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.

International estimated fetal weight standards of the INTERGROWTH-21st Project.

OBJECTIVE: Estimated fetal weight (EFW) and fetal biometry are complementary measures used to screen for fetal growth disturbances. Our aim was to provide international EFW standards to complement the INTERGROWTH-21st Fetal Growth Standards that are available for use worldwide. METHODS: Women with an accurate gestational-age assessment, who were enrolled in the prospective, international, multicenter, population-based Fetal Growth Longitudinal Study (FGLS) and INTERBIO-21st Fetal Study (FS), two components of the INTERGROWTH-21st Project, had ultrasound scans every 5 weeks from 9-14 weeks' until 40 weeks' gestation. At each visit, measurements of fetal head circumference (HC), biparietal diameter, occipitofrontal diameter, abdominal circumference (AC) and femur length (FL) were obtained blindly by dedicated research sonographers using standardized methods and identical ultrasound machines. Birth weight was measured within 12 h of delivery by dedicated research anthropometrists using standardized methods and identical electronic scales. Live babies without any congenital abnormality, who were born within 14 days of the last ultrasound scan, were selected for inclusion. As most births occurred at around 40 weeks' gestation, we constructed a bootstrap model selection and estimation procedure based on resampling of the complete dataset under an approximately uniform distribution of birth weight, thus enriching the sample size at extremes of fetal sizes, to achieve consistent estimates across the full range of fetal weight. We constructed reference centiles using second-degree fractional polynomial models. RESULTS: Of the overall population, 2404 babies were born within 14 days of the last ultrasound scan. Mean time between the last scan and birth was 7.7 (range, 0-14) days and was uniformly distributed. Birth weight was best estimated as a function of AC and HC (without FL) as log(EFW) = 5.084820 - 54.06633 × (AC/100)3 - 95.80076 × (AC/100)3 × log(AC/100) + 3.136370 × (HC/100), where EFW is in g and AC and HC are in cm. All other measures, gestational age, symphysis-fundus height, amniotic fluid indices and interactions between biometric measures and gestational age, were not retained in the selection process because they did not improve the prediction of EFW. Applying the formula to FGLS biometric data (n = 4231) enabled gestational age-specific EFW tables to be constructed. At term, the EFW centiles matched those of the INTERGROWTH-21st Newborn Size Standards but, at < 37 weeks' gestation, the EFW centiles were, as expected, higher than those of babies born preterm. Comparing EFW cross-sectional values with the INTERGROWTH-21st Preterm Postnatal Growth Standards confirmed that preterm postnatal growth is a different biological process from intrauterine growth. CONCLUSIONS: We provide an assessment of EFW, as an adjunct to routine ultrasound biometry, from 22 to 40 weeks' gestation. However, we strongly encourage clinicians to evaluate fetal growth using separate biometric measures such as HC and AC, as well as EFW, to avoid the minimalist approach of focusing on a single value. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A new model of localized ischemia in rat somatosensory cortex produced by cortical compression.

BACKGROUND AND PURPOSE: Because of its precise connectivity and functional specificity, the rat whisker-barrel system offers an excellent opportunity to study experience-dependent neuroplasticity. However, data are lacking regarding the neuroplasticity of this system after cerebral ischemia. The purpose of the present study was to develop a reproducible model for the production of ischemia/reperfusion of the posteromedial barrel subfield (PMBSF) in the rat, which is the visible representation of the large whiskers on the opposite face. METHODS: Focal cortical ischemia was induced in male Sprague-Dawley rats (n=40) by slowly compressing the intact dura (maximum 0.05 mm/s) with a 4- or 5-mm-diameter brass cylinder equipped with a laser-Doppler probe, combined with ipsilateral common carotid artery occlusion. The microvascular blood flow of PMBSF during compression ischemia was maintained at 18% to 20% of baseline flow for 1 hour. The total infarction volume was measured by 2,3,5-triphenyltetrazolium chloride staining at several reperfusion times, and pathological examination was performed on hematoxylin-eosin-stained sections. RESULTS: The infarct volumes were 36.5+/-9.2 (n=9), 40.7+/-7.7 (n=7), and 36.6+/-6.4 mm(3) (n=5) at 24 hours, 72 hours, and 7 days after ischemia, respectively, with no significant differences among these values. There was no evidence of damage to white matter or to deep gray matter and no evidence of hemorrhage. The topographic distribution of the damaged tissue was in good agreement with that of PMBSF. CONCLUSIONS: This stroke model produces a highly consistent cortical infarct in PMBSF and can facilitate the study of behavioral, functional, and structural consequences after cerebral ischemia/reperfusion in the rat somatosensory cortex.

Gait variability in community-dwelling older adults.

OBJECTIVES: To describe gait variability at usual and fast walking speeds in community-dwelling older adults and to describe the effects of increasing gait speed on gait variability. DESIGN: Cross-sectional, descriptive study. SETTING: The Cardiovascular Health Study at the University of Pittsburgh. PARTICIPANTS: Ninety-five community-living older adults, 54 women and 41 men, age 65 and older (mean age +/- standard deviation 79.4 +/- 3.37). MEASUREMENTS: Gait measured at participant's usual and fast walking speed collected using an instrumented walkway. Step-length and step-width variability were determined using the coefficient of variation. RESULTS: Step-length variability was greatest in those who walked the slowest (r = -0.66, P < .001); step-width variability was smallest in those who walked the slowest (r -0.37, P < .001). Individuals who could not increase their walking speed (<0.10 m/second) on command had an increase in step-length variability and a decrease in step-width variability, whereas those who could increase their speed (>0.10 m/second) had an increase in step-width variability when walking at a faster speed. CONCLUSIONS: Step-length and step-width variability have opposite associations with gait speed in older adults. Improvement in step-length and step-width variability with attempted acceleration might be a key factor to examine in future studies of disability risk and therapeutic interventions.

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.

Effects of electrical stimulation or voluntary contraction for strengthening the quadriceps femoris muscles in an aged male population.

Since musculoskeletal impairment increases with age, it is important to determine if exercise changes age-related muscle weakness. This study compared the training effects of electrical stimulation and voluntary isometric contraction, the traditional exercise, on the quadriceps femoris in males 65 years and older. Eighteen informed, nondisabled males, 72 +/- 4 years of age, participated in 12 training sessions over 4 weeks. Maximal voluntary isometric contraction (MVIC) torque was measured with a Cybex II dynamometer prior to and following training. An interclass correlation coefficient (3,1) of 0.982 demonstrated repeated reliable torque measurement. The electrical stimulation group trained at an average of 36% of pretest MVIC; the traditional exercise group trained at an average of 42% MVIC. Average (F = 14.06, p = 0.004) and peak (F = 14.32, p = 0.004) torque values were increased with both modes of training. Both methods of training using a low training load were effective in increasing torque in this older male sample. Electrical stimulation has the same potential as traditional exercise to provide improved strength for aged males. Future research should examine electrical stimulation in older persons with compromised ability to exercise using traditional methods.

Disability following hip fracture.

Risks for hip fractures are greater for women than for men and increase with age. Individuals who sustain hip fractures exhibit higher mortality than age-matched cohorts, and survivors often demonstrate permanent disability and dependency despite successful surgical repair. This review explores de scriptions of the extent of residual disability following hip fracture and details the multiple variables that account for the discrepancy between surgical and functional outcome. Although outcome has been described traditionally in terms of mortality, ability to perform activities of daily living, and ambulatory status, the need to assess functional disability as a measure of recovery is emphasized. The complexities of the recovery process and the current lack of complete descriptions of disability emphasize the need for national research studies. Research is needed to describe the extent of functional disability present following fracture, to develop a meaningful classification scheme, and to decide the effect of intervention on reducing functional disability.

Relationships between physical activity and temporal-distance characteristics of walking in elderly women.

The purpose of this study was to investigate the relationships between physical activity and walking speed in women 64 years of age and over. Data were gathered from 81 nondisabled women ranging from 64.0 to 94.5 years of age. The women were categorized as sedentary, community active, or exercisers based on a combination of their living situation and level of daily activity. Subjects walked over a 3.84-m recording surface at five different paces, ranging from walking as slowly as possible to walking as quickly as possible. Actual walking speed and length of steps were measured. Stepping frequency and step length relative to leg length were derived measures. Mean walking speeds ranged from 0.43 m/s at the very slow pace to 1.42 m/s at the very fast pace. The walking speeds at the very slow pace were significantly different among the three physical activity groups. At the very slow pace, women who exercised were able to walk significantly more slowly than the other women. The groups were not significantly different at any other pace. Normal walking speeds for all groups were slower than those previously reported for younger women, with the walking speed of the fastest pace of the elderly women being closer to the normal walking speed of younger women. The results of this study indicate that physical therapists need to utilize age-appropriate values as the standard when evaluating performance. [Leiper CI, Craik RL. Relationships between physical activity and temporal-distance characteristics of walking in elderly women.

The effects of persistent depressive symptoms on hip fracture recovery.

One hundred ninety-six older. White females were followed for 12 months after hip fracture. We examined the effects of persistently elevated depressive symptoms, measured by the Center for Epidemiological Studies Depression (CES-D) scale during a postsurgery interview and 2, 6, and 12 months later, on ambulation, overall physical function, and return to prefracture physical function 12 months after fracture. Age, prefracture physical function, and cognitive status were predictors of recovery. Controlling for these factors, persons consistently reporting few depressive symptoms were three times more likely than those with persistently elevated CES-D scores to achieve independence in walking, nine times more likely to return to prefracture levels in at least five of seven physical function measures, and nine times more likely to be in the highest quartile of overall physical function. These findings emphasize the importance of persistently elevated depressive symptoms for recovery. Routine screening, evaluation, and treatment of depression or depressed mood may be beneficial to the recovering hip fracture patient.

Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors.

The independent contributions to recovery from hip fracture of psychosocial factors including depression, personality, social connectedness, and self-rated health were studied in 219 women age 59 and older (mean age 78.5) who were community dwelling prior to fracture. Initial assessments were conducted shortly after surgery and follow up assessments 2, 6, and 12 months later. By 12 months, 15 patients had died and 15 had entered a nursing home. Substantial declines in physical functioning though not psychosocial status were observed. Only 21 per cent (compared to 81 per cent prefracture) reported walking independently; fewer than 30 per cent had regained reported prefracture levels of physical function. The proportion with elevated depression scores at 12 months was 20 per cent, down from 51 per cent following surgery; 64 per cent rated their health excellent or good at 12 months, up from 43 per cent after surgery. Poor cognitive status and post-surgical self-rated health were predictive of mortality. Among survivors, age, prefracture physical functioning, and cognitive status were associated with recovery in physical function but not psychosocial status. High post-surgery depression scores, but not the other psychosocial factors, were associated with poorer recovery in both functional and psychosocial status. These findings demonstrate the importance of depressive symptoms as one determinant of recovery from hip fracture and support the need to attend to the affective status of hip fracture patients following surgery.

The role of norepinephrine in adult rat somatosensory (SmI) cortical metabolism and plasticity.

Stimulation of rat facial vibrissae increases glucose utilization in the corresponding barrels (lamina IV) and associated columns in laminae I-VIa of the contralateral first somatosensory (SmI) cortex as assessed autoradiographically by the uptake of [14C]2-deoxy-glucose (2-DG). Chronic deafferentation (2 months) by bilateral vibrissectomy with sparing of the C3 vibrissa (SC3) in adult Sprague-Dawley rats produced no change in the rate of LCGU but led to an increased areal extent of the metabolic representation of the SC3 barrel (39%, P less than 0.001) and column (31%, P less than 0.003) as compared to rats with fully intact vibrissae. In other rats with intact facial vibrissae, 6-hydroxydopamine lesions of the locus coeruleus (LC) depleted ipsilateral cortical norepinephrine (NE) by more than 90% and, 2 months later, led to an 11% and 21% increase in C3 barrel and column metabolic representations, respectively, as compared to the contralateral SmI cortex with intact NE levels (P less than 0.05). When bilateral vibrissectomy was combined with a unilateral LC lesion, the SC3 barrel and column metabolic representation on the LC-intact side enlarged as expected but no enlargement occurred on the NE-depleted side (20% difference; P less than 0.05). Therefore, the effect of NE on the SmI cortex depends on the status of its afferent input. NE inhibits the spread of metabolic activity beyond the activated barrel and column in the intact cortex, but independently modulates plastic enlargement in the partially deafferented SmI cortex.

Locus coeruleus input affects glucose metabolism in activated rat barrel cortex.

Significant depletion (greater than 50%) of neocortical norepinephrine (NE), 2 weeks after unilateral 6-hydroxydopamine lesions of the locus coeruleus, led to a small (8%), ipsilateral decrease in total C3 vibrissa column 14C-2-deoxyglucose uptake, but a larger (24-32%) increase in the areal extent of this uptake into the metabolic representation of both the C3 column and barrel of the rat somatosensory (SmI) cortex during stimulation of the contralateral C3 facial vibrissae. This suggests a predominantly inhibitory role for NE in modulating SmI oxidative metabolism during physiologic stimulation.

Clinical correlates of neural plasticity.

The purpose of this article is to relate the concepts of mammalian nervous system plasticity to clinical practice. The clinical relevance of Dr. Bishop's four-part review of prenatal and postnatal maturation, function-induced plasticity, and nervous system regeneration is discussed. The scope of this paper is limited to the relationship between plasticity and 1) the pathogenesis of congenital malformations, 2) skill acquisition in the infant, and 3) functional recovery and treatment. Limitations in current clinical evidence for functional recovery are examined, and research questions that must be answered are presented. Clinical evidence of functional recovery coupled with current concepts of neural plasticity will provide information to determine the efficacy of treatment intervention for the neurologically handicapped. It is hoped that this discussion will encourage clinicians to renew their efforts to accurately document the clinical course of recovery and the treatment methods used to achieve this recovery and to report their findings.

The role of sensory conflict on stair descent performance in humans.

Electromyographic (EMG) activity produced in the triceps surae (TS) and subsequent landing were examined under various visual conditions during stair descent with the following results: The amount of precontact TS EMG was reduced during each visual perturbation. Perturbations corresponded to no knowledge or visualization of stairs (B), no stair visualization during descent (A) and vertical movement of the surround during descent (M). Erroneous visual information was primarily responsible for altered EMG activity. The only known difference between the M data sets was that the surround moved up (U) or down (D) as the subject descended. However, TS EMG characteristics were different under these two conditions. Specific visual information appeared necessary for vision to override the other sensory systems. There was no difference in EMG when the room moved up (U) compared to the room not moving (NM). However, EMG activity was significantly different when the room moved down (D) compared to the room not moving (NM). The relationship between TS EMG activity and subsequent landing appeared related to landing strategy. Although the EMG was reduced during both the B and M test conditions compared to the control, the landing was "softer" for B and harder for M. The pre-contact EMG is apparently part of a preprogrammed movement pattern which can be modified by sensory information during task execution. Future studies should examine the neuronal mechanisms which provide the visual system access to the center controlling lower limb muscle activity during dynamic movement.

Clinical evaluation of a sensory feedback device: the limb load monitor.

Based on records of 81 patients who used the LLM, and on questionnaire answers and comments from clinicians, the following can be concluded: 1. The LLM can be operated easily after a minimum of training. It does not break down with extended clinical use when handled properly. 2. The LLM manual provides sufficient information for proper operation and clinical use of the device. 3. The number of patients in a clinic who can benefit from LLM training can be predicted, if consideration is given to the type of facility and the size of the patient population and physical therapy staff. 4. The largest diagnostic group of patients who can benefit from LLM therapy are lower-limb amputees, followed by hemiplegic and orthopedic patients. 5. The general selection criteria outlined initially proved sufficient. A patient who is selected properly can be expected to respond to the feedback signal (i.e., make a weight-bearing adjustment) within the first or second session.