Anu Salpakoski

Physical inactivity and pain in older men and women with hip fracture history.

Hip fracture patients often suffer from pain for several months after surgery. This may lead to physical inactivity and subsequent mobility limitation and disability. The purpose of this study was to investigate the association between severe musculoskeletal pain and the level of physical activity in older people with a history of hip fracture. Data were collected from 60- to 85-year-old (n = 78) community-dwelling people, 0.7–7.5 years after hip fracture. Physical activity was assessed with the Yale Physical Activity Survey (YPAS). According to the YPAS summary index distribution, the participants were divided into the physically inactive and physically active groups. Musculoskeletal pain in the lower back, hip or knee region was assessed by the Visual Analog Scale. Pain was defined as severe pain if the subject rated the pain 66 mm or over (upper third of the scale) in at least one of the relevant body regions in the lower body. Thirty-three subjects (42%) experienced severe pain in the lower body, of whom 23 (70%) reported severe pain in the operated hip. Twenty-three patients (30%) used pain medication prescribed by a physician. The level of musculoskeletal pain was significantly higher in the physically inactive (62%) than in the physically active (31%) group (p = 0.011). Logistic regression analysis showed that people with severe pain had over three times (OR: 3.5, 95% CI: 1.30–9.39) the risk for physical inactivity compared to those with less or no pain. Multivariate adjustments for balance confidence, time since fracture, number of chronic diseases and type of surgery did not materially change the estimate (OR: 3.0, 95% CI: 1.00–9.30). Pain is an important associated factor of physical inactivity in older people with a hip fracture history. Pain management may be important in restoring and sustaining the level of physical activity after hip fracture. Further prospective and experimental studies are, however, needed to explore the causality between pain and physical activity as well as the role of pain management and physical activity interventions in preventing mobility limitation and disability among older people recovering from hip fracture.

Promoting mobility after hip fracture (ProMo): study protocol and selected baseline results of a year-long randomized controlled trial among community-dwelling older people.

BackgroundTo cope at their homes, community-dwelling older people surviving a hip fracture need a sufficient amount of functional ability and mobility. There is a lack of evidence on the best practices supporting recovery after hip fracture. The purpose of this article is to describe the design, intervention and demographic baseline results of a study investigating the effects of a rehabilitation program aiming to restore mobility and functional capacity among community-dwelling participants after hip fracture.Methods/DesignPopulation-based sample of over 60-year-old community-dwelling men and women operated for hip fracture (n = 81, mean age 79 years, 78% were women) participated in this study and were randomly allocated into control (Standard Care) and ProMo intervention groups on average 10 weeks post fracture and 6 weeks after discharged to home. Standard Care included written home exercise program with 5-7 exercises for lower limbs. Of all participants, 12 got a referral to physiotherapy. After discharged to home, only 50% adhered to Standard Care. None of the participants were followed-up for Standard Care or mobility recovery. ProMo-intervention included Standard Care and a year-long program including evaluation/modification of environmental hazards, guidance for safe walking, pain management, progressive home exercise program and physical activity counseling. Measurements included a comprehensive battery of laboratory tests and self-report on mobility limitation, disability, physical functional capacity and health as well as assessments for the key prerequisites for mobility, disability and functional capacity. All assessments were performed blinded at the research laboratory. No significant differences were observed between intervention and control groups in any of the demographic variables.DiscussionTen weeks post hip fracture only half of the participants were compliant to Standard Care. No follow-up for Standard Care or mobility recovery occurred. There is a need for rehabilitation and follow-up for mobility recovery after hip fracture. However, the effectiveness of the ProMo program can only be assessed at the end of the study.Trial registrationCurrent Controlled Trials ISRCTN53680197

Balance Confidence Was Associated With Mobility and Balance Performance in Older People With Fall-Related Hip Fracture: A Cross-Sectional Study

OBJECTIVE To study the relationship between balance confidence, a concept closely related to fear of falling, mobility and balance performance, and perceived mobility limitation in older people after a fall-related hip fracture. DESIGN Cross-sectional analyses of pretrial data of 2 randomized controlled trials of physical rehabilitation. SETTING University research center. PARTICIPANTS Community-dwelling people aged over 60 years, 6 weeks to 7.5 years after a fall-related hip fracture (N=130). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The main outcome was the self-reported Activities-specific Balance Confidence (ABC) scale score. Assessments also included perceived ability to walk outdoors or climb 1 flight of stairs, and assessments of self-preferred walking speed, modified Timed-Up-and-Go test, and Berg Balance Scale. RESULTS Higher ABC scale scores were related to better mobility and balance performance (ρ>.47) and perceived mobility function (ρ>.54). In univariate general linear models, all associations also remained significant after adjustment for age, sex, time since fracture, number of chronic diseases, and either level of physical activity or muscle strength of the fractured leg. An ABC scale score <85 points identified those with mobility and balance limitation across measures. CONCLUSIONS In people who have had a fall-related hip fracture, an independent relationship exists between balance confidence and mobility and balance performance as well as perceived mobility function. Since lack of balance confidence may compromise rehabilitation and recovery, the ABC scale may help to identify older hip fracture patients with mobility and balance limitation.

Walking Recovery after a Hip Fracture: A Prospective Follow-Up Study among Community-Dwelling over 60-Year Old Men and Women

Purpose. Recovery of walking outdoors after hip fracture is important for equal participation in the community. The causes of poor recovery are not fully understood. This study investigates recovery of walking outdoors and associated determinants after hip fracture. Methods. A prospective follow-up study, among clinical sample of 81 community-dwelling hip fracture patients over 60 years. Perceived difficulty in walking outdoors and 500 meters was assessed before fracture, at discharge to home (3.2 ± 2.2 weeks after surgery), and on average 6.0 ± 3.3 weeks after discharge. Potential determinants for walking recovery were assessed. Linear latent trajectory model was used to analyse changes during follow-up. Association between walking trajectories and potential determinants was analysed with a logistic regression model. Results. Two trajectories, No-to-minor-difficulty and Catastrophic, were found. Thirty-eight percent of the participants ended up in the Catastrophic trajectory for walking outdoors and 67% for 500 meters. Multivariate logistic regression analysis revealed that use of walking aid and indoor falls before fracture and prolonged pain were independently associated with catastrophic decline in both primary outcomes: difficulty in walking outdoors and 500 meters. Conclusions. A large proportion of community-dwelling older people recovering from hip fracture experienced catastrophic decline in outdoor walking. Acknowledging recovery prognoses at early stage enables individualized rehabilitation.

Balance confidence and functional balance are associated with physical disability after hip fracture

BACKGROUND This cross-sectional study investigated the associations between balance confidence, functional balance, and physical disability among older people after hip fracture. MATERIAL AND METHODS The study utilizes baseline data of two randomized controlled trials (ISRCTN34271567 and ISRCTN53680197). The participants were 159 community-dwelling over 60-year-old people. Health, fracture status, the date and type of surgery, and contraindications for participation were assessed in a clinical examination. Balance confidence was assessed by the Activities-specific Balance Confidence Scale (ABC) and functional balance by the Berg Balance Scale. Physical disability was assessed by a questionnaire containing 14 questions on perceived difficulty in basic (ADL) and instrumental activities of daily living (IADL). Two sum scores were composed: ADL score (range 0-6) and IADL score (range 0-8). Isometric knee extension force was measured using a dynamometer. Pain and use of walking aids were assessed by a questionnaire. The negative binomial regression analysis was used to analyze the associations. RESULTS A higher ABC score was associated with a lower risk for ADL (IRR 0.99; 95% CI 0.98-0.99) and IADL disability (0.99; 0.98-0.99) in the fully adjusted models. Also a higher BBS score was associated with a lower risk for ADL (0.98; 0.96-0.99) and IADL disability (0.98; 0.97-0.99) in the fully adjusted models. CONCLUSION Decreased balance confidence and impaired functional balance are associated with physical disability in older people after hip fracture.

Effects of a Rehabilitation Program on Perceived Environmental Barriers in Older Patients Recovering from Hip Fracture: A Randomized Controlled Trial

Objectives. To study effects of a one-year multicomponent intervention on perceived environmental barriers in hip fracture patients. Design. Randomized controlled trial of a 12-month home-based rehabilitation aiming to improve mobility and function (ISRCTN53680197); secondary analyses. Subjects. Community-dwelling hip fracture patients on average 70 days after trauma (n = 81). Methods. Assessments at baseline, 3, 6, and 12 months later included perceived entrance-related barriers (e.g., indoor/outdoor stairs, lighting, floor surfaces, and storage for mobility devices) and perceived barriers in the outdoor environment (poor street condition, hilly terrain, long-distances, and lack of resting places). Sum scores for entrance-related and outdoor barriers were analyzed using general estimating equation models. Results. At baseline, 48% and 37% of the patients perceived at least one entrance-related barrier, and 62% and 60% perceived at least one outdoor barrier in the intervention and control group, respectively. Over time, (P = 0.003) the number of entrance-related barriers decreased in both groups (group P = 0.395; interaction P = 0.571). For outdoor barriers, time (P = 0.199), group (P = 0.911), and interaction effect (P = 0.430) were not significant. Conclusion. Our intervention had no additional benefit over standard care in hip fracture patients. Further study is warranted to determine whether perceived environmental barriers can be reduced by interventions targeted at the older individual. This trial is registered with ISRCTN53680197.

Type of surgery is associated with pain and walking difficulties among older people with previous hip fracture.

The aim was to assess the level of lower body pain among people with previous femoral neck fracture, and whether the type of surgery was associated with pain and physical function a mean of 2 years after surgery.

Physical Activity After a Hip Fracture: Effect of a Multicomponent Home-Based Rehabilitation Program—A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVES To investigate the effect of a yearlong multicomponent rehabilitation program on the level of physical activity (PA) and the maintenance of the level of PA over 1-year follow-up among older people recovering from a recent hip fracture. DESIGN Secondary analysis of a randomized, controlled, parallel-group trial. SETTING Home-based rehabilitation; measurements in university laboratory. PARTICIPANTS Community-dwelling people (N=81) aged ≥60 years recovering from a hip fracture. Participants were randomly assigned to an intervention (n=40) or a control (n=41) group, on average, 42±23 days after discharge from the hospital. INTERVENTION A yearlong intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacologic pain management, a progressive home exercise program, PA counseling, and standard care. MAIN OUTCOME MEASURES The outcome was the level of PA, which was assessed with the questionnaire (a modified Grimby scale) at baseline, and 3, 6, 12, and 24 months after baseline. Three PA categories were defined: inactivity, light PA, and moderate to heavy PA. Physical function was assessed using the Short Physical Performance Battery (SPPB) at baseline. The effects of the intervention were analyzed with generalized estimating equations. RESULTS In the intervention group, a significant increase was observed in the level of PA after the intervention (interaction P=.005) and after 1-year follow-up (P=.021) compared with the standard care only. The benefit was particularly evident among the participants with a baseline SPPB score of ≥7 (interaction P<.001). CONCLUSIONS The 12-month individualized multicomponent rehabilitation program increased PA among older patients with hip fracture. The increase was found to be maintained at the 1-year follow-up.

Recovery of Lower Extremity Performance After Hip Fracture Depends on Prefracture and Postdischarge Mobility: A Subgroup Analysis of a Randomized Rehabilitation Trial.

The question of opioid diversion related to this intervention was included in a previous letter to the editor: Kind AJ, Jensen LL, Kennelty KA. Far too easy: Opioid diversion during the transition from hospital to nursing home. J Am Geriatr Soc 2014;62:2229–2231. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Dr. Kennelty has received institutional grant support from the Department of Veterans Affairs. She also served as a consultant for the Gerontological Society of America. Dr. Kind has received institutional grant support from the Department of Veterans Affairs, the National Institutes of Health, NIA and National Institute on Minority Health and Health Disparities, and the John Hartford Foundation, and serves as a consultant for the State of Maryland. No other co-authors have any conflicts of interest to disclose. This material is the result of work supported with resources at the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin (Geriatrics Research, Education, and Clinical Center, Manuscript No. 2015–017). The contents do not represent views of the Department of Veterans Affairs or the U.S. government. Dr. Kind was supported by a National Institute on Aging Beeson Career Development Award (K23AG034551, PI: Kind, National Institute on Aging, American Federation for Aging Research, John A. Hartford Foundation, Atlantic Philanthropies, Starr Foundation); National Institute on Aging (NIA) 2P50AG033514–06. Dr. Kind’s time was also partially supported by the University of Wisconsin School of Medicine and Public Health from the Wisconsin Partnership Program. Additional support was provided by the Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research, Grant UL1TR000427 from the Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health. Author Contributions: Kennelty, Jensen, Kind: study concept and design. Kennelty, Jensen, Gehring, Kind: acquisition of subjects and data. Kennelty, Jensen, Gehring, Gilmore-Bykovskyi, Roiland, Kordahl, Kind: analysis and interpretation of data. Kennelty, Jensen, Gehring, Gilmore-Bykovskyi, Roiland, Kordahl, Kind: preparation of manuscript. Sponsor’s Role: No funding source or sponsor had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript, and decision to submit the manuscript for publication.