Falls in community-dwelling older persons following hip fracture: impact on self-efficacy, balance and handicap

Prediction of postoperative gait speed change after bilateral primary total knee arthroplasty in female patients using a machine learning algorithm

BACKGROUND

An important aim of total knee arthroplasty is to achieve functional recovery, which includes post-operative increase in walking speed. Therefore, predicting whether a patient will walk faster or slower after surgery is important in TKA, which has not been studied in previous literatures. Who walks faster and who walks slower after TKA? Can we predict these kinds of patients before surgery?

HYPOTHESIS

Whether or not a patient walk faster after total knee arthroplasty can be predicted with preoperative characteristics.

PATIENTS AND METHODS

In this retrospective cohort study, 128 female patients who underwent staged bilateral total knee arthroplasty were analyzed with gait analysis preoperatively and at postoperative two years. These patients were divided into three different groups according to the percentage of gait speed change after total knee arthroplasty: 1) V(+), more than 10% gait speed increase; 2) V(-), more than 10% gait speed decrease; and 3) V(0), those in-between. Gait parameters, mechanical axis angles, WOMAC pain score and Knee Society scores of the two groups (V(+) and V(-)) were compared. Furthermore, a classification model predicting whether a patient walks faster after total knee arthroplasty was designed using a machine learning algorithm.

RESULTS

After total knee arthroplasty, average gait speed increased by 0.07m/s from 0.87m/s to 0.94m/s (p<0.001) and gait speed increased in 43.8% of the patients (n=56). However, gait speed decreased in a significant number of patients (n=17, 13.3%). When V(+) and V(-) groups were compared, gait speed, cadence, sagittal/coronal knee range of motion, and Knee Society Function score were lower in the V(+) group before surgery, but became higher after surgery. Gait speed change could be predicted using three variables (preoperative gait speed, age, and the magnitude of mechanical axis angle). The area under the receiver operating characteristic curve of the machine learning model was 0.86.

DISCUSSION

After total knee arthroplasty, gait speed was maintained or increased in most patients. However, gait speed decreased in a significant number of patients. The machine learning classification model showed a good predictive performance, which could aid in the decision-making and the timing of total knee arthroplasty.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Factors associated with concerns about falling and activity restriction in older adults after hip fracture: a mixed-methods systematic review

PURPOSE

To investigate factors contributing to concerns about falling and activity restriction in the community among older adults who had a hip fracture.

METHODS

A mixed method systematic review with a convergent segregated approach. We searched Medline, Embase, PsycInfo, PEDRo, CINAHL and the Cochrane library. Results were synthesised narratively considering physical, psychological, environmental, care, and social factors and presented in tables. Critical appraisal was completed in duplicate.

RESULTS

We included 19 studies (9 qualitative, 9 observational, 1 mixed methods) representing 1480 individuals and 23 factors related to concerns about falling and activity restriction. Physical factors included falls history, comorbidities, balance, strength, mobility and functionality. Psychological factors included anxiety and neuroticism scores, perceived confidence in/control over rehabilitation and abilities, and negative/positive affect about the orthopaedic trauma, pre-fracture abilities and future needs. Environmental factors included accessibility in the home, outdoors and with transport. Social and care factors related to the presence or absence of formal and informal networks, which reduced concerns and promoted activity by providing feedback, advice, encouragement, and practical support.

CONCLUSION

These findings highlight that to improve concerns about falling and activity restriction after hip fracture, it is important to: improve physical and functional abilities; boost self-confidence; promote positive affect; involve relatives and carers; increase access to clinicians, and; enhance accessibility of the home, outdoors and transport. Most factors were reported on by a small number of studies of varying quality and require replication in future research.

Prospective Associations Between Fear of Falling, Anxiety, Depression, and Pain and Functional Outcomes Following Surgery for Intertrochanteric Hip Fracture

Objective

Fear of falling, anxiety, depression, and pain levels are important risk factors for poor functional outcomes that may potentially be modifiable. We aimed to examine prospective associations between those factors following surgery for intertrochanteric hip fracture.

Methods

This study is a prospective observational cohort study of patients aged over 65 diagnosed with isolated intertrochanteric hip fracture. Three hundred and seventy patients who underwent intramedullary fixation surgery were screened; 188 cases were included in our final evaluation. Patients with any concomitant fracture, major psychiatric/neurocognitive and neurological disorders and those with any other major disease were excluded from the study. Age, Charlson Comorbidity Index (CCI), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Falls Efficacy Scale International (FES-I), and Visual Analog Scale (VAS) scores on the day of surgery (baseline) were evaluated as predictors of poor/good outcome at 90 days after surgery, by Harris Hip Score (HHS) with a cut-off score of 70.

Results

HHS score was significantly predicted at baseline by the full model [χ2 (7) = 18.18, P = .01]. However, only STAI-state scores were significantly added to the model [Exp (B) 95% CI: .92 (.86-.99)].

Conclusions

In this prospective cohort study, we found that higher levels of anxiety state on the day of surgery predicts a poor outcome at 90 days following surgery. We did not find significant associations between other variables, including age, GDS, STAI-trait, FES-I, VAS, and CCI. This potentially modifiable psychological factor may inform surgeons and could be a potential mediator. Future prospective studies are needed to replicate these findings.

Level of evidence

Prognostic level I.

A systematic review of fear of falling and related constructs after hip fracture: prevalence, measurement, associations with physical function, and interventions

BACKGROUND

Hip fracture is a common and debilitating injury amongst older adults. Fear of falling (FoF) and related constructs (balance confidence and falls efficacy) may impede rehabilitation after hip fracture. An updated systematic review to synthesize existing literature on FoF after hip fracture is needed. This review focussed on four research questions: In the hip fracture population: (1) What is the prevalence of FoF?; (2) What FoF assessment tools are validated? (3) What is the relationship between FoF and physical function?; (4) What interventions are effective for reducing FoF?

METHODS

A systematic search was undertaken in EBSCO Health, Scopus and PsychINFO in January 2021 (and updated December 2022) for articles on FoF after hip fracture. Data in relation to each research question was extracted and analysed. The quality of the studies was appraised using the 'Risk of Bias Tool for Prevalence Studies', 'COSMIN Risk of Bias checklist for Patient-reported outcome measures', modified version of the 'Appraisal Tool for Cross-sectional studies', and the 'Cochrane Risk of Bias 2' tools for each research question, respectively.

RESULTS

36 studies (37 articles) with 5099 participants were included (mean age 80.2 years and average 78% female). Prevalence rates for FoF after hip fracture ranged between 22.5% and 100%, and prevalence tended to decrease as time progressed post hip fracture. The 'Falls Efficacy Scale - International' (FES-I) and 'Fear of Falling Questionnaire - Revised' (FFQ-R) were found to be reliable, internally consistent, and valid tools in hip fracture patients. FoF after hip fracture was consistently associated with measures of physical function including balance, gait speed, composite physical performance measures and self-reported function. Ten of 14 intervention studies were considered high risk of bias. Exercise-based interventions with or without a psychological component were not effective in reducing FoF after hip fracture compared to a control condition.

CONCLUSION

FoF is prevalent after hip fracture and is consistently associated with poorer physical function. Only two instruments (FES-I and FFQ-R) have been validated for measuring FoF in the hip fracture population. However, there remains a need for larger, higher quality randomised controlled trials targeting FoF after hip fracture in order to guide clinical practice.

TRIAL REGISTRATION

PROSPERO registration: CRD42020221836.

Effects of Single-Task, Dual-Task and Analogy Training during Gait Rehabilitation of Older Adults at Risk of Falling: A Randomized Controlled Trial

It has been suggested that implicit motor learning via dual-task or analogy training during gait rehabilitation may yield better outcomes in older adults by reducing the propensity for the conscious processing of movements (movement-specific reinvestment). The current study investigated the immediate effects of single-task, dual-task, and analogy training on reinvestment propensity and fall-related rehabilitation outcomes among older adults at risk of falling. Seventy-one older adults were randomly allocated to the single-task (ST), dual-task (DT), or analogy (AG) training conditions and received 12 training sessions. We assessed the reinvestment propensity, functional gait and balance, functional mobility, balance ability, single-task and dual-task walking abilities, and fear of falling at baseline (before training) and immediately after training. Our findings revealed a lack of training effect on reinvestment propensity for all groups. However, all groups displayed significant improvements in functional gait and balance (p < 0.001), functional mobility (p = 0.02), and balance ability (p = 0.01) after training. AG appeared to be superior to DT and ST, as it was the only condition that resulted in significant improvements in both single-task and dual-task walking abilities (p < 0.001). Implementing movement analogies could be a feasible and useful gait rehabilitation strategy for fall prevention and wellbeing promotion among older adults.

The Relationship between the Activity Balance Confidence and Mobility Tests among Older Adults in Indonesia

Introduction. Unsteady gait, instability, and lower extremity muscle weakness are some of the risk factors for falls. Reduced balance is a further precursor of falls, and injuries adversely affect the instability. In doing an activity without losing their balance, confidence among older adults is also crucial because it will influence their mobility. Objectives. The objective of this study is to examine the association between activity balance confidence and functional mobility, including gait, balance, and strength, among older adults. Methods. A cross-sectional study was conducted among older adults living in long-term care facilities and community dwellings. A total of 326 older adults (>60 years old) participated in this study from three provinces in Java Island, Indonesia. The inclusion criteria were older adults living independently and without obstacles in communication, who have no hearing loss, and who agreed to be respondents. The activity-specific balance confidence (ABC) scale determines the level of confidence. The participants were asked about their balance confidence not to lose their balance while doing 16 activities. The dependent variable is the mobility test, including a gait test using TUG (times up and go) to see how the subjects stand, walk, and turn around; a balance test (four stages); and a strength test (30-second chair stand). Results. The results of the ABC scale showed the respondents felt the most confidence not to lose their balance when they walk around the house (82.01%) and the less confidence when they stepped onto or off an escalator while holding onto a railing (37.7%). The gait, balance, and strength test revealed that 51.2% of the respondents showed an unsteady gait, 63.8% showed instability that felt awkward and unusual when standing on one leg, and 60.1% of the participants showed muscle weakness. The bivariate analysis significantly correlated the ABC scale test and all mobility tests. The older adult participants who are not confident will have 12.03 times higher the unstable result of the gait test, 8.4 times higher the unstable result of the balance test, and 7.47 times higher the less strength result of the strength test who are confident. Conclusion. Older adults who lack balance confidence showed significantly poorer results in mobility tests.

Effectiveness of a Home-Based Fragility Fracture Integrated Rehabilitation Management (FIRM) Program in Patients Surgically Treated for Hip Fractures

Background: The purpose of this study was to investigate the effectiveness of a home-based fragility fracture integrated rehabilitation management (H-FIRM) program following an inpatient FIRM (I-FIRM) program in patients surgically treated for hip fracture. Methods: This nonrandomized controlled trial included 32 patients who underwent hip surgery for a fragility hip fracture. The patients were divided into two groups: a prospective intervention group (n = 16) and a historical control group (n = 16). The intervention group performed a nine-week H-FIRM program combined with the I-FIRM program. The historical control group performed the I-FIRM program only. Functional outcomes included Koval’s grade, Functional Ambulatory Category (FAC), Functional Independence Measure (FIM) locomotion, Modified Rivermead Mobility Index (MRMI), 4 m walking speed test (4MWT), and the Korean version of Modified Barthel Index (K-MBI). All functional outcomes were assessed one week (before I-FIRM), three weeks (before I-FIRM), and three months (after H-FIRM) after surgery. Results: Both groups showed significant and clinically meaningful improvements in functional outcomes over time. Compared with the control group, the intervention group showed clinically meaningful improvements in Koval’s grade, FAC, FIM locomotion, MRMI, 4MWT, and K-MBI from baseline to three months. Conclusion: H-FIRM may be an effective intervention for improving functional outcomes in older people after fragility hip fractures.

Association between physical activity and short-term physical function changes after hip fracture: An observational study

BACKGROUND AND PURPOSE

To investigate whether physical activity levels are predictive of short-term changes in physical function for people discharged to independent living in the community following withdrawal of rehabilitation services after hip fracture; and to describe short-term recovery in physical activity, physical function, walking confidence, health-related quality of life and walking participation.

METHODS

This prospective cohort study comprised 57 older adults (39 females, mean age 80.4, SD 8.4 years) living independently in the community after hip fracture. Accelerometer-based physical activity, physical function (Functional Independence Measure [FIM], de Morton Mobility Index, Frenchay Activities Index and Participation in outdoor walking), walking confidence and health-related quality of life were measured after discharge from rehabilitation services (baseline) and 12 weeks later. Multiple linear regression analyses determined the ability of physical activity (daily steps), walking self-confidence, health-related quality of life and demographic factors (age, sex and time since fracture) to predict Week 12 physical function using Week 0 physical function as a covariate.

RESULTS

Participants at baseline averaged 4439 daily steps which did not change 12 weeks later. There were small increases in all measures of physical function and walking confidence, but not health-related quality of life. Increased walking self-confidence was associated with an increase in FIM total, FIM mobility and de Morton Index scores. Physical activity did not predict change in measures of physical function.

CONCLUSIONS

Walking confidence of adults discharged from rehabilitation services after hip fracture had a greater association with short-term recovery of physical function than level of physical activity. Community-dwelling adults continue to make small short-term improvements in physical function and walking confidence after discharge home and withdrawal of rehabilitation services.

Dual-task training with progression from variable- to fixed-priority instructions versus dual-task training with variable-priority on gait speed in community-dwelling older adults: A protocol for a randomized controlled trial : Variable- and fixed-priority dual-task for older adults

BACKGROUND

Functional independence and safe mobility, especially in older people, mostly rely on the ability to perform dual tasks, particularly during activities with variable- and fixed-priority attention. The aim of this study is to compare the dual-task training with progression from variable- to fixed-priority instructions versus dual-task training with variable-priority on gait speed in community-dwelling older adults.

METHODS

This is an assessor- and participant-blinded, two-arm, randomized controlled trial with 60 community-dwelling male and female older adults between the ages of 60 and 80 years old. Participants will be randomly allocated into either the intervention group or the control group using a computer-generated permuted block randomization schedule. The intervention group will undertake a progressive dual-task training in which the participants will be progressively submitted to dual-task walking and postural balance exercises with variable- to fixed-priority instructions. The control group will be submitted to dual-task training with variable-priority attention exercises. Both groups will receive 48 sessions lasting for 60 min each over 24 weeks. The primary outcome will be the gait speed under single- and dual-task conditions. Secondary outcomes will include spatiotemporal gait parameters, functional balance, executive function, falls, quality of life, and depression symptoms. All the analyses will be based on the intention-to-treat principle.

DISCUSSION

This is the first assessor- and participant-blinded, two-arm, randomized controlled trial with 6 months of intervention and an additional 6-month post-training follow up aiming to evaluate the effectiveness of training with progression from variable- to fixed-priority instructions on gait biomechanics, postural balance, falls episodes, executive functioning, and quality of life in community-dwelling older adults. If our hypotheses are confirmed, this training protocol can be implemented widely to improve gait speed and other functional activities and quality of life in community-dwelling older adults. This study protocol can be used to improve these functional aspects of community-dwelling older adults. This study may also contribute to future guidelines for the improvement of these clinical and biomechanical aspects in older people.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier - NCT03886805, Registered 22 March 2019.

Effectiveness of a Mini-Trampoline Training Program on Balance and Functional Mobility, Gait Performance, Strength, Fear of Falling and Bone Mineral Density in Older Women with Osteopenia

Purpose

To evaluate the effectiveness of a combined balance-, strength-, and jumping-exercise intervention on a mini-trampoline performed by older women with osteopenia on static balance and functional mobility, gait speed, strength of the upper and lower limbs, fear of falling, as well as to investigate its influence on bone mineral density (BMD).

Patient and methods

Using a randomized controlled study design, participants (range: 56-83 years) were assigned either to the intervention group (IG; n=20, mean age 69.6 ± 5.3 years) performing a specifically tailored intervention on a mini-trampoline or to the control group (CG; n=20, 67.4 ± 6.8 years), that did not undertake any intervention beyond regular osteopenia treatment. The intervention was performed twice a week for 12 weeks, each session lasting 45-60 mins and consisted of balance, strength and jumping exercises. Static balance and functional mobility was measured by one-leg stance (OLS) and timed up and go test (TUG). Upper and lower limb strength was evaluated by the arm curl test (ACT) and the 30-s chair stand test (CST) whereas gait speed was measured by the 6 m walking test (WT). Fear of falling was measured using the Falls Efficacy Scale - International (FES-I). BMD was measured at the lumbar spine and femoral neck using Dual-energy X-ray absorptiometry (DXA).

Results

Significant interactions (group x time) were found for all parameters (p<0.001) except for BMD, measured at the lumbar spine (p=0.064) and femoral neck (p=0.073). All test parameters of balance and functional mobility tests (OLS, TUG), strength tests (ACT, CST), WT, FES-I and BMD (femoral neck) showed significant improvement in the IG (p<0.05).

Conclusion

The combined 12-week intervention was highly effective in improving balance and functional mobility, strength, gait performance and fear of falling in patients with osteopenia.

Post-operative Physical Performance Factors Associated With Gait Speed in Patients Surgically Treated for Hip Fracture: A Cross-Sectional Study

OBJECTIVE

To determine post-operative physical performance factors associated with gait speed in patients surgically treated for hip fracture.

METHODS

Cross-sectional data from 59 patients (16 males and 43 females; mean age, 79.2±9.1 years) who underwent hip fracture surgery were enrolled. Patients completed a 10-meter walk test (10MWT) to assess gait speed. Additional physical performance tests included the Timed Up and Go test (TUG), the Berg Balance Scale (BBS), maximum voluntary isometric contraction (MVIC) of the knee extensors and flexors on the operated and non-operated sides as well as of the hip abductors (all tested using air-resistance weight machines), and analysis of spatio-temporal gait parameters at about 6 weeks after hip surgery.

RESULTS

Bivariate analyses revealed a significant positive correlation between the post-operative 10MWT and the post-operative TUG, age, swing phase duration, and gait cycle duration along with a significant negative correlation between post-operative BBS score, MVIC of the knee extensors and flexors on the operated and non-operated sides, MVIC of the hip abductors, and cadence and stance phase duration. Linear regression analyses revealed that the post-operative TUG (β=0.85, p<0.01), gait cycle duration (β=0.17, p=0.02), and osteoporosis (β=-0.18, p=0.02) were associated with the post-operative 10MWT.

CONCLUSION

The presence of osteoporosis, post-operative balance, and isometric muscle strength in the operated and non-operated legs were statistically associated with post-operative gait speed early after hip fracture surgery.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Fear of Falling after Hip Fracture: Prevalence, Course, and Relationship with One-Year Functional Recovery

OBJECTIVES

The effect of fear of falling (FoF) on recovery 1 year after hip fracture is not well known. Furthermore, the potential influence of premorbid function has not been explored. We aimed to describe rates of FoF after hip fracture, to assess the association of FoF with functional recovery 1 year post-fracture, and to evaluate the potential moderating effect of premorbid function on the relationship between FoF and functional recovery.

DESIGN

Secondary analysis of data from a prospective, longitudinal observational study to assess genetic factors influencing functional and psychological outcomes after hip fracture over 52 weeks.

SETTING

Eight area hospitals in St. Louis, MO.

PARTICIPANTS

241 cognitively intact individuals 60 years of age or older requiring surgical repair for hip fracture.

MEASUREMENTS

Fear of falling was measured by the short Falls Efficacy Scale-International 4 and 12 weeks post-fracture. The primary outcome was probability of full recovery 52 weeks post-fracture assessed with the Functional Recovery Score.

RESULTS

High rates of FoF were seen at 4 (60.5%) and 12 weeks (47.0%) post-fracture. Week 12 FoF was associated with lower odds of recovery for those with high function pre-fracture (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.72, 0.93), but not for those with impaired activities of daily living performance (OR: 1.04, 95% CI: 0.91, 1.19).

CONCLUSIONS

Fear of falling is common after hip fracture and is associated with poorer functional recovery 1 year after fracture, particularly in patients with high premorbid function. Fear of falling is a modifiable problem that represents a potential target for interventions to improve functional outcomes after hip fracture.

The effect of single-task and dual-task balance exercise programs on balance performance in adults with osteoporosis: a randomized controlled preliminary trial

Osteoporosis is a serious disease characterized by muscle weakness in the lower extremities, shortened length of trunk, and increased dorsal kyphosis leading to poor balance performance. Although balance impairment increases in adults with osteoporosis, falls and fall-related injuries have been shown to occur mainly during the dual-task performance. Several studies have shown that dual-task performance was improved with specific repetitive dual-task exercises.

INTRODUCTION

The aims of this study were to compare the effect of single- and dual-task balance exercise programs on static balance, dynamic balance, and activity-specific balance confidence in adults with osteoporosis and to assess the effectiveness of dual-task balance training on gait speed under dual-task conditions.

METHODS

Older adults (N = 42) (age range, 45-88 years) with osteoporosis were randomly assigned into two groups. Single-task balance training group was given single-task balance exercises for 4 weeks, whereas dual-task balance training group received dual-task balance exercises. Participants received 45-min individualized training session, three times a week. Static balance was evaluated by one-leg stance (OLS) and a kinesthetic ability trainer (KAT) device. Dynamic balance was measured by the Berg Balance Scale (BBS), Time Up and Go (TUG) test, and gait speed. Self-confidence was assessed with the Activities-specific Balance Confidence (ABC-6) scale. Assessments were performed at baseline and after the 4-week program.

RESULTS

At the end of the treatment periods, KAT score, BBS score, time in OLS and TUG, gait speeds under single- and dual-task conditions, and ABC-6 scale scores improved significantly in all patients (p < 0.05). However, BBS and gait speeds under single- and dual-task conditions showed significantly greater improvement in the dual-task balance training group than in the single-task balance training group (p < 0.05). ABC-6 scale scores improved more in the single-task balance training group than in the dual-task balance training group (p < 0.05).

CONCLUSIONS

A 4-week single- and dual-task balance exercise programs are effective in improving static balance, dynamic balance, and balance confidence during daily activities in older adults with osteoporosis. However, single- and dual-task gait speeds showed greater improvement following the application of a specific type of dual-task exercise programs.

CLINICAL TRIAL REGISTRATION NUMBER

24102014-2.

Development of the Adelaide Driving Self-Efficacy Scale

Objective: To describe the development of the Adelaide Driving Self-Efficacy Scale (ADSES) and to report on its reliability and validity.

Methods: A set of 12 driving behaviours, developed through literature review, clinical experience and expert review, were rated for self-efficacy using a Likert scale. Internal consistency was investigated using a Cronbach's alpha coefficient and construct validity by comparing ADSES scores of stroke and non-stroke drivers. Criterion-related validity was examined by comparing ADSES scores with the result on a standardized on-road assessment.

Setting: A rehabilitation hospital in Adelaide, South Australia.

Participants: Staff from the hospital and stroke patients from the rehabilitation unit. Data from a non-stroke sample (n -/ 79) and stroke patients (n -/ 81) were used to test internal consistency and construct validity. A separate group of 45 people recommended for a driving assessment, of whom 34 were stroke patients, were used to test criterion validity.

Results: Cronbach's alpha coefficient was 0.98, indicating high internal consistency. The non-stroke and stroke groups showed significant differences in ADSES scores (t(158)-/ 5.5, P B < 0.05), demonstrating construct validity. Differences in ADSES scores for those participants who passed or failed the on-road assessment were significant for both the entire driving assessment group (t(43)-/ 3.2, P B < 0.05) and the stroke subgroup (t(43)-/ 3.2, P B < 0.05), indicating criterion validity.

Conclusion: The ADSES has demonstrated internal consistency and construct validity with the stroke and non-stroke population. The scale demonstrated criterion validity in its relationship with outcome of an on-road driving assessment. It appears to be a reliable and valid measure of driving self-efficacy.

Attitudes to falls and injury prevention: what are the barriers to implementing falls prevention strategies?

Objectives: To ascertain the reasons for not taking up a fall or injury prevention strategy among older people who have sustained a fall and attended an emergency department.

Subjects: As part of another trial, we identified 60 people who attended the emergency department of a public hospital with a fall.

Main measures: Participants were interviewed to ascertain the reasons for not taking up a falls prevention strategy, their falls-related health state, and the likelihood of them undertaking a falls and injury prevention strategy.

Results: A total of 31 (52%) of the participants had considered falls prevention after their fall. There were high levels of reluctance to undertake a strategy with 43 (72%) reluctant to take exercise classes, 10 (59%) reluctant to cease psychotropic medications, 26 (43%) reluctant to have a home safety assessment and 17 (28%) reluctant to take osteoporotic medication. When asked specifically about taking up a strategy to prevent a worsening health state, 19 (63%) of participants would take up exercise, 17 (57%) a home safety assessment, 4 of the 17 (59%) already taking implicated medications would stop and 56 (93%) would begin osteoporotic medication. These decisions did not alter when the goal for treatment was to improve a much worse health state. In participants with a lower starting health state, home safety assessments were viewed more favourably.

Conclusions: There were significant obstacles to the implementation of most falls prevention guidelines examined. Treatment for osteoporosis was more acceptable to participants than exercise classes, cessation of psychotropic medication, and having a home safety assessment. Osteoporosis treatment, which had the least resistance, also had the least impact on the participants' lifestyle.

Weight-bearing asymmetry in individuals post-hip fracture during the sit to stand task

BACKGROUND

Individuals post hip fracture decrease force on the involved limb during sit to stand tasks, creating an asymmetry in vertical ground reaction force. Joint specific differences that underlie asymmetry of the vertical ground reaction force are unknown. The purpose of this study was to compare differences in vertical ground reaction force variables and joint kinetics at the hip and knee in participants post-hip fracture, who were recently discharged from homecare physical therapy to controls.

METHODS

Forty-four community-dwelling older adults, 29 who had a hip fracture and 15 elderly control participant's completed the sit to stand task on an instrumented chair with 3 force plates. T-tests were used to compare clinical tests (Berg Balance Scale, activity balance confidence and gait speed, isokinetic knee strength) and vertical ground reaction force variables. Two-way analyses of variance compared vertical ground reaction force variables and kinetics at the hip and knee between hip fracture and elderly control groups. Pearson correlation coefficients were used to determine correlations between clinical and vertical ground reaction force variables.

FINDINGS

Vertical ground reaction force variables were significantly lower on the involved side for the hip fracture group compared to the uninvolved side and controls. Lower involved side hip and knee moments and power contributed to lower involved side vertical ground reaction force. Vertical ground reaction force variables and strength had moderate to high correlations with clinical measures.

INTERPRETATION

Uninvolved side knee moments and powers were the largest contributors to asymmetrical vertical ground reaction force in participants post-hip fracture. The association of vertical ground reaction force variables and clinical measures of function suggesting reducing vertical ground reaction force asymmetry may contribute to higher levels of function post-hip fracture. Functional and strength training should target the involved knee to reduce vertical ground reaction force asymmetry.

Postoperative prevention of falls in older adults with fragility fractures

The postoperative period after correction of a fragility fracture is usually associated with functional deconditioning. This deconditioning is caused by multiple factors associated with a higher risk of falls during the immediate postoperative period and after discharge. Identification of risk and appropriate fall prevention interventions in these patients are pivotal. In this article, an overview is presented of the strategies to identify falls risk in postoperative patients after suffering a fragility fracture. Evidence is presented favoring targeted multicomponent intervention for falls prevention rather than a single intervention in fractured older patients at high risk of new falls and fractures.

Exploring older adults' patterns and perceptions of exercise after hip fracture

PURPOSE

To identify exercise patterns and perceived barriers, enablers, and motivators to engaging in exercise for older adults following hip fracture.

METHOD

Telephone interviews were conducted with older adults (aged 62-97 y) within 1 year after hip fracture. Participants were asked about basic demographic information; level of mobility before hip fracture; current level of mobility; and barriers, enablers, and motivators to participating in exercise.

RESULTS

A total of 32 older adults successfully recovering after hip fracture completed the telephone interviews. Participants reported few problems with their mobility, and all were engaging in exercise. There were few reported barriers to exercise; the most common were health-related concerns (pain, fatigue, illness, or injury). The most frequently reported enablers were intrinsic factors (determination, seeing improvements, and making exercise part of their daily routine); in particular, the most common motivator to exercise was recovery of function to improve mobility and complete daily and leisure activities.

CONCLUSIONS

This study highlights the responses of a group of older adults recovering well after hip fracture. Older adults engage in exercise despite the potential limitations associated with a hip fracture. Participants' responses underscore the importance of intrinsic factors and suggest avenues for future investigation.

Assessing the walking speed of older adults: the influence of walkway length

OBJECTIVE

The aim of this study was to investigate the effect of walkway length (5, 8, or 10 m) on measurements of comfortable and maximum walking speed in healthy older adults.

DESIGN

In this cross-sectional study at a university-based rehabilitation center, 25 healthy older adults (mean age, 60.3 ± 8.3 yrs) participated in timed walking at both comfortable and maximum speeds with different walkway lengths (5-, 8-, and 10-m walkway distances) measured by a stopwatch.

RESULTS

Walkway length did not affect either comfortable walking speed (P = 0.319) or maximum walking speed (P = 0.568). For all walkway lengths, comfortable speed was significantly different from maximum speed (P < 0.001).

CONCLUSIONS

Different walkway lengths (5, 8, and 10 m) do not affect both comfortable and maximum walking speed and can yield consistent results in measuring gait speed clinically. A 5-m walkway with standardized 2-m acceleration and 2-m deceleration distances is recommended because it occupies less space and imposes less stress on the healthy older adults.

Comparison of postdischarge physiotherapy versus usual care following primary total knee arthroplasty for osteoarthritis: an exploratory pilot randomized clinical trial

Objective: To evaluate a pilot trial of a postdischarge physiotherapy intervention to improve patient function versus usual physiotherapy in patients undergoing total knee arthroplasty aiming to assess: recruitment rate, feasibility and acceptability of the intervention and control, suitability of outcomes, retention and adverse events and to inform sample size calculation for a definitive trial.

Design: Exploratory pilot randomized controlled trial using independent assessment.

Setting: Mixed urban and rural, UK.

Participants: Patients undergoing primary, elective unilateral knee arthroplasty for osteoarthritis.

Intervention: Two additional home physiotherapy visits of functional weight-bearing exercises, functional task-specific training versus treatment as usual.

Main outcome: Oxford Knee Score at 12 months. Secondary outcomes: completion rates, adverse events, Knee Injury and Osteoarthritis Outcome Score, leg extensor power, timed 10-m walk, timed sit-to-stand, resource use diaries. Assessments completed at baseline (pre-operatively), 3, 6 and 12 months.

Results: Of 181 eligible participants 107 (59.1%) were randomized over 13 months, one participant withdrew, no adverse events. Intervention group n = 56 (mean age 67.8), control group n = 51 (mean age 70.8). The difference in mean change of Oxford Knee Scores between groups (intervention – control) at 12 months was 0.2 (95% confidence interval (CI) –3.8, 4.2), P = 0.94. Patient diaries revealed non-trial additional physiotherapy requires improved measurement.

Conclusions: Successful recruitment and retention rates were achieved. The intervention appeared feasible and acceptable but may be suboptimal in intensity given recent research. A sample size of 1271 participants would be required for a fully powered randomized controlled trial using the main outcome. However new outcomes, potentially of greater validity and responsiveness, require consideration.

Factors associated with balance confidence in older adults with health conditions affecting the balance and vestibular system

OBJECTIVE

To determine the functional, clinical, and comorbid health condition factors that contribute to balance confidence in persons with balance or vestibular disorders, or both.

DESIGN

Cross-sectional descriptive.

SETTING

Tertiary care center for balance disorders.

PARTICIPANTS

Older adults (N=95) with signs and symptoms of vestibular dysfunction.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activity-specific Balance Confidence Scale (ABC) was administered on examination for complaints of balance, postural instability, or both.

RESULTS

Balance confidence as measured by the ABC was associated with functional balance performance on the Timed Up & Go test and the Dynamic Gait Index. Duration of symptoms and general health-related quality of life (as measured by the Medical Outcomes Study 36-Item Short-Form Health Survey) were significant covariates of balance confidence. Self-reported treatment for anxiety, depression, or both, significantly reduced balance confidence.

CONCLUSIONS

Balance confidence is a complex construct in older adults with signs and symptoms of balance or vestibular dysfunction, or both. Decreased balance confidence in performing functional activities is associated with actual balance performance, duration of vestibular symptoms, general health-related quality of life, and the presence of comorbid psychological and visual impairments. Understanding these relationships can potentially improve management of older adults who present with balance or vestibular disease, or both.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Assessment of pain-related fear in patients with the thrust plate prosthesis (TPP): due to hip fracture and hip osteoarthritis

The aim of this study is to determine the differences between hip fracture and hip arthrosis groups and to assess pain related fear of injury in patients who were operated using the TPP following hip fracture or hip arthrosis. Fifty-eight patients (mean age = 63.9 ± 10.3 years) who were operated using the TPP, following hip fracture (hip fracture group; n = 25) or coxarthrosis (coxarthrosis group; n = 33) were recruited. All of the measurements were performed after a follow-up time of at least 2 years. Functional level by Harris Hip Scoring System (HHS), pain related fear by Tampa Scale for Kinesiophobia (TSK) and pain intensity by numerical rating scale (NRS) was evaluated. There were no significant differences between demographic and clinical characteristics of two groups. However, pain intensity was higher in coxarthrosis group than hip fracture group. There was no correlation between the TSK scores and either Harris scores or NRS scores (p > 0.05) in the hip fracture group. No correlation between NRS and TSK was found in coxarthrosis group but there was a significant correlation between TSK and HHS. TSK scores were high in both groups. High TSK scores proved us that the patients with TPP had fear of movement even they had enough physical performance. The coxarthrosis group had higher pain intensity. Rehabilitation clinicians should consider pain-related belief which is more important than pain intensity and functional level in coxarthrosis patients.

Effects of walking speed and results of timed get-up-and-go tests on quality of life and social participation in elderly individuals with a history of osteoporosis-related fractures

OBJECTIVE

To investigate the relationships between physical performance, quality of life (QoL), and social participation among elderly men and women with a history of osteoporosis-related fractures.

METHOD

The study was a population-based cross-sectional study including 155 participants aged 60 to 93 years from the Swedish longitudinal investigation, "Good Aging in Skåne." The participants had suffered fracture of the vertebrae, hip, pelvis, or ankle. Physical performance was expressed as walking speed (WS) and timed get-up-and-go (TUG). QoL was measured as using the Health Related Quality of Life (HRQoL) and Life Satisfaction (LS) scales. Social participation was defined as taking part in social, cultural, and leisure activities.

RESULTS

Lower WS and/or TUG were associated with lower HRQoL, lower LS, and a reduction in social participation, after adjustment for confounding factors.

DISCUSSION

Measurements of WS and TUG could be used to determine QoL and social participation in elderly people having sustained fractures.

The relationship between physical performance measures, bone mineral density, falls, and the risk of peripheral fracture: a cross-sectional analysis

BACKGROUND

Several factors, in addition to low bone mineral density (BMD), have been identified as risks for fractures, including reduced levels of physical activity, poor balance and low physical performance. The aim of this study was to evaluate the relationship between physical performance measures, BMD, falls, and the risk of peripheral fracture in a population sample of Moroccan women.

METHODS

484 healthy women were included. Three measures were used to assess physical performance: timed get-up-and-go test 'TGUGT', five-times-sit-to-stand test '5 TSTS' and 8-feet timed walk '8 FTW'. The association between physical performance measures and BMD, peripheral fracture and falls was performed by univariate and multivariate analysis.

RESULTS

The mean age was 55.1 years. Higher 'TGUGT', '5 TSTS', '8 FTW' test scores were associated with lower BMD measured at different sites (p range from < 0.001 to 0.005). The relationship between the three tests and BMD in all measured sites remained significant after multiple linear regression (p range from <0.001 to 0.026). In the group of post-menopausal patients, the scores of 'TGUGT' and '8 FTW' were significantly higher in fractured patients compared with patients without. After logistic regression, a score of 'TGUGT' > 14.2 sec, a score of '5 TSTS' > 12.9 sec and a score of '8 FTW' > 4.6 sec respectively, increased the probability of anterior peripheral fracture by 2.7, 2.2 and 2.3 (OR = 2.7; 95% CI = 1.2-6.4, OR = 2.2; 95% CI = 1.1-5.2; and OR = 2.3; 95% CI = 1.1-5.1). There was a significant positive correlation between the number of fall/year and the 3 tests. This correlation persisted after poisson regression.

CONCLUSION

This study suggested that low physical performance is associated with low BMD, and a high risk of history of falls and fractures.

Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial

OBJECTIVE

To compare the effect of 3 different approaches to balance training on dual-task balance performance in older adults with balance impairment.

DESIGN

A double-blind, randomized controlled trial.

SETTING

University research laboratory.

PARTICIPANTS

Older adults (N=23) with balance impairment (mean age, 74.8y). They scored 52 or less on the Berg Balance Scale (BBS) and/or walked with a self-selected gait speed of 1.1m/s or less.

INTERVENTIONS

Participants were randomly assigned to 1 of 3 interventions: single-task training, dual-task training with fixed-priority instructions, and dual-task training with variable-priority instructions. Participants received 45-minute individualized training sessions, 3 times a week for 4 weeks.

MAIN OUTCOME MEASURES

Gait speed under single-task and dual-task conditions was obtained at baseline, the second week, the end of training, and the twelfth week after the end of training. Other measures, including the BBS and the Activities-specific Balance Confidence (ABC) Scale, were collected at baseline and after training.

RESULTS

Participants in all groups improved on the BBS (P<.001; effect size [ES]=.72), and walked significantly faster after training (P=.02; ES=.27). When a cognitive task was added, however, only participants who received dual-task training with fixed-priority instructions and dual-task training with variable-priority instructions exhibited significant improvements in gait speed (P<.001, ES=.57; and P<.001, ES=.46, respectively). In addition, only the dual-task training with variable-priority instructions group demonstrated a dual-task training effect at the second week of training and maintained the training effect at the 12-week follow-up. Only the single-task training group showed a significant increase on the ABC after training (P<.001; ES=.61).

CONCLUSIONS

Dual-task training is effective in improving gait speed under dual-task conditions in elderly participants with balance impairment. Training balance under single-task conditions may not generalize to balance control during dual-task contexts. Explicit instruction regarding attentional focus is an important factor contributing to the rate of learning and the retention of the dual-task training effect.

Predictors of gait speed in patients after hip fracture

PURPOSE

Following hip fracture, patients demonstrate greatly reduced walking speeds 1 year later compared with age-matched elders. The purpose of our study was to examine the factors that relate to gait speed in patients after hip fracture.

METHODS

Forty-two men and women (mean age 79 +/- 7.5 years) who sustained a hip fracture participated in this study. Linear regression analysis was used to determine a statistical model that best predicted gait speed, the dependent variable. Gait speed was measured with a computerized gait mat. The independent variables were age, sex, height, weight, time post-fracture, medications, mental status, depression, balance confidence, Medical Outcome Studies, Short Form (SF-36), balance, and lower extremity isometric force. All subjects were discharged from physical therapy services, and measurements were taken, on average, 17 weeks post-fracture.

RESULTS

Using stepwise regression, 72% of the variance in gait speed was explained by summed lower extremity strength normalized by body weight, general health (SF-36), and balance confidence (Activities-specific Balance Confidence Scale).

CONCLUSIONS

Impairments (summed lower extremity strength) and risk factors (perception of general health and balance confidence) are important predictors of gait speed in elders after hip fracture.

Efeitos da propriocepção no processo de reabilitação das fraturas de quadril

Este estudo teve como objetivo principal realizar uma revisão de literatura dos últimos dez anos, sobre os efeitos dos tratamentos fisioterapêuticos realizados nas fraturas de quadril e a observação da descrição e da influência do treinamento proprioceptivo específico nesse processo de reabilitação. Essas fraturas são muito comuns, principalmente entre a população idosa, provocando diversas conseqüências ao indivíduo, entre elas, a alteração das sensações proprioceptivas, podendo predispor o paciente à importante instabilidade articular. Sendo assim, a reabilitação dessas lesões é de grande importância, afim de restaurar as funções do quadril e prevenir contra recidivas. De acordo com o levantamento bibliográfico realizado, os estudos demonstraram protocolos de tratamento fisioterapêuticos nas fraturas do quadril, porém a maioria dos autores não apresenta um treinamento proprioceptivo específico isoladamente; em geral, relacionam o ganho de força muscular, equilíbrio e o treino de marcha e de funcionalidade à melhora indireta da propriocepção articular. Fica evidente a carência teórica sobre o assunto, e espera-se que novas pesquisas possam surgir, para que se tenha maior significância clínica e estatística em relação ao tema abordado.