Factors Associated With an Immediate Weight-Bearing and Early Ambulation Program for Older Adults After Hip Fracture Repair

Article Outline

• Abstract
• Methods
  • Overview
  • Study Setting and Participants
  • Cotreatment of Patients With Hip Fracture
  • Early Rehabilitation Protocol
  • Data Collection and Measurements
  • Data Analysis
• Results
• Discussion
  • Study Limitations
• Conclusions
• Acknowledgment
• References
• Copyright

Abstract 

Barone A, Giusti A, Pizzonia M, Razzano M, Oliveri M, Palummeri E, Pioli G. Factors associated with an immediate weight-bearing and early ambulation program for older adults after hip fracture repair.

Objective

To evaluate baseline characteristics and in-hospital factors associated with nonadherence with an immediate weight-bearing and early ambulation (IWB-EA) program after hip fracture (HF) surgery.

Design

Prospective inception cohort study.

Setting

Ortho-geriatric unit in an acute care hospital.

Participants

Older adults (N=469) admitted with an osteoporotic HF who underwent surgery.

Interventions

Immediate weight-bearing and assisted ambulation training on the first postoperative day (all patients).

Main Outcome Measure

Proportion of subjects who adhered to the IWB-EA protocol within 48 hours of surgery.

Results

A total of 366 patients (78%) bore weight and ambulated within 48 hours (weight-bearing [WB] group) while the others did not adhere to the protocol (nonweight-bearing [NWB] group). Subjects in the NWB group were significantly older, were more cognitively and functionally impaired, and presented a higher comorbidity at baseline. A higher proportion of subjects in the NWB group (42.7%) than the WB group (23.5%; P<.001) underwent surgery on a preholiday day. In multivariate analysis, having surgery on Friday or a preholiday day (the day before a public holiday) remained the most influent variable related to nonadherence to the IWB-EA protocol (odds ratio=2.5; 95% confidence interval=1.6–4.0; P<.001).

Conclusions

This study establishes that IWB-EA is feasible in a high proportion of patients after surgical stabilization of HF. Neither cognitive impairment nor high comorbidity influenced significantly the adherence to the protocol, indicating that IWB-EA may be offered to an unselected population of the elderly with HF. The day of surgery (eg, preholiday or not) was the only variable influencing the participation to the IWB-EA protocol, suggesting the importance of maintaining the same standard of daytime care every day of the week.

Key Words: Hip fractures, Rehabilitation, Weight-bearing

List of Abbreviations: ASA, American Society of Anesthesiologists classification, CI, confidence interval, CIRS, Cumulative Illness Rating Scale, CIx, cumulative index, IWB-EA, immediate weight-bearing and early ambulation, HF, hip fracture, NWB, nonweight-bearing (nonadherence), OR, odds ratio, POD, postoperative day, RCT, randomized controlled trial, SI, severity index, SPMSQ, Short Portable Mental Status Questionnaire, WB, weight-bearing (adherence)

EVIDENCE-BASED GUIDELINES and RCTs recommend IWB-EA (within 48 hours) after HF surgery.¹, ², ³, ⁴, ⁵, ⁶, ⁷ Delayed ambulation after HF surgery is related to the development of postoperative complications, as well as to an increase of length of hospital stay and a reduction of the proportion of patients discharged directly home.⁴, ⁵ With respect to long-term outcomes, a delay in getting the patients out of bed has proved to produce poor functional recovery and worse 6-month survival.⁷, ⁸

Although in past years, some apprehension has been expressed about immediate weight-bearing and early ambulation after HF surgery because of mechanical failure concerns,⁹, ¹⁰ more than 10 years ago, Zuckerman¹¹ stated that it is a severe misconception that bed rest for a few days after hip fracture is helpful for recovery from the rigors of surgery and for reduction in mechanical failure. Moreover, a recent study by Koval et al¹² showed that IWB-EA after HF surgery is safe and does not result in increased mechanical complications. However, the practice of unrestricted IWB-EA after HF surgery has not been widely implemented.⁵, ¹³

The practices of “as quickly as possible” surgical management and immediate weight-bearing after HF, recommended by guidelines, need complex and coordinated organization and relatively huge resources, with the orthopedic surgeon and the physical therapist available 7 days a week and the operating room working daily.

To date, it is still unclear whether all elderly patients with HF are able to take part in an IWB-EA program after hip surgery, irrespectively of their premorbid cognitive, functional, and comorbid status, because previous RCTs on this topic excluded subjects with cognitive impairment and/or major comorbid conditions.², ⁶, ⁷

The goals of this study were to provide an exploratory description of the implementation of an IWB-EA program for older adults with HF in an orthopedic ward and to evaluate factors related to the patients' characteristics and to organizational aspects potentially associated with nonadherence to the IWB-EA program. This article is not intended to summarize quantitative outcome data. It is hoped that this descriptive study will provide greater insight into the real-world implementation of a model of care in the early in-hospital rehabilitation of older adults with HF.

Back to Article Outline

Methods 

Overview 

The Genoa Galliera Hospital (Liguria, Italy) has been committed to the care of older adults with HF since 2000. In 2004, in recognition of the special needs of elderly people experiencing a fragility fracture, and given the benefit demonstrated by the previous year's pilot project of geriatric-orthopedic multidisciplinary management of older adults with HF, a comanaged Ortho-Geriatric Unit was opened.¹⁴ Since its beginning, a number of evidence-based protocols and standardized orders, including an IWB-EA program, were implemented to improve clinical and rehabilitative management and reduce medical complications in older adults with HF.², ¹⁴, ¹⁵, ¹⁶

Study Setting and Participants 

The hospital has a catchment area of about 350,000 inhabitants. The Ortho-Geriatric Unit is part of the Department of Gerontology and Musculoskeletal Sciences, which includes rehabilitative, orthopedic, and geriatric services.

Subjects participating in this analysis were all patients consecutively admitted to the hospital between November 2005 (implementation of IWB-EA program) and January 2007 with an osteoporotic fracture of the proximal femur (a fracture that occurred in the absence of trauma or with minimal trauma and not related to secondary causes). Subjects were eligible for inclusion in the study if they were age 70 years or older, had surgical stabilization of the fracture, and were able to walk (with or without aid) in the 2 weeks before hospital admission. Patients whose fracture had secondary causes (metastatic cancer, Paget disease of the bone), patients who also had other fractures, patients who had sustained a fracture through a major trauma, patients who had another fracture on the same hip, and patients who refused to give informed consent were excluded. The hospital's ethics committee reviewed and approved the study protocol. When the subjects were too confused to understand the informed consent process, proxy consent was obtained.

Cotreatment of Patients With Hip Fracture 

A team including an orthopedic surgeon, a geriatrician, a nurse trained in the care of older adults, and a physiotherapist was responsible for the treatment of the patients.¹⁴ Patients were assessed by the team at admission and during the hospital stay. The team had daily joint meetings (Monday to Friday) to discuss problems, the patients' daily schedules, and methods for improving rehabilitation.

A geriatrician, available 5 days at week, from Monday to Friday, visited the patients daily and was responsible for medical care.

The orthopedic surgeon was responsible for fracture management and operating decisions: extracapsular fractures were treated with an intramedullary hip screw, while displaced and undisplaced intracapsular fractures were managed with hemiarthroplasty or total hip arthroplasty. Hip fracture surgery was performed during working days, from Monday to Friday.

The physiotherapist planned the schedule and the intensity and duration of physical therapy. Rehabilitation was performed from Monday to Saturday. From Monday to Friday, 2 therapists were involved in the rehabilitative training, while on Saturday, only 1 therapist provided physical therapy. On Sunday and holidays, physical therapy was not provided.

Early Rehabilitation Protocol 

During the preoperative phase, therapists provided their patients with strengthening and range-of-motion exercises (upper extremities and not fractured lower extremity). On the operating day, no rehabilitative procedures were practiced. On the first POD, weight-bearing and ambulation training began for all subjects. They were mobilized out of bed and started on ambulation training, irrespective of the surgical treatment (internal fixation or prosthetic replacement). All patients were allowed to bear weight as tolerated, and the prescription was modified only if fixation instability was noted at surgery. First, the patient, with the therapist providing instructions, was assisted in getting out of bed and into a chair. Then, weight-bearing (as tolerated) and ambulation training with moderate assistance were commenced (5m on POD1). From POD2 to POD4, patients was trained in ambulation with a walker with a progression of distances from 6m to 12m and with decreasing assistance. On the fourth POD, the patient, if able to ambulate with assistance, began stairway climbing, with maximum supervision. Subsequent patient goals (POD5) included progressive ambulation to crutches as tolerated and progressive stair climbing with decreased supervision. While training in ambulation and getting out of bed was taking place, exercise and strength and balance training started. Patients whose fractures were treated with internal fixation had no restriction regarding range of hip motion; patients who had prosthetic replacement, however, were limited to 90° of hip flexion or hip adduction and internal rotation. The physical therapist dedicated about 30 minutes daily to each patient.

Data Collection and Measurements 

Clinicians caring for patients collected data on admission and during hospital stay through a comprehensive geriatric assessment. Demographic characteristics included age, sex, and living situation (home, institution). Prefracture functional status (2wk before) was measured for basic activities of daily living using the Barthel Index (range, 0–100) and the Katz Index (range, 0–6).¹⁷, ¹⁸, ¹⁹ Cognitive status was assessed by the SPMSQ (range, 0–10).²⁰ Medical burden and severity of illness were measured using the CIRS and the ASA score (range, 1–5).²¹, ²² The CIRS scale estimates the severity of pathology in each of 14 categories, using a 5-point Likert-type scale (score, 1–5), with higher ratings indicating greater severity. Based on the rating, 2 indexes were derived: CIRS-CIx, the total number of categories in which moderate or severe levels (score, 4–5) of pathology were noted; and CIRS-SI, based on total severity ratings across all 14 categories (total score divided by number of categories). The score may theoretically vary from 0 to 70 for the CIRS-CIx and from 0 to 5 for the CIRS-SI, although a high score is unlikely, because it would represent several system failures not compatible with life.

Information recorded during hospital stay included time to surgery (days from admission) and day of the week in which surgery was performed, length of hospital stay (days), type of operative treatment (intramedullary hip screw, prosthetic replacement), serum albumin level (standard laboratory method, g/dL), destination at discharge (home, institution), and time to weight-bearing after surgery (number of postoperative days).

The primary outcome was the patient's ability to bear weight and ambulate within 48 hours. Weight-bearing was defined as the ability to stand in the upright position for at least 2 minutes consecutively. Ambulation was considered to have taken place when the patients walked with assistance for at least 5m.

Data Analysis 

All the patients who did not bear weight and ambulate within 48 hours of surgery were considered nonadherent to the IWB-EA program, even if they achieved these goals later during hospital stay. The proportion of subjects nonadherent to the protocol was recorded and used to assess feasibility.

Descriptive statistics were used to identify baseline and in-hospital characteristics of patients who adhered (WB group) and did not adhere (NWB group) to the IWB-EA protocol: categorical variables were expressed in percentages, and continuous variables were reported as mean ± SD.

Bivariate and multivariate analyses were performed to identify the factors affecting nonadherence to the protocol. The dependent variable was the nonadherence to the IWB-EA protocol expressed as a binary value.

We first analyzed the bivariate association between the outcome and each of the independent variables by Student t test, Mann-Whitney U test, and Kruskal-Wallis test, depending on the distribution of the analyzed variable. Then, all the covariates associated with nonadherence with a P value less than .1 were expressed as categorical variables and retained for a logistic regression analysis. Categories were selected on the basis of their clinical significance or distribution (highest quartile) as follows: age (>85y, ≤85y), Katz Index score (<5, ≥5), CIRS-SI (>1.9, ≤1.9), intramedullary hip screw treatment (yes, no), preholiday surgery (eg, Friday or the day before a public holiday; yes, no) and cognitive impairment, defined with a SPMSQ less than or equal to 8 or with a prior diagnosis of dementia (yes, no).

All comparisons were 2-tailed. ORs, 95% CIs, and P values were calculated using standard formulas. Statistical analysis was performed using SPSS for Windows.^a

Back to Article Outline

Results 

Between November 2005 and January 2007, 532 subjects were admitted to the hospital with a hip fracture. Of these, 51 patients not ambulating at the time of fracture (34 subjects), with a fracture that had secondary causes (9 subjects) or was caused by a major trauma (1 patient), and with 1 or more concomitant fractures (7 patients) were excluded.

Overall, 481 subjects matching inclusion criteria were considered for the study. Ten patients died before or immediately after surgery, and 2 were prescribed restricted weight-bearing because of fixation instability. The remaining 469 patients were included in the analysis. Patient characteristics are described in table 1. The patients' average age ± SD was 84.6±7.0 years, 22.6% of the subjects were men, and 10.9% were living in a nursing home at the time of fracture.

Table 1. Baseline and In-Hospital Characteristics of Patients According to Weight-Bearing Group and in the Overall Population

Characteristic	Overall	WB	NWB	P
n (%)	469	366(78)	103(22)	NA
Age (y)	84.6±7.0	83.9±6.8	86.6±7.1	.01
Male (%)	22.6	22.7	22.3	.94
Living in institution (%)	10.9	11.2	9.7	.67
ASA score	2.8±0.8	2.8±0.8	2.9±0.7	.24
Time to surgery (d)	3.1±2.0	3.1±2.0	3.1±2.0	.79
In-hospital stay (d)	15.5±9.9	15.0±8.1	17.2±14.6	.23
Preholiday surgery (%)	27.7	23.5	42.7	<.001
Serum albumin (g/dL)	3.2±0.4	3.2±0.4	3.2±0.4	.38
Barthel Index	73±32	76±30	64±34	<.001
Katz Index	4.5±2.6	4.7±2.6	3.8±2.7	<.001
CIRS-CI	3.6±2.0	3.5±1.9	3.9±2.1	.17
CIRS-SI	1.7±0.4	1.7±0.4	1.8±0.4	.04
SPMSQ	6.1±3.6	6.3±3.6	5.5±3.7	.04
Cognitive impairment (%)	62.5	59.3	73.9	.01
Intramedullary hip screw (%)	59.5	57.1	67.0	.08
Discharged home (%)	24.1	27.3	17.5	.04

NOTE. Values are mean ± SD or as otherwise indicated.

Abbreviation: NA, not applicable.

Overall, 366 patients (78%) bore weight and ambulated within 48 hours of operative management (WB group), while the others (103 subjects; 22%) did not adhere to the IWB-EA protocol (NWB group). In the WB group, 301 subjects (64% of the total population) ambulated within 24 hours of surgery. About half of the patients (54 subjects of 103; 52%) in the NWB group bore weight and ambulated before hospital discharge.

No significant difference was found in the proportion of patients who bore weight and ambulated within 48 hours between subjects living in a nursing home (81%) and those living at home (77%) at the time of fracture.

During the hospital stay, with a mean days ± SD in-hospital stay of 15.5±9.9 days, 2 patients out of 187 with an intracapsular fracture experienced a mechanical complication (prosthetic dislocation) a few days after successful ambulation, and underwent another operation. As shown in table 1, no significant difference was found between the 2 groups (WB vs NWB) with regard to the proportion of men, the number of subjects living in an institution at the time of fracture, the ASA score, the time to surgery, the length of in-hospital stay, serum albumin, and comorbidity (CIRS-CIx, comorbility index subscore). The proportion of subjects treated with an intramedullary hip screw in the 2 subgroups showed a slight but not significant difference (WB, 57%, vs NWB, 67%; P=.084). With respect to the subjects who adhered to the IWB-EA program, those in the NWB group were significantly older, were more cognitively and functionally impaired at the time of fracture, and presented a higher score on the CIRS-SI. In addition, a higher proportion (42.7%) of subjects in the NWB group underwent surgery on a preholiday (eg, Friday or the day before a public holiday) than the WB group (23.5%; P<.001).

Interestingly, more patients in the WB group (27.3%) than the NWB group (17.5%; P=.42) were discharged directly home.

In the multivariate analysis (table 2), having surgery on a preholiday remained the most influential variable related to nonadherence to the IWB-EA protocol (OR=2.5; 95% CI, 1.6–4.0; P<.001). Premorbid disability (Katz index score) showed a slight and insignificant relationship to retarded weight-bearing (OR=1.6; 95% CI, 0.9–2.6; P=.08), while the age, type of operative treatment (sliding hip screw), prefracture cognitive impairment, and severity of illness (CIRS-SI subscore) were no longer associated with retarded weight-bearing.

Table 2. Multivariate Analysis: Predictors of Nonadherence to the Immediate Weight-Bearing and Early Ambulation Protocol

Back to Article Outline

Discussion 

This study establishes that an IWB-EA protocol is feasible in a high proportion of patients after surgical stabilization of hip fracture. Up to 80% of the subjects were able to bear weight and ambulate within 48 hours from surgery. This figure was similar to previous findings from other studies.⁴ Neither cognitive impairment nor high comorbidity significantly influenced adherence to the protocol, indicating that an IWB-EA program may be offered to an unselected population of older adults with HF. As expected, premorbid functional status proved to have a significant influence on the early recovery of ambulation, even if in the multivariate model this relationship proved to be weak. In fact, whether or not frailty could be expected to slow recovery of functional ability, in this series of patients, an organizational variable proved to be the most important factor that influenced adherence to the protocol. The multivariate analysis showed a strong correlation between preholiday surgery and time to ambulation. Although the protocol did not indicate specify patient treatment approaches, those subjects who underwent surgery the day before a weekend showed a higher risk of ambulation failure within 48 hours. This is probably related to the reduction in available resources during the weekend, when only half of the physiotherapists assisted subjects in ambulation training, no joint meetings were held, and geriatricians were not available.

Up to now, there has been a general lack of data about the long-term benefit of an IWB-EA. Most of the studies have focused on the short-term effect of these programs and included small populations and selected patients.⁶, ⁷ Therefore, it seems important to evaluate the effect of IWB-EA in a larger unbiased population of elderly subjects with HF.

Study Limitations 

In our study, the length of hospital stay demonstrated to be longer than the hospital stay reported in the American hospitals, but similar to those reported in other European systems (eg, England).²³ Such difference between the United States and Europe may be related to the fact that in some European Health Care Systems rehabilitation starts early and proceeds, in part, during the hospital stay, producing a high number of patients with HF discharged directly home.¹⁵ Although our study design did not include an outcome analysis, it is interesting to note that more patients in the IWB-EA group were discharged directly home. It is possible that early ambulation after HF surgery may reduce the time of functional recovery and allow a faster discharge. In addition, cost-effectiveness should be demonstrated through ad hoc–designed studies.

Another limitation arises from the fact that data on in-hospital complications have not been collected and their relationship to early ambulation recovery analyzed.

Back to Article Outline

Conclusions 

Our findings demonstrate that an IWB-EA protocol after HF repair is feasible in a real-world setting, but to optimize full adherence, it is necessary to implement a model of care that maintains the same standard of daytime care every day of the week.

Supplier

Back to Article Outline

Acknowledgment 

We thank Paul Sears for his critical review of English version of the article.

Back to Article Outline

References 

1. Scottish Intercollegiate Guidelines Network (SIGN). SIGN 56: prevention and management of hip fractures in older people: a national guideline. Edinburgh: SIGN (serial online); 2002;http://www.sign.ac.uk/guidelines/fulltext/111/index.htmlAccessed October 30, 2008
   • View In Article
2. Pioli G, Giusti A, Barone A. Orthogeriatric care for the elderly with hip fracture: where are we?. Aging Clin Exp Res. 2008;20:113–122
   • View In Article
3. Parker M, Johansen A. Hip fracture. BMJ. 2006;333:27–30
   • View In Article
   • CrossRef
4. Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg. 2006;76:607–611
   • View In Article
   • MEDLINE
   • CrossRef
5. Kamel HK, Iqbal MA, Mogallapu R, et al. Time to ambulation after hip fracture surgery: relation to hospitalization outcomes. J Gerontol A Biol Sci Med Sci. 2003;58:1042–1045
   • View In Article
   • MEDLINE
6. Sherrington C, Lord SR, Herbert RD. A randomised trial of weight-bearing versus non-weight-bearing exercise for improving physical ability in inpatients after hip fracture. Aust J Physiother. 2003;49:15–22
   • View In Article
   • MEDLINE
7. Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Arch Phys Med Rehabil. 2004;85:710–716
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (100 KB)
   • CrossRef
8. Siu AL, Penrod JD, Boockvar KS, et al. Early ambulation after hip fracture: effects on function and mortality. Arch Intern Med. 2006;166:766–771
   • View In Article
   • MEDLINE
   • CrossRef
9. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979;61:216–221
   • View In Article
   • MEDLINE
10. Moller BN, Lucht U, Grymer F, et al. Instability of trochanteric hip fractures following internal fixation. Acta Orthop Scand. 1984;55:517–520
    • View In Article
    • MEDLINE
11. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334:1519–1525
    • View In Article
    • MEDLINE
    • CrossRef
12. Koval KJ, Friend KD, Aharonoff GB, et al. Weight bearing after hip fractures: a prospective series of 596 geriatric hip fracture patients. J Orthop Trauma. 1996;10:526–530
    • View In Article
    • MEDLINE
    • CrossRef
13. Santamaria N, Houghton L, Kimmel L, et al. Clinical pathways for fractured neck of femur: a cohort study of health related quality of life, patient satisfaction and clinical outcome. Aust J Adv Nurs. 2003;20:24–28
    • View In Article
14. Barone A, Giusti A, Pizzonia M, et al. A comprehensive geriatric intervention reduces short- and long-term mortality in older people with hip fracture. J Am Geriatr Soc. 2006;54:711–712
    • View In Article
    • MEDLINE
    • CrossRef
15. Giusti A, Barone A, Oliveri M, et al. An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures. Arch Phys Med Rehabil. 2006;87:826–831
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (103 KB)
    • CrossRef
16. Giusti A, Barone A, Pioli G. Rehabilitation after hip fracture in patients with dementia. J Am Geriatr Soc. 2007;55:1309–1310
    • View In Article
    • CrossRef
17. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61–65
    • View In Article
    • MEDLINE
18. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989;42:703–709
    • View In Article
    • MEDLINE
    • CrossRef
19. Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–919
    • View In Article
    • MEDLINE
20. Pfeiffer E. A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433–441
    • View In Article
    • MEDLINE
21. Parmelee PA, Thuras PD, Katz IR, et al. Validation of the Cumulative Illness Rating Scale in a geriatric residential population. J Am Geriatr Soc. 1995;43:130–137
    • View In Article
    • MEDLINE
22. American Society of Anesthesiologists. New classification of physical status. Anesthesiology. 1963;24:191–198
    • View In Article
    • CrossRef
23. Jarman B, Aylin P, Bottle A. Discharge destination and length of stay: differences between US and English hospitals for people aged 65 and over. BMJ. 2004;328:605
    • View In Article
    • CrossRef

• a SPSS Inc, 2335 Wacker Dr, 11th Fl, Chicago, IL 60606.