Abstract
The findings of this study indicate that optimism positively affected functional ability, and hope positively influenced participation in daily life, 6 mo after a hip fracture among older adults. Long-term intervention should strengthen these powerful aids in older patients’ physical recovery.
In recent years, researchers have made advances in investigating the role of positive psychological factors, such as positive affect, optimism, and hope, in medicine and rehabilitation (Kortte et al., 2012). Positive affect is defined as self-perceived emotion in relation to a specific environment, an object, or a situation (Fredrickson, 2004; Radloff, 1977). It reflects emotional well-being and feelings of joy, contentment, happiness, and personal satisfaction. Optimism is defined as general expectations and beliefs that good outcomes will happen (Scheier & Carver, 1985). Optimism is one part of a two-dimensional psychological trait, with pessimism as the other dimension (Forgeard & Seligman, 2012). Hope is conceived as a one-dimensional structure involving a general perception that a defined goal can be achieved. Hope, according to Snyder et al. (1991), is defined as a dual process, composed of the belief that one can identify the routes to achieve goals (the “pathways” component) and the belief that one can execute these routes to achieve the goals (the “agency” component).
Positive psychological factors have been related to better rehabilitation outcomes among adults with various health conditions. For example, optimism measured 1 wk after acute coronary syndrome predicted better physical health status after 1 yr (Scheier et al., 1989), and optimism measured 1 day before coronary artery bypass graft surgery predicted faster return to normal life activities 6 mo later (Ronaldson et al., 2015). In addition, at the acute rehabilitation stage after a variety of physical injuries, hope and positive affect were significantly associated with activities of daily living (ADLs) and functional role participation 3 mo after discharge from rehabilitation; hope (but not positive affect) predicted functional role participation (Kortte et al., 2012). A prospective study of older adults after a hip fracture found that those who exhibited high positive affect at baseline achieved better mobility over 2 yr after rehabilitation than those with low positive affect and depressive symptoms (Fredman et al., 2006). However, not all studies found significant correlations between positive psychological factors and rehabilitation outcomes (Hartley et al., 2008; Waldrop et al., 2001).
Hip fractures, particularly among older adults, result in deficits that extend beyond the orthopedic injury, such as loss of independent ambulation, limited mobility, interference with ADLs and instrumental activities of daily living (IADLs), and reduced quality of life for up to 1 yr after the fracture (Dyer et al., 2016). In a previous study, we found that older adults who had sustained a hip fracture experienced restricted participation in daily life situations (Segev-Jacubovski et al., 2019); such participation constitutes the highest level of functioning according to the International Classification of Functioning, Disability, and Health (ICF; World Health Organization [WHO], 2001). Even older adults with intact cognition and high prefracture functioning did not fully recover their original ADL or IADL levels; they reached an average of only 66.8% of their prior total participation level after 6 mo (Segev-Jacubovski et al., 2019).
According to the ICF, functioning and participation should be viewed as an interaction among biopsychosocial factors (WHO, 2001). The philosophy of professional occupational therapy likewise places great emphasis on the connection between clients' mind–body–spirit and their participation in daily life occupations because engagement in meaningful everyday activities substantially contributes to people’s health and well-being (American Occupational Therapy Association [AOTA], 2014). Older adults struggle with complex psychological challenges after a hip fracture, which can prevent them from fully engaging in rehabilitation (Proctor et al., 2008). The innovation in our study consisted of applying a broad perspective to examine the personal positive psychological factors along with the physical factors that may affect human functioning and participation among older adults with hip fractures, with a goal of improving the prediction of rehabilitation outcomes from the acute stage to after rehabilitation. We endeavored to predict functional ability and participation in daily life in older adults who had experienced a hip fracture by measuring physical and psychological factors at admission to acute rehabilitation and comparing the results to measurements at discharge and 6 mo later.
Method
Participants and Procedure
This prospective and cross-sectional cohort study included 71 participants who had sustained a hip fracture because of a fall. They were recruited from the Beit Rivka Geriatric Medical Center, a university-affiliated inpatient rehabilitation center in Israel that receives postacute patients from nearby hospitals. The inclusion criteria were age 65 yr or older, ability to independently leave their home before the fall, score of ≥24 on the Mini-Mental State Examination (Folstein et al., 1975) at admission, and agreement to participate by signing informed consent. We established broad exclusion criteria to prevent potential influences on the outcomes and psychological factors. We excluded potential participants who were admitted from a nursing home or who had neurological impairments, multiple fractures, or a pathological fracture; who had a history of metastatic cancer; who were unable to walk before the fracture or were non–weight bearing after surgery; or who had other medical complications during rehabilitation. All the participants received physical and occupational therapy during the acute phase of rehabilitation.
Of these 71 participants, 16 were excluded from the follow-up: 8 refused to participate, 6 were diagnosed with new medical conditions before reaching follow-up, 1 moved to a nursing home, and 1 could not be reached. Therefore, 55 participants were included in the 6-mo follow-up; all but 2 continued with their individualized physical and occupational therapy intervention protocols, either at the clinic or through home visits. However, a large variation was noted in the number of treatments.
Data collection was performed approximately 10 days from admission to acute rehabilitation at discharge and 6 mo after discharge from rehabilitation at homes. The Adult Hope Scale (AHS; Snyder et al., 1991), Life Orientation Test (LOT; Scheier & Carver, 1985), Positive Affect Questionnaire (Radloff, 1977), Numeric Pain Rating Scale (NPRS; Childs et al., 2005), hand-grip strength measures were used at admission and at follow-up. The Geriatric Depression Scale (GDS; Burke et al., 1991) was used only at admission to acute rehabilitation, and the FIM® Motor domain (mFIM; Hamilton et al., 1987) was used at rehabilitation admission, discharge, and at follow-up. In addition, the Activity Card Sort (ACS; Baum & Edwards, 2001) was added at follow-up. The study was approved by Rabin Medical Center’s Helsinki committee (0511-13-RMC).
Measures
Positive Affect Questionnaire
The Positive Affect Questionnaire, a four-item positive affect summary scale, is part of the Center for Epidemiologic Studies Depression Scale (Radloff, 1977). The degrees of positive feelings during the previous week are measured on a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most of the time). Summary scores range from 0 to 12, with higher scores indicating higher positive affect. In this study, the four positive affect items showed moderate internal consistency (Cronbach’s α = .69).
Life Orientation Test
The LOT (Scheier & Carver, 1985) is a self-report questionnaire assessing dispositional optimism as generalized expectancies for positive versus negative outcomes. The test of 12 items is composed of 4 positively oriented, 4 negatively oriented, and 4 distracter items. Respondents rate how strongly they agree with each statement as representative of their life (“trait approach”) on a 5-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). The total score (after reversing the negative item scores) yields an overall optimism score ranging from 4 to 32. Higher scores represent higher optimism. The internal consistency in this study was moderately high (Cronbach’s α = .72).
Adult Hope Scale
The AHS (Snyder et al., 1991) is a self-report inventory composed of 12 items. Four items measure agency thinking, or the respondent’s sense of determination to meet the goals. Another 4 items measure pathways, or the respondent’s perceived ways to attain those goals. Four additional items are used as distracters. Participants express their trait approach via an 8-point Likert-scale ranging from 1 (definitely false) to 8 (definitely true). Three scores are typically used: an agency score (4–32), a pathways score (4–32), and a total hope score (8–64). Higher scores indicate higher levels of hope. In this study, the agency and pathways components showed moderate internal consistency (Cronbach’s αs = .65 and .59, respectively).
Geriatric Depression Scale
The GDS (Burke et al., 1991) is a self-report scale consisting of 15 yes–no questions regarding symptoms of depression experienced lately. The total score on the GDS ranges from 0 to 15, with higher scores representing more depressive symptoms. The sensitivity is 93%, and the specificity is 48%, for adults who are cognitively intact; therefore, it can serve as a screening tool (Burke et al., 1991). The internal consistency in this study was moderately high (Cronbach’s α = .79).
Hand-Grip Strength
Hand-grip strength is a physical measure of general physical condition (Taekema et al., 2010). It is an outcome measure that has been shown to relate directly to functional ability and walking recovery after a hip fracture (Savino et al., 2013). Hand-grip strength was measured with a Camry electronic hand dynamometer (Camry Scale USA, South El Monte, CA). The participants were instructed to keep their shoulders adducted during measurement, with elbow extended and wrist in a neutral position, and then to squeeze the grip with maximal strength. The result, measured in kilograms, was the mean of two trials using the dominant hand in a seated position.
Numeric Pain Rating Scale
The NPRS (Childs et al., 2005) is a self-report rating scale for measuring pain, with scores ranging from 0 (no pain) to 10 (worst pain). Participants rated their pain in the surgical area while resting and while walking.
FIM Motor Domain
The FIM (Hamilton et al., 1987) is a standardized measure of functional ability with 18 items covering three domains. The 8 basic ADL items and 5 mobility level items together compose the mFIM; the 5 items in the FIM Cognitive domain were not used in this study. Items are scored on a 7-point scale ranging from 1 (complete dependence) to 7 (complete independence). Total mFIM scores range from 13 to 91, with higher scores indicating greater functional independence.
Activity Card Sort
The ACS (Baum & Edwards, 2001) measures current activity participation compared with prior activity participation (i.e., before the hip fracture). The ACS includes 89 photographs of adults performing tasks in four domains: IADLs, low-demand leisure activity, high-demand leisure activity, and social activity. Participants were instructed to sort the illustrated activities into three categories: those they continued after the hip fracture, those they stopped because of the hip fracture, and those they partially resumed after the hip fracture. The score is the percentage (0–100) of activities currently performed compared with the activities performed previously. Higher scores demonstrate higher continuation of previous activities. Each domain has a score, and the total score represents general participation. The total ACS score was used in this study.
Statistical Analyses
We performed descriptive and statistical analyses using IBM SPSS Statistics (Version 21) for Windows. The significance level was set at .05. Pearson correlation coefficients were used to test the correlations between measures. Two hierarchical linear regressions were conducted for predicting mFIM scores, at discharge and at follow-up, using determinant factors identified during admission to rehabilitation. The variables were entered into the regressions in the following order: age plus gender, hand-grip strength, mFIM at admission, GDS, and positive affect. The third hierarchical linear regression was conducted for explaining the mFIM scores at 6-mo follow-up using determinant factors at that time in the following order: age plus gender, hand-grip strength, and optimism (which had the highest significant correlation with mFIM of the positive psychological factors). The fourth regression was conducted for predicting the ACS results at follow-up by determinant factors at admission to rehabilitation in the following order: age plus gender, hope–agency component (which had the highest significant correlation with the outcome of positive psychological factors), and pain while walking. The fifth regression was conducted for explaining ACS results after 6 mo by determinant factors at that time in three blocks in the following order: age plus gender, total hope score (which had the highest significant correlation with the outcome of positive psychological factors), and mFIM after 6 mo.
Results
Table 1 presents the characteristics of the 71 participants at admission (and mFIM scores at discharge) and of the 55 participants at 6-mo follow-up. The mean number of days between the fall that caused the fracture and the hip surgery was 1.32 (SD = 1.59), and the mean number of days until arrival at rehabilitation was 8.59 days (SD = 4.33). The mean length of stay in acute rehabilitation was 32.58 days (SD = 10.3).
Demographic, Determinant, and Outcome Characteristics of the Participants
Note. ACS = Activity Card Sort (at follow-up); GDS = Geriatric Depression Scale; mFIM = FIM® Motor domain (at admission, discharge, and follow-up); MMSE = Mini-Mental State Examination; NA = not applicable; NPRS = Numeric Pain Rating Scale.
Bivariate Correlations Between Psychological and Physical Factors and mFIM Scores
At discharge from rehabilitation, significant positive correlations were found among positive affect, hand-grip strength, and mFIM scores. In addition, a significant negative correlation was found between GDS and mFIM scores. No significant correlation was found between explanatory factors at admission to rehabilitation and mFIM scores at 6-mo follow-up. Follow-up data revealed significant positive correlations linking mFIM scores to positive affect, optimism, the hope–pathways component, the total hope score, and hand-grip strength. All correlations are presented in Table 2.
Correlations of Psychological Factors, Physical Factors, and Outcome Measures at Discharge From Rehabilitation and 6-Mo Follow-Up
Note. ACS = Activity Card Sort; GDS = Geriatric Depression Scale; mFIM = FIM® Motor domain; NPRS = Numeric Pain Rating Scale.
Only correlations from follow-up to follow-up are presented.
p < .05.
p < .01.
Bivariate Correlations Between Psychological and Physical Factors and Activity Card Sort Results
A significant positive correlation was found between the hope–agency component at admission and ACS results after 6 mo. Moreover, a significant negative correlation was found between pain while walking at admission and ACS results at 6 mo. At follow-up, significant positive correlations were found linking ACS results with optimism, the hope–agency component, the hope–pathways component, and the total hope score. These correlations are presented in Table 2.
Regression Models for Predicting Rehabilitation Outcomes
Five hierarchical linear regressions are presented in Table 3. The first regression, for predicting mFIM from admission to discharge, revealed a significant effect of age and gender in the first step, accounting for 31.2% of the variance, R 2 = .13, F(2, 64) = 14.51, p < .01. Only the effect of age was significant, however, indicating that relatively younger older adults performed better. Hand-grip strength added 11.0% to the explained variance, R 2 change = .11, F(3, 63) = 15.32, p < .01, and mFIM added another 9.8% to the variance, R 2 change = .10, F(4, 62) = 16.77, p < .01. In the second regression, for predicting mFIM from admission to follow-up, age and gender accounted for 15.1% of the variance, R 2 = .15, F(2, 51) = 4.54, p < .05, but again, only the effect of age was significant. mFIM at admission added 14.2% to the variance, R 2 change = .12, F(4, 49) = 4.89, p < .01.
Hierarchical Linear Regression for Prediction of Performance on the mFIM and ACS
Note. ACS = Activity Card Sort; GDS = Geriatric Depression Scale; mFIM = FIM® Motor domain; NPRS = Numeric Pain Rating Scale.
p = .057.
p = .075.
p < .05.
p < .01.
p < .001.
The third regression, for explaining mFIM at follow-up by determinant factors at that time, revealed that age and gender accounted for 14.2% of the variance, R 2 = .14, F(2, 52) = 4.14, p < .05. Relatively younger older adults performed better, and gender was not significant. Hand-grip strength added 12.7% to the explained variance, R 2 change = .13, F(3, 49) = 5.78, p < .01. Optimism in the third step added another 8.5% to the explained variance, R 2 change = .09, F(4, 48) = 6.39, p < .05. In this regression gender became significant, indicating that women showed better mFIM performance at follow-up.
For predicting ACS performance at 6-mo follow-up by determinant factors at admission, age and gender accounted for 17.7% of the variance, R 2 = .18, F(2, 52) = 5.59, p < .01, as presented in the fourth regression in Table 3. Only age was significant, with older adults of relatively younger ages performing better. The hope–agency component was marginally significant and added 5.0% to the variance, R 2 change = .23, F(3, 51) = 4.99, p = .075, and pain while walking added 8.5%, R 2 = .31, F(4, 50) = 5.67, p < .005. The fifth regression, for explaining ACS by determinant factors at follow-up, revealed that age and gender accounted for 17.7% of the variance, R 2 = .18, F(2, 52) = 5.59, p < .01. As before, only the effect of age was significant. mFIM at follow-up added 20.8% to the explained variance, R 2 change = .21, F(4, 50) = 9.45, p < .000.
Discussion
The novelty of this study was in expanding the perspective concerning which factors may influence rehabilitation outcomes by adding positive psychological factors to the predictive paradigm. Our results indicate that optimism at 6-mo follow-up contributed to functional ability at that time, above and beyond the physical factors of age, gender, and hand-grip strength. In addition, the hope–agency component at admission was marginally significant in predicting participation 6 mo after the fracture, above and beyond age and gender. Our results reinforce previous studies that showed that optimism and hope can facilitate successful adaptation and good outcomes in medical rehabilitation after orthopedic or neurological injuries (Kortte et al., 2012; Ronaldson et al., 2015 ; Scheier et al., 1989). Moreover, optimism and hope were found to be predictors of treatment adherence among primary care patients (Nsamenang & Hirsch, 2015).
Optimism and hope are stable traits that can influence functional outcomes over the long term and enable patients to cope with prolonged physical injury and achieve functional recovery (Carver et al., 2010; Kortte et al., 2012). In contrast, positive affect is considered a transient emotion linked to the current situation (Fredrickson, 2004). Indeed, our results indicate that long-term rehabilitation outcomes might depend less on transient emotional resources. Given that hip fracture can reduce functional ability up to 1 yr later (Dyer et al., 2016; Segev-Jacubovski et al., 2019), high levels of optimism can lead to improving this outcome for several reasons. Optimism is positively associated with an approach coping strategy, which the person uses to reduce and manage stressors or negative emotions (Solberg Nes & Segerstrom, 2006). The approach strategy is negatively associated with the avoidance strategy, in which the person seeks to ignore or retreat from stressors or negative emotions. Hence, optimistic people are more likely to cope in active problem-solving ways and to adjust to stressful life events more effectively (Solberg Nes & Segerstrom, 2006). Optimistic rehabilitation participants in our study dealt better with the stress of the functional disability and returned to their previous self-care abilities despite the objective difficulties.
Participation in daily life is an important rehabilitation outcome and component of a healthy aging process (WHO, 2001). Similar to our participants, community-dwelling people with chronic stroke restrictions improved their participation when their hopeful thinking was higher (Choi et al., 2015). After admission to rehabilitation, a higher level of the hope–agency component, which is related to the expectation of achieving goals (Snyder et al., 1991), can provide determination, initiative, and persistence for achieving those goals (Kortte et al., 2012); it can therefore lead to increased participation in complex and heterogeneous daily life activities.
Nevertheless, positive psychological factors after admission to acute rehabilitation might not predict functional ability at discharge for several reasons. As Forgeard and Seligman (2012) proposed, when it becomes clear that a desired goal will not be achieved in the near future, small doses of realistic pessimism may be advisable to prevent disappointment. Hip fracture rehabilitation patients, as in our study, may have realized during treatment that their goal of independent self-care would not be achieved as quickly as hoped (Zidén et al., 2008). Given that optimism and hope are cognitive sets (Forgeard & Seligman, 2012; Snyder et al., 1991), they might have thus adopted a more realistic view of the future. Alternatively, Gesar et al. (2017) suggested that older adults may have adapted to the routine of the acute ward by becoming passive and insecure about their future life situation. We also propose another explanation: that older adults with intact cognition can overcome and compensate for their difficulties by finding creative solutions for performing daily life activities. Alternatively, they could shift and make their expectations for recovery more modest.
Functional ability as measured with the mFIM was a strong predictor of functional ability and participation because it reflects the strengths and limitations of a person, consistent with the top-down approach (Weinstock-Zlotnick & Hinojosa, 2004). Similarly, Hershkovitz et al. (2020) found that among older adult patients recovering from hip fracture, higher FIM scores at admission were significantly associated with better FIM scores at discharge. In addition, the highest impact on participation was shown by functional ability at the examined time, as was found in a similar study among adult patients who had a stroke (Choi et al., 2015). It is probable that the motor capabilities that were necessary for functional ability and mobility also restricted participation.
Unsurprisingly, age, hand-grip strength, and pain in the surgical area were significant in the recovery process; these factors predicted functional ability and participation, as has been found in previous studies (Gesar et al., 2017; Oh & Feldt, 2000; Taekema et al., 2010). In our results, however, hand-grip strength predicted functional ability but not participation. Participation assessment in our study included IADLs, leisure activities, and cultural–social activities, most of which can be performed sitting, therefore requiring reduced physical strength. Pain while walking at admission predicted low participation at follow-up. Perhaps the memory of pain at admission to rehabilitation caused avoidance of the nonobligatory activities measured at the 6-mo follow-up. Likewise, depressive symptoms after a hip fracture operation have been negatively associated with functional recovery (Oh & Feldt, 2000). However, depressive symptoms and positive affect did not predict functional ability or participation after discharge from acute rehabilitation or at follow-up. Both were measured in relation to contemporary feelings, and as transient emotional resources, they might have had less impact on rehabilitation outcomes.
Limitations
Several limitations in this study should be noted. First, our sample was small. Second, it included only older adults with intact cognitive abilities; therefore, the results can be generalized only to this population of older adults. Future research should examine larger and more diverse populations, including patients with mild cognitive impairments.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice: Our findings indicate that optimism positively affected functional ability, and hope positively influenced participation in daily life, 6 mo after a hip fracture among older adults. Comprehensive rehabilitation evaluation should measure optimism and hope. Long-term intervention should aim to strengthen them as powerful aids in older patients’ physical recovery from hip fractures. Depressive symptoms and positive affect may not predict functional ability or participation during acute rehabilitation or 6 mo after discharge.
Conclusion
The ICF framework focuses on achieving participation in daily life activities and functioning (WHO, 2001), and these concepts have been long considered central within the domain of occupational therapy (AOTA, 2014). In this novel study, we focused on expanding awareness of personal positive psychological factors that may improve long-term rehabilitation outcomes, particularly functional abilities and life participation. We adopted a broad perception by using both prospective and cross-sectional methods. We also aimed for a comprehensive participation assessment in relation to the participation levels before the fracture (Baum & Edwards, 2001).
Our findings indicate that optimism and hope played a role in functional ability and participation among older adults 6 mo after a hip fracture, especially influencing long-term rehabilitation outcomes. This finding reinforces the clinical perspective that comprehensive rehabilitation evaluation should include positive psychological factors to enhance the understanding of likely rehabilitation outcomes. Moreover, long-term rehabilitation intervention should aim at bolstering optimism and hope as a powerful method of channeling patients’ psychological resources to influence their physical recovery.
Various theories from other disciplines include positive psychological factors as determinants for healthy behavior, function, and participation, on the assumption that they contribute to understanding the mechanisms of functional recovery. Occupational therapy embraces the Model of Human Occupation, which addresses the necessity of volition and motivation for participation in occupation (Kielhofner, 2008). Positive psychology also focuses on human strengths such as optimism, hope, courage, and faith for adapting behavior. Its emphasis on expanding these positive qualities helps people to perceive themselves as responsible and masterful decision makers (Seligman, 2000). “Broaden and build” psychological theory recognizes the mutual relationship between positive emotion and functional recovery, producing an “upward spiral” toward enhanced well-being (Fredrickson, 2004). These various theories can be used in future studies to improve functional ability and participation through positive psychological factors.
Footnotes
Acknowledgments
The authors report no conflicts of interest. This research was conducted at the School of Occupational Therapy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.