Ross Hansen

Recurrent and Injurious Falls in the Year Following Hip Fracture: A Prospective Study of Incidence and Risk Factors From the Sarcopenia and Hip Fracture Study

BACKGROUND The incidence and etiology of falls in patients following hip fracture remains poorly understood. METHODS We prospectively investigated the incidence of, and risk factors for, recurrent and injurious falls in community-dwelling persons admitted for surgical repair of minimal-trauma hip fracture. Fall surveillance methods included phone calls, medical records, and fall calendars. Potential predictors of falls included health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, and vision. RESULTS 193 participants enrolled in the study (81 +/- 8 years, 72% women, gait velocity 0.3 +/- 0.2 m/s). We identified 227 falls in the year after hip fracture for the 178 participants with fall surveillance data. Fifty-six percent of participants fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture. Age-adjusted risk factors for recurrent and injurious falls included lower strength, balance, range of motion, physical activity level, quality of life, depth perception, vitamin D, and nutritional status, and greater polypharmacy, comorbidity, and disability. Multivariate analyses identified older age, congestive heart failure, poorer quality of life, and nutritional status as independent risk factors for recurrent and injurious falls. CONCLUSIONS Recurrent and injurious falls are common after hip fracture and are associated with multiple risk factors, many of which are treatable. Interventions should therefore be tailored to alleviating or reversing any nutritional, physiological, and psychosocial risk factors of individual patients.

Methodology and Baseline Characteristics for the Sarcopenia and Hip Fracture Study: A 5-Year Prospective Study

BACKGROUND Age-related hip fractures are associated with poor functional outcomes, resulting in substantial personal and societal burden. There is a need to better identify reversible etiologic predictors of suboptimal functional recovery in this group. METHODS The Sarcopenia and Hip Fracture (SHIP) study was a 5-year prospective cohort study following community-dwelling older persons admitted to three Sydney hospitals for hip fracture. Information was collected at baseline, and 4 and 12 months, including health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, vision, and fall-related data, with residential status, disability, and mortality reassessed at 5 years. RESULTS 193 participants enrolled (81 +/- 8 years, 72% women). High levels of activities of daily living, disability and sedentariness were present prior to fracture. At admission, the cohort had high levels of chronic disease; 38% were depressed, 38% were cognitively impaired, and 26% had heart disease. Seventy-one percent of participants were sarcopenic, 58% undernourished, and 55% vitamin D deficient. Mobility, strength, and vision were severely impaired. There was little evidence that these comorbidities were either recognized or treated during hospitalization. Disability, sedentariness, malnutrition, and walking endurance predicted acute hospitalization length of stay. CONCLUSIONS The complex comorbidity, pre-existing functional impairment, and sedentary behavior in patients with hip fracture suggest the need for thorough screening and targeting of potentially reversible impairments. Rehabilitation outcomes are likely to be highly dependent on amelioration of these highly prevalent accompaniments to hip fracture.

Gastrointestinal Symptoms in Spinal Cord Injury: Relationships With Level of Injury and Psychologic Factors

INTRODUCTIONPrevious surveys of gastrointestinal symptoms after spinal cord injury have not used validated questionnaires and have not focused on the full spectrum of such symptoms and their relationship to factors, such as level of spinal cord injury and psychologic dysfunction. This study was designed to detail the spectrum and prevalence of gastrointestinal symptoms in spinal cord injury and to determine clinical and psychologic factors associated with such symptoms.METHODSEstablished spinal cord injury patients (>12 months) randomly selected from a spinal cord injury database completed the following three questionnaires: 1) Rome II Integrative Questionnaire, 2) Hospital Anxiety and Depression Scale, and 3) Burwood Bowel Dysfunction after spinal cord injury.RESULTSA total of 110 patients participated. The prevalence of abdominal bloating and constipation were 22 and 46 percent, respectively. Bloating was associated with cervical (odds ratio = 9.5) and lumbar (odds ratio = 12.1) level but not with thoracic level of injury. Constipation was associated with a higher level of injury (cervical odds ratio = 5.6 vs. lumbar) but not with psychologic factors. In contrast, abdominal pain (33 percent) and fecal incontinence (41 percent) were associated with higher levels of anxiety (odds ratio = 6.8, and odds ratio = 2.4) but not with the level of injury. CONCLUSIONSThere is a high prevalence and wide spectrum of gastrointestinal symptoms in spinal cord injury. Abdominal bloating and constipation are primarily related to specific spinal cord levels of injury, whereas abdominal pain and fecal incontinence are primarily associated with higher levels of anxiety. Based on our findings, further physiologic and psychologic research studies in spinal cord injury patients should lead to more rational management strategies for the common gastrointestinal symptoms in spinal cord injury.

Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial

BackgroundCurrently 1 in 11 women over the age of 60 in Australia are diagnosed with breast cancer. Following treatment, most breast cancer patients are left with shoulder and arm impairments which can impact significantly on quality of life and interfere substantially with activities of daily living. The primary aim of the proposed study is to determine whether upper limb impairments can be prevented by undertaking an exercise program of prolonged stretching and resistance training, commencing soon after surgery.Methods/designWe will recruit 180 women who have had surgery for early stage breast cancer to a multicenter single-blind randomized controlled trial. At 4 weeks post surgery, women will be randomly assigned to either an exercise group or a usual care (control) group. Women allocated to the exercise group will perform exercises daily, and will be supervised once a week for 8 weeks. At the end of the 8 weeks, women will be given a home-based training program to continue indefinitely. Women in the usual care group will receive the same care as is now typically provided, i.e. a visit by the physiotherapist and occupational therapist while an inpatient, and receipt of pamphlets. All subjects will be assessed at baseline, 8 weeks, and 6 months later. The primary measure is arm symptoms, derived from a breast cancer specific questionnaire (BR23). In addition, range of motion, strength, swelling, pain and quality of life will be assessed.DiscussionThis study will determine whether exercise commencing soon after surgery can prevent secondary problems associated with treatment of breast cancer, and will thus provide the basis for successful rehabilitation and reduction in ongoing problems and health care use. Additionally, it will identify whether strengthening exercises reduce the incidence of arm swelling.Trial RegistrationThe protocol for this study is registered with the Australian Clinical Trials Registry (ACTRN012606000050550).

Evidence for Pelvic Floor Dyssynergia in Patients With Irritable Bowel Syndrome

PURPOSE: Although functional constipation is known to often manifest concomitant features of pelvic floor dyssynergia, the nature of pelvic floor symptoms and anorectal dysfunction in non-diarrhea predominant irritable bowel syndrome is less clear. This study aims to compare anorectal sensorimotor function and symptoms of patients who have non-diarrhea predominant irritable bowel syndrome with those who have functional constipation. METHODS: We studied 50 consecutive female patients referred with constipation and 2 or more symptoms of pelvic floor dyssynergia, who also satisfied Rome II criteria for either non-diarrhea predominant irritable bowel syndrome (n = 25; mean age, 47 ± 3 y) or functional constipation (n = 25; 49 ± 3 y). Assessments included the Rome II Integrative Questionnaire, a validated constipation questionnaire, Hospital Anxiety and Depression scale, visual analog scores for satisfaction with bowel habit and for impact on quality of life, and a comprehensive anorectal physiology study. RESULTS: Both groups displayed physiological evidence of pelvic floor dyssynergia; but patients with non-diarrhea predominant irritable bowel syndrome exhibited a higher prevalence of abnormal balloon expulsion (P < .01) and less paradoxical anal contraction with strain (P = .045) than patients with functional constipation. These patients with irritable bowel syndrome also reported more straining to defecate (P = .04), a higher total constipation score (P = .02), lower stool frequency (P = .02), a trend toward harder stools (P = .06), and less satisfaction with bowel habit (P = .03) than patients with functional constipation. CONCLUSION: Patients with non-diarrhea predominant irritable bowel syndrome with symptoms of pelvic floor dyssynergia exhibit overall pelvic floor dyssynergia physiology similar to that of patients with functional constipation. Certain features, however, such as abnormal balloon expulsion, may be more prominent in the patients with irritable bowel syndrome. Therapeutic modalities, such as biofeedback, that are effective in patients with functional constipation with pelvic floor dyssynergia should therefore be considered in selected patients with irritable bowel syndrome with pelvic floor dyssynergia.

Prolonged Balloon Expulsion Is Predictive of Abdominal Distension in Bloating

OBJECTIVES:Abdominal bloating and distension are common in patients with constipation. The precise mechanism of abdominal distension remains uncertain. We hypothesized that constipated patients with bloating plus distension exhibit a greater degree of anorectal dysfunction, potentially affecting gas evacuation, than those without distension. Therefore, our aim was to evaluate anorectal function and other clinical features in patients with constipation who exhibit bloating with and without distension.METHODS:In all, 88 female patients with abdominal bloating and either non-diarrhea irritable bowel syndrome (IBS) or functional constipation were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire, and all patients underwent comprehensive clinical assessment and anorectal function studies.RESULTS:Patients were divided into two groups: abdominal bloating with distension (D; n=53) and abdominal bloating without distension (ND; n=35). D featured a prolonged balloon expulsion time (P=0.005), a higher resting anal sphincter pressure (P=0.002), and a higher maximum anal sphincter squeeze pressure (P=0.015) than ND. They also experienced more bloating (P<0.001), more abdominal pain (P=0.004), harder stools (P=0.01), and more incomplete emptying (P=0.005). In logistic regression modeling, prolonged balloon expulsion time was a significant predictor of abdominal distension (P=0.018).CONCLUSIONS:This is the first study to show that prolonged balloon expulsion time predicts abdominal distension in patients with bloating and constipation. Hence, ineffective evacuation of gas and stool associated with prolonged balloon expulsion may be an important mechanism underlying abdominal distension.

Feeding and colonic distension provoke altered autonomic responses in irritable bowel syndrome

Objective. Alterations in autonomic balance, detectable by heart rate variability (HRV) analysis, have been shown to occur after a meal in patients with irritable bowel syndrome (IBS). There are few data on changes in sympathovagal responses in IBS to other forms of enteric stimulation such as colonic distension. The aim of this study was to determine the effects of colonic balloon distension on HRV in the fasting and the postprandial state in healthy subjects and in IBS patients. Material and methods. Eight IBS patients and 8 age- and gender-matched healthy subjects underwent unsedated descending colonic distension before and after a 1000 kcal liquid meal. Low- (LF) and high-frequency (HF) HRV band values obtained from 2-min ECG segments recorded before and during distension were compared between groups, and between fasting and postprandial states. A visual analogue scale was used to determine sensation during colonic distension. Results. HF values decreased significantly with feeding in IBS patients (p=0.01), but not in healthy subjects. The low-to-high frequency (LF/HF) ratio was significantly higher postprandially in IBS patients (p=0.02) and, additionally, was decreased (p<0.01) with colonic distension in the fed state, independently of colonic sensitivity or distending volume. Moreover, changes in the LF/HF ratio with distension in the fed versus the fasting state were negatively correlated in IBS patients but positively correlated in healthy subjects (both p<0.05). Conclusions. IBS patients demonstrated altered autonomic responses to feeding and colonic distension. Further studies should determine whether these alterations could explain the postprandial exacerbation of symptoms in IBS.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

Background Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non‐diarrhea predominant IBS (non‐D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

Effects of 20-mg oestradiol implant therapy on bone mineral density, fat distribution and muscle mass in postmenopausal women.

Abstract.This 64-week prospective cohort trial evaluated the effects of 20-mg oestradiol implants, replaced every 4 months, in healthy postmenopausal women aged 45–65 years. Of 20 implant and 14 control subjects who remained in the trial at 32 weeks, 13 implant and seven controls continued to 64 weeks, with no baseline differences between completing and dropout subjects. At 64 weeks, implant subjects displayed increases of 5.4–7.6% in spine and hip bone mineral density (p<0.05 versus controls). The abdominal fat-to-lean soft tissue ratio decreased by 18% in implant subjects (p<0.001), but did not change in controls (p<0.05 implants versus controls). Neither group displayed significant changes in weight, %fat or appendicular skeletal muscle mass. The 32-week data were consistent with these results. Hence, oestradiol implant therapy can reduce abdominal adiposity and could lower the risk of obesityrelated metabolic disorders.

Longitudinal Study of Patients with Anorexia Nervosa 6 to 10 Years after Treatment: Impact of Adequate Weight Restoration on Outcome

Anorexia nervosa continues to present a major health problem in contemporary society and has been shown in North America to be the third most common chronic illness in adolescent girls.1 Treatment options vary in cost and containment, predictors of outcome have been found wanting,2,3 and the long-term benefit of hospital refeeding regimes remains unproven despite efficacy in restoring weight promptly.4 By following up patients treated for anorexia nervosa 6 to 10 years earlier and by measuring parameters associated with long-term morbidity, the aim of this study was to examine the effect of index weight restoration on outcome over the period of time during which recovery usually occurs.