Improving community ambulation after hip fracture: protocol for a randomised, controlled trial.

INTRODUCTION: After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE: To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN: Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING: A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS: Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS: The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS: Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION: This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

Aerobic training in a patient with nonsevere aplastic anemia: a case report.

This case report examined whether a 26-year-old man with a 5-year history of nonsevere aplastic anemia could perform aerobic training and whether exercise was beneficial. Testing was performed at baseline and at 8 and 16 weeks and included complete blood tests, graded exercise tests with breath-by-breath gas analyses, and health status assessment with the Medical Outcomes Survey SF-12 health survey. Training consisted of treadmill walking for 25 minutes, 3 days a week for 16 weeks, at 75% of maximal heart rate. The patient successfully completed 16 weeks of training and had no adverse effects from testing or training. Training did not produce changes in disease-related measures (hematologic values) or impairment measures (cardiopulmonary measures of fitness). The mental component of the SF-12 improved from below 2 standard deviations from the population mean to within 1 standard deviation of the population mean. The benefits of aerobic training for this person with aplastic anemia were that he showed that he could participate in aerobic-type activities and that training appeared to improve his mental health.

The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis.

BACKGROUND: People with osteoarthritis (OA) of the knee experience pain and deconditioning that lead to disability. This study challenged the clinical belief that repetitive lower extremity exercise is not indicated in persons with knee OA. The effects of high-intensity and low-intensity stationary cycling on functional status, gait, overall and acute pain, and aerobic capacity were examined. METHODS: Thirty-nine adults (71+/-6.9 years old) with complaints of knee pain and diagnosis of OA were randomized to either a high-intensity (70% heart rate reserve [HRR]) or low-intensity (40% HRR) exercise group for 10 weeks of stationary cycling. Participants cycled for 25 minutes, 3 times per week. Before and after the exercise intervention they completed the Arthritis Impact Measurement Scale 2 for overall pain assessment, underwent timed chair rise, 6-minute walk test, gait, and graded exercise treadmill tests. Acute pain was reported daily with a visual analog scale and the Western Ontario and McMaster Universities Osteoarthritis Index scale. RESULTS: Analysis of variance revealed that participants in both groups significantly improved in the timed chair rise, in the 6-minute walk test, in the range of walking speeds, in the amount of overall pain relief, and in aerobic capacity. No differences between groups were found. Daily pain reports suggested that cycling did not increase acute pain in either group. CONCLUSIONS: Cycling may be considered as an alternative exercise modality for patients with knee OA. Low-intensity cycling was as effective as high-intensity cycling in improving function and gait, decreasing pain, and increasing aerobic capacity.

Mechanical unweighting effects on treadmill exercise and pain in elderly people with osteoarthritis of the knee.

BACKGROUND AND PURPOSE: People with osteoarthritis (OA) of the knee who have pain generally exhibit decreased activity and physical deconditioning. This study investigated the effects of mechanical unweighting on knee pain and exercise responses in people with OA of the knee who have pain. SUBJECTS: Four men and 23 women, with a mean age of 67.9 years (SD = 11.3, range = 50-88) and having a 12-year average duration of knee OA, participated. METHODS: A mechanical unloading device enabled subjects to perform a modified Naughton treadmill exercise test at 0%, 20%, and 40% of body weight support (BWS). Oxygen consumption (VO2), heart rate (HR), and perceived pain were measured during the last minute of each exercise stage. RESULTS: Mechanical unweighting at 20% and 40% BWS decreased the Vo2 and HR responses to treadmill exercise but did not decrease knee pain during walking in this sample. CONCLUSION AND DISCUSSION: These findings indicate that treadmill exercise accompanied by BWS permits recommended training intensities to be obtained in elderly people with OA, but may not provide pain relief in this group.