Usability and preliminary effectiveness of an app-based physical activity and education program for people with hip or knee osteoarthritis - a pilot randomized controlled trial

BACKGROUND

Hip and knee osteoarthritis (OA) are highly prevalent worldwide. The guidelines recommend physical activity and education as the core treatments for osteoarthritis. Digital health has the potential to engage people in physical activity and disease management. Therefore, we conducted a pilot trial to assess the usability and preliminary effectiveness of an app-based physical activity and education program (Join2Move) compared to usual care for people with hip and/or knee OA in Germany.

METHODS

A randomized controlled pilot study was conducted. Individuals with diagnosed or self-reported knee and hip OA were included. Allocation to the intervention or control group was randomized. The intervention group received the Join2Move program. The Join2Move program was previously developed as a website and evaluated in the Netherlands. For the current study, the program was translated and adapted to the German context and adjusted from a website to an app. The control group received usual care. The primary outcomes were usability and preliminary effectiveness (pain and physical functioning). Measurements were taken at baseline and at twelve weeks. The data analysis was performed using SPSS (IBM SPSS Statistics 29.0).

RESULTS

Sixty participants, with a mean age of 61.9 (SD ± 7.2) years, were allocated to the intervention (n = 32) or the control group (n = 28) and included in the analysis. The majority of participants had knee OA (68%), and 12% had hip and knee OA. The dropout rate was n = 11 (18%). No adverse events were reported. Usability was rated as acceptable (mean System Usability Scale = 71.3/100) with a wide range (32.5 to 100). Statistically significant between-group differences were found only for pain (mean difference 8.52 (95% CI 1.01 to 16.04), p = 0.027).

CONCLUSIONS

Join2Move demonstrated acceptable usability. The preliminary results of the pilot trial indicate the potential of a stand-alone app for the treatment of patients with hip or knee OA. However, the acceptable usability of Join2Move limits its recommendation for everyone. There appears to be room for improvement in app usability and in identifying patients for whom the app is suitable and the right time to use a stand-alone app.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00027164 .

Defining a competency framework for health and social professionals to promote healthy aging throughout the lifespan: an international Delphi study

The promotion of healthy aging has become a priority in most parts of the world and should be promoted at all ages. However, the baseline training of health and social professionals is currently not adequately tailored to these challenges. This paper reports the results of a Delphi study conducted to reach expert agreement about health and social professionals' competencies to promote healthy aging throughout the lifespan within the SIENHA project. Materials and methods: This study was developed following the CREDES standards. The initial version of the competence framework was based on the results of a scoping review and following the CanMEDS model. The expert panel consisted of a purposive sample of twenty-two experts in healthy aging with diverse academic and clinical backgrounds, fields and years of expertise from seven European countries. Agreement was reached after three rounds. The final framework consisted of a set of 18 key competencies and 80 enabling competencies distributed across six domains. The SIENHA competence framework for healthy aging may help students and educators enrich their learning and the academic content of their subjects and/or programs and incentivize innovation.

Professional competences to promote healthy ageing across the lifespan: a scoping review

As societies age, the development of resources and strategies that foster healthy ageing from the beginning of life become increasingly important. Social and healthcare professionals are key agents in this process; therefore, their training needs to be in agreement with societal needs. We performed a scoping review on professional competences for social and health workers to adequately promote healthy ageing throughout life, using the framework described by Arksey and O'Malley and the Joanna Briggs Institute Guidelines. A stakeholder consultation was held in each of the participating countries, in which 79 experts took part. Results show that current literature has been excessively focused on the older age and that more attention on how to work with younger population groups is needed. Likewise, not all disciplines have equally reflected on their role before this challenge and interprofessional approaches, despite showing promise, have not been sufficiently described. Based on our results, health and social professionals working to promote healthy ageing across the lifespan will need sound competences regarding person-centred communication, professional communication, technology applications, physiological and pathophysiological aspects of ageing, social and environmental aspects, cultural diversity, programs and policies, ethics, general and basic skills, context and self-management-related skills, health promotion and disease prevention skills, educational and research skills, leadership skills, technological skills and clinical reasoning. Further research should contribute to establishing which competences are more relevant to each discipline and at what level they should be taught, as well as how they can be best implemented to effectively transform health and social care systems.

Technologies in Home-Based Digital Rehabilitation: Scoping Review

BACKGROUND

Due to growing pressure on the health care system, a shift in rehabilitation to home settings is essential. However, efficient support for home-based rehabilitation is lacking. The COVID-19 pandemic has further exacerbated these challenges and has affected individuals and health care professionals during rehabilitation. Digital rehabilitation (DR) could support home-based rehabilitation. To develop and implement DR solutions that meet clients' needs and ease the growing pressure on the health care system, it is necessary to provide an overview of existing, relevant, and future solutions shaping the constantly evolving market of technologies for home-based DR.

OBJECTIVE

In this scoping review, we aimed to identify digital technologies for home-based DR, predict new or emerging DR trends, and report on the influences of the COVID-19 pandemic on DR.

METHODS

The scoping review followed the framework of Arksey and O'Malley, with improvements made by Levac et al. A literature search was performed in PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The search spanned January 2015 to January 2022. A bibliometric analysis was performed to provide an overview of the included references, and a co-occurrence analysis identified the technologies for home-based DR. A full-text analysis of all included reviews filtered the trends for home-based DR. A gray literature search supplemented the results of the review analysis and revealed the influences of the COVID-19 pandemic on the development of DR.

RESULTS

A total of 2437 records were included in the bibliometric analysis and 95 in the full-text analysis, and 40 records were included as a result of the gray literature search. Sensors, robotic devices, gamification, virtual and augmented reality, and digital and mobile apps are already used in home-based DR; however, artificial intelligence and machine learning, exoskeletons, and digital and mobile apps represent new and emerging trends. Advantages and disadvantages were displayed for all technologies. The COVID-19 pandemic has led to an increased use of digital technologies as remote approaches but has not led to the development of new technologies.

CONCLUSIONS

Multiple tools are available and implemented for home-based DR; however, some technologies face limitations in the application of home-based rehabilitation. However, artificial intelligence and machine learning could be instrumental in redesigning rehabilitation and addressing future challenges of the health care system, and the rehabilitation sector in particular. The results show the need for feasible and effective approaches to implement DR that meet clients' needs and adhere to framework conditions, regardless of exceptional situations such as the COVID-19 pandemic.

Blended Care in Patients With Knee and Hip Osteoarthritis in Physical Therapy: Delphi Study on Needs and Preconditions

BACKGROUND

Osteoarthritis is a major public health concern. Despite existing evidence-based treatment options, the health care situation remains unsatisfactory. Digital care options, especially when combined with in-person sessions, seem to be promising.

OBJECTIVE

The aim of this study was to investigate the needs, preconditions, barriers, and facilitators of blended physical therapy for osteoarthritis.

METHODS

This Delphi study consisted of interviews, an online questionnaire, and focus groups. Participants were physical therapists, patients with hip and/or knee osteoarthritis with or without experience in digital care, and stakeholders of the health care system. In the first phase, interviews were conducted with patients and physical therapists. The interview guide was based on the Consolidated Framework For Implementation Research. The interviews focused on experiences with digital and blended care. Furthermore, needs, facilitators, and barriers were discussed. In the second phase, an online questionnaire and focus groups served the process to confirm the needs and collect preconditions. The online questionnaire contained statements drawn by the results of the interviews. Patients and physical therapists were invited to complete the questionnaire and participate in one of the three focus groups including (1) patients; (2) physical therapists; and (3) a patient, a physical therapist, and stakeholders from the health care system. The focus groups were used to determine concordance with the results of the interviews and the online questionnaire.

RESULTS

Nine physical therapists, seven patients, and six stakeholders confirmed that an increase of acceptance of the digital care part by physical therapists and patients is crucial. One of the most frequently mentioned facilitators was conducting regular in-person sessions. Physical therapists and patients concluded that blended physical therapy must be tailored to the patients' needs. Participants of the last focus group stated that the reimbursement of blended physical therapy needs to be clarified.

CONCLUSIONS

Most importantly, it is necessary to strengthen the acceptance of patients and physical therapists toward digital care. Overall, for development and usage purposes, it is crucial to take the needs and preconditions into account.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023386; https://drks.de/search/en/trial/DRKS00023386.

Smartphone-assisted training with education for patients with hip and/or knee osteoarthritis (SmArt-E): study protocol for a multicentre pragmatic randomized controlled trial

Introduction

Hip and knee osteoarthritis are associated with functional limitations, pain and restrictions in quality of life and the ability to work. Furthermore, with growing prevalence, osteoarthritis is increasingly causing (in)direct costs. Guidelines recommend exercise therapy and education as primary treatment strategies. Available options for treatment based on physical activity promotion and lifestyle change are often insufficiently provided and used. In addition, the quality of current exercise programmes often does not meet the changing care needs of older people with comorbidities and exercise adherence is a challenge beyond personal physiotherapy. The main objective of this study is to investigate the short- and long-term (cost-)effectiveness of the SmArt-E programme in people with hip and/or knee osteoarthritis in terms of pain and physical functioning compared to usual care.

Methods

This study is designed as a multicentre randomized controlled trial with a target sample size of 330 patients. The intervention is based on the e-Exercise intervention from the Netherlands, consists of a training and education programme and is conducted as a blended care intervention over 12 months. We use an app to support independent training and the development of self-management skills. The primary and secondary hypotheses are that participants in the SmArt-E intervention will have less pain (numerical rating scale) and better physical functioning (Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score) compared to participants in the usual care group after 12 and 3 months. Other secondary outcomes are based on domains of the Osteoarthritis Research Society International (OARSI). The study will be accompanied by a process evaluation.

Discussion

After a positive evaluation, SmArt-E can be offered in usual care, flexibly addressing different care situations. The desired sustainability and the support of the participants’ behavioural change are initiated via the app through audio-visual contact with their physiotherapists. Furthermore, the app supports the repetition and consolidation of learned training and educational content. For people with osteoarthritis, the new form of care with proven effectiveness can lead to a reduction in underuse and misuse of care as well as contribute to a reduction in (in)direct costs.

Trial registration

German Clinical Trials Register, DRKS00028477. Registered on August 10, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-023-06255-7.

Association of clinical outcome assessments of mobility capacity and incident disability in community-dwelling older adults - a systematic review and meta-analysis

The objective of the present review is to synthesize all available research on the association between mobility capacity and incident disability in non-disabled older adults. MEDLINE, EMBASE and CINAHL databases were searched without any limits or restrictions until February 2021. Published reports of longitudinal cohort studies that estimated a direct association between baseline mobility capacity, assessed with a standardized outcome assessment, and subsequent development of disability, including initially non-disabled older adults were included. The risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Random-effect models were used to explore the objective. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The main outcome measures were the pooled relative risks (RR) per one conventional unit per mobility assessment for incident disability. A total of 40 reports (85,515 participants at baseline) were included. For usual and fast gait speed, the RR per -0.1 m/s was 1.23 (95% CI: 1.18-1.28; 26,638 participants) and 1.28 (95% CI: 1.19-1.38; 8161 participants), respectively. Each point decrease in Short Physical Performance Battery score increased the risk of incident disability by 30% (RR = 1.30, 95% CI: 1.23-1.38; 9183 participants). The RR of incident disability by each second increase in Timed Up and Go test and Chair Rise Test performance was 1.15 (95% CI: 1.09-1.21; 30,426 participants) and 1.07 (95% CI: 1.04-1.10; 9450 participants), respectively. The review concludes that among community-dwelling non-disabled older adults, poor mobility capacity is a potent modifiable risk factor for incident disability. Mobility impairment should be mandated as a quality indicator of health for older people.

Low test–retest reliability of a protocol for assessing somatosensory cortex excitability generated from sensory nerves of the lower back

In people with chronic low back pain (CLBP), maladaptive structural and functional changes on a cortical level have been identified. On a functional level, somatosensory cortical excitability has been shown to be reduced in chronic pain conditions, resulting in cortical disinhibition. The occurrence of structural and/or functional maladaptive cortical changes in people with CLBP could play a role in maintaining the pain. There is currently no measurement protocol for cortical excitability that employs stimulation directly to the lower back. We developed a protocol for the measurement of single pulse somatosensory evoked potential (SEP) waveforms and paired-pulse behavior (PPB) generated from sensory nerves of the lower back and quantified its test–retest reliability in a sample of 30 healthy individuals to gain insights into the normal variability of cortical responses, which could then be compared to results from people with CLBP. We investigated cortical excitability by measuring SEPs and PPB. PPB was defined as the ratio of the amplitude of the second cortical response (A2s) divided by the first cortical response (A1). A2s was determined by subtracting the response to single-pulse stimuli from the paired pulse stimuli response to account for linear superposition effects. The test–retest reliability of the protocol was very poor with no evidence of systematic bias but a high amount of random variability between sessions. There was no significant difference in the right side PPB for session 1 (Mean ratio A2s/A1 = 0.66, SD = 0.54) and session 2 (Mean ratio A2s/A1 = 0.94, SD = 1.56); mean session difference [(95% CI) = −0.44 (−1.23 to 0.34); t (22) = −1.17, p = 0.26]. The ICC₃.₁ (absolute agreement) for the outlier-removed right side PPB were 0.19 (95% CI: −0.84 to 0.66) and 0.43 for left side PPB (95% CI: −0.37 to 0.76). This finding potentially has wider implications for PPB protocols. If these findings were replicated in other groups and other nerves, it would question the validity of this measure more generally. However, these findings are restricted to healthy people and sensory nerves of the lower back and may not be generalizable.

Feasibility of smartphone-supported, combined physical and cognitive activities in the Neighbourhood for stimulating social participation of the elderly

Background

Combining smartphone-assisted group activities in the neighbourhood and training in physical and cognitive skills may offer the potential to promote social participation and connectedness of older adults. This non-controlled proof-of-concept, retrospectively registered study aimed to determine the feasibility of such an intervention approach, including its evaluation.

Methods

In two consecutive six-month intervention cycles, 39 community-dwelling adults were provided with weekly smartphone, physical and cognitive training by two tutors. Using a specifically designed app, the participants were also encouraged to join and later self-organise physically and cognitively stimulating activities related to hot spots in their Bochum neighbourhood. Indicators of feasibility were documented.

Results

The recruitment and assessments took 3 hours per participant. Excluding smartphone support, the preparation and the implementation of the intervention amounted to nine person-hours per week.

Six participants dropped out, and 13 did not complete one or more assessments. The participants attended 76 ± 15% of the weekly training sessions. The instructors deemed the programme feasible, but familiarisation with the smartphone and the app was very time-consuming.

Twenty-seven of 29 participants reported high overall satisfaction, and 22 agreed that the programme helped them to establish social contacts. The smartphones attracted substantial interest and were used frequently, despite mixed satisfaction with the project-specific app. From baseline to follow-up, the six-minute walking distance, lower extremity strength and moderate to vigorous physical activity, as well as quality of life, were preserved at a high level, while balance performance was significantly improved. Of the 11 tests related to cognitive functioning, 4 tests (a memory test, the Stroop test and 2 tests of verbal fluency) indicated significant improvement. No moderate or serious adverse events occurred in relation to the assessments or the intervention.

Conclusions

The multimodal approach seems safe and feasible and offers the potential to promote social connectedness, bonds in the residential neighbourhood and smartphone competency, as well as to preserve or improve physical and cognitive functions. Adaptations of the intervention and of the outcome assessments may contribute to better assessment and exploitation of the potential of this approach in a future study involving socially, physically and cognitively less active elderly persons.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

Background

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

Methods

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4–6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

Discussion

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

Trial registration

German Clinical Trials Register, . Registered on March 11, 2021.

A generic outcome assessment of mobility capacity in neurorehabilitation: measurement properties of the de Morton Mobility Index

Background

Mobility capacity is a key outcome domain in neurorehabilitation. The de Morton Mobility Index (DEMMI), an established and generic outcome assessment of mobility capacity in older patients, is promising for use in neurorehabilitation. The aim of this study was to examine the measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions.

Methods

Cross-sectional study including a mixed sample of adult inpatients in a neurorehabilitation hospital. Structural validity, unidimensionality and measurement invariance (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the DEMMI (scale range: 0–100 points) were established. The minimal detectable change, the 95% limits of agreement, and possible floor and ceiling effects were calculated to indicate interpretability.

Results

We analyzed validity (n = 348) and reliability (n = 133) in two samples. In both samples, the majority of participants had a sub-acute stroke or Parkinson’s disease.

Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 59.4, P = 0.074). There was no relevant measurement invariance by disease group. Hypotheses-based correlation analyses (DEMMI and other functional outcome assessments) showed sufficient construct validity. Internal consistency reliability (Cronbach’s alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.94; 95% confidence interval: 0.91–0.95) were sufficient. The minimal detectable change with 90% confidence was 15.0 points and the limits of agreement were 39%. No floor or ceiling effects were observed.

Conclusions

Results indicate sufficient measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions. The DEMMI can be used as a generic outcome assessment of mobility capacity in neurorehabilitation.

Trial registration

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02327-0.

An investigation of the measurement properties of the de Morton Mobility Index for measuring mobility capacity in hospital patients with Parkinson's disease

OBJECTIVE

To examine the measurement properties of the de Morton Mobility Index (DEMMI), a performance-based clinical outcome assessment of mobility capacity, in hospital patients with Parkinson's disease.

DESIGN

Cross-sectional study.

PARTICIPANTS

Hospital patients with Parkinson's disease.

MAIN OUTCOME MEASURE(S)

Structural validity and unidimensionality (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the de Morton Mobility Index (scale range: 0-100 points) were established. The minimal detectable change, the 95% limits of agreement and possible floor and ceiling effects were calculated to indicate interpretability.

RESULTS

We analysed validity (n = 100; mean age: 70 years; 71% male) and reliability (n = 47; mean age: 71 years; 68% male) in two samples. The mean Hoehn and Yahr stage was 3.2 and the mean disease duration was 12 years in both samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 21.49, P = 0.122). Seventy-three percent of hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach's alpha = 0.91) and inter-rater reliability (intraclass correlation coefficient = 0.88; 95% confidence interval: 0.80 to 0.93) were sufficient. The minimal detectable change with 90% confidence was 17.5 points and the limits of agreement were 31%. No floor or ceiling effects were observed. The mean administration time was 6.6 minutes.

CONCLUSION

This study provides evidence of unidimensionality, sufficient internal consistency reliability, inter-rater reliability, construct validity, and feasibility of the de Morton Mobility Index in hospital patients with Parkinson's disease.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

An augmented prescribed exercise program (APEP) to improve mobility of older acute medical patients - a randomized, controlled pilot and feasibility trial

Background

There is inconclusive evidence for the effectiveness of additional exercise in older hospital patients. The aims of this study were (1) to assess the feasibility of an augmented prescribed exercise program (APEP) in older acute medical patients and (2) to measure the potential effects of APEP on mobility capacity in order to assess the feasibility of a large full-scale study.

Methods

We conducted a single-center, prospective, parallel-group, single-blinded, randomized (1:1) controlled pilot and feasibility trial. Participants were recruited from acute geriatric wards of a general hospital. Key inclusion criteria were: age ≥ 65 years and walking ability. Key exclusion criteria were severe cognitive impairment and medical restriction for physical exercise interventions.

Both groups received usual care, including physiotherapy. Intervention group participants were scheduled for additional exercise sessions (20–30 min, 4-5x/week). Feasibility of the trial design was assessed along pre-defined criteria for process, resources and management. Feasibility of the APEP intervention was analyzed by means of adherence, compliance and safety. Outcomes were measured at baseline and prior to hospital discharge. The primary outcome was mobility capacity (de Morton Mobility Index; DEMMI). Secondary outcomes were walking ability, physical endurance, fear of falling, frailty and length of stay.

Results

Thirty-five participants were recruited (recruitment rate 20.3%). We lost 7 participants to follow-up (retention rate: 80%). Intervention group participants (n = 17) each participated in 5.3 ± 2.2 additional exercise sessions (mean duration: 23.2 ± 4.0 min; mean adherence rate 78% ± 26%). No severe adverse events occurred during study assessments or APEP sessions.

There were no statistically significant differences in mean change scores in any outcome measure. A sample of 124 participants would be required to detect a difference of 4 DEMMI points (ES = 0.45) with a power of 80%.

Conclusions

This small feasibility RCT indicates that an APEP intervention may be safe and feasible in older acute medical patients. APEP may possibly induce small to moderate effects on mobility, but the clinical relevance of these effects may be limited. These results inform the planning of a larger-scale phase III study.

Trial registration

German Clinical Trials Register (DRKS00011262). Registered 27 October 2016.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1246-4) contains supplementary material, which is available to authorized users.

Prevalence of frailty in older adults in outpatient physiotherapy in an urban region in the western part of Germany: a cross-sectional study

OBJECTIVE

To investigate the prevalence of frailty in older people in outpatient physiotherapy services in an urban region in the western part of Germany.

DESIGN

Cross-sectional study.

SETTING

Outpatient physiotherapy clinics were recruited in the municipal area of the city of Bochum, Germany, and selected randomly.

PARTICIPANTS

Older adults aged 65 years and older seeking outpatient physiotherapy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of frailty was assessed based on the frailty phenotype model of physical frailty and the accumulation of deficit model, expressed as a Frailty Index. Prevalence was calculated for the whole sample and according to age-related, sex-related and diagnosis-related subgroups.

RESULTS

A total of 258 participants (74±6 years, 62% female) from 11 out of 130 (8%) different physiotherapy clinics were included. Participants' main indication for physiotherapy was an orthopaedic or surgical condition (75%). According to the model of a physical frailty phenotype, 17.8% (95% CI 13.2 to 22.5) participants were frail and 43.4% (95% CI 37.4 to 49.5) were prefrail. The Frailty Index identified 31.0% (95% CI 25.4 to 36.7) of individuals as frail. In both models, prevalence increased with age and was higher in women than in men. Slow gait speed (34%), reduced muscle strength (34%) and exhaustion (28%) were the most prevalent indicators of physical frailty.

CONCLUSIONS

Frailty is comparatively common in older patients attending physiotherapy care in Germany, with one out of three individuals being frail and every second individual being physically frail or prefrail.

TRIAL REGISTRATION NUMBER

DRKS00009384; Results.

Interkulturelle Adaptation des Lymph-ICF-Fragebogens für Patienten mit Lymphödemen der unteren Gliedmaßen in Deutschland

Hintergrund Patienten mit Lymphödemen der unteren Gliedmaßen leiden unter körperlichen und psychosozialen Beeinträchtigungen. Das Erfassen von Einschränkungen bei Aktivitäten, Partizipation und Lebensqualität erfordert krankheitsspezifische und ICF-basierte Messinstrumente. In deutscher Sprache liegt ein solches Messinstrument bislang nicht vor.

Ziel Das Ziel der Studie war es, eine interkulturelle Adaptation und psychometrische Prüfung des Lymph-ICF-Fragebogens für Patienten mit Lymphödemen der unteren Gliedmaßen durchzuführen.

Methode In Phase 1 der Studie (n = 24) wurde der Fragebogen übersetzt und anschließend an Patienten mit Lymphödemen der unteren Gliedmaßen evaluiert. Dabei wurden die Augenschein- und Inhaltsvalidität sowie Praktikabilität untersucht. In Phase 2 (n = 11) wurden die Test-Retest-Reliabilität (ICC) und interne Konsistenz (Cronbach Alpha) getestet. Zur Überprüfung der Konstruktvalidität wurden Hypothesen über erwartete hohe Korrelationen zwischen Domänen des Lymph-ICF-UG (Störung, Einschränkung und Teilhabeproblem Fragebogen für Lymphödeme der unteren Gliedmaßen) und des SF-36 überprüft.

Ergebnisse Augenschein- und Inhaltsvalidität sowie Praktikabilität erzielten gute Ergebnisse. Die interne Konsistenz war moderat bis stark (Cronbach Alpha: 0,69 – 0,88), die Test-Retest-Reliabilität moderat bis sehr stark (ICC: 0,36 – 0,95). Mit 5 % angenommener Hypothesen war die Konstruktvalidität schwach.

Schlussfolgerung Der Lymph-ICF-UG ist der erste reliable und valide ICF-basierte Fragebogen für Patienten mit Lymphödemen der unteren Gliedmaßen in Deutschland.

Reliability of mobility measures in older medical patients with cognitive impairment

Background

Mobility is a key indicator of physical functioning in older people, but there is limited evidence of the reliability of mobility measures in older people with cognitive impairment. This study aimed to examine the test-retest reliability and measurement error of common measurement instruments of mobility and physical functioning in older patients with dementia, delirium or other cognitive impairment.

Methods

A cross-sectional study was performed in a geriatric hospital. Older acute medical patients with cognitive impairment, indicated by a Mini-Mental State Examination (MMSE) score of ≤24 points, were assessed twice within 1 day by a trained physiotherapist.

The following instruments were applied: de Morton Mobility Index, Hierarchical Assessment of Balance and Mobility, Performance-Oriented Mobility Assessment, Short Physical Performance Battery, 4-m gait speed, 5-times chair rise test, 2-min walk test, timed up and go test, Barthel Index mobility subscale and Functional Ambulation Categories.

As appropriate, the intraclass correlation coefficient (ICC), Cohen’s kappa, standard error of measurement, limits of agreement and minimal detectable change (MDC) values were estimated.

Results

Sixty-five older acute medical patients with cognitive impairment participated in the study (mean age: 82 ± 7 years; mean MMSE: 20 ± 4, range: 10 to 24 points). Some participants were physically or cognitively unable to perform the gait speed (46%), 2-min walk (46%), timed up and go (51%) and chair rise (75%) tests.

ICC and kappa values were above 0.9 in all instruments except for the gait speed (ICC = 0.86) and chair rise (ICC = 0.72) measures. Measurement error is reported for each instrument. The absolute limits of agreement ranged from 11% (de Morton Mobility Index and Hierarchical Assessment of Balance and Mobility) to 35% (chair rise test).

Conclusions

The test-retest reliability is sufficient (> 0.7) for group-comparisons in all examined instruments. Most mobility measurements have limited use for individual monitoring of mobility over time in older hospital patients with cognitive impairment because of the large measurement error (> 20% of scale width), even though relative reliability estimations seem sufficient (> 0.9) for this purpose.

Trial registration

German Clinical Trials Register (DRKS00005591). Registered 2 February 2015.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1036-z) contains supplementary material, which is available to authorized users.

Current use of measurement instruments by physiotherapists working in Germany: a cross-sectional online survey

Background

The use of measurement instruments in physiotherapy has been recommended in clinical practice guidelines to improve evidence-based practice. The aims of the study were (a) to describe the current use of measurement instruments by physiotherapists working in Germany and (b) to investigate the facilitators and barriers to use measurement instruments.

Methods

This cross-sectional study used a nationwide online survey, which was accessible to all physiotherapists working in Germany.

Results

In total, 522 adult physiotherapists working in Germany completed the questionnaire. The mean age of the respondents was 38 years, 63% were female, and 53% had >10 years of work experience.

Thirty-one percent of the respondents used measurement instruments in ≥80% of their patients, and 26% used measurement instruments in ≤20%. Measurement instruments were used for diagnostic and prognostic purposes by 69% and 22% of respondents, respectively. The three most frequently reported measurement instruments were “goniometer” (n = 254), some kind of a “visual/numeric analogue scale” (n = 139), and the “manual examination of muscle-strength” (n = 54). Seven of the 13 most stated measurement instruments measure activities or participation.

The most important facilitator was physiotherapists’ positive attitudes towards measurement instruments. Two out of three respondents reported having sufficient knowledge and skills to apply measurement instruments in clinical practice. The most pronounced barriers were insufficient additional financial compensations and requiring extra time to document test scores. Seventy-eight percent of the respondents could imagine using an electronic device for a user-friendly patient health record system in clinical practice.

Conclusions

The limited use of measurement instruments reported by physiotherapists working in Germany appears to be due to organisational issues, in combination with a lack of knowledge and skills needed to apply the measurement instruments, rather than due to individual or managerial reasons. To support the use of measurement instruments, sufficient time resources and adequate financial compensation are required. Educational approaches should focus on imparting patient-centred and patient-reported outcomes to quantify activities and participation. Electronic patient health record systems have potential to facilitate the application of standardised measurement instruments if the barriers identified in this survey are addressed properly.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3563-2) contains supplementary material, which is available to authorized users.

The translation, validity and reliability of the German version of the Fremantle Back Awareness Questionnaire

Background

The Fremantle Back Awareness Questionnaire (FreBAQ) claims to assess disrupted self-perception of the back. The aim of this study was to develop a German version of the FreBAQ (FreBAQ-G) and assess its test-retest reliability, its known-groups validity and its convergent validity with another purported measure of back perception.

Methods

The FreBaQ-G was translated following international guidelines for the transcultural adaptation of questionnaires. Thirty-five patients with non-specific CLBP and 48 healthy participants were recruited. Assessor one administered the FreBAQ-G to each patient with CLBP on two separate days to quantify intra-observer reliability. Assessor two administered the FreBaQ-G to each patient on day 1. The scores were compared to those obtained by assessor one on day 1 to assess inter-observer reliability. Known-groups validity was quantified by comparing the FreBAQ-G score between patients and healthy controls. To assess convergent validity, patient’s FreBAQ-G scores were correlated to their two-point discrimination (TPD) scores.

Results

Intra- and Inter-observer reliability were both moderate with ICC_3.1 = 0.88 (95%CI: 0.77 to 0.94) and 0.89 (95%CI: 0.79 to 0.94), respectively. Intra- and inter-observer limits of agreement (LoA) were 6.2 (95%CI: 5.0–8.1) and 6.0 (4.8–7.8), respectively. The adjusted mean difference between patients and controls was 5.4 (95%CI: 3.0 to 7.8, p<0.01). Patient’s FreBAQ-G scores were not associated with TPD thresholds (Pearson’s r = -0.05, p = 0.79).

Conclusions

The FreBAQ-G demonstrated a degree of reliability and known-groups validity. Interpretation of patient level data should be performed with caution because the LoA were substantial. It did not demonstrate convergent validity against TPD. Floor effects of some items of the FreBAQ-G may have influenced the validity and reliability results. The clinimetric properties of the FreBAQ-G require further investigation as a simple measure of disrupted self-perception of the back before firm recommendations on its use can be made.

[Physical training as core component of multimodal treatment of older frail people-study protocol of a randomized controlled pilot study]

BACKGROUND AND OBJECTIVE

Clinical practice guidelines recommend a multimodal intervention based on standardized screening for the treatment of frailty, which includes physical exercise as the main component. This study protocol describes a planned randomized controlled pilot study to evaluate the feasibility of a main study and first assessment of the effects of a multimodal, resource-oriented intervention program on frailty in older people.

METHODS AND ANALYSES

A total of 50 community-dwelling older men and women with frailty, ≥65 years of age, will be randomly allocated to the intervention or control group. The intervention group receives usual care and a multimodal intervention program. This program consists of a multidimensional screening, verbal counselling, written instructions on individual functional and health status, a home-based physical exercise program (high-intensity functional exercise program, HIFE), and support related to cognition, mood, risk of falling, medication, nutrition and self-care as required. The control group participants will receive usual care only. The feasibility will be assessed by indicators for processes, resources and management (practicability), as well as for acceptance, safety and possible effects of the intervention. The frailty index and secondary clinical endpoints will be assessed before and after the 3‑month intervention, as well as after a 3-month follow-up to estimate the effects. Data will be analyzed according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of the German Physiotherapy Association (ref. number: 2017-02). Outcomes will be disseminated in a peer-reviewed journal and at specialist conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register: DRKS00011831.

Wirksamkeit und Durchführbarkeit von Graphästhesie-Training bei Patienten mit chronisch unspezifischen Rückenschmerzen

Hintergrund Chronisch unspezifischer Rückenschmerz (CURS) stellt ein erhebliches Gesundheitsproblem dar. Aktuelle Studien weisen darauf hin, dass kortikale Veränderungen bei den betroffenen Patienten ein beitragender Faktor für die Persistenz von Schmerzen sein können. Bei anderen Patienten mit chronischen Schmerzen und nachgewiesenen kortikalen Veränderungen konnte die Wirksamkeit sensorischer Trainingsansätze gezeigt werden. Unklar ist, ob diese Ansätze auch bei Patienten mit CURS wirksam sind.

Ziel Das Ziel dieser Pilotstudie war es, die Größenordnung möglicher Effekte des Graphästhesie-Trainings einzuschätzen und dessen Durchführbarkeit zu überprüfen.

Methoden 9 Probanden wurden randomisiert in 2 Gruppen eingeteilt. In der 3-wöchigen Interventionsphase erhielt die Kontrollgruppe physiotherapeutische „Usual Care“, während die Interventionsgruppe zusätzlich 2-mal wöchentlich ein 20-minütiges Graphästhesie-Training absolvierte.

Ergebnisse Im Vergleich der beiden Messzeitpunkte innerhalb sowie zwischen den Gruppen zum Messzeitpunkt 2 fanden sich keine signifikanten Unterschiede. Deskriptiv zeigte sich die Tendenz einer verbesserten Graphästhesie-Fehlerrate und Zweipunktdiskriminationsschwelle sowie von Schmerzintensität, -interferenz und körperlicher Funktion in der Interventionsgruppe.

Schlussfolgerung Das Graphästhesie-Training ist im klinischen physiotherapeutischen Kontext durchführbar und führt nicht zu unerwünschten Nebenwirkungen. Bezüglich der Wirksamkeit bestehen lediglich Tendenzen. Aufgrund des Pilotcharakters der Arbeit sind die Ergebnisse mit Vorsicht zu interpretieren. Es bedarf Folgestudien mit größeren Studienpopulationen zu kombinierten sensomotorischen Trainingsprogrammen bei CURS, insbesondere erweitert um den Aspekt einer vorangehenden Klassifizierung der Patienten in Subgruppen.

Comparison of the de Morton Mobility Index and Hierarchical Assessment of Balance and Mobility in older acute medical patients

OBJECTIVE

To compare the measurement properties of the de Morton Mobility Index (DEMMI) and the Hierarchical Assessment of Balance and Mobility (HABAM) in an older acute medical inpatient population.

DESIGN

Cross-sectional.

SUBJECTS

Older acute medical inpatients.

METHODS

The DEMMI, HABAM and further assessments were performed after hospital admission. Construct validity was assessed by testing 13 hypotheses on convergent and known-groups validity. Test-retest reliability and minimal detectable change were estimated based on a re-assessment of unchanged patients. Floor and ceiling effects were used to indicate adequacy of scale width.

RESULTS

For both the DEMMI and HABAM, 11 (85%) hypotheses regarding construct validity were confirmed (n = 158). Both scales showed strong correlations with other multi-component mobility scales (Spearman's rho 0.75-0.92). Neither floor nor ceiling effects were evident. The intraclass correlation coefficient was 0.98 (95% confidence interval (95% CI) 0.96-0.99) for the DEMMI and 0.99 (95% CI 0.99-0.99) for the HABAM, respectively (n = 30). The minimal detectable change with 90% confidence was 6 points on the 100-point DEMMI scale and 1 point on the 26-point HABAM scale.

CONCLUSION

The DEMMI and the HABAM appear to be suitable for measuring mobility in older acute medical patients.

Measuring mobility in older hospital patients with cognitive impairment using the de Morton Mobility Index

Background

Mobility is a key outcome in older patients with cognitive impairment. The de Morton Mobility Index (DEMMI) is an established measure of older people’s mobility that is promising for use in older patients with cognitive impairment. The aim of this study was to examine the DEMMI’s psychometric properties in older patients with dementia, delirium or other cognitive impairment.

Methods

This cross-sectional study was performed in a geriatric hospital and includes older acute medical patients with cognitive impairment indicated by a Mini Mental State Examination (MMSE) score ≤ 24 points. A Rasch analysis was performed to check the DEMMI’s unidimensionality. Construct validity was assessed by testing 13 hypotheses about expected correlations between the DEMMI and outcome measures of similar or related constructs, and about expected differences of DEMMI scores between groups differing in mobility related characteristics. Administration times were recorded.

Results

A sample of 153 patients with mild (MMSE 19–24 points; 63%) and moderate (MMSE: 10–18 points; 37%) cognitive impairment was included (age range: 65–99 years; mean MMSE: 19 ± 4, range: 8–24 points; diagnosis of dementia and delirium: 40% and 18%, respectively). Rasch analysis indicated unidimensionality with an overall fit to the model (P = 0.107). Internal consistency reliability was excellent (Cronbach’s alpha = 0.92). Eleven out of 13 (85%) hypotheses on construct validity were confirmed. The DEMMI showed good feasibility, and no adverse events occurred. The mean administration time of 5 min (range: 1–10) was not influenced by the level of cognitive impairment. In contrast to some other comparator instruments, no floor or ceiling effects were evident for the DEMMI.

Conclusions

Results indicate sufficient psychometric properties of the DEMMI in older patients with cognitive impairment.

Trial registration

German Clinical Trials Register (DRKS00005591). Registered February 2, 2015.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0780-9) contains supplementary material, which is available to authorized users.

Reliability and validity of the de Morton Mobility Index in individuals with sub-acute stroke

PURPOSE

To establish the validity and reliability of the de Morton Mobility Index (DEMMI) in patients with sub-acute stroke.

METHODS

This cross-sectional study was performed in a neurological rehabilitation hospital. We assessed unidimensionality, construct validity, internal consistency reliability, inter-rater reliability, minimal detectable change and possible floor and ceiling effects of the DEMMI in adult patients with sub-acute stroke.

RESULTS

The study included a total sample of 121 patients with sub-acute stroke. We analysed validity (n = 109) and reliability (n = 51) in two sub-samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 12.37, p = 0.577). All hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach's alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.95; 95% confidence interval: 0.92-0.97) were excellent. The minimal detectable change with 90% confidence was 13 points. No floor or ceiling effects were evident.

CONCLUSIONS

These results indicate unidimensionality, sufficient internal consistency reliability, inter-rater reliability, and construct validity of the DEMMI in patients with a sub-acute stroke. Advantages of the DEMMI in clinical application are the short administration time, no need for special equipment and interval level data. The de Morton Mobility Index, therefore, may be a useful performance-based bedside test to measure mobility in individuals with a sub-acute stroke across the whole mobility spectrum. Implications for Rehabilitation The de Morton Mobility Index (DEMMI) is an unidimensional measurement instrument of mobility in individuals with sub-acute stroke. The DEMMI has excellent internal consistency and inter-rater reliability, and sufficient construct validity. The minimal detectable change of the DEMMI with 90% confidence in stroke rehabilitation is 13 points. The lack of any floor or ceiling effects on hospital admission indicates applicability across the whole mobility spectrum of patients with sub-acute stroke.

German translation, cross-cultural adaptation and diagnostic test accuracy of three frailty screening tools : PRISMA-7, FRAIL scale and Groningen Frailty Indicator

BACKGROUND

Routine screening for frailty could be used to timely identify older people with increased vulnerability und corresponding medical needs.

OBJECTIVE

The aim of this study was the translation and cross-cultural adaptation of the PRISMA-7 questionnaire, the FRAIL scale and the Groningen Frailty Indicator (GFI) into the German language as well as a preliminary analysis of the diagnostic test accuracy of these instruments used to screen for frailty.

METHODS

A diagnostic cross-sectional study was performed. The instrument translation into German followed a standardized process. Prefinal versions were clinically tested on older adults who gave structured in-depth feedback on the scales in order to compile a final revision of the German language scale versions. For the analysis of diagnostic test accuracy (criterion validity), PRISMA-7, FRAIL scale and GFI were considered the index tests. Two reference tests were applied to assess frailty, either based on Fried's model of a Physical Frailty Phenotype or on the model of deficit accumulation, expressed in a Frailty Index.

RESULTS

Prefinal versions of the German translations of each instrument were produced and completed by 52 older participants (mean age: 73 ± 6 years). Some minor issues concerning comprehensibility and semantics of the scales were identified and resolved. Using the Physical Frailty Phenotype (frailty prevalence: 4%) criteria as a reference standard, the accuracy of the instruments was excellent (area under the curve AUC >0.90). Taking the Frailty Index (frailty prevalence: 23%) as the reference standard, the accuracy was good (AUC between 0.73 and 0.88).

CONCLUSION

German language versions of PRISMA-7, FRAIL scale and GFI have been established and preliminary results indicate sufficient diagnostic test accuracy that needs to be further established.

[Diagnosis and Treatment of Physical Frailty]

Physical frailty is a physiological syndrome of older people. It is characterized by a reduced reserve, a reduced stressor resistance, and vulnerability to negative health outcomes. The assessment of physical frailty is increasingly applied to identify high risk patients prior to medical or surgical interventions. The present article describes Fried's frailty phenotype, which is the most frequently applied diagnostic instrument of physical frailty, together with evidence based treatment options.

[Effects of Vibrax (Mechanical Vibrations) on the Arterial Blood Gases of Patients in the Intensive Care Unit after Cardiac Surgery]

OBJECTIVE

Respiratory physiotherapy is an integral part of the care of patients in intensive care units (ICU) after cardiac surgery. One of the most commonly used techniques in ICU to prevent pulmonary complications are mechanical vibrations, which can be applied with a tool called Vibrax.The aim of this study was to investigate the effects of Vibrax (mechanical vibrations) on the arterial blood gases of patients in ICU during the 1. or 2. day after cardiac surgery.

METHODS

A randomized controlled pilot study was conducted with 23 patients. The participants of the control group (CG) received a cardiovascular training with mobilization to the edge of the bed and active breathing exercises. On the patients of the intervention group (IG) additionally Vibrax was applied for 5 minutes. As primary outcome parameter the PaO2/FiO2 ratio was measured.

RESULTS

In the CG no significant changes over time were observed (p ≥ 0.06). The IG showed a significant (p = 0.009) increase in the PaO2/FiO2 ratio from before the physiotherapy intervention (M = 296.52, SE = 34.94 mmHg) to 60 minutes after completion of the physiotherapy intervention (M = 331.39, SE = 48.14 mmHg). There was no significant difference between the CG and IG at any measuring time (p ≥ 0.09).

CONCLUSION

The results of this pilot study indicate that the application of Vibrax has positive effects on the arterial blood gases of patients in ICU on the 1. or 2. day after cardiac surgery. But whether the effects are clinically relevant could not be clarified.

Interprofessional education – structural and didactical challenges / Interprofessionelles Lehren, Lernen und Handeln – Strukturelle und didaktische Herausforderungen

After five years of experience in interprofessional education (IPE) in the Bachelor programs occupational therapy, midwifery, nursing, speech therapy, and physiotherapy at the University of Applied Sciences in Bochum (Germany), we have systematically evaluated and substantially revised our IPE concept in 2014/15. The structural and curricular embedding of IPE throughout the course of the five Bachelor programs requires the development and ongoing evolution of a binding concept for the interprofessional competence development. This concept needs to be based on a systematic reflection of current practice and sound scientific knowledge concerning interprofessional topics. Furthermore, it needs to address the promotion of competencies to act inter- and transprofessionally to enable a high quality of care (Wissenschaftsrat, 2012; Walkenhorst, 2012). Results of narrative literature reviews, structured internal discussions, interviews of experts and various internal and external evaluations have been incorporated into a new conceptual framework for IPE. It has been shown that a revision of the structure, the temporal sequences of modules and the framework to facilitate interprofessional practice are essential steps for continuous development of interprofessional education. In addition, barriers and challenges are identified and discussed. Overall, the process of development has been coordinated and accompanied continuously and successfully by an IPE committee involving different groups of representative members from the Department of Applied Health Sciences.

Effects of additional, dynamic supported standing practice on functional recovery in patients with sub-acute stroke: a randomized pilot and feasibility trial

OBJECTIVE

To evaluate the feasibility and preliminary effectiveness of additional dynamic versus static passive standing performed by patients with sub-acute stroke supervised by trained helpers.

DESIGN

Assessor blinded, randomized pilot and feasibility trial.

SETTING

Neurological rehabilitation centre.

PARTICIPANTS

Non-ambulatory participants in the sub-acute phase after stroke.

INTERVENTION

Usual care plus additional standing training, consisting of either dynamic standing practice in a modified standing frame (intervention group, n=14) or static standing practice in a conventional standing frame (control group, n=14) for 5 weeks.

MAIN MEASURES

Feasibility was assessed through occurrence of adverse events, patient satisfaction and operability of the technical device handled by trained helpers. Preliminary effectiveness was assessed with the Berg Balance Scale (primary outcome) and other measures of physical functioning.

RESULTS

Trained helpers were capable to apply the intervention, and no adverse events occurred. Both groups were comparable at baseline. Within-group changes tended to be higher for the intervention group, but did not reach a significant level except for the Functional Ambulation Categories. Specifically, median pre-post improvements in the Berg Balance Scale tended to be higher in the dynamic (20, inter quartile range (IQR): 2-33 points) than in the static standing group (4.5, IQR: 0-16 points; U=62; P=0.052; effect size=0.478).

CONCLUSIONS

In severely affected individuals after stroke, dynamic supported standing practice can be performed safely by trained helpers. In a larger-scale phase III study, a total of 116 patients would be needed to prove the preliminary effectiveness found in this study.

Reliability and validity of the German translation of the de Morton Mobility Index (DEMMI) performed by physiotherapists in patients admitted to a sub-acute inpatient geriatric rehabilitation hospital

BACKGROUND

Mobility is a key outcome in geriatric rehabilitation. The de Morton Mobility Index (DEMMI) is an internationally well-established, unidimensional measure of mobility with good psychometric properties. The aim of this study was to examine the reliability and construct validity of the German translation of the DEMMI in geriatric inpatients.

METHODS

This cross-sectional study included patients admitted to a sub-acute inpatient geriatric rehabilitation hospital (reliability sample: N = 33; validity sample: N = 107). Reliability, validity, and unidimensionality were investigated.

RESULTS

Inter-rater reliability between two graduate physiotherapists was excellent, with intra-class correlation coefficient of 0.94 (95% confidence interval: 0.88-0.97). The minimal detectable change with 90% confidence was 9 points. Construct validity for the DEMMI was evidenced by significant moderate to strong correlations with other measures of mobility and related constructs (Performance Oriented Mobility Assessment: rho = 0.89; Functional Ambulation Categories: rho = 0.70; six-minute walk test: rho = 0.73; gait speed: rho = 0.67; Falls Efficacy Scale International: rho = -0.68). Known-groups validity was indicated by significant DEMMI mean group differences between independent versus dependent walkers and walking aid users versus non-users. Unidimensionality of the German DEMMI translation was confirmed by Rasch analysis.

CONCLUSIONS

The German translation of the DEMMI is a unidimensional instrument producing valid and reproducible measurement of mobility in an inpatient geriatric rehabilitation setting.

The impact of rollator loading on gait and fall risk in neurorehabilitation - a pilot study

PURPOSE

Rollator loading is an application used clinically sometimes to improve functional integrity and security of the patients' gait. As empirical evidence supporting this intervention is equivocal, the purpose of this study was to examine the effects of rollator loading on several gait parameters and fall risk.

METHODS

An explicatory experiment with a follow-up cohort study of falls was conducted. In the experimental part of the study, participants (n = 25) were evaluated three times by means of different gait and fall risk assessments, whereby each trial was carried out with different rollator loading (0, 4.5 and 9 kg, respectively). Participants were blinded towards the applied load. In addition, the odds ratio of falls with respect to rollator loading in all-day rehabilitation life was determined.

RESULTS

No changes in spatio-temporal gait parameters and fall risk in relation to a particular load could be identified by clinical measures in the tested sample. A separate sub-group analysis (Parkinson's disease, hemiparesis and ataxia) showed only little impact of the load in each case. Rollator loading had no impact on the odds ratio of inpatient fall risk.

CONCLUSION

On the basis of our findings, weighting of rollators can neither be discouraged nor recommended. Implications for Rehabilitation Unless more research is has been conducted on this topic, rollator loading can neither be recommended nor discouraged in individuals suffering from neurologic diseases. There is more research needed to examine the impact on ambulation in distinct conditions such as severe ataxia and fear of falling.

[Recommendation of an assessment protocol to describe geriatric inpatient rehabilitation of lower limb mobility based on ICF: an interdisciplinary consensus process]

Because of the growing demand of geriatric rehabilitation, objective and clear indication decisions are needed with respect to limited financial resources. The aim of an interdisciplinary consensus group was to critically evaluate the most commonly used tests of functional performance of the lower limbs and to recommend useful tests to document progress of inpatient rehabilitation. Assessment of standing, walking, walking with a dual-task, sit-to-stand transfer, lying-to-sit-to-stand transfer, and stair climbing were recommended to document functional performance of the lower limbs and to describe rehabilitation targets. Future research is needed, because reasonably validated assessment tools do not exist for all of these domains. In addition to a standardized assessment of physical capacity, physical activity and participation with regard to the International Classification of Functioning, Disability, and Health (ICF) context have to be assessed. Body fixed sensors seem to be a promising assessment tool to objectively document progress in rehabilitation.

ICF components of corresponding outcome measures in flexor tendon rehabilitation - a systematic review

Background

The International Classification of Functioning, Disability and Health (ICF) delivers a holistic approach to health conditions. The objective of the present study is to provide an overview of flexor tendon rehabilitation outcome measures with respect to ICF components. Furthermore, it aims to investigate to which extent current assessments measure aspects of health according to these components primarily focussing on activity and participation.

Methods

A systematic literature review was conducted to identify all studies meeting the inclusion criteria. Studies were only included if they assessed more than body function and body structure and referred to the ICF components activity and participation. The outcome measures were analysed and their linkage to the ICF components were investigated to examine to which degree aspects of health outcome as defined by the ICF were considered.

Results

As anticipated, the application of outcome measures after flexor tendon repair is non conform. In many studies the emphasis still lies on physical impairment neglecting activity limitations and participation restrictions.

Aspects of health after flexor tendon repair could be assessed more adequately and cover patients' needs more sufficiently by choosing outcome measures which refer to all aspects of functioning.

Conclusion

The ICF can help to identify aspects of health which are not being considered. The ICF can help promote further development of adequate outcome measures including activity limitation and participation restrictions by targeting patient centred goals and respecting patients' needs.

Postural responses to multidirectional stance perturbations in cerebellar ataxia

Previous studies of patients with focal cerebellar damage underscored the importance of the cerebellum for balance control. These studies were restricted to postural control in the pitch plane, and focused mainly on leg muscle responses. Here, we examined the effect of degenerative cerebellar lesions on postural control in multiple directions, and studied how such lesions affect intersegmental coordination of the legs, trunk and arms. We formulated two main questions. (a) Do patients with cerebellar ataxia predominantly have balance problems in the sagittal or frontal planes? (b) Is instability in cerebellar ataxia associated with increased joint motion or with reduced joint motion? We selected nine patients with autosomal dominant spinocerebellar ataxia (SCA)--three with pure ataxia and six with mild extra-cerebellar features--and 12 matched controls. Upright standing subjects received support surface rotations (7.5 degrees at 60 degrees /s) that were randomly delivered in eight different directions of pitch or roll. We used full body kinematics to determine displacements of the center of mass (COM) and of individual body segments. We also collected surface EMG from 10 leg, trunk and arm muscles. Primary variables of interest were COM displacement and trunk control (angles and muscle responses). Secondary analyses focused on angles and muscle responses of the legs and arms. COM analysis demonstrated that SCA patients had greatest instability following backward and laterally directed perturbations. Major factors in causing this instability were, first, a marked reduction of stimulus-induced knee flexion and, second, excessive "hypermetric" motion of the pelvis (in roll) and trunk (in pitch). Muscle responses of SCA patients were characterized by increased late balance correcting activity. Responses of patients with pure ataxia were comparable to those of patients with mild extra-cerebellar features. A main underlying cause of postural instability in SCA patients appears to be "locking" of the knees, which may reflect compensation (by reducing interaction between body links) or reduced vestibulocerebellar control over leg muscles. The observed pathophysiology is very different from that seen in other patient populations.

Improvements in balance after total hip replacement

We have investigated whether control of balance is improved during stance and gait and sit-to-stand tasks after unilateral total hip replacement undertaken for osteoarthritis of the hip.

We examined 25 patients with a mean age of 67 years (sd 6.2) before and at four and 12 months after surgery and compared the findings with those of 50 healthy age-matched control subjects. For all tasks, balance was quantified using angular measurements of movement of the trunk.

Before surgery, control of balance during gait and sit-to-stand tasks was abnormal in patients with severe osteoarthritis of the hip, while balance during stance was similar to that of the healthy control group. After total hip replacement, there was a progressive improvement at four and 12 months for most gait and sit-to-stand tasks and in the time needed to complete them. By 12 months, the values approached those of the control group. However, trunk pitch (forwards-backwards) and roll (side-to-side) velocities were less stable (greater than the control) when walking over barriers as was roll for the sit-to-stand task, indicative of a residual deficit of balance.

Our data suggest that patients with symptomatic osteoarthritis of the hip have marked deficits of balance in gait tasks, which may explain the increased risk of falling which has been reported in some epidemiological studies. However, total hip replacement may help these patients to regain almost normal control of balance for some gait tasks, as we found in this study. Despite the improvement in most components of balance, however, the deficit in the control of trunk velocity during gait suggests that a cautious follow-up is required after total hip replacement regarding the risk of a fall, especially in the elderly.

Spatio-temporal separation of roll and pitch balance-correcting commands in humans

This study was designed to provide evidence for the hypothesis that human balance corrections in response to pitch perturbations are controlled by muscle action mainly about the ankle and knee joints, whereas balance corrections for roll perturbations are controlled predominantly by motion about the hip and lumbro-sacral joints. A dual-axis rotating support surface delivered unexpected random perturbations to the stance of 19 healthy young adults through eight different directions in the pitch and the roll planes and three delays between pitch and roll directions. Roll delays with respect to pitch were no delay, a short 50-ms delay of roll with respect to pitch movements, (chosen to correspond to the onset time of leg muscle stretch reflexes), and a long 150-ms delay between roll and pitch movements (chosen to shift the time when trunk roll velocity peaks to the time when trunk peak pitch velocity normally occurs). Delays of stimulus roll with respect to pitch resulted in delayed roll responses of the legs, trunk, arms, and head consistent with stimulus delay without any changes in roll velocity amplitude. Delayed roll perturbations induced only small changes in the pitch motion of the legs and trunk; however, major changes were seen in the time when roll motion of the trunk was arrested. Amplitudes and directional sensitivity of short-latency (SL) stretch reflexes in ankle muscles were not altered with increasing roll delay. Small changes to balance correcting responses in ankle muscles were observed. SL stretch reflexes in hip and trunk muscles were delayed, and balance-correcting responses in trunk muscles became split into two distinct responses with delayed roll. The first of these responses was small and had a directional responsiveness aligned more along the pitch plane. The main, larger, response occurred with an onset and time-to-peak consistent with the delay in trunk roll displacement and its directional responsiveness was roll oriented. The sum of the amplitudes of these two types of balance-correcting responses remained constant with roll delay. These results support the hypothesis that corrections of the body's pitch and roll motion are programmed separately by neural command signals and provide insights into possible triggering mechanisms. The evidence that lower leg muscle balance-correcting activity is hardly changed by delayed trunk roll also indicates that lower leg muscle activity is not predominant in correcting roll motion of the body. Lower leg and trunk muscle activity appears to have a dual action in balance corrections. In trunk muscles the main action is to correct for roll perturbations and the lesser action may be an anticipatory stabilizing reaction for pitch perturbations. Likewise, the small changes in lower leg muscle activity may result from a generalized stabilizing reaction to roll perturbations, but the main action is to correct for pitch perturbations.

Compensation for rotational malalignment after intramedullary nailing for femoral shaft fractures. An analysis by plantar pressure measurements during gait

INTRODUCTION

Even though rotational malalignment due to a femoral shaft fracture leads to clinical complaints, a large number of patients may have none of significance. The ability to compensate may play a role. The purpose of this study is to give insight into aspects of compensatory gait of patients with a femoral malrotation and the relation with clinical complaints.

METHODS

In a cross-sectional laboratory setting, foot-progression angles (FPA) during gait were measured using a foot scan device. Results were related to CT determined femoral torsion and clinical complaints.

RESULTS

Patients with external (EMR) or internal malrotation (IMR) showed differences in foot-progression angles (DeltaFPA) in the same direction of their malrotation. Compared to IMR patients, EMR patients appeared to compensate less for their malrotation. No statistically significant differences were detected between these groups for absolute and relative compensation. EMR patients scored worse at the Oxford 12-item and WOMAC score and experienced more problems executing demanding activities than do patients without malrotation. Correlations were found between Oxford 12-item and WOMAC score and relative compensation.

CONCLUSIONS

Femoral torsion and the FPA are strongly related. All patients compensate towards normal values of FPA at their fractured side. Patients who are less able to compensate have more physical complaints. EMR patients tend to have more complaints and difficulty compensating.

The influence of artificially increased hip and trunk stiffness on balance control in man

Lightweight corsets were used to produce mid-body stiffening, rendering the hip and trunk joints practically inflexible. To examine the effect of this artificially increased stiffness on balance control, we perturbed the upright stance of young subjects (20-34 years of age) while they wore one of two types of corset or no corset at all. One type, the "half-corset", only increased hip stiffness, and the other, the "full-corset", increased stiffness of the hips and trunk. The perturbations consisted of combined roll and pitch rotations of the support surface (7.5 deg, 60 deg/s) in one of six different directions. Outcome measures were biomechanical responses of the legs, trunk, arms and head, and electromyographic (EMG) responses from leg, trunk, and upper arm muscles. With the full-corset, a decrease in forward stabilising trunk pitch rotation compared to the no-corset condition occurred for backward pitch tilts of the support surface. In contrast, the half-corset condition yielded increased forward trunk motion. Trunk backward pitch motion after forwards support-surface perturbations was the same for all corset conditions. Ankle torques and lower leg angle changes in the pitch direction were decreased for both corset conditions for forward pitch tilts of the support-surface but unaltered for backward tilts. Changes in trunk roll motion with increased stiffness were profound. After onset of a roll support-surface perturbation, the trunk rolled in the opposite direction to the support-surface tilt for the no-corset and half-corset conditions, but in the same direction as the tilt for the full-corset condition. Initial head roll angular accelerations (at 100 ms) were larger for the full-corset condition but in the same direction (opposite platform tilt) for all conditions. Arm roll movements were initially in the same direction as trunk movements, and were followed by large compensatory arm movements only for the full-corset condition. Leg muscle (soleus, peroneus longus, but not tibialis anterior) balance-correcting responses were reduced for roll and pitch tilts under both corset conditions. Responses in paraspinals were also reduced. These results indicate that young healthy normals cannot rapidly modify movement strategies sufficiently to account for changes in link flexibility following increases in hip and trunk stiffness. The changes in leg and trunk muscle responses failed to achieve a normal roll or pitch trunk end position at 700 ms (except for forward tilt rotations), even though head accelerations and trunk joint proprioception seemed to provide information on changed trunk movement profiles over the first 300 ms following the perturbation. The major adaptation to stiffness involved increased use of arm movements to regain stability. The major differences in trunk motion for the no-corset, half-corset and full-corset conditions support the concept of a multi-link pendulum with different control dynamics in the pitch and roll planes as a model of human stance. Stiffening of the hip and trunk increases the likelihood of a loss of balance laterally and/or backwards. Thus, these results may have implications for the elderly and others, with and without disease states, who stiffen for a variety of reasons.

Reflex responses in the lower leg following landing impact on an inverting and non-inverting platform

In the lower leg, landing after a jump induces reflexes, the role of which is not well understood. This is even more so for reflexes following landing on inverting surfaces. The latter condition is of special interest since ankle inversion traumata are one of the most common injuries during sport. Most studies have investigated ankle inversions during a static standing condition. However, ankle injuries occur during more dynamic activities such as jumping. Therefore, the present study aimed at reproducing these situations but in a completely safe setting. EMG responses were recorded after landing on an inverting surface, which caused a mild ankle inversion of 25 deg of rotation (in a range sufficient to elicit reflexes but safe enough to exclude sprains). The results are compared with data from landing on a non-inverting surface to understand the effect of the inversion. In general, landing on the platform resulted in short and long latency responses (SLR and LLR) in triceps surae (soleus, gastrocnemius medialis and lateralis) and peroneal muscles (long and short peroneal) but not in the tibialis anterior muscle. Landing on the inverting platform caused significant LLRs in the peroneal muscles (which underwent the largest stretch) but not in the triceps muscles. Conversely, landing on a non-inverting platform induced larger SLRs in triceps than in the peroneal muscles. Although the peroneal LLRs thus appeared to be selectively recruited in an inverting perturbation, their role during such perturbations should be limited since the latency of these responses was about 90 ms while the inversion lasts only 42 ms. The SLRs, if present, had an onset latency of around 44 ms. In the period following the inversion, however, the responses may be important in preventing further stretch of these muscles.

Mechanically induced ankle inversion during human walking and jumping

A new method to study sudden ankle inversions during human walking and jumping is presented. Ankle inversions of 25 degrees were elicited using a box containing a trap door. During the gait task, subjects walked at a speed of 4 km/h. At a pre-programmed delay after left heel strike, an electromagnet released the box on the treadmill. This delay enabled the subject to step on the box without having to change the walking cadence. During the jumping task, subjects jumped from a 30 cm high platform on the box in a standardised way. In both tasks 20 stimulus and 20 control trials were presented randomly. The average tilting velocity of the trap door during the stimulus trials was 403 degrees /s during the walking task and 595 degrees /s during the jumping task. For the control trials a tilting of 0 degrees was used. With this method it is possible to evoke reproducible ankle inversions causing characteristic EMG responses in six lower leg muscles.