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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 30-34

An investigation into the factors related to independent walking in elderly inpatients with collagen diseases


1 Department of Rehabilitation, Hyogo College of Medicine Hospital, Nishinomiya, Japan
2 Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata; Department of Physical Medicine and Rehabilitation, Hyogo College of Medicine, Nishinomiya, Japan
3 Department of Physical Medicine and Rehabilitation, Hyogo College of Medicine, Nishinomiya, Japan

Date of Web Publication22-May-2019

Correspondence Address:
Prof. Shinya Yamauchi
Department of Rehabilitation, Hyogo College of Medicine Hospital, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_3_19

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  Abstract 


Purpose: In elderly patients with collagen disease, walking ability tends to decrease due to treatment with corticosteroids and long-term hospitalization. The purpose of this study was to investigate the factors related to independent walking in elderly patients with collagen disease. Methods: A total of 65 inpatients, aged ≥65 years with collagen disease, were enrolled in this cross-sectional study. Factors such as independent walking, knee extension muscle strength, one-leg standing (OLS) time, and the Geriatric Nutritional Risk Index (GNRI) were evaluated. Independent walking was evaluated using the functional independence measure (FIM). Patients were divided into the physical assistance group (1–4 points on the FIM) and the no physical assistance group (5–7 points on the FIM). Logistic regression analysis was performed, and cutoff values were calculated. Results: Of the 65 patients, 24 were allocated to the physical assistance group and 41 were allocated to the no physical assistance group. The logistic regression analysis showed the OLS time (odds ratio [OR] = 1.373, 95% confidence interval [CI]: 1.115–1.691, P < 0.01) and GNRI ([OR] = 1.076, 95% [CI]: 1.007–1.150, P < 0.05) as parameters that were associated with a probability of walking independence. Furthermore, according to the receiver operating characteristic curve analysis, the cutoff value for the OLS time was 4.1 s (sensitivity 75.6; specificity 91.7; area under the curve [AUC] = 0.906) and that for the GNRI was 81.7 (sensitivity 61.0; specificity 79.2; [AUC] = 0.713). Conclusions: Altogether, the OLS time and GNRI may be factors related to independent walking in elderly inpatients with collagen disease.

Keywords: Collagen disease, disuse syndrome, rehabilitation, rheumatology, walking independence


How to cite this article:
Yamauchi S, Morishita S, Uchiyama Y, Kodama N, Domen K. An investigation into the factors related to independent walking in elderly inpatients with collagen diseases. J Int Soc Phys Rehabil Med 2019;2:30-4

How to cite this URL:
Yamauchi S, Morishita S, Uchiyama Y, Kodama N, Domen K. An investigation into the factors related to independent walking in elderly inpatients with collagen diseases. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2021 Jun 13];2:30-4. Available from: https://www.jisprm.org/text.asp?2019/2/1/30/258764




  Introduction Top


It is important for patients who are admitted to an acute care hospital to walk independently at an early stage in order to prevent disuse syndrome. In particular, it has been reported that elderly hospitalized patients experience decreases in their activities of daily living (ADL) and require increased amounts of care due to the deterioration of physical function accompanying aging, rest, and treatment.[1],[2],[3] Therefore, physical therapists need to be able to accurately judge whether or not patients can walk without assistance. In a few previous studies, factors related to independent walking were studied.[4],[5],[6],[7],[8],[9],[10],[11] However, most of them involved stroke patients. Many patients with collagen diseases are hospitalized and undergo rehabilitation therapy at our institution. Many patients with collagen diseases are treated with corticosteroids. Often, the patients' hospitalizations will be long term with an associated decrease in their ADLs. In particular, the walking ability of elderly patients often declines. We believe that an awareness of the factors related to independent walking in elderly patients with collagen disease will help to reduce the number of patients who would need walking assistance. The purpose of this study was to investigate the factors related to independent walking in elderly patients with collagen diseases.


  Methods Top


This was a cross-sectional study and was performed according to the principles of the Declaration of Helsinki. The study was approved by the Hyogo College of Medical Ethics Review Committee (Approval No. 2715). Informed consent was obtained from each patient.

We evaluated 106 patients with collagen diseases[12] who were >20 years of age and were hospitalized at Hyogo College of Medical Hospital between April 2012 and March 2017. It was imperative for the study that these patients can undergo assessment and that they had requested help with rehabilitation to maintain and improve their physical function. Among these 106 patients, elderly people aged 65 years or older were included. The exclusion criteria were as follows: patients that had recent orthopedic surgery, patients with severe joint deformities, patients with apparent central nervous system symptoms, patients with cognitive impairments, patients who could not walk due to poor respiratory or circulatory function, and patients who could not walk because of pain. After excluding the patients who met the aforementioned criteria and the patients who lacked the data necessary for analysis, the number of target patients for the analysis was 65.

Measurements

The following information was collected from the patients' medical records: sex, age, body mass index (BMI), diagnosis, comorbidities, duration of hospitalization, dose of corticosteroids, and blood chemical analysis data. The BMI was calculated based on the weight and height ratio as follows: body weight in kilograms divided by the height in square meters. Comorbidities included the presence or absence of pulmonary diseases such as interstitial pneumonia, the presence or absence of peripheral neuropathy due to diabetes or other disorders, and the presence or absence of renal failure accompanied by dialysis. The following blood test data were examined: C-reactive protein (CRP), albumin (Alb), hemoglobin (Hb), and creatinine (Cre). In addition, the items in the following sections were measured and used in the evaluation.

Walking independence

Walking independence was evaluated using the functional independence measure (FIM).[13] Walking ability was given a score from 1 to 7 (1 = total assistance from a helper; 2 = maximal assistance from a helper; 3 = moderate assistance from a helper; 4 = minimal assistance from a helper; 5 = walks only short distances [a minimum of 50 ft or 15 m] independently with or without a device, the activity takes more than a reasonable amount of time or there are safety considerations, or supervision or setup from a helper is required; 6 = modified independence with no helper; 7 = complete independence with no helper). Patients with 1–4 points on the FIM were assigned to the physical assistance group, and patients with 5–7 points were assigned to the no physical assistance group.

Knee extension muscle strength

A handheld dynamometer[14] (μ-tas MT1; ANIMA Co., Tokyo, Japan) was used to measure knee extension muscle strength (KES). The measurements were obtained in the sitting position with the upper limbs folded in front of the chest. When the knees were flexed at approximately 90°, the sensor pad was placed on the distal part of the lower leg and the length of the fixing belt was adjusted. An isometric knee extension with maximal effort was performed for 5 s, and these measurements were performed twice on each leg. The higher value of the two measurements was selected for analysis. Measurement values were normalized to body weight, and KES was expressed as a percent of body weight.

One-leg standing time

To measure the patients' balance, we used the one-leg standing (OLS) time. To perform the measurement,[15] patients were instructed to keep their eyes open while in the OLS position, with one foot slightly raised from the floor and the upper limbs hanging down. The time until the raised leg was set back down on the floor was measured, with a maximum time of 30 s recorded for those who could stand on one leg for at least that length of time. Measurements were performed two times each for the right and left legs, and the longest time value of the two measurements was used as the OLS time for each patient.

Geriatric Nutritional Risk Index

The Geriatric Nutritional Risk Index (GNRI)[16] was calculated using the serum albumin level and BMI. We calculated GNRI as follows: GNRI = 14.89 × serum albumin (g/dL) +41.7 × BMI/22.

Statistical analysis

Normality in all data was confirmed using the Shapiro–Wilk test. An unpaired t-test was used to compare BMI, KES, Alb, Hb, and GNRI between the physical assistance group and the no physical assistance group. The Mann–Whitney U-test was used to compare the age, duration of hospitalization, dose of corticosteroid, CRP, and Cre between the two groups. The Chi-square test was used to compare sex, diagnosis, and comorbidities between the two groups. To determine which outcome measures were related to walking independence, a logistic regression analysis was performed using variables that were significantly different according to the univariate analysis. We assessed multicollinearity before performing the logistic regression, and variables having a weaker association with the outcome were eliminated from the independent variables. Variables were chosen using a step-wise forward regression by a likelihood ratio test. Odds ratios (ORs) and their 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curve analyses were performed for some of the items according to the multiple logistic regression analysis. The area under the curve (AUC), sensitivity, and specificity were calculated for the cutoff values. Each cutoff value was determined as the point with the minimum distance from the upper left corner of the item's ROC curve. The statistical analyses were performed using SPSS 19.0 J statistical software (SPSS Japan Inc., Tokyo, Japan). P ≤0.05 was considered to be statistically significant.


  Results Top


[Table 1] shows the participants' characteristics. Of the 65 patients, 24 were allocated to the physical assistance group and 41 were allocated to the no physical assistance group. As a result of the univariate analysis, the KES of the physical assistance group was significantly lower than that of the no physical assistance group (18.6% ±2.2% vs. 35.9% ±2.0%). The groups differed in OLS times (1.2 ± 0.5 s vs. 16.8 ± 1.9 s) and GNRI (77.5 ± 1.8 vs. 84.8 ± 1.7).
Table 1: Characteristics of the patients

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[Table 2] shows the results of the logistic regression analysis. The logistic regression analysis was performed using KES, OLS times, and GNRI, which showed significant differences in the univariate analysis. As a result, the two parameters that were associated with a probability of walking independence were the OLS times (OR = 1.373, 95% CI: 1.115–1.691, P < 0.01) and the GNRI (OR = 1.076, 95% CI: 1.007–1.150, P < 0.05).
Table 2: The logistic regression analysis of related factors of independent walking

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[Figure 1] shows the ROC analysis of the factors related to independent walking. The cutoff value for the OLS time was 4.1 s (sensitivity 75.6; specificity 91.7; AUC = 0.906) and that for the GNRI was 81.7 (sensitivity 61.0; specificity 79.2; AUC = 0.713).
Figure 1: The receiver operating characteristic curve of related factors of independent walking. Each cutoff point was determined as the point with the minimum distance from the upper left corner of the item's receiver operating characteristic curve. The cutoff values of each item were as follows: one-leg standing time, 4.1 s (sensitivity 75.6; specificity 91.7; area under the curve = 0.906); Geriatric Nutritional Risk Index, 81.7 (sensitivity 61.0; specificity 79.2; area under the curve = 0.713)

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  Discussion Top


Our study findings suggest that OLS time and GNRI are factors related to independent walking in elderly inpatients with collagen diseases. The cutoff value was 4.1 s for the OLS time and 81.7 for the GNRI.

In the univariate analysis, KES, OLS time, and GNRI showed significant differences. There have been few reports that have identified independent walking as an outcome, except in the case of stroke patients. There have been many reports that have identified falls and general ADLs as outcomes for older adults.[17],[18],[19],[20] It is reported that muscle strength, balance, and cognitive function are the main parameters affecting walking ability. den Ouden et al.[21] reported that leg strength was associated with a higher probability of being independent in ADLs. It is obvious that muscle strength in the lower limbs affects the walking stability,[22] and it is inferred from this study that KES hindered walking stability, and therefore was a factor related to independent walking.

Regarding OLS time, it has been reported that OLS time affects the walking stability.[23] When the OLS time decreases, the stability of the stance phase during walking is reduced, leading to instability in walking. We also found that a decrease in the OLS time leads to a deterioration of walking stability, and therefore identified OLS time as a factor related to independent walking. The cutoff value for the OLS time was 4.1 s, and the discriminating accuracy was high (sensitivity 75.6; specificity 91.7; AUC = 0.906). There are few studies that have examined the cutoff value for OLS time with independent walking as an outcome. In a study of the elderly that evaluated falling as an endpoint, the cutoff value for the OLS time that was predictive of falls was reported to be 1 s[24] and 5 s.[23] However, because there were different outcomes, making a comparison with this study is difficult. The OLS time reflects lower extremity muscle strength[25] and the function of the foot in terms of ankle control,[26] toe strength, and plantar sensation.[27] Thus, the OLS time provides a functional evaluation of the entire lower limb, including leg strength and the function of the foot. It was thought that the OLS time was chosen as the highest discriminating accuracy item by the logistic regression analysis. Among the balance tests, the OLS time is easy to use in acute-phase patients because it is easy to perform and does not require special equipment or a dedicated location for taking the measurements.[28]

Regarding GNRI, sarcopenia associated with malnutrition has been reported.[29] It has also been reported that physical function and ADLs decrease in older adults with malnutrition.[30] In this study, low GNRI was thought to have led to a decrease in independent walking ability. The cutoff value for the GNRI was 81.7. A low GNRI (<92 points) indicates moderate or severe nutritional risk, and a high GNRI (≥92 points) indicates low or no nutritional risk.[19] Many of the patients in this study had GNRI scores below 92, and even the independent group had relatively low mean scores of 84.8 ± 1.7. There have been no reports that indicate that the collagen diseases are inferior to other diseases with respect to nutritional status. The low results we obtained may have been a result of targeting patients with low stamina who were prescribed rehabilitation.

Study limitations

There are several limitations to the current study. First, we employed a cross-sectional design and only examined factors related to independent walking. Therefore, it will be necessary to verify the predictors of walking independence in a longitudinal study in future. Second, because enrollment in the study was not targeted to all inpatients, and we only included patients who were referred for rehabilitation, some selection bias might have been introduced. Third, the participants had various diagnoses, and the specific characteristics of the diseases were not considered. However, because the patients in this study had diseases designated as rare and intractable in Japan, it was difficult to include a large number of patients. Finally, because it was difficult to identify the definite time of diagnosis from the medical records, it was not possible to clarify the history of the diagnosis in each case.


  Conclusions Top


Our study findings suggest that OLS times and GNRI are factors related to independent walking in elderly inpatients with collagen diseases. The cutoff values were 4.1 s for the OLS time and 81.7 for the GNRI. The cutoff value determined in this study may be helpful for judging independent walking abilities in elderly inpatients with collagen diseases.

Acknowledgments

The authors would like to thank the study participants and the physiotherapists at the hospital's rehabilitation department.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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