Stefan Bachmann

Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials

Objective To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care on functional status, admissions to nursing homes, and mortality. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane database, and reference lists from published literature. Review methods Only randomised controlled trials were included. Trials had to report on inpatient rehabilitation and report at least one of functional improvement, admission to nursing homes, or mortality. Trials of consultation or outpatient services, trials including patients aged <55, trials of non-multidisciplinary rehabilitation, and trials without a control group receiving usual care were excluded. Data were double extracted. Odds ratios and relative risks with 95% confidence intervals were calculated. Results 17 trials with 4780 people comparing the effects of general or orthopaedic geriatric rehabilitation programmes with usual care were included. Meta-analyses of effects indicated an overall benefit in outcomes at discharge (odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function, relative risk 0.64 (0.51 to 0.81) for nursing home admission, relative risk 0.72 (0.55 to 0.95) for mortality) and at end of follow-up (1.36 (1.07 to 1.71), 0.84 (0.72 to 0.99), 0.87 (0.77 to 0.97), respectively). Limited data were available on impact on health care or cost. Compared with those in control groups, weighted mean length of hospital stay after randomisation was longer in patients allocated to general geriatric rehabilitation (24.5 v 15.1 days) and shorter in patients allocated to orthopaedic rehabilitation (24.6 v 28.9 days). Conclusion Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.

EXERCISE REDUCES SICK LEAVE IN PATIENTS WITH NON-ACUTE NON-SPECIFIC LOW BACK PAIN: A META-ANALYSIS

OBJECTIVES To investigate whether exercise alone or as a part of a multidisciplinary treatment reduces sick leave in patients with non-specific non-acute low back pain. METHODS A meta-analysis of randomized controlled trials was performed. A qualitative analysis of the sick leave results was performed applying pre-defined levels of evidence. In studies comparing exercise with usual care, pooled effect sizes were computed. RESULTS Fourteen trials were identified allowing 22 comparisons between treatments. The qualitative and the quantitative analysis showed strong evidence that exercise reduces sick days during the first follow-up year, the effect size (95% confidence interval) was -0.24 ( -0.36, -0.11). In a subgroup of studies on the treatment of severely disabled patients (> 90 sick days under usual care) the effect size was -0.30 (-0.42, -0.17). The effect size of the number of patients receiving a disability allowance was small and not significant. CONCLUSION The reviewed trials provide strong evidence that exercise significantly reduces sick days during the first follow-up year.

Effectiveness of exercise on work disability in patients with non-acute non-specific low back pain: Systematic review and meta-analysis of randomised controlled trials.

OBJECTIVES To determine whether exercise is more effective than usual care to reduce work disability in patients with non-acute non-specific low back pain, and if so, to explore which type of exercise is most effective. METHODS Systematic review and meta-analysis of randomized controlled trials investigating the effectiveness of exercise in non-acute non-specific low back pain, and reporting on work disability. DATA SOURCES MEDLINE, EMBASE, PEDro, Cochrane Library databases, NIOSHTIC-2, and PsycINFO until August 2008. Work disability data were converted to odds ratios. Random effects meta-analyses were conducted. RESULTS A total of 23 trials met the inclusion criteria, 20 of which were suitable for inclusion in meta-analysis allowing 17 comparisons of exercise interventions with usual care and 11 comparisons of 2 different exercise interventions. A statistically significant effect in favour of exercise on work disability was found in the long term (odds ratio (OR) = 0.66, 95% confidence interval (CI) 0.48-0.92) but not in the short (OR = 0.80, 95% CI 0.51-1.25) and intermediate term (OR = 0.78, 95% CI 0.45-1.34). Meta-regression indicated no significant effect of specific exercise characteristics. CONCLUSION Exercise interventions have a significant effect on work disability in patients with non-acute non-specific low back pain in the long term. No conclusions can be made regarding exercise types.

A qualitative study on the role of cultural background in patients' perspectives on rehabilitation

BackgroundLow back pain (LBP) is one of the major concerns in health care. In Switzerland, musculoskeletal problems represent the third largest illness group with 9.4 million consultations per year. The return to work rate is increased by an active treatment program and saves societal costs. However, results after rehabilitation are generally poorer in patients with a Southeast European cultural background than in other patients. This qualitative research about the rehabilitation of patients with LBP and a Southeast European cultural background, therefore, explores possible barriers to successful rehabilitation.MethodsWe used a triangulation of methods combining three qualitative methods of data collection: 13 semi-structured in-depth interviews with patients who have a Southeast European cultural background and live in Switzerland, five semi-structured in-depth interviews and two focus groups with health professionals, and a literature review. Between June and December 2008, we recruited participants at a Rehabilitation Centre in the German-speaking part of Switzerland.ResultsTo cope with pain, patients prefer passive strategies, which are not in line with recommended coping strategies. Moreover, the families of patients tend to support passive behaviour and reduce the autonomy of patients. Health professionals and researchers propagate active strategies including activity in the presence of pain, yet patients do not consider psychological factors contributing to LBP. The views of physicians and health professionals are in line with research evidence demonstrating the importance of psychosocial factors for LBP. Treatment goals focusing on increasing daily activities and return to work are not well understood by patients partly due to communication problems, which is something that patients and health professionals are aware of. Additional barriers to returning to work are caused by poor job satisfaction and other work-related factors.ConclusionsLBP rehabilitation can be improved by addressing the following points. Early management of LBP should be activity-centred instead of pain-centred. It is mandatory to implement return to work management early, including return to adapted work, to improve rehabilitation for patients. Rehabilitation has to start when patients have been off work for three months. Using interpreters more frequently would improve communication between health professionals and patients, and reduce misunderstandings about treatment procedures. Special emphasis must be put on the process of goal-formulation by spending more time with patients in order to identify barriers to goal attainment. Information on the return to work process should also include the financial aspects of unemployment and disability.

What Is the Role of “nonorganic Somatic Components” in Functional Capacity Evaluations in Patients With Chronic Nonspecific Low Back Pain Undergoing Fitness for Work Evaluation?

Study Design. Analytical cross-sectional study. Objective. To assess the association of “nonorganic somatic components” together with physical and other psychosocial factors on functional capacity evaluation (FCE) in patients with chronic nonspecific low back pain (NSLBP) undergoing fitness-for-work evaluation. Summary of Background Data. Functional capacity evaluation is increasingly used for physical fitness-for-work evaluation in patients with chronic NSLBP, but results seem to be influenced by physical as well as psychosocial factors. The influence of nonorganic somatic components together with physical and other psychosocial factors on FCE performance has not yet been investigated. Methods. One hundred twenty-six patients with chronic NSLBP referred for physical fitness-for-work evaluation were included. The 4 FCE tests were lifting from floor to waist, forward bend standing, grip strength, and 6-minute walking. Nonorganic somatic components were assessed with the 8 nonorganic somatic signs as defined by Waddell and were adjusted for age, sex, days off work, salary in the previous occupation, pain intensity, fear avoidance belief, and perceived functional ability in multivariate regression analyses. Results. Between 42% and 58% of the variation in the FCE tests was explained in the final multivariate regression models. Nonorganic somatic components were consistent independent predictors for all tests. Their influence was most important on forward bend standing and walking distance, and less on grip strength and lifting performance. The physical factors of age and/or sex were strongly associated with grip strength and lifting, less with walking distance, and not at all with forward bend standing. The influence of at least 1 other psychosocial factor was observed in all FCE tests, having the highest proportion in the 6-minute walking test. Conclusion. Nonorganic somatic components seem to be consistent independent predictors in FCE testing and should be considered for interpretation of test results.

Are exergames promoting mobility an attractive alternative to conventional self-regulated exercises for elderly people in a rehabilitation setting? Study protocol of a randomized controlled trial

BackgroundMaintaining mobility in elderly persons has become a primary goal within healthcare services. In older adults, exercise programs significantly reduce the risk of falling and death. Long-lasting and high-intensive multi-component exercises are most effective. In a rehabilitation setting, self-regulated exercises are conventionally taught by physiotherapists, using handouts. However, the adherence of elderly persons to executing these self-administered programs varies considerably. They are often considered tedious and boring, and thus prematurely stopped.The primary aim of this clinical trial is to determine whether elderly persons in a rehabilitation setting show higher adherence to self-regulated training when using exergames than when performing conventional exercises. The second objective is to explore which mode of exercise leads to greater improvement in balance performance.Methods/DesignThe study consists of a single blind, stratified, randomized control trial with two parallel groups. Once included, study participants will be stratified according to their balance and computer skills and randomly allocated to self-regulated training with conventional exercise programs or with exergames played with the Windows Kinect® sensor and FitBit® pedometer. In both groups, self-administered exercise programs will be taught by experienced physiotherapists and performed at the patient’s own discretion during the ten days of intervention. The primary outcome is the performed daily training volume, collected by the participants in a logbook. Secondary outcomes are objective and subjective balance skills measured by an activity tracker and the Fall Efficacy Scale self-administered questionnaire. Both assessments will be performed at pre- and post-intervention.DiscussionAccording to the available literature, this study is the first to compare conventional self-regulated exercises with exergames among older patients in a rehabilitation setting. Results of this study will contribute to our understanding of its motivational potential on exercise adherence in elderly persons and provide more insight into the potential effectiveness of exergames promoting mobility.Trial registrationThe present clinical study has been registered on ClinicalTrials.gov under the identifier number: NCT02077049. The detailed trial protocol can be accessed online on: NCT02077049.

Comparison of Two Methods for Interpreting Lifting Performance During Functional Capacity Evaluation

Background Functional capacity evaluation (FCE) requires determination of effort by observation of effort indexes for performance interpretation. Waddell signs have been shown to be associated with decreased functional performance. Whether determination of effort by observational criteria and Waddell sign testing can be used interchangeably to interpret lifting performance is unknown. Objective The purposes of this study were to assess the concurrent validity of submaximal effort and Waddell signs and to determine whether these contribute independently to lifting performance. Design This investigation was an analytical cross-sectional study. Methods A total of 130 people who had chronic nonspecific low back pain and were referred for fitness-for-work evaluation were included. Physical effort was determined on the basis of observational criteria for lifting from floor to waist, lifting from waist to shoulder, and horizontal lifting during FCE. A second assessor conducted Waddell sign testing. The concurrent validity of Waddell signs and submaximal effort was assessed by calculating sensitivity and specificity. Hierarchical regression analysis was used to determine the contributions of Waddell signs and submaximal effort to lifting performance. Age and sex were covariates. Results The FCE assessor found a low sensitivity of Waddell signs for submaximal effort determination. Between 53% and 63% of the participants who were classified as showing submaximal effort had Waddell signs. Waddell signs and submaximal effort were independent contributors to lifting performance. The contribution of submaximal effort was larger than that of Waddell signs, as shown by 20% to 29% higher explained variance in lifting performance when submaximal effort was added to the model first versus 3% to 6% higher explained variance when Waddell signs were added first. Limitations Assessor variability could have influenced the study results. Conclusions In people with chronic nonspecific low back pain, Waddell sign testing and determination of physical effort by observational criteria should not be used interchangeably to interpret lifting performance during FCE.

Physiotherapie und Rehabilitation bei unspezifischen Kreuzschmerzen

Low back pain (LBP) continues to be a major health problem causing personal suffering and enormous socioeconomic costs. Evidence suggests that more than 85 % of individuals with LBP suffer from non-specific low back pain. Physiotherapy for non-specific LBP includes educational, physical, manual and movement therapy measures. In the acute phase, it is very important to prevent chronicity by identifying barriers for a full recovery and a quick return to everyday activities. If there is a chronicity of symptoms, the treatment must focus on improvement of the general physical activity despite the pain and promote participation in the social and work context. These aims are more important than pain relief. Therefore in the acute phase educational and activity-promoting measures are the primary treatment options. In the sub-acute and chronic phase a multidimensional treatment approach including exercise therapy with the aim of improving function, including return to work, should be applied. By now, there is scientific evidence that physiotherapy can reduce pain and disability due to LBP, and that return to usual activities including work can be achieved.

Predictors for living at home after geriatric inpatient rehabilitation: A prospective cohort study.

OBJECTIVE To evaluate patient characteristics predicting living at home after geriatric rehabilitation. DESIGN Prospective cohort study. PATIENTS A total of 210 patients aged 65 years or older receiving inpatient rehabilitation. METHODS Candidate predictors evaluated during rehabilitation were: age, vulnerability (Vulnerable Elders Survey), multimorbidity (Cumulative Illness Rating Scale), cognition (Mini-Mental State Examination), depression (Hospital Anxiety and Depression Scale), living alone, previous independence in activities of daily living, fall risk, and mobility at discharge (Timed Up and Go test). Multiple imputation data-sets, bivariate and multiple regression were used to build a predictive model for living at home, which was evaluated at 3-month follow-up. RESULTS A total of 210 patients (mean age 76.0 years, 46.2% women) were included in the study. Of these, 87.6% had been admitted to geriatric rehabilitation directly from acute hospital care. Follow-up was complete in 75.2% of patients. The strongest predictor for living at home was better mobility at discharge (Timed Up and Go test < 20 s), followed by lower multimorbidity, better cognition, and not living alone. In bivariate regression, living at home was also associated with age, fall risk, vulnerability, depression, and previous independence in activities of daily living. CONCLUSION Mobility is the most important predictive factor for living at home after geriatric rehabilitation. Assessment and training of mobility are therefore key aspects in geriatric rehabilitation.

Exergames versus self-regulated exercises with instruction leaflets to improve adherence during geriatric rehabilitation: a randomized controlled trial.

Background Improving mobility in elderly persons is a primary goal in geriatric rehabilitation (Bachmann 2010). Self-regulated exercises with instruction leaflets are used to increase training volume but adherence is often low. Exergames may improve adherence. This study therefore compared exergames with self-regulated exercise using instruction leaflets. Objectives To evaluate short-term effects of exergames versus self-regulated exercise using instruction leaflets. Primary outcome was adherence. Secondary outcomes were enjoyment, motivation and balance. Methods Design: single center parallel group non-blinded randomized controlled trial with central stratified randomization (Hasselmann 2015). Setting: center for geriatric inpatient rehabilitation. Included were patients over 65 with mobility restrictions who were able to perform self-regulated exercise. Patients were assigned to self-regulated exercise using a) exergames on Windows Kinect® (exergame group EG) or b) instruction leaflets (conventional group CG). Physical therapists instructed self-regulated exercise to be conducted twice daily during thirty minutes during ten working days. Patients reported adherence (primary outcome), enjoyment and motivation daily. Balance during walking was measured blind with an accelerometer. Analysis was by intention to treat. Repeated measures mixed models and Cohens d effect sizes (ES, moderate if >0.5, large if >0.8) were used to evaluate between-group effects over time. Results We evaluated 217 patients and included and 54, 26 in the EG and 28 in the CG. Adverse effects were observed in two patients in the EG who stopped because of pain during exercising. Adherence was comparable at day one (38 min. in the EG and 42 min. in the CG) and significantly higher in the CG at day 10 (54 min. in the CG while decreasing to 28 min. in the EG, p=0.007, ES 0.94, 0.39–0.151). Benefits favoring the CG were also observed for enjoyment (p=0.001, ES 0.88, 0.32 – 1.44) and motivation (p=0.046, ES 0.59, 0.05 -1.14)). There was no between-group effect in balance during walking. Conclusions Self-regulated exercise using instruction leaflets is superior to exergames regarding adherence, enjoyment and motivation in a geriatric inpatient rehabilitation setting. Effects were moderate to large. There was no between group difference in balance during walking. References Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;340, c1718. Hasselmann V, Oesch P, Fernandez-Luque L, Bachmann S. Are exergames promoting mobility an attractive alternative to conventional self-regulated exercises for elderly people in a rehabilitation setting? Study protocol of a randomized controlled trial. BMC Geriatr. 2015;15;108. Acknowledgements The present study is part of the GameUp Project, focusing on game-based mobility training and motivation of elderly persons, and is co-funded by the European research and development joint program “Ambient Assisted Living” (AAL-2011–4-090). We thank Viviane Hasselman and Stine Staubach for data collection. Disclosure of Interest None declared