Early controlled motion (ECM) of the ankle is widely used in the non-operative treatment of acute Achilles tendon rupture, although its safety and efficacy have not been investigated properly in a ...randomised set-up.
To investigate if ECM of the ankle was superior to immobilisation in the treatment of acute Achilles tendon rupture.
This was an assessor-blinded, randomised controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged 18-70 years were eligible for inclusion. The ECM group performed movements of the ankle five times a day from week 3 to week 8 after rupture. The control group was immobilised for 8 weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) evaluated at 1-year postinjury. The secondary outcomes were heel-rise work test (HRW), Achilles tendon elongation and rate of rerupture. Analysis was conducted as intention-to-treat using inverse probability weighting.
189 patients were assessed for eligibility and 130 were included from February 2014 to December 2016. There were 64 patients in the ECM group and 58 in the immobilisation group. There were no statistically significant differences (p>0.3) between the ECM and the immobilisation groups at 1 year: mean (SD) ATRS was 74 (18) and 75 (18), respectively. HRW was 60% (21) and 60% (21) of the uninjured limb, and elongation was 18 mm (13) and 16 mm (11), respectively. Correspondingly, there were six and seven reruptures.
ECM revealed no benefit compared with immobilisation in any of the investigated outcomes.
NCT02015364.
To investigate the predictive value of New Mobility Score, de Morton Mobility Index, and Cumulated Ambulation Score regarding discharge destination, and to determine the feasibility of the tests in ...an acute geriatric ward.
Observational 1-year cohort study of 491 geriatric patients admitted consecutively from own home. New Mobility Score (pre-hospital functional level), de Morton Mobility Index, and Cumulated Ambulation Score were recorded at the first physiotherapy contact.
Univariable logistic regression showed that the odds for not being discharged home were 7 times higher (odds ratio = 7.6, 95%CI; 4.5-12.7) for patients with a non-independent mobility level (Cumulated Ambulation Score ≤ 5) compared to independent (Cumulated Ambulation Score = 6). Corresponding ratios were 6.2 (3.8-10.0) for de Morton Mobility Index ≤ 41 points and 2.8 (1.8-4.5) for New Mobility Score ≤5 points. Adjustment for gender, age, cause of admission, and marital status improved the predictive value of the Cumulated Ambulation Score. Upon admission, 99% of the patients were assessed with New Mobility Score, 100% with Cumulated Ambulation Score, and 81% with de Morton Mobility Index.
Cumulated Ambulation Score is more feasible and superior in predicting discharge destination than de Morton Mobility Index and New Mobility Score in an acute geriatric ward.
Implications for rehabilitation
Easy, quick, and accurate measurement of mobility is essential for discharge planning and effective targeting of physiotherapy in an acute geriatric ward.
The objectively assessed Cumulated Ambulation Score is superior to the de Morton Mobility Index and the pre-hospital New Mobility Score in predicting discharge destination in geriatric patients admitted from their own home.
The Cumulated Ambulation Score and the New Mobility Score are more feasible and less time consuming to complete in an acute geriatric ward compared to the de Morton Mobility Index.
Is acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up ...compared to physiotherapy without strength training in patients with a hip fracture?
Assessor blinded, randomised controlled trial with intention-to-treat analysis.
90 patients with a hip fracture admitted to an acute orthopaedic Hip Fracture Unit at a university hospital between October 2013 and May 2015.
Daily physiotherapy with or without progressive knee-extension strength training (10RM), 3 x 10 repetitions, of the fractured limb using ankle weight cuffs conducted by ward physical therapists during hospital stay.
Primary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from inclusion to postoperative day 10 or discharge (follow-up). Secondary outcome was Timed Up and Go test measured early after surgery and at follow-up.
In the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1% (95% CI -2.3; 18.4) by additional strength training from baseline to follow-up. In the per-protocol analysis of non-missing data, significant between-group improvements by 10.5% (95% CI 0.3; 20.7) were found in favour of additional ST. No significant between-group differences were found in any secondary outcome.
Physiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture. It is debatable whether larger improvements than the observed 8-10% can be expected given that only five exercise sessions, on average, were completed. In fragile patients with a hip fracture in the acute phase, where the ability to participate in functional exercise is compromised, we still consider early strength training a possibility to improve outcomes of clinical importance, given the results of the per-protocol analysis. The present data provides an important basis and call for future investigations including longer term interventions.
Clinicaltrials.gov NCT00848913.
Abstract
Background
A systematic review and meta-analysis was performed to evaluate the short- and long-term effects of exercise therapy on physical function, independence, and well-being in older ...patients following hip fracture and, secondly, whether the effect was modified by trial-level characteristics such as intervention modality, duration, and initiation timepoint.
Method
Medline, CENTRAL, Embase, CINAHL, and PEDro were searched up to November 2020. Eligibility criteria were randomized controlled trials investigating the effect of exercise therapy on physical function, independence, and well-being in older patients following hip fracture, initiated from time of surgery up to 1 year.
Results
Forty-nine studies involving 3 905 participants showed a small-to-moderate effect of exercise therapy at short term (end of intervention) on mobility (standardized mean difference SMD 0.49, 95% confidence interval CI: 0.22–0.76); activities of daily living (ADL) (SMD 0.31, 95% CI: 0.16–0.46); lower limb muscle strength (SMD 0.36, 95% CI: 0.13–0.60); and balance (SMD 0.34, 95% CI: 0.14–0.54). At long term (closest to 1 year), small-to-moderate effects were found for mobility (SMD 0.74, 95% CI: 0.15–1.34), ADL (SMD 0.42, 95% CI: 0.23–0.61), balance (SMD 0.50, 95% CI: 0.07–0.94), and health-related quality of life (SMD 0.31, 95% CI: 0.03–0.59). Certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation ranging from moderate to very low, due to study limitation and inconsistency.
Conclusion
We found low certainty of evidence for a moderate effect of exercise therapy on mobility in older patients following hip fracture at end of treatment and follow-up. Further, low evidence was found for small-to-moderate short-term effect on ADL, lower limb muscle strength and balance.
Clinical Trials Registration Number
CRD42020161131
Physiotherapy can play a vital role in the pathway of care of people after fragility fracture and includes interventions of early mobilisation and prescription of structured exercise programmes for ...maximising functional recovery and reducing the risk of falls and further fractures. Although the optimal nature of physiotherapist interventions after hip and vertebral fracture requires further investigation in large-scale trials, evidence supports the prescription of high-intensity and extended exercise interventions. This article will overview interventions in the acute and chronic phases after hip fractures, interventions after vertebral fracture and the role of physiotherapy in the prevention of further fractures.
Objective:
To examine measurement properties (inter-rater reliability, agreement, validity, and responsiveness) of the Cumulated Ambulation Score French translation in patients with hip fracture.
...Design:
Methodological study.
Setting:
A 20-bed orthopedic unit and 20-bed geriatric unit.
Subjects:
About 140 consecutive patients with a mean (SD) age of 83 (12) years.
Interventions:
The English version of the Cumulated Ambulation Score used to evaluate basic mobility was translated into French following international guidelines. Two raters independently assessed all patients on postoperative days one, two, three, and 30 after a hip fracture surgery. Relative and absolute inter-rater reliability and responsiveness (effect size for improvement from postoperative day two to 30) were evaluated. Convergent validity was analyzed by Spearman’s correlation coefficient comparing the Cumulated Ambulation Score with two other measures on postoperative day two and 30.
Main measure:
Cumulated Ambulation Score.
Results:
The weighted Kappa value ranged from 0.89 to 1.0. The standard error of measurement and the smallest real difference of the Cumulated Ambulation Score ranged, respectively, from 0.12 to 0.23 and from 0.32 to 0.6 points, while the effect size reached 1.03 (95% CI 0.87–1.26). There was a strong positive correlation comparing the Cumulated Ambulation Score with the French Tinetti Assessment Tool (r ⩾ 0.83) and the French Mini Motor Test (r ⩾ 0.79).
Conclusions:
Our findings indicate that the Cumulated Ambulation Score’s French version is a reliable and valid tool to assess patients’ basic mobility with hip fractures.
To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between ...the two groups.
Based on specific eligibility criteria, 120 adults (median age 37.5 years (interquartile range (18 to 61)) and 84% males (n = 101)) diagnosed with an acute displaced mid-shaft fracture were recruited, and randomized to either the operative (n = 60) or nonoperative (n = 60) treatment group. This randomized controlled, partially blinded trial followed patients for 12 months following initial treatment. Functionality was assessed by the Constant score (CS) (assessor blinded to treatment) and Disability of the Arm, Shoulder and Hand (DASH) score. Clinical and radiological evaluation, and review of patient files for complications and reoperations, were added as secondary outcomes.
At 12 months, 87.5% of patients (n = 105) were available for analysis. The two groups were well balanced based on demographic and fracture-related characteristics. At six weeks of follow-up a significant difference in DASH score (p < 0.001) was found in favour of operative treatment. The functionality at 12 months of follow-up based on CS and DASH was excellent in both groups (CS > 90 points and DASH < 10 points) with no significant difference (p = 0.277 for DASH and p = 0.184 for CS) between the two groups. The risk of symptomatic nonunion was significantly higher in the nonoperative group (p = 0.014), with a relative risk of 9.47 (95% confidence interval (CI) 1.26 to 71.53) in this group compared to the operative group. The number-needed-to-treat to avoid one symptomatic nonunion was 6.2. Initial treatment and age were factors significantly associated with nonunion in a logistic analysis. There were 26% in both groups (n = 14 in operative group and n = 15 in nonoperative group) who required secondary surgery, with most indications in the nonoperative group mandatory due to nonunion compared to most relative indications in the operative group requiring intervention due to implant irritation.
Superiority was not identified with either an all-operative or all-nonoperative approach. The functionality at short term (within six weeks) seems igreater following operative treatment but was not found at one year. The risk of nonunion is significantly higher with nonoperative treatment. However, an all-operative approach to lower the nonunion risk may result in unnecessary surgery and is not recommended. Cite this article:
2021;103-B(4):762-768.
Objective To examine whether functional performance upon hospital discharge is influenced by pain in the region of the hip fracture or related to the fracture type. Design Prospective observational ...study. Setting A 20-bed orthopedic hip fracture unit. Patients Fifty-five cognitively intact patients (20 men and 35 women; ages 75.8 ± 10 years), 33 with a cervical hip fracture and 22 with an intertrochanteric hip fracture, all of whom were allowed to bear full weight after surgery. Methods All patients were evaluated upon discharge from the hospital to their own homes at a mean of 10 ± 6 days after surgery. Main Outcome Measurements The Timed Up & Go (TUG) test, supervised by a physical therapist, was used to evaluate functional performance, and a 5-point verbal ranking scale (0 = no pain to 4 = intolerable pain) was used to evaluate pain. Results Patients took an average of 22.7 ± 11.7 seconds to perform the TUG. No significant differences were observed in baseline characteristics or pain medication given for patients with a cervical versus an intertrochanteric fracture ( P ≥ .22), but patients with an intertrochanteric fracture presented more often with moderate to severe pain during testing ( P < .001), with associated poorer performances on the TUG test (29.4 ± 12.8 seconds versus 18.3 ± 8.5 seconds). Univariate analysis showed that TUG scores were associated with age, prefracture function evaluated by the New Mobility Score, fracture type, day of TUG performance, and pain intensity. Multivariate linear regression analyses (fracture type not included) showed that only greater age (B = 0.34), low prefracture function (B = 7.9), and experiencing moderate to severe pain (B = 8.7) were independently associated with having a poorer TUG score. Conclusions Hip fracture−related pain primarily compromises the functional performance of patients with an intertrochanteric hip fracture upon discharge from hospital. Physical therapists should be involved in new and optimized fracture-type stratified pain management strategies.
Background: the impact of anaemia on the outcome after a hip fracture surgery is controversial, but anaemia can potentially decrease the physical performance and thereby impede post-operative ...rehabilitation. We therefore conducted a prospective study to establish whether anaemia affected functional mobility in the early post-operative phase after a hip fracture surgery. Patients and Methods: four hundred and eighty seven consecutive hip fracture patients, treated according to a well-defined multimodal rehabilitation programme with a uniform, liberal transfusion threshold, were studied. Hb was measured on each of the first three post-operative days, and anaemia defined as Hb <100 g/l. Functional mobility was measured with the Cumulated Ambulation Score (CAS). Results: the results were obtained from 170, 132 and 116 patients who were found anaemic on the first, second and third post-operative day, respectively. A significant association between anaemia and the ability to walk independently before the correction of anaemia was present on each of the 3 days separately (P<0.05). A significant correlation was also found on each day between the functional score and the Hb level. A multivariate analysis integrating the type of surgery, medical complications and prefracture function showed that anaemia at the time of the physiotherapy session was an independent risk factor for not being able to walk on the third post-operative day OR 0.41 (0.14–0.73) P = 0.002. Conclusion: anaemia impedes functional mobility in the early post-operative phase after a hip fracture surgery and is an independent risk factor for patients not being able to walk post-operatively. The potential for a liberal transfusion policy to improve the rehabilitation potential in hip fracture patients with anaemia should be investigated.
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