A simple protocol for preventing falls and fractures in elderly individuals with musculoskeletal disease

Changes in Physical Function and Effects on QOL in Patients after Pancreatic Cancer Surgery

This study examined the changes in physical function and quality of life (QOL) of postoperative patients with pancreatic cancer for 3 months after surgery and examined the factors affecting the QOL at the 3 months after surgery. Methods: This study comprised 32 pancreatic cancer patients who underwent surgery at our hospital. Among these patients, 20 patients for whom data was measured before surgery to 3 months after surgery were selected for statistical analyses: 8 males and 12 females, 69.8 ± 7.4 years. The preoperative and postoperative rehabilitation was given to patients under the guidance of a physiotherapist. Nutritional status, body composition, physical function, gait assessments, and QOL were investigated. Results: Body weight, body fat mass, body fat percentage, body mass index (BMI), and muscle mass significantly decreased 3 months after surgery compared with their respective preoperative values. The mean grip strength at the time of 3 months after the surgery had decreased significantly from 27.3 kg to 24.5 kg. The mean skeletal muscle mass index (SMI) had decreased significantly from 6.3 kg before surgery to 5.9 kg after the surgery. The QOL scores for global health status, physical, and role showed significant decreases 2 weeks after surgery compared with the respective preoperative scores. Significant improvements in these scores were observed 3 months after surgery compared with the respective scores 2 weeks after surgery. Physical function assessments after surgery were associated with QOL 3 months after surgery. Conclusion: Recovery of patients after pancreatic cancer surgery in body weight, BMI, body fat percentage, body fat percentage, muscle mass, SMI, and grip strength was not sufficient at the time of 3 months after surgery. It has been observed that physical function of patients has affected the improvement of QOL.

Associations of the step-up test and lower limb dysfunction: A post-hoc analysis of a prospective cohort study

BACKGROUND

Step-up ability is considered to be associated with lower limb dysfunction. The objective of this research was to assess the height of the tallest step that could be mounted and to investigate its association with lower limb dysfunction.

METHODS

We previously conducted a two-year follow-up prospective cohort study. The study subjects were 119 patients receiving physiotherapy or exercise therapy at an orthopedic surgery clinic. The items evaluated were step-up ability (maximum step height), the timed up and go test, one-leg standing time and the 5-question Geriatric Locomotive Function Scale. The primary endpoint was the prevalence of locomotive syndrome, whereas secondary endpoint was musculoskeletal ambulation disability symptom complex (MADS). Evaluations were carried out at the time of the initial assessment and two years later. We used a multiple logistic regression model with age, sex, height, weight and each functional test as exploratory variables. R2 and C-statistics were calculated and these "optimism" biases were corrected using a bootstrap technique.

RESULTS

Maximum step height was strongly correlated with the prevalence of locomotive syndrome [odd ratio (95% confidence intervals), 0.52 (0.32, 0.87), p = 0.0074] and was correlated with MADS [0.45 (0.22, 0.92), p = 0.0138]. Additionally, maximum step height was also strongly correlated with post follow-up locomotive syndrome [0.39 (0.18, 0.84), p = 0.0010].

CONCLUSION

The results suggest that step-up ability may represent a simple and useful tool which is associated with lower limb dysfunction.

Availability of the Two-step Test to evaluate balance in frail people in a day care service

[Purpose] This study evaluated balance tests in users of a day care service who needed nursing care or support, and investigated the usefulness of the Two-step Test for evaluating balance. [Subjects and Methods] The subjects were users of a day care service, and had certified need for long-term care or support. All subjects were able to undergo the balance evaluations. Balance tests included the 3-m Timed Up and Go test (TUG), the one-leg standing time, and the Two-step Test. [Results] The Two-step Test and other balance tests were strongly correlated. [Conclusion] In this study of subjects who needed nursing care or support, the results were the same as in a previous study of subjects who did not need nursing care or support. The Two-step Test should be considered as an indicator of balance ability in elderly individuals requiring nursing care or support.

The NYU Osteoporosis Model of Care Experience

INTRODUCTION

Participants who sustain a fragility fracture are at increased risk for subsequent fractures. Despite the consequences of recurrent fractures, bone mineral density (BMD) testing and treatment rates for osteoporosis after a fracture remain low. The New York University (NYU) Langone Osteoporosis Model of Care was developed to identify women at increased risk for recurrent fractures and to reduce the rates of subsequent fracture through patient and physician education.

METHODS

Women aged 50 years and older who had a fracture and received their care at NYU affiliated hospitals were contacted via mail after discharge. Participants were provided educational materials explaining decreased bone strength and its possible relationship to their fracture and were asked to complete a questionnaire. One year postfracture, participants were sent follow-up questionnaires requesting their most recent fracture treatment and BMD information. Educational material was also provided to the treating orthopedic surgeons.

RESULTS

Overall, 524 patients were contacted and 210 (40%) enrolled. By the end of 24 months, 92 participants completed their 1-year questionnaire (44% of the enrollees). Forty-two (46%) participants had undergone new BMD testing and 37 (40%) were receiving antiresorptive medications, including 6 (6%) who had not been prescribed these medications before enrolling in the program.

CONCLUSIONS

The Osteoporosis Model of Care is a simple and cost-effective educational program, which improved comprehensive fracture care in an actual clinical setting. Patient enrollment remains a challenge in implementing the program. Our program highlights difficulties in providing community-dwelling participants with appropriate postfracture care. With increasing concern among the public regarding the use of bone strengthening medications and continued low postfracture treatment rates, educating patients with high fracture risk is critical to reducing the rate of subsequent fracture. Our Model of Care Program demonstrates both the success and limitations of a postfracture educational approach using discharge diagnosis data to identify patients with fracture.

Development and evaluation of a video exercise program for locomotive syndrome in the elderly

OBJECTIVES

To develop and evaluate an exercise program that the elderly could sustainably perform in the community or at home to recover from locomotive syndrome.

METHODS

We produced 2 types of teaching media, video and pamphlet, describing 10 physical and mobility training exercises. The pilot study examined changes in pulse rate, percutaneous oxygen saturation (SpO2), and the Borg scale rating of perceived exertion in 20 elderly volunteers. Separately, 120 elderly subjects were recruited and divided into 3 groups according to the teaching medium (video, group V; pamphlet, group P; none, group C). Before and 3 months after the intervention, visual analog scale (VAS) scores of low back and knee pain, single-leg standing time, 6-m walking time, Roland-Morris Disability Questionnaire, Oswestry Disability Index, Short Form-8, and 25-question Geriatric Locomotive Function Scale were evaluated.

RESULTS

Pulse-rate changes before and after exercise did not exceed 20 %, and SpO2 changes were within 4 points in all cases. The Borg scale ranged between 11 and 14. The intergroup comparison revealed the advantage of the video program in improving the VAS of low back pain, left-leg standing time, and 6-m walking time.

CONCLUSION

A video exercise program can potentially aid recovery from locomotive syndrome in the elderly.

Determination of the optimal cutoff time to use when screening elderly people for locomotive syndrome using the one-leg standing test (with eyes open)

OBJECTIVE

To establish the cutoff time for the one-leg standing (OLS) test (with eyes open) to use when screening elderly people for locomotive syndrome.

METHODS

Patients visiting orthopedic clinics and healthy volunteers, all ≥65 years old, were recruited. Participants were asked to complete the 25-question Geriatric Locomotive Function Scale (GLFS-25) and then underwent the OLS test. Using the previously determined GLFS-25 cutoff value, participants were divided into two groups: the locomotive and the non-locomotive syndrome groups (GLFS-25 scores of ≥16 and <16, respectively). Conventional receiver operating characteristic curve (ROC) analysis was used to calculate the optimal cutoff time for the OLS.

RESULTS

Data from 880 individuals (261 men, 619 women; mean age (SD), 77 (6) years; range 65-96 years) were analyzed; 497 were in the locomotive syndrome group and 383 were in the non-locomotive syndrome group. A significant difference was seen between each group mean for individual average (IA) OLS times (IA-OLS: the average of the OLS times obtained for both legs of an individual). According to ROC analysis without age adjustment, when the IA-OLS time was ~9 s, the sum of the sensitivity and specificity of the test was highest. However, because of a statistically significant difference in IA-OLS time among the three age groups (aged ≤70, aged >70 and ≤75, and aged >75), we determined the optimal cutoff value for IA-OLS time for each of the three age groups using ROC analysis. According to additional ROC analysis, the optimal cutoff for IA-OLS time was 19 s for individuals aged ≤70, 10 s for individuals aged >70 and ≤75, and 6 s for individuals aged >75 when screening elderly persons for locomotive syndrome.

CONCLUSIONS

We propose using a GLFS-25 score of 16 and/or a cutoff for the IA-OLS time of 19 s for individuals aged ≤70, 10 s for individuals aged >70 and ≤75, and 6 s for individuals aged >75 when screening elderly persons to determine who should receive medical intervention or undergoing training programs.

Evidence-based risk assessment and recommendations for physical activity: arthritis, osteoporosis, and low back pain

We systematically reviewed the safety of physical activity (PA) for people with arthritis, osteoporosis, and low back pain. We searched PubMed, MEDLINE, Sport Discus, and the Cochrane Central Register of Controlled Trials (1966 through March 2008) for relevant articles on PA and adverse events. A total of 111 articles met our inclusion criteria. The incidence for adverse events during PA was 3.4%-11% (0.06%-2.4% serious adverse events) and included increased joint pain, fracture, and back pain for those with arthritis, osteoporosis, and low back pain, respectively. Recommendations were based on the Appraisal of Guidelines for Research and Evaluation, which applies Levels of Evidence based on type of study ranging from high-quality randomized controlled trials (Level 1) to anecdotal evidence (Level 4) and Grades from A (strong) to C (weak). Our main recommendations are that (i) arthritic patients with highly progressed forms of disease should avoid heavy load-bearing activities, but should participate in non-weight-bearing activities (Level 2, Grade A); and (ii) patients with osteoporosis should avoid trunk flexion (Level 2, Grade A) and powerful twisting of the trunk (Level 3, Grade C); (iii) patients with acute low back pain can safely do preference-based PA (i.e., PA that does not induce pain), including low back extension and flexion (Level 2, Grade B); (iv) arthritic patients with stable disease without progressive joint damage and patients with stable osteoporosis or low back pain can safely perform a variety of progressive aerobic or resistance-training PAs (Level 2, Grades A and B). Overall, the adverse event incidence from reviewed studies was low. PA can safely be done by most individuals with musculoskeletal conditions.

More radial shortening after low-energy Colles' fractures is associated with type 2 diabetes mellitus among postmenopausal women, irrespective of bone mineral density

BACKGROUND

Recent meta-analysis data reveal that patients with type 2 diabetes mellitus (DM) have a higher risk of fracture, despite higher bone mineral density (BMD), than patients without type 2 DM. The purpose of this study was to compare BMD and distal radial shortening after low-energy Colles' fractures among Japanese postmenopausal women aged ≥50 years with type 2 DM with those in women without it (non-DM).

METHODS

One-hundred and ten postmenopausal women aged ≥50 years with distal radius fractures resulting from a fall were enrolled in this study. Twelve patients had DM. BMD, type I collagen cross-linked N-telopeptide (NTX), undercarboxylated osteocalcin (ucOC), estimated glomerular filtration rate (eGFR), grip strength of the unfractured hand, unipedal standing time, and the degree of radial shortening were measured.

RESULTS

There were no significant differences in age and body height between the two groups. The DM group had significantly greater body weight and body mass index than the non-DM group. BMDs of the lumbar spine and proximal hip were significantly higher in the DM group than in the non-DM group. NTX, ucOC, grip strength, and the percentage of women with unipedal standing time <15 s did not differ between the two groups. Stepwise regression analysis identified DM and shorter unipedal standing time as significant factors associated with more radial shortening, and identified more radial shortening and lower eGFR as significant factors associated with DM.

CONCLUSIONS

More radial shortening after low-energy Colles' fractures was significantly associated with type 2 DM among postmenopausal women aged ≥50 years, irrespective of BMD.

Osteoporosis diagnosis and medical treatment

Osteoporosis, the presence of either low bone mineral density or a history of a fragility fracture, is known to be associated with an increased risk of future fracture. Fracture prevention is possible through use of both nonpharmacologic and prescription treatments. Despite recent controversy regarding the safety of calcium supplementation and the appropriate dosing of calcium and vitamin D, calcium and vitamin D remain an important part of bone health. However, prescription osteoporosis treatments should be considered for those at higher risk for fracture, and there are currently several treatment options available.

Development and evaluation of a video exercise program for locomotive syndrome in the elderly

OBJECTIVES: To develop and evaluate an exercise program that the elderly could sustainably perform in the community or at home to recover from locomotive syndrome. METHODS: We produced 2 types of teaching media, video and pamphlet, describing 10 physical and mobility training exercises. The pilot study examined changes in pulse rate, percutaneous oxygen saturation (SpO2), and the Borg scale rating of perceived exertion in 20 elderly volunteers. Separately, 120 elderly subjects were recruited and divided into 3 groups according to the teaching medium (video, group V; pamphlet, group P; none, group C). Before and 3 months after the intervention, visual analog scale (VAS) scores of low back and knee pain, single-leg standing time, 6-m walking time, Roland-Morris Disability Questionnaire, Oswestry Disability Index, Short Form-8, and 25-question Geriatric Locomotive Function Scale were evaluated. RESULTS: Pulse-rate changes before and after exercise did not exceed 20 %, and SpO2 changes were within 4 points in all cases. The Borg scale ranged between 11 and 14. The intergroup comparison revealed the advantage of the video program in improving the VAS of low back pain, left-leg standing time, and 6-m walking time. CONCLUSION: A video exercise program can potentially aid recovery from locomotive syndrome in the elderly.

Osteoarthritis, osteoporosis, and exercise

With the aging of the work force, occupational health nurses must prepare for encounters with clients who are challenged by osteoarthritis or osteoporosis. Clients should be encouraged to exercise safely to promote functioning at home and work. This article reviews recent literature on the benefits of exercise for workers with osteoarthritis, osteoporosis, or both.

External validity of physical activity interventions for community-dwelling older adults with fall risk: a quantitative systematic literature review

AIM

To appraise the external validity of physical activity interventions designed to reduce falls among community-dwelling older adults, using the reach, efficacy/effectiveness, adoption, implementation, and maintenance framework.

BACKGROUND

Falls are a globally common, important, and a preventable problem. The efficacy of physical activity interventions to reduce falls among older adults is well established. Translation of this research into practice is slow as evidenced by persistently low proportions of older adults who engage in physical activities and the rising incidence of falls.

DATA SOURCES

Four electronic databases were searched for relevant studies published between 2000-2010. Studies that examined the effects of physical activity interventions designed to reduce falls among community-dwelling older adults were included in this review (n = 46).

DESIGN

This was a quantitative systematic review with narrative synthesis. The reach, efficacy/effectiveness, adoption, implementation, and maintenance framework guided the identification, appraisal, and synthesis of indicators representing study validity.

RESULTS

The majority of studies in this review described indicators representing internal validity. Details about indicators representing external validity were reported infrequently, limiting the generalizability of fall-preventive physical activity interventions in diverse cultures and social contexts over time.

CONCLUSIONS

To foster translational research in real world settings, additional programmatic intervention research is needed that: (i) targets diverse populations; (ii) incorporates theories of behavioural change; (iii) describes and operationalizes critical content that enables replication and translation; (iv) tests innovative measures of fall risk and physical activity; and (v) evaluates feasibility and acceptability.

Development of a screening tool for risk of locomotive syndrome in the elderly: the 25-question Geriatric Locomotive Function Scale

OBJECTIVE

To evaluate the reliability and validity of a new questionnaire, the 25-question Geriatric Locomotive Function Scale (GLFS-25), for early detection of locomotive syndrome.

METHODS

This new screening tool was designed to detect Japanese individuals under high-risk conditions who may soon require care services because of problems of the locomotive organs. Content validity, construct validity, criterion validity, internal-consistency reliability, and reproducibility (test-retest reliability) were examined using psychometric analysis, and a cutoff score to detect locomotive syndrome was determined. To investigate construct validity of the GLFS-25 and determine the cutoff score, the Akaike Information Criteria (AIC) were used.

RESULTS

Study 1 analyzed 711 Japanese elderly people ≥65 years old. No floor or ceiling effects were included in the GLFS-25. Internal consistency was confirmed by a Cronbach's α reliability coefficient of 0.961. As for the association between the GLFS-25 and European Quality of Life Scale-5 Dimensions (EQ-5D), Spearman's correlation coefficient was 0.85 (P < 0.001), showing excellent concurrent validity of the GLFS-25. Categorical principal component analysis showed that the construct structure consisted of one item cluster or the GLFS-25 was unifactorial. The AIC showed that one cluster of seven items was located in the center, with significant associations with the other five clusters. In study 2, 205 individuals were analyzed, and the test-retest interclass correlation was satisfactory (range 0.712-0.924). The cutoff score for identifying locomotive syndrome was set at 16. Validity and reliability of this new measurement were psychometrically confirmed as sufficient.

CONCLUSIONS

The GLFS-25 offers a valid and reliable questionnaire scale for detecting locomotive syndrome in elderly Japanese individuals.

Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care

Secondary prevention involves monitoring and screening to prevent negative sequelae from chronic diseases such as cancer. Breast cancer treatment sequelae, such as lymphedema, may occur early or late and often negatively affect function. Secondary prevention through prospective physical therapy surveillance aids in early identification and treatment of breast cancer-related lymphedema (BCRL). Early intervention may reduce the need for intensive rehabilitation and may be cost saving. This perspective article compares a prospective surveillance model with a traditional model of impairment-based care and examines direct treatment costs associated with each program. Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage BCRL. The prospective surveillance model includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The traditional model cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is $636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is $3,124.92. The prospective surveillance model is emerging as the standard of care in breast cancer treatment and is a potential cost-saving mechanism for BCRL treatment. Further analysis of indirect costs and utility is necessary to assess cost-effectiveness. A shift in the paradigm of physical therapy toward a prospective surveillance model is warranted.

Shorter unipedal standing time and lower bone mineral density in women with distal radius fractures

Unipedal standing time was shorter and bone mineral density was lower in Japanese women aged 50 years and over with low-energy distal radius fractures resulting from falls than those in age-matched community-dwelling Japanese women without distal radius fractures.

INTRODUCTION

The aim of this study was to compare unipedal standing time and bone mineral density (BMD) of women >or=50 years of age with distal radius fractures with those of age-matched women without fractures.

METHODS

Fracture group was 54 Japanese women with low-energy distal radius fractures resulting from fall. Non-fracture group was 52 community-dwelling Japanese women without fractures. Unipedal standing time and BMD were measured.

RESULTS

There were no significant differences in age and body mass index between the two groups. The percentage of women with unipedal standing time <15 s was 44.4% in the fracture group and 13.5% in the non-fracture group, while the respective frequencies for >120 s were 20.4% and 50.0%. The T-score of BMD was significantly lower in the fracture than non-fracture group. Logistic regression analysis identified unipedal standing time <15 s and T-score <70% as significant factors associated with distal radius fractures. Notably, T-score <70% was significant in subjects <65 years, and unipedal standing time <15 s was significant in those >or=65 years.

CONCLUSION

Unipedal standing time was shorter and BMD was lower in women >or=50 years of age with distal radius fractures than those in age-matched women without fractures.

One-leg standing test for elderly populations

BACKGROUND

The one-leg standing (OLS) test is one of the balance tests used to diagnose musculoskeletal ambulation disability symptom complex (MARS), a condition newly defined by three professional Japanese medical societies in 2006 to help identify the symptoms of motor organ deterioration and establish preventive strategies. Although many studies have used the OLS test, none has shown conclusively that the test can be used as a practical marker of frailty among elderly people, especially in community settings. Based on the type of epidemiological study -- i.e., descriptive epidemiology and analytical epidemiology (observational and intervention studies) -- we reviewed evidence on three fundamental issues related to the OLS test: (1) testing procedures and reference values; (2) the associations between the OLS time and negative events; (3) improvement of the OLS time by intervention. These issues are key to any discussion of whether the OLS test can be used as a practical marker for predicting frailty in community-dwelling elderly populations.

METHODS

Articles were collected from MEDLINE databases using the search terms "one- leg standing" and the other names included in the same category.

RESULTS

Because various procedures are used to carry out the OLS test, the measured values for the OLS time varied widely from study to study. Some observational studies showed that the OLS time is related to negative events such as falls, declines in activity of daily living, and other morbidity. OLS times could be improved by several interventions.

CONCLUSIONS

This review suggests that the OLS test can be a tool for predicting frailty in community-dwelling elderly populations. However, our review should be interpreted with caution because we did not confirm the evidence level of each of the studies we selected. Further research on this topic is needed.

Management of osteoporosis among home health and long-term care patients with a prior fracture

Osteoporosis is a growing health concern as the number of senior adults continues to increase worldwide. Falls and fractures are very common among frail older adults requiring home health and long-term care. Preventative strategies for reducing falls have been identified and many therapies (both prescription and nonprescription) with proven efficacy for reducing fracture risk are available. However, many practitioners overlook the fact that a fragility fracture is diagnostic for osteoporosis even without knowledge of bone mineral density testing. As a result, osteoporosis is infrequently diagnosed and treated in the elderly after a fracture. Based on existing literature, we have developed an algorithm for the assessment and treatment of osteoporosis among persons with known prior fracture(s) living in long-term care facilities or receiving home health care based on the data available in the literature.

Simply ask them about their balance--future fracture risk in a nationwide cohort study of twins

The principal causal components of an osteoporotic fracture are a fall and weakened bone strength. While bone quality measures have been frequently studied, the ability of simple measures of impaired balance to predict fracture risk has received less attention. Computer-assisted telephone interviews were conducted between 1998 and 2000 among 24,598 Swedish twins aged 55 years or older. Impaired balance at the time of interview was reported by 2,890 (12%) of the twins. Twin pairs who were discordant with regard to impaired balance were selected for analysis and followed for fractures through 2005. In a pairwise analysis, the odds ratio for hip fracture was 3.13 (95% confidence interval (CI): 1.62, 6.05) among twins with impaired balance as compared with their co-twins with normal balance. When previously recognized clinical risk factors for osteoporotic fracture were considered in the model, the odds ratio for hip fracture with impaired balance was 3.88 (95% CI: 1.40, 10.72). Approximately 40% of all hip fractures were attributable to impaired balance. The odds ratios for any fracture and any osteoporotic fracture for twins with impaired balance were 2.00 (95% CI: 1.29, 3.11) and 2.39 (95% CI: 1.49, 3.82), respectively. These results imply that self-reported impaired balance is a novel and readily assessed risk factor for future fractures in the elderly.