Predicting Delayed In-Hospital Recovery of Physical Function After Total Knee Arthroplasty.

Objective: To identify patients at high risk of delayed in-hospital functional recovery after knee replacement surgery by developing and validating a prediction model, including a combination of preoperative physical fitness parameters and patient characteristics. Design: Retrospective cohort study using binary logistic regression. Setting: University hospital, orthopedic department. Participants: 260 adults (N=260) (≥18y) with knee osteoarthritis awaiting primary unilateral total knee arthroplasty and assessed during usual care between 2016 and 2020. Intervention: Not applicable. Main Outcome Measures: Time to reach in-hospital functional independence (in days), measured by the modified Iowa Level of Assistance Scale. A score of 0 means completely independent. Potential predictor variables are a combination of preoperative physical fitness parameters and patient characteristics. Results: Binary logistic regression modeling was applied to develop the initial model. A low de Morton Mobility Index (DEMMI), walking aid use indoors, and a low handgrip strength (HGS) were the most important predictors of delayed in-hospital recovery. This model was internally validated and had an optimism-corrected R2 of 0.07 and an area under curve of 61.2%. The probability of a high risk of delayed in-hospital recovery is expressed by the following equation:Phighrisk=(1/(1+e(-(2.638-0.193×DEMMI+0.879×indoorwalkingaid-0.007×HGS))))×100%. Conclusions: The model has a low predictive value and a poor discriminative ability. However, there is a positive association between preoperative physical fitness and postoperative recovery of physical function. The validity of our model to distinguish between high and low risk, based on preoperative fitness values and patient characteristics, is limited.

Effects of remote coaching following supervised exercise oncology rehabilitation on physical activity levels, physical fitness, and patient-reported outcomes: a randomised controlled trial.

BACKGROUND: Studies have shown that cancer survivors experience difficulties maintaining physical activity levels after participation in a supervised exercise rehabilitation program. This study aimed to assess the effectiveness of a six-month remote coaching intervention, following a supervised exercise oncology rehabilitation program on maintenance of PA levels; and improvement of aerobic capacity, muscle strength and patient-reported outcomes in cancer survivors. METHODS: Ninety-seven participants from a Dutch University Hospital's exercise rehabilitation program were randomised to the COACH group (n = 46), receiving 6 months of remote coaching after completing the exercise program, or the CONTROL group (n = 50), receiving no additional intervention. Assessment of PA levels; sedentary time; aerobic capacity; muscle strength; fatigue; health-related quality of life (HRQoL); level of anxiety and depression; and return to work (RTW) rates were conducted at baseline (T0) and six months later (T1). Multiple linear regression was used for between-group statistical comparisons of all outcomes measures. Mean differences at T1 were estimated with corresponding 95% confidence intervals (95%CI). RESULTS: No significant between-group differences were observed for all outcomes at T1. An adjusted mean difference in weekly PA of 45 min (95%CI -50;140) was observed between the COACH group and the CONTROL group, favouring the COACH group, yet lacking statistical or clinical significance. CONCLUSIONS: Our six-month remote coaching intervention did not notably improve PA levels; sedentary time; aerobic capacity; muscle strength; HRQoL; fatigue; anxiety and depression symptoms and RTW rates after participation in a supervised exercise oncology program. Although the participants who received coaching showed slightly higher levels of PA, these differences were not significant. More research is needed to identify patients in need for follow-up interventions following supervised exercise program and to investigate the effectiveness of remote coaching interventions in these patients. TRIAL REGISTRATION: Dutch Trial Register NL7729, registered 13 may 2019, https://trialsearch.who.int/Trial2.aspx?TrialID=NL7729 .

The Effect of a Smartphone App with an Accelerometer on the Physical Activity Behavior of Hospitalized Patients: A Randomized Controlled Trial.

Inactive behavior is common in hospitalized patients. This study investigated the effectiveness of using a smartphone app with an accelerometer (Hospital Fit) in addition to usual care physiotherapy on increasing patients' physical activity (PA) behavior. A randomized controlled trial was performed at Maastricht University Medical Centre. Patients receiving physiotherapy while hospitalized at the department of Pulmonology or Internal Medicine were randomized to usual care physiotherapy or using Hospital Fit additionally. Daily time spent walking, standing, and upright (standing/walking) (min) and daily number of postural transitions were measured with an accelerometer between the first and last treatment. Multiple linear regression analysis was performed to determine the association between PA behavior and Hospital Fit use, corrected for functional independence (mILAS). Seventy-eight patients were included with a median (IQR) age of 63 (56-68) years. Although no significant effects were found, a trend was seen in favor of Hospital Fit. Effects increased with length of use. Corrected for functional independence, Hospital Fit use resulted in an average increase of 27.4 min (95% CI: -2.4-57.3) standing/walking on day five and 29.2 min (95% CI: -6.4-64.7) on day six compared to usual care. Hospital Fit appears valuable in increasing PA in functionally independent patients.

Evaluation of Primary Allied Health Care in Patients Recovering From COVID-19 at 6-Month Follow-up: Dutch Nationwide Prospective Cohort Study.

BACKGROUND: Patients recovering from COVID-19 often experience persistent problems in their daily activities related to limitations in physical, nutritional, cognitive, and mental functioning. To date, it is unknown what treatment is needed to support patients in their recovery from COVID-19. OBJECTIVE: This study aimed to evaluate the primary allied health care of patients recovering from COVID-19 at 6-month follow-up and to explore which baseline characteristics are associated with changes in the scores of outcomes between baseline and 6-month follow-up. METHODS: This Dutch nationwide prospective cohort study evaluated the recovery of patients receiving primary allied health care (ie, dietitians, exercise therapists, occupational therapists, physical therapists, and speech and language therapists) after COVID-19. All treatments offered by primary allied health professionals in daily practice were part of usual care. Patient-reported outcome measures on participation, health-related quality of life, fatigue, physical functioning, and psychological well-being were assessed at baseline and at 3- and 6-month follow-up. Linear mixed model analyses were used to evaluate recovery over time, and uni- and multivariable linear regression analyses were used to examine the association between baseline characteristics and recovery. RESULTS: A total of 1451 adult patients recovering from COVID-19 and receiving treatment from 1 or more primary allied health professionals were included. For participation (Utrecht Scale for Evaluation of Rehabilitation-Participation range 0-100), estimated mean differences of at least 2.3 points were observed at all time points. For the health-related quality of life (EuroQol Visual Analog Scale, range 0-100), the mean increase was 12.3 (95% CI 11.1-13.6) points at 6 months. Significant improvements were found for fatigue (Fatigue Severity Scale, range 1-7): the mean decrease was -0.7 (95% CI -0.8 to -0.6) points at 6 months. However, severe fatigue was reported by 742/929 (79.9%) patients after 6 months. For physical functioning (Patient-Reported Outcomes Measurement Information System-Physical Function Short Form 10b, range 13.8-61.3), the mean increase was 5.9 (95% CI 5.9-6.4) points at 6 months. Mean differences of -0.8 (95% CI -1.0 to -0.5) points for anxiety (Hospital Anxiety and Depression Scale range 0-21) and -1.6 (95% CI -1.8 to -1.3) points for depression were found after 6 months. A worse baseline score, hospital admission, and male sex were associated with greater improvement between baseline and 6-month follow-up, whereas age, the BMI, comorbidities, and smoking status were not associated with mean changes in any outcome measures. CONCLUSIONS: Patients recovering from COVID-19 who receive primary allied health care make progress in recovery but still experience many limitations in their daily activities after 6 months. Our findings provide reference values to health care providers and health care policy makers regarding what to expect from the recovery of patients who receive health care from 1 or more primary allied health professionals. TRIAL REGISTRATION: ClinicalTrials.gov NCT04735744; https://tinyurl.com/3vf337pn. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2340/jrm.v54.2506.

Determinants of physical activity maintenance and the acceptability of a remote coaching intervention following supervised exercise oncology rehabilitation: a qualitative study.

PURPOSE: The purpose of the study was to investigate perceived determinants of physical activity (PA) maintenance following supervised exercise oncology rehabilitation and the acceptability of a remote coaching intervention during this period. METHODS: A phenomenological qualitative study with semi-structured interviews was conducted. Nineteen participants (16 women, 3 men) were recruited from the intervention (n = 12) and control group (n = 7) of a randomized controlled trial on the effectiveness of remote coaching following hospital-based, supervised exercise oncology rehabilitation. Participants in the intervention group received a 6-month remote coaching intervention after completing the exercise program, aimed at stimulating PA maintenance. The interviews were based on the Capability, Opportunity, and Motivation model of Behaviour (COM-B model) and the framework of acceptability (TFA) and were coded using template analysis. RESULTS: Key themes regarding determinants of PA maintenance were self-efficacy, PA habits, accountability, physical complaints, and facilities. Remote coaching was perceived acceptable because it stimulated PA maintenance by offering a source of structure and social support and thereby increased accountability. Moreover, it improved confidence to perform PA, leading to increased levels of self-efficacy. The remote nature of the intervention was perceived as convenient by some of the participants, while others would have preferred additional physical appointments. CONCLUSIONS: Cancer survivors considered remote coaching acceptable to stimulate PA maintenance following supervised rehabilitation. Interventions should focus on increasing accountability, self-efficacy, forming habits, and helping cancer survivors to overcome barriers. IMPLICATIONS FOR CANCER SURVIVORS: The ability to maintain PA beyond supervised exercise oncology programs depends on many determinants. Remote coaching interventions have potential to target individually relevant determinants following exercise programs in cancer survivors.

Monitoring aerobic capacity in cancer survivors using self-reported questionnaires: criterion validity and responsiveness.

BACKGROUND: Evaluating the criterion validity and responsiveness of the self-reported FitMáx©-questionnaire, Duke Activity Status Index (DASI) and Veterans Specific Activity Questionnaire (VSAQ) to monitor aerobic capacity in cancer survivors. METHODS: Cancer survivors participating in a 10-week supervised exercise program were included. The FitMáx©-questionnaire, DASI, VSAQ and a cardiopulmonary exercise test (CPET) were completed before (T0) and after (T1) the program. Intraclass correlation coefficients (ICC) were calculated between VO2peak estimated by the questionnaires (questionnaire-VO2peak) and VO2peak measured during CPET (CPET-VO2peak), at T0 to examine criterion validity, and between changes in questionnaire-VO2peak and CPET-VO2peak (ΔT0-T1) to determine responsiveness. Receiver operating characteristic (ROC) analyses were performed to examine the ability of the questionnaires to detect true improvements (≥ 6%) in CPET-VO2peak. RESULTS: Seventy participants were included. Outcomes at T1 were available for 58 participants (83%). Mean CPET-VO2peak significantly improved at T1 (Δ1.6 mL·kg- 1·min- 1 or 8%). Agreement between questionnaire-VO2peak and CPET-VO2peak at T0 was moderate for the FitMáx©-questionnaire (ICC = 0.69) and VSAQ (ICC = 0.53), and poor for DASI (ICC = 0.36). Poor agreement was found between ΔCPET-VO2peak and Δquestionnaire-VO2peak for all questionnaires (ICC 0.43, 0.19 and 0.18 for the FitMáx©-questionnaire, VSAQ and DASI, respectively). ROC analysis showed that the FitMáx©-questionnaire was able to detect improvements in CPET-VO2peak (area under the curve, AUC = 0.77), when using a cut-off value of 1.0 mL·kg- 1·min- 1, while VSAQ (AUC = 0.66) and DASI (AUC = 0.64) could not. CONCLUSION: The self-reported FitMáx©-questionnaire has sufficient validity to estimate aerobic capacity in cancer survivors at group level. The responsiveness of the FitMáx©-questionnaire for absolute change is limited, but the questionnaire is able to detect whether aerobic capacity improved. The FitMáx©-questionnaire showed substantial better values of validity and responsiveness compared to DASI and VSAQ.

Submaximal cardiopulmonary exercise testing to assess preoperative aerobic capacity in patients with knee osteoarthritis scheduled for total knee arthroplasty: a feasibility study.

OBJECTIVE: To investigate the feasibility of submaximal cardiopulmonary exercise testing (CPET) in patients with knee osteoarthritis (OA) scheduled for primary total knee arthroplasty (TKA) surgery. Secondly, to assess their preoperative aerobic capacity. METHODS: In this observational, single-center study, participants performed a submaximal CPET 3-6 weeks before surgery. To examine their experiences, participants completed a questionnaire and one week later they were contacted by telephone. CPET was deemed feasible when five feasibility criteria were met. Aerobic capacity was evaluated by determining the oxygen uptake (VO2) at the ventilatory anaerobic threshold (VAT) and oxygen uptake efficiency slope (OUES). OUES values were compared with two sets of normative values. RESULTS: All feasibility criteria were met as 14 representative participants were recruited (recruitment rate: 60.9%), and all participants were able to perform the test and reached the VAT. No adverse events occurred, and all participants were positive toward submaximal CPET. The median VO2 at the VAT was 12.8 mL/kg/min (IQR 11.3-13.6). The median OUES/kg was 23.1 (IQR 20.2-28.9), 106.4% and 109.4% of predicted. CONCLUSION: Submaximal CPET using cycle ergometry seems feasible in patients with knee OA scheduled for TKA surgery to evaluate preoperative aerobic capacity.

Exercise training as part of multidisciplinary rehabilitation in cancer survivors: an observational study on changes in physical performance and patient-reported outcomes.

PURPOSE: To describe changes in physical performance and patient-reported outcomes in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation and the influence of training adaptations during the coronavirus-19 (COVID-19) pandemic. METHODS: In an observational cohort study, cancer survivors underwent usual-care multidisciplinary rehabilitation including a 10-week exercise program. During the COVID-19 pandemic, the exercise program was adapted with reduced training time and frequency. Mean changes and 95% confidence intervals in physical performance (peak oxygen uptake (VO2peak), peak work rate during a steep ramp test (SRT-WRpeak), 6-min walking distance, muscle strength) and patient-reported outcomes (health-related quality of life, fatigue, anxiety, and depression) were assessed between the start and the end of the exercise program. Linear regression analysis, adjusting for baseline levels of outcomes, was used to investigate differences in changes in outcomes between participants who underwent the original and the adapted program. RESULTS: All outcomes statistically significantly improved over time, regardless of adaptations in the exercise program. VO2peak increased with 9.6% and 7.7% in the original and adapted program, respectively. Significant smaller improvements were observed in SRT-WRpeak (- 3.9%) and upper body muscle strength (- 10.8%) after participation in the adapted compared to the original program. No significant between-group differences were observed for other outcomes. CONCLUSION: Physical performance and patient-reported outcomes statistically and clinically significantly improved in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation. Improvements of performance outcomes were smaller since the training adaptations, though only significant for SRT-WRpeak and upper body strength.

Development and internal validation of a prediction model to identify older adults at risk of low physical activity levels during hospitalisation: a prospective cohort study.

BACKGROUND: Inactive behaviour is common in older adults during hospitalisation and associated with poor health outcomes. If patients at high risk of spending little time standing/walking could be identified early after admission, they could be given interventions aimed at increasing their time spent standing/walking. This study aims to identify older adults at high risk of low physical activity (PA) levels during hospitalisation. METHODS: Prospective cohort study of 165 older adults (≥ 70 years) admitted to the department of Internal Medicine of Maastricht University Medical Centre for acute medical illness. Two prediction models were developed to predict the probability of low PA levels during hospitalisation. Time spent standing/walking per day was measured with an accelerometer until discharge (≤ 12 days). The average time standing/walking per day between inclusion and discharge was dichotomized into low/high PA levels by dividing the cohort at the median (50.0%) in model 1, and lowest tertile (33.3%) in model 2. Potential predictors-Short Physical Performance Battery (SPPB), Activity Measure for Post-Acute Care (AM-PAC), age, sex, walking aid use, and disabilities in activities of daily living-were selected based on literature and analysed using logistic regression analysis. Models were internally validated using bootstrapping. Model performance was quantified using measures of discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer and Lemeshow (H-L) goodness-of-fit test and calibration plots). RESULTS: Model 1 predicts a probability of spending ≤ 64.4 min standing/walking and holds the predictors SPPB, AM-PAC and sex. Model 2 predicts a probability of spending ≤ 47.2 min standing/walking and holds the predictors SPPB, AM-PAC, age and walking aid use. AUCs of models 1 and 2 were .80 (95% confidence interval (CI) = .73-.87) and .86 (95%CI = .79-.92), respectively, indicating good discriminative ability. Both models demonstrate near perfect calibration of the predicted probabilities and good overall performance, with model 2 performing slightly better. CONCLUSIONS: The developed and internally validated prediction models may enable clinicians to identify older adults at high risk of low PA levels during hospitalisation. External validation and determining the clinical impact are needed before applying the models in clinical practise.

Barriers and enablers to physical activity behaviour in older adults during hospital stay: a qualitative study guided by the theoretical domains framework.

BACKGROUND: Older adults admitted with an acute medical illness spent little time active during hospitalisation and this has been associated with negative health outcomes. Understanding which barriers and enablers influence the physical activity behaviour of hospitalised older adults is a first step towards identifying potentially modifiable factors and developing, evaluating and implementing targeted interventions aimed at increasing their physical activity behaviour. Using a theoretical framework has been found to be more successful in changing behaviour than using a non-theory driven approach. This study aimed to explore barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness, as perceived by patients and healthcare professionals, and to categorise them using the Theoretical Domains Framework (TDF). METHODS: A qualitative study was conducted at a combined university and regional hospital in the Netherlands between January 2019 and February 2020. Older adults (≥70 years) admitted with an acute medical illness, and healthcare professionals (nurses, physicians, physiotherapists) were recruited using purposive sampling. Semi-structured interviews were audiotaped, transcribed and analysed using directed qualitative content analysis. Barriers and enablers to physical activity behaviour during hospitalisation were identified and coded using the TDF. RESULTS: Meaning saturation was determined after interviews with 12 patients and 16 healthcare professionals. A large number of barriers and enablers were identified and each categorised to 11 of the 14 domains of the TDF. The 'Environmental Context and Resources' domain in particular yielded many examples, and revealed that the hospital environment exerts an inactivating influence on patients. CONCLUSIONS: The large number of identified barriers and enablers highlights the complexity of influencing older adults' physical activity behaviour during hospitalisation. This overview of barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness represents an initial step towards developing, evaluating and implementing theory-informed behaviour change interventions to improve hospitalised older adults' physical activity levels. It can assist clinicians and researchers in selecting modifiable factors that can be targeted in future interventions.

Acceptability of a perturbation-based balance training programme for falls prevention in older adults: a qualitative study.

INTRODUCTION: Perturbation-based balance training (PBT) is reported to effectively reduce falls in older adults and may even be superior compared with various exercise programmes. Due to the nature of the intervention, requiring unpredictable balance perturbations, the question arises whether acceptability is an issue in PBT. OBJECTIVE: To evaluate the acceptability of PBT in older adults with a recent history of falls. DESIGN, METHOD, PARTICIPANTS AND SETTING: This is a qualitative study in which semistructured interviews were conducted in 16 older adults (14 women and 2 men, mean age 73.6±6.0 years) who completed a three-session PBT protocol as part of another study in a university medical centre in the Netherlands. Typical case and purposive sampling strategies were applied. Interviews were based on the theoretical framework of acceptability (TFA) alongside context-specific factors and analysed using a template analysis approach. RESULTS: The results indicate that this PBT protocol is perceived as acceptable by older adults with a recent history of falls and highlight key areas for potential future modifications. Enjoyment of the novel training and technology, being able to feel safe during training, and perceived impact of increased self-efficacy and balance confidence were identified as facilitating factors. Potential issues included initial apprehension or anxiety during training and perceived impact being predominantly psychological instead of physical. Complementary to the TFA one additional theme emerged which described challenges regarding the training setting, such as preference for group training in some participants and travel to the training location. CONCLUSIONS: The results suggest that PBT is perceived acceptable by older adults with a history of falls. Increasing the social aspect of training and sharing the experiences of peers may be considered to enhance acceptability to new participants who initially feel apprehensive or anxious about their ability to participate in future implementation of PBT. TRIAL REGISTRATION NUMBER: The article is linked to a randomised clinical trial registered on https://www.trialregister.nl/trial/7680, NL7680; Results.

Adaptability to Balance Perturbations During Walking as a Potential Marker of Falls History in Older Adults.

Given that falls most commonly occur during walking due to unexpected balance perturbations like trips and slips, walking-based balance assessment including walking stability and adaptability to such perturbations could be beneficial for fall risk assessment in older adults. This cross-sectional study reanalyzed data from two larger studies conducted with the same walking protocol. Participants completed unperturbed walking trials at speeds of 0.4 m/s up to 1.8 m/s in 0.2 m/s steps. Ten unannounced treadmill belt acceleration perturbations were then applied while participants walked at equivalent stability, assessed using the margins of stability. Retrospective (12 months) falls incidence was collected to divide participants into people with and without a history of falls. Twenty older adults (mean age 70.2 ± 2.9 years) were included in this analysis; eight people with one or more recent falls and 12 people without, closely matched by sex, age and height. No significant differences were found in unperturbed walking parameters or their variability. Overall perturbation-recovery step behavior differed slightly (not statistically significant) between the groups after the first perturbation and differences became more pronounced and significant after repetition of perturbations. The No-Falls group significantly reduced the number of recovery steps needed across the trials, whereas the Falls group did not show these improvements. People with a previous fall tended to have slightly delayed and more variable recovery responses after perturbation compared to non-fallers. Non-fallers demonstrate more signs of adaptability to repeated perturbations. Adaptability may give a broader indication of the ability of the locomotor system to respond and improve responses to sudden walking perturbations than unperturbed walking variability or recovery to a single novel perturbation. Adaptability may thus be a more useful marker of falls history in older adults and should be considered in further research.

Criterion Validity and Responsiveness of the Steep Ramp Test to Evaluate Aerobic Capacity in Survivors of Cancer Participating in a Supervised Exercise Rehabilitation Program.

OBJECTIVE: To evaluate the criterion validity and responsiveness of the steep ramp test (SRT) compared with the cardiopulmonary exercise test (CPET) in evaluating aerobic capacity in survivors of cancer participating in a rehabilitation program. DESIGN: A prospective cohort study in which survivors of cancer performed an SRT and CPET before (T=0) and after (T=1) a 10-week exercise rehabilitation program. Peak work rate achieved during the SRT (SRT-WRpeak) was compared with peak oxygen consumption measured during the CPET (CPET-Vo2peak), which is the criterion standard for aerobic capacity. Correlation coefficients were calculated between SRT-WRpeak and CPET-Vo2peak at T=0 to examine criterion validity and between changes in SRT-WRpeak and CPET-Vo2peak from T=0 to T=1 to determine responsiveness. Receiver operating characteristic analysis was performed to examine the ability of the SRT to detect a true improvement (6%) in CPET-Vo2peak. SETTING: University medical center. PARTICIPANTS: Survivors of cancer (N=106). INTERVENTIONS: Exercise rehabilitation. MAIN OUTCOME MEASURES: Correlation coefficients between CPET-Vo2peak and SRT-WRpeak and between changes in CPET-Vo2peak and SRT-WRpeak. RESULTS: An r of 0.86 (N=106) was found for the relation between SRT-WRpeak and CPET-Vo2peak at T=0. An r of 0.51 was observed for the relation between changes in SRT-WRpeak and CPET-Vo2peak (n=59). Receiver operating characteristic analysis showed an area under the curve of 0.74 for the SRT to detect a true improvement in CPET-Vo2peak, with an optimal cutoff value of +0.26 W/kg (sensitivity 70.7%, specificity 66.7%). CONCLUSIONS: Because SRT-WRpeak and CPET-Vo2peak were strongly correlated, the SRT seems a valid tool to estimate aerobic capacity in survivors of cancer. The responsiveness to measure changes in aerobic capacity appears moderate. Nevertheless, the SRT seems able to detect improvement in aerobic capacity, with a cutoff value of 0.26 W/kg.

Optimization and Validation of a Classification Algorithm for Assessment of Physical Activity in Hospitalized Patients.

Low amounts of physical activity (PA) and prolonged periods of sedentary activity are common in hospitalized patients. Objective PA monitoring is needed to prevent the negative effects of inactivity, but a suitable algorithm is lacking. The aim of this study is to optimize and validate a classification algorithm that discriminates between sedentary, standing, and dynamic activities, and records postural transitions in hospitalized patients under free-living conditions. Optimization and validation in comparison to video analysis were performed in orthopedic and acutely hospitalized elderly patients with an accelerometer worn on the upper leg. Data segmentation window size (WS), amount of PA threshold (PA Th) and sensor orientation threshold (SO Th) were optimized in 25 patients, validation was performed in another 25. Sensitivity, specificity, accuracy, and (absolute) percentage error were used to assess the algorithm's performance. Optimization resulted in the best performance with parameter settings: WS 4 s, PA Th 4.3 counts per second, SO Th 0.8 g. Validation showed that all activities were classified within acceptable limits (>80% sensitivity, specificity and accuracy, ±10% error), except for the classification of standing activity. As patients need to increase their PA and interrupt sedentary behavior, the algorithm is suitable for classifying PA in hospitalized patients.

Perturbation-based balance training to improve balance control and reduce falls in older adults - study protocol for a randomized controlled trial.

BACKGROUND: Falls are a common cause of injuries and hospitalization among older adults. While conventional balance training appears effective in preventing falls, a relatively large number of training sessions are needed and retention of the effects after the training period is hard to accomplish. This may be because these interventions are not sufficiently task-specific for the mechanism of falls. Many falls in older adults occur due to unexpected external perturbations during gait, such as trips. Therefore, there is increasing interest in perturbation-based balance training (PBT), which is a more task-specific intervention to improve reactive balance control after unexpected perturbations. The literature suggests that PBT may be more effective and require fewer training sessions to reduce falls incidence in older adults, than conventional balance training. We aim to evaluate the effect of a three-session PBT protocol on balance control, daily life falls and fear of falling. Secondly, we will evaluate the acceptability of the PBT protocol. METHODS: This is a mixed-methods study combining a single-blind (outcome assessor) randomized controlled trial (RCT) using a parallel-group design, and qualitative research evaluating the acceptability of the intervention. The study sample consists of community-dwelling older adults aged 65 years and older who have recently fallen and visited the MUMC+ outpatient clinic. Subjects are randomized into two groups. The control group (n = 40) receives usual care, meaning referral to a physical therapist. The intervention group (n = 40) receives usual care plus three 30-min sessions of PBT in the Computer Assisted Rehabilitation Environment. Subjects' balance control (Mini-BESTest) and fear of falling (FES-I) will be assessed at baseline, and 4 weeks and 3 months post-baseline. Daily life falls will be recorded with falls calendars until 6 months after the first follow-up measurement, long-term injurious falls will be recorded at 2-years' follow-up via the electronic patient record. Acceptability of the PBT protocol will be evaluated with semi-structured interviews in a subsample from the intervention group. DISCUSSION: This study will contribute to the evidence for the effectiveness of PBT using a training protocol based on the available literature, and also give much needed insights into the acceptability of PBT for older adults. TRIAL REGISTRATION: Nederlands Trial Register NL7680 . Registered 17-04-2019 - retrospectively registered.

Smartphone App with an Accelerometer Enhances Patients' Physical Activity Following Elective Orthopedic Surgery: A Pilot Study.

Low physical activity (PA) levels are common in hospitalized patients. Digital health tools could be valuable in preventing the negative effects of inactivity. We therefore developed Hospital Fit; which is a smartphone application with an accelerometer, designed for hospitalized patients. It enables objective activity monitoring and provides patients with insights into their recovery progress and offers a tailored exercise program. The aim of this study was to investigate the potential of Hospital Fit to enhance PA levels and functional recovery following orthopedic surgery. PA was measured with an accelerometer postoperatively until discharge. The control group received standard physiotherapy, while the intervention group used Hospital Fit in addition to physiotherapy. The time spent active and functional recovery (modified Iowa Level of Assistance Scale) on postoperative day one (POD1) were measured. Ninety-seven patients undergoing total knee or hip arthroplasty were recruited. Hospital Fit use, corrected for age, resulted in patients standing and walking on POD1 for an average increase of 28.43 min (95% confidence interval (CI): 5.55-51.32). The odds of achieving functional recovery on POD1, corrected for the American Society of Anesthesiologists classification, were 3.08 times higher (95% CI: 1.14-8.31) with Hospital Fit use. A smartphone app combined with an accelerometer demonstrates the potential to enhance patients' PA levels and functional recovery during hospitalization.

Enhanced recovery in usual health care improves functional recovery after total knee arthroplasty.

BACKGROUND: The success of total knee arthroplasty (TKA) is determined by an effective surgical procedure as well as a well-organized clinical care pathway. Research has shown that day-of-surgery mobilization decreases length of stay (LOS) and complication rates. We developed, implemented, and evaluated a new clinical care pathway for patients undergoing TKA, that included early mobilization, using 'Lean Six Sigma (LSS)', with the aim of accelerating functional recovery and reducing LOS. METHODS: Data derived from physical therapy reports and LOS were compared between the old (n = 85) and the new (n = 85) clinical care pathways for time to functional recovery (using the modified Iowa Level of Assistance Scale), LOS and joint-related readmission. Group differences were evaluated using Mann-Whitney and Chi-Square tests. The clinical care pathway was redesigned using LSS-methods. RESULTS: After implementation of the new pathway, median time to functional recovery improved from 4 (2-5) to 2 days (1-8)(P < 0.001) and LOS from 7 (5-11) to 4 days (3-12)(P < 0.001), joint-related readmission declined (3.5-2.4%)(P = 0.65). CONCLUSION: Implementation of the new clinical care pathway accelerated functional recovery and reduced LOS for patients undergoing TKA. Future research should focus on having multiple discharge moments per day which might encourage patients to achieve functional recovery as soon as possible.

Limited predictive value of pre-surgical level of functioning for functioning at 3 and 12 months after TKA.

PURPOSE: A total knee arthroplasty (TKA) is a cost-effective option to relieve pain and improve knee function in patients suffering from osteoarthritis. However, results differ among patients. The predictive value of pre-surgically assessed factors on the level of functioning after 3 and 12 months was investigated in this study. METHODS: This study used an inception cohort design and a follow-up of 12 months. One hundred and fifty patients who were to receive a TKA were assessed pre-surgically with an International Classification of Functioning, Disability and Health (ICF) core assessment set: Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form 12 (SF12), Patient-Specific Function Scale (PSFS), range of motion (ROM), quadriceps and hamstring strength and gait parameters. The main outcome measure was WOMAC-Function at 3 and 12 months after surgery. RESULTS: Pre-surgical physical and mental health on the SF12 and functioning and stiffness on the WOMAC explained 23% of the variance in the level of functioning 3 months after surgery. Pre-surgical knee function measured with the KSS-Knee, and functioning as assessed by WOMAC-Function explained 16% of the variance of the level of functioning 12 months after surgery. CONCLUSIONS: The results of this study show that better functioning before surgery, less knee stiffness and a better physical and mental health to some extent predict better functioning 3 months after surgery. This effect is less evident at 12 months. This study is clinically relevant since it provides benchmark data for health care providers who want to compare their individual patients. LEVEL OF EVIDENCE: II.

Functions, disabilities and perceived health in the first year after total knee arthroplasty; a prospective cohort study.

BACKGROUND: In end-stage knee osteoarthritis total knee arthroplasty (TKA) is an effective intervention to reduce pain and improve functioning in the majority of patients. However, after TKA some patients still experience pain, loss of function, deficient muscle strength or reduced walking speed. This study systematically assesses patients' functions, disabilities and health before TKA and at short- (3 months) and long-term (12 months) on all International Classification of Functioning, Disability and Health domains. METHODS: In this prospective cohort study 150 patients underwent the following tests before and at 3 and 12 months after surgery: Western Ontario and McMaster Universities Arthritis Index, Short Form 12, Knee Society Score, Patient Specific Functioning Scale, knee range of motion, quadriceps and hamstring strength, gait parameters, global perceived effect (only after surgery). All data was analyzed with repeated measures ANOVA for all measurement time points. RESULTS: Despite increased gait speed, quadriceps strength and scores on questionnaires being above pre surgical levels, patients do not reach levels of healthy persons. Walking speeds approach normal values and are higher in our study compared with the literature. Quadriceps strength stays at around 70 till 80% of norm values. However, dissatisfaction rates are below 10%, which is low compared to the literature. CONCLUSIONS: Quality of life, activities, muscle strength and gait parameters improve significantly after TKA. However, some complaints regarding activities and walking speed remain. Most striking outcome is the remaining deficit in quadriceps strength.

Aquatic cycling-What do we know? A scoping review on head-out aquatic cycling.

Over the past few years, aquatic cycling has become a trending fitness activity. However, the literature has not been reviewed exhaustively. Therefore, using scoping review methodology, the aim of this review was to explore the current state of the literature concerning aquatic cycling. This study specifically focused on study designs, populations and outcomes. A comprehensive search of seven databases (PubMed, MEDLINE, Cinahl, Embase, PEDro,Web of Science, WorldCat) was conducted up to 30th September 2016. GoogleScholar, World Cat, ResearchGate, specific aquatic therapy websites and aquatic therapy journals were searched to identify additional literature. Full-text publications in English, German or Dutch were included. Studies were included when the intervention involved head-out cycling carried out in 10° to 35° Celsius water. Exclusion criteria were the use of wet suits or confounding interventions that would affect participants' homeostasis. 63 articles were included and the study parameters of these studies were summarized. Using three grouping themes, included studies were categorised as 1) single session tests comparing aquatic versus land cycling, or 2) aquatic cycling only sessions investigating different exercise conditions and 3) aquatic cycling intervention programmes. Although the experimental conditions differed noticeably across the studies, shared characteristics were identified. Cardiovascular parameters were investigated by many of the studies with the results suggesting that the cardiac demand of aquatic cycling seems similar to land-based cycling. Only six studies evaluated the effect of aquatic cycling interventions. Therefore, future research should investigate the effects of aquatic cycling interventions, preferably in individuals that are expected to gain health benefits from aquatic cycling. Moreover, this comprehensive outline of available literature could serve as a starting point for systematic reviews or clinical studies on the effects of aquatic cycling on the cardiovascular responses.