ABSTRACT

1. Use of the Physical Performance Test to Assess Preclinical Disability in Subjects with Asymptomatic Carotid Artery DiseaseLandgraff NC, Whitney SL, Rubenstein EN, Yonas H. Use of the Physical Performance Test to Assess Preclinical Disability in Subjects with Asymptomatic Carotid Artery Disease. Physical Therapy Journal. April 2006. 86: 541-548. BACKGROUND Target group: 39 patients (neurosurgery clinic at University of Pittsburgh Medical Center) with asymptomatic carotid artery disease. Mean age: 73, M>F • Divided into 3 subgroups: (Based off MRI, Computed Tomographic Arteriography scan, or carotid artery Doppler) • 70% Severe carotid artery stenosis • 17% Moderate carotid artery stenosis • 13% Occluded • Exclusion criteria: history of stroke or dementia, unable to speak English or answer questions, NWB status due to an orthopedic condition, or severe CP compromise Comparison group: 71 subjects from an aging Study (National Institutes of Health, AG10009) Mean age: 71.1, F>M • Normal vision and age-adjusted hearing • Normal sensation, tested with Semmes-Weinstein monofilaments • Mini-Mental State Examinations >24(no cognitive deficits • Comorbidities not recorded, living independently • Ascend & descend 4 flights of stairs without complaint Measures: 9-item and 7-item PPT • 9-item PPT: maximum score= 36 • 7-item PPT: maximum score= 28, eliminating stair activities of climbing 1 & 4 flights of stairs • Lower score= more time to complete task • Times were converted to an ordinal scale (0-4) METHODS & MATERIALS Results: Comorbidities of Target Group: • HTN (39%), Hypercholesterolemia (36%), Diabetes Mellitus (33%), CAD (31%), Cardiac Arrhythmia (13%) • No significant correlation of comorbidities & PPT score (r=.07) Common Medications of Target Group: Aspirin (54%) & Zocor: No correlation of medication & PPT score (r= -.14) Time Results of Asymptomatic patients Graph from article Discussion No group received a maximal score on either PPT • Target: mean scores 27/36 (9-item), 21/28 (7-item) • Comparison: mean scores 30/36 (9-item), 23/28 (7-item) Simulated eating was the only item that was significantly different (P<.00) with regard to the level of stenosis severity. Subjects with moderate & severe stenosis & occlusion performed below maximum scores on the 9-item PPT & 7-item PPT. Moderate stenosis (50%-69%) performed the worst, with an average 9-item PPT score of 24/36 and a 7-item score of 19/28. 100% of the asymptomatic subjects with carotid artery stenosis & occlusion had scores at least 25% below optimal function. Yet, only 19% of the comparison group had scores 25% below optimal function. CLINICAL SIGNIFICANCE ARTICLE #1 [KernanWN, Viscoli CM, Brass LM, Gill TM, Sarrel PM, Horwitz RI. Decline in Physical Performance Among Women with a Recent Transient Ischemic Attack or Ischemic Stroke. Stroke. March 2005. 630-634.] This study used the 7-item PPT to evaluate function annually in 557 post-menopausal females >44 years of age that were involved in the Women’s Estrogen for Stroke Trail (WEST) after the event of a TIA or ischemic stroke (mean of 58 days from the event) for up to 5 years. Mean duration for follow-up: 2.7 years, range of <1 y. to 5 yrs. Functional score decline/ improvement: +/-3 points from intial Smaller portion of cohort showed functional improvement: 16% in year 1, 6% in year 5. Larger portion of cohort showed functional decline: 15% in year 1, 35% in year 5. Analysis of 259 women with 3 years of follow-up: 18% experienced non-sustained decline in physical function and 15% experienced a sustained decline. The article demonstrated a greater decline in the 7-item PPT in the activities of bending over to pick an object off of the floor, circling, and dressing (decline of >1.0 points) ARTICLE #2 [HergenroederAL, Brach JS, Otto AD, Sparto PJ, Jakicic JM. The Influence of Body Mass Index on Self-report and Performance-based Measures of Physical Function in Adult Women. Cardiopulmonary Physical Therapy Journal. September 2011. 3: 11-20.] This study used gait speed as one of the indicators of a decline in function (others: 6-Minute Walk and Chair Stand) with 50 middle-aged, female subjects (10 subjects fitting in each BMI category) as well as the Late Life Function & Disability Instrument (LLFDI) for a self-reporting measure. Gait Speed Measurement: subjects walked the central 4 meters of an 8-meter course at self selected pace, using a stopwatch to time • Distance (4 meters)/Time (to complete 4 meters) • Normal: 1.2 m/sec to safely cross traffic intersection Class II & II obesity had slower gait speed than normal weight and class II obesity was slower compared to normal weight. (p<.001).Class I & II obesity reported decreased capability (LLFDI) than the normal and overweight category groups(p<.001) The physical therapy implication for clinical use is a diagnostic tool to define a decline in function in patients with cardiovascular disease(s) or risk factors(s) to compare with self-reported measures. Article #1 supports the initial article documenting decline in function using the PPT in another cardiovascular diagnosis of stroke , of which carotid artery stenosis and/or atherosclerosis could be the cause. Article #2 supports the initial with using self report measures & performance based measures, but this study had functional decline correlating in both measures, since BMI is not routinely overlooked as opposed to an asymptomatic diagnosis. Fried et al 1 describes preclinical as an identifiable functional loss that precedes the recognition of difficulty in performing tasks. A progressive decline in function that is not noted by a subject is most likely the result of disease progression. Brach et al 4 found that the use of the Physical Performance Test (PPT), a performance-based measure, identified more limitations in physical function than did self-report functional questionnaires. Fried et al 1 suggested if a condition of preclinical disability is identified, it may provide an opportunity for the prevention of the onset of disability. To determine whether subjects with asymptomatic carotid artery stenosis and occlusion demonstrate deficits in physical performance compared with a comparison group. These deficits may indicate that a person is demonstrating preclinical disability. Background and Purpose. The purpose of this study was to determine whether subjects with asymptomatic carotid artery stenosis and occlusion demonstrate deficits in physical performance compared with a comparison group. These deficits may indicate that a person is demonstrating preclinical disability. Subjects. Seventy-one subjects with no known disease and 39 subjects with asymptomatic carotid artery stenosis of moderate and severe degrees or with occlusion were included. Methods. Physical performance was assessed with the 9-item and 7-item versions of the Physical Performance Test (PPT). Individual tasks also were timed for the subjects with disease. Results. There were significant differences between the comparison group and the subjects with carotid artery stenosis on the 9-item PPT (P<.00) and on the 7-item PPT (P<.03). Subjects with asymptomatic carotid artery stenosis and occlusion demonstrated less than optimal performance on the PPT (9-item PPT, X=27 of 36; 7-item PPT, X-21 of 28). Subjects with moderate stenosis were the slowest in performing the task of simulated eating. Discussion and Conclusion. Subjects with asymptomatic carotidarterystenosis and occlusion exhibited changes in function, as indicated by their performance on the PPT relative to that of a comparison group. This finding may be indicative of preclinical disability, indicating that these people are symptomatic. This indication may affect the medical and surgical options that can be considered for their care. Asymptomatic carotid artery disease is defined as an incidental finding during medical workup for an unrelated purpose. The PPT was used in this study to determine whether any unreported motor, sensory, or cognitive problems were affecting a subject’s physical function. If preclinical disability, defined by a decline in function in regards to the individual’s PPT score, is determined, the policy of medical management and surgical intervention could change for the asymptomatic population and affect the incidence of stroke through early prevention and intervention. Asymptomatic carotid artery stenosis or occlusion performed less optimal than the comparison group on both the 7-item PPT and the 9-item PPT Asymptomatic carotid artery stenosis or occlusion pts. exhibit changes in functional status not routinely identified or self- reported The use of PPT could contribute to stroke prevention Improve identification of potentially symptomatic people Lead to more appropriate referrals and medical management of patient clientele ABSTRACT SUMMARY Poster presented by: LinseySchmalz, DPT student