Prediction of walking speed one year following hip fracture based on pre-fracture assessments of mobility and physical activity.

BACKGROUND: Older people with hip fracture are often medically frail, and many do not regain their walking ability and level of physical activity. The aim of this study was to examine the relationship between pre-fracture recalled mobility, fear of falling, physical activity, walking habits and walking speed one year after hip fracture. METHODS: The study had a longitudinal design. Measurements were performed 3-5 days postoperatively (baseline) and at one year after the hip fracture. The measurements at baseline were all subjective outcome measures recalled from pre-fracture: The New Mobility Scale (NMS), the 'Walking Habits' questionnaire, The University of California, Los Angeles (UCLA) Activity Scale, Fear of Falling International (FES-I) and demographic variables. At one year 4-meter walking speed, which was a part of the Short Physical Performance Battery (SPPB) was assessed. RESULTS: At baseline 207 participants were included and 151 were assessed after one year. Their age was mean (SD) 82.7 (8.3) years (range 65-99 years). Those with the fastest walking speed at one year had a pre-fracture habit of regular walks with a duration of ≥ 30 min and/or a frequency of regular walks of 5-7 days a week. Age (p =.020), number of comorbidities (p <.001), recalled NMS (p <.001), and recalled UCLA Activity Scale (p =.007) were identified as predictors of walking speed at one year. The total model explained 54% of the variance in walking speed. CONCLUSIONS: Duration and frequency of regular walks before the hip fracture play a role in walking speed recovery one year following the fracture. Subjective outcome measures of mobility and physical activity, recalled from pre-fracture can predict walking speed at one year. They are gentle on the old and medically frail patients in the acute phase after hip fracture, as well as clinically less time consuming.

'Brain fog', guilt, and gratitude: experiences of symptoms and life changes in older survivors 6 months after hospitalisation for COVID-19.

PURPOSE: Several of those who have been infected with COVID-19 suffer from the post-COVID-19 condition months after the acute infection. Little is known about how older survivors have experienced the consequences and how these have affected their lives. The aim of this study was to explore how older survivors experienced post-COVID-19 condition and life changes approximately 6 months after hospitalisation for COVID-19. METHODS: The study had an explorative and descriptive design. Semi-structured interviews were performed with 17 participants from two local hospitals, 11 men and 6 women, aged 60 years and older (age range 60-96), approximately 6 months after hospitalisation for COVID-19. A thematic descriptive analysis inspired by Braun and Clarke was used. RESULTS: Two main themes and seven subthemes were revealed. The main themes were: From few to various persistent symptoms and Existential thoughts and reflections. Most of the participants experienced various physical and/or cognitive symptoms, such as reduced physical fitness, heavy breathing, fatigue, and 'brain fog'. On the other hand, they also experienced guilt and gratitude for having survived. The recognition of having achieved other life perspectives was also present. CONCLUSION: Six months after undergone COVID-19 the participants still experienced various distressing symptoms, which were in line with larger studies. The novel findings of this study were connected to the existential area, where the patients' thoughts and reflections of guilt, gratitude, and new life perspectives were revealed. These findings are important for health professionals to consider when treating patients after COVID-19.

"This path I must walk alone". Challenges experienced by older patients while recovering from severe COVID-19 - a qualitative study.

BACKGROUND: In March 2020, the COVID-19 pandemic challenged both the Norwegian population and healthcare system. In this study we explored how older men and women experienced rehabilitation and recovery after hospitalisation due to severe COVID-19. METHODS: Semi-structured interviews with 17 participants aged 60-96 years were performed 6 months after discharge from hospital. A thematic descriptive analysis was conducted. RESULTS: The results revealed that the participants experienced a challenging span between loneliness and companionship in recovering from severe COVID-19. The four subthemes highlighted experiences of being discharged to home and left to themselves, the importance of exercise and companionship at rehabilitation stay, requirement of self-effort and time to recover, and the challenging span between loneliness and companionship when being with family. CONCLUSION: Among participants, the experiences of loneliness throughout the recovery period were striking. An individualised approach including psychological support should be emphasized in primary healthcare to promote recovery in older survivors after severe COVID-19 and their next-of-kin.

Recovery and prediction of physical function 1 year following hip fracture.

OBJECTIVES: To investigate the recovery of physical function, health related quality of life (HRQoL), and pain for people following hip fracture for the initial 12 months, and to examine whether postoperative outcome measures of physical function, HRQoL, and pain can predict physical function at 3 and 12 months. DESIGN: A prospective single-center observational study, as part of the HIPFRAC trial. SETTINGS: One hospital with two associated municipalities in Norway. SUBJECTS: 207 participants with hip fracture included in the study (140 participants transferred to a short-term nursing home placement and 67 transferred directly home at discharge from hospital). METHOD: Outcome measures were Short Physical Performance Battery (SPPB), Timed Up & Go (TUG), Stair climbing test (SC), Numeric Rating Scale (NRS) for pain at rest and in activity, and EQ-5D-5L index and health score. Data were analysed by repeated measures of variance and multivariate regression analyses. RESULTS: There were statistically significant improvements in physical function (SPPB total score and TUG), NRS-pain in activity, and HRQoL (EQ-5D-5L) from hospital discharge to 3-month follow-up for the whole cohort and the two groups (p < 0.001). However, the largest improvements occurred within the first 3 months. Further statistically significant improvements occurred between 3 and 12 months (p < 0.05). The strongest predictors of physical function at 3 and 12 months post-fracture were physical function (SPPB) at hospital discharge and pre-fracture requirement of a walking aid. CONCLUSION: The recovery of physical function, HRQoL, and pain in participants after hip fracture indicates gradual improvements during the initial 12-month follow-up, with the largest improvements within the first 3 months.

Older patients' perspectives on illness and healthcare during the early phase of the COVID-19 pandemic.

BACKGROUND: Equal access to healthcare is a core principle in Norway's public healthcare system. The COVID-19 pandemic challenged healthcare systems in the early phase - in particular, related to testing and hospital capacity. There is little knowledge on how older people experienced being infected with an unfamiliar and severe disease, and how they experienced the need for healthcare early in the pandemic. AIM: To explore the experiences of older people infected by COVID-19 and their need for testing and hospitalisation. RESEARCH DESIGN: An explorative and descriptive approach, with qualitative interviews conducted in October 2020. PARTICIPANTS AND RESEARCH CONTEXT: Seventeen participants above 60 years of age hospitalised due to COVID-19 during spring 2020 were recruited 6 months after discharge. ETHICAL CONSIDERATIONS: Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics in South-Eastern Norway (155425). FINDINGS: The main finding was that the informants experienced vulnerability and arbitrariness. This finding was supported by three sub-themes: experiences with a severe and unfamiliar disease, the strict criteria and the importance of someone advocating needs. DISCUSSION: Participants described varying access to healthcare. Those who did not meet the national criteria to be tested or hospitalised struggled against the system. Findings reveal arbitrary access to healthcare, in contrast to Norway's ethical principle of fair and just access to health services. Moreover, to access and receive necessary healthcare, informants were dependent on their next-of-kin's advocacy. CONCLUSION: Even when dealing with an unfamiliar disease, health professionals' assessments of symptoms must be performed with an ethical obligation to applicate competent appraisal and the exercise of discernment; this is in line with care ethics and ethical standards for nurses. These perspectives are a significant part of caring and the intension of doing good.

Effect of an additional health-professional-led exercise programme on clinical health outcomes after hip fracture.

PURPOSE: To examine the effect of an additional 2-week health professional-led functional exercise programme compared to usual care for patients after hip fracture during a short-term nursing home stay directly after hospital discharge. METHOD: One hundred and forty participants, 65 years or older with hip fracture, admitted to a short-term nursing home stay were randomised to an intervention group or control group. Participants in the intervention group (n = 78) received the experimental programme consisted of functional exercises, performed by health care professionals up to four times a day, 7 days a week, in addition to usual care during a 2-week short-term nursing home stay. Participants in the control group (n = 62) received usual care alone. Primary outcome was Short Physical Performance Battery (SPPB). Secondary outcomes were Timed Up & Go, New Mobility Score, The University of California, Los Angeles Activity Scale, Fall Efficacy Scale International, The EuroQol five dimension five-level questionnaire, and Numeric Rating Scale for pain. Outcome measures were assessed after 2 weeks in a short-term nursing home stay and 3 months after hip fracture surgery. The activity monitor ActivPal registered activity during the 2-week short-term nursing home stay. RESULTS: No statistically significant differences between groups was found in any outcomes after 2 weeks or 3 months (p > 0.05). There were statistically significant within-group improvements in primary outcome SPPB and in most secondary outcomes at all time points in both groups (p > 0.05). CONCLUSIONS: A 2-week health professional-led functional exercise programme in addition to usual care demonstrated no difference in clinical outcomes compared to usual care alone up to 3 months after hip fracture. The patients with hip fracture are fragile and vulnerable in this early phase, and usual physiotherapy may be sufficient to improve their physical function. TRIAL REGISTRATION: ClinicalTrials.gov NCT02780076.

"To do or not to do": Treatment fidelity to a complex training intervention.

BACKGROUND AND PURPOSE: When a complex intervention is examined it is viewed necessary to perform a qualitative process evaluation paired with an outcome evaluation. The purpose is to provide insights into the fidelity of the experimental intervention and thereby strengthen the validity of the study. In "Recovery after hip fracture" (the HIPFRAC study), the effect of a complex functional training intervention was examined by a randomized controlled trial design. The training was initiated by the physiotherapist and performed by the nurses/nurse assistants (NAs), as part of their daily, habitual routine when the patients with hip fracture were in a short-term stay after discharge from hospital. The aim of the present process evaluation was to explore how contextual factors facilitated or complicated the nurses'/NAs' fidelity to the experimental intervention in the HIPFRAC study. METHODS: A descriptive thematic analysis was used. Data was collected through semi-structured in-depth interviews with three nurses and three NAs working with the HIPFRAC patients in a short-term stay. The interviews were transcribed and analyzed. FINDINGS: Six subthemes, two main themes and one overall theme were identified. The overall theme was: Barriers affecting the implementation process. The main themes related to the barriers were identified as follows: (1) Attitudes within the nurses/NAs and (2) Structural factors. DISCUSSION: The nurses/NAs in the short-term stay experienced contextual barriers, which contributed to complicate fidelity to the experimental intervention. There is a need of further research to investigate whether increased physiotherapy resources at short-term stay will improve the level of physical activity among the patients with hip fracture.

Effect of exercise interventions in the early phase to improve physical function after hip fracture - A systematic review and meta-analysis.

BACKGROUND: The efficacy of exercise interventions in the early recovery phase, i.e. started within the first three months after hip fracture, has been poorly studied compared to prolonged exercise interventions. OBJECTIVE: To examine the effect of exercise interventions to improve physical function in the early phase after hip fracture. DATA SOURCES: Seven databases including MEDLINE via Ovid, The Cochrane Library, Embase, Cinahl, Pedro, AMED and Web of Science were comprehensively searched till December 2019. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) of exercise interventions initiated within the first three months after hip fracture to improve physical function, were eligible for inclusion. Primary outcome was physical function assessed using walking ability, walking speed, balance, muscle strength, mobility, and endurance. DATA EXTRACTION AND DATA SYNTHESIS: We conducted subgroup analyses specifically to investigate outcomes of these individual measurements. A meta-analysis was conducted to examine the overall effect of early exercise interventions. A meta-regression was conducted to examine the impact of study characteristic on exercise interventions. We used the PEDro score to determine quality of the included studies. RESULTS: Nine studies (669 patients) were included. Despite high statistical heterogeneity, there was high to moderate quality evidence that exercise provided benefit in improving physical function (standardised mean difference (SMD) 1.07; 95% CI: 0.44 to 1.70; p<0.001). There was no statistically significant difference in outcome, when measured by the individual physical function outcome (p>0.05). Meta-regression demonstrated no statistically significant association between study characteristics and exercise interventions (p>0.05). CONCLUSION: Exercise in the early phase of hip fracture rehabilitation can improve physical function. It remains unclear what type of exercise is superior in the early phase after hip fracture. LIMITATIONS: This conclusion should be interpreted with caution given the high statistical heterogeneity reported and non-significant subgroup analyses of specific physical function measures, which were underpowered. Protocol Registration (PROSPERO): CRD42018091135.

"I struggle to count my blessings": recovery after hip fracture from the patients' perspective.

BACKGROUND: Recovery outlooks of physical functioning and quality of life after hip fracture have not changed significantly over the past 25 years. Previous research has mainly dealt with causalities and acute treatment, while the recovery process from the patients' perspective has been less comprehensively described. Expanded knowledge of what the patients consider important in their recovery process may have important consequences for how these patients are treated in the future and thereby on future patient outcomes. The aim presently is therefore to explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process. METHOD: The study was qualitative in design. Eight frail elderly in recovery after hip fracture (aged 69-91) were interviewed in their home four months after their fracture. The interviews covered issues related to their experiences of facilitators and barriers throughout the different stages in the recovery process. The patients were already enrolled in an ongoing randomized controlled trial, examining the effects of habitual functional training during their short term stays at nursing homes. The patients were chosen strategically according to age, gender, and participation in rehabilitation. The interviews were recorded, transcribed and subjected to a method of systematic text condensation inspired by Giorgi's phenomenological method. RESULTS: The results revealed that the patients' experiences of the recovery process fell into three main themes: "Feeling vulnerable", "A span between self-reliance and dependency" and "Disruption from a normal life". The feeling of gloominess and vulnerability persisted throughout. Being in recovery was also experienced as a tension between self-reliance and dependency; a disrupted life where loss of mobility and the impact of age was profoundly present. CONCLUSION: Being in recovery after hip fracture was experienced as a life breaking event. Based on these findings, increased focus on individualized treatment to each patient through each stage of the recovery process should be emphasized.

The effects of habitual functional training on physical functioning in patients after hip fracture: the protocol of the HIPFRAC study.

BACKGROUND: The survivors after hip fracture often report severe pain and loss of physical functioning. The poor outcomes cause negative impact on the person's physical functioning and quality of life and put a financial burden on society. Rehabilitation is important to improve physical functioning after hip fracture. To maintain the continuity in rehabilitation we have an assumption that it is of utmost importance to continue and progress the functional training that already started at the hospital, while the patients are transferred to short-term stays in a nursing home before they are returning to home. The aim presently is to examine the effects of a functional training program, initiated by the physiotherapist and performed by the nurses, on physical functioning while the patients are at short term stays in primary health care. METHODS/DESIGN: Inclusion and randomization will take place during hospital stay. All patients 65 years or above who have sustained a hip fracture are eligible, except if they have a score on Mini Mental State (MMS-E) of less than 15, could walk less than 10 m prior to the fracture, or are terminally ill. The intervention consists of additional functional training as part of the habitual daily routine during short term stays at nursing homes after discharge from hospital. The primary outcome is physical functioning measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are Timed "Up & Go" (TUG), hand grip strength, activPAL accelerometer, and self-reported measures like new Mobility Score (NMS), Walking Habits, University of California Los Angeles (UCLA) activity scale, Fall efficacy scale (FES), EuroQol health status measure (EQ-5D-5 L), and pain. DISCUSSION: Issues related to internal and external validity in the study are discussed. The outline for the arguments in this protocol is organized according to the guidelines of the Medical Research Council (MRC) guidance on how to develop and evaluate complex interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02780076 .

The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial.

PURPOSE: To examine the immediate and long-term effects of a walking-skill program compared with usual physiotherapy on physical function, pain and perceived self-efficacy in patients after total knee arthroplasty (TKA). METHOD: A single blind randomized controlled trial design was applied. Fifty-seven patients with primary TKA, mean age of 69 years (SD ± 9), were randomly assigned to a walking-skill program emphasizing weight-bearing exercises or usual physiotherapy. Outcomes were assessed before the interventions started at 6 weeks postoperatively (T1), directly after the interventions at 12-14 weeks (T2) and 9 months after the interventions (T3). Walking was the primary outcome, assessed by the 6 min walk test (6MWT). The secondary outcomes were timed stair climbing, timed stands, Figure-of-eight test, Index of muscle function, active knee range of motion, Knee Injury and Osteoarthritis Outcome Score and self-efficacy score. RESULTS: From T1 to T2, a better 6MWT score was found in favor of the walking-skill program of 39 m (2-76), p = 0.04. The difference between the groups in 6MWT persisted at T3, 44 m (8-80), p = 0.02. No differences in other outcome measures were found. CONCLUSION: The walking-skill program had better effect on walking than usual physiotherapy. Weight bearing was tolerated. Implications for Rehabilitation Weight-bearing exercises are tolerated by the patients in the early stage after TKA. Physiotherapy that focuses on learning different ways of walking through practice may be a plausible way to train patients after TKA.

Recovery and prediction of physical functioning outcomes during the first year after total hip arthroplasty.

OBJECTIVES: To investigate recovery of physical functioning in patients during the first year after total hip arthroplasty (THA), and to predict postoperative walking distance outcomes from preoperative measures. DESIGN: A longitudinal prospective design was used. Data were analyzed by repeated-measures analysis of variance and multivariate regression analyses. SETTING: Two hospitals. PARTICIPANTS: Patients with hip osteoarthritis were consecutively included and assessed preoperatively (n=88), at 3 months (n=88), and at 12 months (n=64) after THA. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical functioning was assessed by objective measures-the 6-minute walk test (6MWT), stair climbing test, Index of Muscle Function, figure-of-eight, and active hip range of motion-and the subjective measures by Harris Hip Score and Hip dysfunction and Osteoarthritis Outcome Score. RESULTS: In objective measures, improvements were found from preoperatively to 3 months in 6MWT (P<.01) and stair climbing test (P<.05) scores, while all measures had improved from 3 to 12 months (P≤.001). In contrast, all the subjective measures showed substantial improvements at 3 months, but small further improvements from 3 to 12 months (P<.001). Age, sex, preoperative 6MWT distance, and hip range of motion predicted 6MWT outcomes at 3 and 12 months (P≤.01). CONCLUSIONS: The objective measures of physical functioning improved gradually during the first postoperative year, while the subjective measures showed large early improvements, but little further improvements. Younger age, male sex, and better scores of walking distance and hip flexibility before surgery predicted better score in walking distance at both 3 and 12 months after surgery.

Effect of a walking skill training program in patients who have undergone total hip arthroplasty: Followup one year after surgery.

OBJECTIVE: To investigate the effect of a 12-session walking skill training program of weight-bearing activities on physical functioning and self-efficacy initiated in patients 3 months after total hip arthroplasty (THA). METHODS: Sixty-eight patients with THA, 35 women and 33 men, with a mean age of 66 years (95% confidence interval [95% CI] 64, 67 years), were randomized to a training group (n = 35) or a control group without physiotherapy (n = 33). Assessments were performed before the intervention at 3 months (pretest), at 5 months (posttest 1), and at 12 months (posttest 2) after surgery. The primary outcome was the 6-minute walk test (6MWT). The secondary outcomes were the stair climbing test (ST); figure-of-eight test; Index of Muscle Function (IMF); active hip range of motion (ROM) in flexion, extension, and abduction; Harris Hip Score (HHS); self-efficacy; and Hip Dysfunction and Osteoarthritis Outcome Score. RESULTS: The training group had larger improvements than the control group at posttest 1 on the 6MWT with an adjusted mean difference of 52 meters (95% CI 29, 74 meters; P < 0.001) and on the ST of -1 second (95% CI -2, 0 seconds; P = 0.01).There were also improvements on the figure-of-eight test (P = 0.02), IMF (P = 0.001), active hip ROM in extension (P = 0.02), HHS (P = 0.05), and self-efficacy (P = 0.04). The difference between the groups persisted at posttest 2 on the 6MWT of 52 meters (95% CI 24, 80 meters; P < 0.001) and on the ST of -1 second (95% CI -3, 0 seconds; P = 0.05). CONCLUSION: The walking skill training program was effective, especially in improving walking both immediately after the intervention and 1 year after THA surgery.

Pain and recovery of physical functioning nine months after total knee arthroplasty.

OBJECTIVE: To describe pain and recovery of physical functioning after total knee arthroplasty. DESIGN: A longitudinal design with assessments preoperatively, and 1 week, 3 and 9 months postoperatively. SUBJECTS: Sixty-three patients participated. METHODS: Pain was assessed by visual analogue scale. Physical functioning was measured by 40-metre timed walking, timed stair-climbing and goniometry. At 9 months the Short Form-36 pain and physical function scales were added to make comparisons with the general population. RESULTS: Pain score one week after surgery was 40 (standard deviation (SD) 23) vs 24 (SD 19) at 3 months (p < 0.001). At 9 months the pain score was 22 (SD 23) vs 49 (SD 18) preoperatively (p < 0.001). Knee extension did not differ from preoperative scores, but knee flexion reduced from 124 (SD 13) to 112 (SD 12) (p < 0.001). Forty-metre walking time improved from 37 (SD 13) to 34 (SD 11) s (p < 0.001), while the number of patients able to climb stairs was unchanged (p > 0.05). The patients' Short-Form 36 pain score did not differ from the general population, while the physical function score was 60 (SD 24) vs 75 (SD 24) (p < 0.001). CONCLUSION: Early pain reduction was registered. At 9 months, pain was equal to that in the general population, but a considerable number of patients still had problems in performing strenuous activities.

Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty - a randomized controlled trial.

PURPOSE: Continuous passive motion is frequently used post-operatively to increase knee range of motion after total knee arthroplasty in spite of little conclusive evidence. The aim of this study was to examine whether continuous passive motion (CPM) as an adjunct to active exercises had any short time effects (after one week and three months) on pain, range of motion, timed walking and stair climbing. METHOD: A randomized controlled trial was conducted. A total of 63 patients undergoing primary TKA were randomly assigned into an experimental group receiving CPM and active exercises and a control group receiving active exercises only. Outcomes were assessed by goniometer, visual analogue scale (VAS), timed 'Up and Go' test (TUG), timed 40 m walking distance and timed stair climbing. RESULTS: There were no statistical differences between the treatment groups for any outcome measures either at one week or after three months. For the whole group, a significant and 50% reduction in pain score was found after three months (p < 0.01). Compared with before surgery, a significantly impaired knee flexion range of motion (p < 0.01) and a significantly decreased number of patients able to climb stairs were found after three months (p < 0.01). CONCLUSION: CPM was not found to have an additional short-time effect compared with active physiotherapy. After three months considerable pain relief was obtained for the whole group, the patients preoperative ROM was not restored and the number of patients able to climb stairs had decreased.