77
Japanese Journal of Comprehensive Rehabilitation Science (2017)

Case Report

Improved activities of daily living in a patient with subtrochantericfemur fracture through incorporation of continuous positive airway
pressure therapy following convalescent rehabilitation
Hiroshi Kakuta, MD,1 Michio Yamaguchi, PT,1 Kazuyoshi Sugawara, PT,1 Naomi Kuge, PT, PhD,1Hirofumi Imai, MD,2 Akira Rikimaru, MD, PhD,1 Hironao Yokomichi, MD, PhD,1Takashi Sakamoto, MD,3 Ken Sugiyama, MD, PhD,4 Shin-Ichi Izumi, MD, PhD,5Michio Hongo, MD, PhD1Kurokawa General Hospital, Taiwa, Miyagi, Japan
Minamisanriku Hospital, Minamisanriku, Miyagi, Japan
3Sendai Red Cross Hospital, Sendai, Miyagi, Japan
4
Sato Hospital, Sendai, MIyagi, Japan
5Tohoku University Graduate School of Biomedical Engineering, Sendai, Miyagi, Japan
12ABSTRACT
Kakuta H, Yamaguchi M, Sugawara K, Kuge N, Imai
H, Rikimaru A, Yokomichi H, Sakamoto T, SugiyamaK, Izumi S, Hongo M. Improved activities of dailyliving in a patient with subtrochanteric femur fracture
through incorporation of continuous positive airway
pressure therapy following convalescent rehabilitation.
Jpn J Compr Rehabil Sci 2017; 8: 77-81.
Objective: Sleep disorders interfere with activities ofdaily living (ADL) in elderly individuals. In Japan, atleast 3 million people are estimated to have sleep apnea
syndrome (SAS), and many potential patients are yet to
be diagnosed and treated. In women, the incidence of
SAS increases 2-4 fold after menopause due to reduced
hormone levels. In addition, women rarely present withtypical symptoms of SAS, such as daytime sleepinessand snoring, and thus they are not screened for SAS asoften as men. This study aimed to evaluate the utility ofcontinuous positive airway pressure therapy (CPAP) toimprove ADL.
Methods: This report describes an elderly woman
with dementia, depression, and angina who developed
disuse syndrome after surgery for subtrochantericfracture of the left femur, and was treated with CPAP
and other general measures.
Results: The patient showed progressive improvement
Correspondence: Hiroshi Kakuta, MD
Department of Medicine, Kurokawa General Hospital,
Nishihinoki 60, Yoshiokaaza, Taiwa, Kurokawagun, Miyagi
981-3682, Japan.
E-mail: hiroshikk@jadecom.jp
Accepted: May 9, 2017.
There are no conflicts of interest associated with this case report.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.77

in ADL by the simplification of medications, managementof general health, diagnosis of SAS, and incorporationof CPAP therapy following convalescent rehabilitation.
Conclusion: Activities of daily living can be improvedin orthopedic patients with SAS by using CPAP andother general lifestyle measures.
Key words: convalescent rehabilitation, sleep apnea
syndrome, continuous positive airway pressure therapy,
subtrochanteric femur fracture, postoperative disuse
syndrome
Introduction
Sleep disorders in elderly individuals adversely affecttheir activities of daily living (ADL) [1], and ADL inelderly patients with sequelae of stroke can be improved
through continuous positive airway pressure (CPAP)
therapy [2]. Here, we diagnosed obstructive sleep apnea
syndrome (OSAS) in a patient who developed disuse
syndrome after surgery for subtrochanteric fracture of
the left femur. We report the improvement in her ADL
through treatment of SAS following convalescentrehabilitation.
CaseThe patient was an 85-year-old woman living with herson and daughter-in-law whose chief complaint was theinability to walk. Her family history was unremarkable.
She had a history of depression, dementia, and angina.
She presented at hospital A after a fall at home. Simple
radiography revealed a subtrochanteric fracture of the left
femur (Figure 1). Wire cerclage was performed under
lumbar anesthesia using the Accord cable system and aJpn J Compr Rehabil Sci Vol 8, 2017

78

Kakuta H et al.: Improved ADL in femur fracture patient through CPAP after convalescent rehabilitation

Figure 2. Chest computed tomography performed at
the time of transfer to our hospital.

Figure 1. Femur fracture on simple radiography
performed at the previous hospital at initial visit.
long Gamma nail. On postoperative day 27, the patient
was transferred to our hospital to undergo rehabilitativeintervention for postoperative disuse syndrome. Oral
medications at admission were loxoprofen sodium,
rebamipide, donepezil, midodrine hydrochloride,
alfacalcidol, bifidobacteria, warfarin, isosorbide dinitrate,and mianserin hydrochloride. Before the bone fracture,
her ADL included slow ambulation with a cane.
On physical examination, the patient was found to
be in poor general health with reduced communication
ability. She had no respiratory discomfort or pain at
the surgical site. Her height was 140 cm, weight was39 kg, body mass index 19.9 kg/m2, and blood pressure
119/83 mmHg. She was wearing a pair of elastic
compression stockings but had no pedal edema. Mild
dry rales were detected in the right lung.
Neurological examination revealed no brain
abnormalities Motor system examination by manualmuscle testing (MMT) revealed MMT4 in the rightand left arms, MMT3 in the right leg, and MMT2 inthe left leg. Cutaneous and proprioceptive sensory
processing were normal. Both coordination and deep
tendon reflexes were normal, and no pathologic
reflexes were detected.
Investigations
a. Imaging: Simple chest radiography (XP) and chest
computed tomography (CT) revealed a large pleural
effusion in the right lung (> left lung).
b. Clinical biochemistry: Total protein, 5.2 g/dL;
Jpn J Compr Rehabil Sci Vol 8, 2017albumin, 3.0 g/dL; aspartate aminotransferase, 14 IU/L;
alanine aminotransferase, 6 IU/L; blood urea nitrogen,15 mg/dL; creatinine, 0.53 mg/dL; sodium, 138 mEq/L;
potassium, 3.3 mEq/L; chloride, 94 mEq/L; glucose,
89 mg/dL; white blood count, 5370 cells/μL; red bloodcount, 3.12 million cells/μL; hemoglobin, 9.4 g/dL;
C-reactive protein, 1.6 mg/dL; urine glucose, (–); urineprotein, (–); B-type natriuretic peptide (BNP), 58.7 pg/mL (normal <18.4); and thyroid function tests (allnormal).
c. Echocardiography: Aortic diameter, left axis
deviation, interventricular septum, posterior wall
thickness in diastole, and left ventricular diastolic andsystolic dimensions were all within normal range.
Additional findings included ejection fraction of 71%,
third-degree aortic insufficiency, third-degree tricuspid
insufficiency, first-degree pulmonary valve insufficiency,
no pericardial fluid, no left ventricular hypertrophy, noleft ventricular wall motion abnormalities, and no leftatrial load.
Evaluation for rehabilitation:
Partial assistance was needed when turning in bed
or getting up from bed, but only standby assistance
was required when seated in bed with her legs hanging
over the side of the bed. She was not examined inother positions. Functional independence measure(FIM) score was 37 points. All motor items scored 1point.
Post-admission course:
From post-admission day 2, physical therapy (average
1.1 units/day) was performed to strengthen muscles,
increase the range of motion at joints, and train for basic
movements.
The patient’s poor communication ability wasattributed to the synergistic effect of multidrug regimens,
not dementia. Accordingly, we terminated theadministration of oral donepezil and maprotilinehydrochloride, the latter having been prescribed uponadmission to our hospital instead of mianserin

Kakuta H et al.: Improved ADL in femur fracture patient through CPAP after convalescent rehabilitation79

hydrochloride. Her communication ability graduallyimproved. The patient presented with hypoxemia; a large
pleural effusion was observed on the chest XP and CT(Figure 2). Echocardiography showed combined valvulardisease and no left ventricular hypertrophy, but mild
heart failure was suspected based on the BNP levels.
Because the patient’s appetite and blood albumin levels
improved along with her communication, short-term
furosemide was administered to treat the pleural effusion.
On post-onset day 7, the pleural effusion was verified tohave resolved, and daytime oxygen saturation (SaO2)
increased to 95-98%. On day 18, while sleeping at night,
SaO2 decreased to around 70-80% due to prolonged
bouts of apnea.
On day 25, out-of-center sleep testing, conducted
for a definitive diagnosis of SAS, revealed an apneahypopnea index (AHI) of 49.2 /h (normal, <5 /h) andan oxygen desaturation index of 56 /h.
On day 30, the patient was transferred to theconvalescent rehabilitation unit. Prompt incorporationof full-night polysomnography (PSG) and CPAP wasinitially planned, but because these procedures are notcovered by national health insurance for screening ortreatment in convalescent rehabilitation inpatient units,
they were both scheduled for after hospital discharge.
The patient underwent rehabilitation (physical therapy
only, average 2.6 units/day) during the day and received
oxygen therapy to prevent hypoxia during the night.
This improved her ADL, and FIM scores increased
from 37 points at admission to 70 points at discharge(day 95). On day 99, she was readmitted for one nightfor full-night PSG. We diagnosed severe OSAS andincorporated CPAP on the next day (day 100) based on
the PSG findings: AHI of 59.6 /h (244 apneic episodes),longest duration of apnea 141.5 s, and lowest SaO2 20%(Table 1). After CPAP, treatment outcome was checked
monthly through EncoreAnywhere™, a cloud-based
patient compliance management system. In the firstmonth, CPAP use was 11%, showing poor adherence totreatment. We carefully explained the danger of leaving
severe SAS untreated and the benefits of CPAP to thepatient and her family. Two months later (day 150), therate of use during the previous month markedly
improved to 89.7%, the mean AHI also improved to 5.4 /h(almost normal, ≤5), and the FIM score increased to93 (Figure 3). Three months after discharge (day 185),
1-month usage of CPAP was 94.1%, the mean AHI was7.1 /h, and the FIM score was 92 points. Subsequently,
the rate of use of CPAP was maintained at above 80%.
FIM items that improved after discharge were dressing(improved from FIM1 (needing assistance) to FIM5(needing standby)), bowel/bladder management(improved from FIM3 to FIM6 (independence)), andbathing (improved from FIM1 to FIM4). The patient wasbedridden at the time of admission to our hospital but wasambulatory, using a wheelchair or walking frame, at thetime of discharge. After undergoing CPAP therapy athome, she could walk 15 m continuously with the help ofa walker (Table 2). The patient no longer had dyspnea,
which she had during hospitalization, and this may be

Table 1. Polysomnography data.
Total sleep time

REM
Stage 1
Stage 2
Stage 3+4

338 min47 min (13.9%)
199.5 min (59%)
91 min (26.9%)
0.5 min (0.1%)

Total number of awakenings (/h)

438 (46.1 /h)

Apnea-hypopnea
Apnea

336 (59.6 /h)
244 (43.3 /h)
2
2366
141.5 sec
92 (16.3 /h)
68.5 sec

Hypopnea

Total number (AHI/h)Total number (AI/h)Type
Longest duration
Total number (HI/h)Longest duration

CentralObstructive
Mixed

Oxygen saturation

MeanLowest
Oxygen desaturation index (ODI)

94%20%37.4 /h

Leg EMG

Leg movement (LM) index /hLM index for periodic limb movement

11.8 /h
6.4 /hBody position

SupineProne
Right lateral
Left lateral

570 min
0 min
0 min
0 min
Jpn J Compr Rehabil Sci Vol 8, 2017

80Kakuta H et al.: Improved ADL in femur fracture patient through CPAP after convalescent rehabilitation

Figure 3. Treatment outcome based on the Functional Independence Measure scores.
attributable to the improvement in ADL due to stablecardiovascular function. After near-continuous CPAP
therapy for three years, hardly any decline in ADL wasobserved. On day 1284, while in CPAP therapy, anexamination was performed using Smart Watch PMP300E, which can also measure respiratory effort. Insteadof sleep apnea, which was previously observed 244 /night, nonpathological hypopnea was observed, and theAHI value was 2.4 /h, indicating marked improvement.
Written informed consent was obtained from the patientand her family prior to preparing this report.
Discussion
In this study, by simplifying medications, performing
rehabilitation and oxygen therapy, and incorporating
CPAP, ADL was improved in a patient with preexisting
dementia and depression, with poor communication

ability, and nighttime SaO2 reduction, as well as
postoperative complications after surgery for
subtrochanteric femur fracture. Improvement wasespecially notable in the motor items; no difference
was observed in the cognition items.
Treatment outcomes of CPAP vary widely among
elderly patients with OSAS. A study of stroke patients
undergoing rehabilitation reported that CPAP therapy
for OSAS improved ADL, but not cognitive
impairment [2]. Also, other studies showed that CPAP
therapy improved (1) exercise tolerance, ventilatory
function, and respiratory pattern during rehabilitation
after coronary artery bypass [3], (2) exercise tolerance
among patients with congestive heart failure [4], and(3) sleepiness, 6-min walking distance, exercise time,
maximum oxygen consumption, dyspnea, and fatigue
in patients with OSAS [5].
Regarding neuropsychological symptoms, 53.9%

Table 2. Summary of treatment courses and outcomes.
Intervention

General ward

Convalescentrehabilitation ward

Treatment

Night: Oxygentherapy
Day: Rehabilitation

Night: Oxygen therapy

Hospital admission for
the night

Day: Intensiverehabilitation

PSG

Day 25:Out-of-center
sleep testing
AHI: 49.2 times/h
ODI (3%): 56 times/h

FIM

At transfer:
37 points

At discharge (day 95):
70 points

Ambulation

Bedridden

Wheelchair
With a walking frame

Post-discharge 2months

Post-discharge 3months

CPAP
Daycare service for
ADL rehabilitation

CPAPDaycare service for
ADL rehabilitation

Day 150: 93 points

Day 185: 92 points

Day 99: Full-nightpolysomnography
AHI: 59.6 times/h
ODI (3%): 37.5 times/hLongest apnea: 141.5 sec
Longest hypopnea: 68.5 sec

Jpn J Compr Rehabil Sci Vol 8, 2017

With a wheeledwalker
15 m without rest

Kakuta H et al.: Improved ADL in femur fracture patient through CPAP after convalescent rehabilitation81and 46.1% of patients with OSAS have anxiety anddepression, respectively [6]. OSAS facilitates thedecline of cognitive function, but CPAP impedes theprogression of cognitive impairment [7].
A previous study described the association of OSAS
and depression with intractable angina [8], suggestingthat the depression, dementia, and angina observed in
our patient might have been features of OSAS.
Additionally, the high incidence of falls and bone
fractures in elderly women who take daily afternoon
naps [9] suggests that daytime somnolence due to SAS
increases the risk of bone fracture.
The present patient was referred to our hospital after
surgery for subtrochanteric femur fracture and had
OSAS in addition to impaired responsiveness due
presumably to the effect of excessive antipsychotic
drugs. Her physical functions were improved
significantly by the incorporation of CPAP.
This patient also had improved ADL by CPAP
therapy for OSAS, in addition to the reduction of overmedication, treatment of pleural effusion, andrehabilitation. Our findings show the importance ofOSAS screening and management in elderly patientswith complicated conditions.

References1.	Song Y, Dzierzewski JM, Fung CH, Rodriguez JC,
Jouldjian S, Mitchell MN, et al. Association between
sleep and physical function in older veterans in an adultday healthcare program. J Am Geriatr Soc 2015; 63:
1622-7.
2.	Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD.
Influence of continuous positive airway pressure onoutcomes of rehabilitation in stroke patients withobstructive sleep apnea. Stroke 2011; 42: 1062-7.
3.	Pantoni CB, Di Thommazo-Luporini L, Mendes RG,Caruso FC, Mezzalira D, Arena R, et al. Continuous
positive airway pressure during exercise improves
walking time in patients undergoing inpatient cardiac
rehabilitation after coronary artery bypass. J Cardiopulm
Rehabil 2016; 36: 20-7.
4.	 Reis HV, Borghi-Silva A, Catai AM, Reis MS. Impact of
CPAP on physical exercise tolerance and sympatheticvagal balance in patients with chronic heart failure. Braz
J Phys Ther 2014; 18: 218-27.
5.	Goel AK, Talwar D, Jain SK. Evaluation of short-term
use of nocturnal nasal continuous positive airway
pressure for a clinical profile and exercise capacity inadult patients with obstructive sleep apnea-hypopnea
syndrome. Lung India 2015; 32: 225-32.
6.	Rezaeitalab F, Moharrari F, Saberi S, Asadpour H,Rezaeetalab F. The correlation of anxiety and depression
with obstructive sleep apnea syndrome. J Res Med Sci
2014; 19: 205-10.
7.	Osorio RS, Gumb T, Pirraglia E, Varga AW, Lu SE, Lim
J, et al. Sleep-disordered breathing advances cognitive
decline in the elderly. Neurology 2015; 84: 1964-71.
8.	Geovanini GR, Gowdak LH, Pereira AC, Danzi-Soares
Nde J, Dourado LO, Poppi NT. OSA and depression arecommon and independently associated with refractoryangina in patients with coronary artery disease. Chest2014; 146: 73-80.
9.	Stone KL, Ewing SK, Lui LY, Ensrud KE, Ancoli-IsraelS, Bauer DC, et al. Self-reported sleep and nap habits andrisk of falls and fractures in older women: the study ofosteoporotic fractures. J Am Geriatr Soc 2006; 54: 117783.

Jpn J Compr Rehabil Sci Vol 8, 2017