Interpreting Meaningful Change in the Distance Walked in the 10-Metre ISWT in Cardiac Rehabilitation

BACKGROUND

The interpretability of change in exercise test scores is an important measurement property. This study aimed to provide a framework for the interpretation of individual change scores of the 10metre incremental shuttle walk test (ISWT) in cardiac rehabilitation.

METHODS

In a quantitative pre-post design study, 52 patients who were referred to a hospital outpatient department for cardiac rehabilitation participated in this study. Participants completed two ISWTs prior to cardiac rehabilitation. Post cardiac rehabilitation, participants completed a global rating of change score and two ISWTs. Change scores were analysed for smallest detectable change (SDC) and minimum important change (MIC).

RESULTS

The SDC for an individual was 47 metres. The predicted MIC for participants to report an improvement ranged from 70 to 92 metres. The predicted MIC for participants who did not report a deterioration in the global rating of change (i.e., those who reported unchanged or improved) ranged from 16 to 42 metres.

CONCLUSIONS

The MIC for patients who report any improvement in physical fitness and functional capacity is 70 metres. These results suggest that over an 8-week program, patients would need to improve by at least seven shuttles to perceive an improvement in their physical fitness and functional capacity. Patients with small increases in the 10-metre ISWT distance may still report deterioration in their physical fitness and functional capacity.

Is the 10 m incremental shuttle walk test a useful test of exercise capacity for patients referred to cardiac rehabilitation?

BACKGROUND

Field exercise tests are a feasible alternative to the symptom-limited exercise test for measuring exercise capacity in patients attending cardiac rehabilitation.

AIMS

To evaluate the criterion validity of the 10 m incremental shuttle walk test (ISWT) as a useful tool for measurement of exercise capacity for patients eligible for cardiac rehabilitation.

METHODS

Fifteen patients eligible for cardiac rehabilitation completed a treadmill symptom-limited exercise test and two ISWTs with the order of testing randomised. Associations between the symptom-limited exercise test and the ISWT were explored and the ability of the ISWT to predict symptom-limited exercise test duration estimated.

RESULTS

There was a moderate to high association ( r² ⩾0.72) between ISWT duration and distance, and symptom-limited exercise test duration; and a moderate association between ISWT peak heart rate and end of test oxygen saturation and these outcomes on the symptom-limited exercise test (0.47⩽ r² ⩽0.67). However, prediction of symptom-limited exercise test duration based on the ISWT produced wide 95% confidence intervals, for example, ranging from 9.1 to 16.3 minutes for an individual who completes the ISWT. Order of testing did not affect the results and the association between the ISWT and symptom-limited exercise test was similar for both the first (ISWT 1) and second test (ISWT 2) ISWT.

CONCLUSIONS

The results provide support for the ISWT as a convenient field test of exercise capacity in a cardiac rehabilitation population, but not as a surrogate to predict symptom-limited exercise test duration for individuals. A single ISWT may provide as good an estimate of exercise capacity as repeating the test.

A common Asn680Ser polymorphism in the follicle-stimulating hormone receptor gene is not associated with ovarian response to gonadotropin stimulation in patients undergoing in vitro fertilization

OBJECTIVE

To assess the role of the variant p.Asn680Ser in the follicle-stimulating hormone receptor (FSHR) gene in determining ovarian response in patients undergoing in vitro fertilization (IVF) treatment.

DESIGN

Prospective observational study.

SETTING

Tertiary referral center for reproductive medicine.

PATIENT(S)

Women (n = 421) undergoing their first cycle of controlled ovarian stimulation for IVF and 83 healthy, ethnically matched controls.

INTERVENTION(S)

Baseline pelvic ultrasound and blood tests taken on days 2 to 3 of the cycle for assessment of baseline hormones and for DNA extraction.

MAIN OUTCOME MEASURE(S)

Genotypes for FSHR p.Asn680Ser determined using TaqMan allelic discrimination assay, and ovarian response to gonadotropin treatment classified as normal, poor, or overresponse based on the number of oocytes retrieved.

RESULT(S)

The FSHR p.Asn680Ser genotype frequencies were similar in IVF patients and controls. The number of oocytes retrieved was comparable between patients with different FSHR receptor genotypes. The total amount of gonadotropin used was also similar in all the genotype groups. A logistic regression analysis showed nonstatistically significant twofold difference in the distribution of genotypes between the groups with poor and normal ovarian response.

CONCLUSION(S)

The variant FSHR p.Asn680Ser was not shown to be predictive of ovarian response, but clinically relevant differences cannot be ruled out.

Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the preoperative effects of exercise-based interventions on pain and physical function for people awaiting joint replacement surgery of the hip or knee.

DATA SOURCES

Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Reference lists of retrieved articles were also screened.

STUDY SELECTION

Randomized or quasi-randomized studies comparing an exercise-based intervention with a no-intervention group for people awaiting hip or knee joint replacement surgery were included. Outcomes were pain and physical function including self-reported function, walking speed, and muscle strength. One of 2 reviewers determined that 18 studies met the inclusion criteria.

DATA EXTRACTION

The methodologic quality of each study was independently assessed by 2 reviewers using the PEDro scale, and a final PEDro score was determined by discussion and consensus between the reviewers. Participants' characteristics, content and design of the interventions, and data for quantitative synthesis were extracted by 1 reviewer.

DATA SYNTHESIS

For participants awaiting knee replacement surgery, quantitative data synthesis found no significant differences between the exercise and no-intervention groups for pain, self-reported function, walking speed, or muscle strength. For participants awaiting hip replacement surgery, quantitative data synthesis found a significant difference between the groups, with standardized mean differences (SMDs) indicating a medium-sized effect in favor of intervention for both pain (SMD=.45; 95% confidence interval .15-.75) and self-reported function (SMD=.46; 95% confidence interval .20-.72).

CONCLUSIONS

Exercise-based interventions can reduce pain and improve physical function for people awaiting hip replacement surgery but not knee replacement surgery.

Assessing individual breast cancer risk within the U.K. National Health Service Breast Screening Program: a new paradigm for cancer prevention

The aim of this study is to determine breast cancer risk at mammographic screening episodes and integrate standard risk factors with mammographic density and genetic data to assess changing the screening interval based on risk and offer women at high risk preventive strategies. We report our experience of assessing breast cancer risk within the U.K. National Health Service Breast Screening Program using results from the first 10,000 women entered into the "Predicting Risk Of breast Cancer At Screening" study. Of the first 28,849 women attending for screening at fifteen sites in Manchester 10,000 (35%) consented to study entry and completed the questionnaire. The median 10-year Tyrer-Cuzick breast cancer risk was 2.65% (interquartile range, 2.10-3.45). A total of 107 women (1.07%) had 10-year risks 8% or higher (high breast cancer risk), with a further 8.20% having moderately increased risk (5%-8%). Mammographic density (percent dense area) was 60% or more in 8.3% of women. We collected saliva samples from 478 women for genetic analysis and will extend this to 18% of participants. At time of consent to the study, 95.0% of women indicated they wished to know their risk. Women with a 10-year risk of 8% or more or 5% to 8% and mammographic density of 60% or higher were invited to attend or be telephoned to receive risk counseling; 81.9% of those wishing to know their risk have received risk counseling and 85.7% of these were found to be eligible for a risk-reducing intervention. These results confirm the feasibility of determining breast cancer risk and acting on the information in the context of population-based mammographic screening.

PCOS and peripheral AMH levels in relation to FSH receptor gene single nucleotide polymorphisms

OBJECTIVES

To determine if an association exists between the follicle-stimulating hormone receptor (FSHR) gene p.Asn680Ser polymorphism and polycystic ovary syndrome (PCOS) or with high anti-mullerian hormone (AMH) levels without PCOS.

PATIENTS

Fifty-eight women with PCOS, 24 women with high AMH (>44.5 pmol/L) without PCOS and 80 healthy ethnically matched female controls.

MAIN OUTCOME MEASURES

Prevalence of the FSHR p.Asn680Ser polymorphism, baseline serum AMH levels and response to ovulation induction with clomiphene citrate.

RESULTS

The frequency of FSHR p.Asn680Ser genotypes were not significantly different between PCOS patients, patients with high AMH without PCOS and controls (p = 0.88). Of the women with PCOS, 34/58 were on clomiphene citrate treatment and 12/34 were resistant. There was no association between sensitivity or resistance to clomiphene and p.Asn680Ser genotypes (p = 0.38).

CONCLUSIONS

There is no evidence that FSHR p.Asn680Ser genotypes are associated with PCOS, high AMH levels or response to clomiphene citrate.

Prevention of breast cancer in the context of a national breast screening programme

Breast cancer is not only increasing in the west but also particularly rapidly in eastern countries where traditionally the incidence has been low. The rise in incidence is mainly related to changes in reproductive patterns and lifestyle. These trends could potentially be reversed by defining women at greatest risk and offering appropriate preventive measures. A model for this approach was the establishment of Family History Clinics (FHCs), which have resulted in improved survival in younger women at high risk. New predictive models of risk that include reproductive and lifestyle factors, mammographic density and measurement of risk-associated single nucleotide polymorphisms (SNPs) may give more precise information concerning risk and enable better targeting for mammographic screening programmes and of preventive measures. Endocrine prevention using anti-oestrogens and aromatase inhibitors is effective, and observational studies suggest lifestyle modification may also be effective. However, referral to FHCs is opportunistic and predominantly includes younger women. A better approach for identifying older women at risk may be to use national breast screening programmes. Here were described pilot studies to assess whether the routine assessment of breast cancer risk is feasible within a population-based screening programme, whether the feedback and advice on risk-reducing interventions would be welcomed and taken up, and to consider whether the screening interval should be modified according to breast cancer risk.

P4-11-07: Feasibility and Acceptability of Offering Breast Cancer Risk Estimation in the Context of the UK National Health Service Breast Cancer Screening Programme: A New Paradigm for Cancer Prevention

Background: Currently there are no real attempts internationally to tailor breast screening programmes to individual risk Methods: We have assessed the feasibility of collecting breast cancer risk information during routine mammographic screening in the National Health Service Breast Screening Programme (NHSBSP) in England, in order to consider, ultimately, adapting the screening interval to risk of breast cancer and introducing preventive strategies in women at high risk. The study Predicting Risk Of Cancer At Screening (PROCAS) aims to recruit 60,000 women over 3 years. Results: 26,000 women (June 8th 2011) have so far given consent to join the study. Thirty six percent of the first 20,000 women in nineteen screening sites in Manchester consented to enter the study and completed a risk factor questionnaire. The median 10 year breast cancer risk was 2.65%, with 926 (9.26%) of the first 10,000 women having a 10 year risk of ≥5% and 92 (0.92%) having a 10 year risk of ≥8% (Tyrer-Cuzick), IQR:1.35. 832 (8.32%) women had a mammographic density of 60% or greater (Visual Analogue Scale). We collected saliva samples from 1019 women for genetic analysis and will extend this to 18% of participants. Of those who agreed to participate in the study, 94% indicated that they wished to know their breast cancer risk. Women with a 10-year risk of ≥8%, and women with a 10-year risk of ≥5% and mammographic density ≥60% were invited to attend or be telephoned to be counselled. To date 138 have accepted with 135, so far, having received risk counselling. Nineteen percent of the high-risk women identified subsequently decided to enter a randomised breast cancer prevention study with either a dietary or drug intervention (IBIS2, anastrazole vs placebo). Results from the first 1,000 women who provided DNA samples suggest that the risk information from the 18 validated SNPS may enhance existing risk models. Conclusion: This study demonstrates that it is feasible to determine individual breast cancer risk and offer women appropriate risk-reducing interventions within the context of a population-based mammographic screening programme.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-07.

Fine-mapping CASP8 risk variants in breast cancer

BACKGROUND

Multiple genome-wide and candidate gene association studies have been conducted in search of common risk variants for breast cancer. Recent large meta analyses, consolidating evidence from these studies, have been consistent in highlighting the caspase-8 (CASP8) gene as important in this regard. To define a risk haplotype and map the CASP8 gene region with respect to underlying susceptibility variant/s, we screened four genes in the CASP8 region on 2q33-q34 for breast cancer risk.

METHODS

Two independent data sets from the United Kingdom and the United States, including 3,888 breast cancer cases and controls, were genotyped for 45 tagging single nucleotide polymorphisms (tSNP) in the expanded CASP8 region. SNP and haplotype association tests were carried out using Monte Carlo-based methods.

RESULTS

We identified a three-SNP haplotype across rs3834129, rs6723097, and rs3817578 that was significantly associated with breast cancer (P < 5 × 10(-6)), with a dominant risk ratio and 95% CI of 1.28 (1.21-1.35) and frequency of 0.29 in controls. Evidence for this risk haplotype was extremely consistent across the two study sites and also consistent with previous data.

CONCLUSION

This three-SNP risk haplotype represents the best characterization so far of the chromosome upon which the susceptibility variant resides.

IMPACT

Characterization of the risk haplotype provides a strong foundation for resequencing efforts to identify the underlying risk variant, which may prove useful for individual-level risk prediction, and provide novel insights into breast carcinogenesis.

Strength training can be enjoyable and beneficial for adults with cerebral palsy

PURPOSE

To explore the positive and negative perceptions of participating in a strength- training programme for adults with cerebral palsy.

METHOD

Ten adults aged over 40 years with cerebral palsy participated in a group-based 10-week progressive resistance strength-training programme in a community gymnasium. After the programme, each participant was interviewed using an in-depth semi-structured format and the results coded thematically.

RESULTS

Participants perceived that their strength, and ability to perform everyday activities had improved. However, the main benefit for participants was enjoyment and social interaction. The only negative perceptions related to fatigue, short-term muscle soreness and a feeling that they had not improved as much as they had expected.

CONCLUSIONS

Enjoyment, a factor that can promote adherence and sustainability, was a key benefit of this strength-training programme for adults with cerebral palsy that led to perceptions of increased strength and physical functioning. These findings suggest that exercise programmes for adults with cerebral palsy should be conducted in a group in the community, thereby promoting community inclusion. In addition, it is important to provide education to participants about the normal responses and expectations of an exercise programme.

Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial

OBJECTIVE

To compare the preoperative effects of multidimensional land-based and pool-based exercise programs for people awaiting joint replacement surgery of the hip or knee.

DESIGN

Randomized, single-blind, before-after trial.

SETTING

Physiotherapy gymnasium and hydrotherapy pool.

PARTICIPANTS

Patients awaiting elective hip or knee joint replacement surgery.

INTERVENTIONS

Land-based (n=40) or pool-based exercise program (n=42). Each 6-week program included an education session, twice-weekly exercise classes, and an occupational therapy home assessment.

MAIN OUTCOME MEASURES

Participants were assessed immediately before and after the 6-week intervention, then 8 weeks later. Primary outcomes were pain and self-reported function (Western Ontario and McMaster Universities Osteoarthritis Index) and patient global assessment. Secondary outcomes were performance-based measures (timed walk and chair stand) and psychosocial status (Medical Outcomes Study 36-Item Short-Form Health Survey mental component score). Pain was also measured before and after each exercise class on a 7-point verbal rating scale.

RESULTS

Although both interventions were effective in reducing pain and improving function, there were no postintervention differences between the groups for the primary and secondary outcomes. However, the pool-based group had less pain immediately after the exercise classes.

CONCLUSIONS

While our multidimensional exercise-based interventions appeared to be effective in reducing disability in those awaiting joint replacement surgery of the hip or knee, there were no large differences in the postintervention effects of the interventions. However, pool-based exercise appeared to have a more favorable effect on pain immediately after the exercise classes.

Reliability of performance-based measures in people awaiting joint replacement surgery of the hip or knee

BACKGROUND AND PURPOSE

Understanding the reliability of selected measurement tools is a prerequisite to understanding the effects of clinical interventions. The aim of this investigation was to determine the reliability of the 50-Foot Timed Walk (50 FTW) and 30-second Chair Stand Test (30 CST) in subjects awaiting joint replacement surgery of the hip or knee.

METHODS

Eighty-two subjects participating in a 6-week exercise programme were assessed at baseline, 7 weeks and 15 weeks. Four trials of the 50 FTW and two trials of the 30 CST were completed at each assessment. Eleven trained assessors completed the assessments.

RESULTS

Intra-class correlations were consistently high for the 50 FTW and 30 CST at all assessments. At the baseline assessment, trial 1 was found to be significantly different from subsequent trials for both the 50 FTW and 30 CST. This effect was not evident at the 7-week and 15-week assessments. At the baseline assessment, scores for the 50 FTW became stable after the first trial. Estimates of minimum detectable change indicated that participants needed to change by more than 3.08 seconds and 1.64 stands to be 90% confident that a real change had occurred for the 50 FTW and 30 CST, respectively.

CONCLUSION

The 50 FTW and 30 CST can be reliable measures of physical performance. However, because we found a practice effect at the baseline assessment, a practice trial should be allowed before data collection begins. Because only two trials of the 30 CST were completed, further research is required to confirm whether scores at the initial assessment become stable on repeated testing.

Telephone based asthma management - financial and individual benefits

METHODS

The authors calculated the cost of delivering telephone based asthma management compared to usual care. Self efficacy and quality of life were measured at recruitment, 6 months and 12 months. Participants were invited to comment on their experience of the telephone based intervention.

RESULTS

The intervention was well accepted. At 12 months there was a clinically important improvement in mean quality of life in the intervention group not seen in the control group. Telephone based management costs were offset by reductions in the number of readmissions in the intervention group.

DISCUSSION

Telephone based asthma management offers a well accepted, low cost yet potentially effective means of delivering asthma care.

A pilot study of telephone based asthma management

BACKGROUND

Self management programs have been advocated for adults who have recently been admitted to hospital or have recently attended an emergency department because of asthma. A new telephone based approach has already been trialled for the management of a number of other chronic conditions. This study sought to determine the effect of a telephone based asthma management program for adults with asthma.

METHODS

Adults with one or more previous admissions for asthma to either or both of two tertiary hospitals between 1 May 2001 and 30 November 2003 were invited to participate. All participants received one face-to-face session with an asthma educator. Participants were randomised to intervention (six telephone calls over 6 months) or control (usual care) groups. Measures of health care utilisation and morbidity were collected weekly for 12 months.

RESULTS

Seventy-one adults (54 females) with a mean age of 36.2 years were recruited to the study. Twenty hospital re-admissions were recorded for the control group and one for the intervention group at 12 months. Re-admission was significantly associated with allocation to control group (p=0.05). The control group was significantly more likely to report being woken by asthma on more than half the nights of the week (p=0.03).

DISCUSSION

Telephone based self management intervention results in clinically important reductions in hospital re-admission in adults previously hospitalised with asthma.

Self management beliefs--attitudes and behaviour of adults with severe life threatening asthma requiring an admission to hospital

BACKGROUND

Adults who have had an admission for severe life threatening asthma are at high risk of future attacks or death. Optimal self management is the key to reducing this risk but relies on people recognising the severity of symptoms and engaging in specific health care behaviour.

METHODS

We used a focus group to examine self management beliefs, attitudes and behaviours in five adults admitted to hospital for asthma.

RESULTS

There were a number of themes. Patients delayed seeking medical attention until asthma symptoms were severe despite ownership of a peak expiratory flow meter, written plan, or experience of previous attack.

DISCUSSION

Insight into the significance of the severity of symptoms and need to change self management behaviour in response to symptoms is key to reducing the risk of future attacks. The general practitioner has a key role in determining and addressing self management behaviour and attitudes that place patients at risk.

Targeted postoperative care improves discharge outcome after hip or knee arthroplasty1,211No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated.22Reprints are not available from the authors

OBJECTIVE

To determine whether targeted postoperative care, based on preoperative risk assessment, can increase the number of patients who are discharged home directly from acute care after elective hip or knee arthroplasty.

DESIGN

Quasiexperimental with historical control.

SETTING

A public university teaching hospital.

PARTICIPANTS

One hundred patients who had an elective hip or knee arthroplasty.

INTERVENTIONS

Between January and July 2001, 50 patients had their risk of discharge to extended inpatient rehabilitation assessed preoperatively with a newly developed Risk Assessment and Prediction Tool (RAPT). Postoperative management was targeted on the basis of the identified level of risk. Results were compared with those of a similar group of 50 patients treated between January and July 2000.

MAIN OUTCOME MEASURES

Discharge destination, length of stay (LOS), and readmission rates.

RESULTS

The percentage of patients discharged directly home increased significantly, from 34% during 2000 to 64% in 2001 (P=.002), with no increase in readmission rates in the 12 months postdischarge. In addition, the mean acute hospital LOS decreased by 1.1 days to 7.5 days in 2001 (P=.02).

CONCLUSIONS

Use of the RAPT and targeted postoperative care resulted in more patients being discharged directly home after hip or knee arthroplasty while hospital LOS further decreased.

Attendance rates and outcomes of cardiac rehabilitation in Victoria, 1998

OBJECTIVE

To describe the patterns of use of cardiac rehabilitation in Victoria and to assess whether the survival benefits predicted in clinical trials have been realised in the community.

DESIGN

Cohort study based on data linkage.

PARTICIPANTS

All patients admitted for acute myocardial infarction (AMI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in Victoria in 1998 (n = 12821).

INTERVENTIONS

Attendance at one of 66 participating outpatient cardiac rehabilitation centres in Victoria.

MAIN OUTCOME MEASURES

Rates of attendance at rehabilitation based on key factors such as diagnosis, age, sex, and comorbidity. Five-year survival for attendees compared with non-attendees.

RESULTS

Rates of participation in rehabilitation were 15% for AMI, 37% for CABG, and 14% for PTCA. Rehabilitation attendance rates dropped sharply after 70 years of age. Attendees had a 35% improvement in 5-year survival (hazard ratio for death associated with rehabilitation attendance, 0.65 [95% CI, 0.56-0.75]).

CONCLUSIONS

Attendance rates at cardiac rehabilitation are suboptimal, even though attendance confers a clinically significant difference in 5-year survival. The elderly, women, and those with comorbid conditions may benefit measurably from increased rates of attendance.

A qualitative analysis of the benefits of strength training for young people with cerebral palsy

This qualitative study investigated the positive and negative outcomes of a home-based strength-training programme for young people with cerebral palsy (CP). Eleven young people with spastic diplegic CP (seven females, four males; mean age 12 years 9 months, SD 2 years 10 months; range 8 to 18 years) and their parents were interviewed. Gross Motor Function Classification System scores ranged from I (walks without limitations) to III (walks with assistive device), with a mode of III. The strength-training programme, which was conducted in the participants' homes three times per week for 6 weeks (total of 18 prescribed sessions), comprised three exercises targeting the major support muscles of the lower limbs. Exercises were bilateral half squats, heel raises, and step-ups. The training load was increased by adding free weights to a backpack so that 8 to 10 repetitions of each exercise could be performed. Using thematic coding, three categories of outcome emerged: body function and structure, activity, and participation, which were influenced by environmental and personal contextual factors. The programme generated overwhelmingly positive outcomes with only minor negative responses about some equipment and the need for parental involvement. Benefits included perceptions that strength, flexibility, posture, walking, and the ability to negotiate steps had improved. In addition, participants reported psychological benefits such as a feeling of increased well-being and improved participation in school and leisure activities. The contextual factors highlighted the fact that sufficient clinician resources must be allocated to solve individual exercise and equipment problems. As well as providing further evidence that strength training can be beneficial, this study provides useful indicators to guide future quantitative studies of outcomes that are meaningful for people with CP.

Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty

This study developed and validated an easily administered method of predicting a patient's risk of needing extended inpatient rehabilitation after hip or knee arthroplasty. Seven factors generated by experts and from the literature were shown to be statistically significantly related to discharge destination (P</=.001). Factor weightings derived from a logistic regression equation and tested on the first 520 cases were used to devise a scoring method. This method was validated using a further 130 cases and the Risk Assessment and Predictor Tool (RAPT) was formulated. The RAPT identified 3 levels of risk of needing extended inpatient rehabilitation after hip or knee arthroplasty, with an accuracy rate of 89% for those most at risk.

Correlation of impairment and activity limitation after wrist fracture

BACKGROUND AND PURPOSE

During physiotherapy rehabilitation, judgements about activity limitation are often based on measurements of impairment. The present paper reports an investigation into the relationship between measurements of impairment and activity limitation in people with a fracture of the distal radius.

METHOD

Twenty people with a fracture of the distal radius were referred to physiotherapy after conservative management of their fractures. Measurements of impairment (grip strength and range of wrist extension) and activity limitation (Jebsen Test of Hand Function) were taken at the second physiotherapy appointment after cast removal. The scores between these measurements were correlated.

RESULTS

There were strong and significant correlations (-0.51 < rs < -0.76) between grip strength and the tasks of the Jebsen Test of Hand Function. The relationship between range of wrist extension and the Jebsen Test of Hand Function was weaker (-0.17 < rs < -0.55). However, subgroup analysis of those subjects with a Colles' type fracture of the distal radius demonstrated significant relationships between wrist extension and three of the seven activity tasks (-0.74 < rs < -0.84).

CONCLUSIONS

Preliminary evidence was found to support the physiotherapy practice of use of measurement of impairment to monitor progress in a person with a fracture of the distal radius.

Hospital stay and discharge outcomes after knee arthroplasty: implications for physiotherapy practice

Patient outcomes at discharge from acute care after knee arthroplasty were investigated in a prospective observational outcome study at three Melbourne public acute care hospitals during a five-month period from November 1999 to March 2000. The participants were 105 consecutive patients (35 at each hospital), with a mean age of 71 years. Outcome measures were length of stay, destination (home or rehabilitation), knee range of movement, and functional mobility at discharge from the acute care facility. During the study period, mean hospital length of stay across the three hospitals was 6.5 days, more than 30% less than the Victorian average for the preceding year. In that time, 56% of patients had achieved functional independence sufficient for discharge directly home, however only 36% were actually discharged home. The reasons identified for discharge to rehabilitation despite the achievement of sufficient functional independence included pressure on clinicians to decrease length of stay and the need to make decisions regarding discharge early in the post-operative recovery when the eventual patient outcome may still be unclear. Unnecessary discharges to rehabilitation increase the overall length of stay in the health care system and costs per patient. This finding suggests a method of risk screening is required to assist clinical decision making with regard to discharge.

Hospital stay and discharge outcomes after knee arthroplasty

The impact of shorter hospital lengths of stay on patient outcomes at discharge from acute care after knee arthroplasty was investigated in a prospective observational outcome study at three Melbourne public hospitals during a 5-month period from October 1999 to March 2000. The participants were 105 consecutive patients (35 at each hospital), with a mean age of 71 years. Outcome measures were length of stay, destination (home or rehabilitation) and functional mobility at discharge from the acute care facility. During the study period mean hospital length of stay across the three hospitals was 6.5 days, more than 30% less than the Victorian average for the preceding year. This was associated with high rates of discharge to rehabilitation facilities (mean 64%), with rates varying between the three hospitals (97%, 57% and 40%). However, in each hospital, one-third of this group had already achieved a level of independent functional mobility adequate for discharge home, highlighting an apparent influence of non-clinical factors on discharge decisions, including pressure to decrease length of stay, hospital policy and availability of a rehabilitation bed. Ways of achieving discharge directly home for a greater number of patients following knee arthroplasty and of determining optimal length of stay are discussed.

Knee joint kinematics from familiarised treadmill walking can be generalised to overground walking in young unimpaired subjects

We studied the familiarisation time required for reliable sagittal-plane knee kinematics and temporal-distance gait measurements to be obtained from treadmill walking. We also studied whether knee kinematics and temporal-distance gait measurements obtained from familiarised treadmill walking can be generalised to overground walking. Sixteen subjects without pathology walked on a level overground walkway and on a treadmill. A motion measurement system was used to measure sagittal plane knee movements and temporal-distance gait parameters during overground and treadmill walking. Highly reliable knee kinematics and temporal-distance gait measurements [intraclass correlation coefficient (ICC)(2,1)>/=0.93] were found after 6 min of treadmill walking. These measurements, obtained after 6 min of treadmill walking, were highly correlated with and not significantly different to those of overground walking. Reliable measurements that can be generalised to overground walking, can be obtained from the treadmill within a familiarisation time of 6 min.

Identifying participation rates at outpatient cardiac rehabilitation programs in Victoria, Australia

BACKGROUND

Much has been achieved in implementing structured outpatient cardiac rehabilitation (CR) programs in Victoria, Australia, but little is known about the percentage of eligible patients who participate. This study was undertaken to determine the feasibility of establishing a database of CR participants and comparing it to the Victorian Inpatient Minimum Database (VIMD), a routinely collected hospital morbidity data set documenting all admissions to Victorian public and private hospitals. This would enable program participants and nonparticipants to be identified and program participation rates to be calculated.

METHODS

Data on program participants were collected from a sample of eight CR programs. Records from the VIMD were extracted for the concurrent time period for patients discharged home after acute myocardial infarction (AMI), coronary artery bypass graft (CABG) surgery, and percutaneous transluminal coronary angioplasty (PTCA), and therefore considered eligible to participate. Victorian Inpatient Minimum Database data were aggregated according to program catchment areas. Data were compared for program participants and patients eligible to participate.

RESULTS

Seven hundred fifty-eight patients were identified as being eligible to attend; 240 (32%) were identified as participating at least once. Discharged CABG patients participated on average at a rate of 53.1%, compared with 27.2% of AMI patients and only 10.3% of PTCA patients.

CONCLUSIONS

Despite a comprehensive network of CR programs in Victoria, they are used on average by only a minority of eligible patients. Further work is required to determine barriers to participation to develop strategies to increase participation rates.