Recovery of physical functioning after total hip arthroplasty

Purpose. The overall aim of this thesis was to examine recovery of physical functioning in patients with hip osteoarthritis (OA) during the first year after total hip arthroplasty (THA). The specific aims were 1) to examine the desires of a group of patients regarding improvements in physical functioning before they underwent THA and at three and 12 months after surgery, 2) to examine changes in physical functioning during the first year of recovery and examine which preoperative measures predicted outcomes in walking distance at 3 and 12 months after surgery, and 3) to examine the immediate and long-term effect of a walking skill training program performed between three and five months after surgery on physical functioning. Materials and Methods. This study had a prospective, longitudinal design. Patients with hip OA scheduled for primary THA were consecutively recruited from two hospitals the day they were hospitalized for surgery (Paper I-III). One hundred and three patients were included in the study. Assessments were performed four times; before surgery, and at three, five, and 12 months after surgery. At three months, 68 patients were randomly allocated to a training group (n = 35) or a control group (n = 32) without supervised physiotherapy (Paper III). The walking skill training program comprised two sessions a week for a total of 12 sessions. It consisted of functional exercises and activities in a weight-bearing position aimed to improve walking, muscle strength, flexibility, balance and endurance. There were continuous supervision and feedback from a physiotherapist during the training sessions. Both performance-based and self-reported measures were applied. The performancebased measures in Papers II and III were the 6-minute walk test (6MWT), which was the primary outcome measure in Papers II and III, the stair climbing test (SCT), the figure-ofeight test, the Index of Muscle Function (IMF), and the active hip range of motion (ROM). Self-reported outcome measures were a modified version of the Patient Specific Functional Scale (PSFS) in Paper I, the Harris Hip Score (HHS) and the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) in Papers II and III, and the self-efficacy for physical activity in Paper III. The free-text responses from the PSFS were coded according to the International Classification of Functioning, Disability and Health (ICF) to the 1st, 2nd, and 3rd category levels (Paper I). Group differences were analyzed by student sample t-tests (Paper II and III). Differences over time within groups were examined by Friedman’s test (Paper I), one-way repeated measures analysis of variance (ANOVA) (Paper II), and differences in changes over time between groups with adjustment for sex and pretest scores were examined by analysis of covariance (ANCOVA) (Paper III). Relationships were analyzed by bivariate and multivariate regression analyses (Paper II). Results. Eighty-eight percent of the desires of improvements in physical functioning reported by the patients were classified into the Activities and Participation component of the ICF, while 12 % were classified into Body Functions and Structures. The categories of Walking (d450), Moving around (d455) and Recreation and leisure (d920) included about half of the responses at all the assessment times. At three months after surgery, there were fewer responses classified into the Recreation and leisure category, while more responses were classified into the category of Dressing (d540). The number of functional improvement desires decreased during the first postoperative year (P In performance-based measures of physical functioning, small improvements were found from preoperative to three months postoperatively in 6MWT (P The training group had larger improvements than the control group immediately after the intervention on 6MWT with an adjusted mean group difference of 52 meters (95% CI 29, 74; P Conclusions. The patients wanted to improve the ability to walk long distances and to participate in usual recreation and leisure activities. Their physical functioning improved during the first year after THA, and those with poor preoperative walking distance gained the most from surgery. Age, sex and preoperative walking capacity and hip flexibility predicted postoperative walking capacity. The walking skill training intervention was effective in improving walking capacity and no adverse events were registered. The effect still sustained one year after surgery

Older patients’ perspectives on illness and healthcare during the early phase of the COVID-19 pandemic

Background Equal access to healthcare is a core principle in Norway’s public healthcare system. The COVID-19 pandemic challenged healthcare systems in the early phase – in particular, related to testing and hospital capacity. There is little knowledge on how older people experienced being infected with an unfamiliar and severe disease, and how they experienced the need for healthcare early in the pandemic Aim To explore the experiences of older people infected by COVID-19 and their need for testing and hospitalisation. Research design An explorative and descriptive approach, with qualitative interviews conducted in October 2020. Participants and research context Seventeen participants above 60 years of age hospitalised due to COVID-19 during spring 2020 were recruited 6 months after discharge. Ethical considerations Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics in South-Eastern Norway (155425). Findings The main finding was that the informants experienced vulnerability and arbitrariness. This finding was supported by three sub-themes: experiences with a severe and unfamiliar disease, the strict criteria and the importance of someone advocating needs. Discussion Participants described varying access to healthcare. Those who did not meet the national criteria to be tested or hospitalised struggled against the system. Findings reveal arbitrary access to healthcare, in contrast to Norway’s ethical principle of fair and just access to health services. Moreover, to access and receive necessary healthcare, informants were dependent on their next-of-kin’s advocacy. Conclusion Even when dealing with an unfamiliar disease, health professionals’ assessments of symptoms must be performed with an ethical obligation to applicate competent appraisal and the exercise of discernment; this is in line with care ethics and ethical standards for nurses. These perspectives are a significant part of caring and the intension of doing good.publishedVersio

Recovery and prediction of physical function 1 year following hip fracture

Objectives: To investigate the recovery of physical function, health related quality of life (HRQoL), and pain for people following hip fracture for the initial 12 months, and to examine whether postoperative outcome measures of physical function, HRQoL, and pain can predict physical function at 3 and 12 months. Design: A prospective single-center observational study, as part of the HIPFRAC trial. Settings: One hospital with two associated municipalities in Norway. Subjects: 207 participants with hip fracture included in the study (140 participants transferred to a short-term nursing home placement and 67 transferred directly home at discharge from hospital). Method: Outcome measures were Short Physical Performance Battery (SPPB), Timed Up & Go (TUG), Stair climbing test (SC), Numeric Rating Scale (NRS) for pain at rest and in activity, and EQ-5D-5L index and health score. Data were analysed by repeated measures of variance and multivariate regression analyses. Results: There were statistically significant improvements in physical function (SPPB total score and TUG), NRS-pain in activity, and HRQoL (EQ-5D-5L) from hospital discharge to 3-month follow-up for the whole cohort and the two groups (p < 0.001). However, the largest improvements occurred within the first 3 months. Further statistically significant improvements occurred between 3 and 12 months (p < 0.05). The strongest predictors of physical function at 3 and 12 months post-fracture were physical function (SPPB) at hospital discharge and pre-fracture requirement of a walking aid. Conclusion: The recovery of physical function, HRQoL, and pain in participants after hip fracture indicates gradual improvements during the initial 12-month follow-up, with the largest improvements within the first 3 months

‘Brain fog’, guilt, and gratitude: experiences of symptoms and life changes in older survivors 6 months after hospitalisation for COVID-19

Purpose Several of those who have been infected with COVID-19 suffer from the post-COVID-19 condition months after the acute infection. Little is known about how older survivors have experienced the consequences and how these have affected their lives. The aim of this study was to explore how older survivors experienced post-COVID-19 condition and life changes approximately 6 months after hospitalisation for COVID-19. Methods The study had an explorative and descriptive design. Semi-structured interviews were performed with 17 participants from two local hospitals, 11 men and 6 women, aged 60 years and older (age range 60–96), approximately 6 months after hospitalisation for COVID-19. A thematic descriptive analysis inspired by Braun and Clarke was used. Results Two main themes and seven subthemes were revealed. The main themes were: From few to various persistent symptoms and Existential thoughts and reflections. Most of the participants experienced various physical and/or cognitive symptoms, such as reduced physical fitness, heavy breathing, fatigue, and ‘brain fog’. On the other hand, they also experienced guilt and gratitude for having survived. The recognition of having achieved other life perspectives was also present. Conclusion Six months after undergone COVID-19 the participants still experienced various distressing symptoms, which were in line with larger studies. The novel findings of this study were connected to the existential area, where the patients’ thoughts and reflections of guilt, gratitude, and new life perspectives were revealed. These findings are important for health professionals to consider when treating patients after COVID-19.publishedVersio

“This path I must walk alone”. Challenges experienced by older patients while recovering from severe COVID-19 – a qualitative study

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Background: In March 2020, the COVID-19 pandemic challenged both the Norwegian population and healthcare system. In this study we explored how older men and women experienced rehabilitation and recovery after hospitali sation due to severe COVID-19. Methods: Semi-structured interviews with 17 participants aged 60–96 years were performed 6 months after dis charge from hospital. A thematic descriptive analysis was conducted. Results: The results revealed that the participants experienced a challenging span between loneliness and com panionship in recovering from severe COVID-19. The four subthemes highlighted experiences of being discharged to home and left to themselves, the importance of exercise and companionship at rehabilitation stay, requirement of self-efort and time to recover, and the challenging span between loneliness and companionship when being with family. Conclusion: Among participants, the experiences of loneliness throughout the recovery period were striking. An individualised approach including psychological support should be emphasized in primary healthcare to promote recovery in older survivors after severe COVID-19 and their next-of-kin.publishedVersio

Prediction of walking speed one year following hip fracture based on pre-fracture assessments of mobility and physical activity

Abstract Background Older people with hip fracture are often medically frail, and many do not regain their walking ability and level of physical activity. The aim of this study was to examine the relationship between pre-fracture recalled mobility, fear of falling, physical activity, walking habits and walking speed one year after hip fracture. Methods The study had a longitudinal design. Measurements were performed 3–5 days postoperatively (baseline) and at one year after the hip fracture. The measurements at baseline were all subjective outcome measures recalled from pre-fracture: The New Mobility Scale (NMS), the ‘Walking Habits’ questionnaire, The University of California, Los Angeles (UCLA) Activity Scale, Fear of Falling International (FES-I) and demographic variables. At one year 4-meter walking speed, which was a part of the Short Physical Performance Battery (SPPB) was assessed. Results At baseline 207 participants were included and 151 were assessed after one year. Their age was mean (SD) 82.7 (8.3) years (range 65–99 years). Those with the fastest walking speed at one year had a pre-fracture habit of regular walks with a duration of ≥ 30 min and/or a frequency of regular walks of 5–7 days a week. Age (p =.020), number of comorbidities (p <.001), recalled NMS (p <.001), and recalled UCLA Activity Scale (p =.007) were identified as predictors of walking speed at one year. The total model explained 54% of the variance in walking speed. Conclusions Duration and frequency of regular walks before the hip fracture play a role in walking speed recovery one year following the fracture. Subjective outcome measures of mobility and physical activity, recalled from pre-fracture can predict walking speed at one year. They are gentle on the old and medically frail patients in the acute phase after hip fracture, as well as clinically less time consuming

The effects of habitual functional training on physical functioning in patients after hip fracture: The protocol of the HIPFRAC study

Background: The survivors after hip fracture often report severe pain and loss of physical functioning. The poor outcomes cause negative impact on the person’s physical functioning and quality of life and put a financial burden on society. Rehabilitation is important to improve physical functioning after hip fracture. To maintain the continuity in rehabilitation we have an assumption that it is of utmost importance to continue and progress the functional training that already started at the hospital, while the patients are transferred to short-term stays in a nursing home before they are returning to home. The aim presently is to examine the effects of a functional training program, initiated by the physiotherapist and performed by the nurses, on physical functioning while the patients are at short term stays in primary health care. Methods/design: Inclusion and randomization will take place during hospital stay. All patients 65 years or above who have sustained a hip fracture are eligible, except if they have a score on Mini Mental State (MMS-E) of less than 15, could walk less than 10 m prior to the fracture, or are terminally ill. The intervention consists of additional functional training as part of the habitual daily routine during short term stays at nursing homes after discharge from hospital. The primary outcome is physical functioning measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are Timed “Up & Go” (TUG), hand grip strength, activPAL accelerometer, and selfreported measures like new Mobility Score (NMS), Walking Habits, University of California Los Angeles (UCLA) activity scale, Fall efficacy scale (FES), EuroQol health status measure (EQ-5D-5 L), and pain. Discussion: Issues related to internal and external validity in the study are discussed. The outline for the arguments in this protocol is organized according to the guidelines of the Medical Research Council (MRC) guidance on how to develop and evaluate complex interventions. Trial registration: ClinicalTrials.gov NCT02780076

“I struggle to count my blessings”: recovery after hip fracture from the patients’ perspective

Abstract Background Recovery outlooks of physical functioning and quality of life after hip fracture have not changed significantly over the past 25 years. Previous research has mainly dealt with causalities and acute treatment, while the recovery process from the patients’ perspective has been less comprehensively described. Expanded knowledge of what the patients consider important in their recovery process may have important consequences for how these patients are treated in the future and thereby on future patient outcomes. The aim presently is therefore to explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process. Method The study was qualitative in design. Eight frail elderly in recovery after hip fracture (aged 69–91) were interviewed in their home four months after their fracture. The interviews covered issues related to their experiences of facilitators and barriers throughout the different stages in the recovery process. The patients were already enrolled in an ongoing randomized controlled trial, examining the effects of habitual functional training during their short term stays at nursing homes. The patients were chosen strategically according to age, gender, and participation in rehabilitation. The interviews were recorded, transcribed and subjected to a method of systematic text condensation inspired by Giorgi’s phenomenological method. Results The results revealed that the patients’ experiences of the recovery process fell into three main themes: “Feeling vulnerable”, “A span between self-reliance and dependency” and “Disruption from a normal life”. The feeling of gloominess and vulnerability persisted throughout. Being in recovery was also experienced as a tension between self-reliance and dependency; a disrupted life where loss of mobility and the impact of age was profoundly present. Conclusion Being in recovery after hip fracture was experienced as a life breaking event. Based on these findings, increased focus on individualized treatment to each patient through each stage of the recovery process should be emphasized

Effect of exercise interventions in the early phase to improve physical function after hip fracture – A systematic review and meta-analysis

Background The efficacy of exercise interventions in the early recovery phase, i.e. started within the first three months after hip fracture, has been poorly studied compared to prolonged exercise interventions. Objective To examine the effect of exercise interventions to improve physical function in the early phase after hip fracture. Data sources Seven databases including MEDLINE via Ovid, The Cochrane Library, Embase, Cinahl, Pedro, AMED and Web of Science were comprehensively searched till December 2019. Eligibility criteria Randomised controlled trials (RCTs) of exercise interventions initiated within the first three months after hip fracture to improve physical function, were eligible for inclusion. Primary outcome was physical function assessed using walking ability, walking speed, balance, muscle strength, mobility, and endurance. Data extraction and data synthesis We conducted subgroup analyses specifically to investigate outcomes of these individual measurements. A meta-analysis was conducted to examine the overall effect of early exercise interventions. A meta-regression was conducted to examine the impact of study characteristic on exercise interventions. We used the PEDro score to determine quality of the included studies. Results Nine studies (669 patients) were included. Despite high statistical heterogeneity, there was high to moderate quality evidence that exercise provided benefit in improving physical function (standardised mean difference (SMD) 1.07; 95% CI: 0.44 to 1.70; p  0.05). Meta-regression demonstrated no statistically significant association between study characteristics and exercise interventions ( p > 0.05). Conclusion Exercise in the early phase of hip fracture rehabilitation can improve physical function. It remains unclear what type of exercise is superior in the early phase after hip fracture. Limitations This conclusion should be interpreted with caution given the high statistical heterogeneity reported and non-significant subgroup analyses of specific physical function measures, which were underpowered

Aquatic high-intensity interval training (HIIT) may be similarly effective to land-based HIIT in improving exercise capacity in people with chronic conditions: a systematic review and meta-analysis

Objective To investigate the effect of aquatic high-intensity interval training (AHIIT) on exercise capacity in people with chronic conditions.Design Systematic review and meta-analysis.Participants Adults (age ≥18 years) with any chronic conditions (long duration, continuing health problems).Data sources The databases Medline, EMBASE, CINAHL, SPORTSDiscus, PEDro and The Cochrane Library were searched from inception to 11 August 2023.Eligibility criteria Randomised or non-randomised controlled trials of adults reporting one or more chronic conditions were included, comparing the effect of AHIIT with a non-exercising control group, land-based high-intensity interval training (LBHIIT) or aquatic moderate-intensity continuous training (AMICT).Results Eighteen trials with 868 participants with chronic musculoskeletal, respiratory, cardiovascular, metabolic or neurological conditions were included. Adherence to AHIIT was high, ranging from 84% to 100%. There was moderate certainty in evidence according to the Grading of Recommendations Assessment, Development and Evaluation system for a moderate beneficial effect on exercise capacity standardised mean differences (SMD) 0.78 (95% CI 0.48 to 1.08), p&lt;0.00001) of AHIIT compared with a non-exercising control group. There was moderate certainty in evidence for no difference of effects on exercise capacity (SMD 0.28 (95% CI −0.04 to 0.60), p=0.08) of AHIIT compared with LBHIIT. There was moderate certainty in evidence for small effect on exercise capacity (SMD 0.45 (95% CI 0.10 to 0.80), p=0.01) of AHIIT compared with AMICT.Conclusion There are beneficial effects of AHIIT on exercise capacity in people with a range of chronic conditions. AHIIT has similar effects on exercise capacity as LBHIIT and may represent an alternative for people unable to perform LBHIIT.PROSPERO registration number CRD42022289001