Suzanne Kuys

Impact of malnutrition on 12-month mortality following acute hip fracture

Studies investigating the relationship between malnutrition and post‐discharge mortality following acute hip fracture yield conflicting results. This study aimed to determine whether malnutrition independently predicted 12‐month post‐fracture mortality after adjusting for clinically relevant covariates.

Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study

Objective The aims of this point-prevalence study were to investigate a representative inpatient population to determine the prevalence of people admitted to hospital for the reason of a foot-related condition, and identify associated independent factors. Methods Participants were adult inpatients in 5 different representative hospitals, admitted for any reason on the day of data collection. Maternity, mental health and cognitively impaired inpatients were excluded. Participants were surveyed on a range of self-reported demographic, social determinant, medical history, foot disease history, self-care, footwear, past foot treatment prior to hospitalisation and reason for admission variables. Physical examinations were performed to clinically diagnose a range of foot disease and foot risk factor variables. Independent factors associated with being admitted to hospital for the primary or secondary reason of a foot-related condition were analysed using multivariate logistic regression. Results Overall, 733 participants were included; mean (SD) age 62 (19) years, male 55.8%. Foot-related conditions were the primary reason for admission in 54 participants (7.4% (95% CI 5.7% to 9.5%)); 36 for foot disease (4.9%), 15 foot trauma (2.1%). Being admitted for the primary reason of a foot-related condition was independently associated with foot infection, critical peripheral arterial disease, foot trauma and past foot treatment by a general practitioner and surgeon (p<0.01). Foot-related conditions were a secondary reason for admission in 28 participants (3.8% (2.6% to 5.6%)), and were independently associated with diabetes and current foot ulcer (p<0.01). Conclusions This study, the first in a representative inpatient population, suggests the direct inpatient burden caused by foot-related conditions is significantly higher than previously appreciated. Findings indicate 1 in every 13 inpatients was primarily admitted because of a foot-related condition with most due to foot disease or foot trauma. Future strategies are recommended to investigate and intervene in the considerable inpatient burden caused by foot-related conditions.

Aquatic exercise training and stable heart failure: A systematic review and meta-analysis

AIM A meta-analysis and review of the evidence was conducted to determine the efficacy of aquatic exercise training for individuals with heart failure compared to traditional land-based programmes. METHODS A systematic search was conducted for studies published prior to March 2014, using MEDLINE, PUBMED, Cochrane Library, CINAHL and PEDro databases. Key words and synonyms relating to aquatic exercise and heart failure comprised the search strategy. Interventions included aquatic exercise or a combination of aquatic plus land-based training, whilst comparator protocols included usual care, no exercise or land-based training alone. The primary outcome of interest was exercise performance. Studies reporting on muscle strength, quality of life and a range of haemodynamic and physiological parameters were also reviewed. RESULTS Eight studies met criteria, accounting for 156 participants. Meta-analysis identified studies including aquatic exercise to be superior to comparator protocols for 6 minute walk test (p < 0.004) and peak power (p < 0.044). Compared to land-based training programmes, aquatic exercise training provided similar benefits for VO(2peak), muscle strength and quality of life, though was not superior. Cardiac dimensions, left ventricular ejection fraction, cardiac output and BNP were not influenced by aquatic exercise training. CONCLUSIONS For those with stable heart failure, aquatic exercise training can improve exercise capacity, muscle strength and quality of life similar to land-based training programmes. This form of exercise may provide a safe and effective alternative for those unable to participate in traditional exercise programmes.

Recovery of ambulation activity across the first six months post-stroke.

Stroke survivors commonly adopt sedentary activity behaviours by the chronic phase of recovery. However, the change in activity behaviours from the subacute to chronic phase of stroke is variable. This study explored the recovery of ambulation activity (volume and bouts) at one, three and six months after hospital discharge post-stroke. A total of 42 stroke survivors were recruited at hospital discharge and followed up one, three and six months later. At follow-up, ambulation activity was measured over four days using the ActivPAL™ accelerometer. Measures included volume of activity and frequency and intensity of ambulation activity bouts per day. Linear mixed effects modelling was used to determine changes over time. There was wide variation in activity. Total step counts across all time points were below required levels for health benefits (mean 4592 SD 3411). Most activity was spread across short bouts. While most number of bouts was of low intensity, most time was spent in moderate intensity ambulation across all time points. Daily step count and time spent walking and sitting/lying increased from one month to three and six months. The number of and time spent in short and medium duration bouts increased from one to six months. Time in long duration bouts increased at three months only. Time spent in moderate intensity ambulation increased over time. No change was observed for any other measures. In future, it would be valuable to identify strategies to increase engagement in activity behaviours to improve health outcomes after stroke.

The silent overall burden of foot disease in a representative hospitalised population

The aims of this study were to investigate the point prevalence, and associated independent factors, for foot disease (ulcers, infections and ischaemia) in a representative hospitalised population. We included 733 (83%) of 883 eligible adult inpatients across five representative Australian hospitals on one day. We collected an extensive range of self‐reported characteristics from participants. We examined all participants to clinically diagnose foot disease (ulcers, infections and ischaemia) and amputation procedures. Overall, 72 participants (9·8%) [95% confidence interval (CI):7·2–11·3%] had foot disease. Foot ulcers, in 49 participants (6·7%), were independently associated with peripheral neuropathy, peripheral arterial disease, previous foot ulcers, trauma and past surgeon treatment (P < 0·05). Foot infections, in 24 (3·3%), were independently associated with previous foot ulcers, trauma and past surgeon treatment (P < 0·01). Ischaemia, in 33 (4·5%), was independently associated with older age, smokers and past surgeon treatment (P < 0·01). Amputation procedures, in 14 (1·9%), were independently associated with foot infections (P < 0·01). We found that one in every ten inpatients had foot disease, and less than half of those had diabetes. After adjusting for diabetes, factors linked with foot disease were similar to those identified in diabetes‐related literature. The overall inpatient foot disease burden is similar in size to well‐known medical conditions and should receive similar attention.

A pragmatic implementation of a 6-day physiotherapy service in a mixed inpatient rehabilitation unit

Abstract Purpose: This study determined the impact of a pragmatic 6-day physiotherapy service on length of stay, functional independence, gait and balance in people undergoing inpatient rehabilitation, compared to a 5-day service. Method: A prospective cohort study with historical comparison was undertaken in a mixed inpatient rehabilitation unit. Intervention period participants (2011) meeting inclusion criteria were eligible for a 6-day physiotherapy service. All other participants, including the historical cohort (2010) received usual care (5-day physiotherapy). Length of stay, functional independence, gait and balance performance were measured. Results: A total of 536 individuals participated in this study; 270 in 2011 (60% received 6-day physiotherapy) and 266 in 2010. Participants in 2011 showed a trend for reduced length of stay (1.7 days, 95%CI −0.53 to 3.92) compared to 2010. Other measures showed no significant differences between cohorts. In 2011, those receiving 6-day physiotherapy were more dependent, but showed significantly improved functional independence and balance compared to those receiving 5-day physiotherapy (p < 0.040) without impacting length of stay. Conclusion: Implementing a 6-day physiotherapy service in a “real-world” rehabilitation setting demonstrated a trend towards reduced length of stay, and improved functional gains. This service could lead to cost-savings for hospitals and improved patient flow. Implications for Rehabilitation “Real-world” implementation of a 6-day physiotherapy service in rehabilitation shows a trend for reducing length of stay. This reduction in length of stay may lead to cost-savings for the hospital system, and improve patient flow into rehabilitation. Patients receiving 6-day physiotherapy made significant gains in balance and functional independence compared to patients receiving 5-day physiotherapy services in the rehabilitation setting.

Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial

BACKGROUND Providing flexible models and a variety of exercise options are fundamental to supporting long-term exercise participation for patients with heart failure (HF). The aim of this pilot study was to determine the feasibility and efficacy of aquatic exercise training during a maintenance phase for a clinical heart failure population. METHODS In this 2 x 2 crossover design trial, individuals who had previously completed HF rehabilitation were randomised into either a land-based or aquatic training program once per week for six weeks, after which time they changed to the alternate exercise training protocol for an additional six weeks. Six-minute walk test (6MWT), grip strength, walk speed, and measures of balance were compared for the two training protocols. RESULTS Fifty-one participants (43 males, mean age 69.2 yrs) contributed data for the analysis. Both groups maintained function during the follow-up period, however improvements in 6MWT were greater in the land-based training group (95% CI: 0.7, 22.5; p=0.038), by a mean difference of 10.8 metres. No significant difference was observed for other parameters when the two training protocols were compared. CONCLUSION Attending an aquatic exercise program once per week is feasible for patients with stable HF and may provide a suitable option to maintain functional performance in select patients.

Gait outcomes of older adults receiving subacute hospital rehabilitation following orthopaedic trauma: a longitudinal cohort study

Objectives This study aimed to describe gait speed at admission and discharge from inpatient hospital rehabilitation among older adults recovering from orthopaedic trauma and factors associated with gait speed performance and discharge destination. Design A longitudinal cohort study was conducted. Setting Australian tertiary hospital subacute rehabilitation wards. Participants Patients aged ≥60 years recovering from orthopaedic trauma (n=746, 71% female) were eligible for inclusion. Interventions Usual care (multidisciplinary inpatient hospital rehabilitation). Primary and secondary outcome measures Gait speed was assessed using the timed 10 m walk test. The proportion of patients exceeding a minimum gait speed threshold indicator (a priori 0.8 m/s) of community ambulation ability was calculated. Generalised linear models were used to examine associations between patient and clinical factors with gait speed performance and being discharged to a residential aged care facility. Results At discharge, 18% of patients (n=135) exceeded the 0.8 m/s threshold indicator for community ambulation ability. Faster gait speed at discharge was found to be associated with being male (B=0.44, 95% CI −0.01 to 0.88), admitted with pelvic (B=0.76, 95% CI 0.15 to 1.38) or multiple fractures (B=1.13, 95% CI 0.25 to 2.02) (vs hip fracture), using no mobility aids (B=−0.94, 95% CI −1.89 to 0.01) and walking at a faster gait speed at admission (B=5.77, 95% CI 5.04 to 6.51). Factors associated with being discharged to residential aged care included older age (OR 1.07, 95% CI 1.04 to 1.11), longer length of stay (OR 1.02, 95% CI 1.01 to 1.03), having an upper limb fracture (vs hip fracture) (OR 2.80, 95% CI 1.32 to 5.94) and lower Functional Independence Measure cognitive score (OR 0.90, 95% CI 0.87 to 0.93). Conclusions Patients with a range of injury types, not only those presenting to hospital with hip fractures, are being discharged with slow gait speeds that are indicative of limited functional mobility and a high risk of further adverse health events.

Tracking changes in glenohumeral joint position in acute post-stroke hemiparetic patients: an observational study

Abstract Aims: The majority of people develop hemiparetic shoulder inferior subluxation following stroke, but the timing of onset is unknown. This study aimed to assess changes in glenohumeral joint centre of rotation (GHJC) during the first six weeks following stroke. Methods: Thirty patients with confirmed diagnosis of stroke (age 65 ± 19 years, 60% female, 40% right side affected) were assessed within 14 days of admission and at six weeks along with matched controls. Bilateral GHJC was determined using a three-dimensional electromagnetic tracking device (ETD). Results: At baseline, GHJC in the stroke group was positioned posteriorly on the hemiparetic side compared to the non-hemiparetic side (mean difference −4.0, 95% confidence interval (CI) − 7.7 to −3.0 mm). In matched controls, GHJC was positioned anterior to the acromion with no significant difference between limbs. At six weeks, the only significant difference occurred for the stroke group; non-hemiparetic GHJC was positioned 12.3 mm (95% CI 2.5–22.1) closer to the acromion compared with control group. Conclusion: Minimal changes in glenohumeral joint positioning occurs early post-stroke. Clinicians should consider changes in glenohumeral joint position for both non- and hemiparetic sides during the early rehabilitation phase following stroke. Implications for rehabilitation Changes occur in glenohumeral joint centre of rotation (GHJC) position between hemiparetic and non-hemiparetic sides early in people with mild stroke. Clinicians need to be aware of early GHJC positional changes. Early GHJC positional changes may contribute to the development of hemiparetic shoulder pain (HSP), anterior humeral subluxation and glenohumeral joint impingement. Clinicians should employ current best practice guidelines which promote safe positioning and handling of the upper limb to minimise subluxation forces and potential trauma to the passive restraints of the shoulder in the acute phase following stroke, to reduce the possibility of glenohumeral subluxation in the short term.

Health-related quality of life of people with multimorbidity at a community-based, interprofessional student-assisted clinic: implications for assessment and intervention

Objective This study examined the relationship between the number of comorbidities and health-related quality of life (HRQoL) and between select physical conditions and HRQoL. Differences in HRQoL in comparison to a normative sample were also examined. Method A cross-sectional study among people with multimorbidity (n = 401) attending a community-based, interdisciplinary health clinic was conducted. HRQoL was measured using the eight dimensions of the SF-36. Multiple linear regression and t-tests were used to analyse the data. Results A downward trend in HRQoL continued from 2 to 14 concurrent comorbidities. Patients with a higher number of comorbidities reported greater deficits in HRQoL, when age, gender, education and perceived social support were controlled for (beta = −0.11 to −0.31). The impact of the number of comorbidities was greatest for the bodily pain dimension of the SF-36 (beta = −0.31). Deficits were greatest for people with gastrointestinal conditions and back pain or sciatica. Moderate to large deficits in HRQoL compared to a normative population were found (Cohen’s d = 0.54–1.16). Discussion Understanding associations between the number and type of physical comorbidities and HRQoL may assist clinical services to design broad but targeted interventions to optimize HRQoL in this group of people.