Knee-extension strength, postural control and function are related to fracture type and thigh edema in patients with hip fracture

Factors associated with an improvement in extracellular water-to-total body water ratio in older adults with hip fractures: A decision tree analysis

BACKGROUND & AIMS

The extracellular water-to-total body water ratio (ECW/TBW) increases with age and after fractures. A high ECW/TBW may hinder improvements in physical function and skeletal muscle mass. However, the effects of ECW/TBW improvement have not been properly investigated. The aim of this study was to investigate the factors associated with ECW/TBW improvement in older adults with hip fractures.

METHODS

This retrospective cohort study included 203 patients with hip fractures who were admitted to a convalescent rehabilitation ward. ECW/TBW and skeletal muscle mass index (SMI) were measured using bioelectrical impedance analysis. The patients were classified into two groups: those with an improvement in ECW/TBW (n = 123) and those without an improvement (n = 80). Decision tree analysis was performed to examine the factors associated with ECW/TBW improvement. As a secondary objective, a multiple regression analysis was performed to identify the factors associated with SMI gain.

RESULTS

Decision tree analysis identified rehabilitation volume and protein intake as the first and second factors most significantly associated with an improvement in ECW/TBW, respectively. Multiple regression analysis showed that improved ECW/TBW (β: 0.400, p < 0.001) was significantly associated with SMI gain.

CONCLUSIONS

Rehabilitation volume and protein intake are clinically important for improving ECW/TBW in older adults with hip fractures.

Early Postoperative Weight-Bearing Ability after Total Hip Arthroplasty versus Bipolar Hemiarthroplasty in Elderly Patients with Femoral Neck Fracture

Background: Femoral neck fractures are among the most common types of fractures and particularly affect elderly patients. Two of the most common treatment strategies are total hip arthroplasty (THA) and bipolar hemiarthroplasty (BA). However, the role of the different treatment strategies in the postoperative weight-bearing ability in the early postoperative phase is still not entirely clear. Methods: Patients who underwent either THA or BA were consecutively included in our prospective cohort study. Gait analysis was performed during the early postoperative period. The gait analysis consisted of a walking distance of 40 m coupled with the turning movement in between. During the gait analysis, the duration of the measurement, the maximum peak force and the average peak force were recorded. Results: A total of 39 patients were included, 25 of whom underwent BA and 14 of whom underwent THA. The maximum peak force during the gait analysis was, on average, 80.6% ± 19.5 of the body weight in the BA group and 78.9% ± 21.6 in the THA group. The additionally determined average peak force during the entire gait analysis was 66.8% ± 15.8 of the body weight in the BA group and 60.5% ± 15.6 in the THA group. Conclusions: Patients with femoral neck fractures undergoing THA and BA can achieve sufficient weight bearing on the operated leg in the early postoperative period. In our study, BA did not allow for a significantly higher average and maximum loading capacity compared with THA.

Improvement of muscle quality assessed using the phase angle is influenced by recovery of knee extension strength in patients with hip fractures

BACKGROUND AND AIMS

Studies reported that knee extension strength on the operated side in patients with hip fractures was not recovered to the level on the non-operated side 6 months after surgery or later. In a cross-sectional study, we revealed that a reduction in isometric knee extension muscle strength on the operated side in patients with hip fractures approximately 6 months after surgery was associated with not only a reduction in skeletal muscle mass but also a reduction in muscle quality, characterized by a reduction in the phase angle (PhA). Furthermore, the mechanisms of knee extension strength improvement can be clarified in more detail using the minimal significant change as the index of recovery. However, no longitudinal studies have examined the factors for knee extension strength improvement based on the minimal significant change in patients with hip fractures 6 months after surgery. This study aimed to longitudinally examine the factors influencing the recovery of knee extension strength based on the minimal significant change in patients with hip fractures between 2 weeks and approximately 6 months after surgery.

METHODS

In this study, the outcomes used were basic and medical information, PhA, skeletal muscle index (SMI), pain, one-leg standing time, movement control during one-leg standing, and walking speed. For PhA, SMI, pain, one-leg standing time, movement control during one-leg standing, and walking speed, the amount of change was calculated by subtracting the data at 2 weeks from the data at 6 months. Group classification was determined by dividing the patients into two groups using a previous study as a reference: recovery group if the knee extension strength value approximately 6 months after surgery minus that 2 weeks after surgery was ≥3.3 kgf and non-recovery group if the value was <3.3 kgf. Logistic regression analysis was performed to explore the association between the recovery and non-recovery groups.

RESULTS

The recovery group contained 55 patients, while the non-recovery group comprised 35 patients. The only significant factor associated with knee extension muscle strength in the recovery group was the amount of change in PhA. The odds ratio for the amount of change in PhA was 2.26. The discrimination rate of the model was 62.5%.

CONCLUSIONS

Our results suggest that recovery of knee extension strength in patients with hip fractures after surgery was mainly because of improvements in muscle quality, not improvements in muscle mass or pain.

Investigation of Factors Related to the Week 1 Cumulated Ambulation Score in Patients With Proximal Femoral Fractures Post-surgery Using Decision Tree Analysis

This study aimed to identify factors associated with the Cumulated Ambulation Score (CAS) in the first week post-surgery (Week 1 CAS) in patients with proximal femoral fractures. Proximal femoral fractures are prevalent in the elderly, with rising incidence rates and significant social and functional implications. The ability to walk postoperatively is a critical determinant of patient prognosis. The study included 53 patients out of 79 who underwent surgery for proximal femoral fractures at the orthopedics department of Oita Oka Hospital from January 2021 to December 2021. Exclusion criteria were pre-existing walking difficulties, inability to be evaluated in the first postoperative week, non-weight bearing post-surgery, and complications during hospitalization. The physical therapy program followed Oita Oka Hospital's clinical path, starting ambulation with a walker within the first week post-surgery. Data collected included patient background, surgical techniques, pre-injury ambulatory status, and pre-admission residential environment. Physical function assessments one week postoperatively included range of motion (ROM), manual muscle testing (MMT), pain evaluation (NRS), and CAS. Statistical analyses involved the Shapiro-Wilk test, independent t-test, Mann-Whitney U test, chi-square test, and decision tree analysis using classification and regression trees (CART). Patients were categorized into 'favorable' and 'poor' groups based on Week 1 CAS. Significant differences in dementia presence and pre-admission living environment were noted between groups. Knee extension MMT at Week 1 postoperatively showed a significant difference. The decision tree analysis identified knee extension MMT as the primary variable, with a threshold of 3.5. In patients with MMT below 3.5, dementia presence was a secondary factor, with 81% in the poor CAS group. In patients with MMT above 3.5, knee extension strength continued to be significant. The model's accuracy was 64%, with precision at 71%, recall at 63%, and an F1-score of 0.67. The study highlights knee extension MMT and dementia presence as significant factors influencing Week 1 CAS in patients with proximal femoral fractures. The poor CAS group had a higher proportion of dementia and weaker knee extension MMT. Dementia hinders rehabilitation effectiveness, impacting recovery in knee extension strength and CAS. The decision tree analysis provided an intuitive understanding of variable interrelationships, emphasizing knee extension strength as the primary factor, followed by dementia in cases with lower MMT scores. This study elucidated factors related to Week 1 CAS in postoperative patients with proximal femoral fractures. Knee extension MMT emerged as the initial factor, followed by the presence of dementia, influencing Week 1 CAS. These findings are crucial for rehabilitation planning and long-term prognostic predictions in this patient population. However, the study's limitations include potential selection bias and a small sample size, necessitating further research for enhanced predictive accuracy.

The impact of early mobility on functional recovery after hip fracture surgery

PURPOSE

To examine the effect of early mobility (EM) on functional recovery after hip fracture surgery, and to investigate the potential factors that delay mobility.

METHODS

In this retrospective observational study, 110 hip fracture patients were divided into two groups according to the days between surgery and mobility referred to as the EM and the delayed mobility groups. Demographic data, perioperative data, functional outcomes, and discharge destination were compared statistically between the groups using univariate analysis and logistic regression analysis. As a sensitivity analysis, the factors associated with the timing of physiotherapy were also assessed.

RESULTS

The EM group had significantly better walking ability and Barthel index (p < 0.05), and home discharge rate (p = 0.004). The factors associated with delayed mobility (odds ratio; 95% confidence interval) were delayed postoperative physiotherapy initiation (3.59; 1.76-7.33), days from admission to surgery (1.23; 1.04-1.46), and postoperative CRP (1.14; 1.01-1.29) and hemoglobin level (0.72; 0.54-0.96). Furthermore, patients who received surgery on the day before any holiday were significantly delayed in physiotherapy intervention (p = 0.006).

CONCLUSIONS

This study demonstrated that EM after hip fracture surgery was associated with improving functional recovery and home discharge rate, and early physiotherapy intervention was associated with EM.

COVID-19 Infection Was Associated with the Functional Outcomes of Hip Fracture among Older Adults during the COVID-19 Pandemic Apex

Background and Objectives: Hip fractures are associated with mortality and poor functional outcomes. The COVID-19 pandemic has affected patterns of care and health outcomes among fracture patients. This study aimed to determine the influence of COVID-19 infection on hip fracture recovery. Materials and Methods: We prospectively collected data on patients with hip fractures who presented at Hualien Tzu Chi Hospital between 9 March 2022 and 9 September 2022. The data included demographic information and functional scores taken before, during, and after surgery. The patients were divided into two groups: COVID-19 (+) and COVID-19 (-). Results: This study recruited 85 patients, 12 of whom (14.12%) were COVID-19 (+). No significant differences in preoperative or perioperative parameters between the two groups were observed. The postoperative Barthel index score was significantly impacted by COVID-19 infection (p = 0.001). The incidence of postoperative complications was significantly correlated with general anesthesia (p = 0.026) and the length of stay (p = 0.004) in hospital. Poor postoperative functional scores were associated with lower preoperative Barthel index scores (p < 0.001). Male sex (p = 0.049), old age (p = 0.012), a high American Society of Anesthesiologists grade (p = 0.029), and a high Charlson comorbidity index score (p = 0.028) were associated with mortality. Conclusions: Hip fracture surgeries were not unduly delayed in our hospital during the COVID-19 pandemic, but the patients' postoperative Barthel index scores were significantly influenced by COVID-19 (+). The preoperative Barthel index score may be a good predictive tool for the postoperative functional recovery of these patients.

Not only muscle mass but also muscle quality is associated with knee extension muscle strength in patients with hip fractures

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

PURPOSE

This study aimed to assess the relationship between isometric knee extension muscle strength on the operated or nonoperated sides and PhA in patients with hip fractures at approximately 6 months postoperatively.

METHODS

This study was a cross-sectional study. Skeletal muscle index (SMI), PhA, knee extension muscle strength on the operated and nonoperated sides, and other physical function variables were assessed at approximately 6 months postoperatively. To identify predictors of knee extension muscle strength on the operated and nonoperated sides, hierarchical multiple regression analysis was performed.

RESULTS

A total of 90 patients with hip fractures were included (mean age, 80.1 ± 6.9 years). SMI (0.45) and PhA on the operated side (0.27) were the significant associated factors extracted for isometric knee extension muscle strength on the operated side (standardized partial regression coefficients), independent of age, sex, and body mass index (BMI). Movement control during one-leg standing on the nonoperated side (0.26), SMI (0.32), and PhA on the nonoperated side (0.40) were the significant associated factors extracted for isometric knee extension muscle strength on the nonoperated side, independent of age, sex and BMI.

CONCLUSIONS

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures at approximately 6 months postoperatively was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

The Effect of Postoperative Physical Therapy Following Hip Fracture: A Literature Review

Hip fractures in the elderly have become a major public health concern as the population ages. Post-operative rehabilitation is associated with improved outcomes and a greater likelihood of returning to pre-operative functional capacity. Several studies have been conducted to investigate various post-operative recovery pathways. However, little is known about which post-operative rehabilitation pathways for hip fractures are most effective in improving patient outcomes. No clear evidence-based guidelines for a standard mobilization protocol for patients are currently available. This review aims to investigate post-operative recovery pathways to help patients suffering from hip fracture return to pre-fracture condition and to quantify pre-operative and post-operative scores for objective rehabilitation evaluation. Measuring pre-operative activity and comparing it to post-operative follow-up values can help predict post-operative rehabilitation functional outcomes.

Factors predictive of functional outcomes and quality of life in patients with fragility hip fracture: A retrospective cohort study

To determine the predictors of functional outcomes and quality of life (QoL) of patients who were surgically treated for fragility hip fracture. This was a retrospective cohort study performed in the 3 tertiary rehabilitation facilities. A total of 165 patients who had undergone surgery for fragility hip fracture were followed up to 6 months postoperatively. The factors expected to be related to the functional outcomes and QoL at 6 months post-surgery were as follows: baseline demographics, fracture site, operation type, fall characteristics including fall location and fall direction, comorbidities, and initial functional status. The following were comorbidities: hypertension, diabetes mellitus, dementia, cerebrovascular accident, and osteoporosis. Functional outcome and QoL measures were represented using the Koval grade, functional ambulatory category (FAC), Berg balance scale, 4-m walking speed test, the Korean version of Mini-Mental State Examination, EuroQol 5-dimension (EQ-5D) questionnaire, the Korean version of Modified Barthel Index, and the Korean version of instrumental activities of daily living (K-IADL). For all tests, each patient was assessed immediately after transfer and at 6 months post-surgery. Multivariable regression analyses adjusting for factors mentioned above were as follows. Old age led to a significantly less favorable outcome on FAC and K-IADL at 6 months. Intertrochanteric fracture had a significantly positive impact on Koval at 6 months compared to femur neck and intertrochanteric fractures. Total hip replacement arthroplasty and bipolar hemiarthroplasty had a significantly positive impact on EQ-5D and FAC at 6 months respectively compared to other operation types. Fall characteristics didn't reveal any significant impact on functional outcomes and QoL. Patients with hypertension and diabetes mellitus had a significantly negative outcome on EQ-5D and K-IADL respectively. Among initial assessments of function and QoL, initial 4-m walking speed test, Korean version of Mini-Mental State Examination, K-IADL, and Korean version of Modified Barthel Index were independent predictors of function and QoL at 6 months. This study confirmed that age, fracture site, operation type, comorbidities, and initial physical and cognitive function significantly influenced recovery of function and QoL at 6 months in patients with fragility hip fractures.

Older patients' perspectives on participating in multimodal rehabilitation including anabolic steroids following hip fracture: a qualitative study embedded within a pilot RCT

PURPOSE

To explore patient perspectives of participating in a pilot RCT evaluating feasibility and effect of anabolic steroid, physiotherapy and nutritional supplement following hip fracture.

METHODS

Semi-structured telephone-based interviews of 16 women and three men (average age 73 years) were conducted at baseline and after a 12-week intervention. Qualitative content analysis was performed.

RESULTS

Two main categories were identified: (1) Trust and hope for a positive change with three sub-categories; reflections on anabolic steroids, anticipation of extra attention, lack of energy. (2) Curiosity, care, and commitment with four sub-categories; a sense of anabolic steroids, feeling of exclusivity and privileges, challenges and sense of obligation, and perspectives on personal gain.

CONCLUSIONS

Findings suggest high acceptability of the intervention. Participants motivated their participation on a trust that the intervention would "do more good than harm". They found the randomization and possibility of receiving anabolic steroids intriguing, and especially valued trial participation because of their experience of getting extra care and "deluxe" rehabilitation including close contact and support by health professionals. Our findings may help inform future research recruiting older patients and generally considered relevant for health professionals in rehabilitation, emphasizing the impact of professional guidance and social support to encourage self-efficacy.Implications for rehabilitationWith muscle enhancing medicine being suggested as a supplement in rehabilitation following hip fracture, exploring patients' perspectives is warranted and may help inform future trials in this area.Factors reported as important by older adults for engaging in rehabilitation trials are: simple but thorough information, friendly and trustful relation with study staff and opportunities of extra care and attention.Older patients with hip fracture highly valued professional guidance and support by health professionals during the rehabilitation intervention. High acceptability was identified for the supervised outpatient rehabilitation, where especially the individually structured progressive strength training was highlighted as the "active ingredient" accelerating recovery and potentially promoted self-efficacy.

Postoperative complications, mortality, and quality of in-hospital care among hip fracture patients with Parkinson's disease

AIM

The aim of this study was to investigate the association between Parkinson's disease (PD) and postoperative complications, mortality, and quality of in-hospital care in patients with hip fracture.

METHODS

We included patients aged 65+ years with an incident hip fracture from 2004-2017, registered in the Danish Multidisciplinary Hip Fracture Registry. Patients with PD were identified using diagnosis codes prior to hip fracture. Using log-binomial regression, we calculated both 30-day crude and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) for the following outcomes: any hospital-treated infections, pneumonia, urinary tract infection, sepsis, community-treated infections, cardiovascular events, mortality, and fulfilment of quality indicators of in-hospital care. Analyses were adjusted for age, sex and Charlson comorbidity index score.

RESULTS

We identified 77,550 hip fracture patients of which 1,915 had PD. Compared to non-PD, patients with PD had higher risk of any hospital-treated - (aRR = 1.27 (CI: 1.10-1.45) and community-treated infection (aRR = 1.22 (CI: 1.13-1.32)), pneumonia (aRR = 1.38 (1.11-1.69)), urinary tract infection (aRR of 1.58 (CI: 1.28-1.92)) and sepsis (aRR = 1.18 (CI: 0.67-1.89)), but a reduced risk of cardiovascular events (aRR = 0.59 (CI: 0.41-0.82)). The aRR for 30-day mortality was 1.11 (CI: 0.97-1.27) for PD vs non-PD patients, and the aHR for 1-year mortality was 1.19 (CI: 1.09-1.30). The aRRs for fulfillment of all relevant quality indicators was about 1 for PD vs non-PD patients.

CONCLUSION

Hip fracture patients with PD have a higher risk of infections and mortality within 30 days after surgery after adjustment for sex, age, and comorbidity. They do, however, receive comparable quality of in-hospital care after hip fracture compared to non-PD patients.

Six Versus 12 Weeks of Outpatient Physical Therapy Including Progressive Resistance Training in Cognitively Intact Older Adults After Hip Fracture: A Multicenter Randomized Controlled Trial

BACKGROUND

Recovery of function and regaining muscle strength is challenging after hip fracture. We compared the effectiveness of a 12 versus 6-weeks outpatient physical therapy program with progressive resistive training (PRT) to increase strength and physical performance.

METHODS

This parallel, superiority, 2-group randomized controlled trial was conducted in 4 clinics enrolled community-dwelling, cognitively intact older adults (+60 years) with a surgical repair of a hip fracture and no major medical conditions. Participants received 12 or 6-weeks of PRT and standardized physical therapy, twice weekly. Pain was monitored throughout. Primary outcome was the change in the 6-minute walk test (6MWT) from baseline to 12-weeks follow-up. Randomization via a computer-generated allocation sequence was implemented using sealed, sequentially numbered opaque envelopes and assessors were blinded to group assignment.

RESULTS

Participants (81% women) with a mean (SD) age of 77 (8.1) years were enrolled at an average of 18 days post-hip fracture surgery and randomized into a 12-week group (n=50) or a 6-week group (n=50). A mean (SD) change score in the 6MWT of 143.8 (81.1) and 161.5 (84.1) meters found in the 12 and 6-week group, respectively (both exceeding the minimal clinically important difference of 55 meters). The mean between-group difference was -17.7 (95%CI -50.1, 14.8) meter. Pain during training did not exceed moderate levels nor increase as training intensity increased.

CONCLUSION

Twelve weeks of physical therapy with PRT was not superior to 6-weeks in improving walking distance. Hip fracture-related pain was relatively low and indicated strength testing and training was well tolerated.

Exercise therapy is effective at improving short- and long-term mobility, ADL and balance in older patients following hip fracture: a systematic review and meta-analysis

BACKGROUND

A systematic review and meta-analysis was performed to evaluate the short- and long-term effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, and secondly, whether the effect was modified by trial level characteristics such as intervention modality, duration and initiation timepoint.

METHODS

Medline, CENTRAL, Embase, CINAHL and PEDro was searched up-to November 2020. Eligibility criteria was randomized controlled trials investigating the effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, initiated from time of surgery up-to 1-year.

RESULTS

Forty-nine studies involving 3905 participants showed a small to moderate effect of exercise therapy at short term (end of intervention) on mobility (Standardized mean difference, SMD 0.49, 95%CI 0.22-0.76); Activities of Daily Living (ADL) (SMD 0.31, 95%CI 0.16-0.46); lower limb muscle strength (SMD 0.36, 95%CI 0.13-0.60); balance (SMD 0.34, 95%CI 0.14-0.54). At long term (closest to 1-year), small to moderate effects were found for mobility (SMD 0.74, 95%CI 0.15-1.34); ADL (SMD 0.42, 95%CI 0.23-0.61); balance (SMD 0.50, 95%CI 0.07-0.94) and Health related Quality of Life (HRQoL) (SMD 0.31, 95%CI 0.03-0.59). Certainty of evidence was evaluated using GRADE ranging from moderate to very low, due to study limitation and inconsistency.

CONCLUSION

We found low certainty of evidence for a moderate effect of exercise therapy on mobility in older patients following hip fracture at end-of-treatment and follow-up. Further, low evidence was found for small to moderate short-term effect on ADL, lower limb muscle strength and balance.

Does the type of hip fracture affect functional recovery in elderly patients undergoing inpatient rehabilitation?

BACKGROUND

Hip fractures should not be considered as a single, homogeneous condition. Various determinants of functional recovery of patients with hip fracture have been proposed, such as age or type of fracture. The aim of this study was to determine if patients with an intertrochanteric fracture (ITF) had lower functional recovery characteristics with respect to those with a femoral neck fracture (FNF).

METHODS

A retrospective study was carried out on 531 elderly patients with hip fracture, surgically treated, admitted to a rehabilitation institute between December 1, 2014, and December 31, 2017. Patients underwent an individualized rehabilitation program for improving their physical function. The outcome measures of this study were the length of stay (LOS) in the rehabilitation institute, the Functional Independence Measure (FIM) gain, i.e. the difference in FIM score between discharge and admission, and the FIM efficiency, which represents the daily gain. Patients were also stratified by age categories and by different levels of functional independence, as evaluated with the FIM total score at baseline.

RESULTS

Age (p<0.05), LOS (p<0.005) and rehabilitation outcomes (FIM score and efficiency; p<0.05) differed significantly between patients with FNF and ITF. In particular, patients with ITF were older and more dependent at baseline. Moreover, they showed a lower FIM efficiency with respect to patients with FNF (p<0.05), which obtained a similar improvement in FIM total score of about 26 points but were discharged on average 3 days before. With aging, FIM efficiency decreased, while LOS increased. Patients highly dependent at baseline (FIM total score <40) had the lowest FIM gain and efficiency and the longest LOS respect to the more independent patients. Moreover, in older (85+ years) and in higher dependent patients the differences in the outcome measures between ITF and FNF were reduced.

CONCLUSIONS

The type of hip fracture could affect the LOS and FIM efficiency of younger and more independent patients with hip fracture during inpatient rehabilitation. In particular, patients with ITF require a longer rehabilitation period to achieve a similar functional gain as those with FNF.

Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial)

Background

Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery.

Methods

Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition.

Results

Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4years, 78% women). Target sample size was 48. Main limitations for inclusion were not home-dwelling (18%) and cognitive dysfunction (16%). Among eligible patients, the main reason for declining participation was Overwhelmed and stressed by situation (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic=10, control=8).

Conclusions

Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid.

Trial registration

Clinicaltrials.gov NCT03545347.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02273-z.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Knee Extension Strength Measures Indicating Probable Sarcopenia Is Associated with Health-Related Outcomes and a Strong Predictor of 1-Year Mortality in Patients Following Hip Fracture Surgery

To examine if knee-extension strength (KES) measures indicating probable sarcopenia are associated with health-related outcomes and if KES and hand grip strength (HGS) measures are associated with 1-year mortality after hip fracture. Two groups of older patients with hip fracture had either HGS (n = 32) or KES (n = 150) assessed during their acute hospital stay. Cut-points for HGS (<27 kg for men and <16 kg for women), and cut-points for maximal isometric KES (non-fractured limb), being the lowest sex-specific quintile (<23.64 kg for men and <15.24 kg for women), were used to examine association with health-related outcomes and 1-year mortality. Overall, 1-year mortality was 12.6% in the two strength groups, of which 47% (HGS) and 46% (KES) respectively, were classified as probable sarcopenia. Probable sarcopenia patients (KES) had lower prefracture function, performed poorly in mobility measures and expressed a greater concern of falling compared to their stronger counterparts. Hazard ratio for 1-year mortality was 2.7 (95%CI = 0.49–14.7, p = 0.3) for HGS and 9.8 (95%CI = 2.2–43.0, p = 0.002) for KES for probable sarcopenia patients compared to those not. Sex-specific KES measures indicating sarcopenia is associated with health-related outcomes and a strong predictor of 1-year mortality after hip fracture.

Postoperative Rehabilitation after Hip Fracture: A Literature Review

As the proportion of elderly individuals within the population grows, the incidence of hip fractures increases. Traditionally, orthopedic surgeons used to focus on surgical treatment of hip fractures; however, the field's appreciation for the importance of postoperative rehabilitation has been increasing recently. Many studies have shown that proper rehabilitation after hip fracture surgery can shorten hospital stays and improve clinical outcomes. However, such studies use different methods and published rehabilitation protocols address varying aspects that do not always overlap. Here, we review and summarize the latest guidelines and studies on postoperative rehabilitation of elderly patients with hip fractures.

Factors influencing performances and indicating risk of falls using the true Timed Up and Go test time of patients with hip fracture upon acute hospital discharge

OBJECTIVE

To examine the influence and risk of falls of individual factors on timed up and go test (TUG) times using standardized instructions in patients with hip fracture upon discharge from an acute orthopaedic hip fracture unit.

METHODS

Following instructions, the TUG was performed three times with a rollator (standardized aid), as fast as safely possible. Up to a 1-min rest was given after the first and second TUG trial. Multivariable linear regression analysis was used to investigate the factors influencing TUG-times and corresponding logistic analysis was used to investigate factors indicating risk of falls, using a cut-off of 24 s for TUG.

RESULTS

A total of 181 patients (122 women), 60 years or older, with a mean (SD) age of 78.1 (9.1) years were studied. The fastest of three TUG trials performed within a mean of 10.0 (5.2) post-surgery days and used in analyses reached a mean of 25.6 (11.0) s. Multivariable regression analysis showed that greater age (B = 0.24; 2.4s more per decade older), a low pre-fracture function level (New Mobility Score <7 points, B = 6.4s more than high level), having a trochanteric fracture (B = 6.2 s, vs. cervical), and the post-surgery day of testing (B = 0.42, 4.2s per 10 days later) were independently associated with using more time for performing the TUG. Correspondingly, the same four factors indicated an increased risk of falls in the logistic analysis. The linear model explained 28% of the variance on TUG, while the accuracy of the logistic model to predict patients having TUG≥24 s was 69%.

CONCLUSION

The age, pre-fracture function, fracture type and post-surgery day of TUG testing were identified as strong factors influencing TUG performances and TUG-times indicating risk of falls in patients with hip fracture. We suggest that these factors be considered when interpreting TUG test results and in further rehabilitation and fall prevention efforts.

Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial)

BACKGROUND

A 2014 Cochrane review evaluating the effect of anabolic steroids after hip fracture concluded that the quality of the studies was insufficient to draw conclusions on the effects and recommended further high-quality trials in the field. Therefore, the aim of this pilot trial is to determine the preliminary effect and feasibility of a 12-week multimodal intervention consisting of physiotherapy (with strength training), protein-rich nutritional supplement and anabolic steroid on knee-extension muscle strength and function 14 weeks after hip fracture surgery.

METHODS

We plan to conduct a randomized, placebo-controlled pilot trial with 48 patients operated for acute hip fracture. The patients are randomized (1:1) to either (1) physiotherapy with protein-rich nutritional supplement plus anabolic steroid or (2) physiotherapy with protein-rich nutritional supplement plus placebo. Outcome assessments will be carried out blinded at baseline (3-10 days after surgery) and at 14 weeks after entering the trial. Primary outcome is the change from baseline to follow-up in maximal isometric knee-extension muscle strength in the fractured limb. Secondary outcomes are physical performance test, patient-reported outcomes, and measures of body composition.

DISCUSSION

If the trial is found feasible and the results show an indication of anabolic steroid being a relevant addition to further enhance the recovery of muscle strength and function in an enhanced recovery after surgery program, this trial will constitute the basis of a larger confirmatory trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545347. Preregistered on 4 June 2018.

Asymmetries Identified in Sit-to-Stand Task Explain Physical Function After Hip Fracture

BACKGROUND

Several known demographic and functional characteristics combine to predict physical function after hip fracture. Long-term weight-bearing asymmetries, evident during functional movements after hip fracture, contribute to limited mobility and large asymmetries in muscle function are linked to a high rate of injurious falls. Although postfracture mobility is commonly measured as whole body movement, a force-plate imbedded chair can identify individual limb contributions to an important task like moving from a sitting to standing position. The modified Physical Performance Test (mPPT) and stair climb test (SCT) are reliable, valid measures of function that predict independence after hip fracture. The purpose of this study was to determine to what extent asymmetry during a sit-to-stand task (STST) predicts function (mPPT, 12-step SCT), above and beyond other known predictors.

METHODS

Thirty-one independent community-dwelling older adults, recently discharged from usual care physical therapy (mean [standard deviation], 77.7 [10.5] years, 10 male), within 2 to 8 months postfracture, volunteered for this study. Participants performed an STST on a force-plate-imbedded chair designed to identify individual limb contributions during an STST. Asymmetry magnitude during the STST was determined for each individual. In addition, mPPT and SCT were assessed and regression analyses were performed to determine the contribution of asymmetry to the variance in these physical function scores beyond other factors predicting function.

RESULTS

Demographic factors (sex, time since fracture, repair type, and body mass index) were not significantly related to function in this sample. Age, gait speed, knee extension strength, balance confidence, and functional self-report were each significantly related to both mPPT (r = 0.43-0.86) and SCT (r = 0.40-0.83), and were retained in the regression model. Included variables accounted for 83.4% of the variance in mPPT score, and asymmetry during the STST did not significantly contribute to explaining variability in mPPT (P = .23). Variables in the regression model accounted for 78.0% of the variance in SCT score, and STST asymmetry explained 7.1% (P < .005) of the variance in SCT score.

DISCUSSION

In this small sample, asymmetry contributed significantly to explaining the variability in SCT performance, but not mPPT score. The SCT requires greater unilateral strength and control than the battery of items that comprise the mPPT. This contributes to the disproportionate number of falls occurring during stair ambulation (>10% of all fall-related deaths), relative to the minimal time typically involved in stair negotiation. Our results indicate potential benefit to identifying injured limb asymmetries as they predict function in challenging, high-risk functional tasks after hip fracture.

CONCLUSION

Although gait speed is the best explanator of physical function in older adults after hip fracture, lower extremity asymmetry during an STST provides a unique contribution to explaining high-level ambulatory performance after hip fracture. Efforts to reduce weight-bearing asymmetry during rehabilitation following hip fracture may improve function and recovery.

Multidimensional investigation of chronic pain experience and physical functioning following hip fracture surgery: clinical implications

Introduction

Older adults experience significant chronic pain after hip fracture, resulting in decreased physical functioning. However, pain investigation in this population is mostly limited to self-reported pain intensity. Detailed pain assessment may identify intervention targets other than pain relief. The aim of this study is to investigate multiple dimensions of pain experience (intensity, sensory, affective, evaluative and miscellaneous dimensions) and to correlate them to lower limb functionality and limitations in daily living activities.

Methods

We conducted a cross-sectional study of 50 older adults (77.1 ± 8.1 years old) who underwent hip fracture surgery in the past 4 months. We used the Numeric Rating Scale (NRS), the McGill Pain Questionnaire (MPQ) and an algometer to assess pain intensity, pain quality and pressure pain threshold, respectively. Lower limb functionality and limitation in basic (activities of daily living (ADL)) and instrumental activities of daily living (IADL) were assessed using the Short Physical Performance Battery (SPPB) and the Brazilian OARS Multidimensional Functional Assessment Questionnaire.

Results

Participants described pain as brief, momentary and transient, especially during weight-bearing activities. Although the pain intensity measured by the NRS was reported as moderate to severe (7.5 ± 1.6 points), it was not correlated with physical functioning. However, we observed a moderate negative correlation between pressure pain threshold, ADL and IADL disability (r = -0.41, p < 0.01). Among pain qualities, the sensory category was moderately negatively correlated to SPPB (r = -0.41, p < 0.01), and the evaluative category was moderately correlated to ADL and IADL disability (r = 0.43, p < 0.01).

Conclusion

Pain can be present 4 months after hip fracture surgery, particularly during weight-bearing activities, and it is associated with poor lower limb functionality, as well as ADL and IADL disability. Older adults may benefit from pain assessments that go beyond pain intensity measurements after hip fracture, as this helps clinicians optimise pain management and overall functional recovery.

Translation, inter-rater reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation score in patients after hip fracture

Purpose: To translate the Cumulated Ambulation Score into Spanish, and to examine its inter-rater reliability, agreement and internal consistency.Materials and Methods: Two occupational therapists independently used the Spanish version of the Cumulated Ambulation Score (three activities scored from 0-2 points) to assess 60 consecutive patients with hip fracture within the first post-surgery week at a traumatology service of a public hospital. We used linear weighted kappa (κ) statistics to determine inter-rater reliability, percent agreement to assess measurement error, Cronbach's α coefficient to establish the internal consistency, and the McNemar-Bowker test to evaluate for systematic between-rater differences.Results: The κ was ≥ 0.83 for the three individual activities and the total score, the percent agreement was ≥ 0.87, and Cronbach's α was 0.89 with no observed systematic between-rater difference.Conclusions: This study provides evidence for almost perfect inter-rater reliability, excellent internal consistency, and high percent agreement of the Spanish version of the Cumulated Ambulation Score. Due to the strong psychometric properties, and its ease of use, we suggest it be used in Spanish speaking countries to assess early basic mobility status of patients with hip fracture until independence is reached.Implications for rehabilitationThe Spanish version of the Cumulated Ambulation Score is a reliable outcome measure to assess basic mobility of patients with hip fracture.We suggest the Spanish version of the Cumulated Ambulation Score be used in Spanish speaking settings to indicate small changes in basic mobility of patients with hip fracture until an independent level is reached.The Spanish version of the Cumulated Ambulation Score can be used with a high reliability by experienced and inexperienced occupational therapists, corresponding to the already established reliability when used by physicians and physiotherapists.

Functional Outcomes of Fragility Fracture Integrated Rehabilitation Management in Sarcopenic Patients after Hip Fracture Surgery and Predictors of Independent Ambulation

OBJECTIVES

To compare the changes in the functional level of patients with versus without sarcopenia who received by fragility fracture integrated rehabilitation management (FIRM) after hip fracture (HF) surgery over a 6-month follow-up period and to identify variables influencing independent ambulation (IA) at 6 months after HF.

DESIGN

Prospective observational study.

SETTING

Three in-hospital rehabilitation setting.

PARTICIPANTS

Patients older than 65 years of age (N=80) categorized by the presence of sarcopenia.

INTERVENTION

The FIRM program during the-2 week hospital stay after surgery.

MEASUREMENTS

Main outcomes for ambulatory function (Koval score, Functional Ambulatory Category) and other secondary outcomes were measured at rehabilitation admission, at discharge, at 3 months and 6 months after surgery. Other secondary outcomes were measured. The possibility of IA at 6 months after surgery were also investigated.

RESULTS

Sarcopenia and non-sarcopenia patients did not differ significantly in terms of changes in ambulation or other functions over a 6-month follow-up (p < 0.001 or p = 0.001). The two groups did not differ significantly in terms of final functional status (6 months). The IA ratios of the two groups did not significantly differ at 6 months after surgery (sarcopenia [54.3%] and non-sarcopenia [64.5%]). IA before fracture (p = 0.039) and age (≥80 years) (p = 0.03) were independent predictors and sarcopenia was not a predictor for the possibility of IA at 6-months after surgery.

CONCLUSIONS

The FIRM program was effective for promoting functional recovery in older patients with fragility HF, either with or without sarcopenia. The present findings provide evidence of the pressing need for integrated rehabilitation management in fragility fracture care to improve functional recovery in patients with sarcopenia.

Physiotherapy following fragility fractures

Physiotherapy can play a vital role in the pathway of care of people after fragility fracture and includes interventions of early mobilisation and prescription of structured exercise programmes for maximising functional recovery and reducing the risk of falls and further fractures. Although the optimal nature of physiotherapist interventions after hip and vertebral fracture requires further investigation in large-scale trials, evidence supports the prescription of high-intensity and extended exercise interventions. This article will overview interventions in the acute and chronic phases after hip fractures, interventions after vertebral fracture and the role of physiotherapy in the prevention of further fractures.

Psychometric properties of the Cumulated Ambulation Score: a systematic review

INTRODUCTION

In the geriatric population, independent mobility is a key factor in determining readiness for discharge following acute hospitalization. The Cumulated Ambulation Score (CAS) is a potentially valuable score that allows day-to-day measurements of basic mobility. The CAS was developed and validated in older patients with hip fracture as an early postoperative predictor of short-term outcome, but it is also used to assess geriatric in-patients with acute medical illness. Despite the fast-accumulating literature on the CAS, to date no systematic review synthesizing its psychometric properties has been published. Therefore, we aimed to provide a comprehensive review of the psychometric properties of the CAS, summarizing the present evidence on this measure as a basis for further research to investigate its applicability across a wider range of functional abilities and care settings.

EVIDENCE ACQUISITION

A literature search was conducted on research articles published between 2006 and June 2016 in journals indexed by MEDLINE and Scopus databases using as a search item "Cumulated Ambulation Score"[All Fields], and selecting studies that presented a psychometric analysis of the scale. Of 49 studies identified, 17 examined the psychometric properties of the CAS.

EVIDENCE SYNTHESIS

Most papers dealt with patients after hip fracture surgery, and only 4 studies assessed the CAS psychometric characteristics also in geriatric in-patients with acute medical illness. Two versions of CAS (CAS1 and the more detailed CAS2 version) and two different methods to calculate the total score (1-day and 3-day CAS) were used in the selected papers. Most of the papers assessed reliability and validity, using different statistics, and only one showed evidence of sensitivity to change of the score.

CONCLUSIONS

This systematic review shows international interest of researchers in the CAS, despite the short time frame since its first publication in 2006. The results support the reliability, validity, and sensitivity to change of the tool. Since different versions of CAS are available and two scores are commonly used, we suggest that clinicians and researchers in the future choose the more detailed CAS2 version, already used by the large majority of studies, and report whether they used the 1- or 3-day score.

High-Intensity Multimodal Resistance Training Improves Muscle Function, Symmetry during a Sit-to-Stand Task, and Physical Function Following Hip Fracture

OBJECTIVES

Post rehabilitation, older adults with hip fracture display low vertical ground reaction force (vGRF) on the involved lower extremity during a sit-to-stand task and low physical function. The purpose of this study was to test whether muscle performance, involved side vGRF during a sit-to-stand task, and physical function improved following multimodal high-intensity resistance training, when initiated after usual care (2 to 6 months after hip fracture).

DESIGN

Case series study, 12 weeks extended high-intensity strength training intervention following hip fracture.

SETTING

University hospital outpatient facility.

PARTICIPANTS

Twenty-four community-dwelling older adults (mean age 78.4 years (SD 10.4), 16 female/8 male), 3.6 (SD 1.2) months post-hip fracture and discharged from physical therapy participated. Intervention/Measurement: All participants performed sit-to-stand tasks, muscle performance tests, and modified physical performance test (mPPT) before and after 12 weeks (3x/wk) of training. Variables were compared using paired t-tests.

RESULTS

The vGRF rate of force development (RFD) and magnitude of discrepancy between limb loading during rising phase of sit-to-stand task (AREA) variables improved post-training (RFD ratio = Pre: 0.78 - Post: 0.82, AREA ratio = Pre: 0.79 - Post: 0.86). Surgical leg extension power gains were large (~65%) while strength gains were moderate (~34%); yielding improved symmetry in both strength (Pre: 0.74 - Post: 0.88) and power (Pre: 0.75 - Post: 0.82). Physical function improved pre-training 25 (SD 5.2) to post training 30 (SD 4.3), (p < 0.001).

CONCLUSION

Unique to this study, participants recovering from hip fracture demonstrated improved symmetry in sit-to-stand vGRFs, muscle function, and physical function after training. However, a high percentage of patients continued to experience persistently low vGRF of the involved side compared to previous studies of healthy elderly controls. Developing alternative strategies to improve involved side vGRF may be warranted.

Effect of Lower-Limb Progressive Resistance Exercise After Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

OBJECTIVE

Although several studies have reported the effect of progressive resistance exercise (PRE) after hip fracture surgery, little is known about the functional efficacy of PRE. Thus, we conducted a meta-analysis to evaluate whether PRE can improve (1) mobility and (2) other physical functions in elderly patients after hip fracture surgery.

METHODS

Eight randomized controlled trials investigating the effects of PRE after hip fracture surgery were retrieved from a PubMed, Embase, and Cochrane Library search. Our pair-wise meta-analysis used a fixed or random effects model.

RESULTS

PRE significantly improved participants' overall physical functions after hip fracture surgery compared with the control group (standardized mean difference = 0.408; 95% confidence interval, 0.238-0.578; P < .001). It was particularly effective in the areas of mobility (standardized mean difference = 0.501; 95% confidence interval, 0.297-0.705; P < .001), activities of daily living, balance, lower-limb strength or power, and performance task.

CONCLUSIONS

Our meta-analysis revealed that PRE after hip fracture surgery improves mobility, activities of daily living, balance, lower-limb strength or power, and performance task outcomes. Because of the small sample size in this meta-analysis and considering the increasing incidence of hip fractures, there is a need for large-scale randomized controlled trials to confirm the functional improvement and adverse effects of PRE.

Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: A randomised controlled trial

Question

Is acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up compared to physiotherapy without strength training in patients with a hip fracture?

Design

Assessor blinded, randomised controlled trial with intention-to-treat analysis.

Participants

90 patients with a hip fracture admitted to an acute orthopaedic Hip Fracture Unit at a university hospital between October 2013 and May 2015.

Intervention

Daily physiotherapy with or without progressive knee-extension strength training (10RM), 3 x 10 repetitions, of the fractured limb using ankle weight cuffs conducted by ward physical therapists during hospital stay.

Outcome measures

Primary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from inclusion to postoperative day 10 or discharge (follow-up). Secondary outcome was Timed Up and Go test measured early after surgery and at follow-up.

Results

In the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1% (95% CI -2.3; 18.4) by additional strength training from baseline to follow-up. In the per-protocol analysis of non-missing data, significant between-group improvements by 10.5% (95% CI 0.3; 20.7) were found in favour of additional ST. No significant between-group differences were found in any secondary outcome.

Conclusion

Physiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture. It is debatable whether larger improvements than the observed 8–10% can be expected given that only five exercise sessions, on average, were completed. In fragile patients with a hip fracture in the acute phase, where the ability to participate in functional exercise is compromised, we still consider early strength training a possibility to improve outcomes of clinical importance, given the results of the per-protocol analysis. The present data provides an important basis and call for future investigations including longer term interventions.

Trial registration

Clinicaltrials.gov NCT00848913

Interrater Reliability of the 6-Minute Walk Test in Women With Hip Fracture

BACKGROUND AND PURPOSE

The 6-minute walk test (6MWT) is widely used as a clinical outcome measure. However, the reliability of the 6MWT is unknown in individuals who have recently experienced a hip fracture. The aim of this study was to evaluate the relative and absolute interrater reliability of the 6MWT in individuals with hip fracture.

METHODS

Two senior physical therapy students independently examined a convenience sample of 20 participants in a randomized order. Their assessments were separated by 2 days and followed the guidelines of the American Thoracic Society. Hip fracture-related pain was assessed with the Verbal Ranking Scale.

RESULTS

Participants (all women) with a mean (standard deviation) age of 78.1 (5.9) years performed the test at a mean of 31.5 (5.8) days postsurgery. Of the participants, 10 had a cervical fracture and 10 had a trochanteric fracture. Excellent interrater reliability (intraclass correlation coefficient [ICC2.1] = 0.92; 95% confidence interval, 0.81-0.97) was found, and the standard error of measurement and smallest real difference were calculated to be 21.4 and 59.4 m, respectively. Bland-Altman plots revealed no significant difference (mean of 3.2 [31.5] m, P = .83) between the 2 raters, and no heteroscedasticity was observed (r = -0.196, P = .41). By contrast, participants walked an average of 21.7 (22.5) m longer during the second trial (P = .002). Participants with moderate hip fracture-related pain walked a shorter distance than those with no or light pain during the first test (P = .04), but this was not the case during the second test (P = .25).

CONCLUSION

The interrater reliability of the 6MWT is excellent, and changes of more than 21.4 m (group level) and 59.4 m (individual participants with hip fracture) indicate a real change in the 6MWT. Measuring hip fracture-related pain during testing is recommended for individuals with hip fracture who undergo the 6MWT.

The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial

BACKGROUND

The number of hip fractures and resulting post-surgical outcome are a major public health concern and the incidence is expected to increase significantly. The acute recovery phase after hip fracture surgery in elder patients is often complicated by severe pain, high morphine consumption, perioperative blood loss with subsequent transfusion and delirium. Postoperative continuous-flow cryocompression therapy is suggested to minimize these complications and to attenuate the inflammatory reaction that the traumatic fracture and subsequent surgical trauma encompass. Based on a pilot study in patients undergoing total hip arthroplasty for osteoarthritis, it is anticipated that patients treated with continuous-flow cryocompression therapy will have less pain, less morphine consumption and lower decrease of postoperative hemoglobin levels. These factors are associated with a shorter hospital stay and better long-term (functional) outcome.

METHODS/DESIGN

One hundred and sixty patients with an intra or extracapsular hip fracture scheduled for internal fixation (intramedullary hip nail, dynamic hip screw or cannulated screws) or prosthesis surgery (total hip or hemiarthroplasty) will be included in this prospective, open-label, parallel, multicenter, randomized controlled, clinical superiority trial. Patients will be allocated to two treatment arms: group 'A' will be treated with continuous-flow cryocompression therapy and compared to group 'B' that will receive standard care. Routine use of drains and/or compressive bandages is allowed in both groups. The primary objective of this study is to compare acute pain the first 72 h postoperative, measured with numeric rating scale for pain. Secondary objectives are: (non-) morphine analgesic use; adjusted postoperative hemoglobin level; transfusion incidence; incidence, duration and severity of delirium and use of psychotropic medication; length of stay; location and duration of rehabilitation; functional outcome; short-term patient-reported health outcome; general and cryotherapy related complications and feasibility.

DISCUSSION

This is the first randomized controlled trial that will assess the analgesic efficiacy of continuous-flow cryocompression therapy in the acute recovery phase after hip fracture surgery.

TRIAL REGISTRATION

www.trialregister.nl, NTR4152 (23(rd) of August 2013).

Determinants of Slow Walking Speed in Ambulatory Patients Undergoing Maintenance Hemodialysis

Walking ability is significantly lower in hemodialysis patients compared to healthy people. Decreased walking ability characterized by slow walking speed is associated with adverse clinical events, but determinants of decreased walking speed in hemodialysis patients are unknown. The purpose of this study was to identify factors associated with slow walking speed in ambulatory hemodialysis patients. Subjects were 122 outpatients (64 men, 58 women; mean age, 68 years) undergoing hemodialysis. Clinical characteristics including comorbidities, motor function (strength, flexibility, and balance), and maximum walking speed (MWS) were measured and compared across sex-specific tertiles of MWS. Univariate and multivariate logistic regression analyses were performed to examine whether clinical characteristics and motor function could discriminate between the lowest, middle, and highest tertiles of MWS. Significant and common factors that discriminated the lowest and highest tertiles of MWS from other categories were presence of cardiac disease (lowest: odds ratio [OR] = 3.33, 95% confidence interval [CI] = 1.26–8.83, P<0.05; highest: OR = 2.84, 95% CI = 1.18–6.84, P<0.05), leg strength (OR = 0.62, 95% CI = 0.40–0.95, P<0.05; OR = 0.57, 95% CI = 0.39–0.82, P<0.01), and standing balance (OR = 0.76, 95% CI = 0.63–0.92, P<0.01; OR = 0.81, 95% CI = 0.68–0.97, P<0.05). History of fracture (OR = 3.35, 95% CI = 1.08–10.38; P<0.05) was a significant factor only in the lowest tertile. Cardiac disease, history of fracture, decreased leg strength, and poor standing balance were independently associated with slow walking speed in ambulatory hemodialysis patients. These findings provide useful data for planning effective therapeutic regimens to prevent decreases in walking ability in ambulatory hemodialysis patients.

Feasibility of progressive strength training implemented in the acute ward after hip fracture surgery

IMPORTANCE

Patients with a hip fracture lose more than 50% knee-extension strength in the fractured limb within one week of surgery. Hence, immediate progressive strength training following hip fracture surgery may be rational, but the feasibility unknown.

OBJECTIVE

To examine the feasibility of in-hospital progressive strength training implemented in the acute ward following hip fracture surgery, based on pre-specified criteria for feasibility.

DESIGN, SETTING AND PATIENTS

A prospective cohort study conducted in an acute orthopedic hip fracture unit at a university hospital. A consecutive sample of 36 patients, 18 with a cervical and 18 with a trochanteric hip fracture (27 women and 9 men, mean (SD) age of 79.4 (8.3) years) were included between June and December 2012.

INTERVENTION

A daily (on weekdays) program of progressive knee-extension strength training for the fractured limb, using ankle weight cuffs in 3 sets of 10 repetition maximum loadings.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in training load (kg) during the knee-extension strength training. The secondary outcomes were changes in hip fracture-related pain and maximal isometric knee-extension strength.

RESULTS

The strength training was commenced at a mean of 2.4 (0.7) days after surgery. The training loads (kilograms lifted) increased from 1.6 (0.8) to 4.3 (1.7) kg over 4.3 (2.2) training sessions (P<.001). The maximal isometric knee-extension strength of the fractured limb increased from 0.37 (0.2) to 0.61 (0.3) Nm/kg (P<.001), while the average strength deficit in the fractured limb decreased from 50% to 32% (% non-fractured, P<.001). Only 3 of 212 sessions were not performed because of severe hip fracture-related pain.

CONCLUSION AND RELEVANCE

Progressive knee-extension strength training of the fractured limb commenced in the acute ward seems feasible, and may reduce strength asymmetry between limbs without hip pain interfering. The clinical efficacy needs confirmation in a randomized controlled design.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01616030.

Feasibility of progressive strength training shortly after hip fracture surgery

AIM: To investigate the feasibility of a 6-wk progressive strength-training programme commenced shortly after hip fracture surgery in community-dwelling patients.

METHODS: This prospective, single-blinded cohort study evaluated 31 community-dwelling patients from four outpatient geriatric health centres aged 60 years or older, who started a 6-wk programme at a mean of 17.5 ± 5.7 d after hip fracture surgery. The intervention consisted primarily of progressive fractured knee-extension and bilateral leg press strength training (twice weekly), with relative loads commencing at 15 and increasing to 10 repetitions maximum (RM), with three sets in each session. The main measurements included progression in weight loads, hip fracture-related pain during training, maximal isometric knee-extension strength, new mobility score, the timed up and go test, the 6-min walk test and the 10-meter fast speed walk test, assessed before and after the programme.

RESULTS: Weight loads in kilograms in the fractured limb knee-extension strength training increased from 3.3 ± 1.5 to 5.7 ± 1.7 and from 6.8 ± 2.4 to 7.7 ± 2.6, respectively, in the first and last 2 wk (P < 0.001). Correspondingly, the weight loads increased from 50.3 ± 1.9 to 90.8 ± 40 kg and from 108.9 ± 47.7 to 121.9 ± 54 kg in the bilateral leg press exercise (P < 0.001). Hip fracture-related pain was reduced, and large improvements were observed in the functional outcome measurements, e.g., the 6-min walk test improved from 200.6 ± 79.5 to 322.8 ± 68.5 m (P < 0.001). The fractured limb knee-extension strength deficit was reduced from 40% to 17%, compared with the non-fractured limb. Ten patients reported knee pain as a minor restricting factor during the last 10 RM knee-extension strength-training sessions, but with no significant influences on performance.

CONCLUSION: Progressive strength training, initiated shortly after hip fracture surgery, seems feasible and does not increase hip fracture-related pain. Progressive strength training resulted in improvement, although a strength deficit of 17% persisted in the fractured limb compared with the non-fractured limb.

Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study

BACKGROUND

By measuring very early changes in muscle strength and functional performance after fast-track total hip arthroplasty (THA), post-operative rehabilitation, introduced soon after surgery, can be designed to specifically target identified deficits.

OBJECTIVES

Firstly, to quantify changes (compared to pre-operative values) in hip muscle strength, leg-press power, and functional performance in the first week after THA, and secondly, to explore relationships between the muscle strength changes, and changes in hip pain, systemic inflammation, and thigh swelling.

DESIGN

Prospective, cohort study.

SETTING

Convenience sample of patients receiving a THA at Copenhagen University Hospital, Hvidovre, Denmark, between March and December 2011.

PARTICIPANTS

Thirty-five patients (65.9 ± 7.2 years) undergoing THA.

MAIN OUTCOME MEASURES

Hip muscle strength, leg-press power, performance-based function, and self-reported disability were determined prior to, and 2 and 8 days after, THA (Day 2 and 8, respectively). Hip pain, thigh swelling, and C-Reactive Protein were also determined.

RESULTS

Five patients were lost to follow-up. Hip muscle strength and leg press power were substantially reduced at Day 2 (range of reductions: 41-58%, P<0.001), but less pronounced at Day 8 (range of reductions: 23-31%, P<0.017). Self-reported symptoms and function (HOOS: Pain, Symptoms, and ADL) improved at Day 8 (P<0.014). Changes in hip pain, C-Reactive Protein, and thigh swelling were not related to the muscle strength and power losses.

CONCLUSIONS

Hip muscle strength and leg-press power decreased substantially in the first week after THA - especially at Day 2 - with some recovery at Day 8. The muscle strength loss and power loss were not related to changes in hip pain, systemic inflammation, or thigh swelling. In contrast, self-reported symptoms and function improved. These data on surgery-induced changes in muscle strength may help design impairment-directed, post-operative rehabilitation to be introduced soon after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246674.

Hip fracture-related pain strongly influences functional performance of patients with an intertrochanteric fracture upon discharge from the hospital

OBJECTIVE

To examine whether functional performance upon hospital discharge is influenced by pain in the region of the hip fracture or related to the fracture type.

DESIGN

Prospective observational study.

SETTING

A 20-bed orthopedic hip fracture unit.

PATIENTS

Fifty-five cognitively intact patients (20 men and 35 women; ages 75.8 ± 10 years), 33 with a cervical hip fracture and 22 with an intertrochanteric hip fracture, all of whom were allowed to bear full weight after surgery.

METHODS

All patients were evaluated upon discharge from the hospital to their own homes at a mean of 10 ± 6 days after surgery.

MAIN OUTCOME MEASUREMENTS

The Timed Up & Go (TUG) test, supervised by a physical therapist, was used to evaluate functional performance, and a 5-point verbal ranking scale (0 = no pain to 4 = intolerable pain) was used to evaluate pain.

RESULTS

Patients took an average of 22.7 ± 11.7 seconds to perform the TUG. No significant differences were observed in baseline characteristics or pain medication given for patients with a cervical versus an intertrochanteric fracture (P ≥ .22), but patients with an intertrochanteric fracture presented more often with moderate to severe pain during testing (P < .001), with associated poorer performances on the TUG test (29.4 ± 12.8 seconds versus 18.3 ± 8.5 seconds). Univariate analysis showed that TUG scores were associated with age, prefracture function evaluated by the New Mobility Score, fracture type, day of TUG performance, and pain intensity. Multivariate linear regression analyses (fracture type not included) showed that only greater age (B = 0.34), low prefracture function (B = 7.9), and experiencing moderate to severe pain (B = 8.7) were independently associated with having a poorer TUG score.

CONCLUSIONS

Hip fracture-related pain primarily compromises the functional performance of patients with an intertrochanteric hip fracture upon discharge from hospital. Physical therapists should be involved in new and optimized fracture-type stratified pain management strategies.

Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty

OBJECTIVE

To (1) quantify changes in knee-extension strength and functional-performance at discharge after fast-track total hip arthroplasty (THA) and (2) investigate whether these changes correlate to changes in thigh and knee circumference (ie, swelling) or pain.

DESIGN

A prospective, descriptive, hypothesis-generating study.

SETTING

A special unit for fast-track hip and knee arthroplasty operations at a university hospital.

PARTICIPANTS

Twenty-four patients (20 women and 4 men; ages 69 ± 6.1 years) scheduled for primary unilateral THA.

METHODS

All patients were evaluated before surgery and on the day of hospital discharge.

MAIN OUTCOME MEASURES

Knee-extension strength, thigh and knee joint circumference, hip pain, and functional performance (Timed Up & Go, 30-Second Chair Stand, and 10-Meter Walk tests).

RESULTS

All investigated variables changed significantly from before to after surgery, except for hip pain. The average loss in knee-extension strength after surgery (32%, P = .01) did not correlate with increased thigh circumference (6%, P < .01) or knee circumference (3%, P < .01) or with reductions in functional performance: Timed Up & Go test (114%, P = .01), 30-Second Chair Stand test (36%, P = .01), and 10-Meter Walk test (50%, P < .01). Only the increase in knee circumference correlated significantly with reduced performance in the 10-Meter Walk test time (R = -0.59, P < .01), explaining 34% of the variance in the 10-Meter Walk test. No correlations between changes in hip pain and functional performance or knee-extension strength were found. Mean postoperative hospital stay was 2.1 days.

CONCLUSIONS

Knee-extension strength is considerably reduced at discharge after THA, but the early strength reduction does not correlate with changes in thigh or knee circumferences. Because functional performance is also considerably reduced at discharge (unrelated to reduced knee-extension strength), other mechanisms such as fear, avoidance of movement, or decreased hip-muscle strength also may be involved.

How many trials are needed to achieve performance stability of the Timed Up & Go test in patients with hip fracture?

OBJECTIVE

To examine the number of trials needed to achieve performance stability of the Timed Up & Go (TUG) test using a standardized walking aid in patients with hip fracture who are allowed full weight bearing (FWB).

DESIGN

Prospective methodologic study.

SETTING

An acute 14-bed orthopedic hip fracture unit.

PARTICIPANTS

Patients (N=122; 89 women, 33 men) with hip fracture with a median age (25%-75%, quartiles) of 80 (67-85) years performed the TUG on hospital discharge to their own home (n=115) or further inpatient rehabilitation (n=7).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

After a demonstration by a physical therapist how to perform the TUG with a standardized walking aid (a 4-wheeled rollator), the patients performed 6 timed TUG trials with up to 1-minute seated rest intervals. The participants were given a few minutes to familiarize with the rollator before commencing the timed trials. Repeated-measures analysis of variance (ANOVA) with Bonferroni corrections were used to examine the number of trials needed to ensure statistically stable TUG scores.

RESULTS

A total of 106 (87%) patients performed all 6 TUG trials, while 120 patients performed a minimum of 3 timed trials. Repeated-measures ANOVAs of both groups showed that TUG scores improved significantly (P< or =.007) up to and including the third TUG trial.

CONCLUSIONS

These results suggest that the original TUG manual, described as 1 practice trial followed by 1 timed trial, needs modification when used in patients with hip fracture who are allowed FWB. The best (fastest) of 3 timed TUG trials performed with a standardized walking aid is recommended.

Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery

BACKGROUND AND PURPOSE

Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture.

PATIENTS AND METHODS

We studied 280 patients with a median age of 81 (interquartile range 72-86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status.

RESULTS

Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases.

INTERPRETATION

The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.

High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture

OBJECTIVE

To examine the intertester reliability of the three activities of the Cumulated Ambulation Score (CAS) and the total CAS, and to define limits for the smallest change in basic mobility that indicates a real change in patients with hip fracture.

DESIGN

An intertester reliability study.

SETTING

An acute 20-bed orthopaedic hip fracture unit.

SUBJECTS

Fifty consecutive patients with a median age of 83 (25-75% quartile, 68-86) years.

INTERVENTIONS

The CAS, which describes the patient's independency in three activities - (1) getting in and out of bed, (2) sit to stand from a chair, and (3) walking ability - was assessed by two independent physiotherapists at postoperative median day 3. Each activity was assessed on a three-point ordinal scale from 0 (not able to) to 2 (independent of human assistance). The cumulated score for each activity provides a total CAS from 0 to 6, with 6 indicating independent ambulation.

MAIN MEASURES

Reliability was evaluated using weighted kappa statistics, the standard error of measurement (SEM) and the smallest real difference (SRD).

RESULTS

The kappa coefficient, the SEM and the SRD in the three activities and the total CAS were >or=0.92, <or=0.20 and <or=0.55 CAS points, respectively.

CONCLUSIONS

The intertester reliability of the CAS is very high, and a change of more than 0.20 and 0.55 CAS points for the total CAS indicates a real change in basic mobility, at group level and for an individual patient, respectively.

Timed up & go test score in patients with hip fracture is related to the type of walking aid

Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed Up & Go test score in patients with hip fracture is related to the type of walking aid.

OBJECTIVE

To determine the relationship between Timed Up & Go (TUG) test scores and type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG in patients with hip fracture who were allowed full weight-bearing (FWB).

DESIGN

Prospective methodological study.

SETTING

An acute orthopedic hip fracture unit at a university hospital.

PARTICIPANTS

Patients (N=126; 90 women, 36 men) with hip fracture with a mean age +/- SD of 74.8+/-12.7 years performed the TUG the day before discharge from the orthopedic ward.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The TUG was performed with the walking aid the patient was to be discharged with: a walker (n=88) or elbow crutches (n=38). In addition, all patients also performed the TUG using a rollator.

RESULTS

Patients who performed the TUG with a walker were on average 13.6 (95% confidence interval [CI], 11.2-16.1) seconds faster using a rollator compared with the walker (P<.001). Correspondingly, patients who performed the TUG with crutches were on average 3.5 (95% CI, 1.5-5.4) seconds faster using a rollator compared with elbow crutches (P=.001). In both patient groups, the between walking-aid scores were strongly correlated (r>.833, P<.001).

CONCLUSIONS

TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who are allowed FWB when discharged from the hospital, but all patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid when evaluating changes or comparing TUG scores in patients with hip fracture.