Effectiveness of sensor monitoring in an occupational therapy rehabilitation program for older individuals after hip fracture, the SO-HIP trial: study protocol of a three-arm stepped wedge cluster randomized trial

A scoping review of coaching in occupational therapy: Mapping methods, populations and outcomes

INTRODUCTION

Coaching is proposed as a core enabling skill of occupational therapy and increasingly suggested for a diverse range of health populations. In recent years, research on coaching has proliferated, emerging from within and outside of occupational therapy. Yet, concern has been raised about the absence of theoretical underpinning and diversity of descriptions of coaching in occupational therapy, as well as low-quality evidence supporting its effectiveness. The aim of this study is to map the use of coaching by occupational therapists from 2007 to 2022 to identify the populations, settings and outcomes it is applied to, differences between coaching interventions and evidence supporting its use.

METHODS

This systematic scoping review applied Arksey and O'Malley's five-stage methodological framework with further methodological direction using the Levac framework. There was no consumer involvement in undertaking this review.

RESULTS

Findings from 60 research publications on coaching indicate its use with populations across the lifespan in primarily community settings to improve occupational performance, participation and self-efficacy. A wide range of coaching interventions are designed or used by occupational therapists, with Occupational Performance Coaching being the most researched (16/27, 59% of named interventions). Common elements of coaching interventions included collaborative goal setting and problem-solving; however, a lack of described theory or coaching methods persists. High-quality study designs indicate its effectiveness; however, an absence of fidelity definition or monitoring limits interpretation of many studies.

CONCLUSION

The language of coaching is becoming common practice within occupational therapy, and evidence indicates effectiveness of some coaching interventions. Advances in coaching research and use by occupational therapists will be aided by an explicit statement of the theoretical basis for coaching interventions, with congruent coaching methods, mechanisms and outcomes stated.

PLAIN LANGUAGE SUMMARY

This scoping review maps the use of coaching by occupational therapists in current published research. Key aspects of coaching examined include how coaching is defined, who it is used with and how effective it is. The kinds of outcomes that coaching is intended to improve are also reported. From 633 publications, 60 research publications were fully analysed. The use of coaching by occupational therapists has grown rapidly over the past 10 years. Strong evidence of its effectiveness exists for achieving the personal goals of people receiving occupational therapy when goals describe changes in everyday life activities. Coaching is being used with people across the lifespan with a variety of disabilities and chronic conditions and their caregivers/parents, most commonly parents of children with developmental issues. The key features of coaching interventions used by occupational therapists include collaborative goal setting, shared problem-solving and client-led action planning. Some elements of coaching are also used within other interventions with a wider range of methods. Coaching is believed to work by supporting an individual's self-belief that they can make changes. Theories that underpin coaching vary but commonly focus on self-determination, behaviour change and occupational therapy theory. However, many of the coaching interventions do not describe any theoretical basis nor coaching methods in detail. Future research on coaching in occupational therapy should ensure a clear explanation of the theory that underpins it, coaching methods and monitoring of how well coaching is applied.

Perspectives of Rehabilitation Professionals on Implementing a Validated Home Telerehabilitation Intervention for Older Adults in Geriatric Rehabilitation: Multisite Focus Group Study

BACKGROUND

Owing to demographic trends and increasing health care costs, quick discharge with geriatric rehabilitation at home is advised and recommended for older adults. Telerehabilitation has been identified as a promising tool to support rehabilitation at home. However, there is insufficient knowledge about how to implement a validated home telerehabilitation system in other contexts. One of the major challenges for rehabilitation professionals is transitioning to a blended work process in which human coaching is supplemented via digital care.

OBJECTIVE

The study aimed to gain an in-depth understanding of the factors that influence the implementation of an evidence-based sensor monitoring intervention (SMI) for older adults by analyzing the perspectives of rehabilitation professionals working in 2 different health ecosystems and mapping SMI barriers and facilitators.

METHODS

We adopted a qualitative study design to conduct 2 focus groups, 1 in person in the Netherlands during winter of 2017 and 1 on the web via Zoom (Zoom Video Communications; owing to the COVID-19 pandemic) in Canada during winter of 2022, to explore rehabilitation providers' perspectives about implementing SMI. Qualitative data obtained were analyzed using thematic analysis. Participants were a group of rehabilitation professionals in the Netherlands who have previously worked with the SMI and a group of rehabilitation professionals in the province of Manitoba (Canada) who have not previously worked with the SMI but who were introduced to the intervention through a 30-minute web-based presentation before the focus group.

RESULTS

The participants expressed different characteristics of the telerehabilitation intervention that contributed to making the intervention successful for at-home rehabilitation: focus on future participation goals, technology support provides the rehabilitation professionals with objective and additional insight into the daily functioning of the older adults at home, SMI can be used as a goal-setting tool, and SMI deepens their contact with older adults. The analysis showed facilitators of and barriers to the implementation of the telerehabilitation intervention. These included personal or client-related, therapist-related, and technology-related aspects.

CONCLUSIONS

Rehabilitation professionals believed that telerehabilitation could be suitable for monitoring and supporting older adults' rehabilitation at home. To better guide the implementation of telerehabilitation in the daily practice of rehabilitation professionals, the following steps are needed: ensuring that technology is feasible for communities with limited digital health literacy and cognitive impairments, developing instruction tools and guidelines, and training and coaching of rehabilitation professionals.

Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials

BACKGROUND

Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery.

OBJECTIVES

We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures.

METHODS

We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis.

RESULTS

Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported.

CONCLUSIONS

The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Challenges in the implementation and evaluation of a transmural palliative care pathway for acutely hospitalized older adults; lessons from the PalliSupport program: A qualitative process evaluation study

OBJECTIVES

To improve transmural palliative care for acutely admitted older patients, the PalliSupport transmural care pathway was developed. Implementation of this care pathway was challenging. The aim of this study was to improve understanding why the implementation partly failed.

DESIGN

A qualitative process evaluation study.

SETTING/PARTICIPANTS

17 professionals who were involved in the PalliSupport program were interviewed.

METHODS

Online semi-structured interviews. Thematic analysis to create themes according to the implementation framework of Grol & Wensing.

RESULTS

From this study, themes within four levels of implementation emerged: 1) The innovation: challenges in current palliative care, the setting of the pathway and boost for improvement; 2) Individual professional: feeling (un)involved and motivation; 3) Organizational level: project management; 4) Political and economic level: project plan and evaluation.

CONCLUSION AND IMPLICATIONS

We learned that the challenges involved in implementing a transmural care pathway in palliative care should not be underestimated. For successful implementation, we emphasize the importance of creating a program that fits the complexity of transmural palliative care. We suggest starting on a small scale and invest in project management. This could help to involve all stakeholders and anticipate current challenges in palliative care. To increase acceptance, create one care pathway that can start and be used in all care settings. Make sure that there is sufficient flexibility in time and room to adjust the project plan, so that a second pilot study can possibly be performed, and choose a scientific evaluation with both rigor and practical usefulness to evaluate effectiveness.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Translating Promoting Factors and Behavior Change Principles Into a Blended and Technology-Supported Intervention to Stimulate Physical Activity in Children With Asthma (Foxfit): Design Study

Background

Children with asthma can decrease the impact of their disease by improving their physical activity (PA). However, health care providers lack interventions for children with asthma that effectively increase their PA levels and achieve behavior change. A technology-supported approach can positively influence PA and physical functioning in children.

Objective

The aims of this study were to develop a technology-supported intervention that facilitates health care providers in promoting PA for children (aged 8 to 12 years) with asthma and to systematically describe this developmental process.

Methods

Intervention mapping (IM) was applied to develop a blended and technology-supported intervention in cocreation with children with asthma, their parents, and health care providers. In accordance with the IM framework, the following steps were performed: conduct a needs assessment; define the intervention outcome, performance objectives, and change objectives; select theory-based intervention methods and strategies; create components of the intervention and conduct pilot tests; create an implementation plan; and create an evaluation plan.

Results

We developed the blended intervention Foxfit that consists of an app with a PA monitor for children (aged 8 to 12 years) with asthma and a web-based dashboard for their health care provider. The intervention focuses on PA in everyday life to improve social participation. Foxfit contains components based on behavior change principles and gamification, including goal setting, rewards, action planning, monitoring, shaping knowledge, a gamified story, personal coaching and feedback, and a tailored approach. An evaluation plan was created to assess the intervention’s usability and feasibility for both children and health care providers.

Conclusions

The IM framework was very useful for systematically developing a technology-supported intervention and for describing the translational process from scientific evidence, the needs and wishes of future users, and behavior change principles into this intervention. This has led to the technology-supported intervention Foxfit that facilitates health care providers in promoting PA in children with asthma. The structured description of the development process and functional components shows the way behavior change techniques are incorporated in the intervention.

Trial Registration

International Clinical Trial Registry Platform NTR6658; https://tinyurl.com/3rxejksf

Sensors and digital medicine in orthopaedic surgery

Digital health principles are starting to be evident in medicine. Orthopaedic trauma surgery is also being impacted —indirectly by all other improvements in the health ecosystem but also in particular efforts aimed at trauma surgery. Data acquisition is changing how evidence is gathered and utilized. Sensors are the pen and paper of the next wave of data acquisition. Sensors are gathering wide arrays of information to facilitate digital health relevance and adoption. Early adaption of sensor technology by the nonlegacy health environment is what has made sensor driven data acquisition so palatable to the normal health care system. As it applies to orthopaedic trauma, current sensor driven diagnostics and surveillance are nowhere near as developed as in the larger medical community. Digital health is being explored for health care records, data acquisition in diagnostics and rehabilitation, wellness to health care translation, intraoperative monitoring, surgical technique improvement, as well as some early-stage projects in long-term monitoring with implantable devices. The internet of things is the next digital wave that will undoubtedly affect medicine and orthopaedics. Internet of things (loT) devices are now being used to enable remote health monitoring and emergency notification systems. This article reviews current and future concepts in digital health that will impact trauma care.

Preferences for WeChat-Based and Hospital-Based Family Intervention Among Caregivers of People Living with Schizophrenia

PURPOSE

This study examines the preferences for WeChat-based and hospital-based family intervention among caregivers of people living with schizophrenia (PLS) and identify correlates associated with these preferences.

PATIENTS AND METHODS

A cross-sectional study was conducted with 449 family caregivers of PLS. Face-to-face interviews were conducted to collect information on socio-demographics, preferences for WeChat-based and hospital-based family intervention, social support, and coping.

RESULTS

Over 72.16% of participants endorsed hospital-based family intervention, while 50.11% endorsed WeChat-based family intervention. Endorsement of WeChat-based family intervention was associated with younger age (OR=0.42, 95% CI: 0.22, 0.79), WeChat use (OR=12.90, 95% CI: 7.48, 22.23), and higher social support (OR=1.03, 95% CI: 1.01, 1.04). Endorsement of hospital-based family intervention was associated with lower education (OR=0.19-0.37, 95% CI: 0.07, 0.66) and WeChat use (OR=3.27, 95% CI: 1.91, 5.59).

CONCLUSION

The studies showed a higher endorsement rate for hospital-based family intervention than WeChat-based family intervention and provide implications for developing targeted family intervention programs based on participants' own unique characteristics.

Early Predictors for Discharge to Geriatric Rehabilitation after Hip Fracture Treatment of Older Patients

OBJECTIVE

To investigate early predictors for discharge to a geriatric rehabilitation department at a skilled nursing home in older patients after hospitalization for hip fracture surgery.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data from 21,176 patients with hip fracture aged ≥70 years, who were registered in the Dutch Hip Fracture Audit database between January 1, 2017, and December 31, 2019, were included.

METHODS

Patients were categorized into 3 discharge groups: home (n=7326), rehabilitation (n=11,738), and nursing home (n=2112). Age, gender, Pre-Fracture Mobility Score (PFMS), premorbid Katz index of independence in Activities of Daily Living (Katz-ADL), history of dementia, American Society of Anesthesiologists physical status classification (ASA score), type of anesthesia, fracture type, surgical treatment, and cotreatment by a geriatrician were gathered. Multinomial regression analysis was used to assess for early predictors.

RESULTS

Higher age, poor premorbid mobility, lower premorbid Katz-ADL, no history of dementia, ASA score 3-5, general anesthesia, intramedullary implant, and cotreatment by a geriatrician were independent predictors for discharge to geriatric rehabilitation vs discharge home. Identical predictors were found for discharge to a nursing home vs discharge home. History of dementia and premorbid Katz-ADL were distinguishing factors; a higher premorbid Katz-ADL and a history of dementia were associated with a higher risk of discharge to a nursing home vs discharge home. The multinomial regression model correctly predicted 86%, 38.6%, and 2.4% of the patients in the rehabilitation group, home group, and nursing home group, respectively.

CONCLUSIONS AND IMPLICATIONS

This study showed that age, PFMS, premorbid Katz-ADL, surgical treatment, ASA score, type of anesthesia, history of dementia, and cotreatment by a geriatrician were independent early predictors for discharge to geriatric rehabilitation vs discharge home in older patients after hip fracture surgery. Identical predictors were found as predictors for discharge to a nursing home vs discharge home, except for history of dementia and premorbid Katz-ADL.

Evaluation of a covariate-constrained randomization procedure in stepped wedge cluster randomized trials

In stepped wedge (SW) designs, differing cluster-level characteristics or individual-level covariate distributions that differ by cluster can lead to imbalance by treatment arm and potential confounding of the treatment effect. Adapting a method used in cluster-randomized trials, we propose a covariate-constrained randomization method to be used in SW designs. First, we define a balance metric to be calculated for all possible randomizations of cluster order for a given SW design. The resulting distribution of this balance metric across all possible randomizations is used to select a candidate set of randomizations with acceptable covariate balance. One cluster order is selected at random from this candidate set to be used as the cluster order for treatment implementation. In a simulation study, we implement the covariate-constrained randomization procedure and compare treatment effect estimation, type I error, and power under varying SW design and confounding settings, and using multiple analysis methods. We observed optimal statistical properties when the balance metric was used to exclude a small set of potential randomizations with the highest level of imbalance, and when analysis methods were adjusted for the potential confounders. The covariate-constrained randomization was most beneficial in settings with a small number of clusters and in the presence of cluster-level confounding.

Variance formulae for multiphase stepped wedge cluster randomized trial

In a multiphase stepped wedge cluster randomized trial (MSW-CRT), more than one intervention will be initiated on each sequence in a fixed order. Hence, with the MSW-CRT design, the effect of the first intervention can be evaluated when compared to control, as well as the added-on effects of the subsequent interventions. Studies that use MSW-CRT have been proposed, but properties of this design have not been explicitly studied. We derive closed-form variance formulae to test the interventions' effects, which can be readily used for sample size and power calculation. Additionally, we provide relationships between variances to test the interventions' effects and design parameters. Under special conditions, some important properties include: (i) the variances to test different interventions' effects (ie, the first intervention effect and the second intervention effect) may be same; (ii) as the cluster-period mean autocorrelation increases, the variance to test an intervention effect may first increase and then decrease; (iii) as the amount of periods between the initiations of two interventions (ie, lag) increases, the variance to test an intervention effect may remain unchanged. We illustrate the relationships between power and design parameters using the variance formulae. From a few illustrative examples, we observe that the statistical test that uses data only relevant to a specific intervention has inferior power (relative power loss <15%) compared to the test when using all the study data. Also, power is reduced when both the total number of periods and lag are decreased simultaneously (relative power loss <20%).

Determining the cost-effectiveness requirements of an exoskeleton preventing second hip fractures using value of information

Background

Falls may lead to hip fractures, which have a detrimental effect on the prognosis of patients as well as a considerable impact on healthcare expenditures. Since a secondary hip fracture (SHF) may lead to even higher costs than primary fractures, the development of innovative services is crucial to limit falls and curb costs in high-risk patients. An early economic evaluation assessed which patients with a second hip fracture could benefit most from an exoskeleton preventing falls and whether its development is feasible.

Methods

The life-course of hip fractured patients presenting with dementia or cardiovascular diseases was simulated using a Markov model relying on the United Kingdom administrative data and complemented by published literature. A group of experts provided the exoskeleton parameters. Secondary analyses included a threshold analysis to identify the exoskeleton requirements (e.g. minimum impact of the exoskeleton on patients’ quality of life) leading to a reimbursable incremental cost-effectiveness ratio. Similarly, the uncertainty around these requirements was modelled by varying their standard errors and represented alongside population Expected Value of Perfect Information (EVPI).

Results

Our base-case found the exoskeleton cost-effective when providing a statistically significant reduction in SHF risk. The secondary analyses identified 286 cost-effective combinations of the exoskeleton requirements. The uncertainty around these requirements was explored producing further 22,880 scenarios, which showed that this significant reduction in SHF risk was not necessary to support the exoskeleton adoption in clinical practice. Conversely, a significant improvement in women quality of life was crucial to obtain an acceptable population EVPI regardless of the cost of the exoskeleton.

Conclusions

Our study identified the exoskeleton requisites to be cost-effective and the value of future research. Decision-makers could use our analyses to assess not only whether the exoskeleton could be cost-effective but also how much further research and development of the exoskeleton is worth to be pursued.

Motivational factors mediate the association of general self-efficacy and performance outcomes in acutely hospitalised older patients

Objectives

To study (i) the association of general self-efficacy (GSE) on the course of subjective (i.e. basic and instrumental activities of daily living (ADLs and IADLs) and objective physical performance outcomes (short physical performance battery (SPPB)) among older persons from discharge up to 3 months post-discharge and (ii) the extent to whether motivational factors such as depressive symptoms, apathy and fatigue mediate this association.

Methods

Prospective multi-centre cohort of acutely hospitalised patients aged ≥70 (Hospital-ADL study). Structural equation modelling was used to analyse the structural relationships.

Results

The analytic sample included 236 acutely hospitalised patients. GSE had a significant total effect on the course of subjective and objective performance outcomes (ADLs: β = −0.21, P < 0.001, IADLs: β = −0.24, P < 0.001 and SPPB: β = 0.17, P < 0.001). However, when motivational factors as mediator were included into the same model, motivational factors (IADLs: β = 0.51, P < 0.001; SPPB: β = 0.49, P < 0.001) but not GSE remained significantly associated with IADLs (β = −0.06, P = 0.16) and SPPB (β = 0.002, P = 0.97). Motivational factors partially mediated the relationship between GSE and ADLs (β = −0.09, P = 0.04). The percentage of mediation was 55, 74 and 99% for ADLs, IADLs and SPPB, respectively.

Conclusions

Motivational factors and GSE are both associated with subjective and objective performance outcomes. However, the relationship between GSE and subjective and objective performance outcomes was highly mediated by motivational factors. Taken together, this suggests that GSE is important to being physically active but not sufficient to becoming more physical active in acutely hospitalised older patients; motivation is important to improving both subjective and objective performance.

Developing an international research of health-care ICT applied for rehabilitation and daily living support between Japan and the Netherlands

While many health-care issues and technological solutions are viewed locally, developing new technological solutions might benefit from lessons learned globally. The aim of this study was to develop a shared international research agenda of health-care ICT, applied to rehabilitation and daily living support. This study was focused on sensor technology and social robots used for supporting older persons in the Netherlands (Amsterdam) and Japan (Tokyo). Three researchers from Amsterdam University of Applied Sciences visited Japan and four researchers from Tokyo Metropolitan University visited the Netherlands and conducted field-visits and mutual presentations. Using a nominal group technique (NGT) facilitated the expert panel deliberations. Research priorities were identified qualitatively through in-action critical reflection on emerging ideas, and quantitatively by ranking of identified knowledge gaps (using the Mentimeter© app). The resulting joint research agenda identified topics around the utility of sensor monitoring and processes of acceptance of health-care ICT among older persons and occupational therapists. The agenda was complemented by formulating underlying assumptions prescribing such research to be embedded in real-life situations with the participation of stakeholders.

Effectiveness of sensor monitoring in a rehabilitation programme for older patients after hip fracture: a three-arm stepped wedge randomised trial

OBJECTIVES

to test the effects of an intervention involving sensor monitoring-informed occupational therapy on top of a cognitive behavioural treatment (CBT)-based coaching therapy on daily functioning in older patients after hip fracture.

DESIGN, SETTING AND PATIENTS

three-armed randomised stepped wedge trial in six skilled nursing facilities, with assessments at baseline (during admission) and after 1, 4 and 6 months (at home). Eligible participants were hip fracture patients ≥ 65 years old.

INTERVENTIONS

patients received care as usual, CBT-based occupational therapy or CBT-based occupational therapy with sensor monitoring. Interventions comprised a weekly session during institutionalisation, followed by four home visits and four telephone consultations over three months.

MAIN OUTCOMES AND MEASURES

the primary outcome was patient-reported daily functioning at 6 months, assessed with the Canadian Occupational Performance Measure.

RESULTS

a total of 240 patients (mean[SD] age, 83.8[6.9] years were enrolled. At baseline, the mean Canadian Occupational Performance Measure scores (range 1-10) were 2.92 (SE 0.20) and 3.09 (SE 0.21) for the care as usual and CBT-based occupational therapy with sensor monitoring groups, respectively. At six months, these values were 6.42 (SE 0.47) and 7.59 (SE 0.50). The mean patient-reported daily functioning in the CBT-based occupational therapy with sensor monitoring group was larger than that in the care as usual group (difference 1.17 [95% CI (0.47-1.87) P = 0.001]. We found no significant differences in daily functioning between CBT-based occupational therapy and care as usual.

CONCLUSIONS AND RELEVANCE

among older patients recovering from hip fracture, a rehabilitation programme of sensor monitoring-informed occupational therapy was more effective in improving patient-reported daily functioning at six months than to care as usual.

TRIAL REGISTRATION

Dutch National Trial Register, NTR 5716.

Community rehabilitation interventions after hip fracture: Pragmatic evidence-based practice recommendations

Practice development enables practitioners to develop their knowledge and allows the application of evidence-based care for their patients. It happens within the practitioner's own clinical practice area and enhances personal and professional growth whilst focusing on patients' specific needs. This is important when working with patients in the rehabilitation phase following fragility hip fracture whose care should be provided by practitioners knowledgeable about the best way to approach their needs. This article, which followed the methods for a scoping review, aims to provide the practitioner with an overview of rehabilitation interventions for patients following hip fracture discussed in the literature. There is an introduction to the nature of rehabilitation and the issues raised for the patient with a hip fracture, a discussion of the existing literature, and recommendations for practice based on both that evidence and a pragmatic approach to care. Scoping reviews provide overviews of broad topic areas (Peterson et al., 2017). This gives the reader the opportunity to consider how other factors, besides research evidence, can contribute to best practice and to reflect on how their own practice needs to develop. At the end of the discussion, an overview of pragmatic recommendations for practice is provided based on the findings of the literature considered. Some points for individual reflection are also provided to help the practitioner to consider how the contents of the paper might impact on their own practice.

Everyday life after a hip fracture: what community-living older adults perceive as most beneficial for their recovery

OBJECTIVE

to gain insight into what older adults after hip fracture perceive as most beneficial to their recovery to everyday life.

DESIGN

qualitative research approach.

SETTING

six skilled nursing facilities.

PARTICIPANTS

19 older community dwelling older adults (aged 65-94), who had recently received geriatric rehabilitation after hip fracture.

METHODS

semi-structured interviews were conducted with 19 older adults after hip fracture. Coding techniques based on constructivist grounded theory were applied.

RESULTS

four categories were derived from the data: 'restrictions for everyday life', 'recovery process', 'resources for recovery' and 'performing everyday activities'. Physical and psychological restrictions are consequences of hip fracture that older adults have struggled to address during recovery. Three different resources were found to be beneficial for recovery; 'supporting and coaching', 'myself' and 'technological support'. These resources influenced the recovery process. Having successful experiences during recovery led to doing everyday activities in the same manner as before; unsuccessful experiences led to ceasing certain activities altogether.

CONCLUSION

participants highlight their own role ('myself') as essential for recovery. Additionally, coaching provides emotional support, which boosts self-confidence in performing everyday activities. Furthermore, technology can encourage older adults to become more active and being engaged in the recovery process. The findings suggest that more attention should be paid to follow-up interventions after discharge from inpatient rehabilitation to support older adults in finding new routines in their everyday activities.A conceptual model is presented and provides an understanding of the participants' experiences and perspectives concerning their process of recovery after hip fracture to everyday life.

A Low-Cost Indoor Activity Monitoring System for Detecting Frailty in Older Adults

Indoor localization systems have already wide applications mainly for providing localized information and directions. The majority of them focus on commercial applications providing information such us advertisements, guidance and asset tracking. Medical oriented localization systems are uncommon. Given the fact that an individual’s indoor movements can be indicative of his/her clinical status, in this paper we present a low-cost indoor localization system with room-level accuracy used to assess the frailty of older people. We focused on designing a system with easy installation and low cost to be used by non technical staff. The system was installed in older people houses in order to collect data about their indoor localization habits. The collected data were examined in combination with their frailty status, showing a correlation between them. The indoor localization system is based on the processing of Received Signal Strength Indicator (RSSI) measurements by a tracking device, from Bluetooth Beacons, using a fingerprint-based procedure. The system has been tested in realistic settings achieving accuracy above 93% in room estimation. The proposed system was used in 271 houses collecting data for 1–7-day sessions. The evaluation of the collected data using ten-fold cross-validation showed an accuracy of 83% in the classification of a monitored person regarding his/her frailty status (Frail, Pre-frail, Non-frail).

Gender differences in caregiving among a schizophrenia population

Background

The present study aimed to investigate differences in family burden and caregiver distress in a population of caregivers for schizophrenia, by separating patient gender and caregiver gender.

Methods

A sample of 327 primary family caregivers was recruited from a Chinese rural community through a one-stage cluster-sampling method. A cross-sectional design was employed, using validated measures to assess both family burden and primary caregivers' depression and anxiety.

Results

Significant differences by gender were detected in family burden and caregiver distress. Family burden was significantly higher for male patients on the domains of effect on physical and mental health of others, and significantly higher for female caregivers on the domains of financial burden and effect on physical and mental health of others. Caregivers of male patients were more likely to suffer from anxiety than caregivers of female patients (52.7% vs 38.1%, P=0.012); female caregivers were more likely to suffer from depression (51.2% vs 38.6%, P = 0.031) and anxiety (51.6% vs 38.1%, P=0.020) than male caregivers.

Conclusion

The results reinforced the expected differences in caregiving experiences of a schizophrenia population by gender, which has implications for the future design of gender-specific interventions to alleviate family burden and caregiver distress.

Activity Classification Feasibility Using Wearables: Considerations for Hip Fracture

Falls in the elderly are a common health issue that can involve severe injuries like hip fractures, requiring considerable medical attention, and subsequent care. Following surgery, physiotherapy is essential for strengthening muscles, mobilizing joints and fostering the return to physical activities. Ideally, physiotherapy programmes would benefit from active home-based monitoring of the elderly patients’ daily activities and exercises. This paper aims at providing a preliminary analysis addressing three key research questions. First, what are the key involved activities (at-hospital, home exercises, and activities of daily living) during the post-operative hip fracture rehabilitation process? Second, how can one monitor and identify a range of leg exercises accurately? Last, what is the most suitable sensor location that can categorize the majority of the physical activities thought to be important during the rehabilitation programme? During preliminary testing, it was noted that a standard deviation of the acceleration signal was suitable for classification of static activities like sitting, whereas classification of the ambulatory activities like walking, both the frequency content and related amplitude of the acceleration signal, plays a significant role. The research findings suggest that the ankle is an appropriate location for monitoring most of the leg movement physical activities.

Admissible multiarm stepped-wedge cluster randomized trial designs

Numerous publications have now addressed the principles of designing, analyzing, and reporting the results of stepped‐wedge cluster randomized trials. In contrast, there is little research available pertaining to the design and analysis of multiarm stepped‐wedge cluster randomized trials, utilized to evaluate the effectiveness of multiple experimental interventions. In this paper, we address this by explaining how the required sample size in these multiarm trials can be ascertained when data are to be analyzed using a linear mixed model. We then go on to describe how the design of such trials can be optimized to balance between minimizing the cost of the trial and minimizing some function of the covariance matrix of the treatment effect estimates. Using a recently commenced trial that will evaluate the effectiveness of sensor monitoring in an occupational therapy rehabilitation program for older persons after hip fracture as an example, we demonstrate that our designs could reduce the number of observations required for a fixed power level by up to 58%. Consequently, when logistical constraints permit the utilization of any one of a range of possible multiarm stepped‐wedge cluster randomized trial designs, researchers should consider employing our approach to optimize their trials efficiency.

Evaluating the impact of a home-based rehabilitation service on older people and their caregivers: a matched-control quasi-experimental study

Introduction

Previous studies evaluating home-based rehabilitation service (HBRS) merely focused on the period immediately after the patients’ discharge from hospitals. The present study focuses on HBRS that covers clients who have not been recently hospitalized. HBRS aims to meet older clients’ rehabilitation needs and support their caregivers in the community. This study intended to evaluate the impact of HBRS on the older clients’ health outcomes and hospital services utilization, and caregivers’ strain in providing care for clients.

Methods

This study used a matched-control quasi-experimental design with a 3-month follow-up to evaluate HBRS. The health outcome measures used for the older clients included Elderly Mobility Scale, Timed Up and Go test, Modified Barthel Index, Lawton’s Instrumental Activities of Daily Living Scale, Mini-Mental State Examination, and World Health Organization Quality of Life Scale, Short Form, Hong Kong version (WHOQOL-BREF [HK]). Meanwhile, the Caregiver Strain Index was used to measure the caregivers’ caregiving strain. Data on clients’ hospital services utilization 3 and 6 months before and after the study were also collected and evaluated.

Results

The final sample consisted of 122 pairs of older clients and caregivers who live in a community in Hong Kong. In the follow-up after 3 months, the intervention group showed immensely substantial improvements across all the health outcome measures compared with the control group. The intervention group also demonstrated substantial reduction in the clients’ hospital services utilization compared with the control group. However, no significant differences in the clients’ hospital services utilization exist between the two groups in the follow-up after 6 months.

Conclusion

HBRS of this study is an effective intervention service to improve health outcomes and reduce hospital services utilization among older people living in the community. Moreover, HBRS of this study was effective in reducing the caregivers’ caregiving strain.