Older patients with higher self-reported levels of psychological resilience experienced faster walking speed and longer walking distance after hip fracture surgery, the researchers report.
The findings suggest that treating psychological resilience in rehabilitation programs may improve walking ability in older adults after hip fracture, the authors write.
The study was published July 20 in the Journal of the American Geriatrics Society.
Hip fracture in the elderly can cause significant morbidity and mortality, especially if not surgically treated within 48 to 72 hours. Lying in bed and not moving can lead to multisystem decompensation in the body. Surgical repair of hip fractures can help patients move more and reduce their risk of morbidity and mortality.
Yet even after hip fracture surgery, many older people do not achieve their pre-fracture level of function. In light of this, researchers from the University of Connecticut set out to understand why recovery of walking ability after hip fracture remains highly variable and what psychological factors, in addition to depression, might affect recovery of walking ability.
Richard H. Fortinsky, PhD, co-director of the University of Connecticut Older Americans Independence Center, is the corresponding author. To learn more about the role of resilience, he and his colleagues turned to data they collected through the Community Ambulation Project, a multisite, randomized, controlled trial of 210 older adults randomized to two protocols of different physiotherapy for hip fracture repair.
The role of resilience in recovery
Most study participants were female (77%) and white (96%). The average age was 80.7 years, with 40% being aged 85 or over. About half were widowed and 47% needed a caregiver for help. The mean time from hospital admission to randomization was 103.8 (± 38.2) days.
In the trial, patients’ resilience was measured by the brief 6-point Resilience Scale. Four months later, timed walking tests were performed on the same patients.
When Fortinsky and coauthors analyzed the data, they found that the self-perceived level of psychological resilience in older adults after sustaining a hip fracture was associated with better walking ability, even after controlling for speed and the walking distance at the time the resilience was measured.
Mental toughness is an area of recent research in multiple orthopedic studies. As previously reported by Medscape Medical Newspatients with low grit may have worse functional outcomes after rotator cuff surgery.
In an interview with Medscape Medical NewsFortinsky points out that courage and resilience can be related but should be considered separate attributes.
Courage may be an attribute of how patients may cope with illness or surgery, but “resilience must be considered in the context of an adverse event and how well individuals believe they can cope. recover from adversity”. From his point of view, courage does not presuppose that an adverse event has been added to the equation.
Other orthopedic studies have shown that depression can play a role in how well a patient recovers from surgery, but it can be an independent factor in resilience.
“In our study, depression and resilience were only moderately associated with each other, and even after controlling for depression severity, resilience had a positive effect on demonstrated walking ability. “, said Fortinsky.
It is not yet clear whether pre-existing depression affects psychological resilience after surgery differently than depression resulting from the injury itself. Fortinsky thinks it’s “a great question but we didn’t have the data to distinguish these situations.”
Recovery involves more than physical factors
Kevin Freedman, MD, an orthopedic surgeon at the Rothman Institute in Bryn Mawr, Pennsylvania, who was not involved in the study, agrees with Fortinsky that there may be more than just factors involved in the healing of a patient’s injury.
Doctor Kevin Freeman
“As orthopedists, we need to consider all of the psychological factors that impact our patients’ outcomes after injury or surgery, including resilience,” Freedman said. Medscape Medical News. “In order to use this information to help our patients, we need to measure it and then study how we can improve it.”
Freedman is the senior author of a recent journal titled Resilience in the orthopedic patientpublished in the Journal of Bone and Joint Surgery. “Much of resilience is innate in the person, but research shows that there is behavioral therapy that can improve resilience,” he said. “Some of this literature in orthopedics is summarized in our recent review article. The focus of further research in this area must be on how to improve patients’ resilience after injury to lead to better outcomes.”
Falls and resulting hip fractures remain important causes of significant physical disability in the elderly population. Fortinsky believes that “creative rehabilitation approaches that combine physical and psychological elements are needed to increase the proportion of older adults who can achieve an optimal level of walking ability after hip fracture and maintain an independent lifestyle.” Fortinsky hopes his research and others will become an impetus for these kinds of integrated protocols to be developed.
Freedman would also like to see resilience measures more commonly used in the assessment of orthopedic patients. “We need to recognize patients with low resilience who may be at higher risk for poor outcomes,” he commented.
“Adding a brief resilience scale to interview patients when seen with these injuries can really help identify those at risk for impaired ambulatory ability after surgery,” he said. “We also need to consider cognitive therapy in these patients.”
Freedman thinks surgeons often need to be reminded that their patients’ mental health can be one of the biggest factors correlating to outcomes after surgery.
“No matter how good the surgery we perform,” he says, “if we don’t pay close attention to psychological factors such as the resilience of our patients, we risk missing the warning signs of poor outcomes or opportunities for improvement”.
J Am Geriatr Soc. Published online July 20, 2022. doi: 10.1111/jgs.17930. Full Text.
Fortinsky and Freedman have no financial relationship relevant to this study.
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