dual task experiment.

OBJECTIVE: (1) To compare the performance of subjects who have suffered a single lateralized cortical, ischemic stroke versus controls on measures of attention including a computerized dual visual attentional task to determine if this task is more sensitive for detecting the presence of subtle hemi-inattention compared to traditional attention tasks; (2) to determine if there is evidence of hemi-inattention in persons who completed spontaneous neurological recovery after a cortical, ischemic stroke compared to controls. SUBJECTS: Thirty-six patients (N = 20 Right Hemisphere and N = 16 Left Hemisphere) who had previously undergone stroke rehabilitation and who were at least 1 year poststroke. All patients were currently living in the community. A control group of 20 subjects was recruited from the community. RESULTS: There was no difference in performance between the three groups on gross clinical testing for hemi-inattention, or on the traditional letter-cancellation tasks. All subjects also participated in two computer generated tasks: (1) tracking a moving stimulus and (2) detecting briefly appearing targets. On the single task performance the control group performed significantly better than both cerebrovascular accident (CVA) groups (p < .004), but with no trend for hemi-inattention in any individual group. When the two computer tasks were combined, there was a significant difference in performance between the control group and all stroke subjects (p < .02) for target detection. A fatiguing effect over time was also found in the right CVA group on the dual task. Stroke subjects driving at the time of data collection performed better on the dual attentional task compared to stroke subjects not driving (p = .05). CONCLUSIONS: On single and dual dynamic computerized visual attentional tasks, individuals who have suffered a cortical stroke more than 1 year before testing have significantly impaired attention compared to controls.

Age and education correction of Mini-Mental State Examination for English and Spanish-speaking elderly.

Previous research has shown that the Mini-Mental State Examination (MMS) is biased as a measure of cognitive impairment in minority and low-education patients. The purpose of this study was to (1) develop a statistical correction for effects of age and education and (2) test the efficacy of the statistically adjusted MMS (MMSAdj) as a screening test for dementia using different ethnic groups and education levels. We used a population-base community survey sample (n=590) composed of 46.6% Hispanics and 53.4% non-Hispanics to derive the statistical correction, defined as:MMSAdj = Raw MMS - (0.471 X [Education-12]) + (0.131 X [Age-70]). Ethnicity and language of test administration were not significantly related to MMSAdj in the community survey sample, but the raw MMS was strongly influenced by these factors. We used an independent sample (n=2,983) of patients evaluated through the California Alzheimer's Disease Diagnostic and Treatment Centers to test the diagnostic accuracy of the MMS and the MMSAdj across low- and high-education groups and across whites, Hispanics, and blacks. Results showed greater stability of sensitivity and specificity across education levels and ethnic groups for the MMSAdj than for the raw MMS and suggest that the MMSAdj is a preferable measure of cognitive impairment for low- education and minority individuals.

Transcriptional repression by Msx-1 does not require homeodomain DNA-binding sites.

This study investigates the transcriptional properties of Msx-1, a murine homeodomain protein which has been proposed to play a key role in regulating the differentiation and/or proliferation state of specific cell populations during embryogenesis. We show, using basal and activated transcription templates, that Msx-1 is a potent repressor of transcription and can function through both TATA-containing and TATA-less promoters. Moreover, repression in vivo and in vitro occurs in the absence of DNA-binding sites for the Msx-1 homeodomain. Utilizing a series of truncated Msx-1 polypeptides, we show that multiple regions of Msx-1 contribute to repression, and these are rich in alanine, glycine, and proline residues. When fused to a heterologous DNA-binding domain, both N- and C-terminal regions of Msx-1 retain repressor function, which is dependent upon the presence of the heterologous DNA-binding site. Moreover, a polypeptide consisting of the full-length Msx-1 fused to a heterologous DNA-binding domain is a more potent repressor than either the N- or C-terminal regions alone, and this fusion retains the ability to repress transcription in the absence of the heterologous DNA site. We further show that Msx-1 represses transcription in vitro in a purified reconstituted assay system and interacts with protein complexes composed of TBP and TFIIA (DA) and TBP, TFIIA, and TFIIB (DAB) in gel retardation assays, suggesting that the mechanism of repression is mediated through interaction(s) with a component(s) of the core transcription complex. We speculate that the repressor function of Msx-1 is critical for its proposed role in embryogenesis as a regulator of cellular differentiation.

Forum.

A Forum for our Readers Forum provides an opportunity for our readers to comment on the articles that we publish. Illustrative figures are welcome. Address correspondence to Forum, THE PHYSICIAN AND SPORTSMEDICINE, 4530 W 77th St Minneapolis, MN 55435.