Original research| Volume 99, ISSUE 6, P1108-1115, June 2018

Toward a Meaningful Definition of Recovery After Hip Fracture: Comparing Two Definitions for Community-Dwelling Older Adults

Published:February 15, 2018DOI:


      • We should rethink the definition of recovery after hip fractures in research and clinical practice.
      • A standardized definition of recovery can improve our understanding of the recovery process and help take clinical decisions.
      • The ability to climb stairs can be used as an indicator of physical functional recovery after hip fracture.
      • Climbing stairs reflects functional reserve and is strongly associated with patients’ quality of life.



      To examine the course of recovery and resulting health-related quality of life (HRQL) after low-trauma hip fracture using 2 different definitions of recovery.


      Inception cohort with 8 assessments over 1 year.


      Participants were recruited from a tertiary-care hospital and followed up in the community.


      Community-dwelling hip fracture patients (N=47, 75% of all eligible; aged ≥65y).


      Not applicable.

      Main Outcome Measures

      Prefracture functional level was used to identify subgroups of participants with similar trajectories of mobility over time. Recovery in functional mobility was defined in 2 ways: the “traditional” definition (return to prefracture level of functional mobility) and a “targeted recovery” definition (ability to climb 10 steps). Both were measured using the Lower Extremity Functional Scale. HRQL was measured using the RAND 36-Item Short-Form Health Survey.


      Participants were categorized into 3 subgroups with: low, medium, and high prefracture functional abilities. Agreement between the 2 definitions of recovery (quantified using κ coefficient) was strong for the medium group (.81; 95% confidence interval, .56–1.00), weak for the high group (.46; 95% confidence interval, 0.0–.99), and minimal for the low group (.12; 95% confidence interval, 0.0–.328). Contrary to the traditional definition, patients who achieved targeted recovery had statistically and clinically better HRQL than the rest of the cohort throughout the study (estimated average difference of 10.8 points on RAND 36-Item Short-Form Health Survey; 95% confidence interval, 6.67–15.07).


      The agreement between the 2 definitions of recovery ranged from minimal to strong according to patient group. Using a functional target to define recovery predicted HRQL better. It is vital to consider the definition of recovery carefully for research or clinical practice because it can influence subsequent decisions (eg, endorsing a specific intervention or discharging patients).


      List of abbreviations:

      GEE (generalized estimating equation), HRQL (health-related quality of life), LEFS (Lower Extremity Functional Scale)
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        • Cummings S.R.
        • Melton III, L.J.
        Osteoporosis I: epidemiology and outcomes of osteoporotic fractures.
        Lancet. 2002; 359: 1761-1767
        • Siris E.S.
        Patients with hip fracture: what can be improved?.
        Bone. 2006; 38: S8-S12
        • Koot V.C.
        • Peeters P.H.
        • de Jong J.R.
        • Clevers G.J.
        • van der Werken C.
        Functional results after treatment of hip fracture: a multicentre, prospective study in 215 patients.
        Eur J Surg. 2000; 166: 480-485
        • Magaziner J.
        • Hawkes W.
        • Hebel J.R.
        • et al.
        Recovery from hip fracture in eight areas of function.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M498-M507
        • Ariza-Vega P.
        • Jimenez-Moleon J.J.
        • Kristensen M.T.
        Change of residence and functional status within three months and one year following hip fracture surgery.
        Disabil Rehabil. 2013; 36: 1-6
        • Bellelli G.
        • Frisoni G.B.
        • Pagani M.
        • Magnifico F.
        • Trabucchi M.
        Does cognitive performance affect physical therapy regimen after hip fracture surgery?.
        Aging Clin Exp Res. 2007; 19: 119-124
        • Alarcon T.
        • González-Montalvo J.I.
        • Gotor P.
        • Madero R.
        • Otero A.
        Activities of daily living after hip fracture: profile and rate of recovery during 2 years of follow-up.
        Osteoporos Int. 2011; 22: 1609-1613
        • Duke R.G.
        • Keating J.L.
        An investigation of factors predictive of independence in transfers and ambulation after hip fracture.
        Arch Phys Med Rehabil. 2002; 83: 158-164
        • Uriz-Otano F.
        • Pla-Vidal J.
        • Tiberio-López G.
        • Malafarina V.
        Factors associated to institutionalization and mortality over three years, in elderly people with a hip fracture—an observational study.
        Maturitas. 2016; 89: 9-15
        • Jones C.A.
        • Jhangri G.S.
        • Feeny D.H.
        • Beaupre L.A.
        Cognitive status at hospital admission: postoperative trajectory of functional recovery for hip fracture.
        J Gerontol A Biol Sci Med Sci. 2015; 21: 21
        • Aguero-Torres H.
        • Fratiglioni L.
        • Guo Z.
        • Viitanen M.
        • von Strauss E.
        • Winblad B.
        Dementia is the major cause of functional dependence in the elderly: 3-year follow-up data from a population-based study.
        Am J Public Health. 1998; 88: 1452-1456
        • Rozzini R.
        • Frisoni G.B.
        • Barbisoni P.
        • Trabucchi M.
        Dementia does not prevent the restoration of safe gait after hip fracture.
        J Am Geriatr Soc. 1997; 45: 1406-1407
        • Hacke W.
        • Kaste M.
        • Fieschi C.
        • et al.
        Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators.
        Lancet. 1998; 352: 1245-1251
        • Duncan P.W.
        • Lai S.M.
        • Keighley J.
        Defining post-stroke recovery: implications for design and interpretation of drug trials.
        Neuropharmacology. 2000; 39: 835-841
        • Auais M.
        • Eilayyan O.
        • Mayo N.E.
        Extended exercise rehabilitation after hip fracture improves patients' physical function: a systematic review and meta-analysis.
        Phys Ther. 2012; 92: 1437-1451
        • Schultz-Larsen K.
        • Lomholt R.K.
        • Kreiner S.
        Mini-Mental Status Examination: a short form of MMSE was as accurate as the original MMSE in predicting dementia.
        J Clin Epidemiol. 2007; 60: 260-267
        • Paveza G.J.
        • Cohen D.
        • Blaser C.J.
        • Hagopian M.
        A brief form of the Mini-Mental State Examination for use in community care settings.
        Behav Health Aging. 1990; 1: 133-139
        • Marsh J.
        • Bryant D.
        • MacDonald S.J.
        Older patients can accurately recall their preoperative health status six weeks following total hip arthroplasty.
        J Bone Joint Surg Am. 2009; 91: 2827-2837
        • Binkley J.M.
        • Stratford P.W.
        • Lott S.A.
        • Riddle D.L.
        The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network.
        Phys Ther. 1999; 79: 371-383
        • Stratford P.W.
        • Binkley J.M.
        • Watson J.
        • Heath-Jones T.
        Validation of the LEFS on patients with total joint arthroplasty.
        Physiother Can. 2000; 52: 97-105
        • Stratford P.W.
        • Hart D.
        • Binkley J.
        • et al.
        Interpreting lower extremity functional status score.
        Physiotherapy Can. 2005; 57: 154-162
        • Mayo N.E.
        • Nadeau L.
        • Levesque L.
        • Miller S.
        • Poissant L.
        • Tamblyn R.
        Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly?.
        Med Care. 2005; 43: 1194-1202
        • Gill T.M.
        • Allore H.G.
        • Hardy S.E.
        • Guo Z.
        The dynamic nature of mobility disability in older persons.
        J Am Geriatr Soc. 2006; 54: 248-254
        • Hays R.D.
        • Sherbourne C.D.
        • Mazel R.M.
        The RAND 36-Item Health Survey 1 .0.
        Health Econ. 1993; 2: 217-227
        • Hays R.D.
        Dr. Ron Hays’ webpage.
        (Available at:)
        Date: 2017
        Date accessed: June 5, 2017
        • Randell A.G.
        • Nguyen T.V.
        • Bhalerao N.
        • Silverman S.L.
        • Sambrook P.N.
        • Eisman J.A.
        Deterioration in quality of life following hip fracture: a prospective study.
        Osteoporos Int. 2000; 11: 460-466
        • Ware J.E.
        • Snow K.K.
        • Kosinski M.
        • Gandek B.
        SF-36 health survey: manual and interpretation guide.
        Health Institute, New England Medical Center, Boston1993
        • Barnett S.D.
        • Heinemann A.W.
        • Libin A.
        • et al.
        Small N designs for rehabilitation research.
        J Rehabil Res Dev. 2012; 49: 175-186
        • Mayo N.E.
        • Moriello C.
        • Scott S.C.
        • Dawes D.
        • Auais M.
        • Chasen M.
        Pedometer-facilitated walking intervention shows promising effectiveness for reducing cancer fatigue: a pilot randomized trial.
        Clin Rehabil. 2014; 28: 1198-1209
        • Hanley J.A.
        • Negassa A.
        • Edwardes M.D.
        • Forrester J.E.
        Statistical analysis of correlated data using generalized estimating equations: an orientation.
        Am J Epidemiol. 2003; 157: 364-375
        • Shen C.W.
        • Chen Y.H.
        Model selection for generalized estimating equations accommodating dropout missingness.
        Biometrics. 2012; 68: 1046-1054
        • McHugh M.L.
        Interrater reliability: the kappa statistic.
        Biochem Med (Zagreb). 2012; 22: 276-282
        • Levin M.F.
        • Kleim J.A.
        • Wolf S.L.
        What do motor “recovery” and “compensation” mean in patients following stroke?.
        Neurorehabil Neural Repair. 2009; 23: 313-319
        • Laukkanen P.
        • Era P.
        • Heikkinen R.L.
        • Suutama T.
        • Kauppinen M.
        • Heikkinen E.
        Factors related to carrying out everyday activities among elderly people aged 80.
        Aging (Milano). 1994; 6: 433-443
        • Biccard B.M.
        Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the pre-operative assessment of functional capacity.
        Anaesthesia. 2005; 60: 588-593
        • Reddy S.
        • Contreras C.M.
        • Singletary B.
        • et al.
        Timed stair climbing is the single strongest predictor of perioperative complications in patients undergoing abdominal surgery.
        J Am Coll Surg. 2016; 222: 559-566
        • Shyu Y.I.
        • Chen M.C.
        • Liang J.
        • Wu C.C.
        • Su J.Y.
        Predictors of functional recovery for hip fractured elders during 12 months following hospital discharge: a prospective study on a Taiwanese sample.
        Osteoporos Int. 2004; 15: 475-482
        • Salpakoski A.
        • Törmäkangas T.
        • Edgren J.
        • et al.
        Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial.
        J Am Med Dir Assoc. 2014; 15: 361-368
        • Roberts L.
        • Counsell C.
        Assessment of clinical outcomes in acute stroke trials.
        Stroke. 1998; 29: 986-991
        • Diggle P.
        • Heagerty P.
        • Liang K.-Y.
        • Zeger S.L.
        Analysis of longitudinal data. 2nd ed. Oxford statistical science series.
        Oxford Univ Pr, Oxford2002