| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Research Reports |
NJ Kirk-Sanchez, PT, PhD, is Assistant Professor, Department of Physical Therapy, School of Health, College of Health and Urban Affairs, Florida International University, University Park, Miami, FL 33199 (USA) (sanchezn{at}fiu.edu)
Submitted May 24, 2002;
Accepted October 29, 2003
 | Abstract |
|---|
Key Words: Depression • Disablement • Functional limitation • Hip fracture • Hispanic Americans • Social support
| Introduction |
|---|
 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
|---|
|
The results of all of these studies suggest that psychosocial variables may be important mediators in the recovery process. Social support in the form of physical or emotional assistance may be related to better premorbid physical abilities and may encourage better recovery of physical abilities after hip fracture. Similarly, elderly people with symptoms of depression such as feelings of sadness and low energy levels show more functional limitations prior to hip fracture and may have more difficulty recovering functional abilities. In addition, those with fewer comorbid conditions, or those who are able to bear weight more quickly following a fracture, may show faster and better recovery of abilities.
Researchers9–12 examining health status in community-dwelling Hispanic people have found higher levels of activity limitation and disability in this population than in nonminority populations. A few researchers have examined the association between physical, cognitive, and emotional factors and health status in Hispanic populations. After studying living arrangements and multiple measures of physical, cognitive, and emotional function in a nationally representative sample of white, black, and Hispanic adults, Waite and Hughes10 concluded that, in general, older Hispanic adults tended to have more physical, cognitive, and emotional impairments than older non-Hispanic adults. This disadvantage, however, seems to vary according to the living arrangement of the individual. When compared with non-Hispanic adults, married Hispanic adults living in households with others (eg, children, parents) show higher levels of self-rated physical and emotional health, less difficulty performing functional tasks, and less depression.10 Single Hispanic men and women 51 to 61 years of age who are living alone showed more depression and poorer cognitive function than non-Hispanic adults.10 Thus, there seems to be some interaction between mental health status and social support factors among Hispanic adults. Cultural differences in the value of family relationships and different cultural preferences may lead to different expectations in the availability and presence of social support in time of need.13 Social support systems and psychological status differ in Hispanic and non-Hispanic populations, and these differences have rarely been accounted for in previous studies of disability and health status.3–8
The purpose of my study was to determine factors related to activity limitations in a group of Cuban Americans recovering from hip fracture. Activity limitation was examined at 3 points in time: prior to hip fracture, at the time of discharge from a rehabilitation facility, and 2 months after discharge from the rehabilitation facility. The theoretical basis for my study is the expanded disablement model described by Guccione2 and in the Guide to Physical Therapist Practice.1 This model suggests that a number of individual, environmental, and health-related factors might interact to mediate the disablement process. In my study, I examined the role of several of these factors, including social support, psychological status, and comorbidity, as determinants of activity limitations before and after hip fracture. I also examined the role of factors such as weight-bearing status, age, and sex in recovery of physical abilities after a hip fracture.
| Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Measurement
Activity limitations prior to hip fracture and activity limitations 2 months after discharge from the rehabilitation hospital were measured by use of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical function subscale (PF-10). The SF-36 is designed to test general health status in 8 domains.14 For the purpose of this study, an English-Spanish translation of the SF-36 was used. This translation is unpublished, but was obtained from the International Quality of Life Assessment Project (B Gandek; personal communication; April 26, 2001). Reliability and construct validity of measurements obtained with this instrument have been demonstrated in groups of Cuban-American men with varying severity of benign prostatic hypertrophy.15,16 Validity testing and normative testing of all subscales of the SF-36 have been performed with a large nationally representative sample of Americans.14 Subgroups with chronic diseases such as osteoarthritis, diabetes, and hypertension were analyzed in this testing, but the researchers did not examine subgroups of patients with acute diseases and disorders.14
The PF-10 is used to measure degree of limitation in performing vigorous and moderate activities of daily living, walking, climbing stairs, and self-care. The PF-10 contains 10 items rated on a 3-point scale so that high scores indicate less activity limitation and low scores indicate more activity limitation.14 Raw scores were transformed to a scale ranging from 0 to 100, as described in the SF-36 user's manual as standard use of the instrument.14
Activity limitations at the time of discharge from the rehabilitation facility were measured by use of the mobility subscale of the Functional Independence Measure (FIM). The FIM is part of the Uniform Data Set (UDS),17 which was developed to document the severity of physical disability and measure the outcomes of rehabilitation for people following a stroke. This instrument has been shown to yield reliable and valid measurements of rehabilitation outcomes in a sample of 11,102 patients receiving inpatient rehabilitation in the northwestern United States.18 The FIM is designed to measure the degree of assistance an individual needs to perform basic mobility, locomotion, and self-care activities, and it examines 11 items on a 7-point scale, with high scores indicating less need for assistance in performing activities.
Mental health status was measured using the mental health and role-emotional subscales of the SF-36.14 The mental health subscale measures the frequency at which an individual feels depressed, nervous, calm, or happy. This subscale contains 5 items that are measured on a 6-point scale ranging from "all of the time" to "none of the time." Higher scores indicate that the individual frequently feels calm and happy and infrequently feels depressed and nervous.14 The role-emotional subscale measures the extent to which emotional problems interfere with the kind or amount of work that an individual does. This subscale consists of 3 items measured on a 4-point scale, with higher scores indicating no problems with work or other daily activities as a result of emotional problems and lower scores indicating problems.14 Raw scores were transformed to a scale ranging from 0 to 100 according to SF-36 criteria, and scores for the 2 subscales were summated.
Social support was measured by a survey instrument derived from and utilized in the MacArthur Studies of Successful Aging.19 This survey instrument was used to measure the amount of social support received from 4 different sources: spouse, children, relatives, and friends. The amount of social support received from each source in several domains, including instrumental support (physical or tangible support), emotional support, and negative support, also was measured.19 The emotional support subscale measures the frequency at which each source of support makes the individual feel loved and cared for and the extent to which people listen to the individual's problems. The instrumental support subscale measures the frequency at which the individual receives physical or financial assistance from each source. The negative support subscale measures the frequency at which the individual feels that each support source is demanding or critical. Each subscale produces ordinal measurements and has a possible range of scores from 6 to 24.19 For instrumental support and emotional support, higher scores indicate more support. Higher scores for negative support indicate more feelings that the source is demanding or critical. The scores obtained with these subscales have been found to be reliable and valid in describing the quantity and quality of social support in older community-dwelling adults.19 The reliability and validity of data obtained with this social support scale have not been examined in Cuban-American or other Hispanic populations.
Comorbidity was measured by the number of other coexisting diagnosed medical conditions identified by the subjects utilizing a checklist of diagnoses and the UDS.17 Weight-bearing status, according to documentation in the medical record, was noted at the time of discharge from the rehabilitation facility.
Procedure
Data were collected at 4 points in time: before fracture (data were collected retrospectively by interview at the time of discharge from the rehabilitation hospital), at the time of admission to the rehabilitation hospital (data were extracted from quality assurance records), at the time of discharge from the rehabilitation hospital (data were collected by interview and extracted from quality assurance records), and 2 months after discharge from the rehabilitation hospital (data were collected by interview). Table 1 summarizes the data for each time point. Each subject was interviewed 2 times: 1 or 2 days before discharge from the rehabilitation facility and 2 months after discharge from the rehabilitation facility. All interviews were conducted in Spanish, and all survey instruments were in Spanish. During the first interview, subjects were instructed to complete the SF-36 with reference to the 4 weeks preceding their injuries. Subjects also completed the social support interview and demographics survey at this time. The second interview was conducted in the subject's home 2 months after discharge from the rehabilitation facility. At this time, subjects completed the SF-36 a second time with reference to the previous 4 weeks. All other data were obtained from quality assurance records.
|
For each point in time, a full model was developed using all of the variables, and variables that did not contribute to the model were deleted one at a time to develop the final model in which all of the variables were significant at P<.10. In this way, independent variables that were related to each of the dependent variables were identified, and variables that were not related were deleted from the model. For each of the models, collinearity diagnostics were run, including calculation of eigenvalues, variance inflation factors, and condition indices.21 Data were analyzed using SAS statistical software.*
Thirty-seven subjects participated in the first interview, and 28 subjects participated in the second interview. A total of 9 subjects were lost to follow-up. Six subjects were lost to follow-up due to their refusal to participate in the interview process or due to inability to contact them, and 3 subjects were hospitalized and unable to participate in the interview process. Therefore, data for 28 subjects were used in the final data analysis. The subjects were 82.1% female and had a mean age of 78.7 years (SD=9.4). They had a median of 3 comorbid conditions. All of the subjects were of Hispanic origin (Tab. 2). The mean score for premorbid activity limitations was 70.7 (SD=34.0) (n=37) on a scale of 0 to 100, and the mean activity limitation score 2 months after discharge from the rehabilitation facility was 33.6 (SD=20.9) (n=28). The mean FIM mobility subscale score at the time of admission to the rehabilitation facility was 34.6 (SD=5.4) (out of a possible 77), and the mean FIM mobility subscale score at the time of discharge from the rehabilitation facility was 51.8 (SD=7.0).
|
| Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
through 5. Final models were developed that accounted for 31% of the variance in prefracture activity limitations, 53% of the variance in activity limitations at the time of discharge from the rehabilitation hospital, and 43% of the variance in activity limitations 2 months after discharge from the rehabilitation hospital. The partial correlations indicate the relative contribution of each of the variables to the model; variables with larger partial correlations explain more of the variance in the model than do variables with smaller partial correlations. An assumption of multilinear regression is that the predictors or independent variables are correlated to the dependent variable, but are not correlated among themselves. When there are intercorrelations among the predictors, the importance of a single factor is confounded by the other factors with which it is correlated. Thus, it is important to determine whether multicollinearity exists in the model.20(p76) Results of collinearity diagnostics indicated that there was no evidence of collinearity in any of the 3 models. All of the variance inflation factors were less than 10, none of the eigenvalues approached 0, and none of the condition indices approached 30.
|
|
|
Most of the variance in activity limitations at the time of discharge from the rehabilitation facility was related to activity limitations at the time of admission, sex, and age, but weight-bearing status and mental health status also contributed to the model. More activity limitations at the time of discharge were associated with more activity limitations at the time of admission, status for weight bearing as tolerated, older age, and male sex. Variables that did not contribute to the model included all of the social support variables, prefracture activity limitations, and number of comorbid conditions.
Most of the variance in activity limitations 2 months after discharge from the rehabilitation facility was accounted for by 3 social support variables: instrumental (physical) support, emotional support, and negative support. Partial weight-bearing status also contributed to the model. More activity limitations 2 months after discharge were related to more instrumental support, less emotional support, and less negative support; status for weight bearing as tolerated or non–weight bearing (versus partial weight bearing); and older age. Social support accounted for 43% of the variance in activity limitations at 2 months after discharge, such that those subjects with more emotional support and more negative support were less limited and those subjects with more instrumental support were more limited.
| Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
My results indicate that mental health status, defined in terms of the frequency of an individual's report of feelings of depression or anxiety and the extent to which emotional health limited activities, was related to activity limitations both before the fracture and at the time of discharge from the rehabilitation hospital. Mental health status, however, was not related to activity limitations 2 months after discharge from the rehabilitation facility.
The findings related to mental health status are consistent with those of several other studies that have investigated depressive symptoms and functional decline.22–24 Bruce et al22 showed that depressive symptoms represented a risk factor for functional limitations even in the absence of acute medical events. Penninx and colleagues23,24 replicated this finding and found that chronicity of depression had an impact on decline in physical function over time. Treatment and remission of depression was found to be protective against future decline. These researchers' findings support my findings that mental health status and activity limitations are associated and that subjects with more depressive symptoms tend to have more activity limitations prior to hip fracture. Because Hispanic Americans25 and Cuban Americans26 have higher levels of depression than non-Hispanic people, these are important culturally and ethnically dependent findings.
My results suggest that mental health status also is related to activity limitations at the time of discharge from a rehabilitation facility. Other researchers3,6–8 have shown that depressive symptoms are related to recovery from hip fracture. In 3 of these studies, the influence of depression 12 months after fracture was examined, and it was found that individuals reporting fewer depressive symptoms were more likely to achieve independence in walking and other functional tasks6 and to have better recovery in both functional status7,8 and psychosocial status.7 Mutran et al3 investigated functional outcomes 2 months after hip fracture surgery and found that inadequacy of social support and depression resulted in less improvement in walking ability than occurred with more social support and less depression, but the researchers did not examine other types of activity limitations. Mental health status appears to mediate the process of recovery after hip fracture in the general population, and my study suggests that it also might be particularly important in the Cuban-American population because of higher prevalence of depression in this population.10
None of the social support variables were related to prefracture activity limitations or activity limitations at the time of discharge from the rehabilitation facility, but social support was related to activity limitations 2 months after discharge. Previously, researchers22–29 have shown that social support is related to activity limitations in the community-dwelling elderly population, whereas other researchers30 have not been able to demonstrate this association.
Research by Berkman et al30 failed to support the relationship between social support and functional level. In that study, subjects were grouped into 3 cohorts (high, medium, and low function) based on their performance on a series of cognitive and physical tests. Neither levels of emotional support, instrumental support, and negative support nor support size were different in these 3 groups.30 Mendes de Leon et al31 found that being "embedded" in a network of social relationships provides long-term protection against disability (activity limitations), either by reducing the risk of developing disability or by promoting recovery from disability. Further study of the effects of quality and quantity of social support on activity limitations in the absence of a medical event is needed. Because of variations in social norms and customs in different cultural groups, it is important to examine these relationships in culturally diverse populations.
Instrumental support, such as having someone to help with activities of daily living, was associated with more activity limitations, and emotional support, such as feeling cared for and having someone to listen to you when you have problems, was associated with less activity limitations 2 months after discharge from the rehabilitation facility. Cummings et al5 found social support to be important in recovery of function 6 months after hip fracture, such that individuals with larger social support networks were less limited. Cummings et al, however, did not differentiate among types of social support. Mutran et al3 found that social support influenced the recovery process primarily 2 months following injury and was less important 6 months following injury. Similarly, Wilcox et al4 found that emotional support was more important early in the process of recovery from hip fracture (6 weeks) and that instrumental support was more important later in the recovery process (6 months). In my study, high levels of instrumental support might have been the cause of more activity limitations and physical dependence because other people in the support network are available to provide them with the help that they need. Based on my data and the findings of previous studies, appropriate type and timing of social support appears to be highly important in facilitating recovery from hip fracture.
I found that negative support, such as a feeling of demand or criticism from the social network, was inversely related to hip fracture recovery 2 months after discharge from the rehabilitation facility, such that those with more negative support were less limited. Both criticism and feelings of being needed may facilitate the process of recovery by encouraging the individual to resume prefracture activities independently as soon as possible. No previous studies have investigated the influence of negative aspects of social support on recovery from hip fracture.
Examination of the scores for activity limitations at the 3 time points by weight-bearing status reveals that weight-bearing status was related to activity limitations 2 months after discharge from the rehabilitation facility. Those subjects who had full weight bearing at the time of discharge from the rehabilitation facility had the most activity limitations 2 months after discharge, and those who had partial weight bearing at discharge had the least activity limitations (Tab. 6). Examination of prefracture activity limitations shows that the trend in activity limitations 2 months after discharge from the rehabilitation facility was the same as the trend in prefracture activity limitations: subjects who were weight bearing as tolerated at the time of discharge were more limited prior to hip fracture. An individual's initial status for weight bearing as tolerated appears to offer an advantage during the acute stage of recovery, but that advantage disappears in the later stages. The importance of weight-bearing status in predicting activity limitations 2 months after discharge from the rehabilitation facility may be a reflection of the prefracture differences among the 3 groups.
|
Prefracture activity limitations were not a predictor of activity limitations at the time of discharge from the rehabilitation facility or 2 months after discharge. This relationship is contrary to the findings of other researchers3,6,8,35 who found that prefracture activity limitations were related to activity limitations after hip fracture. That my study did not confirm the relationship between prefracture activity limitations and activity limitations 2 months after discharge from the rehabilitation facility might be explained by the fact that this effect is more powerful later in the recovery process (6–12 months). It also could be that this effect is population-specific, and it is impossible to determine if this is the case with the design of this study. Most of the recovery in functional abilities occurs in the first 6 months after hip fracture.33 A severe traumatic injury, such as hip fracture, may be an equalizer between those who were quite active and those who were quite limited at the time of fracture, so that in the period immediately following hip fracture, the acute effect of the fracture on activity limitations masks the effect of prefracture differences in activity limitations. Some of the effects for prefracture activity limitations and comorbidities may have been less apparent in my sample because of the homogeneity of this group (ie, Cuban-Americans), as they were all living at home, were cognitively functional, qualified for admission to the rehabilitation program, and were discharged to their homes.
The expanded disablement model also proposes that a person's sex has an effect on the process of disablement. The results of my study showed that sex was a predictive factor in prefracture activity limitations and activity limitations at the time of discharge from the rehabilitation facility. Although sex was a predictor of activity limitations at the time of discharge, activity limitation scores for men and women were the same (FIM mobility subscale scores of 52.0 and 51.5, respectively). The fact that women tended to have much higher levels of depressive symptoms than did men probably accounts for the importance of sex in the model, as all of the other variables in the model (length of stay, hours of therapy, and activity limitations at admission) were similar in men and women. Although all predictive models included sex as a control, there was a potential sex bias in my study because only 16% of the sample was male.
There are several limitations to my study. Prefracture activity limitations and activity limitations 2 months after discharge from the rehabilitation facility were measured using the SF-36, and activity limitations at discharge were measured using the FIM mobility scale. These scales have different measurement properties and constructions that lead to some difficulty in interpreting the findings in a clinical context. For example, the FIM measures the assistance that a subject needs to perform a particular task, whereas the SF-36 measures how much assistance a subject feels that he or she needs to complete a particular functional task. In addition, the FIM is an instrument with which measurements are made by direct observation, whereas the SF-36 relies on self-report. Although these measurement scales are different from each other, the fact that age, sex, and weight-bearing status were predictors across 2 time frames lends some credibility to the use of different measurement scales. Another limitation to my study was that the prefracture health information was collected retrospectively, rather than prior to admission to the rehabilitation facility. This may have led to some bias due to subjects' poor recollection or interpretation of their prior level of function. Finally, the small number of subjects enrolled in the study leads to some limitation in generalization. The validity of the statistical inferences made in this article may be affected by the small sample size because there may be instability in the statistical models. The small number of subjects also may lead to some difficulty in generalizing the findings of this study to larger groups.
| Conclusion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
High levels of social support are thought to be helpful in recovery from hip fracture.3–5 In my sample of Cuban-American adults, however, high levels of instrumental support were detrimental in recovery of activity levels during the later stages of rehabilitation. In contrast, high levels of emotional support and the presence of some negative aspects of support, such as criticism and demand from the social network, seemed to offer an advantage in the later phases of recovery. Although several researchers demonstrated that mental health status was related to recovery of activity levels after hip fracture, this relationship was important only in the early stages of recovery. Perhaps there are cultural differences in the meaning of disability and disease that mediate the effect of poor mental health status on recovery in this group.
The expanded disablement model discussed here suggests that individual factors such as mental health status and social processes and relationships may have an effect on the process of disablement. The results of my study provide evidence supporting the expanded disablement model. The data describe the relationships among factors in the model in a distinct cultural group, a group of Cuban-American adults. Perhaps cultural variations in mental health, social support, and activity limitations lead to some differences between Cuban Americans and other groups regarding the importance of these factors on recovery from hip fracture. Future studies of this nature should include measures of physical and cognitive impairment and health habits and lifestyle and should include a comparison group of nonminority adults. In addition, the effects of these individual and environmental factors on disability, as defined by the Guide to Physical Therapist Practice,1 should be investigated.
| Footnotes |
|---|
This study was supported by a PODS-II Scholarship from the Foundation for Physical Therapy.
This study was approved by the University of Miami Medical Sciences Subcommittee for the Protection of Human Subjects in Research and the institutional review board of the hospital from which the cohort was drawn.
* SAS Institute Inc, PO Box 8000, Cary, NC 27511. 
| References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
