Prognostic factors of functional outcome after hip fracture surgery: a systematic review.

Objective: this systematic review aimed to identify immutable and modifiable prognostic factors of functional outcomes and their proposed mechanism after hip fracture surgery. Design: systematic search of MEDLINE, Embase, CINAHL, PEDRO, OpenGrey and ClinicalTrials.gov for observational studies of prognostic factors of functional outcome after hip fracture among surgically treated adults with mean age of 65 years and older. Study selection, quality assessment, and data extraction were completed independently by two reviewers. The Quality in Prognosis Studies Tool was used for quality assessment and assigning a level of evidence to factors. Proposed mechanisms for reported associations were extracted from discussion sections. Results: from 33 studies of 9,552 patients, we identified 25 prognostic factors of functional outcome after hip fracture surgery. We organised factors into groups: demographics, injury and comorbidities, body composition, complications, and acute care. We assigned two factors a weak evidence level-anaemia and cognition. We assigned Parkinson's disease an inconclusive evidence level. We could not assign an evidence level to the remaining 22 factors due to the high risk of bias across studies. Frailty was the proposed mechanism for the association between anaemia and functional outcome. Medication management, perceived potential, complications and time to mobility were proposed as mechanisms for the association between cognition and functional outcome. Conclusion: we identified one modifiable and one immutable prognostic factor for functional outcomes after hip fracture surgery. Future research may target patients with anaemia or cognitive impairment by intervening on the prognostic factor or the underlying mechanisms.

Do behaviour-change techniques contribute to the effectiveness of exercise therapy in patients with intermittent claudication? A systematic review.

This systematic narrative review of randomised controlled trials (RCTs) identifies and evaluates the efficacy of behaviour-change techniques explicitly aimed at walking in individuals with intermittent claudication. An electronic database search was conducted up to December 2012. RCTs were included comparing interventions incorporating behaviour-change techniques with usual care, walking advice or exercise therapy for increasing walking in people with intermittent claudication. Studies were evaluated using the Cochrane Collaboration risk of bias tool. The primary outcome variable was maximal walking ability at least 3 months after the start of an intervention. Secondary outcome variables included pain-free walking ability, self-report walking ability and daily walking activity. A total of 3,575 records were retrieved. Of these, six RCTs met the inclusion criteria. As a result of substantial heterogeneity between studies, no meta-analysis was conducted. Overall, 11 behaviour-change techniques were identified; barrier identification with problem solving, self-monitoring and feedback on performance were most frequently reported. There was limited high-quality evidence and findings were inconclusive regarding the utility of behaviour-change techniques for improving walking in people with intermittent claudication. Rigorous, fully powered trials are required that control for exercise dosage and supervision in order to isolate the effect of behaviour-change techniques alongside exercise therapy.

Neuromuscular and psychomotor function in elderly subjects who fall and the relationship with vitamin D status.

Vitamin D and calcium supplementation significantly reduces the incidence of fractures. Evidence suggests vitamin D deficiency impairs neuromuscular function, causing an increase in falls and thereby fractures. The relationship between vitamin D, functional performance, and psychomotor function in elderly people who fall was examined in a prospective cross-sectional study. Patients were recruited from a falls clinic and stratified according to serum 25-hydroxyvitamin-D levels (25OHD): group 1, 25OHD < 12 microg/liter; group 2 25OHD, 12-17 microg/liter; and group 3, 25OHD > 17 microg/liter. Healthy elderly volunteers with 25OHD > 17 microg/liter comprised group 4 (n = 20/group). Measures included aggregate functional performance time (AFPT, seconds), isometric quadriceps strength (Newtons), postural sway (degrees), and choice reaction time (CRT, seconds). Serum bone biochemistry, 25OHD, and parathyroid hormone levels were measured. Patients who fell had significantly impaired functional performance, psychomotor function, and quadriceps strength compared with healthy subjects (AFPT: 51.0 s vs. 32.8 s,p < 0.05; CRT: 1.66 s vs. 0.98 s,p < 0.05; strength: 223N vs. 271N, t = 2.35, p = 0.02). Group 1 had significantly slower AFPT (66.0 s vs. 44.8 s, t = 4.15, p < 0.05) and CRT (2.37 s vs. 0.98 s, t = 3.59, p < 0.05) than groups 2 and 3. Group 1 had the greatest degree of postural sway and the weakest quadriceps strength, although this did not reach significance. Multivariate analysis revealed 25OHD as an independent variable for AFPT, CRT, and postural sway. PTH was an independent variable for muscle strength. Older people who fall have impaired functional performance, psychomotor function, and muscle strength. Within this group, those with 25OHD < 12 microg/liter are the most significantly affected.

Exercise can reverse quadriceps sensorimotor dysfunction that is associated with rheumatoid arthritis without exacerbating disease activity.

OBJECTIVES: To compare quadriceps sensorimotor function, lower limb functional performance and disability in patients with rheumatoid arthritis (RA) and healthy subjects, and to investigate the efficacy and safety of a brief rehabilitation regime. METHODS: Quadriceps strength, voluntary activation, proprioceptive acuity and the aggregate time [aggregate functional performance time (AFPT)] taken to perform four common activities [aggregate functional performance time (AFPT)] were compared between 103 RA patients who had lower limb involvement and 25 healthy subjects. In addition, disability (Health Assessment Questionnaire), clinical disease activity and the plasma concentration of proinflammatory cytokines were measured in the RA patients. In a follow-on randomized controlled trial of rehabilitation, these variables were used as baseline data for 93 of the RA patients, who were randomized to a rehabilitation or a control group. Changes in the variables were analysed within and between groups. RESULTS: Compared with healthy subjects, RA patients had weaker quadriceps [mean difference 157 N; 95% confidence interval (CI) 125-189], poorer activation (8%, 95% CI 4.5-15) and proprioceptive acuity (0.8 degrees, 95% CI 0.4-1.3) and took longer to perform the AFPT (34 s, CI 23.5-44.8). Rehabilitation increased quadriceps strength (mean increase 61 N, 95% CI 28-95) and voluntary activation (8%, 95% CI 3-12.4) and decreased the AFPT (12.3 s, 95% CI -2 to 27.7) and subjective disability (0.21 HAQ points, 95% CI 0-0.35) without exacerbating disease activity. All the improvements were maintained at the 6-month follow-up. There was no change during the control period. CONCLUSIONS: Patients with RA that affected their lower limb had quadriceps sensorimotor deficits that were associated with lower limb disability. A clinically applicable rehabilitation regime increased quadriceps sensorimotor function and decreased lower limb disability without exacerbating pain or disease activity. For patients with well-controlled RA that causes lower limb involvement, the regime is effective and safe.