Does the 'Otago exercise programme' reduce mortality and falls in older adults?: a systematic review and meta-analysis.

BACKGROUND: the 'Otago exercise programme' (OEP) is a strength and balance retraining programme designed to prevent falls in older people living in the community. The aim of this review was to evaluate the effect of the OEP on the risk of death and fall rates and to explore levels of compliance with the OEP in older adults. METHODS: a systematic review with meta-analysis. Clinical trials where the OEP was the primary intervention and participants were community-dwelling older adults (65+) were included. Outcomes of interest included risk of death, number of falls, number of injurious falls and compliance to the exercise programme. RESULTS: seven trials, involving 1503 participants were included. The mean age of participants was 81.6 (±3.9) years. The OEP significantly reduced the risk of death over 12 months [risk ratio = 0.45, 95% confidence interval (CI) = 0.25-0.80], and significantly reduced fall rates (incidence rate ratio = 0.68, 95% CI = 0.56-0.79). There was no significant difference in the risk of a serious or moderate injury occurring as the result of a fall (risk ratio = 1.05, 95% CI = 0.91-1.22). Of the 747 participants who remained in the studies at 12 months, 274 (36.7%) were still exercising three or more times per week. CONCLUSION: the OEP significantly reduces the risk of death and falling in older community-dwelling adults.

Motor function in 5-year-old children with cerebral palsy in the South Australian population.

The aim of this study was to describe the motor function of a population of children at age 5 years enrolled on the South Australian Cerebral Palsy Register. Among children born between 1993 and 1998, there were 333 with confirmed cerebral palsy (prevalence rate 2.2 per 1000 live births), in whom 247 assessments (56.7% males, 43.3% females) were completed. The distribution by Gross Motor Function Classification System (GMFCS) level was: level I, 50.6%; level II, 18.2%; level III, 9.3%; level IV, 9.7%; level V, 12.1%. The most common topographical classification was spastic diplegia (38.5%), followed by spastic hemiplegia (34.8%) and spastic quadriplegia (14.6%). Abnormal movements occurred at rest or with intention in 19.4% of children. A high proportion of the population with relatively mild gross motor impairments have difficulty with everyday bimanual tasks, reinforcing the need to assess upper limb function independently of gross motor function. The use of ankle-foot orthoses was common, particularly across GMFCS levels II to IV. Further refinement is indicated for this population's motor dataset, to include more recently described classification measures as well as future novel measures to better describe the presence of both spasticity and dystonia.

The distribution of health services for older people in Australia: where does transition care fit?

INTRODUCTION: The purpose of this study was to describe the distribution of hospital and aged care services for older people, with a particular focus on transition care places, across Australia and to determine the relationships between the provision of these services. METHODS: Aggregation of health and aged care service indicators by Aged Care Assessment Team (ACAT) region including: public and private acute and subacute (rehabilitation and geriatric evaluation and management) hospital beds, flexible and mainstream aged care places as at 30 June 2006. RESULTS: There was marked variation in the distribution of acute and subacute hospital beds among the 79 ACAT regions. Aged care places were more evenly distributed. However, the distribution of transition care places was uneven. Rural areas had poorer provision of all beds. There was no evidence of coordination in the allocation of hospital and aged care services between the Commonwealth and state/territory governments. There was a weak relationship between the allocation of transition care places and the distribution of health and aged care services. DISCUSSION: Overall, the distribution of services available to older persons is uneven across Australia. While the Transition Care Program is flexible and is providing rural communities with access to rehabilitation, it will not be adequate to address the increasing needs associated with the ageing of the Australian population. An integrated national plan for aged care and rehabilitation services should be considered.

Home versus day rehabilitation: a randomised controlled trial.

OBJECTIVE: to assess the effect of home versus day rehabilitation on patient outcomes. DESIGN: randomised controlled trial. SETTING: post-hospital rehabilitation. PARTICIPANTS: two hundred and twenty-nine hospitalised patients referred for ambulatory rehabilitation. INTERVENTIONS: hospital-based day rehabilitation programme versus home-based rehabilitation programme. MAIN OUTCOME MEASURES: at 3 months, information was collected on hospital readmission, transfer to residential care, functional level, quality of life, carer stress and carer quality of life. At 6 months, place of residence, hospital re-admissions and mortality status were collected. RESULTS: there were significant improvements in the functional outcomes from baseline to 3 months for all participants. At discharge, carers of patients in day hospital reported higher Caregiver Strain Index (CSI) scores in comparison to home rehabilitation carers (4.95 versus 3.56, P = 0.047). Patients in day hospital had double the risk of readmission compared to those in home rehabilitation (RR = 2.1; 95% CI 1.2-3.9). This effect persisted at 6 months. CONCLUSIONS: day hospital patients are more likely to be readmitted to hospital possibly due to increased access to admitting medical staff. This small trial favours the home as a better site for post-hospital rehabilitation.

Bioelectrical phase angle values in a clinical sample of ambulatory rehabilitation patients.

BACKGROUND: Phase angle (PhA) is derived from the resistance and reactance measurements obtained from bioelectric impedance analysis (BIA) and is considered indicative of cellular health and membrane integrity. This study measured PhA values of rehabilitation patients and compared them to reference values, measures of functional ability and serum C-reactive protein (CRP) levels to explore their utility as a clinical tool to monitor disease progression and treatment efficacy. METHODS: This cross-sectional observational study was conducted on 215 ambulatory rehabilitation patients aged 20 - 94 years. All participants had been hospitalised for a stroke, orthopaedic or other condition resulting in a functional limitation. PhA was derived from BIA analysis and functional ability characterised using the Functional Independence Measure (FIM), timed up and go (TUG) and maximal quadriceps strength (MQS). Serum levels of CRP were also collected. RESULTS: Stroke patients had the highest PhA (5.3 degrees) followed by elective orthopaedic surgery (5.0 degrees) with the other group (4.3 degrees) significantly lower than both previous categories (p < 0.001). Ambulatory rehabilitation patients' PhA values were dependent on age and sex (p < 0.001), lower than published age matched healthy reference values (p < or = 0.05) and similar to other hospitalised or sick groups, but also higher than values reported in critically ill patients. Patients with CRP values less than 10 mg.L-1 had significantly (p = 0.005) higher mean PhA values. Furthermore, the highest functional status quartiles had significantly higher PhAs (p < or = 0.04) for the FIM, MQS and TUG measures. CONCLUSION: The results suggest that the phase angles of rehabilitation patients are between those of healthy individuals and seriously ill patients, thereby supporting claims that PhA is indicative of general health status. Phase angles are a potentially useful indicator of functional status in patients commencing an ambulatory rehabilitation program with a normal hydration status.

Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: A systematic review.

BACKGROUND: While hip fractures are an important cause of disability, dependency and death in older adults, the benefit of multi-disciplinary rehabilitation for people who have sustained hip fracture has not been demonstrated. METHODS: Systematic review of randomized controlled trials which compare co-ordinated multi-disciplinary rehabilitation with usual orthopaedic care in older people who had sustained a hip fracture. Outcome measures included: mortality, return home, "poor outcome", total length of hospital stay, readmissions and level of function. RESULTS: We identified 11 trials including 2177 patients. Patients who received multi-disciplinary rehabilitation were at a lower risk (Risk Ratio 0.84, 95% CI 0.73-0.96) of a "poor outcome" - that is dying or admission to a nursing home at discharge from the programme, and showed a trend towards higher levels of return home (Risk Ratio 1.07, 95% CI 1.00-1.15). Pooled data for mortality did not demonstrate any difference between multi-disciplinary rehabilitation and usual orthopaedic care. CONCLUSION: This is the first review of randomized trials to demonstrate a benefit from multi-disciplinary rehabilitation; a 16% reduction in the pooled outcome combining death or admission to a nursing home. This result supports the routine provision of organized care for patients following hip fracture, as is current practice for patients after stroke.

Evidence for the optimal management of acute and chronic phantom pain: a systematic review.

OBJECTIVES: The objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. METHODS: Trials were identified by a systematic search of MEDLINE, review articles, and references of relevant trials from the period 1966-1999, including only English-language articles. Included trials involved a control group, any intervention, and reported phantom pain as an outcome. RESULTS: Twelve trials were identified, including 375 patients whose follow-ups ranged in duration from 1 week to 2 years. Only three randomized, controlled studies with parallel groups and three randomized crossover trials were identified. Eight trials examined treatment of acute phantom pain, including epidural treatments (three trials), regional nerve blocks (three trials), treatment with calcitonin (one trial), and transcutaneous electrical nerve stimulation (one trial). Three trials demonstrated a positive impact of the intervention on phantom limb pain, but the remainder demonstrated no difference between the intervention and control groups. Four trials examined late postoperative interventions, including transcutaneous electrical nerve stimulation (two trials) and the use of Farabloc (a metal threaded sock) and ketamine (one trial each). With regard to late postoperative interventions, three of the four trials showed modest short-term reduction of phantom limb pain. There was no relation between the quality of the trial and a positive result of the intervention. CONCLUSIONS: Although up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.

An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475].

BACKGROUND: The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting. METHODS: Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis. RESULTS: Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69-14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up. CONCLUSIONS: While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained.

Sociodemographic factors associated with self-reported exercise and physical activity behaviors and attitudes of South Australians: results of a population-based survey.

OBJECTIVE: To determine self-reported physical activity barriers, behaviors, and beliefs about exercise of a representative sample and to identify associated sociodemographic factors. METHOD: Face-to-face interviews conducted between September and December 2008, using a random stratified sampling technique. RESULTS: Barriers injury and illness were associated with being older, single, and not engaged in full-time work; lack of time was associated with being married, younger, female, and working full-time; and lack of motivation and cost were associated with being younger than 65 years. Advancing age was significantly associated (p < .001) with reduced physical activity. Factors including age, education, marital status, and area of residence were all associated with preferences for environment to exercise in, while all age groups (74%) felt that walking was the most important type of exercise for older adults. DISCUSSION: A better understanding of these factors may improve uptake of and adherence to exercise programs across the ages.

Determining current physical therapist management of hip fracture in an acute care hospital and physical therapists' rationale for this management.

BACKGROUND: Physical therapy has an important role in hip fracture rehabilitation to address issues of mobility and function, yet current best practice guidelines fail to make recommendations for specific physical therapy interventions beyond the first 24 hours postsurgery. OBJECTIVES: The aims of this study were: (1) to gain an understanding of current physical therapist practice in an Australian acute care setting and (2) to determine what physical therapists consider to be best practice physical therapist management and their rationale for their assessment and treatment techniques. DESIGN AND METHODS: Three focus group interviews were conducted with physical therapists and physical therapist students, as well as a retrospective case note audit of 51 patients who had undergone surgery for hip fracture. RESULTS: Beyond early mobilization and a thorough day 1 postoperative assessment, great variability in what was considered to be best practice management was displayed. Senior physical therapists considered previous clinical experience to be more important than available research evidence, and junior physical therapists modeled their behavior on that of senior physical therapists. The amount of therapy provided to patients during their acute inpatient stay varied considerably, and none of the patients audited were seen on every day of their admission. CONCLUSIONS: Current physical therapist management in the acute setting for patients following hip fracture varies and is driven by system pressures as opposed to evidence-based practice.

Patient readiness and ability to set recovery goals during the first 6 months after stroke.

UNLABELLED: Goal setting is recommended both in the acute and rehabilitation phases after stroke, yet this presents multiple challenges for patients and clinicians. The aim of this study was to describe the participants' readiness and ability to set goals over time. METHODS: Fifteen stroke survivors aged 18-70 yrs were interviewed using a semi-structured interview guide at three time points: on the acute stroke unit, while participating in a subacute rehabilitation program, and 6 mos after the stroke. Content analysis was performed using NVivo. RESULTS: Participants had difficulty setting goals early after stroke. Contributing to this was limited understanding of goal terminology, wanting to "get back to normal," differences in readiness to set goals, and poor knowledge about typical stroke recovery. CONCLUSION: Future models need to acknowledge the importance of timing and education in goal setting. People who have just had a stroke need time to understand many of the terms and concepts that treating clinicians use, and new models need to acknowledge the importance of health literacy if both patients and carers are to participate in the rehabilitation process. People that have had a stroke have an important role to play in the development of these new models.

Development and testing of a questionnaire to measure older people's experience of the Transition Care Program in Australia.

AIM: Transition Care (TC) is a new program for older adults in Australia. At present, program quality is assessed using provider reports of compliance with key requirements established by the Australian Government Department of Health and Ageing. As part of the National Evaluation of the Transition Care Program, the authors developed a questionnaire to measure recipient experience of TC. METHOD: Validity and reliability were assessed via interviews with 582 recipients or proxies 3 months after discharge from TC. RESULTS: Concordance between test-retest observations was high. Principal component analysis suggested three subscales were important: restoration, continuity of care and patient involvement. Recipients of TC in a residential care setting had lower mean scores on the restoration subscale compared to those who received services in the community. CONCLUSION: This study found that a standardised measure of recipient experience could inform quality improvement in TC and is feasible to administer via questionnaire.

Walking aid use after discharge following hip fracture is rarely reviewed and often inappropriate: an observational study.

QUESTIONS: What walking aid prescription occurs at discharge after hip fracture? What changes in walking aid use occur in the following six months? Who initiates changes in walking aids and why? DESIGN: Prospective longitudinal observational study. PARTICIPANTS: 95 community-dwelling older adults who had undergone surgical treatment of a hip fracture. OUTCOME MEASURES: Range of walking aids prescribed at discharge and participants' recall of advice about progression were recorded. Progression of walking aids was observed fortnightly over 6 months. With any change in walking aid use, an independent physiotherapist determined if it was appropriate and participants reported the reason for the change. RESULTS: Most participants were discharged from their final inpatient setting with a wheeled frame (92%). Eighty-two (86%) participants were not aware of any goals set by the physiotherapist for the first 6 months and 89 (94%) stated that a review time had not been set. Despite this, 78 (82%) participants changed their walking aid, on average 8 weeks (SD 6) after discharge. However, 32% of those who changed their walking aids were using an inappropriate aid or using it incorrectly. Six months after discharge, 40% of participants had not returned to using their pre-morbid indoor aid and 50% their outdoor aid. CONCLUSION: A review of walking aid by a physiotherapist is rare within six months after discharge following hip fracture. Most patients make their own decision about what walking aid is most appropriate. This has safety implications in a group at high risk of falls.

What are the first quality reports from the Transition Care Program in Australia telling us?

Transition Care is a new program in Australia, jointly funded by the Commonwealth and State/Territory Governments. Implementation is undertaken by state health departments, in some cases through aged care organisations, against a set of key requirements. This paper examines reports from providers to reveal enablers and barriers to compliance with the requirements and to highlight emerging patterns of practice. The first 23 self-reports were content analysed. Person-centred and goal-orientated care was evidenced. General practitioner, pharmacist and geriatrician involvement in care planning and review was low. While service agreements between Transition Care services, referring hospitals and community providers improved the efficiency of information transfer and discharge arrangements, these were rare, hindering entry and discharge from the program. Transition Care offers older people a flexible model of care. While the flexibility of the model is a strength, service providers are struggling to achieve integration with existing services.

Nutritional status of adults participating in ambulatory rehabilitation.

AIMS: To assess the overall nutritional status of older adults participating in ambulatory rehabilitation and determine its association with relevant outcomes including physical function and quality of life. DESIGN: Cross-sectional. SETTING: Ambulatory rehabilitation service in the Southern region of Adelaide, Australia. SUBJECTS: A total of 229 participants recruited as part of a RCT between June 2005 and June 2006, stroke (n=83), elective orthopedic procedure (n=44) and other medical condition (n=102). METHODS: Nutritional status was measured using Mini Nutritional Assessment (MNA), Simplified Nutrition Appetite Questionnaire (SNAQ) and Body Mass Index. Functional performance was assessed using the Modified Barthel Index (MBI) and quality of life was measured using the Short Form-36 (SF-36). RESULTS: Sixty-three percent of participants were malnourished or at risk of malnutrition according to the MNA and a third had a risk of >or= 5% weight loss in the subsequent six months, according to the SNAQ. Participants with a diagnosis other than stroke or elective orthopedic procedure were the most vulnerable, with 53% (n=74/140) classified as at risk of malnutrition or malnourished and a longer length of stay in hospital. Functional performance was no different for participants assessed as at risk of malnutrition or malnourished compared to the well nourished, but the SF-36 mental component score was significantly higher for those who were well nourished (p=0.003). CONCLUSION: Findings emphasise the magnitude of the malnutrition problem in ambulatory rehabilitation settings. Further research is required to evaluate the resource implications against expected benefits of providing nutrition interventions at this point.

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing.

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.