改善虛弱者髖骨骨折後的情況


  【24drs.com】根據線上發表於2012年1月American Medical Directors Association期刊的報告,髖骨骨折之後一年,護理之家住院率和死亡風險大幅增加,強化耐力訓練和多元介入方式可改善整體健康,減少這些負面結果。
  
  雪梨大學的Nalin A. Singh等人探討了有關虛弱者發生髖骨骨折的議題,假設增加耐力強度可以比現有的復健治療更能影響日常生活能力(ADLs)。他們寫道,減少髖骨骨折後的發病率和死亡率,需要的不只是治療骨折,還包括虛弱者本身的議題。
  
  研究者的「Hip Fracture Intervention Trial (HIPFIT)」這篇試驗探討了一個新的、實證基礎的治療策略,目的在改善髖骨骨折後的長期結果,方法是藉由高強度耐力訓練12個月,以免肌肉減少。研究計畫也探討了之前定義的虛弱、死亡率與護理之家住院,採用跨科介入方式處理平衡問題、骨質疏鬆、營養不佳、維他命D/鈣質缺乏、憂鬱、認知不佳、視力不佳、不安全的居家環境、服用多種藥物、使用髖骨保護器、自我照護與社會支持。
  
  這是篇隨機、控制、平行組別研究,研究對象是124名55歲以上、在2003- 2007年因為手術治療輕微創傷髖骨骨折住入公立醫院的病患。各有62名病患被指定接受介入計劃或僅接受一般照護(骨科住院與專職醫療諮商加上6-12週的標準物理治療),每週監督進行舉重訓練2天、為期12個月,從物理治療結束時開始,約是骨折後6-8週。
  
  分析了功能獨立性、死亡率資料、護理之家住院資料、ADL情況、以及輔具使用情況。
  
  介入組的62人中,4人死亡,對照組的62人有8人死亡,死亡風險降低81%(年齡校正勝算比0.19;95%信心區間0.04 - 0.91;P < .04),介入組的護理之家住院率降低84%(年齡校正勝算比0.16;95%信心區間0.04 - 0.64;P < .01)。
  
  介入組中,12 個月後的輔具使用率顯著降低(P = .01),基本的ADL退化較少,如廁與移動也比較容易。ADL改善和較佳的營養、視力、平衡、認知、自我照護、上半身強度增加等有關。
  
  研究者結論表示,12個月受監督的高強度耐力訓練,加上解決其他的虛弱問題,對於減少髖骨骨折後副作用是可行且有效的。HIPFIT介入後有顯著改善,死亡率、住護理之家、ADL獨立性、輔具使用等都有臨床意義的降低。研究限制包括,樣本數有限,對介入方式缺乏分類,無法確認特定的改善程度。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6704&x_classno=0&x_chkdelpoint=Y
  

Addressing Frailty Improves Post-Hip-Fracture Experience

By Ricki Lewis, PhD
Medscape Medical News

January 5, 2012 — The risks for mortality and nursing home admission rise greatly in the year after hip fracture. High-intensity resistance training coupled with multiple interventions to improve general health and well-being can minimize these negative outcomes, according to a report published in the January 2012 issue of the Journal of the American Medical Directors Association.

Nalin A. Singh, MBBS, and colleagues from the University of Sydney, Australia, addressed the frailty of patients sustaining hip fracture, hypothesizing that increasing strength might affect activities of daily living (ADLs) more than the current clinical focus on repair and rehabilitation. "Lowering the burden of excess morbidity and mortality after hip fracture requires treatment of the underlying frailty itself, not just the broken bone," they write.

The researcher's Hip Fracture Intervention Trial (HIPFIT) tests "a novel, evidence-based treatment strategy to improve long-term outcomes after hip fracture by targeting sarcopenia with 12 months of high-intensity progressive resistance training." The protocol also addresses previously identified predictors of frailty, mortality, and nursing home admission with "targeted multidisciplinary intervention" to handle balance problems, osteoporosis, poor nutrition, vitamin D/calcium deficiency, depression, impaired cognition, poor vision, unsafe home conditions, taking multiple drugs, using hip protectors, and self-care and social support.

The study was a randomized, controlled, parallel-group superiority design on 124 patients older than 55 years who were admitted to a public hospital for surgical repair of minimal-trauma hip fracture from 2003 to 2007. Equal numbers of patients (62) were assigned to the intervention protocol or to receive only usual care (inpatient orthogeriatric and allied health consultation plus 6 - 12 weeks of standard physical therapy). The supervised weight-lifting took place 2 days per week for 12 months, beginning after the end of physiotherapy, about 6 to 8 weeks postfracture.

Outcomes assessed functional independence, using data on mortality, nursing home admission, ADL scales, and use of assistive devices.

Of the 62 individuals in the intervention group, 4 died compared with 8 of the 62 patients in the control group, indicating reduction in risk for death of 81% (age-adjusted odds ratio, 0.19; 95% confidence interval, 0.04 - 0.91; P < .04). Nursing home admissions were reduced in the experimental group by 84% (age-adjusted odds ratio, 0.16; 95% confidence interval, 0.04 - 0.64; P < .01).

In the intervention group, assistive device use was significantly lower after 12 months (P = .01), basic ADLs declined less, and toileting and transferring became easier. The ADL improvements were associated with better nutrition, vision, balance, cognition, and self-care, as well as increased upper body strength.

The investigators conclude that 12 months of supervised, high-intensity resistance training, coupled with addressing other problems related to frailty, is a feasible and effective approach for minimizing adverse events after hip fracture. "The HIPFIT intervention resulted in statistically significant and clinically meaningful reductions in mortality, nursing home use, ADL dependency, and assistive device usage," they write. Limitations of the study include the small sample sizes and the lack of stratification of the interventions to identify which were responsible for specific improvements.

This study was funded by the Australian National Health and Medical Research Council. The authors have disclosed no relevant financial relationships.

J Am Med Dir Assoc. 2012;13:24-30.

    
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