Physical Therapy Management of Older Adults With Hip Fracture.

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Detectable changes in physical performance measures in elderly African Americans.

BACKGROUND: African American older adults have higher rates of self-reported disability and lower physical performance scores compared with white older adults. Measures of physical performance are used to predict future morbidity and to determine the effect of exercise. Characteristics of performance measures are not known for African American older adults. OBJECTIVE: The purpose of this study was to estimate the standard error of measurement (SEM) and minimal detectable change (MDC) for the Short Physical Performance Battery (SPPB), Timed "Up & Go" Test (TUG) time, free gait speed, fast gait speed, and Six-Minute Walk Test (6MWT) distance in frail African American adults. DESIGN: This observational measurement study used a test-retest design. METHODS: Individuals were tested 2 times over a 1-week period. Demographic data collected included height, weight, number of medications, assistive device use, and Mini-Mental Status Examination (MMSE) scores. Participants then completed the 5 physical performance tests. RESULTS: Fifty-two participants (mean age=78 years) completed the study. The average MMSE score was 25 points, and the average body mass index was 29.4 kg/m(2). On average, participants took 7 medications, and the majority used assistive devices. Intraclass correlation coefficients (ICC [2,1]) were greater than .90, except for the SPPB score (ICC=.81). The SEMs were 1.2 points for the SPPB, 1.7 seconds for the TUG, 0.08 m/s for free gait speed, 0.09 m/s for fast gait speed, and 28 m for 6MWT distance. The MDC values were 2.9 points for the SPPB, 4 seconds for the TUG, 0.19 m/s for free gait speed, 0.21 m/s for fast gait speed, and 65 m for 6MWT distance. LIMITATIONS: The entire sample was from an urban area. CONCLUSIONS: The SEMs were similar to previously reported values and can be used when working with African American and white older adults. Estimates of MDC were calculated to assist in clinical interpretation.

Gait variability detects women in early postmenopause with low bone mineral density.

BACKGROUND: Women in early postmenopause and with low bone mineral density (BMD) may exhibit early markers for physical frailty as a result of sarcopenia and osteopenia. OBJECTIVE: The purpose of this study was to determine whether women in early postmenopause and with low BMD exhibit decreased physical performance and differences in gait variability and fall and fracture rates. DESIGN: This study was an observational cohort design with participants assigned to groups on the basis of BMD status. METHODS: Fifty-four women, 31 with low BMD and 23 with normal BMD, participated. This study was conducted in a university research facility. Physical performance was measured by assessment of dynamic balance (timed backward tandem walk test), strength (handheld dynamometry of isometric quadriceps muscle force production), and free gait speed. Gait variability was assessed on the basis of the coefficient of variation for temporal-spatial gait characteristics. Falls and fractures were assessed for the year after initial testing. RESULTS: Significant between-group differences were found for step time and stance time variability. LIMITATIONS: The limitations of this study included group assignment on the basis of the results of the most recent bone density scan within the preceding 2 years. CONCLUSIONS: Women in early postmenopause and with low BMD exhibited increased gait variability in step time and stance time but did not exhibit differences in balance, strength, or gait speed. Gait variability may be more sensitive for detecting differences in women in early postmenopause and with or without low BMD than more typical measures of physical performance.

Interventions used by physical therapists in home care for people after hip fracture.

BACKGROUND AND PURPOSE: The majority of older people who survive a hip fracture have residual mobility disabilities. Any attempt to systematically reduce mobility disabilities after hip fracture, however, requires knowledge of the adequacy of current management practices. Therefore, the purpose of this study was to begin to understand the nature of physical therapy home care management by describing "usual care" for people after hip fracture. SUBJECTS AND METHODS: In 2003 and 2004, a national survey was conducted of all members of the American Physical Therapy Association who identified home care as their primary practice setting (n=3,130). "Usual care" was operationally defined as when more than 50% of respondents reported that they "always" or "often" use a specific intervention. RESULTS: Survey questionnaires (1,029) were returned with a response rate of 32.9%. Functional training activities, including bed mobility, transfer and gait training, balance training, safety training, and patient education, were reported very frequently. Active-range-of-motion exercises were performed much more frequently than exercises involving added resistance. DISCUSSION AND CONCLUSION: This study provides a detailed description of the physical therapy interventions provided in the home care setting for patients after hip fracture. The sample size and national representation increase our confidence that this description accurately depicts physical therapist practice.

Does delirium need immediate medical referral in a frail, homebound elder?

BACKGROUND AND PURPOSE: This case report describes the clinical decision making process of a physical therapist whose examination of a home bound elderly woman led to a referral for hospitalization. We illustrate how the use of a comprehensive systems screen and thorough examination identified a patient with treatable conditions that required medical care. CASE DESCRIPTION: The patient was a frail 93-year-old woman. She was referred for home-care physical therapy with multiple medical comorbidities and functional decline following a short hospitalization for fall-related injuries. Her function improved after several visits, but upon resuming treatment after a 2- week hiatus, the patient demonstrated major decline in cognitive and physical function. OUTCOMES: The comprehensive systems screen revealed that the patient had increased pallor, loose and frequent bowel movements, urinary incontinence and increased frequency of micturition, confusion and apathy, and extreme fatigue. Her examination showed large declines in scores for Functional Independence Measures, Mini Mental Status Examination, Berg Balance Test, and Timed Up and Go. These results were consistent with indicators for delirium, dehydration, and anemia. The findings were reported to the patient's physician and family members agreed to have the patient evaluated in the local emergency room. CONCLUSIONS: This case report illustrates how knowledge of the pathologies associated with delirium and thorough examination can assist the physical therapist in making clinical decisions when homecare patients require prompt medical referral.