Improvement in aerobic fitness during rehabilitation after hip fracture.

OBJECTIVE: To evaluate the effect of an upper-body exercise program on cardiorespiratory fitness in older adults with hip fracture during inpatient rehabilitation. DESIGN: Randomized controlled trial using a convenience sample. SETTING: An inpatient rehabilitation unit. PARTICIPANTS: Twenty older patients (age, 81.3+/-7.2y; 14 women). INTERVENTION: Patients were randomly assigned to a control group (n=10) or a training group (n=10). Both groups attended physical and occupational therapy sessions 5 times a week during rehabilitation (mean length of stay, 32.9+/-5.3d). Patients in the training program used an arm crank ergometer 3 times a week for 4 weeks. MAIN OUTCOME MEASURE: Peak oxygen consumption (Vo(2)peak). RESULTS: Vo(2)peak increased significantly in the training group (8.9+/-1.4 to 10.8+/-1.7mL x kg(-1) x min(-1)) and did not change in the control group (8.9+/-1.2 to 8.8+/-1.6mL x kg(-1).min(-1)). At discharge, both groups were significantly improved in all functional outcome measures (Timed Up & Go [TUG] test, Berg Balance Scale [BBS], FIM instrument, two-minute walk test [2MWT], and ten-minute walk test [10MWT]). The training group performed significantly better in mobility (TUG, 2MWT, 10MWT) and balance (BBS) compared with the control group. There was a significant correlation between Vo(2)peak and the 2MWT (r=.81) and 10MWT (r=.85) in the training group at discharge. CONCLUSIONS: The upper-body exercise program had a significant effect on aerobic power. Our results suggest that aerobic endurance exercise should be integrated into standard rehabilitation to enhance patients' aerobic fitness and mobility after hip fracture surgery.

Improving the Quality of Radiation Treatment for Patients in Ontario: Increasing Peer Review Activities on a Jurisdictional Level Using a Change Management Approach.

PURPOSE: Peer review of radiation treatment (RT) plans is a key component of quality assurance programs in radiation medicine. A 2011 current state assessment identified considerable variation in the percentage of RT plans peer reviewed across Ontario's 14 cancer centers.In response, Cancer Care Ontario launched an initiative to increase peer review of plans for patients receiving radical intent RT. METHODS: The initiative was designed consistent with the Kotter eight-step process for organizational transformation. A multidisciplinary team conducted site visits to promote and guide peer review and to develop education and implementation processes in collaboration with the centers. A centralized reporting infrastructure enabled the monitoring of the percentage of RT courses peer reviewed and the timing of peer review (before completion of 25%of treatment visits, after completion of >25%treatment visits). RESULTS: The initiative is ongoing, but early results indicate that the proportion of radical intent RT courses peer reviewed province wide increased from 43.5% (April 2013) to 68.0%(March 2015). This proportion is now a quality metric in Ontario and is publicly reported through the Cancer System Quality Index. The performance target for this metric was initially set at 50%(cases treated with radical intent) and revised to 60% in 2014. Provincial performance exceeded targets in both years (58.2% and 68.2%, respectively). Considerable variation was observed, however, in rates and timing of peer review among Cancer Care Ontario centers. CONCLUSION: This initiative demonstrates that a change management framework can be useful for planning and achieving substantial increases in jurisdictional peer review activities.

A systematic review of screening tools for predicting the development of dementia.

Early detection of dementia is essential to guide front-line health care practitioners in further clinical evaluations and treatments. There is a paucity of literature assessing the effectiveness of screening tools to predict the development of dementia, thus we conducted a systematic review to fill this gap. The purpose of the systematic review was to make recommendations to health care practitioners on which screening tool best predicts the development of dementia and is most feasible in the primary care setting. Ten databases were searched for relevant articles, yielding 751 papers. Of these, 12 met relevance criteria for inclusion. Screening tools were assessed for test accuracy, cognitive domain coverage, predictive ability, and feasibility. Four screening tools were recommended. Addenbrooke's Cognitive Examination (ACE) was considered to be the ideal tool. A revised version of this tool is now used in clinical practice but the psychometric properties of the ACE-R remain to be established.

Effect of upper body aerobic exercise on arterial stiffness in older adults.

The authors evaluated the effects of acute arm-cycling exercise on arterial stiffness of the brachial artery (BA: working limb) and posterior tibial artery (PTA: nonworking limb) in healthy older participants. Eleven participants were tested to evaluate BA and PTA stiffness. Blood pressure (BP), heart rate (HR), and arterial stiffness indices of the BA and PTA measured by Doppler ultrasound were determined before and 10 min after graded arm-cycling exercise to volitional fatigue on 2 separate days. After the exercise, although BA diameter, brachial systolic BP, pulse pressure, and HR increased significantly (all p < .05), arterial stiffness indices of the BA remained unchanged. Similarly, arterial stiffness indices of the PTA remained unchanged after the exercise, whereas HR increased significantly (p < .05). These results show that acute arm-cycling exercise failed to modify arterial stiffness of the BA and PTA, suggesting that it has no systemic effect on arterial stiffness in healthy older adults.

Validity of values for metabolic equivalents of task during submaximal all-extremity exercise and reliability of exercise responses in frail older adults.

BACKGROUND AND PURPOSE: Physical therapists and rehabilitation professionals in hospital and long-term care centers are using all-extremity semirecumbent exercise machines in their treatment programs. This study was undertaken to investigate the concurrent validity of values for software-generated metabolic equivalents of task (MET) from an all-extremity semirecumbent exercise machine and directly measured values for MET from a portable metabolic unit across a range of submaximal exercise intensities. A second purpose of this study was to determine the test-retest reliability of oxygen consumption and heart rate responses in older adults between standardized sessions of submaximal all-extremity aerobic exercise. SUBJECTS AND METHODS: The study participants were 18 older adults (mean age=82 years, SD=5; 3 women, 15 men) who were living in long-term care centers and who completed 2 test sessions of a standardized exercise protocol 1 week apart. The exercise protocol included a warm-up period, three 4-minute stages of exercise at incremental workload levels, and a cool-down period. The breath-by-breath metabolic data from the portable metabolic unit, heart rate, MET values from the exercise machine, Borg Rating of Perceived Exertion, and watts were recorded continuously throughout the exercise protocol. RESULTS: The concurrent validity of the MET values from the exercise machine and the portable metabolic unit ranged from very good to excellent on both day 1 and day 2 (r=.85-.97). The test-retest reliability of subjects' heart rate responses and MET values from the portable metabolic unit was moderate to high across submaximal exercise intensities (intraclass correlation coefficients [2,1]=.85-.91). DISCUSSION AND CONCLUSION: The exercise machine software-generated MET values were representative of directly measured oxygen consumption values across a range of submaximal intensities during all-extremity semirecumbent exercise in older adults with multisystem impairments.

Reliability and validity of responses to submaximal all-extremity semirecumbent exercise in older adults.

Although popular in clinical settings, little is known about the utility of all-extremity semirecumbent exercise machines for research. Twenty-one community-dwelling older adults performed two exercise trials (three 4-min stages at increasing workloads) to evaluate the reliability and validity of exercise responses to submaximal all-extremity semirecumbent exercise (BioStep). Exercise responses were measured directly (Cosmed K4b2) and indirectly through software on the BioStep. Test-retest reliability (ICC2,1) was moderate to high across all three stages for directly measured METs (.92, .87, and .88) and HR (.91, .83, and .86). Concurrent criterion validity between the K4b2 and BioStep MET values was moderate to very good across the three stages on both Day 1 (r = .86, .71, and .83) and Day 2 (r = .73, .87, and .72). All-extremity semirecumbent submaximal exercise elicited reliable and valid responses in our sample of older adults and thus can be considered a viable exercise mode.

Effect of rehabilitation on hip and knee proprioception in older adults after hip fracture: a pilot study.

OBJECTIVE: Impaired proprioception may predispose patients with hip fracture to increased risk of future disability. The purpose of the study was to determine the effect of rehabilitation on proprioceptive changes in both the hip and knee joints of patients after hip fracture. DESIGN: Data were collected on 30 patients with hip fracture (mean age, 79.6 +/- 6.7 yrs) who attended physical and occupational therapy sessions five times per week during a rehabilitation hospital stay of 24.8 +/- 8.1 days. Proprioception was assessed with an electrogoniometer within 48 hrs of admission to and discharge from the rehabilitation unit. The passive-to-active reproduction of joint angle technique determined absolute angular error in non-weight-bearing positions at 15, 30, and 60 degrees of hip flexion and knee extension in both injured and noninjured sides. RESULTS: Absolute angular error decreased significantly (P < 0.05) from admission (5.3 +/- 2.6 degrees, 4.1+/- 3.1 degrees) to discharge (3.0 +/- 2.3 degrees, 2.8 +/- 3.1 degrees) in hip flexion and knee extension, respectively, on the injured side. Absolute angular error was significantly less (P < 0.05) at 15 degrees compared with 30 and 60 degrees of hip flexion at admission and discharge on the injured side. CONCLUSIONS: Hip and knee joint proprioception significantly improved in the injured side after the rehabilitation program. This may be an important outcome regarding future disability in this population.

Specificity of functional mobility measures in older adults after hip fracture: a pilot study.

OBJECTIVE: To determine the relationships between measures of functional mobility (Timed Up and Go [TUG], Self-Paced Walking [SPW], Berg Balance Scale [BBS]) and global functional status (FIM trade mark instrument), the motor component of the FIM instrument (motor FIM), and the mobility/locomotor-specific FIM component (ML-FIM) in older patients admitted to an inpatient rehabilitation program after hip fracture. DESIGN: The TUG, SPW, BBS, and FIM instrument were administered within 24 hr after admission and before discharge to 20 patients undergoing inpatient rehabilitation after a hip fracture. RESULTS: Significant correlations at admission were found between FIM and TUG scores (r = -0.47; p < 0.05), TUG and motor FIM (r = -0.45; p < 0.05), TUG and ML-FIM (r = -0.58; p < 0.01), FIM and BBS (r = 0.60; p < 0.01), motor FIM and BBS (r = 0.50; p < 0.05), and ML-FIM and BBS (r = 0.45; p < 0.05). At discharge, a significant correlation was found between the motor FIM and SPW (r = -0.49; p < 0.05). Change scores between both the motor FIM and ML-FIM and TUG scores were significantly correlated (r = -0.47, p < 0.05, r = -0.50, p < 0.05, respectively). CONCLUSIONS: The FIM instrument, motor FIM, and ML-FIM may not be specific measures of functional mobility in patients with hip fracture.