Community ambulation before and after hip fracture: a qualitative analysis

Purpose.?This qualitative study explored mobility levels around the home and in the community before and after hip fracture.

Methods.?Twenty-four people receiving rehabilitation after hip fracture were interviewed using an in-depth semi-structured format: 12 who were receiving rehabilitation as inpatients, and 12 who had been discharged home from inpatient rehabilitation and were continuing therapy as outpatients. The recorded interviews were transcribed and coded independently by two researchers. From these codes themes were developed.

Results.?Before their fracture, participants were independent about their houses, but their level of community ambulation had been reducing over recent months or years, often associated with another health problem. Participants who had returned home after inpatient rehabilitation for hip fracture reported much reduced levels of mobility both in their house and in the community compared with their pre-fracture performance. This reduced level of mobility was associated with psychological factors (fear, lack of confidence, frustration), physical factors (pain, the presence of another health problem) and social/environmental factors (reliance on daughter, and car). The level of optimism expressed by people receiving inpatient rehabilitation contrasted with the pessimism of those receiving outpatient rehabilitation.

Conclusions.?Patients living back in the community after hip fracture described a reduced level of functioning and a pessimism that contrasted with the optimism expressed by people who were still in the inpatient phase of rehabilitation. These findings, and the importance of psychological factors and social support, may be considered when designing rehabilitation strategies to support the successful transition of people to their community after hip fracture.     

Complications and limitations related to periprostatic local anesthesia before TRUS-guided prostate biopsy

PURPOSE: To assess the frequency of complications specifically related to local anesthetic infiltration prior to transrectal ultrasound (TRUS)-guided prostate biopsy. METHODS: A total of 200 patients receiving 10 cm(3) (5 cm(3) on each side) of 2% lidocaine injected around the periprostatic nerve plexus under TRUS guidance before prostate biopsy were included. Various complications presumed to be associated with local anesthesia were noted during and after the biopsy procedure. Two weeks later, periprostatic tissue integrity and vascularization were re-examined with TRUS Doppler examination to assess for fibrosis or infection. RESULTS: The most common finding was pain due to puncture with the needle used for local anesthesia (27%). Also recorded were the need for repeated injections during the biopsy procedure (4.5%), symptoms associated with systemic lidocaine toxicity (2%), urinary incontinence (1.5%), and degradation of the image resolution due to anesthetic injection (1%). Increased vascularization within the periprostatic region was uncommon (2%) on the 2-week follow-up examination. No TRUS finding consistent with rectal wall hematoma or other periprostatic change and no erectile dysfunction associated with the procedure occurred. There was a significant difference in overall pain scores between the subgroups of patients (p < 0.001). CONCLUSION: TRUS-guided periprostatic nerve blockade is an effective method for relieving discomfort from prostate biopsy with very few complications.     

Factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture

Purpose: To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture. Method: Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables. Results: Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes. Conclusions: While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.

• Implications for Rehabilitation

• In almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation.

• Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation.

• A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

     

Factors associated with a second hip fracture: a systematic review

OBJECTIVE: To provide a systematic review of factors associated with subsequent hip fracture among individuals who have fractured a hip. DATA SOURCES: We searched Ageline, CINAHL, EMBASE and MEDLINE, from database inceptions to the week of 5 June 2006. REVIEW METHODS: Studies were selected if they provided information regarding risk of subsequent hip fracture among individuals who had fractured a hip. Study quality was assessed using the Jadad criteria for randomized controlled trials (RCTs) and a simple scale based on the MOOSE criteria for cohort studies. RESULTS: Four RCTs and seven cohort studies were identified. Older age, cognitive impairment and lower bone mass appear to increase the risk of subsequent fracture, as did impaired depth perception, impaired mobility, previous falls, dizziness and poor or fair self-perceived health. Pharmacologic treatment for osteoporosis decreased the risk of subsequent fracture. Use of hip protectors by community-dwelling seniors did not appear to protect against a second fracture. CONCLUSION: A number of easily observed risk factors may help identify those individuals at higher risk for subsequent fracture.     

非手术治疗老年髋部骨折影响预后的因素

背景：髋部骨折是老年人常见的骨折类型,多数有条件的患者均采用手术治疗。但仍有相当部分的病例因各种原因采取非手术治疗。目的：分析影响非手术治疗老年人髋部骨折预后的相关因素。方法：回顾性分析2001年1月至2007年12月收治的61例60岁以上选择非手术治疗的髋部骨折病例的临床资料。采用SPSS13.0统计软件对临床数据进行单因素及多因素生存分析,以期发现影响非手术治疗老年髋部骨折患者生存的因素。结果与结论：随访至2008年7月,19例患者存活,Harris评分平均为43.58分。其中〈70岁11例,Harris评分（55.81±29.59）分;〉70岁8例,Harris评分（26.75±23.58）分,两者间比较差异有显著性意义（P〈0.05）。生存分析显示1,2,5年总存活率分别为0.803±0.051,0.607±0.063,0.301±0.072。单因素分析显示年龄、治疗期间能否早期摆脱卧位状态以及血清白蛋白水平对预后的影响差异具有显著性意义（P〈0.05）。COX多因素回归模型分析提示年龄、治疗期间能否早期摆脱卧位状态具有独立预后意义（P〈0.05）。可见对于非手术方法治疗的70岁以上高龄髋部骨折患者,年龄、治疗期间能否早期摆脱卧位状态是影响生存率的主要因素。     

Successful rehabilitation after hip fracture to a patient with previous above-elbow amputation

We experienced successful rehabilitation of an elderly man after hip fracture (HF) who had had ipsilateral above-elbow amputation. He was a wounded soldier whose right arm had been amputated more than 60 yrs ago, and he had never used a prosthesis. He had been admitted to our hospital because of exacerbation of chronic obstructive pulmonary disease. During his admission, he had a fall-related hip fracture. We devised a special upper-limb prosthesis so that he could hold an ipsilateral crutch to enable appropriate acute-phase rehabilitation for HF. As a result, effects of disuse were prevented and he gained improvement of lower-limb function. The specialized upper-limb prosthesis also reduced his anxiety regarding walking. It can be considered that the prosthesis contributed to his quality of life with regard to activities of daily living after discharge.     

非手术治疗老年髋部骨折影响预后的因素

背景:髋部骨折是老年人常见的骨折类型,多数有条件的患者均采用手术治疗。但仍有相当部分的病例因各种原因采取非手术治疗。目的:分析影响非手术治疗老年人髋部骨折预后的相关因素。方法:回顾性分析2001年1月至2007年12月收治的61例60岁以上选择非手术治疗的髋部骨折病例的临床资料。采用SPSS13.0统计软件对临床数据进行单因素及多因素生存分析,以期发现影响非手术治疗老年髋部骨折患者生存的因素。结果与结论:随访至2008年7月,19例患者存活,Harris评分平均为43.58分。其中<70岁11例,Harris评分(55.81±29.59)分;>70岁8例,Harris评分(26.75±23.58)分,两者间比较差异有显著性意义(P<0.05)。生存分析显示1,2,5年总存活率分别为0.803±0.051,0.607±0.063,0.301±0.072。单因素分析显示年龄、治疗期间能否早期摆脱卧位状态以及血清白蛋白水平对预后的影响差异具有显著性意义(P<0.05)。COX多因素回归模型分析提示年龄、治疗期间能否早期摆脱卧位状态具有独立预后意义(P<0.05)。可见对于非手术方法治疗的70岁以上高龄髋部骨折患者,年龄、治疗期间能否早期摆脱卧位状态是影响生存率的主要因素。     

Establishing well-being after hip fracture: a systematic review and meta-synthesis

Purpose: This study aimed to identify, appraise, aggregate and synthesize findings of experiences of self-confidence and well-being after hip fracture.

Method: The systematic review followed the Joanna Briggs Institute (JBI) guidelines. A three-step literature search strategy was followed. Included studies were critically appraised using the JBI critical appraisal tool. Data were analyzed into a meta-summary and a meta-synthesis using a hermeneutic approach.

Results: Twenty-nine studies were included in the analysis. The category “balancing a new life” was illustrated through older people’s “adaptations”, “adjustments” and “worries”. The second category “striving for interaction with new life possibilities” was built on experiences of “supportive interaction”, “missing interaction” and “obstacles”. The abstraction of the categories into the meta-synthesis “establishing well-being described the process of older people gradually coming to terms with new life conditions”. It was a process of building confidence through cooperation with staff.

Conclusions: Experiences of well-being were possible after hip fracture. Self-confidence enhanced adaptations and adjustments. Older people strived for an active everyday life where they had a sense of identity. Health professionals can facilitate the establishing of well-being through supportive interaction being aware of vulnerabilities and possibilities. This study provides information that may help in the development of interventions taking into account what is meaningful for older people.

• Implications for Rehabilitation

• Both staff and significant others play a significant role during rehabilitation after hip fracture and can give rise to both well-being and suffering.

• During rehabilitation, experiences of self-efficacy can be important as they support progress and adaptation towards a new way of living.

• After hip fracture, older people may have worries and can experience a diversity of obstacles. A sensitivity towards these experiences by health care professionals can be a support for older people striving to establish well-being after hip fracture.

• To enhance functional ability and experiences of independency, it may be important to consider what it is about activities that are meaningful in the lives of older people after a hip fracture.

     

Exercise prescription for a patient 3 months after hip fracture

BACKGROUND AND PURPOSE: Most patients with hip fracture do not return to prefracture functional status 1 year after surgery. The literature describing interventions, however, does not use classic overload and specificity principles. The purpose of this case report is to describe the use of resistance training to improve functional outcomes in a patient following hip fracture. CASE DESCRIPTION: The patient was a 68-year-old woman who had a comminuted intertrochanteric fracture of the left hip 3 months previously. She used a cane for ambulation, and her walking was limited. The patient received 16 sessions of lower-extremity strengthening exercises, aerobic training on a stationary bicycle, functional training supervised by a physical therapist, and a home stretching program. OUTCOME: The patient's isometric muscle force for involved hip extension, hip abduction, and knee extension improved by 86%, 138%, and 33%, respectively; walking endurance increased by 22.5%; balance improved by 400%; balance confidence increased by 41%; and self-reported ability to perform lower-extremity functional activities increased by 20%. DISCUSSION: The authors believe that some patients can perform comprehensive exercise programs after hip fracture and that properly designed programs can affect patient outcomes beyond observed impairments.     

Training-induced strength and functional adaptations after hip fracture

BACKGROUND AND PURPOSE: At 3 months after hip fracture, most people are discharged from physical therapy despite residual muscle weakness and overall decreased functional capabilities. The purposes of this study were: (1) to determine, in frail elderly adults after hip fracture and repair, whether a supervised 6-month exercise program would result in strength gains in the fractured limb equivalent to the level of strength in the nonfractured limb; (2) to determine whether the principle of specificity of training would apply to this population of adults; and (3) to determine the relationship between progressive resistance exercise training (PRT) intensity and changes in measures of strength and physical function. SUBJECTS: The study participants were 31 older adults (9 men and 22 women; age [X+/-SD], 79+/-6 years) who had surgical repair of a hip fracture that was completed less than 16 weeks before study enrollment and who completed at least 30 sessions of a supervised exercise intervention. METHODS: Participants completed 3 months of light resistance and flexibility exercises followed by 3 months of PRT. Tests of strength and function were completed at baseline, before PRT, and after PRT. RESULTS: After PRT, the subjects increased knee extension and leg press 1-repetition maximum by 72%+/-56% and 37%+/-30%, respectively. After 3 and 6 months of training, lower-extremity peak torques all increased. Specificity of training appeared to apply only to the nonfractured limb after PRT. Strong correlations were observed between training intensity and lower-extremity strength gains as well as improvements in measures of physical function. DISCUSSION AND CONCLUSION: Frail elderly adults after hip fracture can benefit by extending their rehabilitation in a supervised exercise setting, working at high intensities in order to optimize gains in strength and physical function.     

Knee-extension strength,postural control and function are related to fracture type and thigh edema in patients with hip fracture

Background

Post-surgery thigh edema, loss of knee-extension strength, and reduced physical performance are common following a hip fracture. It is not known if knee-extension strength and physical performance are related to the edema and fracture type. The aim of this study was to examine the influence of fracture type and post-surgery edema on physical performances in patients with hip fracture.

Methods

Fifteen women and five men admitted from their own home to an acute orthopedic hip fracture unit were examined. Ten had cervical and ten had intertrochanteric fractures. Correlations between fracture type and thigh edema in the fractured limb (% non-fractured) to physical performances of basic mobility, postural control (sway), and isometric knee-extension strength were examined. All measures, except those of basic mobility, were conducted at the time of discharge, 8.5 days post-surgery.

Findings

Patients with intertrochanteric fractures had greater edema (111% non-fractured limb) compared with cervical fractures (104% non-fractured, P < 0.001). Thigh edema was significantly correlated to lower scores of basic mobility (r = −0.61, P = 0.004), reduced postural control (r = 0.67, P = 0.001), and fractured limb knee-extension strength deficit ([% non-fractured], r = −0.77, P < 0.001), explaining between 32% and 59% of the variance (r²) in performances.

Interpretation

Our results indicate that fracture type and the corresponding thigh edema are important factors influencing physical performances after hip fracture. These findings have important implications for rehabilitation programs and for further research in patients with hip fracture.