Acceptability of physical activity monitoring in older adults undergoing inpatient rehabilitation.

BACKGROUND: There is little research into interventions to increase activity levels of hospitalised older adults. AIMS: To assess the feasibility of using a physical activity monitor (PAL2) in hospitalized older adults and the effect of group exercise on activity levels. METHODS: Participants were hospitalized, ambulant adults ≥ 65 years randomized to individual physical therapy alone or combined with a high intensity exercise group and wore the PAL2 for five consecutive days. RESULTS: Only 33% of eligible participants agreed to participate with 19/30 (63%) complete data sets obtained; physical activity levels were low regardless of intervention. CONCLUSION: Acceptability of physical activity monitoring in hospitalized older adults was low and physical activity levels of those monitored was low across groups. To improve monitor compliance, future studies may consider excluding patients with specific comorbidities that impact on wear time, or selection of an alternative monitor.

The effects of a high-intensity functional exercise group on clinical outcomes in hospitalised older adults: an assessor-blinded, randomised-controlled trial.

Objective: to investigate a high-intensity functional exercise (HIFE) group in hospitalised older adults. Design: assessor-blinded, randomised-controlled trial. Setting: sub-acute wards at a metropolitan rehabilitation hospital. Participants: older adults ≥65 years (n = 468) able to stand with minimum assistance or less from a chair and follow instructions. Intervention: 'group' participants were offered a standing HIFE group three times a week and individual physiotherapy sessions twice a week. Control participants were offered daily individual physiotherapy sessions. Main outcome measures: the primary outcome measure was the Elderly Mobility Scale (EMS). Secondary measures included the Berg Balance Scale, gait speed, Timed Up and Go Test, falls, length of stay and discharge destination. Results: participants' mean age was 84.3 (7.1) years and 61% were female. There was no difference between groups for the improvement in EMS from admission to discharge (effect size -0.07, 95% confidence interval: -0.26 to 0.11, P = 0.446) and no difference in discharge destination, P = 0.904. Therapists saved 31-205 min/week treating group participants compared with control participants. Conclusion: the results suggest that a HIFE group programme combined with individual physiotherapy may improve mobility to a similar extent to individual physiotherapy alone in hospitalised older adults. Providing physiotherapy in a group setting resulted in increased therapist efficiency. A high-intensity exercise group with individual physiotherapy may be an effective and efficient method to provide care to older inpatients.

Intra- and interrater reliability of the Modified Tardieu Scale for the assessment of lower limb spasticity in adults with neurologic injuries.

OBJECTIVE: To examine the intra- and interrater reliability of the Modified Tardieu Scale (MTS) for lower limb assessment of adults with chronic neurologic injuries. DESIGN: Single-center intra- and interrater reliability study. SETTING: Outpatient neurorehabilitation unit. PARTICIPANTS: Adults (N=30; mean age ± SD, 54.1±12.5y) with various chronic neurologic injuries and lower limb spasticity. INTERVENTIONS: Two experienced physiotherapists performed slow (R2) and fast (R1) passive movements for lower limb muscles half an hour apart on the same day (interrater reliability), while a third physiotherapist took goniometric measurements only. One physiotherapist repeated the assessment 1 to 3 days earlier or later (intrarater reliability). Assessors qualitatively rated the resistance to fast passive movements. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs) and limits of agreement (LOA) were calculated for R1, R2, and R2-R1. Kappa coefficients were calculated for tibialis range of movement and qualitative spasticity ratings. RESULTS: Intra- and interrater R1 and R2 measurements showed moderate to high reliability for the affected hamstrings, rectus femoris, gastrocnemius, soleus (mean ICC ± SD, .79±.08), and tibialis anterior (mean κ ± SD, .58±.10). Only intrarater measurements of the affected tibialis posterior were moderately reliable (R1=.57, R2=.77). Seven of 16 spasticity angle measurements of the affected muscles were moderately reliable. LOA were mostly unacceptably wide. Qualitative spasticity ratings were moderately reliable for affected hamstrings, gastrocnemius, and tibialis muscles (mean κ ± SD, .52±.10). CONCLUSIONS: The MTS is reliable for assessing spasticity in most lower limb muscles of adults with chronic neurologic injuries. Repeated MTS measurements of spasticity are best based on R1 measurements rather than spasticity angle or qualitative ratings of spasticity. Optimally, MTS measurements should be undertaken by the same clinician.

Systematic review of high-intensity progressive resistance strength training of the lower limb compared with other intensities of strength training in older adults.

OBJECTIVE: To examine the effect of high-intensity progressive resistance strength training (HIPRST) on strength, function, mood, quality of life, and adverse events compared with other intensities in older adults. DATA SOURCES: Online databases were searched from their inception to July 2012. STUDY SELECTION: Randomized controlled trials of HIPRST of the lower limb compared with other intensities of progressive resistance strength training (PRST) in older adults (mean age ≥ 65y) were identified. DATA EXTRACTION: Two reviewers independently completed quality assessment using the Physiotherapy Evidence Database (PEDro) scale and data extraction using a prepared checklist. DATA SYNTHESIS: Twenty-one trials were included. Study quality was fair to moderate (PEDro scale range, 3-7). Studies had small sample sizes (18-84), and participants were generally healthy. Meta-analyses revealed HIPRST improved lower-limb strength greater than moderate- and low-intensity PRST (standardized mean difference [SMD]=.79; 95% confidence interval [CI], .40 to 1.17 and SMD=.83; 95% CI, -.02 to 1.68, respectively). Studies where groups performed equivalent training volumes resulted in similar improvements in leg strength, regardless of training intensity. Similar improvements were found across intensities for functional performance and disability. The effect of intensity of PRST on mood was inconsistent across studies. Adverse events were poorly reported, however, no correlation was found between training intensity and severity of adverse events. CONCLUSIONS: HIPRST improves lower-limb strength more than lesser training intensities, although it may not be required to improve functional performance. Training volume is also an important variable. HIPRST appears to be a safe mode of exercise in older adults. Further research into its effects on older adults with chronic health conditions across the care continuum is required.

Trials needed to assess knee proprioception following stroke.

BACKGROUND AND PURPOSE: This study explores the number of trials required to identify clinically significant impairments in knee joint position sense and movement sense following stroke. METHOD: Proprioception was assessed in 33 stroke patients aged 37-87 years. Ten trials for each assessment were performed in sitting and supine positions using both verbal response techniques and contralateral limb matching. RESULTS: Forty-six percent of participants were identified with a proprioceptive deficit. The trial where the first incorrect response occurred varied across individuals and testing positions. Performing only one trial detected proprioceptive impairments in less than 10% patients, and incorrect responses did not always occur in the first 5 trials. In sitting, no participant failed the assessment of knee joint position sense using the verbal response technique after only 6 trials. In supine, no participant failed the assessment of knee movement sense using the verbal response technique after only 6 trials. For the assessment of knee joint position sense in sitting using contralateral limb matching an estimated 9.4% of patients with a deficit would be missed if only 3 trials were used in preference to 5. For assessment of knee joint position sense in sitting, an estimated 18.8% of patients with deficits would be missed if only 3 trials were used rather than 10 trials. CONCLUSIONS: Clinicians should perform at least 10 trials in either sitting or supine to quantify joint position sense and movement sense at the knee following stroke.

The reliability of knee joint position testing using electrogoniometry.

BACKGROUND: The current investigation examined the inter- and intra-tester reliability of knee joint angle measurements using a flexible Penny and Giles Biometric electrogoniometer. The clinical utility of electrogoniometry was also addressed. METHODS: The first study examined the inter- and intra-tester reliability of measurements of knee joint angles in supine, sitting and standing in 35 healthy adults. The second study evaluated inter-tester and intra-tester reliability of knee joint angle measurements in standing and after walking 10 metres in 20 healthy adults, using an enhanced measurement protocol with a more detailed electrogoniometer attachment procedure. Both inter-tester reliability studies involved two testers. RESULTS: In the first study, inter-tester reliability (ICC[2,10]) ranged from 0.58-0.71 in supine, 0.68-0.79 in sitting and 0.57-0.80 in standing. The standard error of measurement between testers was less than 3.55 degrees and the limits of agreement ranged from -12.51 degrees to 12.21 degrees . Reliability coefficients for intra-tester reliability (ICC[3,10]) ranged from 0.75-0.76 in supine, 0.86-0.87 in sitting and 0.87-0.88 in standing. The standard error of measurement for repeated measures by the same tester was less than 1.7 degrees and the limits of agreement ranged from -8.13 degrees to 7.90 degrees . The second study showed that using a more detailed electrogoniometer attachment protocol reduced the error of measurement between testers to 0.5 degrees . CONCLUSION: Using a standardised protocol, reliable measures of knee joint angles can be gained in standing, supine and sitting by using a flexible goniometer.

Experiences of older adults in a group physiotherapy program at a rehabilitation hospital: A qualitative study.

Physiotherapy delivered in a group setting has been shown to be effective in a variety of populations. However, little is known about the attitudes of older adults toward participating in group physiotherapy. The objectives of this study were to explore older inpatients' perceptions and experiences of group physiotherapy using qualitative methods. Twelve hospitalized adults aged ≥65 years who were involved in a larger randomized controlled trial undertook individual semistructured interviews regarding their experiences in group physiotherapy. Interviews were transcribed verbatim, and line by line, iterative thematic analysis was undertaken. Descriptive codes were developed, compared, and grouped together to create themes. Analysis revealed 6 major themes and 10 subthemes. All participants reported feeling happy to attend group sessions, a satisfactory alternative to individual physiotherapy. Participants described physical benefits that increased their motivation, and comparisons with their peers either motivated them or made them feel gratitude for their own health. Perceived attentiveness of group instructors contributed to participants reporting that treatment was individualized and similar to individual physiotherapy. Motivation and camaraderie with peers contributed to their enjoyment of group physiotherapy. Hospitalized older adults enjoyed exercising with their peers and valued the physical and social benefits of group physiotherapy. Journal of Hospital Medicine 2016;11:358-362. © 2016 Society of Hospital Medicine.

Frequency and characteristics of goal attainment following BoNT-A injection for management of spasticity.

PURPOSE: To determine which Goal Attainment Scale (GAS) goals are commonly achieved in patients with upper limb and/or lower limb spasticity following Botulinum Neurotoxin Type A (BoNT-A) injection. METHOD: Adults who attended a Spasticity Management Clinic for upper and/or lower limb BoNT-A injection were included in this prospective cohort study. Goals were set by participants and/or carers in conjunction with the therapist using the GAS, prior to injection and reviewed at one month following the injection. Three out of the five categories of goals were passive. Goals were categorised into: mobility/transfers, pain/comfort, upper limb use, hygiene, and cosmesis. The number of responders for the GAS total score, and in each of the GAS categories, was calculated. RESULTS: Sixty-seven participants were recruited (mean age 51 ± 16 years; range 18-85), 70% had a stroke. Responders for mobility and transfer goals were further post injury or disease onset than non-responders (median 5.9 vs. 1.2 years, p = 0.03). Clients with stroke were less likely than other participants to achieve mobility and transfer goals (p = 0.02). There was a trend for those who achieved mobility and transfer goals to be younger (mean 49 years vs. 55 years, p = 0.06). Although active goals are more commonly identified, passive goals were more likely to be achieved. CONCLUSIONS: Although active goals are commonly identified by people with spasticity, passive goals were more likely to be achieved following BoNT-A injection. A long duration of spasticity does not preclude patients from achieving mobility and transfer goals. Non-stroke participants were more likely to achieve mobility and transfer goals. Implications for Rehabilitation Patients with chronic spasticity should be considered for BoNT-A as clinically meaningful outcomes can be achieved. When spasticity is present in multiple muscles, the GAS can be an assistive tool to guide clinicians in determining which muscles are a priority for injection, because the client will be more motivated to improve those specific goals. Although carers and patients are more willing to set active goals, these are more difficult to achieve possibly because follow up intervention or independent practise is required.

Validation of an Activity Monitor in Older Inpatients Undergoing Slow Stream Rehabilitation.

BACKGROUND: Older adults undergoing rehabilitation may have limited mobility, slow gait speeds and low levels of physical activity. Devices used to quantify activity levels in older adults must be able to detect these characteristics. OBJECTIVE: To investigate the validity of the Positional Activity Logger (PAL2) for monitoring position and measuring physical activity in older inpatients (slow stream rehabilitation). METHODS: Twelve older inpatients (≥65 years) underwent a 1-hour protocol (set times in supine, sitting, standing; stationary and moving). Participants were video-recorded while wearing the PAL2. Time spent in positions and walking (comfortable and fast speeds) were ascertained through video-recording analysis and compared with PAL2 data. RESULTS: There was no difference between the PAL2 and video recording for time spent in any position (P-values 0.055 to 0.646). Walking speed and PAL2 count were strongly correlated (Pearson's r = .913, P < .01). The PAL2 was responsive to within-person changes in gait speed: activity count increased by an average of 52.47 units (95% CI 3.31, 101.63). There was 100% agreement for transitions between lying to sitting and < 1 transition difference between siting to standing. CONCLUSION: The PAL2 is a valid tool for quantifying activity levels, position transitions, and within-person changes in gait speed in older inpatients.

Are gait and mobility measures responsive to change following botulinum toxin injections in adults with lower limb spasticity?

PURPOSE: To determine whether gait and mobility measures are responsive to change following botulinum toxin (BoNT) injections in adults with lower limb spasticity. METHOD: Independently ambulant adults who attended a spasticity clinic for lower limb BoNT injections were eligible to participate. The 10 m walk test (shoes on and off), timed up and go test and 6-min walk test were performed before injection and 1 month later. Participants completed a global rating of change scale (GRCS) at follow up. Comparisons were made between participants' ratings of change and change in walking performance. Effect sizes (ES) and standard error of measurement (SEM) were calculated for each outcome. RESULTS: Thirty-nine patients (22 female, 17 male; mean age 51 ± 12 years; range 26-74 years) with a median spasticity duration of 53 months participated. Statistically significant changes were found in all gait and mobility measures at 1 month following injection. All ES were small (<0.2) and SEM for each measure was large. The global rating of change scale (GRCS) indicated that 66% of participants perceived that their walking had improved. However, there was a significant relationship between GRCS and performance on walking tests for the 10 m walk test with shoes off (p = 0.01) and timed up and go test (p = 0.02) only. CONCLUSION: Commonly used walking tests may not be responsive to change following BoNT injection. The small ES suggest that BoNT has a modest effect on walking ability. Tests of walking performance may not be sufficient to capture all clinically relevant changes in walking ability following BoNT injection of the lower limb.