Body Weight–supported Treadmill in the Physical Rehabilitation of Severely Demented Subjects After Hip Fracture: A Case Report

To the Editor: Hip fracture (HF) is common in older individuals and often results in functional and walking disabilities.1 In HF patients, the prevalence of cognitive impairment is high, ranging from 31% to 88%, according to different studies.2 Although recent evidence suggests that cognitive impairment is not per se a barrier to functional recovery,3 the rehabilitation of HF patients with severe dementia remains a problem, associated with worse clinical and functional outcomes.4,5 This topic has recently been approached with the body weight–supported treadmill (BWST), a new “technique” that has been evaluated in the rehabilitation of patients with various clinical conditions but has never been attempted in subjects with severe dementia. BWST training involves stepping on a motorized treadmill while unloading a percentage of a person's body weight using a counterweight harness system. Manual assistance is provided as necessary to promote upright posture and lower-extremity trajectories associated with human normal gait.6 The case of an 82-year-old woman with Alzheimer's disease who underwent BWST rehabilitation after cemented arthroplasty for femoral neck fracture is reported here. The patient was admitted to the Rehabilitation and Aged Care Unit, “Ancelle della Carità” Hospital, Cremona, Italy, 4 days after surgical intervention. Severe anemia that required blood transfusions complicated the postsurgical course. The patient had been hypertensive for about 5 years and had been receiving galantamine 8 mg twice a day for 2 years. One month before fracture, her Barthel Index was 68/100, and her Mini-Mental State Examination (MMSE) score, as scored by a neurologist, was 9/30. On admission, the patient was confused and agitated, trying continuously to get up from bed; her daughter reported that these symptoms, previously observed at home, worsened significantly after surgery. On clinical examination, the patient was hypokinetic, able to maintain balance when sitting but not while standing and walking. Blood pressure was normal (120/80 mmHg), and hemoglobin level was 11 g/dL. When a geriatric multidimensional assessment was administered her Barthel Index score was 4/100 and Tinetti scale 1/28,7 denoting severe functional impairment. Pharmacological treatment for pain (paracetamol 500 mg three times per day) and deep venous thromboprophylaxis (nadroparin 0.4 mL per day) was continued according to orthopedic prescription. During the first 4 days, the patient did not participate actively in rehabilitation; specifically, she did not respond to the team's encouragement and was unable to maintain attention to external stimuli. From the 5th day, there was a slight clinical improvement, but although she accepted passive mobilization, she refused to stand up. On the 12th day, clinical conditions further improved, and her cognitive performance regained its prefracture status, with a MMSE score of 9/30, although she continued to be resistive to the physiotherapist encouragement, refusing to walk. Therefore, it was decided to change rehabilitative strategy, using the BWST. Since the first days of treatment, the patient seemed to enjoy BWST training, progressively increasing her endurance and the length of daily sessions in the following days. According to functional improvement, the body-weight suspension was progressively reduced. After the 18th day, she was able to walk for about 40 minutes daily on the treadmill without body-weight support. On the 29th day, she was able to get up autonomously from a chair, maintaining balance without support and walking on floor a few meters with aid. She was discharged on the 36th day, with a Tinetti score of 16/28 and a Barthel Index of 49/100. At 6 months, functional performance, assessed in a clinical visit, was similar to that measured at discharge. BWST had been used after total hip arthroplasty and for hemiparetic spinal cord injuries and parkinsonian patients, improving gait and balance better than conventional training.6,8,9 Only one trial has been performed on patients with HF, but all subjects were nondemented.10 Studies of BWST suggest that it might allow a task-specific repetitive approach and minimize the delay during which gait training can be initiated.6,9 Furthermore, by providing symmetrical removal of weight from the lower extremities, BWST may reduce pain of the affected limb, resulting in more comfort and confidence in walking abilities.8 In addition, when a severely demented patient does not comply with conventional approach because fear of falling (which commonly develops in these subjects after HF), BWST may reduce worry about gait. Furthermore, it might be useful to overcome programming difficulty that these patients frequently exhibit when they have to learn new complex motor strategies (use of walking aids). If these findings can be replicated in case-control studies, BWST should represent an interesting technique for the rehabilitation of patients with HF with severe dementia. The authors wish to thank the patient, relatives, and staff who made this study possible. Financial Disclosure: All authors declare that they have not received financial arrangements from any organization or company for this letter. Author Contributions: The authors were both fully responsible for the writing of this letter. Sponsor's Role: None.