Sarah L. Mitchell

Randomized controlled trial of quadriceps training after proximal femoral fracture

Objective: To determine whether systematic progressive high-intensity quadriceps training increases leg extensor power and reduces disability in patients rehabilitating after proximal femoral fracture. Design: Open parallel group randomized controlled trial comparing the addition of six weeks quadriceps training (40 patients) with standard physiotherapy alone (40 patients). The training group exercised twice weekly, with six sets of 12 repetitions of knee extension (both legs), progressing up to 80% of their one-repetition maximum. Setting: Orthogeriatric unit, and community follow-up. Subjects: Eighty patients rehabilitating after proximal femoral fracture. Main outcome measures: Measurements of leg extensor power (Nottingham Power Rig), functional mobility (elderly mobility score), disability (Barthel Index) and quality of life (Nottingham Health Profile) were made at baseline, after six weeks (at the end of the intervention) and at 16 weeks. Results: Leg extensor power increased significantly in the quadriceps training group (fractured leg mean improvement at six weeks 157% (standard error 16), nonfractured leg 80% (12)) compared with the control group (63% (11) and 26% (8) respectively, unpaired Students t-test p = 0.007 and p = 0.01 for between-group comparisons). Significant benefits were maintained at 16 weeks. Quadriceps training resulted in a greater increase in elderly mobility scale score compared with standard rehabilitation (between-group difference of 2.5 (95% CI 1.1,3.8) at week 6 and 1.9 (0.4,3.4) at week 16). Barthel score increased significantly from week 0 to 6 in the quadriceps training group compared with controls (Mann–Whitney U-test p = 0.05). Patients in the quadriceps training group scored significantly better in the energy subscore of the Nottingham Health Profile at the end of follow-up (Mann–Whitney U-test p = 0.0185). Conclusions: Progressive high-intensity quadriceps training in elderly proximal femoral fracture patients increased leg extensor power and reduced disability. This was accompanied by an increase in energy as measured by the Nottingham Health Profile. This intervention may provide a simple practical way of improving outcome in these patients.

A comparison of mobility assessments in a geriatric day hospital

Objective: To assess the sensitivity of the Elderly Mobility Scale (EMS) to detect improvements in mobility after physiotherapy in comparison with the Barthel Index (BI) and Functional Ambulation Category (FAC) in routine clinical day hospital practice. Subjects: Eighty-three patients who completed a course of physiotherapy were studied. Methods: Each was assessed by an independent physiotherapist before and after a programme of physiotherapy, using the EMS, BI and FAC. Results: The mean age was 79 years (SD 7.7). Fifty-three out of 83 (64%) patients were female and 92% were community dwelling. The median number of physiotherapy sessions undergone by each patient was 9 (range 3–51). All three scales detected an improvement in mobility with physiotherapy (p < 0.001). However, using the EMS, 68 out of 82 (83%) patients had a detectable improvement in mobility compared with only 34 out of 80 (42%) using the BI and 28 out of 81 (35%) using the FAC. Using a matched-pairs comparison, the EMS was significantly more likely to detect an improvement in mobility following physiotherapy within the study group than the BI (p < 0.001) or the FAC (p < 0.001). Conclusion: Although all three scales detected improvements in mobility, the EMS detected mobility improvements in a significantly greater number of patients.

A comparison of home and hospital-based exercise training in heart failure: immediate and long-term effects upon physical activity level:

Background: In heart failure, reduced physical activity level can adversely affect physical and psychosocial functioning. No previous heart failure research has compared effects of home and hospital-based exercise training upon physical activity level, or has objectively assessed their long-term effects upon physical activity. This study used an activPAL™ monitor to examine immediate and long-term effects of home and hospital-based aerobic exercise training upon physical activity level. Design: Randomized controlled trial. Methods: Sixty patients with heart failure (mean age 66 years; NYHA class II/III; 51 male/9 female) were randomized to home training, hospital training or control. Both programmes consisted of aerobic circuit training, undertaken twice a week for one hour, for eight weeks. All participants wore the activPAL™ at baseline, and after eight weeks, for one week. Six months after cessation of training, a subgroup of participants from the home and hospital training groups (n = 10 from each group) wore the activPAL™ for a further week. Results: Hospital-based training significantly increased steps taken per day during ‘extra long’ (P = 0.04) and ‘long’ (P = 0.01) walks. Neither programme had any immediate effect upon physical activity level otherwise. Though daily upright duration for the home group significantly improved six months after cessation of training (P = 0.02), generally physical activity level was maintained in the long term for both training groups. Conclusions: Hospital-based training enabled participants to walk for longer periods. It is clinically important that both training groups maintained physical activity level in the long term, given the potential for heart failure to worsen over this time period.

Randomised controlled trial of electrical stimulation of the quadriceps after proximal femoral fracture

Background and aims: Proximal femoral fracture is often associated with long-term residual disability. Quadriceps weakness may be a factor in poor outcome. This study aimed to determine whether training of the quadriceps using electrical stimulation (ES) increases leg extensor power and decreases disability in elderly subjects rehabilitating after fracture. Methods: A single-blind randomized controlled trial of elderly postsurgical proximal femoral fracture patients, comparing 6 weeks of supplementary electrical stimulation of the quadriceps (15 patients) to usual physiotherapy alone (11 patients). The electrical stimulation on:off duty cycle was 7:23 seconds, with 36 cycles per session, given daily as an in-patient and twice weekly after discharge. The primary outcome measure was change in leg extensor power (Nottingham Power Rig). Functional mobility (Elderly Mobility Scale), disability (Barthel Index) and health status (Nottingham Health Profile) were also measured. Results: There was no significant difference in change in leg extensor power, or any other outcome measure, in the ES group compared to usualcare controls. Fractured leg extensor power increased by 10.9 (standard error of the mean 2.1) Watts at 6 weeks in the ES group compared to 15.3 (5.5) in the controls (mean adjusted difference −3.1, 95% CI −7.8, 1.6 Watts). Only 3 (20%) of the intervention patients tolerated sufficient stimulation intensity to produce repetitive knee extension, while 11 (73%) sustained palpable or visible contractions with no leg movement. Conclusion: A 6-week program of electrical stimulation of the quadriceps did not increase leg extensor power, or reduce disability, in elderly patients rehabilitating after surgical fixation of proximal femoral fracture. In many patients local discomfort limited the intensity of electrical stimulation that could be delivered.

Falls risk following discharge from a geriatric day hospital

Objective: To assess the predictive validity of the Elderly Mobility Scale (EMS), Functional Reach (FR) and the Barthel Index (BI) in identifying recurrent fallers following discharge from a geriatric day hospital (GDH). Subjects: Seventy-six GDH patients with identified mobility problems. Methods: Each patient was assessed by an independent physiotherapist before and after a programme of physiotherapy using the EMS, FR and BI and a ‘falls follow-up’ assessment was performed after four months. Results: Fifty-four per cent (29 out of 54) of patients had reduced mobility at follow-up. Twenty-five per cent (18 out of 71) of patients had two or more falls post discharge. Using logistic regression analysis for EMS, FR and BI at discharge, each of these variables individually was significantly associated with the risk of having two or more falls (p = 0.008, 0.017 and 0.031 respectively). A prognostic tree was developed for GDH patients identifying high-risk and low-risk groups. Conclusion: EMS, FR and BI were all significantly associated with GDH patients with mobility problems having two or more falls. A prognostic tree identified high and low-risk groups of GDH patients and should now be tested prospectively. Introduction

Comparison of neural activation and energy cost during treadmill walking with body weight unloading between frail and healthy older women

The aims of the study were to investigate whether body weight unloading (BWU) enables frail older women to walk on a treadmill without increasing energy and cardiac cost compared to normal gravity conditions and whether BWU affects lower extremity muscle activation levels. Oxygen uptake, heart rate (HR) and surface electromyography (EMG) of vastus medialis (VM) and biceps femoris (BF) of 10 frail older women (mean±SD; 78±3.6 years) and 10 healthy older women (78.5±4.2 years) were measured during various walking conditions overground and on a treadmill with BWU. Frail older women exercising at their self-selected comfortable walking speed on the treadmill at 0% BWU had a higher walking energy cost per unit of time (WECt) compared to overground walking at the same speed (255±46 vs 207±32 J kg(-1) min(-1), P<0.05), whereas healthy older women had similar responses in the two conditions (262±31 vs 260±39 J kg(-1) min(-1)). However, WECt of treadmill walking at self-selected fast walking speed with 40% BWU was not statistically different to overground walking at comfortable walking speed for frail (218±36 vs 207±31 J kg(-1) min(-1)) or healthy older women (265±65 vs 262±32 J kg(-1) min(-1)). EMG of the VM and BF muscles did not significantly change in either group during treadmill walking at any speeds up to 40% BWU (P>0.05). Frail older women could therefore be safely trained on a treadmill with 40% BWU thus achieving faster speeds without increasing energy and cardiac cost and without compromising lower extremity muscle activation levels.

Electrical stimulation of quadriceps during rehabilitation following proximal femoral fracture.

Proximal femoral fracture (PFF) is associated with high mortality and substantial decline in physical function in survivors (Marottoli et al., 1992; Todd et al., 1995). Quadriceps weakness may be an important factor in disability following PFF (Mitchell et al., 2001). Leg extensor power (LEP) in the fractured leg in PFF patients 1 week after surgery is a key determinant of walking speed and stair climbing time (Lamb et al., 1995). Electrical stimulation (ES) of skeletal muscles has shown promise in enhancing recovery in a variety of pathological conditions, including after cruciate ligament injuries (Callaghan and Oldham, 1997). ES can achieve stronger muscle contractions than voluntary training and, unlike the latter, does not depend on patient motivation or effort. The aim of the current study was to assess whether ES of quadriceps increases LEP and decreases disability following PFF.