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Adaptability treadmill vs. conventional treadmill and PT in post-hip fracture rehab
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September 2017
Adaptability treadmill vs. conventional treadmill and PT in post-hip fracture rehab
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial
BMC Geriatr. 2016 Dec 28;16(1):215Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
70 patients who had suffered a fall-related hip fracture and were undergoing acute postoperative rehabilitation for 6 weeks were randomized to one of three regimens: adaptability treadmill training in addition to usual physical therapy sessions; conventional treadmill training in addition to usual physical therapy sessions; or usual physical therapy sessions alone. Patients were assessed for measures of walking ability, walking adaptability, fear of falling and the incidence of falls at the end of the 6-week programs, and at 4-week and 12-month follow-up. All three groups significantly improved in general walking ability, general health, and fear of falling over time. The only significant differences noted in a priori analyses were a greater increase in the Functional Ambulation Category in the conventional treadmill group compared to the other two groups after 4 weeks, and a smaller reduction in walking speed during the 10-meter walking test with obstacles in the adaptability treadmill group compared to the conventional treadmill group. All other outcomes did not significantly differ between the three groups.
Publication Funding Details
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Funding:
Non-Industry funded
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
1/4
Randomization
4/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
3/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Falls within the elderly population are common and can result in serious injuries, such as hip fracture. Accordingly, interventions for fall avoidance and prevention are an important area of research currently. Walking adaptability and stepping training using a specialized treadmill is an intervention that has been suggested to reduce the incidence of falls in elderly individuals, though efficacy has not been investigated in a number of trials previously.
What was the principal research question?
In elderly patients following a fall-related hip fracture, does adaptability treadmill training lead to significantly better walking ability, significantly reduced fear of falling, and significantly lower incidence of fall when compared to either conventional treadmill training or usual physical therapy?
Study Characteristics
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Population:
70 patients, over the age of 65 years, with a hip fracture related to a fall and within 3 days of admission to a residential or rehabilitation center following discharge from the hospital.
Intervention:
Adaptability treadmill group: Patients participated in 15 sessions of adaptability treadmill training (C-Mill; Motekforce Link) in addition to 15 supervised sessions of usual physical therapy (described below). Training exercises included guided stepping using regularly or irregularly spaced markers, obstacle avoidance, moving walking zones, and interactive adaptability games illuminated on the treadmill walk surface while set at a comfortable walking pace. The 30 total sessions were completed over 6 weeks (5 per week), and were 40 minutes in duration each. (n=24; Mean age: 82.9+/-6.5)
Comparison:
Conventional treadmill group: Patients participated in 15 sessions of conventional treadmill training in addition to 15 supervised sessions of usual physical therapy. Sessions were completed at a speed comfortable for participants. The 30 total sessions were completed over 6 weeks (5 per week), and were 40 minutes in duration each. (n=23; mean age: 83.9+/-5.5)
Usual physical therapy group: Patients participants in 30 supervised sessions of usual physical therapy. Sessions consisted of exercises for lower limb strengthening exercises, balance transfer, overground walking, and daily activities. The 30 sessions were completed over 6 weeks (5 per week), and were 40 minutes in duration each. (n=23; Mean age: 83.3+/-8.0)
Outcomes:
Primary outcomes were walking ability and walking adaptability. Walking ability was assessed using the Performance Oriented Mobility Assessment, the Elderly Mobility Scale, the Timed Up-and-Go test, the Functional Ambulation Category, the 10 meter Walking Test (10MWT), and the Nottingham Extended Activities of Daily Living, and walking adaptability was assessed using the 10MWT with obstacles, and the 10MWT while simultaneously completing a cognitive task. Secondary outcomes included the Falls Efficacy Scale International for fear of falling, and the incidence of falls. In addition, general health was assessed using a visual analog scale (VAS; 0-100), the Hip Disability and Osteoarthritis Outcome Score - Quality of Life (HOOS-Q), and the Trail Making Tests - part A and B.
Methods:
RCT
Time:
Patients were assessed at the end of the 6-week programs, and at 4-week and 12-month follow-up.
What were the important findings?
- For measures of walking ability, no significant differences were observed between the three groups in the outcome of the Performance Oriented Mobility Assessment, the Elderly Mobility Scale, the Timed Up-and-Go test or the Nottingham Extended Activities of Daily Living (all p>0.05).
- Increase in FAC from baseline was significantly greater in the conventional treadmill group compared to the adaptability treadmill group and usual physical therapy group at post-intervention and after 4-week follow-up (p<0.05); the difference between groups in the increase to 12-month follow-up was not significant (p=0.417).
- For measures of walking adaptability, the only significant difference between groups was a significantly smaller decrease in walking speed with obstacle avoidance during the 10MWT at post-intervention in the adaptability treadmill group (-21.48+/-18.13%) compared to the conventional treadmill group (-35.91+/-18.56%) (p=0.017); difference compared to the usual physical therapy group (-31.77+/-15.52%) did not reach statistical significance (p=0.070).
- The difference between groups in the decrease in walking speed with obstacle avoidance during the 10MWT at 4-week follow-up was not significant (p=0.091).
- Falls Efficacy Scale International scores did not significantly differ between the three groups at post-intervention, 4-week follow-up, or 12-month follow-up (p>0.05).
- The incidence of falls included 11 falls among 4 patients of the adaptability treadmill group, 11 falls among 5 patients of the conventional treadmill group, and 20 falls among 9 patients of the usual physical therapy group; the differences between groups were not statistically significant (p>0.05).
What should I remember most?
In post-hip fracture rehabilitation in the elderly, adaptability treadmill training over 6 weeks in addition to standard physical therapy session results in statistically similar results to conventional treadmill training and usual physical therapy when considering measures of walking ability, walking adaptability, fear of falling and incidence of falls. The only significant differences noted in a priori analyses were a greater increase in the Functional Ambulation Category in the conventional treadmill group after 4 weeks and a smaller reduction in walking speed during the 10-meter walking test with obstacles in the adaptability treadmill group compared to the conventional treadmill group.
How will this affect the care of my patients?
The results of this study suggest that adaptability treadmill training for elderly patients following hip fracture produces similar results to that of either conventional training or a usual physical therapy program for 6 weeks. However, with only 70 patients enrolled and randomized, the study fell well short of the original 126 sample size based on previous calculations. For this reason, the study is likely underpowered for any clear conclusion on the efficacy of adaptability treadmill for these patients. Therefore, additional studies are required before its potential role in post-hip fracture rehabilitation is determined.
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