Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial

Home-based Rehabilitation After Inpatient Rehabilitation: Utilization Rate and Characteristics of Referred Patients

OBJECTIVE

To determine the utilization rate of a home-based rehabilitation program after an inpatient rehabilitation stay, and to investigate the profile of users.

DESIGN

Observational study.

SETTING

Inpatient rehabilitation facility in a tertiary hospital.

PARTICIPANTS

Older patients (N=1913) discharged home between June 2018 and May 2021, after an inpatient rehabilitation stay.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge to home-based rehabilitation.

RESULTS

Over the study period, 296 (15.5%) patients were discharged to home-based rehabilitation. Compared with the others, home-based rehabilitation patients were more frequently women (69.6% vs 61.5%; P=.008), and admitted after orthopedic surgery (elective or for fracture) (30.1% vs 16.1%; P<.001). They had worse functional performance at admission (mean Functional Independence Measure self-care score: 27.8±7.3 vs 30.8±6.7; P<.001), but greater gain in self-care during their inpatient stay (5.0±4.8 vs 4.4±4.7; P=.038). In multivariable analysis, being a woman (adjusted odds ratio [adjOR], 1.36; 95% confidence interval [CI], 1.01-1.82; P=.040), being admitted after orthopedic surgery (adjOR, 2.32; 95% CI, 1.64-3.27; P<.001), being admitted for gait disorders or falls (adjOR, 1.38; 95% CI, 1.01-1.88; P=.039), and showing greater gain in mobility during the inpatient stay (adjOR, 1.12; 95% CI, 1.07-1.17; P<.001) remained associated with discharge to home-based rehabilitation. In contrast, higher mobility at discharge decreased the odds of discharge to home-based rehabilitation (adjOR, 0.87; 95% CI, 0.83-0.91; P<.001).

CONCLUSIONS

One in 6 patients benefited from home-based rehabilitation after their inpatient stay. Although these patients had poorer functional performance at admission and discharge, they showed greater mobility improvement during their inpatient stay, suggesting that their good recovery potential was a key determinant of their orientation toward home-based rehabilitation.

Association of the @ctivehip tele-rehabilitation with the fear of falling of older adults with hip fracture and their family caregivers: Secondary analysis of a non-randomised controlled trial

INTRODUCTION

Osteoporotic hip fracture is a major health problem. Falls, the primary cause, might lead to a persistent fear of falling (FoF) among older adults, affecting their daily activities and rehabilitation. While in-person interventions exist, limited research is available on the effects of tele-rehabilitation on the FoF after a hip fracture. Thus, this study aims to test the association of the @ctivehip tele-rehabilitation programme on reducing the levels of FoF experienced by both older adults with hip fracture and their family caregivers.

METHODS

A non-randomised controlled trial (ClinicalTrials.gov; Identifier: NCT02968589) that compared a webpage-based tele-rehabilitation (@ctivehip) against usual care. Fear of falling was assessed using the Short Falls Efficacy Scale-International. Patients' functional status was evaluated using the Functional Independence Measure. Physical performance was assessed by the Timed Up and Go test and Short Physical Performance Battery. We conducted a per-protocol analysis as the primary outcome, and an intention-to-treat approach as secondary analysis.

RESULTS

A total of 71 patients with hip fracture (78.75 ± 6.12 years, 75% women) and their family caregivers participated. Participants in the intervention showed a higher decrease in FoF in comparison to those in the usual care (0.5 Cohen's d; p = 0.042). The reduction in FoF resulting from participation in the tele-rehabilitation programme was mediated by improvements in functional status by 79%. The @ctivehip programme did not decrease FoF of family caregivers.

DISCUSSION

@ctivehip is associated with a reduction of the FoF in older adults with hip fractures, but not in their family caregivers, with the reduction being mostly explained by improvements in the patients' functional status. Although the intervention seems promising, it should not be applied in clinical settings until confirmed by appropriate-designed randomised clinical trials.

Multimodal home-based rehabilitation intervention after discharge from inpatient geriatric rehabilitation (GeRas): study protocol for a multicenter randomized controlled trial

BACKGROUND

Geriatric rehabilitation aims to maintain the functional reserves of older adults in order to optimize social participation and prevent disability. After discharge from inpatient geriatric rehabilitation, patients are at high risk for decreased physical capacity, increased vulnerability, and limitations in mobility. As a result, ageing in place becomes uncertain for a plethora of patients after discharge from geriatric rehabilitation and effective strategies to prevent physical decline are required. Collaboration between different health-care providers is essential to improve continuity of care after discharge from inpatient geriatric rehabilitation. The aim of this study is to evaluate the effectiveness of a multi-professional home-based intervention program (GeRas) to improve functional capacity and social participation in older persons after discharge from inpatient geriatric rehabilitation.

METHODS

The study is a multicenter, three-arm, randomized controlled trial with a three-month intervention period. Two hundred and seventy community-dwelling older people receiving inpatient geriatric rehabilitation will be randomized with a 1:1:1 ratio to one of the parallel intervention groups (conventional IG or tablet IG) or the control group (CG). The participants of both IGs will receive a home-based physical exercise program supervised by physical therapists, a nutritional recommendation by a physician, and social counseling by social workers of the health insurance company. The collaboration between the health-care providers and management of participants will be realized within a cloud environment based on a telemedicine platform and supported by multi-professional case conferences. The CG will receive usual care, two short handouts on general health-related topics, and facultative lifestyle counseling with general recommendations for a healthy diet and active ageing. The primary outcomes will be the physical capacity measured by the Short Physical Performance Battery and social participation assessed by the modified Reintegration to Normal Living Index, three months after discharge.

DISCUSSION

The GeRas program is designed to improve the collaboration between health-care providers in the transition from inpatient geriatric rehabilitation to outpatient settings. Compared to usual care, it is expected to improve physical capacity and participation in geriatric patients after discharge from inpatient geriatric rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00029559). Registered on October 05, 2022.

Emerging trends and prospects in telerehabilitation for hip fracture: Bibliometric and visualization study

Background

Telerehabilitation provide distant physical rehabilitation services and help overcome the barriers associated with face-to-face interventions for hip fractures. This study aims to analyse the progress of the application of telerehabilitation in hip fracture and reveal its research profile, hotspots and development trends.

Methods

The articles and reviews related to telerehabilitation in hip fracture were retrieved from 1992 to 2024. A bibliometric visualization and comparative analysis of countries, institutions, journals, authors, references and keywords were conducted using Java-based CiteSpace and VOSviewer.

Results

A total of 79 documents were obtained. Spain was the most academically influential country. The University of Granada was the most prolific institution. The author Ariza-vega P listed first in terms of publications and citations. Most publications were published in high academic impact journals. The major frontier keywords were "older adults," "functional recovery," "reliability," "mortality," "rehabilitation," "mobility" and "quality of life." The most popular keywords from 2020 to 2024 were "geriatric medicine," "family caregiver" and "digital health."

Conclusions

The historical and prospective perspective in telerehabilitation following hip fracture were presented. A primary focus in the early years was the impact of telerehabilitation on functional independence for hip fracture patients. Future outcomes are expected to include patient satisfaction, health-related quality of life and psychiatric symptoms. Exercise was also designed to eliminate travel burdens and strengthen self-efficacy, and improve the physical and psychosocial function of hip fracture patients. This work will provide a fundamental reference as well as a directional guide for future research.

Effects of rehabilitation therapy based on exercise prescription on motor function and complications after hip fracture surgery in elderly patients

BACKGROUND

Exercise rehabilitation training is an important measure for improving the prognosis of patients with hip fractures. However, the particular program that works effectively and the efficiency of exercise therapy are still controversial.

OBJECTIVE

To compare the effects of usual postoperative care combined with rehabilitation based on exercise prescription on motor function and complications in elderly patients who underwent surgery for hip fracture.

METHODS

This was an observational study. A total of 71 elderly patients with hip fractures who were treated with hip arthroplasty and internal fixation of the proximal femur with an intramedullary nail at Suzhou Municipal Hospital from October 2020 to December 2021 were included; 11 cases were excluded (eight cases were excluded due to loss of follow-up, two due to deaths from other causes, and one due to other reasons). Finally, 60 patients (18 males and 42 females) were included. Patients were randomly assigned to the control (n = 30) and experimental (n = 30) groups using a random number generator. Patients in the control group received usual postoperative care, whereas those in the experimental group received usual postoperative care combined with rehabilitation training based on the principles of exercise prescription. We recorded the motor function (Harris hip score), daily living ability (Barthel Index), and complications at discharge and 1, 3, and 6 months postoperatively for statistical analysis.

RESULTS

The Harris hip score and Barthel Index score were significantly higher at 1, 3, and 6 months postoperatively than at discharge in both groups (p < 0.05). The Harris hip score and Barthel Index score at discharge and 1, 3, and 6 months postoperatively were significantly higher in the experimental group than in the control group (p < 0.05). The incidence of complications at 6 months postoperatively was significantly lower in the experimental group than in the control group (13% vs. 37%).

CONCLUSIONS

Rehabilitation therapy based on exercise prescription helps improve hip function and the ability to perform activities of daily living and related postoperative complications after hip fracture surgery in elderly patients. The findings of our study will guide decision-making in clinical practice and improve the clinical management of hip fractures in elderly patients postoperatively.

Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials

BACKGROUND

Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery.

OBJECTIVES

We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures.

METHODS

We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis.

RESULTS

Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported.

CONCLUSIONS

The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Is a telerehabilitation programme for older adults with hip fracture associated with burden of family caregivers who provide support?

Objective

@ctivehip is a home-based multidisciplinary telerehabilitation programme for older adults with hip fracture, conducted with the assistance of their family caregivers. This programme was useful in improving their functional recovery. Nevertheless, we were concerned about how the programme might have affected caregivers, whose assistance was essential for supporting older adults in using new technologies and ensuring their safety during the exercises and activities at home. The aim of the present study was to compare the burden, psychological factors and physical fitness of the family caregivers of older adults who opted the @ctivehip telerehabilitation programme versus those family caregivers of older adults who received the face-to-face rehabilitation provided by the Andalusian Public Healthcare System (in Spain).

Methods

In this single-blinded, non-randomized clinical trial, participants were older adults with hip fracture and their family caregivers. The telerehabilitation group (n = 30) underwent a 12-week multidisciplinary telerehabilitation programme, and the comparative group (n = 32) received face-to-face rehabilitation. Caregivers outcomes measured were (i) the burden using the Zarit Burden Interview, (ii) the anxiety and depression with the Hospital Anxiety and Depression Scale (HADS), and (iii) the Physical Fitness with the International Fitness Scale (IFIS).

Results

There were not statistically significant differences on caregiver burden between family caregivers in the @ctivehip and the comparative group, although there was a trend towards lower values [[Mean (95%CI); 14.73 (9.09 to 20.37) vs 16.03 (10.63 to 21.43); p = 0.771] as well as for anxiety and depression [5.66 (3.21 to 8.78) vs 11.19 (8.52 to 13.86); p = 0.022]. Likewise achieved better, though not statistically significant, scores in physical fitness [19.37 (17.94 to 20.81) vs 17.15 (15.77 to 18.53); p = 0.055].

Conclusion

Caregiver burden is not associated with telerehabilitation. In addition, telerehabilitation is associated with lower anxiety and depression levels among family caregivers who opt for this programme. Physical fitness is not related with telerehabilitation.

Effectiveness of multicomponent home-based rehabilitation in older patients after hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Hip fracture is a major burden on health care systems worldwide and requires hospitalisation for a long period.

OBJECTIVE

The aim was to evaluate the effectiveness of multicomponent home-based rehabilitation compared with different control interventions (in-hospital rehabilitation, active control or usual care) in older patients after hip fracture surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

We searched three electronic databases, including Ovid-MEDLINE, Ovid-Embase, CINAHL and the Cochrane Library for relevant articles up to March 2020.

REVIEW METHODS

Two investigators independently extracted data and assessed study quality using the risk of bias. Data were analysed using Review Manager 5.3. The current review employs the PRISMA procedure.

RESULTS

Out of 2996 studies, 22 articles were relevant for this review and meta-analysis. Among them, five compared the multicomponent home-based rehabilitation with in-hospital rehabilitation, one compared it with active control, six with usual care and ten compared the home exercise only with usual care. There was no significant difference in activities of daily living (ADL) between multicomponent home-based rehabilitation and in-hospital rehabilitation, while multicomponent home-based rehabilitation significantly increased in ADL when compared to usual care. Home exercises also had significant effects on ADL, quality of life(QoL), balance, gait and muscle strength of the knee extensor compared with usual care (p < .05).

CONCLUSIONS

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL.

RELEVANT TO CLINICAL PRACTICE

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL. Also, high adherence to home exercise may be associated with better clinical outcomes. Therefore, more compliance-oriented multicomponent home-based rehabilitation programmes for older patients after hip fracture must be developed by health care professionals, including physical therapist, to ensure optimum home-based rehabilitation.

Effects of a Home-Based Physical Training and Activity Promotion Program in Community-Dwelling Older Persons with Cognitive Impairment after Discharge from Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Older people with cognitive impairment (CI) are at high risk for mobility limitations and adverse outcomes after discharge from geriatric rehabilitation settings. The aim was to estimate the effects of a specifically designed home-based physical training and activity promotion program on physical capacity, different aspects of physical activity (PA), and psychosocial status.

METHODS

Patients with mild to moderate CI (Mini-Mental State Examination [MMSE]: 17-26 points) discharged home after rehabilitation were included in this randomized, double-blind, placebo-controlled trial with a 12-week intervention and 12-week follow-up period. The intervention group performed a CI-specific, autonomous, home-based strength, balance, and walking training supported by tailored motivational strategies to foster training adherence and promote PA. The control group participated in an unspecific motor placebo activity. Primary outcomes were physical capacity (Short Physical Performance Battery [SPPB]) and PA (sensor-based activity time).

RESULTS

Among 118 randomized participants (82.3 ± 6.0 years) with CI (MMSE: 23.3 ± 2.4) and high levels of multimorbidity, those participants undergoing home-based training demonstrated superior outcomes to the control group in SPPB (mean difference between groups 1.9 points; 95% CI: 1.0-2.8; p < .001), with persistent benefits over the follow-up (1.3 points; 95% CI: 0.4-2.2; p < .001). There were no differences in PA across any time points. Among secondary outcomes, fear of falling and activity avoidance behavior were reduced in the intervention group at all time points, life-space mobility improved short-term.

CONCLUSIONS

The results demonstrate clinically important benefits of an individually tailored autonomous physical training and activity promotion program on physical capacity and secondary outcomes in different domains in a vulnerable, multimorbid population.

CLINICAL TRIAL REGISTRATION

ISRCTN82378327.

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.

Effects of a 12-month home-based exercise program on functioning after hip fracture - Secondary analyses of an RCT

BACKGROUND

Long-term functional limitations are common after hip fractures. Exercise may alleviate these negative consequences but there is no consensus on an optimal training program. The objective was to study the effects of a 12-month home-based supervised, progressive exercise program on functioning, physical performance, and physical activity.

METHODS

Secondary analysis of a randomized controlled trial targeting patients with surgical repair of a hip fracture, aged ≥60 years, Mini-Mental State Examination (MMSE) score of ≥12. The participants were randomized into Exercise (n = 61) or Usual care (n = 60). Assessments at baseline, 3, 6, and 12 months included Lawton's Instrumental Activities of Daily Living (IADL), Short Physical Performance Battery (SPPB), handgrip strength, and self-reported frequency of sessions of leisure-time physical activity. Analyzed using mixed-effects models.

RESULTS

Participants' (n = 121) mean age was 81 years (SD 7), and 75% were women. The mean IADL score at baseline was 17.1 (SD 4.5) in the exercise group, and 17.4 (5.1) in the usual care group. The mean SPPB scores were 3.9 (1.6) and 4.2 (1.8), and handgrip strength was 17.7 (8.9) kg and 20.8 (8.0) kg, respectively. The age- and sex-adjusted mean changes in IADL over 12 months were 3.7 (95% CI 2.8-4.7) in the exercise and 2.0 (1.0-3.0) in the usual care group (between-group difference, p = 0.016); changes in SPPB 4.3 (3.6-4.9) and 2.1 (1.5-2.7) (p < 0.001); and changes in handgrip strength 1.2 kg (0.3-2.0) and 1.0 kg (-1.9 to -0.2) (p < 0.001), respectively. We found no between-group differences in changes in the frequency of leisure-time activity sessions.

CONCLUSION

A 12-month home-based supervised, progressive exercise program improved functioning and physical performance more than usual care among patients with hip fractures. However, the training did not increase leisure-time physical activity.

Adherence to Exercise Programs in Community-Dwelling Older Adults Postdischarge for Hip Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

To determine whether older adults adhere to exercise programs after discharge for hip fracture and how adherence relates to exercise program characteristics and intervention efficacy.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, Embase, Physiotherapy Evidence Database, Web of Science, SPORTDiscus, PsycINFO, PubMed, and Ovid MEDLINE were searched from inception to August 2020.

STUDY SELECTION

Randomized controlled trials of exercise interventions in adults older than 60 years with a surgically managed hip fracture that provided a measure of adherence were selected by 2 independent reviewers.

DATA EXTRACTION

Data were extracted independently by 1 reviewer and cross-checked by a second reviewer for accuracy. Risk of bias was assessed with 2 tools: a customized checklist was used to examine sources of bias and ambiguity for adherence data, and the Cochrane Risk of Bias tool was used to assess the interval validity of studies.

DATA SYNTHESIS

Seventeen trials with 1850 participants (mean age, 78.8 years) were included in the review. The pooled estimate of adherence to exercise programs post hip fracture was 0.88 (95% CI, 0.78-0.95). Programs that were more than 6 months in duration were associated with a decrease in adherence (odds ratio, 0.29; 95% CI, 0.11-0.77). However, increased adherence was not associated with improvements in functional outcomes. None of the other program characteristics were associated with improvements in functional outcomes.

CONCLUSIONS

Adherence to exercise programs after hip fracture appears to be high and may be related to program duration. However, there is a need for a standardized approach to measure and report adherence data in future studies to determine whether exercise adherence is associated with improvements in function for this population.

Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effect of rehabilitation on the physical, social, and psychological dimensions of community reintegration after hip fracture.

DATA SOURCES

Electronic databases Embase, EMCare, MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched from the earliest date available to second June 2021.

STUDY SELECTION

Searching identified 1844 potentially relevant articles. Twenty randomized controlled trials evaluating physical retraining, cognitive retraining, and model of care interventions on physical, social and psychological aspects of community reintegration for 3075 adults after hip fracture were included.

DATA EXTRACTION

Data were extracted using predetermined templates for participant characteristics, intervention type and setting, and outcomes related to community reintegration. Methodological quality was assessed using the Physiotherapy Evidence Database scale, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was applied to each meta-analysis.

DATA SYNTHESIS

Post intervention data were pooled to calculate risk ratios (RRs), mean differences, standardized mean differences, and 95% confidence intervals (CIs) using inverse variance methods and a random-effects model. Compared with usual care or no rehabilitation, there was moderate-quality evidence to suggest that physical retraining interventions improved outdoor mobility (RR, 1.45; 95% CI, 1.09-1.91; I2=0%) and moderate-quality evidence to suggest that physical retraining improved Nottingham Extended Activities of Daily Living Scale scores (physical and social reintegration) by a mean 3.5 units (95% CI, 0.99-6.01; I2=0%). Meta-analyses showed no significant effect for cognitive retraining and model of care interventions on any dimension of community reintegration.

CONCLUSIONS

Preliminary evidence suggests that physical rehabilitation after hip fracture improves physical and social aspects of community reintegration. The effect of psychological and home-based interventions on community reintegration is currently unclear. Further research is needed to determine the effect of rehabilitation on community reintegration, using interventions and measures that encompass all dimensions of community reintegration.

Effectiveness of Multicomponent Home-Based Rehabilitation in Elderly Patients after Hip Fracture Surgery: A Randomized Controlled Trial

This randomized controlled study aimed to assess the clinical effectiveness of an 8-week personalized multicomponent home-based rehabilitation (MHR) program by comparing it with a home exercise program after discharge. Forty patients (≥60 years old) who underwent hip surgery were randomly assigned to multicomponent home-based rehabilitation (MHR) and home exercise groups. The MHR program included strength, endurance, balance, and breathing exercises; modifications to the home environment; education on assistive device use; pressure ulcer care; nutrition management; and motivational counseling. The MHR group received 24 visits from rehabilitation staff for 8 weeks (3 times a week), while the home exercise group received home exercises focusing on strengthening described in the leaflet. The rehabilitation staff prescribed the intensity of exercise at the first visit, and the home exercise group exercised without supervision after that for 8 weeks. Both groups received a 10-min phone call once a week for overall counseling to ensure high adherence to home exercises. Among the 40 participants, 29 (72.5%) completed the trial. The primary outcomes were balance and mobility. Balance was assessed using the functional reach test (FRT), and the timed up-and-go test (TUG) was used to assess balance and mobility. Data were analyzed using the intention-to-treat principle. The MHR group showed significant improvement compared to the home exercise group for FRT (mean difference (MD) 4.4 cm; 95% confidence interval (CI) 1.0 to 7.8) and TUG (MD: −4.2 s; 95% CI −8.0 to −0.3) after 8 weeks of intervention. Subjective pain and physical components of general health-related quality of life also improved significantly in the MHR group. No serious adverse events related to the interventions were observed. The eight-week of MHR program can effectively improve balance and mobility.

Domains of Balance Training Delivered in Rehabilitation Programs Following Hip Fracture Surgery in Older Adults: A Systematic Review

BACKGROUND AND PURPOSE

The aim of this systematic review was to assess the domains and characteristics of balance training (BT) interventions delivered in rehabilitation programs following hip fracture to identify potential treatment gaps.

METHODS

Manual and electronic searches (Web of Science, Medline, EMBASE, CINAHL, and ProQuest) were conducted. We selected randomized controlled trials with older adults following hip fracture surgery that included either specific BT or gait, mobility, or transfer training. Two independent reviewers extracted data and rated the methodological quality using the Physiotherapy Evidence Database scale. A third reviewer provided consensus. Extracted BT data included balance domain, progression, frequency, duration, intensity, level of supervision, setting, and rehabilitation phase.

RESULTS AND DISCUSSION

We included 17 trials from 19 studies; 11 studies were rated as moderate to high methodological quality, but only 8 were considered to have high-quality BT components. Half of the interventions included only one balance domain, with stability during movement being the most commonly included domain. The primary balance progression utilized was reducing hand support. Dual task, anticipatory postural adjustment, reactive strategies, and perceptual training domains were rarely included. Balance training duration and intensity were poorly described. Although most programs were home-based with minimal levels of supervision, a few extended beyond postacute phase of rehabilitation.

CONCLUSION

Further consideration should be given to include more challenging BT domains with planned progressions to maximize patient recovery through hip fracture rehabilitation programs.

The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors

PURPOSE

To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture.

METHODS

Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures.

RESULTS

Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy.

CONCLUSION

Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

ActiveHip+: A feasible mHealth system for the recovery of older adults after hip surgery during the COVID-19 pandemic

OBJECTIVE

Half of older adults undergoing hip surgery do not recover their previous functional status. mHealth is a promising tool for rehabilitating older adults after hip surgery. This study aimed to test the feasibility of the ActiveHip+ mHealth system in older adults after hip surgery.

METHODS

Sixty-nine older adults who had undergone hip surgery and their family caregivers were recruited from hospitals in Spain and Belgium and used the ActiveHip+ mHealth system for 12 weeks. Assessments were made during hospital stay and 3 months after surgery. Feasibility assessment included: adoption (participation proportion), usage (access to the app), satisfaction with the app (Net Promoter Score) and user perception of the quality of the app (Mobile App Rating Scale). Clinical assessment included: patient-reported outcomes, such as functional status (Functional Independence Measure) and performance-based outcomes, such as physical fitness (Short Physical Performance Battery).

RESULTS

The ActiveHip+ mHealth system obtained satisfactory feasibility results in both countries. In Spain, we observed 85% adoption, 64% usage, 8.86/10 in satisfaction with the app and 4.42/5 in perceived quality of the app. In Belgium, we observed 82% adoption, 84% usage, 5.16/10 in satisfaction with the app and 3.52/5 in app's perceived quality. The intervention had positive effects on levels of functional status, pain and physical fitness.

CONCLUSIONS

The ActiveHip+ mHealth system is a feasible tool to conduct the rehabilitation in older adults after hip surgery. Although the intervention seemed beneficial clinically, we do not recommend its implementation in clinical settings until appropriately designed randomised clinical trials confirm these results.

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.

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.

Outpatient and Home-Based Treatment: Effective Settings for Hip Fracture Rehabilitation in Elderly Patients

Femoral neck fractures are a major source of disability in the elderly. Rehabilitation is fundamental to recover pre-fracture functionality. We conducted an observational cohort study with the aim of comparing the efficacy of rehabilitation programs in different therapeutic settings. We included elderly patients who had undergone surgical stabilization of a hip fracture. The participants were divided into 3 groups: group 1, outpatient rehabilitation; group 2, inpatient rehabilitation; group 3, home-based rehabilitation. Patients were evaluated at baseline, at three months, and at six months after fracture. Our outcome measures were the Barthel Index (BI), Functional Ambulation Categories, passive and active range of motion of hip flexion and abduction, and muscle strength in hip flexion, abduction, and knee extension. At six months, all three groups showed an average statistically significant improvement (p < 0.05) in all outcome measures compared to the baseline. Considering the between-group analysis, final BI was significantly higher in outpatient than inpatient-treated patients (p = 0.018), but no statistical difference was found between outpatient and home-based patients. Our findings suggest that rehabilitation leads to significant functional recovery after hip fracture in elderly patients. Both outpatient and home-based rehabilitation seem to be reasonable options for hip fracture rehabilitation.

Patient perspectives of recovery after hip fracture: a systematic review and qualitative synthesis

PURPOSE

The purpose of the current review is to synthesize the evidence of patients' perspectives of recovery after hip fracture across the care continuum.

METHODS

A systematic search was conducted, focusing on qualitative data from hip fracture patients. Screening, quality appraisal, and a subset of articles for extraction were completed in duplicate. Themes were generated using a thematic synthesis of data from original studies.

RESULTS

Fourteen high-quality qualitative studies were included. Four review themes were identified: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support. Patients considered recovery as a return to pre-fracture activities or "normal" enabling independence. Feelings of vulnerability were observed irrespective of the time since hip fracture and only diminished when recovery of function and activities enabled participation in valued activities, e.g., outdoor mobility. Participants expressed a desire to engage in recovery with realistic expectations and the benefits of meaningful feedback reported. While reliance on healthcare professionals decreased towards a later stage of recovery, reliance on social support persisted until recovery was perceived to have been achieved.

CONCLUSION

Patient perspectives highlighted hip fracture as a major life event requiring health professional and social support to overcome feelings of vulnerability and enable active engagement in recovery.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals should ensure expectations and goals are set early in the recovery process.Rehabilitation professionals should ensure goals set with patients are tailored to the individual's pre-fracture activities or "normal" promoting independence.Rehabilitation professionals should monitor goals ensuring they are providing support, motivation, and managing expectations across the care continuum.Rehabilitation professionals should address patients' feelings of vulnerability, particularly in the absence of social support, and ensure appropriate ongoing input to maximize recovery.

Exercise therapy is effective at improving short- and long-term mobility, ADL and balance in older patients following hip fracture: a systematic review and meta-analysis

BACKGROUND

A systematic review and meta-analysis was performed to evaluate the short- and long-term effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, and secondly, whether the effect was modified by trial level characteristics such as intervention modality, duration and initiation timepoint.

METHODS

Medline, CENTRAL, Embase, CINAHL and PEDro was searched up-to November 2020. Eligibility criteria was randomized controlled trials investigating the effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, initiated from time of surgery up-to 1-year.

RESULTS

Forty-nine studies involving 3905 participants showed a small to moderate effect of exercise therapy at short term (end of intervention) on mobility (Standardized mean difference, SMD 0.49, 95%CI 0.22-0.76); Activities of Daily Living (ADL) (SMD 0.31, 95%CI 0.16-0.46); lower limb muscle strength (SMD 0.36, 95%CI 0.13-0.60); balance (SMD 0.34, 95%CI 0.14-0.54). At long term (closest to 1-year), small to moderate effects were found for mobility (SMD 0.74, 95%CI 0.15-1.34); ADL (SMD 0.42, 95%CI 0.23-0.61); balance (SMD 0.50, 95%CI 0.07-0.94) and Health related Quality of Life (HRQoL) (SMD 0.31, 95%CI 0.03-0.59). Certainty of evidence was evaluated using GRADE ranging from moderate to very low, due to study limitation and inconsistency.

CONCLUSION

We found low certainty of evidence for a moderate effect of exercise therapy on mobility in older patients following hip fracture at end-of-treatment and follow-up. Further, low evidence was found for small to moderate short-term effect on ADL, lower limb muscle strength and balance.

Analysis of Home-Based Rehabilitation Awareness, Needs and Preferred Components of Elderly Patients with Hip Fracture Surgery in South Korea

The importance and necessity of home-based rehabilitation with professional and systematic interventions should be considered since home-based rehabilitation has been institutionalized as it is more feasible, cost effective, and even safer than in-hospital rehabilitation in most countries—though not in South Korea. In addition, the need for home-based rehabilitation is increasing due to the increasing number of hip fracture patients and limited capacity of acute hospital rehabilitation. Therefore, the purpose of this study was to investigate the awareness, needs, and preferred components of home-based rehabilitation services after discharge for elderly patients with hip fracture surgery in South Korea. A survey of 98 elderly patients who recently underwent hip fracture surgery was performed using a questionnaire. More than 75% of patients agreed on the need for home-based rehabilitation, even though most had never heard of it. The reason for the need for home-based rehabilitation was that it is possible to receive continuously ongoing treatment (53.0%), and it alleviates the inconvenience of visiting hospitals (27.7%). In addition to this, about 15.7% of patients responded that they could achieve mental comfort. In other words, patients can recover in an emotionally stable environment without the psychological anxiety they might experience in hospital. Thus, in order to maximize the effectiveness of home-based rehabilitation and provide comprehensive guidance including exercise, education, motivational support, and environmental modification, to patients undergoing hip fracture surgery, the component of the rehabilitation program must be developed based upon rehabilitation experts’ knowledge and patients’ value. Additionally, corresponding policies should be established.

Exercise interventions, physical function, and mobility after hip fracture: a systematic review and meta-analysis

PURPOSE

To investigate the effects of different exercise components on physical function and mobility in adults after hip fracture.

METHODS

Pubmed, Embase, Cochrane Library, Web of Science, CINAHL, and PsycINFO were searched up to March 2021. Randomized controlled trials investigating the effects of exercise interventions on physical function and mobility in adults after hip fracture were included.

RESULTS

Fifteen studies (12 trials) were included (n = 1198, age = 80 ± 8 years). Exercise interventions had a moderate effect on overall physical function after hip fracture compared to non-exercise (SMD = 0.46, 95% CI = 0.27-0.65). Among different exercise components, progressive resistance exercise showed the largest effect (SMD = 0.48, 95% CI = 0.27-0.69), while aerobic exercise alone had no effect (SMD 0.41, 95% -0.44 to1.26) on physical function. Exercise had a small effect on mobility (SMD = 0.28, 95% CI = 0.12-0.43). Specifically, functional exercise showed a moderate effect (SMD = 0.41, 95% CI = 0.16-0.65) on mobility.

CONCLUSIONS

Available evidence supports that exercise interventions improve physical function and mobility in older adults after hip fracture; specifically, resistance exercise with progressive load of 60-80% 1RM, and functional exercise may be critical intervention components respectively. Future high-quality research is needed to establish best practices.IMPLICATIONS FOR REHABILITATIONProgressive resistance exercise with 60-80% 1RM resulted in the largest improvement in physical function after hip fracture.Functional exercise appears to be a critical component for improving mobility after hip fracture. Functional exercise plus resistance and balance exercises was the most effective intervention for enhancing mobility.Exercise should be supervised by a trainer or a physiotherapist, and self-reported exercise may not result in the same benefits.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Effects of Home-Based Physical Exercise on Days at Home, Health Care Utilization, and Functional Independence Among Patients With Hip Fractures: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of a physical exercise program on days lived at home, the use and costs of health care and social services, mortality, and functional independence among patients with hip fractures.

DESIGN

Randomized controlled trial with a parallel 2-group design consisting of a 12-month intervention and 12-month registry follow-up.

SETTING

Home-based intervention.

PARTICIPANTS

Patients aged ≥60 years (N=121) with operated hip fracture and who were living at home were randomized into physical exercise (n=61) and usual care (n=60) groups.

INTERVENTIONS

Supervised physical exercise twice a week.

MAIN OUTCOME MEASURES

The primary outcome was the number of days lived at home over 24 months. Secondary outcomes were the use and costs of health care and social services, mortality over 24 months, and Functional Independence Measure (FIM) over 12 months.

RESULTS

Over 24 months, there was no significant difference between the groups in terms of days lived at home (incidence rate ratio, 1.01; 95% confidence interval [CI], 0.90-1.14) or mortality (hazard ratio, 1.01; 95% CI, 0.42-2.43). The mean total costs of health care and social services did not differ between the groups. The costs per person-year were 1.26-fold (95% CI, 0.87-1.86) greater in the physical exercise group than in the usual care group over 12 months and 1.08-fold (95% CI, 0.77-1.70) over 24 months. The mean difference between the change in FIM of the groups over 12 months was 4.5 points (95% CI, 0.5-8.5; P=.029) in favor of the physical exercise group.

CONCLUSIONS

Long-term home-based physical exercise had no effect on the number of days lived at home over 24 months among patients with hip fractures. The intervention was cost neutral over these 24 months. The FIM scores improved in both groups over 12 months, but the improvement was significantly greater in the physical exercise group than in the usual care group.

Effectiveness of community-based rehabilitation interventions incorporating outdoor mobility on ambulatory ability and falls-related self-efficacy after hip fracture: a systematic review and meta-analysis

There is limited evidence from 11 randomised controlled trials on the effect of rehabilitation interventions which incorporate outdoor mobility on ambulatory ability and/or self-efficacy after hip fracture. Outdoor mobility should be central (not peripheral) to future intervention studies targeting improvements in ambulatory ability.

PURPOSE

Determine the extent to which outdoor mobility is incorporated into rehabilitation interventions after hip fracture. Synthesise the evidence for the effectiveness of these interventions on ambulatory ability and falls-related self-efficacy.

METHODS

Systematic search of MEDLINE, Embase, PsychInfo, CINAHL, PEDro and OpenGrey for published and unpublished randomised controlled trials (RCTs) of community-based rehabilitation interventions incorporating outdoor mobility after hip fracture from database inception to January 2021. Exclusion of protocols, pilot/feasibility studies, secondary analyses of RCTs, nonrandomised and non-English language studies. Duplicate screening for eligibility, risk of bias, and data extraction sample. Random effects meta-analysis. Statistical heterogeneity with inconsistency-value (I²).

RESULTS

RCTs (n = 11) provided limited detail on target or achieved outdoor mobility intervention components. There was conflicting evidence from 2 RCTs for the effect on outdoor walking ability at 1-3 months (risk difference 0.19; 95% confidence intervals (CI): 0.21, 0.58; I² = 92%), no effect on walking endurance at intervention end (standardised mean difference 0.05; 95% CI: - 0.26, 0.35; I² = 36%); and suggestive (CI crosses null) of a small effect on self-efficacy at 1-3 months (standardised mean difference 0.25; 95% CI: - 0.29, 0.78; I² = 87%) compared with routine care/sham intervention.

CONCLUSION

It was not possible to attribute any benefit observed to an outdoor mobility intervention component due to poor reporting of target or achieved outdoor mobility and/or quality of the underlying evidence. Given the low proportion of patients recovering outdoor mobility after hip fracture, future research on interventions with outdoor mobility as a central component is warranted.

TRIAL REGISTRATION

PROSPERO registration: CRD42021236541.

Longitudinal changes in physical activity levels and fear of falling after hip fracture

BACKGROUND AND PURPOSE

Due to global ageing, more people will suffer from hip fracture in the future, and many will be left with permanent physical impairments. The care burden for people post hip fracture is high. The aim of this study is to measure longitudinal changes in physical activity levels and fear of falling in people after hip fracture who return home after inpatient rehabilitation.

METHODS

Longitudinal observational study. Participants were recruited from three rehabilitation centres in Victoria, Australia. Self-reported fear of falling (Short Falls Efficacy Scale - International) and physical activity levels (Human Activity Profile - Adjusted Activity Score and Frenchay Activity Index) were assessed at 2 weeks, 3 and 6 months after discharge. Mobility (walking speed) and balance (Timed Up-and-Go test and Step Test) were measured at discharge from rehabilitation.

RESULTS

Thirty-four participants (mean age: 82 years [SD 8]; 62% female) with unilateral hip fracture were recruited. Participants had moderately impaired balance and mobility at discharge compared to age-matched normative data; they were all discharged with a walking aid and were 40% slower in their walking speed. Participants had increased fear of falling and reduced physical activity 2 weeks after discharge, which improved significantly (p < 0.01) over the following 6 months, but scores were still lower than the normative values. At 6 months, participants also had moderate to high levels of fear of falling and were less active than the general population of similar age.

DISCUSSION

Although fear of falling and physical activity improved in the 6 months following discharge, both remained negatively affected compared to normative data. Rehabilitation post hip fracture should include routine assessment of fear of falling as a potential barrier for return of physical activities.

Comprehensive Geriatric Care to Improve Mobility after Hip Fracture: An RCT

BACKGROUND

Comprehensive geriatric care (CGC) for older adults during hospitalization for hip fracture can improve mobility, but it is unclear whether CGC delivered after a return to community living improves mobility compared with usual post-discharge care.

OBJECTIVE

To determine if an outpatient clinic-based CGC regime in the first year after hip fracture improved mobility performance at 12 months.

METHODS

A two-arm, 1:1 parallel group, pragmatic, single-blind, single-center, randomized controlled trial at 3 hospitals in Vancouver, BC, Canada. Participants were community-dwelling adults, aged ≥65 years, with a hip fracture in the previous 3-12 months, who had no dementia and walked ≥10 m before the fracture occurred. Target enrollment was 130 participants. Clinic-based CGC was delivered by a geriatrician, physiotherapist, and occupational therapist. Primary outcome was the Short Physical Performance Battery (SPPB; 0-12) at 12 months.

RESULTS

We randomized 53/313 eligible participants with a mean (SD) age of 79.7 (7.9) years to intervention (n = 26) and usual care (UC, n = 27), and 49/53 (92%) completed the study. Mean 12-month (SD) SPPB scores in the intervention and UC groups were 9.08 (3.03) and 8.24 (2.44). The between-group difference was 0.9 (95% CI -0.3 to 2.0, p = 0.13). Adverse events were similar in the 2 groups.

CONCLUSION

The small sample size of less than half our recruitment target precludes definitive conclusions about the effect of our intervention. However, our results are consistent with similar studies on this population and intervention.

Promoting physical activity in geriatric patients with cognitive impairment after discharge from ward-rehabilitation: a feasibility study

The aim of the present study was to examine adherence and acceptance of a home-based program to promote physical activity (PA) in older persons with cognitive impairment (CI) following inpatient rehabilitation. Sixty-three older persons (≥ 65 years) with mild to moderate CI (Mini-Mental State Examination score 17-26), allocated to the intervention group of a randomized, controlled intervention trial underwent a 12-week home-based PA intervention including (1) physical training and outdoor walking to improve functional fitness and (2) motivational strategies (goal-setting, pedometer-based self-monitoring, social support delivered by home visits, phone calls) to promote PA. Training logs were used to assess adherence to physical training, outdoor walking and to motivational strategies (goal-setting, pedometer-based self-monitoring). Acceptance (subjective feasibility and effectiveness) of the program components was assessed by a standardized questionnaire. Mean adherence rates over the intervention period were 63.6% for physical training, 57.9% for outdoor walking, and between 40.1% (achievement of walking goals), and 60.1% (pedometer-based self-monitoring) for motivational strategies. Adherence rates significantly declined from baseline to the end of intervention (T1: 43.4-76.8%, T2: 36.1-51.5%, p values<.019). Most participants rated physical training, outdoor walking, goal-setting, and pedometer self-monitoring as feasible (68.2-83.0%) and effective (63.5-78.3%). Highest ratings of self-perceived effectiveness were found for home visits (90.6%) and phone calls (79.2%). The moderate to high adherence to self-performed physical training and motivational strategies proved the feasibility of the home-based PA program in older persons with CI following inpatient rehabilitation.

Being active 1½ years after hip fracture: a qualitative interview study of aged adults' experiences of meaningfulness

Background

Being active is vital and a source of well-being. However, 18 months after hip fracture (HF), progress seems to have come to a halt. Aged adults may feel vulnerable, experiencing ongoing dependency and limited possibilities for socializing. How they experience the meaningfulness of being active during these circumstances is unknown. The aim of this study was to explore experiences of the meaningfulness of being active for aged adults 18 months after HF.

Methods

A phenomenological-hermeneutic methodology based on the philosophies of Heidegger and Gadamer was applied. Data were collected using individual interviews conducted in participants’ homes. The study was part of a longitudinal study, and three former interviews helped build trusting relationships with participants and focus the semi-structured interview guide. An existential theory of well-being and suffering considering health to be a balancing of mobility and dwelling was applied.

Participants were nine aged adults 65 years or older with pre-fracture dependency included in the study 18 months earlier while still in hospital after HF. The interpretation was a process of analyzing data by moving between the parts and the whole as a means of gaining a deeper understanding and continuously testing pre-understandings. The analysis followed five steps: a) getting a sense of the whole b) delineating and condensing meaning units, c) interpreting meaning units, d) relating to study purpose, and e) developing themes and sub-themes.

Results

Two main themes emerged. The main-theme “Feeling the continuity of life “had four sub-themes: “Gratitude for present possibilities, ““Connected with earlier life-experience, ““Thoughtfully managing vulnerability, “and “Belonging with other people. “The main-theme “Feeling vulnerable “had two sub-themes: “Thwarted “and “Sad and regretting lost continuity in life.“.

Conclusions

Eighteen months after HF, aged adults seem to be struggling on their own to be active in meaningful ways. To maintain hope, relieve the strain in everyday life, and maintain a sense of safety and self-confidence, they may need help. However, to avoid suffering, there is a need to balance additional training and a struggle for progress with well-being experiences in terms of feeling gratitude, restoring a sense of normality, and feeling kinship with other people.

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.

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.

Effects of an individually targeted multicomponent counseling and home-based rehabilitation program on physical activity and mobility in community-dwelling older people after discharge from hospital: a randomized controlled trial

OBJECTIVES

The aim of this study is to evaluate the effects of multicomponent rehabilitation on physical activity, sedentary behavior, and mobility in older people recently discharged from hospital.

DESIGN

Randomized controlled trial.

SETTING

Home and community.

PARTICIPANTS

Community-dwelling people aged ⩾60 years recovering from a lower limb or back musculoskeletal injury, surgery, or disorder were recruited from local health center hospitals and randomly assigned into an intervention (n = 59) or a control (standard care, n = 58) group.

INTERVENTION

The six-month intervention consisted of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program, physical activity counseling, and standard care.

MEASUREMENTS

Physical activity and sedentary time were assessed using an accelerometer and a single question. Mobility was evaluated with the Short Physical Performance Battery, self-reported use of a walking aid, and ability to negotiate stairs and walk outdoors. Intervention effects were analyzed with generalized estimating equations.

RESULTS

Daily physical activity was 127 ± 78 minutes/day and 121 ± 70 at baseline and 167 ± 81 and 164 ± 72 at six months in the intervention and control group, respectively; mean difference of 3.4 minutes (95% confidence interval (CI) = -20.3 to 27.1). In addition, no significant between-group differences were shown in physical performance.

CONCLUSION

The rehabilitation program was not superior to standard care for increasing physical activity or improving physical performance. Mobility-limited older people who had recently returned home from hospital would have needed a longer and more frequently monitored comprehensive geriatric intervention.

Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults: The CAP Randomized Clinical Trial

IMPORTANCE

Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community.

OBJECTIVE

To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community.

DESIGN, SETTING, AND PARTICIPANTS

Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later.

INTERVENTIONS

The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins.

MAIN OUTCOMES AND MEASURES

The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control.

RESULTS

Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2).

CONCLUSIONS AND RELEVANCE

Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01783704.

Community rehabilitation interventions after hip fracture: Pragmatic evidence-based practice recommendations

Practice development enables practitioners to develop their knowledge and allows the application of evidence-based care for their patients. It happens within the practitioner's own clinical practice area and enhances personal and professional growth whilst focusing on patients' specific needs. This is important when working with patients in the rehabilitation phase following fragility hip fracture whose care should be provided by practitioners knowledgeable about the best way to approach their needs. This article, which followed the methods for a scoping review, aims to provide the practitioner with an overview of rehabilitation interventions for patients following hip fracture discussed in the literature. There is an introduction to the nature of rehabilitation and the issues raised for the patient with a hip fracture, a discussion of the existing literature, and recommendations for practice based on both that evidence and a pragmatic approach to care. Scoping reviews provide overviews of broad topic areas (Peterson et al., 2017). This gives the reader the opportunity to consider how other factors, besides research evidence, can contribute to best practice and to reflect on how their own practice needs to develop. At the end of the discussion, an overview of pragmatic recommendations for practice is provided based on the findings of the literature considered. Some points for individual reflection are also provided to help the practitioner to consider how the contents of the paper might impact on their own practice.

Effects of a Home-Based Physical Rehabilitation Program on Tibial Bone Structure, Density, and Strength After Hip Fracture: A Secondary Analysis of a Randomized Controlled Trial

Weight‐bearing physical activity may decrease or prevent bone deterioration after hip fracture. This study investigated the effects of a home‐based physical rehabilitation program on tibial bone traits in older hip fracture patients. A population‐based clinical sample of men and women operated for hip fracture (mean age 80 years, 78% women) was randomly assigned into an intervention (n = 40) and a standard care control group (n = 41) on average 10 weeks postfracture. The intervention group participated in a 12‐month home‐based rehabilitation intervention, including evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacological pain management, motivational physical activity counseling, and a progressive, weight‐bearing home exercise program comprising strengthening exercises for the lower legs, balance training, functional exercises, and stretching. All participants received standard care. Distal tibia (5% proximal to the distal end plate) compressive bone strength index (BSI; g²/cm⁴), total volumetric BMD (vBMD_TOT; mg/cm³), and total area (CSA_TOT; mm²), as well as midtibia (55%) strength–strain index (SSI; mm³), cortical vBMD (vBMD_CO; mg/cm³), and ratio of cortical to total area (CSA_CO/CSA_TOT) were assessed in both legs by pQCT at baseline and at 3, 6, and 12 months. The intervention had no effect (group × time) on either the distal or midtibial bone traits. At the distal site, BSI of both legs, vBMD_TOT of the fractured side, and CSA_TOT of the nonfractured side decreased significantly over time in both groups 0.7% to 3.1% (12 months, p < 0.05). At the midshaft site, CSA_CO/CSA_TOT and SSI of both legs, and vBMD_CO of the fractured leg, decreased significantly over time in both groups 1.1% to 1.9% (12 months, p < 0.05). Trabecular and cortical bone traits of the tibia on the fractured and the nonfractured side deteriorated throughout follow‐up. The home‐based physical rehabilitation intervention aimed at promoting mobility recovery was unable to prevent bone deterioration in older people after hip fracture. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Effectiveness of a tele-rehabilitation intervention to improve performance and reduce morbidity for people post hip fracture - study protocol for a randomized controlled trial

BACKGROUND

Most surviving hip-fracture patients experience reduced mobility and lose some of their functional ability, which increases the risk of complications and rehospitalization. Post-discharge transitional programs to reduce readmissions and disabilities have shown some success. Telerehabilitation refers to the use of technologies to provide rehabilitation services to people in their homes. Considering the need for long-term follow-up care for people with hip fracture, in-home telerehabilitation could increase independence, decrease hospital stays and reduce the burden for caregivers. The objective of this study is to investigate the effectiveness of an intervention program based on telerehabilitation on activities of daily living (ADL), quality of life (QOL), depression and burden on caregivers compared to face-to-face home visits and usual care of community-dwelling older adults after hip fracture.

METHODS/DESIGN

This will be a three-armed randomized control trial (RCT) including pre/post intervention and follow-up. The trial will include 90 older people with hip fractures who will be randomly assigned to a telerehabilitation group (N = 30), face-to-face visits (N = 30) and a control group. The aim of the intervention is to improve the transition from rehabilitation units to community dwelling. It will include 10 videoconferencing/ face-to-face sessions from an occupational therapist in the presence of the primary caregiver. Each session will be utilized to guide the participants to achieve their self-identified goals, focusing on problem-solving for daily life situations and on the ability to implement the discussed strategies for a variety of activities. Outcome measures include Functional Independence Measure (FIM) for evaluation of ADL, SF-12 for evaluation of Health-related QOL, The Geriatric Depression Scale (GDS) and The Zarit Caregiver Burden Scale. Data will be analyzed using Repeated measures MANOVA.

DISCUSSION

The current study will enable the cost-effectiveness examination of a suggested rehabilitation service based on available technology. The proposed intervention will increase accessibility of in-home rehabilitation services, improve function and health, and reduce economic burden.

TRIAL REGISTRATION

NCT03376750 (12/15/2017).

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).

A home-based tele-rehabilitation protocol for patients with hip fracture called @ctivehip

Home-based tele-rehabilitation programs are under development and may be a future option for some patients. The objectives of this non-randomized clinical trial are to design a home-based multidisciplinary tele-rehabilitation protocol for patients with hip fracture, and to compare this protocol versus the home-based usual outpatient rehabilitation protocol. Seventy patients treated for an acute hip fracture, aged 65 years or older, with a high pre-fracture functional level (Functional Independence Measure score >90), without severe cognitive impairment, absence of terminal disease, discharged to their own home or a relativés home postoperatively, allowed weight-bearing, and with signed informed consent, will be allocated into a tele-rehabilitation group (n = 35) or a control group (n = 35). The inclusion criterion for the intervention group will be to have a caregiver with the ability to access the Internet who is willing to perform exercises and activities with the patient at home. The intervention includes a program of physical exercise and occupational therapy (five weekly sessions during 12 weeks), and recommendations for patients and their caregivers, all delivered through a website. The patient's functional level (Functional Independence Measure), quality of life (Euro-Qol), physical performance (Timed Up and Go), caregiver burden (Zarit Interview), and other descriptive data will be assessed at hospital discharge, 4 weeks, and 12 weeks. This project will add to the knowledge concerning the feasibility of tele-rehabilitation as an option to promote recovery of the pre-fracture functional level for some patients with a hip fracture. ClinicalTrials.gov Identifier: NCT02968589NCT.

Effects of 12-month home-based physiotherapy on duration of living at home and functional capacity among older persons with signs of frailty or with a recent hip fracture - protocol of a randomized controlled trial (HIPFRA study)

Background

Health concerns, such as frailty and osteoporotic fractures decrease functional capacity and increase use of health and social care services in the aging population. The ability to continue living at home is dependent on functional capacity, which can be enhanced by rehabilitation.

We study the effects of a 12-month home-based physiotherapy program with 12-month follow-up on duration of living at home, functional capacity, and the use of social and health care services among older persons with signs of frailty, or with a recently operated hip fracture.

Methods

This is a non-blinded, parallel group, randomized controlled trial performed in South Karelia Social and Health Care District, Finland (population 131,000). Three hundred community-dwelling older persons with signs of frailty (age ≥ 65) and 300 persons with a recent hip fracture (age ≥ 60) will be recruited. Frailty is screened by FRAIL questionnaire and verified by modified Fried’s frailty criteria. Both patient groups will be randomized separately to a physiotherapy and a usual care arm. Individualized, structured and progressive physiotherapy will be carried out for 60 min, twice a week for 12 months at the participant’s home. The primary outcome at 24 months is duration of living at home. Our hypothesis is that persons assigned to the physiotherapy arm will live at home for six months longer than those in the usual care arm. Secondary outcomes are functional capacity, frailty status, health-related quality-of-life, falls, use and costs of social and health care services, and mortality. Assessments, among others Short Physical Performance Battery, Functional Independence Measure, Mini Nutritional Assessment, and Mini-Mental State Examination will be performed at the participant’s home at baseline, 3, 6, and 12 months. Register data on the use and costs of social and health care services, and mortality will be monitored for 24 months.

Discussion

Our trial will provide new knowledge on the potential of intensive, long-term home-based physiotherapy among older persons at risk for disabilities, to enhance functional capacity and thereby to postpone the need for institutional care, and diminish the use of social and health care services.

Trial registration

ClinicalTrials.gov Identifier: NCT02305433, Registered Nov 28, 2014.

Promoting safe walking among older people: the effects of a physical and cognitive training intervention vs. physical training alone on mobility and falls among older community-dwelling men and women (the PASSWORD study): design and methods of a randomized controlled trial

Background

Safe and stable walking is a complex process involving the interaction of neuromuscular, sensory and cognitive functions. As physical and cognitive functions deteriorate with ageing, training of both functions may have more beneficial effects on walking and falls prevention than either alone. This article describes the study design, recruitment strategies and interventions of the PASSWORD study investigating whether a combination of physical and cognitive training (PTCT) has greater effects on walking speed, dual-task cost in walking speed, fall incidence and executive functions compared to physical training (PT) alone among 70–85-year-old community-dwelling sedentary or at most moderately physically active men and women.

Methods

Community-dwelling sedentary or at most moderately physically active, men and women living in the city of Jyväskylä will be recruited and randomized into physical training (PT) and physical and cognitive training (PTCT). The 12-month interventions include supervised training sessions and home exercises. Both groups attend physical training intervention, which follows the current physical activity guidelines. The PTCT group performes also a web-based computer program targeting executive functions. Outcomes will be assessed at baseline and at 6 and 12 months thereafter. Falls data are collected during the interventions and the subsequent one-year follow-up. The primary outcome is 10-m walking speed. Secondary outcomes include 6-min walking distance, dual-task cost in walking speed, fall incidence and executive function assessed with color Stroop and Trail Making A and B tests. Explanatory outcomes include e.g. body composition and bone characteristics, physical performance, physical activity, life-space mobility, fall-related self-efficacy, emotional well-being and personality characteristics.

Discussion

The study is designed to capture the additive and possible synergistic effects of physical and cognitive training. When completed, the study will provide new knowledge on the effects of physical and cognitive training on the prevention of walking limitations and rate of falls in older people. The expected results will be of value in informing strategies designed to promote safe walking among older people and may have a significant health and socio-economic impact.

Trial registration

ISRCTN52388040.

Handgrip Strength Cannot Be Assumed a Proxy for Overall Muscle Strength

OBJECTIVES

Dynapenia, low muscle strength, is predictive for negative health outcomes and is usually expressed as handgrip strength (HGS). Whether HGS can be a proxy for overall muscle strength and whether this depends on age and health status is controversial. This study assessed the agreement between HGS and knee extension strength (KES) in populations differing in age and health status.

DESIGN

Data were retrieved from 5 cohorts.

SETTING AND PARTICIPANTS

Community, geriatric outpatient clinics, and a hospital. Five cohorts (960 individuals, 49.8% male) encompassing healthy young and older individuals, geriatric outpatients, and older individuals post hip fracture were included.

MEASURES

HGS and KES were measured according to the protocol of each cohort. Pearson correlation was performed to analyze the association between HGS and KES, stratified by sex. HGS and KES were standardized into sex-specific z scores. The agreement between standardized HGS and standardized KES at population level and individual level were assessed by intraclass correlation coefficients (ICC) and Bland-Altman analysis.

RESULTS

Pearson correlation coefficients were low in healthy young (male: 0.36 to 0.45, female: 0.45) and healthy older individuals (male: 0.35 to 0.37, female: 0.44), and moderate in geriatric outpatients (male and female: 0.54) and older individuals post hip fracture (male: 0.44, female: 0.57) (P < .05, except for male older individuals post hip fracture [P = .07]). Intraclass correlation coefficient values were poor to moderate in all populations (ie, healthy young individuals [0.41, 0.45], healthy older individuals [0.37, 0.41, 0.44], geriatric outpatients [0.54], and older individuals post hip fracture [0.54]). Bland-Altman analysis showed that within the same population of age and health status, agreement between HGS and KES varied on individual level.

CONCLUSIONS

At both population and individual level, HGS and KES showed a low to moderate agreement independently of age and health status. HGS alone should not be assumed a proxy for overall muscle strength.

A tailored counseling and home-based rehabilitation program to increase physical activity and improve mobility among community-dwelling older people after hospitalization: protocol of a randomized controlled trial

BACKGROUND

Physical activity (PA) decreases during hospitalization. In particular, the amount of PA engaged in by older people who are hospitalized following musculoskeletal injury is likely to be limited for months after discharge home. Given the importance of an active lifestyle for their recovery and the prevention of future adverse outcomes, there is clearly a need for interventions to increase PA. This article describes the protocol of a randomized controlled trial set up to investigate the effects of a physical activity oriented home rehabilitation program (ProPA) on PA and the restoration of mobility in community-dwelling older people.

METHODS

Men and women aged 60 years or older hospitalized due to a musculoskeletal injury or disorder in the back or lower limbs are recruited. After discharge from hospital to home, participants are randomized into a six-month ProPA program or a standard care (control) group. The ProPA program consists of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program and physical activity counseling. In addition, frail participants who are not able to go outdoors alone receive support from volunteers. Primary outcomes are PA measured using a 3-dimentional accelerometer, and mobility assessed by the Short Physical Performance Battery and self-reports. Secondary outcomes are life space mobility, participation restriction, fear of falling, pain, mood, and grip strength. Information on barriers to and enablers of PA participation are also collected. Data on mortality and use of health services are collected from the national register. In this 6-month intervention, all participants are assessed in their homes at baseline and after three and six months, and at 12 months after randomization they will receive a follow-up questionnaire.

DISCUSSION

This study investigates the effects of a rehabilitation program on PA and mobility among older people at risk for increased sedentary time and mobility problems. If positive effects are observed, the program can be considered for incorporation into the health care system and thereby contribute to the rehabilitation of older people who have recently been discharged from hospital.

TRIAL REGISTRATION

ISRCTN13461584 . Registered 27 January 2016.