Systematic Review of Hip Fracture Rehabilitation Practices in the Elderly

Article Outline

• Abstract
• Methods
• Results
  • Clinical Pathway
    • Within an acute care setting—intensive occupational therapy and/or physical therapy exercises
    • Within an acute care setting—early mobilization
  • Early Supported Discharge
    • Within an acute care setting
  • Interdisciplinary Care
    • Within an acute care setting—joint postoperative management
    • Within an acute care setting—interdisciplinary team monitored by a geriatrician
  • Occupational Therapy/Physical Therapy
    • Within an acute care setting—high-frequency occupational therapy/physical therapy
    • Within an acute care setting—additional occupational therapy combined with physical therapy
    • Inpatient setting—occupational therapy and physical therapy on a rehabilitation ward
    • Inpatient setting—quadriceps training; high-intensity PT
    • Outpatient setting—programs with a progressive home-based PT component
    • Outpatient setting—aerobic training followed by aerobic exercise and PRT in an indoor facility
  • Exercise
    • Inpatient setting—treadmill gait retraining
    • Inpatient setting—weight-bearing exercise
    • Inpatient setting—PT plus neuromuscular stimulation of the quadriceps muscle
    • Outpatient setting—weight-bearing exercise
    • Outpatient setting—PRT and/or aerobic exercise
    • Outpatient setting—strength and functional training
  • Discharge Settings
    • Rehabilitation settings: IRFs, SNFs, and/or home care
    • Home-based rehabilitation: intensive face-to-face contacts
• Conclusions
• Acknowledgment
• Appendix
• References
• Copyright

Abstract 

Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly.

Objective

To address the need for a research synthesis on the effectiveness of the full range of hip fracture rehabilitation interventions for older adults and make evidence based conclusions.

Data Sources

Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2007 for studies published in English. The terms rehabilitation and hip fracture were exploded in order to obtain related search terms and categories.

Study Selection

In the initial search of the databases, a combined total of 1031 articles was identified. Studies that did not focus on hip fracture rehabilitation, did not include persons over the age of 50 years, and/or did not include measures of physical outcome were excluded.

Data Extraction

Only studies with an Oxford Center for Evidence-Based Medicine Levels of Evidence level of I (randomized controlled trial, RCT) or II (cohort) were reviewed. The methodologic quality of both types of studies was assessed using a modified version of the Downs and Black checklist.

Data Synthesis

There were 55 studies that met our selection criteria: 30 RCTs and 25 nonrandomized trials. They were distributed across 6 categories for rehabilitation intervention (care pathways, early rehabilitation, interdisciplinary care, occupational and physical therapy, exercise, intervention not specified) and 3 settings (acute care hospital, postacute care/rehabilitation, postrehabilitation).

Conclusions

When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Eleven intervention categories across 3 settings were associated with improved ambulatory outcomes. Seven intervention approaches were related to improved functional recovery, while 6 intervention approaches were related to improved strength and balance recovery. Decreased length of stay and increased falls self-efficacy were associated with 2 interventions, while 1 intervention had a positive effect on lower-extremity power generation.

Key Words: Elderly, Evidence-based medicine, Hip fractures, Rehabilitation

List of Abbreviations: ADL, activity of daily living, CI, confidence interval, CP, clinical pathway, IADL, instrumental activity of daily living, IRF, inpatient rehabilitation facility, LOS, length of stay, NRT, nonrandomized trial, OR, odds ratio, OT, occupational therapy, PRT, progressive resistance training, PT, physical therapy, RCT, randomized controlled trial, SNF, skilled nursing facility

HIP FRACTURE INCIDENCE increases substantially with age, rising from 22.5 and 23.9 per 100,000 population at age 50 years to 630.2 and 1289.3 per 100,000 population by age 80 years, for men and women, respectively.¹ In 2000, about 12.5% of the Canadian population was age 65 years and older; this figure is expected to rise to 25% by 2041.², ³ In accordance with this aging population trend, the annual number of proximal femoral fractures is projected to increase from 23,375 in 1993/1994 to 88,124 in 2041, requiring an estimated 1.8 million acute care hospital days.³ Even with successful repair, persons who sustain hip fracture exhibit high mortality and often demonstrate permanent disability and dependency.⁴

Despite the high social costs associated with hip fractures, scientific knowledge about best practices is not applied systematically or expeditiously to rehabilitative services. The purpose of this review is to conduct a critical examination of the literature in the area of rehabilitation after hip fracture, to identify practices that have strong evidentiary bases as well as areas needing further research.

When the term rehabilitation is applied to the hip fracture, it encompasses a wide variety of practices across time points after fracture. Reviews published to date have focused on studies within a domain of rehabilitation practice, such as physical therapy or multidisciplinary care, and have not compared strength of evidence across domains. This review examined all practices included in the hip fracture rehabilitation continuum, from clinical pathways (beginning with preoperative assessment) through inpatient and outpatient care, to home-based rehabilitation.

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Methods 

The internet databases Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched using similar search strategies focusing on treatment outcomes in hip fracture rehabilitation. The terms rehabilitation and hip fracture were exploded in order to obtain related search terms and categories. The searches were limited to studies published in English between the years 1980 and 2007 and carried out in human subjects. Both prospective and retrospective studies were considered, as were studies that used either experimental or nonexperimental designs, but unpublished data or studies were not included. Reference Manager 11.0 was used for database management.

In the initial search of the databases, a combined total of 1031 articles were identified. After combining the database results using Reference Manager 11.0, the abstracts of the articles were reviewed, and studies that did not contain hip fracture patients as their study population, did not perform separate analyses for hip fracture subjects, or did not focus on the effects of physical rehabilitative practices on hip fracture outcomes were excluded. A second reviewer confirmed the decision to exclude an abstract. The abstracts of the remaining studies were re-reviewed, and hard copies of studies that did not contain an abstract, or whose abstract did not give a clear insight into the nature of the study, were obtained. Articles that did not contain measures that focused on physical outcomes, contained a study population younger than 50 years old, or focused on dietary interventions were further excluded. Bibliographies of applicable reviews and meta-analyses were checked in order to identify other relevant articles that were not found through the database searches.

Studies were assigned the following evidence levels, determined in accordance with an adapted version of the Oxford Centre for Evidence-Based Medicine Levels of Evidence: (I) RCT, (II) cohort, (III) case control, (IV) case series, and (V) expert opinion. Articles whose evidence level was below (II) were not included in this review. The methodologic quality of both experimental and nonexperimental studies was assessed using the Downs and Black⁵ checklist. The tool was modified slightly for use in this review. Specifically, the scoring for question 27 dealing with statistical power was simplified to a choice of awarding either 1 point or 0 points, depending on whether there was sufficient power to detect a clinically important effect. Downs and Black⁵ score ranges were grouped into the following 4 quality levels: excellent (26–28), good (20–25), fair (15–19), and poor (≤14).

Although this approach provides an evidence level and quality level for each study, it does not take account of the number of studies and the consistency of results across different studies of the same type. Accordingly, the following strength of evidence levels were adapted from methods used by the authors of the Evidence-Based Review of Stroke Rehabilitation (appendix 1).

In total, 55 studies were included in this review (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6). They are organized into 6 different rehabilitation intervention approaches, including a category for studies in which the approach was not well defined. The Table 1, Table 2, Table 3, Table 4, Table 5, Table 6 summarizing the studies and their outcomes are also organized by intervention approach.

Table 1. Key Features of the Studies Selected for Evaluation — Clinical Pathway

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviations: CG, control group (subjects); Dynamic balance, time taken to walk 10m and back; IG, intervention group (subjects); MBI, Modified Barthel Index; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔, no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

Table 2. Key Features of the Studies Selected for Evaluation — Early Supported Discharge

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviations: ABC, Activities Specific Balance Confidence Scale; BBS, Berg Balance Scale; CG, control group; DCOOP, Dartmouth COOP Functional Health Assessment Charts; FES, Falls Efficacy Scale; IG, intervention group; LHS, London Handicap Scale; MBI, Modified Barthel Index; NHP, Nottingham Health Profile; RAP, Rehabilitation Activities Profile; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; TUG, Timed Up and Go test; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔, no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

Table 3. Key Features of the Studies Selected for Evaluation — Interdisciplinary Care

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviations: CAPE, Clifton Assessment Procedure for the Elderly; CG, control group; FAC, Functional Ambulation Classification; IG, interventions group; IQR, interquartile range; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔, no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

Table 4. Key Features of the Studies Selected for Evaluation — OT/PT

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviations: ABC, Activities Specific Balance Confidence Scale; BADLs, basic activities of daily living; BBS, Berg Balance Scale; CG, control group; DRI, Disability Rating Index; FES, Falls Efficacy Scale; FR, Functional Reach Test; IG, intervention group; MRFS, Montebello Rehabilitation Factor score; OARS, Older American Resources and Services Functional Assessment Questionnaire; PPT, modified Physical Performance Test; POMA, Performance Oriented Mobility Assessment; QT, quadriceps training; RM, repetition maximum; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; SWED-QUAL, Swedish Health-Related Quality of Life Survey; TUG, Timed Up and Go test; WHOQOL-BREF, abbreviated WHO Quality of Life Questionnaire; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔, no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

Table 5. Key Features of the Studies Selected for Evaluation — Exercise

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviations: ABC, Activities Specific Balance Confidence Scale; ANOVA, analysis of variance; BBS, Berg Balance Scale; CG, control group; FES; Falls Efficacy Scale; FHI, Falls Handicap Inventory; FR, functional reach; IG, intervention group; I1, intervention 1; I2, intervention 2; NWBE; nonweight-bearing exercise; PNMS, patterned neuromuscular intervention; PPME, Physical Performance and Mobility Examination; PPT, Physical Performance Test; RM, repetition maximum; TUG, Timed Up and Go Test; SF-36; Medical Outcomes Study 36-Item Short-Form Health Survey; WBE, weight bearing exercise; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔ , no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

Table 6. Key Features of the Studies Selected for Evaluation — Discharge Settings

NOTE. Number listed under evidence level refers to study's score on the Downs and Black checklist.⁵

Abbreviation: CG, control group; HC, home care without formal care; HCH, home care with formal help; HR, rehabilitation at home; IG, intervention group; OARS, Older Americans Resources and Services; Multidimensional Functional Assessment Questionannaire; ⇑, significantly greater/significant improvement; ⇓, significantly decreased/significantly less; ⇔, no significant difference; where P<.05 considered significant between-group difference unless otherwise noted.

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Results 

The selected studies investigated the effectiveness of hip fracture rehabilitation using 6 different approaches, in 3 types of setting, as summarized in appendix 2.

Clinical Pathway 

A CP is a multidisciplinary tool designed to promote a consistent approach to outcome-focused care, within a predefined time, by reducing unnecessary variation in practice. It describes routine interventions for a group of patients with similar needs and includes the expected outcomes at each step.

Improved functional recovery⁶, ⁷ and decreased LOS⁶, ⁷, ⁸—Evidence Level 2a (Moderate)^⁎

More favorable discharge destination⁶—Evidence Level 2b (Limited)^†

Four studies⁶, ⁷, ⁸, ⁹ investigated the roles of multidisciplinary CPs whose focus on PT and/or OT exercises was more intensive than that of the standard groups used for comparison. Cameron et al⁶ conducted an RCT in which different care paths were established for nursing home and nonnursing home patients, with care extending posthospital discharge and patients receiving twice-daily PT. Although there was no difference between the 2 groups in functional recovery on discharge or 4 months postfracture, the study found that among subjects with limited pre-existing disability, subjects in the intervention group had superior functional recovery 2 weeks and 1 month after surgery. In the randomized controlled study by Swanson et al,⁷ a multidisciplinary approach characterized by early surgery and mobilization, as well as intensive, twice-daily PT and daily OT, was associated with higher mean functional levels at discharge, as well as a shorter LOS in the hospital. Koval et al⁸ found that the initiation of a multidisciplinary CP in which OT and PT were initiated on the first postoperative day, and carried out at least twice daily, did not result in differences in recovery of ambulatory ability, but did result in shorter LOS, compared with data gathered before initiation of the pathway. Jette et al⁹ conducted a cohort study investigating the effects of a CP in which daily rehabilitation exercises were organized by a multidisciplinary team. Despite the increased focus on rehabilitative exercises, subjects in the CP displayed patterns of 12-month recovery in physical and social functioning that were similar to those of subjects who had received standard care.

^‡Improved functional recovery¹⁰—Evidence Level 2c (Weak)

Discharge location¹⁰, ¹¹, ¹² and LOS¹⁰, ¹¹, ¹³—Conflicting Evidence

Four cohort studies¹⁰, ¹¹, ¹², ¹³ with large sample sizes and broad inclusion criteria evaluated the effects of implementation of evidence-based CPs, with early mobilization as part of their pathway procedures. No differences were found before and after the implementation of the CPs in terms of hospital readmission¹¹, ¹³ and mortality¹¹, ¹²; moreover, Beaupre et al¹⁰ noted differences in functional recovery only after accounting for levels of social support among both groups.

Early Supported Discharge 

Improved falls efficacy¹⁴ and ^§short-term functional recovery¹⁴, ¹⁵—Evidence Level 2b (Limited)

LOS¹⁴, ¹⁶, ¹⁷—Conflicting Evidence

The effects of early supported discharge on outcomes in patients with hip fracture were investigated by 2 RCTs and 2 nonrandomized trials. A trial by Crotty et al¹⁴ and its 12-month follow-up¹⁵ compared conventional care to an intervention consisting of early discharge to home-based therapy. Patients in the intervention group had greater increased functional recovery and falls efficacy 4 months after the start of the trial, but at 12 months, there was no difference between the groups in functional recovery or mobility. Van Balen et al¹⁶ found that early discharge to a rehabilitation ward in a nursing home had no benefit over standard care in terms of mortality rates, ambulation, total LOS in an institution, and health-related quality of life. A pilot study was carried out by Jaglal et al¹⁷ in which the intervention aimed to discharge patients out of acute care on postoperative day 5, after which they received an enhanced 7-day service plan. At hospital discharge, patients in the intervention group performed worse on measures of ambulation and functional recovery than subjects who had received standard care, but after discharge from the home-based rehabilitation program, differences in ambulation and functional recovery were no longer present between the groups.

Interdisciplinary Care 

All 11 articles,¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸ 9 of which were RCTs¹⁸, ¹⁹, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷ and 2 of which were nonrandomized trials,²⁰, ²⁸ exploring the benefits of interdisciplinary care contained sample sizes of over 100 subjects and a control group that received “standard care.” However, the exact nature of standard care varied between the studies, and the descriptions of what standard care constituted were often lacking. All but 3 studies²¹, ²², ²⁶ involved an intervention group receiving postoperative management of hip fracture from a geriatrician and an orthopedic surgeon, with support from a multidisciplinary team composed of varying health and community-support professions; in the other 3 studies, the intervention group consisted of an interdisciplinary team monitored by a geriatrician.

Ambulatory outcomes,²⁴, ²⁷, ²⁸ LOS,¹⁸, ¹⁹, ²⁰, ²³, ²⁴, ²⁷, ²⁸ functional recovery¹⁸, ²⁰, ²³, ²⁴, ²⁷—Conflicting Evidence

Of the studies involving joint postoperative management, only 3 found some evidence of increased functional²³, ²⁷ and/or ambulatory²⁷, ²⁸ recovery in the intervention group compared with the control group. At discharge, Zuckerman et al²⁸ found that the intervention group had significantly better ambulatory ability, while Kennie et al²³ reported that the intervention group had better functional recovery. Although significantly more subjects in the intervention group reported functional and ambulatory recovery 3 months postfracture in the study by Vidan et al,²⁷ these between-group differences in functional outcome were no longer present 6 and 12 months postfracture.

Improved ambulation,²⁶ quadriceps strength²⁶—Evidence Level 2c (Weak)

Shorter LOS²² and short-term improvements in residential status^∥,²²—Evidence Level 2c (Weak)

Functional recovery of ADLs²¹, ²⁶—Conflicting Evidence

An RCT by Huusko et al²¹ found that intensive geriatric rehabilitation resulted in improved IADLs recovery at 3 months, but not 1 year, compared with standard care. In a subanalysis of this study, Huusko et al²² found that patients with mild or moderate dementia who were treated by the pathway had a shorter total LOS than the control group, and more were living independently at 3 months; however, at 12 months postsurgery, differences in independent living were no longer present. In a pilot study carried out by Shyu et al,²⁶ a geriatric consultation service in addition to discharge planning and rehabilitation resulted in better ADLs recovery, ambulation, quadriceps strength, and quality of life 3 months postdischarge compared with standard care.

Occupational Therapy/Physical Therapy 

Increased likelihood of early ambulation^¶,²⁹ functional recovery³⁰—Evidence Level 2c (Weak)

Hoenig et al²⁹ conducted a study exploring the timing of surgical intervention and frequency of OT/PT on hip fracture patient outcomes. When frequency of OT/PT was looked at as the single independent variable, receiving more than 5 sessions a week of OT/PT was determined to be a significant predictor of early ambulation. Early ambulation, in turn, was associated with return home on discharge. An outcome study by Jones et al³⁰ found that patients undergoing intensive PT (1.5h/d, 5/wk) and OT (1h/d, 5d/wk) experienced significant within-group increases in total FIM scores and motor FIM scores at discharge compared with baseline.

Improved short-term functional recovery of ADLs³¹—Evidence Level 2b (Limited)

Improved ambulation³², ³³—Evidence Level 2c (Weak)

Three studies investigated the role of additional OT, combined with PT, in the functional recovery of patients with hip fracture in acute care. Hagsten et al³¹, ³² conducted 2 studies investigating whether receiving OT in addition to PT had an impact on outcomes that was greater than the impact of receiving PT and conventional nursing care. Despite evidence of some short-term improvements in ADLs performance in intervention group subjects, after 2 months, the mean percentage of recovered ADLs and IADLs ability was almost 100% for subjects in both the intervention and control groups.³¹ In a study by Roberts et al,³³ the implementation of an integrated care pathway in which patients received twice as much OT as the standard care pathway was related to a statistically significant increase in ability to walk alone at discharge.

Increased hospital LOS³⁴—Evidence Level 2c (Weak)

Improved balance³⁵, ³⁶ and falls self-efficacy³ —Evidence Level 2c (Weak)^#

Improved functional recovery,³⁵, ³⁶ ambulation,³⁶ and strength³⁶ at discharge^#vii—Evidence Level 2c (Weak)

Three studies investigated the role of rehabilitation ward programs emphasizing various intensities of OT and PT. Koval et al³⁴ found that an intensive (2 hours of PT and 1 hour of OT daily) rehabilitation program resulted in an increase in total LOS in an institution and decreased basic ADLs recovery 3 months postoperation, with no differences in hospital discharge status, discharge location, or functional measures at 6-month and 12-month postoperation follow-ups compared with a control group. Petrella et al³⁵ and Mendelsohn et al³⁶ conducted studies investigating the benefits of combined OT/PT sessions of various intensities and durations. Both studies reported significant within-group improvements in measures of functional recovery and balance from admission to discharge.

Improved power,³⁷ balance,³⁷ and short-term general mobility³⁷—Evidence Level 2c (Weak)

The addition of quadriceps training to 20-minute sessions of standard inpatient PT, taking place 5 days a week, was found to result in greater improvements in leg extensor power, functional reach, the Elderly Mobility Scale, and the quality of life measure of energy, compared with standard PT only, 10 weeks after the end of the 6-week intervention.³⁷ Increasing inpatient PT intensity, while maintaining the same duration of training period, was not found to result in a quicker ability to perform functional objectives.³⁸

^⁎⁎Improved balance³⁹—Evidence Level 2c (Weak)^††

Tsauo et al⁴⁰ conducted a study investigating the effects of a home-based PT intervention. On acute care discharge, patients in the treatment group were instructed to continue their inpatient PT regimen, in addition to being visited at home by a physical therapist 8 times in a 12-week period. Six months after acute care discharge, more than 50% of the study participants dropped out, at which point the intervention group had better outcomes on the Harris_total-pain Scores, but not measures of range of motion, strength, or ambulation. Tinetti et al³⁹ found that a program consisting of a progressive exercise PT component, as well as OT focusing on ADLs, lasting a median length of 12 weeks, resulted in significant within-group improvements in balance, strength, and ambulation 6 months after the start of the intervention.

Improved strength,⁴¹ balance,⁴¹ ambulation,⁴¹ and functional recovery⁴¹—Evidence Level 2c (Weak)

The effects of 6 months of extended outpatient rehabilitation, led by a physical therapist in an indoor facility, were examined in patients who had been community-dwelling prior to hip fracture.⁴¹ On completion of standard PT, subjects were randomized into a control group receiving low-intensity home exercise focusing on flexibility, or into an intervention group participating in PT consisting of aerobic exercises for 3 months, followed by the addition of PRT to the exercises for another 3 months. The intervention group had significantly greater increases in measures of balance, lower-extremity strength, functional recovery, and gait speed between baseline and 3 and 6 months.

Exercise 

Improved ambulation⁴²—Evidence Level 2c (Weak)

Baker et al⁴² conducted a nonrandomized trial investigating an alternate method of gait retraining in 40 female patients with hip fracture. Patients in the intervention group underwent treadmill gait retraining, while the control group received standard gait retraining with an ambulatory aid. On discharge from hospital, patients in the intervention group had better overall mobility than patients in the control group. When a subgroup analysis was performed matching treadmill-control pairs for number of predictors of poor outcome, the treadmill group was superior to the control group in outcome measures of strength and ambulation.

Improved ambulation with 1 stick or no aid,⁴³ increased requirement for less supportive walking aid⁴³—Evidence Level 2b (Limited)

Sherrington et al⁴³ investigated the effects of weight-bearing and nonweight-bearing inpatient exercise taking place on a rehabilitation ward. While the trial failed to find differences between the exercise groups on balance and functional performance measures, the trial did find some support for better outcomes in gait parameters in the weight-bearing group.

Improved ambulation⁴⁴ and short-term improvement in postural stability⁴⁴—Evidence Level 2c (Weak)

One RCT investigated the effects of neuromuscular stimulation of the quadriceps muscle in patients living in a home or in sheltered housing prior to hip fracture.⁴⁴ The study found that the addition of 6 weeks of daily 3-hour patterned neuromuscular stimulation to standard PT resulted in significant improvements in recovery of walking speed and ability 13-weeks posthip fracture fixation, as well as recovery of postural stability during the stimulation period, compared with a patient group receiving placebo stimulation and PT.

Improved knee extensor⁴⁵ and quadriceps⁴⁶ strength—Evidence Level 2c (Weak)

Balance⁴⁵, ⁴⁶—Conflicting Evidence

Sherrington et al⁴⁵ compared the effects of a weight bearing program designed to approximate daily functional tasks with exercise performed in nonweight-bearing position, and a control group receiving no intervention. No differences were found between the groups at the 1-month assessment, but at 4 months, the weight-bearing group had significant improvements in measures of balance and knee extensor strength. In another trial, Sherrington and Lord⁴⁶ found that participants randomized to a home exercise intervention involving the use of phone books as stepping blocks had significantly greater improvements in quadriceps strength in the affected leg and gait velocity compared with a control group. The effects of a 2-hour weekly group learning program, with an educational component focusing on osteoporosis, falls, and ADLs and a weight-bearing component focusing on muscle strength and balance, were investigated by Elinge et al.⁴⁷ At the end of the 10-session intervention period, more participants in the intervention group than the control group had regained their perceived ability to take part in social life, but there were no between-group differences in measures of functional recovery and quality of life 12 months after the intervention.

Improved strength⁴⁸—Evidence Level 2c (Weak)

Mangione et al⁴⁸ found that subjects randomized to 3 months of home-based PRT or aerobic exercise showed greater improvement in isometric force production than a no-exercise group, but no differences were present between the groups on measures of mobility and self-reported physical function. Peterson et al⁴⁹ found that combined aerobic and progressive weight-lifting circuit training after discharge from rehabilitative PT did not result in differences in strength, balance, and ambulatory outcomes compared with a control group of patients not involved in the program.

Improved strength⁵⁰, ⁵¹, ⁵² and short-term ambulation⁵⁰, ⁵¹, ⁵²—Evidence Level 2c (Weak)

Functional recovery⁵⁰, ⁵¹, ⁵²—Conflicting Evidence

Hauer et al⁵⁰ investigated the effects of high-intensity PRT for the lower body with a progressive functional training component targeting balance. The intervention resulted in a greater increase in lower-extremity strength in both legs and short-term improvements in ambulatory outcomes compared with placebo motor exercises, but no overall differences in measures of functional recovery or balance. Host et al⁵¹ looked at the effects of 3 months of light resistance and flexibility exercises followed by 3 months of PRT in a group exercise format. They found that subjects who attended at least 30 sessions in each phase of the supervised exercise program showed significant within-group increases in strength of the fractured limb after the end of both exercise phases, as well as in measures of ambulation and physical function after the PRT phase. Jones et al⁵² investigated the impact of a community exercise program involving progressive functional stepping and lower-extremity strength training on subjects who had a hip fracture more than a month before participating in the study. Compared with subjects who had been receiving conventional home-care services, subjects in the intervention group had greater improvements in overall lower extremity strength, 1 of 3 balance measures, and 1 of 3 ambulatory outcomes. Although subjects in the intervention group had significant between-group improvements in self-reported physical activity from baseline to 16 weeks, there were no differences in ambulatory behavior as measured by a pedometer.

Discharge Settings 

In the United States, the Medicare program pays for rehabilitation services within different settings, which vary with respect to the type and amount of care they provide to patients.⁵³ IRFs, SNFs, and home care are 3 common rehabilitation settings. IRFs within a hospital provide multidisciplinary care and are mandated to provide at least 3 hours of intensive therapy daily.⁵⁴ SNFs also provide postacute hospital care rehabilitation but have no requirement for an interdisciplinary approach and generally provide less intense therapy than IRFs.⁵³, ⁵⁴ Two RCTs and 6 nonrandomized trials included studies in which discharge settings were investigated as a form of intervention.

Functional recovery⁵⁵, ⁵⁶, ⁵⁷, ⁵⁹, ⁶⁰ and postrehabilitation discharge location⁵⁶, ⁶⁰—Conflicting Evidence

Increased LOS (related to SNFs)⁵⁹; increased rates of rehospitalization⁵⁵ and improved community and short-term flat surface ambulation⁵⁸ (related to home care)—Evidence Level 2c (Weak)

Kane et al⁵⁵ investigated differences in outcome between 4 discharge locations: home care without formal care, home care with formal help, SNFs, and IRFs. At 6 weeks and 6 months postdischarge, patients discharged to home care or to an IRF had significantly higher functional status improvements than those discharged home without formal care or to an SNF. At 1 year, the pattern persisted in the rehabilitation group; however, patients discharged to home care continued to have significantly higher functional improvement than those discharged to an SNF, but not those discharged home without formal care. Munin et al⁵⁶ reported that after adjusting for baseline characteristics, subjects discharged to IRFs were more likely to regain 95% of their prefracture FIM motor score 12 weeks postfracture than patients discharged to SNFs, despite similar baseline FIM scores. In an RCT, Giusti et al⁵⁷ investigated the differences in outcomes between subjects discharged to an IRF and those discharged to home-based rehabilitation. After adjusting for baseline characteristics, the home-based rehabilitation group had significantly greater functional recovery than the inpatient rehabilitation group 12 months postdischarge from acute care. Kuisma⁵⁸ found that patients discharged home from acute hospital care after hip fracture surgery had significantly higher community ambulation scores at discharge from PT and 4, 8, and 12 months after surgery compared with subjects discharged to a rehabilitation center after acute hospital care for hip fracture surgery; these differences were present despite the fact that patients receiving institution-based rehabilitation underwent daily PT for an average of 36.2 days, whereas those discharged home were visited by a physical therapist an average of 4.6 times.

Levi⁵⁹ failed to find a difference in functional ability 2 and 6 months posthip fracture among subjects treated in SNFs, IRFs, and home care, respectively, while Kramer et al⁶⁰ failed to find a significant difference in 6-month functional outcomes and discharge location between patients with hip fracture admitted from the community and discharged into IRFs or SNFs for rehabilitation. Roder et al⁶¹ compared 12-month outcomes for patients discharged to supervised inpatient rehabilitation in an orthopedic or geriatric hospital with outcomes for patients receiving no specialized rehabilitation because they were discharged directly home. Despite significant interindividual variability, the same time pattern in recovery of prefracture ADLs and mobility scores was reported, with no significant differences among the 3 groups of patients in approaching their baseline status.

Because of lack of evidence, no recommendations can be made regarding beneficial outcomes. Ryan et al⁶² investigated whether receiving 6 or more face-to-face contacts a week as opposed to 3 or fewer face-to-face contacts from identically composed multidisciplinary inpatient rehabilitation teams had an effect on disability, well-being, and quality-of-life measures 3 months after the initiation of the intervention. There were no differences in outcome measures between the 2 groups, although after adjusting for missing data, subjects receiving 6 or more face-to-face contacts had a significant between-group improvement in self-reported baseline depression scores.

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Conclusions 

When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Postoperative management monitored by a geriatrician,²⁶ high-frequency PT/OT,²⁹ and additional OT combined with PT³², ³³ were the interventions carried out within an acute care setting that were related to increased recovery of ambulatory ability. PT and OT on a rehabilitation ward,³⁶ treadmill gait retraining,⁴² PT plus quadriceps training,³⁷ weight-bearing exercise,⁴³ and PT plus neuromuscular stimulation of the quadriceps muscle⁴⁴ were related to increased recovery of ambulatory abilities in an inpatient setting. In an outpatient setting, combined aerobic and progressive resistance training,⁴¹ combined strength and functional training,⁵⁰, ⁵¹, ⁵² and a home care rehabilitation setting⁵⁸ were associated with improved ambulatory outcomes. Clinical pathways involving intensive OT and/or PT exercises⁶, ⁷ and early mobilization,¹⁰ early supported discharge,¹⁴, ¹⁵ high-frequency OT/PT,³⁰ and additional OT combined with PT³¹ were associated with improved functional recovery during acute care; OT and PT on a rehabilitation ward³⁵, ³⁶ and combined aerobic and progressive resistance training⁴¹ in an outpatient setting were also associated with improved functional recovery. Increases in lower-extremity strength were related to postoperative interdisciplinary care monitored by a geriatrician²⁶ and OT and PT on a rehabilitation ward,³⁶ as well as outpatient interventions involving combined aerobic and progressive resistance training,⁴¹ weight bearing,⁴⁵, ⁴⁶ progressive resistance training and/or aerobic exercise,⁴⁸ or combined strength and functional training.⁵⁰, ⁵¹, ⁵² Intensive OT and/or PT exercises⁶, ⁷, ⁸ and postoperative care from a geriatrician (among patients with mild to moderate dementia)²² in an acute care setting were associated with decreased LOS and a more favorable discharge destination, while SNFs⁵⁹ and OT and PT on a rehabilitation ward³⁴ were related to increased LOS. Improved balance outcomes were related to OT and PT on a rehabilitation ward,³⁵, ³⁶ inpatient PT plus quadriceps training,³⁷ and inpatient PT plus neuromuscular stimulation of the quadriceps⁴⁴; outpatient programs with a progressive home-based PT component³⁹ as well as those consisting of combined aerobic and progressive resistance training⁴¹ were also related to improvements in balance. Finally, early supported discharge¹⁴ and OT and PT on a rehabilitation ward³⁵ were associated with increased falls self-efficacy, while PT plus quadriceps training³⁷ was related to improved power, and a home care rehabilitation setting⁵⁵ was related to increased rates of rehospitalization.

Similar to other recent reviews,⁶³, ⁶⁴ we observed wide variations in practices for hip fracture rehabilitation and the design and methods used in studies that report on their effectiveness. No standard set of key outcomes or measures was used across the better designed investigations. The ingredients of programs and practices evaluated were dissimilar, and varied in their intensity, duration, and timing of the initiation. Interventions evaluated were often poorly defined with respect to specific treatments, making replication of the intervention design very difficult. Interactions between patient characteristics (eg, sex and psychologic factors) and functional recovery were not consistently reported and may be important.⁶⁵, ⁶⁶ Perhaps as a result, there was little duplication of study designs. A related problem exists with the control conditions in the studies in which the control group received standard or usual care. There was a dearth of information about what exactly these control conditions entailed, and other data indicate that it is likely that usual care differs significantly across treatment settings and reimbursement systems.

Our findings showed that measures and methods for characterizing rehabilitation interventions and settings were not well standardized, making it difficult to make evidence-based conclusions about best practices in hip fracture rehabilitation in the elderly. Usual care conditions need to be described in terms of components, intensity, duration, and timing of initiation in studies examining hip fracture rehabilitation practices. Perhaps more importantly, hip fracture rehabilitation outcomes research needs improved conceptual frameworks and taxonomies that would help locate all critical variables and their interrelationships within the same theoretical space.⁶⁷, ⁶⁸, ⁶⁹ They should include consideration of the natural course of recovery from hip fracture and how rehabilitation might substantially affect the dynamics of recovery. The expected outcome would be much greater consistency in research design and methodology. These concerns are not restricted to hip fracture but reflect the perspectives of the broader rehabilitation research community on this pervasive problem.⁷⁰ National and international efforts are needed to focus on addressing this problem if rehabilitation is to move forward as a field.

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Acknowledgment 

We thank Madeline Brown, BASc, for her work in manuscript editing.

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Appendix 

Appendix 1. Strength of Supporting Evidence

Appendix 2. Rehabilitation Approaches and Settings Represented by the Selected Studies

NOTE: Numbers in the columns represent the actual number of studies that covered each intervention approach within a given setting.

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• ⁎ Results from 2 NRTs⁸, ⁹ of fair quality show that CPs with intensive OT and/or PT exercise do not have an impact on discharge destination—Evidence Level 2c (Weak).
• † Results from 1 RCT⁷ of good quality show that there is Limited Evidence (Level 2b) that CPs with intensive OT and/or PT exercise do not have an impact on mortality, while results from 1 nonrandomized trial⁸ of fair quality show that there is Weak Evidence (Level 2c) that CPs in this category are related to decreased mortality.
• ‡ In subjects undergoing care in a CP with early mobilization as part of its pathway procedures, compared with subjects with low social support receiving standard care.
• § Results from 1 NRT of fair quality¹⁷ show that early supported discharge may be associated with decreased functional recovery at hospital discharge, with no differences present after discharge from home care—Evidence Level 2c (Weak).
• ∥ Among individuals with mild-to-moderate dementia.
• ¶ Based on within-group differences.
• # Based on within-group differences.
• ⁎⁎ Based on within-group differences.
• †† Results from 1 NRT of fair quality⁴⁰ did not find differences in strength and ambulatory outcomes between a program with a progressive home-based PT component and a control group, while another nonrandomized trial³⁹ of fair quality found that a program with a progressive home-based PT component was associated with within-group increases in strength and ambulatory outcomes.