This study describes patients’ perspectives on recovery during participation in a randomized controlled trial that tested a postoperative hip fracture management program (B4 Clinic), compared with usual care, on mobility. Semistructured qualitative interviews were conducted with 50 older adults with hip fracture (from both groups) twice over 12 months. A total of 32 women (64%) and 18 men (36%) participated in the study with a mean age at baseline of 82 (range = 65-98) years. A total of 40 participants reported recovery goals at some point during their recovery from hip fracture but only 18 participants realized their goals within 12 months. Recovering mobility, returning to prefracture activities, and obtaining stable health were the most commonly reported goals. Participants described good social support, access to physiotherapy, and positive perspective as most important to recovery. These factors were influenced by participants’ knowledge, resources, and monthly contact with study staff (perceived as a form of social support). The most frequently reported barriers to participants’ recovery were the onset of complications, pain, and limited access to physiotherapy. Potential implications of these findings include design and modification of new or preexisting fracture programs, prioritizing patient engagement and enhanced knowledge for future clinical research in hip fracture recovery.
Background: Physical activity confers many health benefits to older adults, and adopting activity into daily life routines may lead to better uptake. The purpose of this study was to test the effect of a lifestyle intervention to increase daily physical activity in older women through utilitarian walking and use of public transportation. Methods: In total, 25 inactive women with mean age (SD) of 64.1 (4.6) years participated in this pilot randomized controlled trial [intervention (n = 13) and control (n = 12)]. Seven-day travel diaries (trips per week) and the International Physical Activity Questionnaire (minutes per week) were collected at baseline, 3, and 6 months. Results: At 3 months, intervention participants reported 9 walking trips per week and 643.5 minutes per week of active transportation, whereas control participants reported 4 walking trips per week and 49.5 minutes per week of active transportation. Adjusting for baseline values, there were significant group differences favoring Everyday Activity Supports You for walking trips per week [4.6 (0.5 to 9.4); P = .04] and active transportation minutes per week [692.2 (36.1 to 1323.5); P = .05]. At 6 months, significant group differences were observed in walking trips per week [6.1 (1.9 to 11.4); P = .03] favoring the intervention (9 vs 2 trips per week). Conclusion: Given these promising findings, the next step is to test Everyday Activity Supports You model's effectiveness to promote physical activity in older women within a larger study.
Maintaining physical activity is an important goal with positive health benefits, yet many people spend most of their day sitting. Our Everyday Activity Supports You (EASY) model aims to encourage movement through daily activities and utilitarian walking. The primary objective of this phase was to test study feasibility (recruitment and retention rates) for the EASY model.This 6-month study took place in Vancouver, Canada, from May to December 2013, with data analyses in February 2014. Participants were healthy, inactive, community-dwelling women aged 55-70 years. We recruited through advertisements in local community newspapers and randomized participants using a remote web service. The model included the following: group-based education and social support, individualized physical activity prescription (called Activity 4-1-1), and use of a Fitbit activity monitor. The control group received health-related information only. The main outcome measures were descriptions of study feasibility (recruitment and retention rates). We also collected information on activity patterns (ActiGraph GT3X+ accelerometers) and health-related outcomes such as body composition (height and weight using standard techniques), blood pressure (automatic blood pressure monitor), and psychosocial variables (questionnaires).We advertised in local community newspapers to recruit participants. Over 3 weeks, 82 participants telephoned; following screening, 68% (56/82) met the inclusion criteria and 45% (25/56) were randomized by remote web-based allocation. This included 13 participants in the intervention group and 12 participants in the control group (education). At 6 months, 12/13 (92%) intervention and 8/12 (67%) control participants completed the final assessment. Controlling for baseline values, the intervention group had an average of 2,080 [95% confidence intervals (CIs) 704, 4,918] more steps/day at 6 months compared with the control group. There was an average between group difference in weight loss of -4.3 [95% CI -6.22, -2.40] kg and reduction in diastolic blood pressure of -8.54 [95% CI -16.89, -0.198] mmHg, in favor of EASY.The EASY pilot study was feasible to deliver; there was an increase in physical activity and reduction in weight and blood pressure for intervention participants at 6 months.ClinicalTrials.gov identifier: NCT01842061.
Objectives: To determine gait characteristics of community-dwelling older adults at different speeds and during a crosswalk simulation. Methods: Twenty-two older adults completed walking trials at self-selected slow, usual, and fast paces, and at a crosswalk simulation, using the GAITRite walkway. These objective measures were complemented by self-report health and mobility questionnaires. Results: Gait speeds at self-selected slow, usual, and fast paces were 98.7 (18.1) cm/s, 140.9 (20.4) cm/s, and 174.0 (20.6) cm/s, respectively, and at simulated crosswalk conditions was 144.2 (22.3) cm/s. For usual pace, right step length variability was 2.0 (1.4) cm and step time variability was 13.6 (7.2) ms, compared with 2.4 (1.3) cm and 17.3 (9.7) ms, respectively, for crosswalk conditions. Discussion: Our sample of healthy older adults walked at a speed exceeding standards for crossing urban streets; however, in response to a crosswalk signal, participants adopted a significantly faster and more variable gait.
To the Editor: Hip fractures are potentially catastrophic events for older adults and significantly affect survival and independence.1 A multidisciplinary approach is recommended to optimize recovery and functional status.2 Many such strategies focus on the immediate postoperative period before discharge,3 but care gaps persist.4 Recognizing the importance of multidisciplinary care in promoting mobility in older adults after hip fracture, a novel postdischarge clinic was designed to improve recovery from hip fracture. A feasibility study was conducted to discern recruitment and retention rates, assess the appropriateness of outcome measures, and identify challenges for a larger randomized study.5 The study was also designed to characterize recovery of mobility in a sample of older adults in the 12 months after hip fracture. The study took place at two academic hospitals in Vancouver, Canada. Community-dwelling adults aged 65 and older with a recent history (≤3 months) of hip fracture were included. People who were unable to walk 10 m before the hip fracture (self-reported), were diagnosed with dementia, or were living in a residential care facility before hip fracture or after discharge were excluded. Participants were not randomized; all received usual orthopedic postoperative treatment for the hip fracture plus a geriatrician-led postfracture follow-up clinic described in the protocol.5 The primary objective was to determine recruitment and retention rates. Participants were assessed at approximately 3, 6, and 12 months after hip fracture. The Short Physical Performance Battery (SPPB)6 was used to assess standing balance, gait speed, and sit to stand performance. Gait speed was calculated as meters per second based on a 3-m walk. Health was assessed using the visual analog scale of the EuroQol 5 Dimensions (EQ5D-5L).7 Chart reviews from the follow-up clinic were conducted to describe the intervention (e.g., health professional visits). Means and standard deviations were reported for the SPPB and self-reported health. From December 2010 to May 2011, 110 charts were screened. Only 37% (41/110) of individuals were eligible. Nine enrolled, a 22% (9/41) recruitment rate. The most frequent reasons for noneligibility were younger than 65 (21%, n = 23), not community dwelling before or after the fracture (15%, n = 17), and dementia (14.5%, n = 16). The top reasons for nonparticipation were unable to contact (25%, n = 8), language barrier (22%, n = 7), and no explanation (19%, n = 6). Participant mean age was 78.8 ± 10.7 (range 66–94) years, and an average of 101.8 ± 18.2 days elapsed between fracture repair and study enrollment. All participants saw a geriatrician and at least one other health professional (e.g., physiotherapist, occupational therapist); all received an exercise program. Seven (77.8%) participants completed the final assessment; one died before the 6-month assessment, and one experienced an unrelated health complication that prevented the final SPPB assessment (Table 1). The objective was to determine the feasibility of the multidisciplinary intervention to enhance mobility recovery of older adults after hip fracture. The most striking finding related to recruitment was that 37% of individuals hospitalized in two major hospitals were ineligible for the study in part because of prior dementia and residing in residential care. The study sought to identify participants who would be able to attend and participate in an outpatient clinic with some regularity and had considered these two exclusions as barriers to participation. Also notable was the low (22%) enrollment of eligible individuals approached during their acute hospitalization. The inclusion criteria and recruitment sites were therefore revisited to include another hospital and to enroll individuals up to 12 months after their fracture. Once participants were enrolled, retention was high. Mobility, the primary outcome for the main study, increased according to performance-based measures. Improvements in mobility were clinically significant, with the greatest change seen in gait speed,8 although most participants would still be considered to be “limited community ambulators.”9 An unexpected finding was the decrease in participants' self-reported health at 12 months. This may have occurred because study participants were not back to their prefracture status. This will be explored further with qualitative interviews within the larger study. This was a small select sample and thus may not be generalizable to all older adults with hip fracture, but the process information gained from this feasibility study was an invaluable opportunity before starting the larger trial. Furthermore, the intention was not to generate definitive answers with respect to the effect of the intervention on mobility; although participants improved mobility over the year, without a control group, it is not known whether these changes would occur naturally. These results await clarification in the full study protocol. We extend sincere thanks to the study participants for their generosity with their time. We gratefully acknowledge financial support from Canadian Institutes of Health Research (CIHR) Grant FRN 99051 and career award support for Dr. Ashe from CIHR and the Michael Smith Foundation for Health Research. Conflict of Interest: Wendy Cook, Penelope Brasher, Meghan Donaldson, Pierre Guy, and Maureen Ashe received funding from CIHR to conduct this study. Author Contributions: Ashe, Cook, Brasher, Guy: study concept and design. Schiller, McAllister, Hanson, Macri: acquisition of subjects and data. All authors: analysis and interpretation of data, preparation of manuscript. Sponsor's Role: The sponsors had no role in the study design, analysis or preparation of this manuscript.
Hand osteoarthritis (HOA) includes different subsets; a particular and uncommon form is erosive HOA (EHOA). Interleukin- (IL-) 1β plays a crucial role in the pathogenesis of osteoarthritis (OA); it is synthesized as an inactive precursor which requires the intervention of a cytosolic multiprotein complex, named inflammasome, for its activation. The aim of this study was to investigate the involvement of IL-1β and the NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome in patients with EHOA and nonerosive HOA (NEHOA) compared to healthy controls. In particular, we evaluated the gene expression of IL-1β and NLRP3, the serum levels of IL-1β, IL-6, IL-17, and tumor necrosis factor- (TNF-) α, and the protein levels of IL-1β and NLRP3. We also assessed the relationships between IL-1β and NLRP3 and clinical, laboratory, and radiological findings. Fifty-four patients with HOA (25 EHOA and 29 NEHOA) and 20 healthy subjects were included in the study. Peripheral blood mononuclear cell (PBMC) gene and protein expressions of IL-1β and NLRP3 were quantified by quantitative real-time PCR and western blot. IL-1β, IL-6, IL-17, and TNF-α serum levels were determined by ELISA. IL-1β gene expression was significantly reduced (p = 0.0208) in EHOA compared to healthy controls. NLRP3 protein levels were significantly increased in the NEHOA group versus the control (p = 0.0063) and EHOA groups (p = 0.0038). IL-1β serum levels were not significantly different across the groups; IL-6, IL-17, and TNF-α were not detectable in any sample. IL-1β concentrations were negatively correlated with the Kellgren-Lawrence score in the whole population (r = -0.446; p = 0.0008) and in NEHOA (r = -0.608; p = 0.004), while IL-1β gene expression was positively correlated with the number of joint swellings in the EHOA group (r = 0.512; p = 0.011). Taken together, our results, showing poorly detectable IL-1β concentrations and minimal inflammasome activity in the PBMCs of HOA patients, suggest a low grade of systemic inflammation in HOA. This evidence does not preclude a possible involvement of these factors at the local level.
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