Validity of the activPAL and ActiGraph for measuring sitting time and steps in hospitalised orthopaedic patients with altered weight bearing

PURPOSE

To determine the criterion validity of the activPAL and ActiGraph for measuring steps and sitting/sedentary time, compared to observation, in people hospitalised following orthopaedic lower limb injury who were weight bearing (WB) (i.e., walking) or non-weight bearing (NWB) (i.e., hopping).

MATERIALS AND METHODS

Participants wore an activPAL and ActiGraph on the hip/thigh/unaffected (UA)/affected ankle (AA) while completing bouts of walking and sitting. Lin's concordance correlation coefficient, Bland-Altman methods, and ratio of agreement were used to compare device-measured to observed (videoed) step count, sitting/sedentary time.

RESULTS

In 42 participants, the ActiGraph demonstrated excellent concordance with the observed step count when worn on the ankle (LCC 0.91-0.92) compared to the hip (LCC 0.56) in participants that were WB. The ActiGraph AA achieved the highest concordance (LCC 0.71) with observed steps in participants NWB. The activPAL had poor concordance with observed steps, particularly at slow gait speeds, in participants that were WB (LCC 0.38-0.46), however was less influenced by gait speed and had good concordance in NWB participants (LCC 0.52-0.69). The activPAL (LCC 0.79-0.88) and ActiGraph UA (LCC 0.94) showed excellent concordance with observed sitting and sedentary time, respectively.

CONCLUSIONS

The ActiGraph worn at the ankle provided the most valid measure of steps in people who are WB and NWB following orthopaedic injury, while the activPAL was best for measuring sitting time.Implications for rehabilitationTo accurately measure both steps and sitting time in people with lower limb orthopaedic injuries, a combination of activity monitors should be used (i.e., ActiGraph for steps, activPAL for sitting time).The ActiGraph device when worn on the ankle demonstrated the strongest agreement with observed step count in people who were weight bearing and non-weight bearing.Caution is needed when using thigh- or hip-worn devices in people who walk slowly.

Altered longitudinal structural connectome in paediatric mild traumatic brain injury: an Advancing Concussion Assessment in Paediatrics study

Advanced diffusion-weighted imaging techniques have increased understanding of the neuropathology of paediatric mild traumatic brain injury (i.e. concussion). Most studies have examined discrete white-matter pathways, which may not capture the characteristically subtle, diffuse and heterogenous effects of paediatric concussion on brain microstructure. This study compared the structural connectome of children with concussion to those with mild orthopaedic injury to determine whether network metrics and their trajectories across time post-injury differentiate paediatric concussion from mild traumatic injury more generally. Data were drawn from of a large study of outcomes in paediatric concussion. Children aged 8-16.99 years were recruited from five paediatric emergency departments within 48 h of sustaining a concussion (n = 360; 56% male) or mild orthopaedic injury (n = 196; 62% male). A reliable change score was used to classify children with concussion into two groups: concussion with or without persistent symptoms. Children completed 3 T MRI at post-acute (2-33 days) and/or chronic (3 or 6 months, via random assignment) post-injury follow-ups. Diffusion-weighted images were used to calculate the diffusion tensor, conduct deterministic whole-brain fibre tractography and compute connectivity matrices in native (diffusion) space for 90 supratentorial regions. Weighted adjacency matrices were constructed using average fractional anisotropy and used to calculate global and local (regional) graph theory metrics. Linear mixed effects modelling was performed to compare groups, correcting for multiple comparisons. Groups did not differ in global network metrics. However, the clustering coefficient, betweenness centrality and efficiency of the insula, cingulate, parietal, occipital and subcortical regions differed among groups, with differences moderated by time (days) post-injury, biological sex and age at time of injury. Post-acute differences were minimal, whereas more robust alterations emerged at 3 and especially 6 months in children with concussion with persistent symptoms, albeit differently by sex and age. In the largest neuroimaging study to date, post-acute regional network metrics distinguished concussion from mild orthopaedic injury and predicted symptom recovery 1-month post-injury. Regional network parameters alterations were more robust and widespread at chronic timepoints than post-acutely after concussion. Results suggest that increased regional and local subnetwork segregation (modularity) and inefficiency occurs across time after concussion, emerging after post-concussive symptom resolve in most children. These differences persist up to 6 months after concussion, especially in children who showed persistent symptoms. While prognostic, the small to modest effect size of group differences and the moderating effects of sex likely would preclude effective clinical application in individual patients.

Serious Injury in Metropolitan and Regional Victoria: Exploring Travel to Treatment and Utilisation of Post-Discharge Health Services by Injury Type

This study aimed to describe regional variations in service use and distance travelled to post-discharge health services in the first three years following hospital discharge for people with transport-related orthopaedic, brain, and spinal cord injuries. Using linked data from the Victorian State Trauma Registry (VSTR) and Transport Accident Commission (TAC), we identified 1597 people who had sustained transport-related orthopaedic, brain, or spinal cord injuries between 2006 and 2016 that met the study inclusion criteria. The adjusted odds of GP service use for regional participants were 76% higher than for metropolitan participants in the orthopaedic and traumatic brain injury (TBI) groups. People with spinal cord injury (SCI) living in regional areas had 72% lower adjusted odds of accessing mental health, 76% lower adjusted odds of accessing OT services, and 82% lower adjusted odds of accessing physical therapies compared with people living in major cities. People with a TBI living in regional areas on average travelled significantly further to access all post-discharge health services compared with people with TBI in major cities. For visits to medical services, the median trip distance for regional participants was 76.61 km (95%CI: 16.01-132.21) for orthopaedic injuries, 104.05 km (95% CI: 51.55-182.78) for TBI, and 68.70 km (95%CI: 8.34-139.84) for SCI. Disparities in service use and distance travelled to health services exist between metropolitan Melbourne and regional Victoria following serious injury.

A multicenter observational study on the distribution of orthopaedic fracture types across 17 low- and middle-income countries

Objectives:

To describe the regional distribution of fractures sustained by women and health care system characteristics across 17 low- and middle-income countries (LMICs).

Methods:

The INternational ORthopaedic MUlticentre Study in fracture care (INORMUS) is an observational study collecting data on patients in LMICs who sustained a fracture or musculoskeletal injury. As a planned analysis for the INORMUS study, we explored differences in fracture locations and demographics reported among 9878 female patients who sustained a fracture within 17 LMICs in 5 regions (China, Africa, India, Other Asia, and Latin America).

Results:

Half of our study population (49.6%) was ≥60 years of age. Across all regions, 58.3% of patients possessed health insurance. Latin America possessed the highest proportion (88.8%) of health insurance, while in Africa, patients possessed the lowest (18.0%). Falls from standing were the most prevalent mechanism of injury (51.7%) followed by falls from height (12.8%) and motorcycle-related road traffic injuries (9.7%). The majority of the fractures (65.6%) occurred in patients aged 50 and older. Hip fractures were the most common fracture (26.8%), followed by tibia/fibula (12.6%) and spine fractures (9.7%). Open fractures accounted for 7.6% of fractures and were most commonly tibia/fibula fractures (35.1%). Despite these severe injuries, less than one-third (28.8%) of patients were transported for care after sustaining a fracture by ambulance. Regionally, a majority of female patients in Africa were working age and suffered tibia/fibula (21.6%) and femur fractures (14.0%). Patients in the regional category Other Asia, suffered the highest frequencies of open fractures (9.6% low grade, 7.1% high grade), and disproportionately from motorcycle road traffic injuries (29.9%).

Conclusion:

Across all regions, the most significant source of fracture burden was in the elderly, and included common fragility fractures, such as hip fractures. Notable regional deviations in fracture distributions were observed within Africa, and Other Asia. Across all studied LMICs, ambulance usage was low, and health insurance coverage was particularly low in Africa and India.

Water slide injuries in Jamaica

Background

Patients are presented in this study to describe injuries, each of which have not been previously described in the literature, as a result of a specific mechanism of injury on a water slide. Some of these injuries are potentially fatal and are usually the result of a very high energy mechanism of injury. All injuries occurred in a 6-week time span in the summer of 2015.

Method

Injuries arising from water slides and their definitive treatment were documented. All of the cases presented to Saint Ann's Bay Hospital in Saint Ann's Bay, Jamaica. The mechanism of injury was analyzed with a view to implement preventative measures.

Results

Three cases had open book pelvic injuries and one of them also had a vaginal tear. All of the open book injuries occurred after the patron's thighs violently abducted despite adhering to the recommended starting position that suggested patrons cross their legs. The fourth case was of a 25-year-old man who sustained a posterior shoulder dislocation as a result of his arms flailing despite attempting to adhere to the rule recommending that the patron place his arms across his chest. The final case was of a 14-year-old boy who was involved in an atypical collision injury, resulting in the boy sustaining a displaced distal femoral fracture.

Conclusions

Modern water slides will expose patrons to more frequent and severe injuries from atypical mechanisms of injuries. Risk factors for injury must be factored into preventative measures. Improved surveillance strategies to monitor these injuries are suggested.

Comparison of measures of comorbidity for predicting disability 12-months post-injury

BACKGROUND

Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.

METHODS

12-month Glasgow Outcome Scale - Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7-8 were considered "recovered". A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with "recovery" as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.

RESULTS

All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).

CONCLUSIONS

The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.