Supervised progressive cross-continuum strength training compared with usual care in older medical patients: study protocol for a randomized controlled trial (the STAND-Cph trial).

BACKGROUND: Hospitalization in older adults is characterized by physical inactivity and a risk of losing function and independence. Systematic strength training can improve muscle strength and functional performance in older adults. Few studies have examined the effect of a program initiated during hospitalization and continued after discharge. We conducted a feasibility study prior to this trial and found a progression model for loaded sit-to-stands feasible in older medical patients. This study aims to determine whether a simple supervised strength training program for the lower extremities (based on the model), combined with post-training protein supplementation initiated during hospitalization and continued at home for 4 weeks, is superior to usual care on change in mobility 4 weeks after discharge in older medical patients. METHODS: Eighty older medical patients (65 years or older) acutely admitted from their own homes will be included in this randomized, controlled, parallel-group, investigator-blinded, superiority trial. After baseline assessments patients will be randomized to (1) intervention: progressive strength training during hospitalization and after discharge (home-based), or (2) control: usual care. Shortly after discharge, 4 weeks after discharge (primary end point) and 6 months after discharge patients will be assessed in their own homes. The intervention encompasses strength training consisting of two lower extremity exercises (sit-to-stand and heel raise) daily during hospitalization and three times per week for 4 weeks after discharge. Both exercises follow pre-defined models for progression and will be performed for three sets of 8-12 repetitions maximum in each training session. Thereafter, the patient will be asked to consume a protein supplement given orally containing 18 g milk-based protein. The primary outcome will be change in the de Morton Mobility Index score from baseline to 4 weeks after discharge. Secondary outcomes will be 24-h mobility level, isometric knee extension strength, the 30-sec sit-to-stand test, habitual gait speed, hand-grip strength, and Activities of Daily Living. DISCUSSION: We chose to investigate the effect of a minimal time-consuming treatment approach, i.e. two well-performed strength training exercises combined with protein supplementation, to facilitate implementation in a busy clinical care setting, given a positive trial outcome. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01964482 .

The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients - A randomized controlled trial.

BACKGROUND & AIM: Stress metabolism is associated with accelerated loss of muscle that has large consequences for the old medical patient. The aim of this study was to investigate if an intervention combining protein and resistance training was more effective in counteracting loss of muscle than standard care. Secondary outcomes were changes in muscle strength, functional ability and body weight. METHODS: 29 acutely admitted old (>65 years) patients were randomly assigned to the intervention (n = 14) or to standard care (n = 15). The Intervention Group received 1.7 g protein/kg/day during admission and a daily protein supplement (18.8 g protein) and resistance training 3 times per week the 12 weeks following discharge. Muscle mass was assessed by Dual-energy X-ray Absorptiometry. Muscle strength was assessed by Hand Grip Strength and Chair Stand Test. Functional ability was assessed by the de Morton Mobility Index, the Functional Recovery Score and the New Mobility Score. Changes in outcomes from time of admission to three-months after discharge were analysed by linear regression analysis. RESULTS: The intention-to-treat analysis showed no significant effect of the intervention on lean mass (unadjusted: ß-coefficient = -1.28 P = 0.32, adjusted for gender: ß-coefficient = -0.02 P = 0.99, adjusted for baseline lean mass: ß-coefficient = -0.31 P = 0.80). The de Morton Mobility Index significantly increased in the Control Group (ß-coefficient = -11.43 CI: 0.72-22.13, P = 0.04). No other differences were found. CONCLUSION: No significant effect on muscle mass was observed in this group of acutely ill old medical patients. High compliance was achieved with the dietary intervention, but resistance training was challenging. Clinical trials identifier NCT02077491.

Feasibility of progressive sit-to-stand training among older hospitalized patients.

Background. In older patients, hospitalization is associated with a decline in functional performance and loss of muscle strength. Loss of muscle strength and functional performance can be prevented by systematic strength training, but details are lacking regarding the optimal exercise program and dose for older patients. Therefore, our aim was to test the feasibility of a progression model for loaded sit-to-stand training among older hospitalized patients. Methods. This is a prospective cohort study conducted as a feasibility study prior to a full-scale trial. We included twenty-four older patients (≥65 yrs) acutely admitted from their own home to the medical services of the hospital. We developed an 8-level progression model for loaded sit-to-stands, which we named STAND. We used STAND as a model to describe how to perform the sit-to-stand exercise as a strength training exercise aimed at reaching a relative load of 8-12 repetitions maximum (RM) for 8-12 repetitions. Weight could be added by the use of a weight vest when needed. The ability of the patients to reach the intended relative load (8-12 RM), while performing sit-to-stands following the STAND model, was tested once during hospitalization and once following discharge in their own homes. A structured interview including assessment of possible modifiers (cognitive status by the Short Orientation Memory test and mobility by the De Morton Mobility Index) was administered both on admission to the hospital and in the home setting. The STAND model was considered feasible if: (1) 75% of the assessed patients could perform the exercise at a given level of the model reaching 8-12 repetitions at a relative load of 8-12 RM for one set of exercise in the hospital and two sets of exercise at home; (2) no ceiling or floor effect was seen; (3) no indication of adverse events were observed. The outcomes assessed were: level of STAND attained, the number of sets performed, perceived exertion (the Borg scale), and pain (the Verbal Ranking Scale). Results. Twenty-four patients consented to participate. Twenty-three of the patients were tested in the hospital and 19 patients were also tested in their home. All three criteria for feasibility were met: (1) in the hospital, 83% could perform the exercise at a given level of STAND, reaching 8-12 repetitions at 8-12 RM for one set, and 79% could do so for two sets in the home setting; (2) for all assessed patients, a possibility of progression or regression was possible-no ceiling or floor effect was observed; (3) no indication of adverse events (pain) was observed. Also, those that scored higher on the De Morton Mobility Index performed the exercise at higher levels of STAND, whereas performance was independent of cognitive status. Conclusions. We found a simple progression model for loaded sit-to-stands (STAND) feasible in acutely admitted older medical patients (≥65 yrs), based on our pre-specified criteria for feasibility.

Is the American Society of Shoulder and Elbow Therapists' rehabilitation guideline better than standard care when applied to Bankart-operated patients? A controlled study.

OBJECTIVE: To determine whether there is a difference in shoulder-related physical function and quality of life between postoperative rehabilitation patients receiving standard care and those receiving care according to the American Society of Shoulder and Elbow Therapists' rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder. DESIGN: Descriptive studies with comparison between a retrospective and a prospective cohort. SETTING: Municipal outpatient rehabilitation centre. PATIENTS: A total of 96 arthroscopic Bankart-operated patients. INTERVENTIONS: A total of 52 patients received standard care; 44 patients underwent rehabilitation according to the American Society of Shoulder and Elbow Therapists' rehabilitation guideline. MAIN MEASUREMENTS: Primary outcome variable was Western Ontario Shoulder Instability Index. Secondary outcome measures were Patient-Specific Functional Scale, shoulder range of motion, return to work, return to sports, and costs. RESULTS: There was no significant difference in adjusted mean change scores between the standard care group and the guideline group in the primary outcome variable (Western Ontario Shoulder Instability Index total = 574.85 vs. 644.48) or the secondary outcomes (Patient-Specific Functional Scale = 4.6 vs. 5.0; range of motion in forward flexion = 46.49° vs. 49.58°; external rotation in adduction = 28.58° vs. 34.18°; external rotation in abduction = 51.29° vs. 47.55°; weeks until return to work = 5.2 vs. 6.9; weeks until return to sports =13.9 vs. 13.1; costs = number of visits; 18.5 vs. 15.9). CONCLUSIONS: There were no significant between-group differences in shoulder-related physical function and quality of life between the standard care group and the guideline group, following Bankart operations.

Factors associated with the prescription of antidepressive medication to breast cancer patients.

UNLABELLED: We evaluated factors associated with use of antidepressant medication subsequent to a diagnosis of breast cancer. We also evaluated the effect of participation in a cancer rehabilitation program on use of antidepressants. MATERIAL AND METHODS: We conducted a register-based cohort study of 1 247 women with breast cancer diagnosed between 1998 and 2006 who attended a week-long rehabilitation program and a comparison group of 2 903 women who did not attend the program matched through the registers of the Danish Breast Cancer Cooperative Group. The associations between breast cancer-related, treatment-related, and sociodemographic factors and use of antidepressants were evaluated in multivariate Cox proportional hazard models separated on use of antidepressants before diagnosis of breast cancer. RESULTS: The mean follow-up for the 4 150 women in the study was 3.3 years (5-95% range, 0.3-7.0 years) and 1 020 (25%) were users of antidepressants after diagnosis of breast cancer. Among women who had not used antidepressants before their breast cancer, the diagnosis of a new primary cancer increased the adjusted hazard ratio (HR) to 3.34 (95% CI, 1.50-7.76), and recurrence of breast cancer increased the HR for first use of antidepressants to 2.56 (95% CI, 1.86-3.52). Unemployment was associated significantly with use of antidepressants, whereas having no children living at home, lower income, and the number of tumor-positive axillary lymph nodes were of borderline significance. No effect of the rehabilitation program was observed on first use of antidepressants after breast cancer. DISCUSSION: Diagnosis of a new cancer or recurrence of breast cancer considerably increased the rate of use of antidepressants. Sociodemographic rather than disease- or treatment-related characteristics at the time of diagnosis were associated with first use of antidepressants after a breast cancer diagnosis.

Breast cancer and early retirement: Associations with disease characteristics, treatment, comorbidity, social position and participation in a six-day rehabilitation course in a register-based study in Denmark.

INTRODUCTION: The purpose of this register-based study was to identify factors related to disease, treatment, sociodemographics and comorbidity associated with taking early retirement among women treated for breast cancer, and to evaluate the risk for taking early retirement among breast cancer survivors who attended a six-day rehabilitation course. MATERIAL AND METHODS: The study population consisted of 856 women who attended the rehabilitation course and a comparison group of 1 805 women who did not attend the course identified through the Danish Breast Cancer Cooperative Group. We obtained information on receipt of unemployment benefits, sickness benefits and early retirement pension for each of the years 1996-2007. Multivariate cox-regression models were used to analyze disease-specific, treatment-related, comorbidity and sociodemographics factors associated with early retirement after breast cancer and to evaluate the effect of attending a rehabilitation course on taking early retirement. RESULTS: The rate of retirement was higher for women with somatic comorbidity (hazard ratio [HR], 1.91; 95% CI, 1.3; 2.9 for score 1, and HR 1.42; 95% CI, 0.7; 2.7 for score ≥2), previous depression (HR, 2.29; 95% CI, 1.7; 3.2) or having received sickness benefits in the year before their breast cancer diagnosis (HR, 3.75; 95% CI, 1.8; 7.8). Living with a partner was associated with a reduced hazard ratio for taking early retirement (HR, 0.70; 95% CI, 0.5-0.9). Having received chemotherapy, alone or in combination with anti-hormone treatment, reduced the hazard ratio (HR, 0.49; 95% CI, 0.3; 0.8 and HR, 0.5; 95% CI, 0.3; 0.8, respectively). The rate of retirement was higher for women the year after attending the rehabilitation course but returned to unity by three years. DISCUSSION: The results of this study contribute to the identification of at-risk women and point to the need for tailored rehabilitation to avoid unnecessary marginalization of breast cancer survivors due to permanent labor market withdrawal.