Interventions for improving mobility after hip fracture surgery in adults

Impact of physiotherapy access on health-related quality of life following hip fracture: an observational study on 30 752 hip fractures from the Norwegian Hip Fracture Register 2014-2018

OBJECTIVES

The main objective of this study was to investigate the characteristics of patients receiving private community physiotherapy (PT) the first year after a hip fracture. Second, to determine whether utilisation of PT could improve health-related quality of life (HRQoL).

METHODS

In an observational cohort study, 30 752 hip fractures from the Norwegian Hip Fracture Register were linked with data from Statistics Norway and the Norwegian Control and Payment of Health Reimbursements Database. Association between covariates and utilisation of PT in the first year after fracture, the association between covariates and EQ-5D index score and the probability of experiencing 'no problems' in the five dimensions of the EQ-5D were assessed with multiple logistic regression models.

RESULTS

Median age was 81 years, and 68.4% were females. Most patients with hip fracture (57.7%) were classified as American Society of Anesthesiologists classes 3-5, lived alone (52.4%), and had a low or medium level of education (85.7%). In the first year after injury, 10 838 of 30 752 patients with hip fracture (35.2%) received PT. Lower socioeconomic status (measured by income and level of education), male sex, increasing comorbidity, presence of cognitive impairment and increasing age led to a lower probability of receiving postoperative PT. Among those who used PT, EQ-5D index score was 0.061 points (p<0.001) higher than those who did not. Correspondingly, the probability of having 'no problems' in three of the five dimensions of EQ-5D was greater.

CONCLUSIONS

A minority of the patients with hip fracture had access to private PT the first year after injury. This may indicate a shortcoming in the provision of beneficial post-surgery rehabilitative care reducing post-treatment HRQoL. The findings underscore the need for healthcare policies that address disparities in PT access, particularly for elderly patients, those with comorbidities and reduced health, and those with lower socioeconomic status.

Comparing the Clinical and Radiographic Outcomes of Humeral Shaft Fractures by Treatment Type

PURPOSE

Humeral shaft fractures are common orthopedic injuries, representing 1-5% of all fractures. There is conflicting literature regarding the superiority of operative versus nonoperative treatment of these fractures. The purpose of this study was to examine functional outcomes and time to radiographic union in humeral shaft fractures with the hypothesis that both would be improved in patients treated operatively relative to those treated nonoperatively.

METHODS

This retrospective cohort study examined patients with humeral shaft fractures treated at a single large healthcare system between 2010 and 2020. A chart and radiograph review were performed to collect information on demographics, fracture, treatment, and outcome information. These measures were compared between patients treated operatively and nonoperatively.

RESULTS

Five hundred seventeen adult patients meeting inclusion criteria were identified; 233 were treated nonoperatively, and 284 were treated operatively. The mean patient age was 50.2 years in those who underwent surgery relative to 59.9 years in those treated without surgery (P<0.001). Operatively-treated patients had significantly faster time to radiographic union at a median of 113 days compared to a median of 161 days in nonoperatively-treated patients (P=0.001). The operative group was made weight-bearing as tolerated significantly faster than the nonoperative group (84 days versus 98 days, respectively, P=0.002). No statistically significant difference was seen between the two treatment groups in rates of complications or range of motion at the time of radiographic union. However, patients who underwent surgery were found to be up to two times more likely to achieve full shoulder forward elevation by the time of their final follow-up than those treated without surgery (P=0.011).

CONCLUSION

Patients with humeral shaft fractures treated operatively have faster time to union, earlier weight bearing, and no change in the rate of complications compared to patients treated nonoperatively.

Home Versus Hospital Rehabilitation of Older Adults Following Hip Fracture Yields Similar Patient-Reported Outcome Measures

The increase in hip fractures (HF) due to aging of the population and the rise in attractiveness of services provided at home following the COVID-19 pandemic, emphasize the need to compare outcomes of home versus hospital HF rehabilitation. To date, studies comparing the 2 services have focused primarily on clinical outcomes rather than patient-reported outcomes (PROs). This longitudinal observational study evaluated PROs of older adults with HF in the 2 settings. The SF36 questionnaire was used to measure PROs 3 times after surgery. The first PRO was retrospective and reflected pre-fracture health status. Descriptive statistics and mixed-effect logistic regression were used. Of 86 patients participating in the study, 41 had home rehabilitation and 45 had hospital rehabilitation. In both groups, the mental and physical scores plummeted 2 weeks after the HF, compared to pre-fracture status. The difference in improvement from pre-fracture status to recovery in both groups, were not significantly (P < .05) different, except for the pain domain. PROs of home versus hospital rehabilitation were similar, suggesting that rehabilitation at home can be as effective as hospital rehabilitation for suitable patients. This knowledge can improve quality of care in an aging global population.

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

BACKGROUND

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs.

METHODS

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture.

RESULTS

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

CONCLUSIONS

Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Patient preferences for physical therapy programs after a lower extremity fracture: a discrete choice experiment

OBJECTIVE

To quantify patients' preferences for physical therapy programmes after a lower extremity fracture and determine patient factors associated with preference variation.

DESIGN

Discrete choice experiment.

SETTING

Level I trauma centre.

PARTICIPANTS

One hundred fifty-one adult (≥18 years old) patients with lower extremity fractures treated operatively.

INTERVENTION

Patients were given hypothetical scenarios and asked to select their preferred therapy course when comparing cost, mobility, long-term pain, session duration, and treatment setting.

MAIN OUTCOME MEASURES

A multinomial logit model was used to determine the relative importance and willingness to pay for each attribute.

RESULTS

Mobility was of greatest relative importance (45%, 95% CI: 40% to 49%), more than cost (23%, 95% CI: 19% to 27%), long-term pain (19%, 95% CI: 16% to 23%), therapy session duration (12%, 95% CI: 9% to 5%) or setting (1%, 95% CI: 0.2% to 2%). Patients were willing to pay US$142 more per session to return to their preinjury mobility level (95% CI: US$103 to US$182). Willingness to pay for improved mobility was higher for women, patients aged 70 years and older, those with bachelor's degrees or higher and those living in less-deprived areas. Patients were willing to pay US$72 (95% CI: US$50 to US$93) more per session to reduce pain from severe to mild. Patients were indifferent between formal and independent home therapy (willingness to pay: -US$12, 95% CI: -US$33 to US$9).

CONCLUSIONS

Patients with lower extremity fractures highly value recovering mobility and are willing to pay more for postoperative physical therapy programmes that facilitate returning to their pre-injury mobility level. These patient preferences might be useful when prescribing and designing new techniques for postoperative therapy.

Perception of Goals and Expected Outcomes in Older Hip Fracture Patients and Their Medical Staff: A Cross Sectional Study

Background

Goal-oriented patientcare is a key element in qualityhealthcare. Medical-caregiver's (MC) are expected to generate a shared decision-making process with patients regarding goals and expected health-outcomes. Hip-fracture patients (HFP) are usually older-adults with multiple health-conditions, necessitating that agreed-upon goals regarding the rehabilitation process, take these conditions into consideration. This topic has yet to be investigated by pairing and comparing the perception of expected outcomes and therapeutic goals of multidisciplinary MCs and their HF patient's. Our aim was to assess in a quantitative method whether HFPs and their multidisciplinary MCs agree upon target health-outcomes and their most important goals as they are reflected in the SF12 questionnaire.

Methods

This was a cross-sectional, multi-center, study of HFPs and their MCs. Patients and MCs were asked to rate their top three most important goals for rehabilitation from the SF12 eight subscales: physical functioning, physical role limitation, bodily pain, general health, vitality, social functioning, emotional role limitation and mental health, and indicate their expected outcome. Descriptive statistics and mixed effect logistic-regression were used to compare concordance of the ratings. Agreement between patients and MCs was assessed using interclass coefficients (ICCs).

Results

A total of 378 ratings were collected from 52 patients, 12 nurses, 12 physicians and 6 paramedical personnel. Each patient had between 3 and 9 raters. Patients considered physical functioning and physical role limitation more important than did MCs. Physicians and nurses emphasized the importance of bodily pain while patients referred to it as relatively less significant. The total ICC was low (2%) indicating poor agreement between MCs and patients. With the exception of physical-functioning, MCs predicted a less optimistic outcome in all of the SF12's subscales in comparison to HFPs.

Conclusion

Effective intervention in HFPs requires constructive communication between MCs and patients. The study suggests that caregivers have an insufficient understanding of the expectations of HFPs. More effective communication channels are required in order to better understand HFPs' needs and expectations.

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) to predict postoperative pneumonia in elderly hip fracture patients

PURPOSE

Investigate the association between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) about the presence of postoperative pneumonia (POP) in geriatric patients with hip fractures. Compare the predictive value of these biomarkers for POP and assess their potential for early detection of POP.

METHODS

We retrospectively included elderly patients with hip fractures who underwent surgical treatment at our institution. POP was diagnosed according to the guidelines provided by the American Thoracic Society. We collected neutrophil, lymphocyte, and platelet counts upon admission to calculate the NLR, PLR, and SII. Receiver operating characteristic curves were utilized to establish the optimal cutoff values for each index. Multivariate logistic regression analysis and propensity score matching analysis were utilized to assess the independent association between each index and POP after adjusting for demographic, comorbidity, and surgery-related variables.

RESULTS

The study included a total of 1199 patients, among whom 111 cases (9.26%) developed POP. NLR exhibited the highest predictive value for POP in elderly patients with hip fractures compared to PLR and SII (AUC = 0.648, 95% CI 0.594-0.701). A high NLR, using the optimal cutoff value of 5.84, was significantly associated with an increased incidence of POP (OR = 2.24, 95% CI 1.43-3.51). This finding remained statistically significant even after propensity score matching (OR = 2.04, 95% CI 1.31-3.20).

CONCLUSIONS

Among the three inflammatory/immune markers considered, the NLR demonstrates the highest reliability as a predictor for POP in elderly patients with hip fractures. Therefore, it serves as a valuable tool for early identification.

D-dimer-albumin ratio (DAR) as a new biomarker for predicting preoperative deep vein thrombosis after geriatric hip fracture patients

PURPOSE

Hip fractures in the elderly are complicated by preoperative deep vein thrombosis (DVT). The objective of this study is to determine the usefulness of blood-based biomarkers, particularly the D-dimer-albumin ratio (DAR), in predicting preoperative DVT.

METHODS

A retrospective observational study was carried out on 1149 patients from a single hospital, and subsequently validated on an additional 626 patients from a separate hospital. The aim was to evaluate the prognostic and predictive value of 10 biomarkers, with a specific emphasis on DAR, in both cohorts. The primary measure of interest was the occurrence of preoperative DVT.

RESULTS

The ratio of D-dimer to albumin demonstrated superior predictive capability for preoperative DVT in older patients with hip fractures compared to other biomarkers (AUC = 0.677). Using the optimal cutoff point of 0.24, high DAR was significantly associated with preoperative DVT (OR 3.45, 95% CI 2.00-5.95). Notably, all the DAR definitions detailed above were successfully validated in an external, independent cohort.

CONCLUSIONS

DAR may be a valuable biomarker for predicting preoperative DVT in elderly patients with hip fractures.

Assessing real-world gait with digital technology? Validation, insights and recommendations from the Mobilise-D consortium

BACKGROUND

Although digital mobility outcomes (DMOs) can be readily calculated from real-world data collected with wearable devices and ad-hoc algorithms, technical validation is still required. The aim of this paper is to comparatively assess and validate DMOs estimated using real-world gait data from six different cohorts, focusing on gait sequence detection, foot initial contact detection (ICD), cadence (CAD) and stride length (SL) estimates.

METHODS

Twenty healthy older adults, 20 people with Parkinson's disease, 20 with multiple sclerosis, 19 with proximal femoral fracture, 17 with chronic obstructive pulmonary disease and 12 with congestive heart failure were monitored for 2.5 h in the real-world, using a single wearable device worn on the lower back. A reference system combining inertial modules with distance sensors and pressure insoles was used for comparison of DMOs from the single wearable device. We assessed and validated three algorithms for gait sequence detection, four for ICD, three for CAD and four for SL by concurrently comparing their performances (e.g., accuracy, specificity, sensitivity, absolute and relative errors). Additionally, the effects of walking bout (WB) speed and duration on algorithm performance were investigated.

RESULTS

We identified two cohort-specific top performing algorithms for gait sequence detection and CAD, and a single best for ICD and SL. Best gait sequence detection algorithms showed good performances (sensitivity > 0.73, positive predictive values > 0.75, specificity > 0.95, accuracy > 0.94). ICD and CAD algorithms presented excellent results, with sensitivity > 0.79, positive predictive values > 0.89 and relative errors < 11% for ICD and < 8.5% for CAD. The best identified SL algorithm showed lower performances than other DMOs (absolute error < 0.21 m). Lower performances across all DMOs were found for the cohort with most severe gait impairments (proximal femoral fracture). Algorithms' performances were lower for short walking bouts; slower gait speeds (< 0.5 m/s) resulted in reduced performance of the CAD and SL algorithms.

CONCLUSIONS

Overall, the identified algorithms enabled a robust estimation of key DMOs. Our findings showed that the choice of algorithm for estimation of gait sequence detection and CAD should be cohort-specific (e.g., slow walkers and with gait impairments). Short walking bout length and slow walking speed worsened algorithms' performances. Trial registration ISRCTN - 12246987.

The Effect of Postoperative Physical Therapy Following Hip Fracture: A Literature Review

Hip fractures in the elderly have become a major public health concern as the population ages. Post-operative rehabilitation is associated with improved outcomes and a greater likelihood of returning to pre-operative functional capacity. Several studies have been conducted to investigate various post-operative recovery pathways. However, little is known about which post-operative rehabilitation pathways for hip fractures are most effective in improving patient outcomes. No clear evidence-based guidelines for a standard mobilization protocol for patients are currently available. This review aims to investigate post-operative recovery pathways to help patients suffering from hip fracture return to pre-fracture condition and to quantify pre-operative and post-operative scores for objective rehabilitation evaluation. Measuring pre-operative activity and comparing it to post-operative follow-up values can help predict post-operative rehabilitation functional outcomes.

Geriatric rehabilitation care after hip fracture

PURPOSE

After acute hospital admission, patients with a hip fracture are frequently discharged to skilled nursing homes providing geriatric rehabilitation (GR). There are few evidence-based studies regarding specific treatment times and assessments during GR. This study aims to provide a description of care for hip fracture patients during GR in the Netherlands.

METHODS

Descriptive study analyzing the care pathways from GR facilities, regarding healthcare professionals involved, allocated treatment time per profession, total length of rehabilitation stay, and assessment instruments. Based on the reimbursement algorithm (diagnostic treatment combination = DBCs), of 25 patients, the registered actual treatment time per profession was calculated.

RESULTS

The care pathways pivoted on three groups of health care professionals: medical team (MT), physiotherapy (PT), and occupational therapy (OT). There was some discrepancy between the allocated time in the care pathways and the calculated mean actual treatment time from the DBCs. First week: MT 120-180 min, DBC 120 (SD: 59) minutes; PT 120-230 min, DBC 129 (SD: 58) minutes; and OT 65-165 min, DBC 93 (SD: 61) minutes. From week two onwards, MT 15-36 min, DBC 49 (SD: 29) minutes; PT 74-179 min, DBC 125 (SD: 50) minutes; and OT 25-60 min, DBC 47 (SD: 44) minutes. Dieticians, psychologists, and social workers were sporadically mentioned. There was heterogeneity in the assessment and screening tools.

CONCLUSIONS

It is difficult to define current standard care in GR after hip fracture in the Netherlands due to the diversity in care pathways and large practice variation. This is a problem in conducting randomized effectiveness research with care provided as control.

TRIAL REGISTER AND DATE OF REGISTRATION

NL7491 04-02-2019.

Does delayed weight bearing in the surgical management of fractures of the upper end of the femur in the elderly lead to more complications? A prospective study

INTRODUCTION

Fractures of the upper end of the femur (FUEF) lead to increased mortality and dependence in the elderly. However, mechanical complications after surgery persist in up to 20% of cases, which may justify a delayed resumption of full weight bearing to protect the osteosynthesis during consolidation.

HYPOTHESIS

Our hypothesis was that the late resumption of weight bearing in an elderly population after a FUEF would be limited by a higher frequency of medical complications.

METHODS

This was a prospective monocentric study including patients aged 80 or over with an isolated FUEF requiring osteosynthesis. The operator decided on the discharge. The primary endpoint was to show a difference in a medical complication score created for this study (APRETAR), between a group with, and a group without, weight bearing delayed by 45 days.

RESULTS

Between 2016 and 2019, 254 patients (88±5.6 years, 77.6% women) were included, and of these, 70 (27.6%) had delayed weight bearing. The mean APRETAR at 45 days was greater in the delayed weight bearing group (5.9±8.6 vs. 5.7±11.0; p<0.001). One-year mortality was 12.6% (32 patients), with no difference between the two groups (p=0.51). The level of dependence was significant (IADL at 2.2±1.7), with some comorbidities (Charlson at 2.9±2.2 and CIRS-G at 6.5±4.3) and all comparable across the two groups but with low cognitive levels, especially in the group with delayed weight bearing (MMSE 15.9±10.7 vs. 21±6.9; p<0.001).

CONCLUSION

This prospective study shows that delaying weight bearing in the elderly population, even for mechanical problems with FUEF, statistically increases medical complications but in a clinically acceptable manner.

LEVEL OF EVIDENCE

II, Prospective cohort study.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review

BACKGROUND

To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission.

METHODS

A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2).

RESULTS

Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes.

CONCLUSION

Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication.

TRIAL REGISTRATION

PROSPERO Registration CRD42018114323 .

The effectiveness of a physiatrist-led acute hospital based postoperative hip fracture inpatient rehabilitation program: A single-center retrospective study

Background

Postoperative hip fracture rehabilitation in Singapore has historically been carried out in both acute and community hospitals (CH). An increasing majority of patients with hip fractures now receive inpatient rehabilitation in CH, and it is often believed that Acute hospital (AH) - based rehabilitation may be less cost-effective than their CH counterparts. Objective: This retrospective study aims to review the effectiveness of an AH-based hip fracture postoperative rehabilitation program.

Methods

This study retrospectively reviewed the database of postoperative hip fracture patients who underwent a physiatrist-led AH-based inpatient rehabilitation from Jan 2010 to Dec 2016. The primary outcomes were the functional improvement assessed by functional independence measure (FIM) and FIM efficiency. The secondary outcome included the length of stay (LOS), successful discharge to home rate, mortality rate, and complication rate.

Results

A total of 293 cases were included in the study. After participation in the inpatient rehabilitation program, the mean total FIM increased from 83.9 ± 12.7 (mean ± SD) to 93.9 ± 16.2 ( p < .001). The motor FIM increased from 47.1 ± 10.9 to 56.1 ± 10.1 ( p < .001). 269 (91.8%) patients were successfully discharged home. Inpatient mortality was 0.3% (1/293). The complications rate during inpatient rehabilitation was 16.0% with urinary tract infection being the most frequent complication (10.2%). The median LOS for inpatient rehabilitation was 19 days (15, 28).

Conclusions

After completing a physiatrist-led postoperative hip fracture inpatient rehabilitation program in an acute hospital, patients demonstrated significant functional improvement ( p < .0001). The inpatient rehabilitation program has a high discharge home rate and low in-hospital mortality.

Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review

Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.

Factors Influencing Length of Stay and Discharge Destination of Patients with Hip Fracture Rehabilitating in a Private Care Setting

Background: Rehabilitation after a hip fracture has long-term importance, prompting some patients to utilise private services. Insufficient data regarding private rehabilitation in the UK can cause ambiguity and potential problems for all involved. Aim: The present study, involving patients with hip fractures rehabilitating in a private UK care setting, examined relationships between length of stay (LoS), discharge destination (DD) and 12 predictor variables. Methods: The variables included the retrospective measurement of the Functional Independence Measure. The variables were informed by a literature review and patient and public involvement. Retrospective data from the records of patients with hip fractures were utilised. Data were analysed using Spearman's rho, Mann-Whitney U, Kruskal-Wallis H and chi-squared tests as appropriate. Odds ratios, distribution quartiles and survivor analysis were also utilised. Results: The median length of stay (LoS) was 20.5 days: 82% returned home, 6.5% died and 11.5% remained as long-term residents. Significant relationships existed between LoS and age (p = 0.004), comorbidities (p = 0.001) and FIMadmission (p = 0.001). DD was associated with age (p = 0.007), delirium (p = 0.018), comorbidities (p = 0.001) and both FIMpre-fracture and FIMadmission (p = 0.000). Conclusions: Factors associated with length of stay were identified, but further research incorporating multiple sites is required for greater predictor precision. Discharge destination was evident by 90 days, facilitating long-term planning.

Improving hip fracture care in Spain: evolution of quality indicators in the Spanish National Hip Fracture Registry

This study was carried out to analyze the evolution of the quality indicators in the Spanish National Hip Fracture Registry, after disseminating a series of recommendations based on available clinical practice guidelines to the participating hospitals. Six of the seven proposed quality indicators showed a significant improvement.

PURPOSE

The Spanish National Hip Fracture Registry (RNFC) arises from the need to know the process and improve the quality of care. Our goal was to analyze the changes in the RNFC's quality indicators after an intervention based on disseminating specific recommendations among the participating hospitals, following available clinical practice guidelines.

METHODS

Study comparing before and after performing an intervention in hospitals participating in the RNFC. Data from the hospitals that registered cases in 2017, and that kept registering cases in 2019. Seven quality indicators were chosen, and a standard to be achieved for each indicator was proposed. The intervention consisted in the dissemination of 25 recommendations with practical measures to improve each quality indicator, based on available clinical practice guidelines, by drafting and publishing a scientific paper and sending it via email and printed cards. Fulfilment of each quality indicator was measured after carrying out the intervention.

RESULTS

Forty-three hospitals registered 2674 cases between January and May, 2017, and 8037 during 2019. The quality indicators chosen and the degree of compliance were (all with p<0.05): (1) surgery ≤48 h increased from 38.9 to 45.8%; (2) patients mobilised on the first postoperative day increased from 58.9 to 70.3%; (3) patients with anti-osteoporotic medication at discharge increased from 34.5 to 49.8%; (4) patients with calcium supplements at discharge increased from 48.7 to 62.8%; (5) patients with vitamin D supplements at discharge increased from 71.5 to 84.7%; (6) patients developing a grade >2 pressure ulcer during admission decreased from 6.5 to 5.0%; (7) patients able to move on their own at 1 month fell from 58.8 to 56.4%. More than 48% of hospitals improved the proposed indicators.

CONCLUSION

Establishing quality indicators and standards and intervening through the dissemination of specific recommendations to improve these indicators achieved an improvement in hospital performance results on a national level.

Enduring life in between a sense of renewal and loss of courage: lifeworld perspectives one year after hip fracture

Purpose: To explore everyday life experiences of being active in aged adults´ with walking impairment one year after hip fracture (HF).Methods: A phenomenological-hermeneutic study design is based on Heidegger´s and Gadamer´s thinking focusing on aged adults being-in-the-world one year after HF. Individual semi-structured interviews were conducted from May to July 2017 in the homes of nine participants, who were part of a longitudinal qualitative study with four interview-rounds for a period of 18 months after the HF event. The analysis was interpretative and secured that the authors´ pre-understanding was put at stake through a five-step process of meaning condensation.Results: One theme, "Enduring life in between a sense of renewal and loss of courage", described aged adults´ experiences of being active in three sub-themes: "Facing loss and losing courage", "Taking up the challenge and maintaining courage ", and "Renewing the energy to be active". Living with being under change and increased vulnerability created a challenge in maintaining courage and reaching for possibilities to unfold their own being in life.Conclusion: This study contributes knowledge on how the aged adults´ experiences of the balance between courage and loss in being active one year after HF are profoundly connected with experiences of well-being.

Subcutaneous fat area at the upper thigh level is a useful prognostic marker in the elderly with femur fracture

BACKGROUND

The aim of this study was to evaluate prognostic value of body tissue composition at the upper thigh level for 1 year mortality in elderly patients with proximal femur fracture.

METHODS

This retrospective cohort study included consecutive elderly (aged ≥65) patients diagnosed with proximal femur fracture based on the findings of pelvic bone computed tomography (CT) performed at the emergency department of a tertiary care hospital and treated with surgery between 2010 and 2017. The cross-sectional area of subcutaneous fat and skeletal muscle at the upper thigh level was measured using CT. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 1 year mortality were estimated using a Cox proportional hazards model. Survival based on the SFA quartiles was assessed using nonparametric Kaplan-Meier survival analysis and compared used log-rank tests.

RESULTS

Among 876 elderly patients included in this study, the median age was 79.0 years, and 646 (73.7%) patients were female. A total of 93 (10.6%) died within 1 year after admission to the emergency department. Survivors had a significantly higher median subcutaneous fat area (SFA) than non-survivors (170.2 vs. 133.0 cm² , P < 0.001), but no significant difference was observed between the skeletal muscle area (median, 156.7 vs. 160.3 cm² , P = 0.504) and muscle density (median, 19.0 vs. 19.1 HU, P = 0.861) of both groups. After adjustment of other clinical characteristics and body compositions, the multivariate Cox proportional hazard analysis showed that SFA (adjusted HR, 0.987; 95% CI, 0.982-0.992; P < 0.001) was independently associated with 1 year mortality. With 384 deaths during 51 322 person-months of follow-up, the median estimated survival duration of all the patients was 92.8 months (95% CI, 80.8-104.7 months). The patients with SFA in the third (165.6-195.0 cm² ) and fourth (>195.0 cm² ) quartiles showed significantly longer survival duration than those with SFA in the first (<131.4 cm² ; median survival time, 51.3 months) and second (131.4-165.5 cm² ; median survival time, 88.7 months) quartiles (P < 0.001 by log-rank test).

CONCLUSIONS

The SFAs measured at the upper thigh level and 1 year mortality are positively associated in elderly patients with proximal femur fracture. SFA may be an independent prognostic biomarker for 1 year mortality of femur fracture.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Assessing the Outcome of Rehabilitation after Hip Fracture with a Wearable Device-A Study Protocol for a Randomized Control Trial in Community Healthcare

BACKGROUND

The increase of the aging population is a challenge to society, as age is related to dependence. Injuries such as hip fractures cause morbidity, loss of independent life, and mortality. The purpose of this protocol is to describe a randomized control trial, with three intervention arms, aiming at investigating if there are any differences in outcomes after hip fracture between different rehabilitation interventions including (1) High-Intensity Functional Exercise (HIFE), (2) HIFE with the addition of continuous measures of movement and body positions with a wearable device, or (3) standard rehabilitation. A secondary aim is to evaluate physiotherapists' satisfaction with using the wearable device in rehabilitation.

METHOD

Patients with hip fracture that require rehabilitation at home will be invited to participate and randomly assigned to one intervention arm. The primary outcome is balance, measured by postural sway using an Inertial Measurement Unit and by Functional Balance test for Geriatric patients. Secondary outcomes are functional independence in everyday activities, measured with the Barthel Index, and health-related quality of life measured with EuroQol 5 Dimension questionnaire and EuroQol Visual Analogue Scale for health and user satisfaction measured by the User Satisfaction Evaluation Questionnaire.

DISCUSSION

This study protocol is the first step in securing the research process before performing a full randomized controlled trial. The next step will be a pilot- and feasibility study.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Mobility-A Bridge to Sense of Coherence in Everyday Life: Older Patients' Experiences of Participation in an Exercise Program During the First 3 Weeks After Hip Fracture Surgery

Our aim with this article was to explore the experiences of older people who participated in the evidence-based High-Intensity Functional Exercise (HIFE) Program during the first 3 weeks of rehabilitation after hip fracture surgery. Nineteen older people participated in the study. Data were analyzed using systematic text condensation. One overarching theme "Exercise is the key for regaining mobility and a sense of coherence (SOC) in everyday life" emerged from the analysis in addition to these five themes: (a) understanding the existential importance of mobility; (b) maintaining a positive self-image by regaining mobility; (c) regaining one's old life and independence in everyday living; (d) maintaining interpersonal relationships through mobility; and (e) creating positive emotions by being able to move. The findings highlight the importance of exercise as a strategy for regaining mobility, illustrated by the essential role it played in the participants' lives after suffering a hip fracture.

Discharge transition experienced by older Korean women after hip fracture surgery: a qualitative study

BACKGROUND

This study aimed to explore older Korean women's discharge transition experiences after hip fracture surgery.

METHODS

This was a descriptive qualitative study. Face-to-face interviews following hip fracture surgery were conducted on 12 women aged 65-87 years. Data were collected 1 to 2 days before discharge and again 4 weeks after discharge following hip fracture surgery, and were analyzed using qualitative content analysis.

RESULTS

Four main themes were identified: (1) challenge of discharge transition: unprepared discharge, transfer into other care settings, and eagerness for recovery; (2) physical and psychological distress against recovery: frail physical state and psychological difficulties; (3) dependent compliance: absolute trust in healthcare providers, indispensable support from the family, and passive participation in care; and (4) walking for things they took for granted: hope of walking and poor walking ability.

CONCLUSIONS

After their hip fracture surgeries, older women hoped to be able to walk and perform simple daily chores they previously took for granted. Considering the physical and psychological frailty of older women undergoing hip surgery, systematic nursing interventions including collaboration and coordination with other healthcare professionals and settings are necessary to ensure the quality of continuous care during their post-surgery discharge transition. Encouraging partial weight bearing and initiating intervention to reduce fear of falling at the earliest possible time are essential to attain a stable discharge transition. Additionally, older women should be invited to participate in their care, and family involvement should be encouraged during the discharge transition period in South Korea.

Motivational interviewing with community-dwelling older adults after hip fracture (MIHip): protocol for a randomised controlled trial

INTRODUCTION

Community-dwelling people recovering from hip fracture have the physical capacity to walk in their community but lack the confidence to do so. The primary aim of this trial is to determine whether motivational interviewing increases time spent walking at 12 months in community-dwelling people after hip fracture compared with an attention placebo control group. Secondary aims are to evaluate cost effectiveness, patient and health service outcomes and to complete a process evaluation.

METHODS AND ANALYSIS

An assessor-blinded parallel group randomised controlled design with embedded health economic evaluation and process evaluation will compare the effects of n=270 participants randomly allocated to an experimental group (motivational interviewing) or a control group (dietary advice). For inclusion, participants are aged ≥65 years, living at home independently within 6 months of discharge from hospital after hip fracture and able to walk independently and communicate with conversational English. Key exclusion criteria are severe depression or anxiety, impaired intellectual functioning and being medically unstable to walk. Participants allocated to the experimental group will receive 10 (8 weekly and 2 booster) telephone-based sessions of motivational interviewing to increase walking over 16 weeks. Participants allocated to the control group will receive an equivalent dose of telephone-based dietary advice. The primary outcome is daily time spent walking over 7 days assessed at weeks 0, 9, 26 and 52. Secondary outcomes include measures of psychological-related function, mobility-related function, community participation, health-related quality of life and falls. Health service utilisation and associated costs will be assessed. Process evaluation will assess the fidelity of the motivational interviewing intervention and explore contextual factors through semistructured interviews.

ETHICS AND DISSEMINATION

Ethical approval obtained from Eastern Health (E19-002), Peninsula Health (50261/EH-2019), Alfred Health (617/20) and La Trobe University (E19/002/50261). The findings will be disseminated in peer-reviewed journals, conference presentations and public seminars.

TRIAL REGISTRATION NUMBER

ACTRN12619000936123.

Predicting the length of stay at admission for emergency general surgery patients a cohort study

Introduction

Predicting length of stay (LOS) is beneficial to patients and the health service. When a prolonged LOS is predicted, it gives the opportunity for focused therapies and allocation of resources to reduce this period. In emergency general surgery (EGS) there has been limited investigation of variables that may be important predictors of LOS. This study examines social characteristics alongside measures of severity of acute illness and co-morbidities in an adult EGS population to establish their contribution to LOS.

Methods

Data were collected prospectively from patients at admission including medical variables, demographics, and therapeutic requirements. The length of hospital admission was measured, and multiple regression analysis was used to identify variables which predicted the LOS.

Results

Data were collected from 105 patients. The regression model gave an R² of 0.34, p = 0.0006. Barthal index (measure of independence in activities of daily living) was a significant predictor of LOS [logworth 1.649, p0.02243]. Housing status and Level of social support both correlated in one-way analysis with LOS.

Conclusion

There are non-surgical variables, measurable at admission which are of significant value in predicting LOS of EGS patients. This warrants further investigation through a larger study to better quantify the contributions of these variables, and establish potential early interventions to reduce the LOS.

•

Barthal Index is a significant predictor of length of stay at admission for patients admitted under EGS.

•

Unstable housing and a lack of social support independently correlate with a longer length of stay.

•

It may be possible to intervene at admission to reduce the length of stay for patients admitted under EGS.

Protocol for a definitive randomised controlled trial and economic evaluation of a community-based rehabilitation programme following hip fracture: fracture in the elderly multidisciplinary rehabilitation-phase III (FEMuR III)

INTRODUCTION

Proximal femoral (hip) fracture is common, serious and costly. Rehabilitation may improve functional recovery but evidence of effectiveness and cost-effectiveness are lacking. An enhanced rehabilitation intervention was previously developed and a feasibility study tested the methods used for this randomised controlled trial (RCT). The objectives are to compare the effectiveness and cost-effectiveness of the enhanced rehabilitation programme following surgical repair of proximal femoral fracture in older people compared with usual care.

METHODS AND ANALYSIS

Protocol for phase III, parallel-group, two-armed, superiority, pragmatic RCT with 1:1 allocation ratio; allocation sequence by minimisation programme with a built-in random element; secure web-based allocation concealment. The two treatments will be usual care (control) and usual care plus an enhanced rehabilitation programme (intervention). The enhanced rehabilitation will consist of a patient-held information workbook, goal setting diary and up to six additional therapy sessions. Outcome assessment and statistical analysis will be performed blind; patient and carer participants will be unblinded. Outcomes will be measured at baseline, 17 and 52 weeks' follow-up. Primary outcome at 52 weeks will be the Nottingham Extended Activities of Daily Living scale. Secondary outcomes will measure anxiety and depression, health utility, cognitive status, hip pain intensity, falls self-efficacy, fear of falling, grip strength and physical function. Carer strain, anxiety and depression will be measured in carers. All safety events will be recorded, and serious adverse events will be assessed to determine whether they are related to the intervention and expected. Concurrent economic evaluation will be a cost-utility analysis from a health service and personal social care perspective. An embedded process evaluation will determine the mechanisms and processes that explain the implementation and impacts of the enhanced rehabilitation programme.

ETHICS AND DISSEMINATION

National Health Service research ethics approval reference 18/NE/0300. Results will be disseminated by peer-reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN28376407; Pre-results registered on 23 November 2018.

Functional outcomes after the treatment of hip fracture

Osteoporotic hip fracture is a major public health issue. Estimation of the outcome and maximization of functional recovery after fracture is very important in the treatment of older patients. The purposes of this study were to clarify the functional outcomes after the treatment of hip fracture and to identify the factors that influence functional recovery. In the present study, 228 patients admitted to an acute-care hospital from January 2016 to June 2018 were evaluated. The patients were categorized into a trochanteric fracture group (n = 128) and a neck fracture group (n = 100). We retrospectively reviewed their ambulation ability 6 months after fracture using the Functional Ambulation Category (FAC) score. The other survey items were the presurgical duration, length of hospital stay, time until beginning to walk using parallel bars, complications affecting treatment, and mortality rate. The 6-month follow-up rate was 54.4% (n = 124). The results showed that the patients with trochanteric fracture were significantly older than those with neck fracture (86 vs. 82 years, respectively; p = 0.03). In total, 85.0% of patients with trochanteric fracture and 92.2% of patients with neck fracture were independent ambulators before injury (FAC score of 4 or 5). The FAC score 6 months after fracture was positively correlated with the FAC score before fracture and at discharge (all p<0.001) and negatively correlated with patient age (p<0.001) and presurgical duration for patients with neck fracture (p = 0.04). There was no statistically significant correlation with the length of hospital stay or the time until beginning to walk using parallel bars. In conclusion, patients with trochanteric fractures were older than those with neck fractures. In both fracture types, walking recovery 6 months after hip fracture was related to the FAC score before injury and at discharge from an acute-care hospital but not to the time until beginning to walk using parallel bars.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Exercise for people with a fragility fracture of the pelvis or lower limb: a systematic review of interventions evaluated in clinical trials and reporting quality

BACKGROUND

To aid design of exercise trials for people with pelvic and lower limb fragility fractures a systematic review was conducted to identify what types of exercise interventions and mobility outcomes have been assessed, investigate intervention reporting quality, and evaluate risk of bias in published trials.

METHODS

Systematic searches of electronic databases (CENTRAL, MEDLINE, EMBASE, PEDro) 1996-2019 were conducted to identify randomised controlled trials of exercise for pelvic or lower limb fragility fractures. Two reviewers independently screened titles and abstracts. One reviewer extracted data, a second verified. Two reviewers independently assessed risk of bias. Intervention reporting quality was based on TIDieR, assessed by one reviewer and verified by a second. Narrative synthesis was undertaken. Registration: PROSPERO CRD42017060905.

RESULTS

Searches identified 37 trials including 3564 participants, median sample size 81 (IQR 48-124), participants aged 81 years (IQR 79-82) and 76% (2536/3356) female. All trials focussed on people with hip fracture except one on ankle fracture. Exercise types focussed on resistance exercise in 14 trials, weight bearing exercise in 5 trials, 13 varied dose of sessions with health professionals, and 2 trials each focussed on treadmill gait training, timing of weight bearing or aerobic exercise. 30/37 (81%) of trials reported adequate sequence generation, 25/37 (68%) sufficient allocation concealment. 10/37 (27%) trials lacked outcome assessor blinding. Of 65 exercise interventions, reporting was clear for 33 (51%) in terms of when started, 61 (94%) for where delivered, 49 (75%) for who delivered, 47 (72%) for group or individual, 29 (45%) for duration, 46 (71%) for session frequency, 8 (12%) for full prescription details to enable the exercises to be reproduced, 32 (49%) clearly reported tailoring or modification, and 23 (35%) reported exercise adherence. Subjectively assessed mobility was assessed in 22/37 (59%) studies and 29/37 (78%) used an objective measure.

CONCLUSIONS

All trials focussed on hip fracture, apart from one ankle fracture trial. Research into pelvic and other lower limb fragility fractures is indicated. A range of exercise types were investigated but to date deficiencies in intervention reporting hamper reproducibility. Adoption of TIDieR and CERT guidelines should improve intervention reporting as use increases. Trials would be improved by consistent blinded outcome assessor use and with consensus on which mobility outcomes should be assessed.

Older adults' perceptions of early rehabilitation and recovery after hip fracture surgery: a UK qualitative study

Purpose: To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture.Methods: In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework.Results: Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants.Conclusions: This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self.Implications for rehabilitationHip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions.Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital.Healthcare professionals need to educate and empower older adults to take charge of their own recovery.For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self.

High variability in hip fracture post-acute care and dementia patients having worse chances of receiving rehabilitation: an analysis of population-based data from Estonia

PURPOSE

Rehabilitation is a fundamental part of hip fracture (HF) care; however, the best strategies are unclear. This study maps index HF patients' post-acute care (PAC) in Estonia and compares the PAC of patients with and without a diagnosis of dementia.

METHODS

A retrospective cohort study was conducted using validated population-based data from the Estonian Health Insurance Fund using inclusion criteria: age ≥ 50 years, International Classification of Diseases code (S72.0-2) indicating HF between 1 January 2009 and 30 September 2017, and the survival of PAC. The presence of dementia diagnosis was based on the 10th revision of the International Classification of Diseases codes.

RESULTS

A total of 8729 patients were included in the study, 11% of whom had a dementia diagnosis. The PAC of HF patients varied from extensive to no care: 8.7% received combined inpatient and outpatient care; 59% received hospital care (13% had a length of stay (LOS) > 6 weeks; 33% had LOS between 2-4 weeks, 14% had LOS < 2 weeks); 4% received only community-based care; 28% received no PAC. Physical therapy (PT) was received by 56% of patients and by 35% of those with dementia diagnosis. Dementia patients had 1.5-fold higher odds of not receiving PT.

CONCLUSION

In Estonia, the PAC after index HF varies from extensive to no care, and the provision of PT is limited and unequal, affecting dementia patients in particular. Thus, there is an urgent need to standardise index HF PAC by reviewing the resources of PT and developing effective rehabilitation practices.

Physical function and lean body mass as predictors of bone loss after hip fracture: a prospective follow-up study

Background

Predictors of bone deterioration after hip fracture have not been well characterized. The aim of this study was to examine the associations of physical function and lean body mass (LBM) with loss of bone density and strength in older people recovering from a hip fracture.

Methods

A total of 81 over 60-year-old, community-dwelling men and women operated for a hip fracture participated in this 1-year prospective follow-up study. Distal tibia total volumetric bone mineral density (vBMD_TOT, mg/cm³) and compressive strength index (BSI, g²/cm⁴) and mid-tibia cortical vBMD (vBMD_CO, mg/cm³) and bending strength index (SSI, mm³) were assessed in both legs by peripheral quantitative computed tomography (pQCT) at baseline (on average 10 weeks after fracture) and at 12 months. At baseline, LBM was measured with a bioimpedance device and physical function with the Short Physical Performance Battery (SPPB) and perceived difficulty in walking outdoors. Robust multivariable linear regression models were used to estimate the associations of physical function and LBM with the change in bone parameters at 12-months.

Results

The mean change in distal tibia vBMD_TOT and BSI in both legs ranged from − 0.9 to − 2.5%. The change in mid-tibia vBMD_CO and SSI ranged from − 0.5 to − 2.1%. A lower SPPB score, difficulty in walking outdoors and lower LBM predicted greater decline in distal tibia vBMD_TOT in both legs. A lower SPPB score and difficulty in walking outdoors were also associated with a greater decline in distal tibia BSI in both legs. At the midshaft site, a lower SPPB score and lower LBM were associated with greater decline in SSI on the fractured side.

Conclusions

Older hip fracture patients with low physical function and lower LBM may be at risk for greater decline in tibia bone properties during the first post-fracture year. Acknowledgement of the risk factors could assist in developing interventions and care to promote bone health and overall recovery.

Trial registration

ISRCTN, ISRCTN53680197. The trial was registered retrospectively but before the recruitment was completed. Registered March 3, 2010.

The importance of a good therapeutic alliance in promoting exercise motivation in a group of older Norwegians in the subacute phase of hip fracture; a qualitative study

Background

Hip fractures represent a global public health issue that demands high cost both from the patient and from the society. Functional exercise in the subacute phase of a hip fracture is essential in reducing these costs. To the best of our knowledge, no qualitative study has explored the patients’ experiences in participating in an exercise program during the first month after surgery. Thus, this study aims to explore how older people who had participated in an evidence-based exercise intervention describe their relationship with their therapists and how this relationship might contribute to their motivation for exercise.

Methods

Thirteen women and six men, who all had experienced a hip fracture and were staying in the same short-term rehabilitation unit, were interviewed by the last author. The interviews lasted from 30 to 70 min. The participants’ mean age was 86 years and they had all participated in a High Intensity Functional Exercise (HIFE) program in one-on-one sessions for 2 weeks, a total of 10 sessions. The recruitment was done by therapists involved in an RCT evaluating the HIFE-program with the attempt to obtain maximum variation. Data were analyzed through systematic text condensation in collaboration between all authors.

Results

The analysis yielded three main themes integrated in the core theme “Therapeutic alliance is an interpretative filter for the participants’ experiences.” The three themes were “The feeling of mutuality and respect in the alliance”; “A trusting and motivating relationship” and “Tailoring of the instruction and program to make the task understandable”. These themes concerned basic needs in the relationship between the participants and the therapists which brought forward a feeling of mutual respect. The most prominent finding was the experience of trust in the therapists’ abilities, and how this contributed to the participants’ motivation to fulfil the program and achieve meaningful changes.

Conclusion

Our findings suggest that therapeutic alliance is an indispensable aspect of a therapy, and relational knowledge and competence are prerequisites in the transfer of professional knowledge in a therapy. Our findings can be useful to therapists involved in clinical practice, especially to those working with vulnerable groups.

Gender and Musculoskeletal Comorbidity Impact on Physical Functioning in Elderly after Hip Fracture: The Role of Rehabilitation

The study aim was to evaluate the effects of presence and level of musculoskeletal impairment along with gender on physical functioning outcome after the rehabilitation program in aged adults with a hip fracture. We analyzed 203 elderly people with hip fractures above 65 years of age that were treated after the hip surgery. According to the time of examination, patients were tested three times: at admission, discharge, and at three months post-discharge. Musculoskeletal impairments were analyzed, and for the estimation of severity of degree impairment, we used a cumulative index rating scale for geriatrics (CIRS-G). Regarding the gender, we separately analyzed males and females. To evaluate physical functioning of aged adults after a hip fracture, we used the physical functioning component (PFC) from the quality of life (SF-36) questionnaire. For males, on all three occasions we found non-significant differences were found in SF-36 PFC values between different degrees of CIRS-G musculoskeletal impairment. A significant difference was noticed in females three months post-discharge. Effects size of different examination periods for every CIRS-G severity degree of musculoskeletal impairment were high, where males had higher values for severity degrees 1 and 2, and females had higher values for severity degrees 0 and 3. Our findings might suggest that there is a certain degree of different rehabilitation treatment effects for males versus females. Moreover, it might be assumed that other factors could influence different degrees of functional improvement and outcome of individuals after a hip fracture with musculoskeletal impairment.

Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial)

BACKGROUND

A 2014 Cochrane review evaluating the effect of anabolic steroids after hip fracture concluded that the quality of the studies was insufficient to draw conclusions on the effects and recommended further high-quality trials in the field. Therefore, the aim of this pilot trial is to determine the preliminary effect and feasibility of a 12-week multimodal intervention consisting of physiotherapy (with strength training), protein-rich nutritional supplement and anabolic steroid on knee-extension muscle strength and function 14 weeks after hip fracture surgery.

METHODS

We plan to conduct a randomized, placebo-controlled pilot trial with 48 patients operated for acute hip fracture. The patients are randomized (1:1) to either (1) physiotherapy with protein-rich nutritional supplement plus anabolic steroid or (2) physiotherapy with protein-rich nutritional supplement plus placebo. Outcome assessments will be carried out blinded at baseline (3-10 days after surgery) and at 14 weeks after entering the trial. Primary outcome is the change from baseline to follow-up in maximal isometric knee-extension muscle strength in the fractured limb. Secondary outcomes are physical performance test, patient-reported outcomes, and measures of body composition.

DISCUSSION

If the trial is found feasible and the results show an indication of anabolic steroid being a relevant addition to further enhance the recovery of muscle strength and function in an enhanced recovery after surgery program, this trial will constitute the basis of a larger confirmatory trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545347. Preregistered on 4 June 2018.

Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties

BACKGROUND

Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility.

METHODS

We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS.

RESULTS

Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41).

CONCLUSIONS

IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Changes in Use of Postacute Care Associated With Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts

OBJECTIVE

To examine changes in more and less discretionary condition-specific postacute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation.

DATA SOURCES

2009-2014 Medicare fee-for-service claims.

STUDY DESIGN

Difference-in-difference methodology comparing postacute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers.

PRINCIPAL FINDINGS

Across all 3 cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid postacute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6%-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared with home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in postacute location, but episodic spending decreased 2%-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation.

CONCLUSIONS

ACOs decreased spending on postacute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional postacute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.

Fracture Experiences and Long-Term Care Initiation among Older Population: Analysis of Korean National Health Insurance Service-Senior Cohort Study

BACKGROUND

Long-term care is a burden on individuals, families, and society. It is important to find ways to delay the onset of disability to lessen the burden of long-term care in aging societies. Fracture is one of the risk factors that affect physical functions and make older people dependent. This study aimed to examine how much more often older adults who experienced fractures initiated long-term care compared to those who did not, and whether the risk of entering long-term care differed significantly by fracture site.

METHODS

The analyses included insurants aged 65 years and over from the Korean National Health Insurance Service-senior cohort study (2002-2013). Cox proportional hazard models were used to calculate the hazard ratios of the first certification of initiation of long-term care after fracture, by fracture site, and for multiple recurrent fractures.

RESULTS

The incidence rate of initial long-term care beneficiaries was approximately 2.5 times higher when older people had experienced fractures; these individuals entered long-term care beneficiary status 3 years earlier compared to those who had no fracture events. Lower extremity fracture and multiple recurrent fractures more than doubled the risk for long-term care.

CONCLUSION

Additional attention to fracture sites in prevention and rehabilitation settings is warranted to reduce disability and the related long-term care burden.

Identification of Factors Related to Functional Decline of Korean Older Adults After Hip Fracture Surgery: A Cross-Sectional Study

Reducing functional decline is an essential treatment goal in older adults after hip fracture surgery. The current study examined different effects of functional decline-related factors according to activities of daily living (ADL) and instrumental ADL (IADL) in older adults after hip fracture surgery. A total of 120 participants were included. In quantile regression, preoperative walking and fear of falling were significantly associated with ADLs in the 25th percentile ADL group. Fear of falling was the only significant factor in the poorest IADL group (25th percentile). Efforts should be made to reduce fear of falling after hip fracture surgery. Preoperative walking status was significant in patients with poor ADL after hip fracture surgery; therefore, walking status should be taken into consideration when planning rehabilitation care in this group, so that the best possible ADL outcomes can be attained. [Research in Gerontological Nursing, 12(6),312-320.].

Exercise for improving outcomes after osteoporotic vertebral fracture

BACKGROUND

Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events.

SEARCH METHODS

We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward.

SELECTION CRITERIA

We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model.

MAIN RESULTS

Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence).

AUTHORS' CONCLUSIONS

In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).

Increased therapy demand and impending loss of previous residence status after proximal femur fractures can be determined by continuous gait analysis - A clinical feasibility study

Proximal femur fractures account for increased healthcare costs whenever patients are unable to return to their previous state of residence. Studies suggest that patients benefit from early weight-bearing, yet compliance to weight-bearing regimes is poorly investigated. Aim of the study was thus to show the clinical feasibility of a new measurement tool able to determine continuous weight-bearing behavior after intramedullary nail osteosynthesis of intertrochanteric femur fractures, assess the influence of weight-bearing on clinical outcome and determine rehabilitation demand based on early postoperative gait performance. In an observational study, gait data of 22 patients with intertrochanteric femur fractures were evaluated. During the inpatient stay patients were continuously monitored with a gait analysis insole. Primary outcome was the amount of weight-bearing reached. Short-term functional outcome, as well as return to the previous state of living were evaluated in relation to weight-bearing and activity during the inpatient stay. With the presented technique continuous gait data of all patients during postoperative mobilization could be obtained. Only 13 patients reached full weight-bearing. The technique was feasible to determine correlations between weight-bearing and outcome, as well as between gait activity and outcome. Significant gait differences between patients able to return to their previous state of living and those who could not were seen. Dynamic insole measurements are feasible to continuously determine the postoperative gait performance. Their postoperative use showed, that the continuous compliance to permissive weight-bearing after intertrochanteric fractures is low. The presented measurement technique has the potential to identify patients at risk for reduced outcome and impending loss of previous residence status. Further studies will have to investigate the effects of technology assisted "patient at risk" identification and adapted therapy on clinical outcome.

Pre-discharge prognostic factors of physical function among older adults with hip fracture surgery: a systematic review

INTRODUCTION

To identify, organize, and assess the evidence level of pre-discharge prognostic factors of physical function beyond discharge after hip fracture surgery.

METHODS

We performed a systematic search of four databases (PubMed, Embase, CINAHL, PsycINFO) for longitudinal studies of prognostic factors of physical function at ≥ 1 month among older adults ≥ 50 years old with surgically treated hip fracture, complemented with hand-searching. Two reviewers independently screened papers for inclusion and assessed the quality of all the included papers using the Quality in Prognosis Studies (QUIPS) tool. We assigned the evidence level for each prognostic factor based on consistency in findings and study quality.

RESULTS

From 98 papers that met our inclusion criteria, we identified 107 pre-discharge prognostic factors and organized them into the following seven categories: demographic, physical, cognitive, psychosocial, socioeconomic, injury-related, and process of care. Potentially modifiable factors with strong or moderate evidence of an association included total length of stay, physical function at discharge, and grip strength. Factors with strong or moderate evidence of no association included gender, fracture type, and time to surgery. Factors with limited, conflicting, or inconclusive evidence included body-mass index, psychological resilience, depression, and anxiety.

CONCLUSIONS

Our findings highlight potentially modifiable prognostic factors that could be targeted and non-modifiable prognostic factors that could be used to identify patients who may benefit from more intensive intervention or to advise patients on their expectations on recovery. Examining the efficacies of existing interventions targeting these prognostic factors would inform future studies and whether any of such interventions could be incorporated into clinical practice.

Everyday life after a hip fracture: what community-living older adults perceive as most beneficial for their recovery

OBJECTIVE

to gain insight into what older adults after hip fracture perceive as most beneficial to their recovery to everyday life.

DESIGN

qualitative research approach.

SETTING

six skilled nursing facilities.

PARTICIPANTS

19 older community dwelling older adults (aged 65-94), who had recently received geriatric rehabilitation after hip fracture.

METHODS

semi-structured interviews were conducted with 19 older adults after hip fracture. Coding techniques based on constructivist grounded theory were applied.

RESULTS

four categories were derived from the data: 'restrictions for everyday life', 'recovery process', 'resources for recovery' and 'performing everyday activities'. Physical and psychological restrictions are consequences of hip fracture that older adults have struggled to address during recovery. Three different resources were found to be beneficial for recovery; 'supporting and coaching', 'myself' and 'technological support'. These resources influenced the recovery process. Having successful experiences during recovery led to doing everyday activities in the same manner as before; unsuccessful experiences led to ceasing certain activities altogether.

CONCLUSION

participants highlight their own role ('myself') as essential for recovery. Additionally, coaching provides emotional support, which boosts self-confidence in performing everyday activities. Furthermore, technology can encourage older adults to become more active and being engaged in the recovery process. The findings suggest that more attention should be paid to follow-up interventions after discharge from inpatient rehabilitation to support older adults in finding new routines in their everyday activities.A conceptual model is presented and provides an understanding of the participants' experiences and perspectives concerning their process of recovery after hip fracture to everyday life.

Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE)

Background

A hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients.

Methods/design

This dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17–26) are recruited at the end of inpatient rehabilitation.

The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient’s home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed.

Discussion

Existing service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective.

Trial registration

German Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).

Conceptual Framework for an Episode of Rehabilitative Care After Surgical Repair of Hip Fracture

Researchers face a challenge when evaluating the effectiveness of rehabilitation after a surgical procedure for hip fracture. Reported outcomes of rehabilitation will vary depending on the end point of the episode of care. Evaluation at an inappropriate end point might suggest a lack of effectiveness leading to the underuse of rehabilitation that could improve outcomes. The purpose of this article is to describe a conceptual framework for a continuum-care episode of rehabilitation after a surgical procedure for hip fracture. Definitions are proposed for the index event, end point, and service scope of the episode. Challenges in defining the episode of care and operationalizing the episode, and next steps for researchers are discussed. The episode described is intended to apply to all patients eligible for entry to rehabilitation after hip fracture and includes most functional recovery end points. This framework will provide a guide for rehabilitation researchers when designing and interpreting evaluations of the effectiveness of rehabilitation after hip fracture. Evaluation of all potential care episodes facilitates transparency in reporting of outcomes, enabling researchers to determine the true effectiveness of rehabilitation after a surgical procedure for hip fracture.

Being active after hip fracture; older people's lived experiences of facilitators and barriers

Hip fracture (HF) incidents can severely restrict the activity and well-being of older people. While participation in activities may be related to lived experiences of meaningfulness, the aim of this study was to explore facilitators and barriers for being active as experienced by older people during the first six months after HF. The study used a phenomenological-hermeneutic methodology informed by the philosophies of Heidegger and Gadamer. Two men and 11 women with reduced functioning prior to the HF were interviewed 2 weeks (n=13) and again 6 months (n=11) after discharge. Referring to own pre-understanding including a theoretical framework of well-being, a method of meaning condensation was applied to structure the data. A deeper understanding was gradually achieved through a movement between the parts and the wholes. Two themes emerged: (1) "Inner dialogue and actions" with the sub-themes "Inner driving forces" and "Inner limitations"; (2) "Struggling and Striving" with the sub-themes "Building relationships" and "Considering complications and conditions". We conclude that facilitators for older people to experience well-being while being active involve meaningful relationships with other people, a sense of own identity and being at peace and may be influenced by relationships with staff, physical surroundings, public health services, and health problems.