Effect of exercise interventions in the early phase to improve physical function after hip fracture – A systematic review and meta-analysis

Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community

BACKGROUNDS

Falls affect a significant number of older Australians and present a major challenge to health care providers and health systems with over 380 older Australians hospitalised for a fall each day.

OBJECTIVES

This statement seeks to inform and guide exercise practitioners and health professionals in safe and effective prescription of exercise to prevent falls amongst community-dwelling older people.

EXERCISE PRESCRIPTION TO PREVENT FALLS

Exercise is crucial for preventing falls in older age. Research evidence has identified that programmes which include functional balance and muscle strength training are the most effective in preventing falls. It is also important for exercise to be progressively challenging, ongoing and of sufficient dose to maximise its benefits in reducing falls. Additional (non-exercise) interventions are necessary for people with complex medical conditions, recent hospitalisation and/or particular risk factors not improved by exercise. People at a higher risk of falls may need greater support to undertake safe and effective fall prevention exercise.

SUMMARY

Global guidelines for fall prevention and management recommend that all older adults should receive advice about exercise to prevent falls. Qualified exercise professionals are well placed to prescribe and supervise functional balance and muscle strength training to older people with varied functional abilities, including those with co-morbidities.

[Care models for older people based on a case study-Geriatrics as an active discipline]

Geriatrics can enable and monitor a holistic care of older people through a comprehensive geriatric assessment in a structured way. Therefore, it must be integrated much more closely with preventive, rehabilitative and acute care units. Geriatrics are not seen in any aspects as a replacement for general practitioners or in-hospital structures but much more as a supplement to them. With its function-oriented concept, geriatrics can best coordinate the demographically necessary triage between prevention, acute treatment, rehabilitation and palliative care, thus avoiding undertreatment and overtreatment. This can only succeed in collaboration with general practitioners and specialist colleagues. The article categorizes geriatric care structures, such as preventive home visits, acute complex medical treatment, delirium prevention, outpatient and inpatient rehabilitation services based on a case example and makes proposals for structural changes that urgently need to be considered in the current healthcare reform, such as outpatient geriatric centers (AGZ).

Developing a consensus-based motivational care pathway for individuals with lower limb fractures: a Delphi protocol

Older adults with lower limb fractures often harbor concerns about losing their mobility, fearing a loss of independence. It is vital to develop strategies that foster their active engagement in the rehabilitation process. The present protocol aims to create a care pathway tailored to motivate individuals with lower limb fractures to adhere to rehabilitation. We will develop an observational, cross-sectional, and descriptive study using the Delphi data-gathering approach. Purposive sampling will recruit a panel of healthcare professionals and experts who care for patients with lower limb fractures. Aligned with the Delphi method, a series of iterative rounds will be developed to gather consensus around the motivational strategies used by health professionals in the rehabilitation of people with lower limb fractures. We will employ the Qualtrics platform for data collection and analysis, and a consensus target of 75% has been predetermined. For quantitative data analysis, we will use descriptive statistics encompassing a range of measures, including count, mean, standard deviation, median, minimum, maximum, and range. An inductive thematic analysis procedure will be employed to extract meaningful themes and patterns from qualitative data. The study results are expected to significantly impact clinical practice by creating a specialized care pathway to motivate individuals with lower limb fractures to adhere to rehabilitation. Adopting these explicit standards by professionals will ensure uniform and high-quality care.

The effectiveness of optimal exercise-based strategy for patients with hip fracture: a systematic review and Bayesian network meta-analysis

The implementation of exercise intervention (EI) presents a promising and economical way for patients with hip fracture. However, the optimal type of EI remains unclear. The objective of this study is to evaluate the efficacy of various EI approaches and identify the optimal intervention for improving the prognosis of patients with hip fracture. A comprehensive search of Medline (via PubMed), Web of Science, Embase, Cochrane Central Register of Controlled Trials, CINAHL, CNKI, Wan Fang, VIP, and CBM was conducted from their earliest records to June 2022. The included randomized controlled trials (RCTs) included at least one type of exercise for patients with hip fracture. The methodological quality of these trials was assessed using the Cochrane Collaboration Risk of Bias Tool. All direct and indirect comparisons were analyzed by Stata 14.0 and OpenBUGS 3.2.3 software. The primary outcome was hip function, and the secondary outcomes were activity of daily living (ADL), walking capacity and balance ability of patients. Based on the ranking probabilities, resistance exercise (RE) was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRA]: 94.8%, [MD]: - 11.07, [Crl]: - 15.07 to - 7.08) in improving the efficacy of patients' hip function, followed by balance exercise (BE) ([SUCRA]:81.1%, [MD]: - 8.79, [Crl]: - 13.41 to - 4.18) and muscle strength exercise ([SUCRA]:57.6%, [MD]: - 5.35, [Crl]: - 9.70 to - 0.95). For the improvement of ADL for patients with hip fracture, BE ([SUCRA]:98.4%, [MD]: - 17.38, [Crl]: - 23.77 to - 11.04) may be the best EI. The findings of this study indicate that RE and BE might be the best approach to improve prognosis for patients with hip fracture. However, further rigorous and meticulously planned RCTs are required to substantiate the conclusions drawn from this study.

Interventions Using Wearable Activity Trackers to Improve Patient Physical Activity and Other Outcomes in Adults Who Are Hospitalized: A Systematic Review and Meta-analysis

Importance

Low levels of physical activity during hospitalization are thought to contribute to a range of poor outcomes for patients. Using wearable activity trackers during hospitalization may help improve patient activity, sedentary behavior, and other outcomes.

Objective

To evaluate the association of interventions that use wearable activity trackers during hospitalization with patient physical activity, sedentary behavior, clinical outcomes, and hospital efficiency outcomes.

Data Sources

OVID MEDLINE, CINAHL, Embase, EmCare, PEDro, SportDiscuss, and Scopus databases were searched from inception to March 2022. The Cochrane Central Register for Controlled trials, ClinicalTrials.gov, and World Health Organization Clinical Trials Registry were also searched for registered protocols. No language restrictions were imposed.

Study Selection

Randomized clinical trials and nonrandomized clinical trials of interventions that used wearable activity trackers to increase physical activity or reduce sedentary behavior in adults (aged 18 years or older) who were hospitalized were included.

Data Extraction and Synthesis

Study selection, data extraction, and critical appraisal were conducted in duplicate. Data were pooled for meta-analysis using random-effects models. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed.

Main Outcomes and Measures

The primary outcomes were objectively measured physical activity or sedentary behavior. Secondary outcomes included clinical outcomes (eg, physical function, pain, mental health), and hospital efficiency outcomes (eg, length of stay, readmission).

Results

Fifteen studies with a total of 1911 participants were included, representing various surgical cohorts (4 studies), stroke rehabilitation (3 studies), orthopedic rehabilitation (3 studies), mixed rehabilitation (3 studies), and mixed medical (2 studies). All studies were included in meta-analyses. There was a significant association between wearable activity tracker interventions with higher overall physical activity (standardized mean difference, 0.35; 95% CI, 0.15 to 0.54; I2 = 72%; P < .002) and less sedentary behavior (mean difference, -35.46 min/d; 95% CI, -57.43 to -13.48 min/d; I2 = 0; P = .002), and a significant association between wearable activity tracker interventions with improvements in physical function (standardized mean difference, 0.27; 95% CI, 0.08 to 0.46; I2 = 0; P = .006) compared with usual care. There was no significant association between wearable activity tracker interventions with pain, mental health, length of stay, or readmission risk.

Conclusions and Relevance

In this systematic review and meta-analysis, interventions that used wearable activity trackers with patients who are hospitalized were associated with higher physical activity levels, less sedentary behavior, and better physical functioning compared with usual care.

Bone loss induced by cancer treatments in breast and prostate cancer patients

Cancer and cancer therapies are a major factor risk for osteoporosis due to bone loss and deterioration of bone microarchitecture. Both factors contribute to a decrease in bone strength and, consequently, increased bone fragility and risk of fracture. Cancer-associated bone loss is a multifactorial process, and optimal interdisciplinary management of skeletal health, accurate assessment of bone density, and early diagnosis are essential when making decisions aimed at reducing bone loss and fracture risk in patients who have received or are receiving treatment for cancer. In this document, a multidisciplinary group of experts collected the latest evidence on the pathophysiology of osteoporosis and its prevention, diagnosis, and treatment with the support of the Spanish scientific society SEOM. The aim was to provide an up-to-date and in-depth view of osteoporotic risk and its consequences, and to present a series of recommendations aimed at optimizing the management of bone health in the context of cancer.

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.

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.

Progressive Resistance Training Program Characteristics in Rehabilitation Programs Following Hip Fracture: A Meta-Analysis and Meta-Regression

Introduction: Older adults often experience incomplete recovery after a hip fracture. Rehabilitation programs with progressive resistance training are associated with improved functional recovery. This systematic review and meta-analysis with meta-regression a) evaluated resistance training characteristics reported in hip fracture rehabilitation programs, b) performed meta-analysis of resistance training impact on strength (primary outcome), gait and physical activity (secondary outcomes), and c) explored resistance training program characteristics associated with improved outcomes using meta-regression. Materials and Methods: Medline, EMBASE, CINAHLPLUS, and Web of Science Core Collection databases were searched (January2000–February2021). Randomized controlled trials including progressive resistance training rehabilitation programs after hip fracture surgery in adults ≥50 years old were included. Meta-analyses and exploratory meta-regression were performed. Results: Meta-analysis showed significant increases in strength (10 trials-728 participants; Standardized Mean Difference (SMD) [95%CI]; .40 [.02, .78]) immediately following program completion in intervention relative to control participants. Meta-analysis on 5 trials (n = 384) with extended follow up found no significant group differences (SMD = .47 [-.28, 1.23]) in strength. Center-based relative to home-based programs were associated with significantly greater improvements in strength (P < .05) as were programs where resistance training intensity was prescribed using one-repetition maximum relative to other exercise prescription methods (P < .05). In gait meta-analysis (n = 10 trials-704 participants), gait speed in intervention participants immediately after the program was significantly higher than control (SMD = .42 [.08, .76]) but this finding was not maintained in extended follow-up (n = 5 trials-240 participants; SMD = .6 [-.26, .38]). Higher resistance training intensity was associated with significant improvements in gait speed (P < .05). No meta-analysis was performed for the 3 heterogeneous studies reporting physical activity. Discussion: Progressive resistance training improved muscle strength and gait speed after hip fracture surgery in adults ≥50years old immediately after the program ended, but the longer-term impact may be more limited. Conclusions: Higher resistance training intensity and center-based programs may be associated with more improvement, but require further research.

The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: a secondary analysis of UK national linked audit data

Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture.

INTRODUCTION

To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital.

METHODS

We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death.

RESULTS

The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19-1.30) and 1.26 (95% CI 1.19-1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18-1.52) and 1.33 (95% CI 1.12-1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08-1.15) and 1.10 (95% CI 1.05-1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge.

CONCLUSION

We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

Validity, Responsiveness, and Predictive Ability of the Japanese Version of the Cumulated Ambulation Score in Patients with Hip Fracture

Objectives:

The aim of the current study was to investigate the validity, the responsiveness, and the predictive ability for discharge to own home of the Japanese version of the Cumulated Ambulation Score (CAS-JP). This was achieved by analyzing the CAS-JP after hip fracture surgery at multiple time points until patient discharge.

Methods:

Patients who underwent hip fracture surgery were evaluated using CAS-JP, the Barthel Index, and walking ability on postoperative day (POD) 1, 7, and 14 and at discharge. Floor and ceiling effects, responsiveness, and correlations between CAS-JP and other functional outcomes were assessed at each time point. The predictive ability of CAS-JP for discharge to own home was also analyzed using the area under the curve (AUC) of the receiver operating characteristic.

Results:

A total of 121 patients were included in this study. On POD7, POD14, and at discharge, strong correlations were observed between CAS-JP and the Barthel Index (r=0.81, 0.82, and 0.87, respectively), and between CAS-JP and walking status (r=0.82, 0.81, and 0.76, respectively). CAS-JP had a large effect size (1.64–2.25) and standardized response mean (1.49–1.81). The predictive ability of CAS-JP for discharge to own home, as indicated by the AUCs, were 0.73 (95% CI: 0.62–0.83) on POD7 and 0.74 (95% CI: 0.62–0.86) on POD14.

Conclusions:

CAS-JP has sufficient validity and responsiveness as a mobility assessment tool in postoperative hip fracture patients. Furthermore, this study showed that early postoperative mobility status evaluation using CAS-JP can sufficiently predict discharge to own home.

Cross-sectional survey of rehabilitation service availability for stroke and hip fracture in Australian public hospitals

OBJECTIVE

To describe the rehabilitation services available for people with stroke and hip fracture across New South Wales/Australian Capital Territory metropolitan and rural/regional public hospitals in Australia.

DESIGN

A cross-sectional study design was used.

SETTING

New South Wales/Australian Capital Territory public hospital providing rehabilitation services for stroke and hip fracture.

PARTICIPANTS

Delegates from 59 eligible hospitals.

INTERVENTION

Information about the type, number and availability of inpatient and outpatient rehabilitation services at each hospital was collected via survey.

MAIN OUTCOME MEASURES

Counts, percentages, mean (SD), median (IQR) were used to quantify the number and type of inpatient and outpatient services available.

RESULTS

Across inpatient rehabilitation units, reduced availability was noted in the number of clinical disciplines available, availability of neuropsychology and social work in rural units. Across outpatient rehabilitation services, reduced availability was noted in the number of disciplines available, availability of occupational therapy, psychology, rehabilitation physicians, specialist nursing, geriatricians, and podiatry in rural services. Five rural hospitals had no access to outpatient rehabilitation.

CONCLUSION

There was reduced availability of rehabilitation services and health disciplines in rural/regional settings. A follow-up study is underway investigating relationships between reduced outpatient service availability and inpatient length of stay in rural/regional versus metropolitan hospitals.

The journey of recovery after hip-facture surgery: older people's experiences of recovery through rehabilitation services involving physical activity

Purpose: This study sought to explore and describe the experiences of recovery among community-living older people undergoing rehabilitation involving physical activity following hip-fracture surgery. Methods: We conducted in-depth interviews with 5 men and 16 women (age range: 67 - 84 years). The data were analysed by means of systematic text condensation.Results: The analysis revealed the following four interrelated themes: (1) what participants bring to the recovery situation matters; (2) support through individually tailored rehabilitation services, involving physical activity, - is key to recovery following hip fracture surgery; (3) needing professional help on the journey from helplessness and vulnerability to being more confident and active; and (4) making progress and regaining function represent the essence of recovery.Conclusions: All four identified themes relate to how physical activity, as an aspect of rehabilitation services, contributes to the recovery process for patients who have experienced a hip fracture. Differences were reported with regard to the services used, and all the participants were at the mercy of what their municipalities chose to offer in terms of rehabilitation services.IMPLICATIONS FOR REHABILITATIONMunicipal healthcare services should address patients' individual needs when planning, organising and implementing rehabilitation programmes involving physical activity.Healthcare professionals need to recognise older patients' experiences of reduced physical, psychological and social functioning following hip-fracture surgery and then take those experiences into account when tailoring rehabilitation programmes.Healthcare professionals providing physical rehabilitation programmes to people who have undergone hip-fracture surgery should take into account their patients' situation and lifestyle prior to experiencing a hip fracture.Municipal healthcare services should consider using recovery as a conceptual framework in relation to rehabilitation services involving physical activity.

Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial)

Background

Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery.

Methods

Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition.

Results

Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4years, 78% women). Target sample size was 48. Main limitations for inclusion were not home-dwelling (18%) and cognitive dysfunction (16%). Among eligible patients, the main reason for declining participation was Overwhelmed and stressed by situation (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic=10, control=8).

Conclusions

Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid.

Trial registration

Clinicaltrials.gov NCT03545347.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02273-z.

Effect of an additional health-professional-led exercise programme on clinical health outcomes after hip fracture

PURPOSE

To examine the effect of an additional 2-week health professional-led functional exercise programme compared to usual care for patients after hip fracture during a short-term nursing home stay directly after hospital discharge.

METHOD

One hundred and forty participants, 65 years or older with hip fracture, admitted to a short-term nursing home stay were randomised to an intervention group or control group. Participants in the intervention group (n = 78) received the experimental programme consisted of functional exercises, performed by health care professionals up to four times a day, 7 days a week, in addition to usual care during a 2-week short-term nursing home stay. Participants in the control group (n = 62) received usual care alone. Primary outcome was Short Physical Performance Battery (SPPB). Secondary outcomes were Timed Up & Go, New Mobility Score, The University of California, Los Angeles Activity Scale, Fall Efficacy Scale International, The EuroQol five dimension five-level questionnaire, and Numeric Rating Scale for pain. Outcome measures were assessed after 2 weeks in a short-term nursing home stay and 3 months after hip fracture surgery. The activity monitor ActivPal registered activity during the 2-week short-term nursing home stay.

RESULTS

No statistically significant differences between groups was found in any outcomes after 2 weeks or 3 months (p > 0.05). There were statistically significant within-group improvements in primary outcome SPPB and in most secondary outcomes at all time points in both groups (p > 0.05).

CONCLUSIONS

A 2-week health professional-led functional exercise programme in addition to usual care demonstrated no difference in clinical outcomes compared to usual care alone up to 3 months after hip fracture. The patients with hip fracture are fragile and vulnerable in this early phase, and usual physiotherapy may be sufficient to improve their physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02780076.

"To do or not to do": Treatment fidelity to a complex training intervention

BACKGROUND AND PURPOSE

When a complex intervention is examined it is viewed necessary to perform a qualitative process evaluation paired with an outcome evaluation. The purpose is to provide insights into the fidelity of the experimental intervention and thereby strengthen the validity of the study. In "Recovery after hip fracture" (the HIPFRAC study), the effect of a complex functional training intervention was examined by a randomized controlled trial design. The training was initiated by the physiotherapist and performed by the nurses/nurse assistants (NAs), as part of their daily, habitual routine when the patients with hip fracture were in a short-term stay after discharge from hospital. The aim of the present process evaluation was to explore how contextual factors facilitated or complicated the nurses'/NAs' fidelity to the experimental intervention in the HIPFRAC study.

METHODS

A descriptive thematic analysis was used. Data was collected through semi-structured in-depth interviews with three nurses and three NAs working with the HIPFRAC patients in a short-term stay. The interviews were transcribed and analyzed.

FINDINGS

Six subthemes, two main themes and one overall theme were identified. The overall theme was: Barriers affecting the implementation process. The main themes related to the barriers were identified as follows: (1) Attitudes within the nurses/NAs and (2) Structural factors.

DISCUSSION

The nurses/NAs in the short-term stay experienced contextual barriers, which contributed to complicate fidelity to the experimental intervention. There is a need of further research to investigate whether increased physiotherapy resources at short-term stay will improve the level of physical activity among the patients with hip fracture.