Effects of Multicomponent Home-Based Intervention on Muscle Composition, Fitness, and Bone Density After Hip Fracture.

BACKGROUND: Mechanistic factors on the pathway to improving independent ambulatory ability among hip fracture patients by a multicomponent home-based physical therapy intervention that emphasized aerobic, strength, balance, and functional training are unknown. The aim of this study was to determine the effects of 2 different home-based physical therapy programs on muscle area and attenuation (reflects muscle density) of the lower extremities, bone mineral density (BMD), and aerobic capacity. METHODS: Randomized controlled trial of home-based 16 weeks of strength, endurance, balance, and function exercises (PUSH, n = 19) compared to seated active range-of-motion exercises and transcutaneous electrical neurostimulation (PULSE, n = 18) in community-dwelling adults >60 years of age within 26 weeks of hip fracture. RESULTS: In PUSH and PULSE groups combined, the fractured leg had lower muscle area and muscle attenuation and higher subcutaneous fat than the nonfractured leg (p < .001) at baseline. At 16 weeks, mean muscle area of the fractured leg was higher in the PUSH than PULSE group (p = .04). Changes in muscle area were not significantly different when compared to the comparative PULSE group. There was a clinically relevant difference in change in femoral neck BMD between groups (p = .05) that showed an increase after PULSE and decrease after PUSH. There were generally no between-group differences in mean VO2peak tests at 16-week follow-up, except the PUSH group reached a higher max incline (p = .04). CONCLUSIONS: The treatment effects of a multicomponent home-based physical therapy intervention on muscle composition, BMD, and aerobic capacity were not significantly different than an active control intervention in older adults recovering from hip fracture. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01783704.

High-intensity home health physical therapy among older adult Veterans: A randomized controlled trial.

BACKGROUND: Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events. METHODS: We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization. RESULTS: There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds. CONCLUSIONS: Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.

Feasibility of a Modified Otago Exercise Program for Older Adults With Cognitive Vulnerability.

Cognitive vulnerability, that is, clinically significant symptoms of dementia, depression, or delirium, puts older adults at high risk for physical inactivity and falls. Programs addressing activity and falls are needed. The purpose was to determine feasibility of an in-home, modified, Otago Exercise Program (OEP) for those with cognitive vulnerability, based on acceptability (retention and adherence), safety (pain intensity and falls), and potential positive effects (change in short physical performance battery (SPPB)). This secondary analysis of a randomized controlled trial included 80 participants who received the OEP; 64 completed it, 48% had depression, 22% had dementia, and 30% had a combination dementia/depression/delirium. Adherence to home exercise was low to moderate; pain was stable over 16 weeks; 31% of participants reported falls unrelated to OEP. SPPB increased from 6.95 to 7.74 (p < .01); age by time and diagnosis by time interactions were not significant. The modified OEP shows promising feasibility for older adults with cognitive vulnerability.

Effect of Multicomponent Home-Based Training on Gait and Muscle Strength in Older Adults After Hip Fracture Surgery: A Single Site Randomized Trial.

OBJECTIVE: To investigate the effect of 16-week home-based physical therapy interventions on gait and muscle strength. DESIGN: A single-blinded randomized controlled trial. SETTING: General community. PARTICIPANTS: Thirty-four older adults (N=34) post hip fracture were randomly assigned to either experimental group (a specific multi-component intervention group [PUSH], n=17, 10 women, age=78.6±7.3 years, 112.1±39.8 days post-fracture) or active control (a non-specific multi-component intervention group [PULSE], n=17, 11 women, age=77.8±7.8 years, 118.2±37.5 days post-fracture). INTERVENTION: PUSH and PULSE groups received 32-40 sessions of specific or non-specific multi-component home-based physical therapy, respectively. Training in the PUSH group focused on lower extremity strength, endurance, balance, and function for community ambulation, while the PULSE group received active movement and transcutaneous electrical nerve stimulation on extremities. MAIN OUTCOME MEASURES: Gait characteristics, and ankle and knee muscle strength were measured at baseline and 16 weeks. Cognitive testing of Trail Making Test (Part A: TMT-A; Part-B: TMT-B) was measured at baseline. RESULTS: At 16 weeks, both groups demonstrated significant increases in usual (P<.05) and fast (P<.05) walking speed, while there was no significant difference in increases between the groups. There was only 1 significant change in lower limb muscle strength over time (non-fractured side) between the groups, such that PUSH did better (mean: 4.33%, 95% confidence interval:1.43%-7.23%). The increase in usual and fast walking speed correlated with the baseline Trail-making Test-B score (r=-0.371, P=.037) and improved muscle strength in the fractured limb (r=0.446, P=.001), respectively. CONCLUSION: Gait speed improved in both home-based multicomponent physical therapy programs in older adults after hip fracture surgery. Muscle strength of the non-fractured limb improved in the group receiving specific physical therapy training. Specific interventions targeting modifiable factors such as muscle strength and cognitive performance may assist gait recovery after hip fracture surgery.

Application of the 4-Element Movement System Model to Sports Physical Therapy Practice and Education.

The 4-Element Movement System Model describes primary elements (motion, force, motor control, and energy) essential to the performance of all movements. The model provides a framework or scaffolding which allows for consistent processes to be used in examination and intervention decisions. The process starts with task identification followed by a systematic observation of control, amount, speed, symmetry, and symptoms during movement. Testable hypotheses are generated from the observations which inform the examination and the interventions. This commentary describes the use of the 4-Element Movement System Model in entry level and post-graduate residency educational programs and in clinical care with three common sports-related diagnoses. LEVEL OF EVIDENCE: 5.

Six Versus 12 Weeks of Outpatient Physical Therapy Including Progressive Resistance Training in Cognitively Intact Older Adults After Hip Fracture: A Multicenter Randomized Controlled Trial.

BACKGROUND: Recovery of function and regaining muscle strength are challenging after hip fracture. We compared the effectiveness of a 12- versus 6-week outpatient physical therapy program with progressive resistive training (PRT) to increase strength and physical performance. METHODS: This parallel, superiority, 2-group randomized controlled trial was conducted in 4 clinics that enrolled community-dwelling, cognitively intact older adults (+60 years) with a surgical repair of a hip fracture and no major medical conditions. Participants received 12 or 6 weeks of PRT and standardized physical therapy, twice weekly. Pain was monitored throughout. Primary outcome was the change in the 6-minute walk test (6MWT) from baseline to 12-week follow-up. Randomization via a computer-generated allocation sequence was implemented using sealed, sequentially numbered opaque envelopes and assessors were blinded to group assignment. RESULTS: Participants (81% women) with a mean (SD) age of 77 (8.1) years were enrolled at an average of 18 days after hip fracture surgery and randomized into a 12-week group (n = 50) or a 6-week group (n = 50). Mean (SD) change scores in the 6MWT were 143.8 (81.1) and 161.5 (84.1) m in the 12- and 6-week groups, respectively (both exceeding the minimal clinically important difference of 55 m). The mean between-group difference was -17.7 m (95% CI -50.1, 14.8). Pain during training did not exceed moderate levels nor increase as training intensity increased. CONCLUSION: Twelve weeks of physical therapy with PRT was not superior to 6 weeks in improving walking distance. Hip fracture-related pain was relatively low and indicated strength testing and training was well tolerated. Clinical Trials Registration Number: NCT01174589.

Using Treatment Fidelity Measures to Understand Walking Recovery: A Secondary Analysis From the Community Ambulation Project.

OBJECTIVES: Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (∆6MWD). METHODS: This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was ∆6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed. RESULTS: Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to ∆6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31-93 m) more than those who did not get on the floor. CONCLUSIONS: Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture. IMPACT: This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor.

The Effect of Frailty on Walking Recovery After Hip Fracture: A Secondary Analysis of the Community Ambulation Project.

BACKGROUND: The impact of frailty on walking recovery after hip fracture has not been reported. We describe the prevalence of frailty approximately 3 months after hip fracture, and identify the impact of baseline frailty on ambulation recovery. METHODS: Data from the Community Ambulation Project, that examined the effects of 2 multicomponent home exercise programs on 6-minute walk test in participants post hip fracture, were used to reconstruct the 5-item frailty phenotype. We detailed the prevalence of frailty by subgroup and assessed the comparability between frailty groups for the categorical variable of achieving 300 m in 6-minute walk test (community ambulation threshold), and the continuous variable of total distance in 6-minute walk test before and after 16 weeks of intervention. RESULTS: Of the 210 participants, 9% were nonfrail, 59% were prefrail, and 32% were frail. The odds of a nonfrail participant achieving the 300-m threshold were 14.4 (95% CI: 2.4-87.6) times the odds of a frail participant, while a prefrail participant's odds were 6.1 (95% CI: 1.3-28.4) times after controlling for treatment group and baseline walking distance. The nonfrail participants had an increase of 92.1 m from baseline to 16 weeks, the prefrail had a 50.8 m increase, and the frail group had the smallest increase of 36.6 m (p < .001 for all). CONCLUSIONS: Prefrailty and frailty were highly prevalent in this sample of community-dwelling survivors of a recent hip fracture. Gains in walking distance and attaining a level of community ambulation were affected significantly by the level of baseline frailty.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society.

BACKGROUND: The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY: A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION: A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults: The CAP Randomized Clinical Trial.

Importance: Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community. Objective: To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community. Design, Setting, and Participants: Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later. Interventions: The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins. Main Outcomes and Measures: The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control. Results: Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2). Conclusions and Relevance: Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks. Trial Registration: ClinicalTrials.gov Identifier: NCT01783704.

Progressive Multicomponent Intervention for Older Adults in Home Health Settings Following Acute Hospitalization: Randomized Clinical Trial Protocol.

BACKGROUND: Hospitalization is a profound contributor to functional loss for older adults. Many modifiable risk factors (ie, weakness) may persist after hospitalization, representing portents of poor health, re-hospitalization, or death. Older adults frequently receive home health (HH) care after hospitalization to manage functional deficits that have worsened during hospital stays. However, how best to manage these deficits in HH settings has yet to be determined. OBJECTIVE: The objective is to determine if a higher intensity, progressive, multi-component (PMC) intervention, initiated upon admission to HH after an acute hospitalization, improves objectively measured and self-reported physical function more than usual care (UC) physical therapy. DESIGN: This will be a 2-arm randomized controlled clinical trial. SETTING: The setting will be participant homes. PARTICIPANTS: A total of 200 older adults with deconditioning following acute hospitalization and referred for HH physical therapy will participate. INTERVENTION: Participants will be randomized to either a PMC treatment group or a UC group and receive 12 therapy visits over a 60-day period. PMC participants will perform lower extremity resistance training at 80% of a 1-repetition maximum, task-specific activities of daily living training, along with advanced gait and balance training. PMC groups will also receive nutritional supplementation and nursing support during transition from hospital to home. The UC group will receive standard of care HH interventions. MEASUREMENTS: Physical performance, self-reported function, fatigue, and health care utilization outcomes will be measured at baseline, 30 days, 60 days, 90 days, and 180 days. All measures will be assessed by blinded study personnel. LIMITATIONS: The limitation is an inability to blind treating therapists to study allocation. CONCLUSIONS: The authors hope to determine whether higher intensity, multi-component exercise interventions improve outcomes more than UC physical therapy for older adults recovering from acute hospitalization in HH settings.

Methods and Impact of Correcting Heart Rate Data Errors during Exercise in Older Adults.

Heart rate (HR) by time curves could be useful as a measure of treatment fidelity. The purposes were to describe the frequency of common recording irregularities (e.g. errors) observed during exercise, validate a process to correct those errors, and determine whether there is a clinically meaningful benefit to data correction. 1895 exercise sessions from 69 older adults with hip fracture were inspected for errors in the placement of event markers (duration of exercise) and signal artifacts. Marker errors occurred in 33% of the participants, and corrected in 324 sessions. Signal artifacts occurred in 96% of the participants, and eliminated in 702 sessions. Computer code was 85% accurate in detecting signal artifacts, compared to 97% for investigators. HR was significantly higher after correction, but the average change was only 0.69 + 1.20 beats per minute. A HR monitor showing HR by time curves can be used to evaluate treatment fidelity during exercise.

Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial.

OBJECTIVE: To determine whether a progressive multicomponent physical therapy intervention in the home setting can improve functional mobility for deconditioned older adults following acute hospitalization. DESIGN: Randomized controlled trial. SETTING: Patient homes in the Denver, CO, metropolitan area. PARTICIPANTS: A total of 22 homebound older adults age 65 and older (mean ± SD; 85.4 ±7.83); 12 were randomized to intervention group and 10 to the control group. INTERVENTION: The progressive multicomponent intervention consisted of home-based progressive strength, mobility and activities of daily living training. The control group consisted of usual care rehabilitation. MEASUREMENTS: A 4-meter walking speed, modified Physical Performance Test, Short Physical Performance Battery, 6-minute walk test. RESULTS: At the 60-day time point, the progressive multicomponent intervention group had significantly greater improvements in walking speed (mean change: 0.36 m/s vs. 0.14 m/s, p = 0.04), modified physical performance test (mean change: 6.18 vs. 0.98, p = 0.02) and Short Physical Performance Battery scores (mean change: 2.94 vs. 0.38, p = 0.02) compared with the usual care group. The progressive multicomponent intervention group also had a trend towards significant improvement in the 6-minute walk test at 60 days (mean change: 119.65 m vs. 19.28 m; p = 0.07). No adverse events associated with intervention were recorded. CONCLUSIONS: The progressive multicomponent intervention improved patient functional mobility following acute hospitalization more than usual care. Results from this study support the safety and feasibility of conducting a larger randomized controlled trial of progressive multicomponent intervention in this population. A more definitive study would require 150 patients to verify these conclusions given the effect sizes observed.

Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift.

Physical therapists often treat older adults with marked deficits in physical function secondary to an acute hospitalization. These deficits are often collectively defined as hospital-associated deconditioning (HAD). However, there is a paucity of evidence that objectively demonstrates the efficacy of physical therapy for older adults with HAD. Older adults with HAD represent a highly variable and complex population and thus may be difficult to study and develop effective interventions for using our current rehabilitation strategies. This perspective article outlines an innovative framework to operationalize and treat older adults with HAD. This framework may help therapists apply emerging exercise strategies to this population and facilitate additional research to support the total value of physical therapy for older adults in postacute care settings-with value measured not only by improvements in physical performance but perhaps also by reduced rates of disability development, rehospitalization, and institutionalization.

Meaningful improvement in gait speed in hip fracture recovery.

OBJECTIVES: To estimate meaningful improvements in gait speed observed during recovery from hip fracture and to evaluate the sensitivity and specificity of gait speed changes in detecting change in self-reported mobility. DESIGN: Secondary longitudinal data analysis from two randomized controlled trials SETTING: Twelve hospitals in the Baltimore, Maryland, area. PARTICIPANTS: Two hundred seventeen women admitted with hip fracture. MEASUREMENTS: Usual gait speed and self-reported mobility (ability to walk 1 block and climb 1 flight of stairs) measured 2 and 12 months after fracture. RESULTS: Effect size-based estimates of meaningful differences were 0.03 for small differences and 0.09 for substantial differences. Depending on the anchor (stairs vs walking) and method (mean difference vs regression), anchor-based estimates ranged from 0.10 to 0.17 m/s for small meaningful improvements and 0.17 to 0.26 m/s for substantial meaningful improvement. Optimal gait speed cutpoints yielded low sensitivity (0.39-0.62) and specificity (0.57-0.76) for improvements in self-reported mobility. CONCLUSION: Results from this sample of women recovering from hip fracture provide only limited support for the 0.10-m/s cut point for substantial meaningful change previously identified in community-dwelling older adults experiencing declines in walking abilities. Anchor-based estimates and cut points derived from receiver operating characteristic curve analysis suggest that greater improvements in gait speed may be required for substantial perceived mobility improvement in female hip fracture patients. Furthermore, gait speed change performed poorly in discriminating change in self-reported mobility. Estimates of meaningful change in gait speed may differ based on the direction of change (improvement vs decline) or between patient populations.

Recruitment and retention strategies among older African American women enrolled in an exercise study at a PACE program.

PURPOSE: This study examined employment of specific recruitment and retention strategies in a study evaluating outcomes of a moderate activity exercise program for older African American women with functional impairments attending a Program for All-Inclusive Care of Elders (PACE). DESIGN AND METHODS: Recruitment and retention strategies focused on (1) partnership between researchers and participants, (2) partnership between researchers and clinicians, (3) overcoming administrative issues, and (4) reducing burden on clinicians and participants. The exercise protocol consisted of strength and endurance activity 2 to 3 times per week for 16 weeks. RESULTS: Fifty-two African American women (61.2% of target) were enrolled and 37 (71.2%) completed the 16-week exercise program. Fifteen did not complete due to non-descript reasons and/or preference for other program activities (n = 11), medical problems (n = 2), or need for physical therapy (n = 2). IMPLICATIONS: Success in recruitment and retention included use of a PACE program, hiring an advanced practice nurse to improve retention, and integration with site activities and sustaining the exercise program at the site. Challenges for recruitment and retention remain to engage older, frail adults in exercise as a life habit, and availability of time and place to do so.

Home-based leg-strengthening exercise improves function 1 year after hip fracture: a randomized controlled study.

OBJECTIVES: To compare the effectiveness of a short-term leg-strengthening exercise program with that of attentional control on improving strength, walking abilities, and function 1 year after hip fracture. DESIGN: Randomized controlled pilot study. SETTING: Patients' homes. PARTICIPANTS: Community-dwelling older adults (n=26) 6 months after hip fracture at baseline. INTERVENTION: Exercise and control participants received interventions from physical therapists twice a week for 10 weeks. The exercise group received high-intensity leg-strengthening exercises. The control group received transcutaneous electrical nerve stimulation and mental imagery. MEASUREMENTS: Isometric force production of lower extremity muscles, usual and fast gait speed, 6-minute walk (6-MW) distance, modified Physical Performance Test (mPPT), and Medical Outcomes Study 36-item Short Form Survey (SF-36) physical function. RESULTS: The primary endpoint was 1 year after fracture. Isometric force production (P=.006), usual (P=.02) and fast (P=.03) gait speed, 6-MW distance (P=.005), and mPPT score (P<.001) were improved 1 year after fracture with exercise. Effect sizes were 0.79 for strength, 0.81 for mPPT score, 0.56 for gait speed, 0.49 for 6-MW, and 0.30 for SF-36 score. More patients in the exercise group made meaningful changes in gait speed and 6-MW distance than control patients (chi-square P=.004). CONCLUSION: A 10-week home-based progressive resistance exercise program was sufficient to achieve moderate to large effects on physical performance and quality of life and may offer an alternative intervention mode for patients with hip fracture who are unable to leave home by 6 months after the fracture. The effects were maintained at 3 months after completion of the training program.

Case report: an evidence-based approach to examination and intervention following hip fracture.

BACKGROUND AND PURPOSE: A majority of older adults with hip fracture retain longstanding disabilities following surgery. Research suggests that more aggressive treatment techniques can improve outcome. The purpose of this case report is to describe an evidence-based approach to guide physical therapy examination and intervention for a woman with significant frailty recovering from hip fracture. CASE DESCRIPTION: The patient is a 97-year-old woman residing in a skilled nursing facility 3 months status-postsurgical repair of an intertrochanteric hip fracture. She had received 2 1/2 months of physical therapy care using conventional interventions, however, had not regained her prefracture mobility status. She agreed to participate in a progressive high-intensity resistance training program over a 2-month period to augment her lower-extremity strength and function. The 5-day training regimen emphasized resistance training with a weighted belt twice-weekly with endurance and balance training interposed on nonstrength training days. The patient's goal was to return to community dwelling. EXAMINATION: Lower-extremity isometric force was measured using handheld dynamometry. Functional mobility was assessed via Timed Up and Go, Six-Minute Walk, Berg Balance, and gait speed tests. A 9-item Physical Performance Test gauged degree of frailty. RESULTS: Hip extension, hip abduction, and knee extension isometric force scores on the involved lower-extremity increased by 8 kg, 3 kg, and 7 kg, respectively. Balance, frailty, and gait speed indices improved from 14 to 45, 8 to 18, and 0.50 to 0.83 m/s, respectively. CONCLUSION: Prescribed high-intensity resistance training was used to improve the patient's functional status 2 months after completing a conventional physical therapy program.

Determining meaningful changes in gait speed after hip fracture.

BACKGROUND AND PURPOSE: Older subjects after hip fracture walk more slowly than age-matched peers. The extent to which they walk more slowly is difficult to define because the standard error of the measure (SEM), sensitivity to change, and clinically important change have not been reported for gait speed. The purposes of this study were to quantify the SEM for habitual and fast gait speeds among older subjects after hip fracture, to define the minimal detectable change (MDC), and to estimate the minimal clinically important difference (MCID) for habitual gait speed. SUBJECTS: A sample of 92 subjects after hip fracture was drawn from 3 studies that collected gait speed data. METHODS: An estimate of the MDC was determined by use of the SEM. The MCID was determined from expert opinion and from a receiver operating characteristic (ROC) curve. RESULTS: The SEM and the MDC were 0.08 m/s and 0.10 m/s for habitual speed and fast speed, respectively. Both methods of MCID estimation identified 0.10 m/s as a meaningful change in habitual gait speed. DISCUSSION AND CONCLUSION: The estimated MCID for gait speed of 0.10 m/s was supported by clinical expert opinion and the cutoff point of the ROC curve.

Effect of therapeutic exercise on gait speed in community-dwelling elderly people: a meta-analysis.

BACKGROUND AND PURPOSE: Inconsistent research findings make it unclear whether therapeutic exercise improves gait speed in community-dwelling elderly people. Using meta-analytical procedures, we examined the effect of therapeutic exercise on changing gait speed in community-dwelling older adults and the effect of type, intensity, and dose of therapeutic exercise on gait speed. METHOD: Studies were retrieved using a comprehensive database search. Two independent reviewers determined study eligibility based on inclusion criteria, rated study quality, and extracted information on study methods, design, intervention, and results. Data were combined to obtain an overall effect size, its 95% confidence interval, and a measure of significance. In addition, analyses to characterize the clinical relevance of the findings were performed. RESULTS: One hundred seventeen studies were evaluated, with 24 studies (n=1,302 subjects) meeting the inclusion criteria for habitual gait speed and 18 studies (n=752 subjects) meeting the inclusion criteria for fast gait speed. Therapeutic exercise--or, more specifically, strength training and combination training (aerobic plus other exercise)--had significant effects (r=.145, P=.017; r=.176, P=.002, respectively) on habitual gait speed. High-intensity (effort expended by subjects) exercise and high-dosage (frequency and duration of exercise sessions) intervention also had a significant effect (r=.184, P=.001; r=.190, P=.001, respectively) on gait speed, whereas there was no effect for moderate- and low-intensity exercise or for low-dosage exercise. No exercise intervention affected fast gait speed in this analysis. DISCUSSION AND CONCLUSION: The results provide support for the belief that therapeutic exercise can improve gait speed in community-dwelling elderly people and that intensity and dosage are important contributing factors. The relatively weak correlation found between therapeutic exercise and gait speed merits further study.