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.

Duloxetine plus exercise for knee osteoarthritis and depression: A feasibility study.

Objective: To assess the feasibility of a 24-week, center-based, aerobic exercise program plus duloxetine to treat symptomatic knee osteoarthritis (OA) and major depression. Design: Patients with symptomatic knee OA and major depression were recruited between August 2021 and November 2022 from the University of Maryland and VA Maryland Health Care Systems and Baltimore metropolitan area using medical records and advertisements. The intervention included 1) supervised treadmill walking 3 times weekly and 2) duloxetine starting at 30 â€‹mg each day and titrating up to the optimal dosage of 60 â€‹mg daily. Data collection occurred at baseline and 12- and 24-weeks follow-up. Feasibility was evaluated from recruitment rates, reasons for drop out, and treatment adherence. Clinical measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hamilton Depression Rating Scale (HAM-D). Results: Among 377 interested participants, 9 patients were enrolled, and 1 completed treatment. The most common reason reported for not prescreening was time commitment (n â€‹= â€‹39), many patients did not satisfy depression screening criteria (n â€‹= â€‹45), and most enrolled participants were not experiencing a major depressive episode (n â€‹= â€‹6). The single treated participant was 100 â€‹% adherent to duloxetine and depression severity decreased (HAM-D â€‹= â€‹25 to 1), but compliance to supervised exercise was only 26 â€‹%, and knee pain severity changed little (KOOS â€‹= â€‹41.7 to 44.4). Conclusions: This intervention had low feasibility. Time commitment to supervised exercise sessions reduced accessibility, and depression defined by diagnostic criteria precluded knee OA patients with depressive symptoms not a meeting case-level diagnosis from receiving treatment. Clinical trial registration number: NCT04111627.

Sex Differences in Recovery Across Multiple Domains Among Older Adults With Hip Fracture.

BACKGROUND: Hip fractures are a public health problem among older adults, but most research on recovery after hip fracture has been limited to females. With growing numbers of hip fractures among males, it is important to determine how recovery outcomes may differ between the sexes. METHODS: 168 males and 171 females were enrolled within 15 days of hospitalization with follow-up visits at 2, 6, and 12 months postadmission to assess changes in disability, physical performance, cognition, depressive symptoms, body composition, and strength, and all-cause mortality. Generalized estimating equations examined whether males and females followed identical outcome recovery assessed by the change in each outcome. RESULTS: The mean age at fracture was similar for males (80.4) and females (81.4), and males had more comorbidities (2.5 vs 1.6) than females. Males were significantly more likely to die over 12 months (hazard ratio 2.89, 95% confidence interval: 1.56-5.34). Changes in outcomes were significantly different between males and females for disability, gait speed, and depressive symptoms (p < .05). Both sexes improved from baseline to 6 months for these measures, but only males continued to improve between 6 and 12 months. There were baseline differences for most body composition measures and strength; however, there were no significant differences in change by sex. CONCLUSIONS: Findings confirm that males have higher mortality but suggest that male survivors have continued functional recovery over the 12 months compared to females. Research is needed to determine the underlying causes of these sex differences for developing future prognostic information and rehabilitative interventions.

Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades.

OBJECTIVE: To examine trends in 12-month postfracture residual disability, nursing home placement, and mortality among patients with a hip fracture between 1990 and 2011. DESIGN: Secondary analysis of 12-month outcomes from 3 cohort studies and control arms of 2 randomized controlled trials. SETTING: Original studies were conducted as part of the Baltimore Hip Studies (BHS). PARTICIPANTS: Community-dwelling patients ≥65 years of age hospitalized for surgical repair of a nonpathologic hip fracture (N=988). MAIN OUTCOME MEASURES: Twelve-month residual disability, mortality, and nursing home residency were examined in case-mix adjusted models by sex and study. Residual disability was calculated by subtracting prefracture scores of Lower Extremity Physical Activities of Daily Living from scores at 12 months postfracture. We also examined the proportion of individuals with a 12-month score higher than their prefracture score (residual disability>0). RESULTS: Only small improvements were seen in residual disability between 1990 and 2011. No significant differences were seen for men between BHS2 (enrollment 1990-1991; mean residual disability=3.1 activities; 95% confidence interval [CI], 2.16-4.10) and BHS7 (enrollment 2006-2011; mean=3.1 activities; 95% CI, 2.41-3.82). In women, residual disability significantly improved from BHS2 (mean=3.5 activities; 95% CI, 2.95-3.99) to BHS3 (enrollment 1992-1995; mean=2.7 activities; 95% CI, 2.01-3.30) with no significant improvements in later studies. After adjustment, a substantial proportion (91% of men and 79% of women) had a negative outcome (residual disability, died, or nursing home residence at 12 months) in the most recently completed study (BHS7). CONCLUSIONS: Over 2 decades, patients undergoing usual care post-hip fracture still had substantial residual disability. Additional clinical and research efforts are needed to determine how to improve hip fracture treatment, rehabilitation, and subsequent outcomes.

Delivery and outcomes of a yearlong home exercise program after hip fracture: a randomized controlled trial.

BACKGROUND: Hip fracture affects more than 1.6 million persons worldwide and causes substantial changes in body composition, function, and strength. Usual care (UC) has not successfully restored function to most patients, and prior research has not identified an effective restorative program. Our objective was to determine whether a yearlong home-based exercise program initiated following UC could be administered to older patients with hip fracture and improve outcomes. METHODS: A randomized controlled trial of 180 community dwelling female patients with hip fracture, 65 years and older, randomly assigned to intervention (n = 91) or UC (n = 89). Patients were recruited within 15 days of fracture from 3 Baltimore-area hospitals from November 1998 through September 2004. Follow-up assessments were conducted at 2, 6, and 12 months after fracture. The Exercise Plus Program was administered by exercise trainers that included supervised and independently performed aerobic and resistive exercises with increasing intensity. Main outcome measures included bone mineral density of the contralateral femoral neck. Other outcomes included time spent and kilocalories expended in physical activity using the Yale Physical Activity Scale, muscle mass and strength, fat mass, activities of daily living, and physical and psychosocial functioning. The effect of intervention for each outcome was estimated by the difference in outcome trajectories 2 to 12 months after fracture. RESULTS: More than 80% of participants received trainer visits, with the majority receiving more than 3 quarters (79%) of protocol visits. The intervention group reported more time spent in exercise activity during follow-up (P < .05). Overall, small effect sizes of 0 to 0.2 standard deviations were seen for bone mineral density measures, and no significant patterns of time-specific between-group differences were observed for the remaining outcome measures. CONCLUSION: Patients with hip fracture who participate in a yearlong, in-home exercise program will increase activity level compared with those in UC; however, no significant changes in other targeted outcomes were detected. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00390741.

Adherence to an Exercise Intervention Among Older Women Post Hip Fracture.

The purpose of this study was to evaluate adherence to home-based exercise interventions among older women post hip fracture that were randomized to one of three exercise intervention groups or a routine care group. A total of 157 female hip fracture patients provided data for the intervention analysis. Factors evaluated baseline, 2, 6, and 12 months post hip fracture included demographic variables, adherence to treatment visits, self-efficacy, outcome expectations, stage of change for exercise, social support for exercise, mood, health status, pain, and fear of falling. The hypothesized model tested the direct and indirect impact of all study variables on adherence to exercise intervention sessions. Different factors appeared to influence adherence to visits across the recovery trajectory.

Factors that influence exercise activity among women post hip fracture participating in the Exercise Plus Program.

Using a social ecological model, this paper describes selected intra- and interpersonal factors that influence exercise behavior in women post hip fracture who participated in the Exercise Plus Program. Model testing of factors that influence exercise behavior at 2, 6 and 12 months post hip fracture was done. The full model hypothesized that demographic variables; cognitive, affective, physical and functional status; pain; fear of falling; social support for exercise, and exposure to the Exercise Plus Program would influence self-efficacy, outcome expectations, and stage of change both directly and indirectly influencing total time spent exercising. Two hundred and nine female hip fracture patients (age 81.0 +/- 6.9), the majority of whom were Caucasian (97%), participated in this study. The three predictive models tested across the 12 month recovery trajectory suggest that somewhat different factors may influence exercise over the recovery period and the models explained 8 to 21% of the variance in time spent exercising. To optimize exercise activity post hip fracture, older adults should be helped to realistically assess their self-efficacy and outcome expectations related to exercise, health care providers and friends/peers should be encouraged to reinforce the positive benefits of exercise post hip fracture, and fear of falling should be addressed throughout the entire hip fracture recovery trajectory.

Testing the effectiveness of the exercise plus program in older women post-hip fracture.

BACKGROUND: Exercise is an important strategy with potential to improve recovery in older adults following a hip fracture. PURPOSE: The purpose of this study was to test the impact of a self-efficacy based intervention, the Exercise Plus Program, and the different components of the intervention, on self-efficacy, outcome expectations, and exercise behavior among older women post-hip fracture. METHODS: Participants were randomized to one of four groups: exercise plus, exercise only, plus only (i.e., motivation), or routine care. Data collection was done at baseline (within 22 days of fracture), 2, 6, and 12 months post-hip fracture. RESULTS: A total of 209 women were recruited with an average age of 81.0 years (SD=6.9). The majority was White (97.1%), was widowed (57.2%), and had a high school education (66.7%). Generalized Estimating Equations were used to perform repeated measures analyses. No differences in trajectories of recovery were observed for self-efficacy or outcome expectations. A statistically significant difference in the overall trajectory of time in exercise was seen (p<.001), with more time spent exercising in all three treatment groups. CONCLUSIONS: The study demonstrated that it was possible to engage these women in a home-based exercise program and that the plus only, exercise only, and the exercise plus groups all increased exercise.

The relationship between psychosocial state and exercise behavior of older women 2 months after hip fracture.

Despite the potential benefits associated with exercise after hip fracture, those who have sustained hip fractures are among the least likely to engage in regular exercise (resistive or aerobic). This article describes the psychosocial state, specifically the self-efficacy expectations and outcome expectations related to exercise, mood, fear of falling, pain, and health status of older women who enrolled in either of two Baltimore Hip Studies (BHS), BHS-4 and BHS-5, and to test a self-efficacy-based model to explain exercise behavior after hip fracture. A total of 389 older women with hip fractures participated in these studies. The participants reported moderate confidence in their ability to exercise and a general belief in the benefits of exercise, high perceived health status, limited depressive symptoms, and some pain and fear of falling. Consistently across these two samples, age and mental status or depressive symptoms influenced outcome expectations, such that older women with more depressive symptoms or lower mental health status had weaker outcome expectations for exercise. Self-efficacy expectations consistently influenced exercise behavior across both samples. It was also consistent across both models that age, cognitive status, physical and mental health status, pain, fear, outcome expectations, and depressive symptoms did not directly influence exercise behavior.

Testing of the SEE and OEE post-hip fracture.

The purpose of this study was to test the reliability and validity of the Self-Efficacy for Exercise (SEE) and the Outcome Expectations for Exercise (OEE) scales in a sample of 166 older women post-hip fracture. There was some evidence of validity of the SEE and OEE based on confirmatory factor analysis and Rasch model testing, criterion based and convergent validity, and evidence of internal consistency based on alpha coefficients and separation indices and reliability based on R2 estimates. Rasch model testing demonstrated that some items had high variability. Based on these findings suggestions are made for how items could be revised and the scales improved for future use.