Optimizing geriatric rehabilitation: Evidence-based fitness training and patient-centred goal-setting

This thesis addresses two aims: 1) developing recommendations for the training of physical fitness (muscle strength and endurance) in orthopedic geriatric rehabilitation (GR) and 2) developing an evidence-based practical guideline for patient-centered goal setting. The first chapters examine the required FITT characteristics of physical fitness training for orthopedic GR patients, concerning frequency, intensity, time, and type. Chapter 2 presents a systematic review of 49 systematic reviews, evaluating endurance training in older adults with various health statuses. Most reviews report positive effects on endurance capacity, though training frequency, intensity, and duration vary widely. Mixed aerobic exercise programs, often combined with strength training, are common. Subgroup analyses show benefits for most health conditions. The thesis concludes that ACSM guideline characteristics are broadly applicable, but lower intensities and frequencies also benefit vulnerable older adults, with some conditions requiring specific adjustments. Chapter 3 details an international Delphi study to reach expert consensus on exercise testing and training in orthopedic GR. Thirty experts participated, and recommend the six-minute walk test (6MWT) for endurance and functional tasks for muscle strength assessment. For endurance training, they agree on ACSM-based recommendations: moderate intensity (≥5 sessions/week, 30-60 minutes, Borg 5-6/10) or vigorous intensity (≥3 sessions/week, 20-30 minutes, Borg 7-8/10). For resistance training, consensus supports lower intensities: 2 sessions per week, 2-3 sets of at least 15 repetitions at 40-60% 1RM. Training should be tailored to the individual. Experts stress the importance of continuing the training after GR. Chapter 4 investigates the feasibility of the talk test—a submaximal, incremental cycle ergometer test estimating the first ventilatory threshold—in orthopedic GR patients. Among 93 patients, only 41 (51%) complete the test, mainly due to pain and fatigue, despite selecting patients expected to complete the test. The authors conclude that the talk test is not a feasible alternative for assessing endurance capacity in orthopedic GR, underscoring the need for better testing methods. Chapters 5 and 6 examine current practices in orthopedic rehabilitation. Chapter 5 describes an observational study of 48 patients, revealing significant variation in training characteristics. Adherence to ACSM guidelines is better for resistance training than for endurance training, where no patient meets the recommendations. Muscle strength improves moderately, but endurance capacity does not, resulting in low fitness levels at discharge. Physical functioning gains are not directly related to changes in muscle strength or endurance, possibly due to suboptimal fitness improvements. Chapter 6 presents an interview study identifying 78 factors that influence physical fitness training, spanning patient, family, staff, program, and organizational levels. Barriers include weight-bearing restrictions, patient motivation, staff workload, and equipment availability, while facilitators include family involvement and well-trained staff. The comprehensive overview enables multidisciplinary teams to both enhance interventions and tailor individual training programs to patient needs. Chapter 7 details the development of an evidence-based practical guideline for patient-centered goal setting using participatory action research, involving GR professionals and researchers. The resulting guideline offers eight recommendations, with practical advice for three, focusing on conversational skills for goal setting. The guideline emphasizes involving patients and families, setting meaningful and individualized goals, fostering multidisciplinary collaboration, and regularly evaluating progress throughout the rehabilitation process. In the general discussion, the thesis integrates findings from the Delphi study and the other studies, confirming alignment in recommendations for both training and testing. The authors highlight the need for better endurance capacity tests and increased focus on physical fitness training. Addressing the identified barriers can significantly improve rehabilitation trajectories. The guideline enables teams to evaluate and enhance their goal-setting practices. Future research should develop and test new fitness programs and endurance assessments, and examine the impact of the guideline on patient involvement