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      Partial weight bearing in hip fracture rehabilitation

      editorial
      * , 1
      Future Science OA
      Future Science Ltd
      biofeedback systems, hip fractures, partial weight bearing

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          Abstract

          Orthopedic rehabilitation is very important for ensuring the best outcomes of treatment for musculoskeletal disorders and disabilities, especially in terms of hip fracture in old-aged patients. This field of research attempts to maximize the use of biomechanics and biology to improve functional outcomes and the overall well-being of patients. Orthopedic rehabilitation is a very important part of every musculoskeletal care delivery system. This article highlights recent research and advances in hip fracture in geriatric patients’ rehabilitation. Hip fractures in older patients are one of the most common injuries; in the USA alone, in 2003, hip fracture cases represented around 30% of all hospitalized cases [1]. Early postoperative improvement has been shown to improve following early ambulation after hip surgery, and early mobility enhances early recovery. When therapists use partial weight bearing, it helps early recovery [2]. Some degree of weight bearing is very important to activate osteoblasts and other cells responsible for bone healing. Further complications may result from immobilization postsurgery. In an attempt to generate a maximum mechanical environment at different stages of fracture healing, many studies prescribe partial weight bearing for lower extremities after a period of nonweight bearing. Partial weight bearing includes increasing weight loading on the limb progressively over time, which varies between patients based on the extent of the injury and the judgment of the clinician [3]. Control of postoperative pain is a vital part of rehabilitation for ensuring patient safety [4]. Partial weight bearing is prescribed for patients following pelvic fracture to protect the healing of bone and/or surgical constructs and provide a stimulus for bone growth. To date, the ability of patients to produce partial weight bearing is attached to their ability to reproduce partial weight-bearing orders; in other words, when the therapist provides clear and comprehensive orders of how much weight should put on the patient's affected limb, this leads to accurate weight bearing and good healing [5]. A study by Yu et al. [6] attempted to measure the ability of patients to reproduce partial weight-bearing orders with the hand under foot, bathroom scale and verbal methods of instruction, as well as to determine the effect of partial weight bearing on long-term clinical outcomes. This study concluded that partial weight bearing could not accurately be reproduced with any of the weight-bearing techniques prescribed, which was supported by previous evidence showing an inability to accurately reproduce partial weight-bearing orders. Biomechanically, nonweight-bearing causes the effective center of gravity to move distally and away from the nonsupporting leg. This increases abductor muscle forces, which results in joint compressive forces that are several times the body weight [7]. Consequently, partial weight bearing or at least toe-touch weight bearing is favorable. The use of biofeedback devices seems promising to support weight-bearing instructions. Smart steps and biofeedback devices could provide real-time feedback by enabling the therapist to determine accurately what is the weight bearing that can be applied for the patient and when they can increase the weight-bearing load [8]. Accelerated rehabilitation following hip fracture comprises early unrestricted weight bearing and muscle strengthening. The effect of crutches, an orthotic garment and strapping system, TheraTogs and no walking aids over 3–4 weeks on walking speed, trunk sway and muscle activity have been examined. All measured parameters increased in the TheraTogs phase more than in the crutches or no-aids phases. This may be because muscle activity was facilitated, enabling active support of recovering structures [9]. In an observational study, patients with hip fracture were monitored 1 day per week with the Feet B@ck system during their admission and after 1 week. Outcome measures of the Feet B@ck system are steps, walking bouts and loading rate. The study concluded that the loading rate is a sensitive weight-loading parameter for analysis of dynamic weight loading during rehabilitation in old patients with hip fractures and this parameter correlates with clinical improvement [10]. Alternatively, aquatic therapy is an ideal method for early mobilization, allowing graduated increase in lower extremity weight bearing due to a decrease in displacement with depth of immersion. Since the water provides a partial weight-bearing environment, upper extremity muscle mass is not required to protect the lower extremity [9]. To make predictions for the most effective method for partial weight bearing, we must discuss partial weight-bearing training in terms of two questions that deserve attention: What limitations in weight provide the best clinical improvement? What is the best method to train patients to comply with weight-bearing instructions? Weight-bearing loads are partially affected by the surgeon's choice of a conservative approach to weight bearing with respect to patient tolerance. Adequate training needs to be initiated before we can expect that patients will comply with weight-bearing instructions, considering pain and fatigue. Thus, in order to better determine the proper ambulation of patients following pelvic fracture, researchers need to better define weight-bearing classifications and find improved methods to rehabilitate patients. Physical therapists commonly train patients to comply with weight-bearing instructions, utilizing clinical techniques as well as devices that can include scales, biofeedback systems and force plates. Future research should focus on defining the suitable quantity of partial weight bearing and the best way to use biofeedback devices and include the investigation of outcomes of weight-bearing strategies. With the best-designed studies, this area of research has the potential to improve care for the large majority of lower extremity, weight-bearing orthopedic patients.

          Most cited references12

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          Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis.

          To investigate the discriminative ability and diagnostic accuracy of the Timed Up and Go Test (TUG) as a clinical screening instrument for identifying older people at risk of falling. Systematic literature review and meta-analysis. People aged 60 and older living independently or in institutional settings. Studies were identified with searches of the PubMed, EMBASE, CINAHL, and Cochrane CENTRAL data bases. Retrospective and prospective cohort studies comparing times to complete any version of the TUG of fallers and non-fallers were included. Fifty-three studies with 12,832 participants met the inclusion criteria. The pooled mean difference between fallers and non-fallers depended on the functional status of the cohort investigated: 0.63 seconds (95% confidence (CI) = 0.14-1.12 seconds) for high-functioning to 3.59 seconds (95% CI = 2.18-4.99 seconds) for those in institutional settings. The majority of studies did not retain TUG scores in multivariate analysis. Derived cut-points varied greatly between studies, and with the exception of a few small studies, diagnostic accuracy was poor to moderate. The findings suggest that the TUG is not useful for discriminating fallers from non-fallers in healthy, high-functioning older people but is of more value in less-healthy, lower-functioning older people. Overall, the predictive ability and diagnostic accuracy of the TUG are at best moderate. No cut-point can be recommended. Quick, multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
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            Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature.

            The purpose of this review article was to examine the efficacy of an early mobilization protocol in hospitalized medical-surgical inpatient population.
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              An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures.

              A recent systematic review has indicated that mortality within the first year after hip fracture repair increases significantly if the time from hospital admission to surgery exceeds forty-eight hours. Further investigation has shown that avoidable, systems-based factors contribute substantially to delay in surgery. In this study, an economic evaluation was conducted to determine the cost-effectiveness of a hypothetical scenario in which resources are allocated to expedite surgery so that it is performed within forty-eight hours after admission. We created a decision tree to tabulate incremental cost and quality-adjusted life years in order to evaluate the cost-effectiveness of two potential strategies. Several factors, including personnel cost, patient volume, percentage of patients receiving surgical treatment within forty-eight hours, and mortality associated with delayed surgery, were considered. One strategy focused solely on expediting preoperative evaluation by employing personnel to conduct the necessary diagnostic tests and a hospitalist physician to conduct the medical evaluation outside of regular hours. The second strategy added an on-call team (nurse, surgical technologist, and anesthesiologist) to staff an operating room outside of regular hours. The evaluation-focused strategy was cost-effective, with an incremental cost-effectiveness ratio of $2318 per quality-adjusted life year, and became cost-saving (a dominant therapeutic approach) if =93% of patients underwent expedited surgery, the hourly cost of retaining a diagnostic technologist on call was 1.28, =88% of patients underwent early surgery, or =339.9 patients with a hip fracture were treated annually. The results of our study suggest that systems-based solutions to minimize operative delay, such as a dedicated on-call support team, can be cost-effective. Additionally, an evaluation-focused intervention can be cost-saving, depending on its success rate and associated personnel cost.
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                Author and article information

                Journal
                Future Sci OA
                Future Sci OA
                FSO
                Future Science OA
                Future Science Ltd (London, UK )
                2056-5623
                January 2018
                12 October 2017
                : 4
                : 1
                : FSO254
                Affiliations
                [1 ]Lecturer at the Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Egyptian–Chinese University, Cairo, Egypt
                Author notes
                *Author for correspondence: Tel.: +20 100 504 7018; saharabdalbary@ 123456gmail.com
                Article
                10.4155/fsoa-2017-0068
                5729597
                256b648c-3fae-46aa-b48b-dd2d3276cd5f
                © 2017 Sahar Ahmed Abdalbary

                This work is licensed under a Creative Commons Attribution 4.0 License

                History
                : 30 May 2017
                : 15 September 2017
                Categories
                Editorial

                biofeedback systems,hip fractures,partial weight bearing

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