The effects of habitual functional training on physical functioning in patients after hip fracture: the protocol of the HIPFRAC study

Prediction of walking speed one year following hip fracture based on pre-fracture assessments of mobility and physical activity

BACKGROUND

Older people with hip fracture are often medically frail, and many do not regain their walking ability and level of physical activity. The aim of this study was to examine the relationship between pre-fracture recalled mobility, fear of falling, physical activity, walking habits and walking speed one year after hip fracture.

METHODS

The study had a longitudinal design. Measurements were performed 3-5 days postoperatively (baseline) and at one year after the hip fracture. The measurements at baseline were all subjective outcome measures recalled from pre-fracture: The New Mobility Scale (NMS), the 'Walking Habits' questionnaire, The University of California, Los Angeles (UCLA) Activity Scale, Fear of Falling International (FES-I) and demographic variables. At one year 4-meter walking speed, which was a part of the Short Physical Performance Battery (SPPB) was assessed.

RESULTS

At baseline 207 participants were included and 151 were assessed after one year. Their age was mean (SD) 82.7 (8.3) years (range 65-99 years). Those with the fastest walking speed at one year had a pre-fracture habit of regular walks with a duration of ≥ 30 min and/or a frequency of regular walks of 5-7 days a week. Age (p =.020), number of comorbidities (p <.001), recalled NMS (p <.001), and recalled UCLA Activity Scale (p =.007) were identified as predictors of walking speed at one year. The total model explained 54% of the variance in walking speed.

CONCLUSIONS

Duration and frequency of regular walks before the hip fracture play a role in walking speed recovery one year following the fracture. Subjective outcome measures of mobility and physical activity, recalled from pre-fracture can predict walking speed at one year. They are gentle on the old and medically frail patients in the acute phase after hip fracture, as well as clinically less time consuming.

Preference-based patient participation in intermediate care: Translation, validation and piloting of the 4Ps in Norway

INTRODUCTION

The implementation and evaluation of patient participation to obtain high-quality transitional care for older people is an international priority. Intermediate care (IC) services are regarded as an important part of the patient's pathway from the specialist to the primary care levels, bridging the gap between the hospital and the home. Patients may experience varying capacities and conditions for patient participation. Yet, few tools for evaluating patients' preferences for patient participation within IC services are at hand. Accordingly, further knowledge is needed to understand and scaffold processes for patient participation in IC. Therefore, the aim of this project was to translate, validate and pilot test the Patient Preferences for Patient Participation (the 4Ps) with patients in IC services in Norway.

METHODS

This project comprised two phases: (1) a careful translation and cultural adaptation process, followed by a content validity trial among 15 patients and staff in Norwegian IC and (2) a cross-sectional survey of the instrument with 60 patients admitted to IC.

RESULTS

The translation between Swedish and Norwegian required no conceptual or contextual adaptations. The subsequent cross-sectional study, designed as a dialogue between the patients and staff, revealed that only 50% of the participants received a sufficient level of patient participation based on their preferences, mostly indicating that patients were receiving less-than-preferred conditions for engaging in their health and healthcare issues.

CONCLUSION

The 4Ps instrument was deemed suitable for measuring patient participation based on patient preferences in the IC context and was feasible for both healthcare professionals and patients to complete in an interview when arriving at and leaving services. This may support person-centred communication and collaboration, calling for further research on what facilitates patient participation and the implementation of person-centred services for patients in IC.

PATIENT OR PUBLIC CONTRIBUTION

First, the current paper is part of the IPIC study (i.e., the implementation of patient participation in IC). Influenced by a James Lind Alliance process, the study addresses research uncertainties identified by patients, next of kin, staff and researchers in the cocreation process. Second, cognitive interviewing was conducted with 15 representatives of the target population: seven patients receiving IC services, one home-dwelling previous IC patient (altogether four women and four men, most of them 80 years or older) and seven healthcare staff working in IC services. The interviews determined the relevance, comprehensiveness and clarity of the 4Ps. Finally, 60 patients admitted to IC took part in the cross-sectional study.

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.

Recovery and prediction of physical function 1 year following hip fracture

Objectives

To investigate the recovery of physical function, health related quality of life (HRQoL), and pain for people following hip fracture for the initial 12 months, and to examine whether postoperative outcome measures of physical function, HRQoL, and pain can predict physical function at 3 and 12 months.

Design

A prospective single‐center observational study, as part of the HIPFRAC trial. Settings: One hospital with two associated municipalities in Norway. Subjects: 207 participants with hip fracture included in the study (140 participants transferred to a short‐term nursing home placement and 67 transferred directly home at discharge from hospital).

Method

Outcome measures were Short Physical Performance Battery (SPPB), Timed Up & Go (TUG), Stair climbing test (SC), Numeric Rating Scale (NRS) for pain at rest and in activity, and EQ‐5D‐5L index and health score. Data were analysed by repeated measures of variance and multivariate regression analyses.

Results

There were statistically significant improvements in physical function (SPPB total score and TUG), NRS‐pain in activity, and HRQoL (EQ‐5D‐5L) from hospital discharge to 3‐month follow‐up for the whole cohort and the two groups (p < 0.001). However, the largest improvements occurred within the first 3 months. Further statistically significant improvements occurred between 3 and 12 months (p < 0.05). The strongest predictors of physical function at 3 and 12 months post‐fracture were physical function (SPPB) at hospital discharge and pre‐fracture requirement of a walking aid.

Conclusion

The recovery of physical function, HRQoL, and pain in participants after hip fracture indicates gradual improvements during the initial 12‐month follow‐up, with the largest improvements within the first 3 months.

Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rehabilitation has often been seen as a disability-specific service needed by only few of the population. Despite its individual and societal benefits, rehabilitation has not been prioritised in countries and is under-resourced. We present global, regional, and country data for the number of people who would benefit from rehabilitation at least once during the course of their disabling illness or injury.

METHODS

To estimate the need for rehabilitation, data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were used to calculate the prevalence and years of life lived with disability (YLDs) of 25 diseases, impairments, or bespoke aggregations of sequelae that were selected as amenable to rehabilitation. All analyses were done at the country level and then aggregated to seven regions: World Bank high-income countries and the six WHO regions (ie, Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific).

FINDINGS

Globally, in 2019, 2·41 billion (95% uncertainty interval 2·34-2·50) individuals had conditions that would benefit from rehabilitation, contributing to 310 million [235-392] YLDs. This number had increased by 63% from 1990 to 2019. Regionally, the Western Pacific had the highest need of rehabilitation services (610 million people [588-636] and 83 million YLDs [62-106]). The disease area that contributed most to prevalence was musculoskeletal disorders (1·71 billion people [1·68-1·80]), with low back pain being the most prevalent condition in 134 of the 204 countries analysed.

INTERPRETATION

To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services and to show that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. This number counters the common view of rehabilitation as a service required by only few people. We argue that rehabilitation needs to be brought close to communities as an integral part of primary health care to reach more people in need.

FUNDING

Bill & Melinda Gates Foundation.

Does additional weekend and holiday physiotherapy benefit geriatric patients with hip fracture? - A case-historical control study

OBJECTIVE

To evaluate the new service model of additional weekend and holiday physiotherapy (PT) by comparing functional outcomes and hospital length of stay between a group of geriatric patients with hip fracture receiving daily PT training and a group of geriatric patients with hip fracture receiving weekdays PT training.

METHODS

A retrospective case-historical control chart review was conducted and a total of 355 patients were identified. Between-group comparisons were done on functional outcomes including Modified Functional Ambulation Classification (MFAC), Elderly Mobility Scale (EMS), Modified Barthel Index (MBI) and process outcome in terms of length of stay (LOS) in hospitals.

RESULTS

With similar characteristics, patients who received weekend and holiday PT training had a significant higher percentage of MFAC Category III and a significant lower percentage of MFAC Category II ( p = 0 . 015 ) and significant higher MBI scores ( mean ± standard deviation, median; Study group: 47 . 4 ± 19 . 6 points, 51 points; Control group: 43 . 0 ± 20 . 0 points, 43 points; p = 0 . 042 ) upon admission to rehabilitation hospital. A similar trend in EMS scores (Study group: 8 . 2 ± 5 . 5 points, 7 points; Control group: 8 . 4 ± 6 . 1 points, 6 points; p = 0 . 998 ) and MBI scores (Study group: 63 . 0 ± 23 . 4 points, 68 points; Control group: 61 . 2 ± 26 . 1 points, 64 points; p = 0 . 743 ) were observed upon discharge from the rehabilitation hospital. The average LOS in acute hospitals remained static (Study group: 7 . 7 ± 3 . 9 days, 7 days; Control group: 7 . 4 ± 5 . 0 days, 6 days; p = 0 . 192 ). The average LOS in rehabilitation hospital (Study group: 20 . 0 ± 5 . 5 days, 20 days; Control group: 24 . 3 ± 9 . 9 days, 23 days; p < 0 . 001 ) and total in-patient LOS (Study group: 26 . 7 ± 6 . 4 days, 26 days; Control group: 30 . 7 ± 11 . 2 days, 28 days; p < 0 . 001 ) were significantly reduced. A higher percentage of days having PT training during hospitalization in rehabilitation hospital was shown with the implementation of new service (Study group: 89.1%; Control group: 65.9%, p < 0 . 001 ).

CONCLUSION

Additional weekend and holiday PT training in post-operative acute and rehabilitation hospitalization benefits geriatric patients with hip fracture in terms of improved training efficiency, where hospital LOS was shortened with more PT sessions, without any significant impacts on functional outcome.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Effect of an additional health-professional-led exercise programme on clinical health outcomes after hip fracture

PURPOSE

To examine the effect of an additional 2-week health professional-led functional exercise programme compared to usual care for patients after hip fracture during a short-term nursing home stay directly after hospital discharge.

METHOD

One hundred and forty participants, 65 years or older with hip fracture, admitted to a short-term nursing home stay were randomised to an intervention group or control group. Participants in the intervention group (n = 78) received the experimental programme consisted of functional exercises, performed by health care professionals up to four times a day, 7 days a week, in addition to usual care during a 2-week short-term nursing home stay. Participants in the control group (n = 62) received usual care alone. Primary outcome was Short Physical Performance Battery (SPPB). Secondary outcomes were Timed Up & Go, New Mobility Score, The University of California, Los Angeles Activity Scale, Fall Efficacy Scale International, The EuroQol five dimension five-level questionnaire, and Numeric Rating Scale for pain. Outcome measures were assessed after 2 weeks in a short-term nursing home stay and 3 months after hip fracture surgery. The activity monitor ActivPal registered activity during the 2-week short-term nursing home stay.

RESULTS

No statistically significant differences between groups was found in any outcomes after 2 weeks or 3 months (p > 0.05). There were statistically significant within-group improvements in primary outcome SPPB and in most secondary outcomes at all time points in both groups (p > 0.05).

CONCLUSIONS

A 2-week health professional-led functional exercise programme in addition to usual care demonstrated no difference in clinical outcomes compared to usual care alone up to 3 months after hip fracture. The patients with hip fracture are fragile and vulnerable in this early phase, and usual physiotherapy may be sufficient to improve their physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02780076.

"To do or not to do": Treatment fidelity to a complex training intervention

BACKGROUND AND PURPOSE

When a complex intervention is examined it is viewed necessary to perform a qualitative process evaluation paired with an outcome evaluation. The purpose is to provide insights into the fidelity of the experimental intervention and thereby strengthen the validity of the study. In "Recovery after hip fracture" (the HIPFRAC study), the effect of a complex functional training intervention was examined by a randomized controlled trial design. The training was initiated by the physiotherapist and performed by the nurses/nurse assistants (NAs), as part of their daily, habitual routine when the patients with hip fracture were in a short-term stay after discharge from hospital. The aim of the present process evaluation was to explore how contextual factors facilitated or complicated the nurses'/NAs' fidelity to the experimental intervention in the HIPFRAC study.

METHODS

A descriptive thematic analysis was used. Data was collected through semi-structured in-depth interviews with three nurses and three NAs working with the HIPFRAC patients in a short-term stay. The interviews were transcribed and analyzed.

FINDINGS

Six subthemes, two main themes and one overall theme were identified. The overall theme was: Barriers affecting the implementation process. The main themes related to the barriers were identified as follows: (1) Attitudes within the nurses/NAs and (2) Structural factors.

DISCUSSION

The nurses/NAs in the short-term stay experienced contextual barriers, which contributed to complicate fidelity to the experimental intervention. There is a need of further research to investigate whether increased physiotherapy resources at short-term stay will improve the level of physical activity among the patients with hip fracture.

The Dramaturgical Act of Positioning Within Family Meetings: Negotiation of Patients' Participation in Intermediate Care Services

Family meetings are a cornerstone in intermediate care (IC) and a powerful tool in achieving patient participation. Staff in IC are nevertheless uncertain about how to run these meetings. This study explores the negotiation of patient participation in 14 family meetings by observing the interactions between patients, relatives, and staff. Using Goffman's dramaturgical theory, supplemented by positioning theory, we illustrate, through four cases, how the participants negotiate their opinions by enacting positions like performer, director, audience, and nonperson. Patient participation takes place when the family meetings are characterized by respect and empathy, when the staff restore and elicit patients' and relatives' preferences, and there exist real alternative outcomes of the meetings. The emphasis should be on meeting structure, group composition, and preparation of the patient team. The findings are valuable for staff, patient organizations, and policy makers responsible for program development and tools to optimize patient participation within family meetings.

Balance training can enhance hip fracture patients' independence in activities of daily living: A meta-analysis of randomized controlled trials

BACKGROUND

We conducted this meta-analysis to analyze the effectiveness of balance training in improving postoperative rehabilitation outcomes in hip fracture surgery patients.

METHODS

The Cochrane Library, Web of Science, Embase, and PubMed electronic databases were searched from their inception to December 2018. We selected prospective clinical control analyses and high-quality randomized controlled trials (RCTs) following the inclusion standards. We used Stata 12.0 to perform the meta-analysis. Where possible, the standard mean difference (SMD) with the 95% confidence interval (CI) was determined using a random effects model.

RESULTS

Ten RCTs involving 955 hips (balance training = 487, control = 468) published between 2002 and 2019 were assessed for eligibility of inclusion in the meta-analysis. Balance training was shown to remarkably improve the aspects of quality of life associated with physical health (standard mean difference [SMD], 2.20; 95% CI, 1.63-2.78, P = .000), a fast gait speed (SMD, 1.01; 95% CI, 0.25-1.77, P = .009), and balance (SMD = 0.26, 95% CI: [0.12, 0.41], P = .000). Moreover, the balance training group showed increases in independence in activities of daily living (ADLs), performance task scores, and health-related quality of life (HRQoL) scores compared with the control group (P < .05).

CONCLUSION

According to the present meta-analysis, balance training improves one's independence in activities of daily living, performance tasks, lower limb strength, gait, and total physical function compared with no balance training. More high-quality RCTs with large sample sizes are required for the identification of the best balance training program after hip fracture.

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.

Efficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials

Background

To investigate whether the clinical effects of balance training were improved in hip fracture patients.

Methods

Electronic databases which included PubMed, Embase, Web of Science, and the Cochrane Library up to December 2018 were searched. High-quality randomized controlled trials (RCTs) and prospective clinical controlled studies were selected based on inclusion criteria. Stata 12.0 was used for the meta-analysis. Standard mean difference (SMD) with 95% confidence interval (CI) was used to assess the effects.

Results

Finally, 9 studies with 872 patients (balance training = 445, control = 427) were included in our meta-analysis (published between 1997 and 2018). Compared with the control group, balance training group showed a significant increase in overall function (SMD = 0.59, 95% CI [0.25, 0.93], P = 0.001), gait speed (SMD = 0.63, 95% CI [0.19, 1.07], P = 0.005), lower limb strength (SMD = 0.73, 95% CI [0.50, 0.95], P = 0.000), activities of daily living (ADLs) (SMD = 0.97, 95% CI [0.61, 1.34], P = 0.000), performance task scores (SMD = 0.41, 95% CI [0.21, 0.61], P = 0.000), and health-related quality of life (HRQoL) scores (SMD = 0.32, 95% CI [0.16, 0.47], P = 0.000).

Conclusions

Our meta-analysis revealed that the balance training group has improved overall physical functioning, gait, lower limb strength, performance task, and activity of daily living than the control group. More high-quality and large-scale RCTs are needed to identify the optimal regimen of balance training after hip fracture.

Interventions for preventing falls in older people in care facilities and hospitals

BACKGROUND

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals.

DATA COLLECTION AND ANALYSIS

One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence.

MAIN RESULTS

Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.

"I struggle to count my blessings": recovery after hip fracture from the patients' perspective

Background

Recovery outlooks of physical functioning and quality of life after hip fracture have not changed significantly over the past 25 years. Previous research has mainly dealt with causalities and acute treatment, while the recovery process from the patients’ perspective has been less comprehensively described. Expanded knowledge of what the patients consider important in their recovery process may have important consequences for how these patients are treated in the future and thereby on future patient outcomes. The aim presently is therefore to explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process.

Method

The study was qualitative in design. Eight frail elderly in recovery after hip fracture (aged 69–91) were interviewed in their home four months after their fracture. The interviews covered issues related to their experiences of facilitators and barriers throughout the different stages in the recovery process. The patients were already enrolled in an ongoing randomized controlled trial, examining the effects of habitual functional training during their short term stays at nursing homes. The patients were chosen strategically according to age, gender, and participation in rehabilitation. The interviews were recorded, transcribed and subjected to a method of systematic text condensation inspired by Giorgi’s phenomenological method.

Results

The results revealed that the patients’ experiences of the recovery process fell into three main themes: “Feeling vulnerable”, “A span between self-reliance and dependency” and “Disruption from a normal life”. The feeling of gloominess and vulnerability persisted throughout. Being in recovery was also experienced as a tension between self-reliance and dependency; a disrupted life where loss of mobility and the impact of age was profoundly present.

Conclusion

Being in recovery after hip fracture was experienced as a life breaking event. Based on these findings, increased focus on individualized treatment to each patient through each stage of the recovery process should be emphasized.

Prognostic value of the c-reactive protein/prognostic nutritional index ratio after hip fracture surgery in the elderly population

Background

More and more older patients receive the surgery after hip fracture. However, the mortality rate is high. Prognostic nutritional index (PNI) is associated with prognosis in hip fracture patients. In the current study, we proposed a novel prognostic score, named c-reactive protein/PNI ratio (CRP/PNI ratio), for predicting the prognosis for geriatric orthopedic population.

Methods

This is a prospective study. Eighty cases of hip fracture surgery in the elderly population were studied to reveal the relationship between the CRP/PNI ratio and the clinicopathological characteristics of the elderly patients. Clinical data included age, sex, weight, length of stay, duration of surgery, comorbidity, and biological data were collected. The primary endpoint was the 1-year mortality rate.

Results

Cox regression and log-rank tests were used to evaluate the correlation of CRP/PNI to the one-year mortality. The one-year mortality rate was low in the patients with a low CRP/PNI ratio (P < 0.001). Univariate and multivariate survival analyses proved that CRP/PNI was an important factor to predict the one-year mortality rate of the geriatric hip fracture surgery patients.

Conclusion

Low CRP/PNI ratio was significantly associated with low one-year mortality rate in older patients after hip fracture surgery.