Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture

Abstract

IMPORTANCE For many older people, long-term functional limitations persist after a hip fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established. OBJECTIVE To determine whether a home exercise program with minimal contact with a physical therapist improved function after formal hip fracture rehabilitation ended. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from September 2008 to October 2012 in the homes of 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture. INTERVENTIONS The intervention group (n = 120) received functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months. The attention control group (n = 112) received in-home and telephone-based cardiovascular nutrition education. MAIN OUTCOMES AND MEASURES Physical function assessed at baseline, 6 months (ie, at completion of the intervention), and 9 months by blinded assessors. The primary outcome was change in function at 6 months measured by the Short Physical Performance Battery (SPPB; range 0-12, higher score indicates better function) and the Activity Measure for Post-Acute Care (AM-PAC) mobility and daily activity (range, 23-85 and 9-101, higher score indicates better function). RESULTS Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed significant improvement relative to the control group (n=95) in functional mobility (mean SPPB scores for intervention group: 6.2 [SD, 2.7] at baseline, 7.2 [SD, 3] at 6 months; control group: 6.0 [SD, 2.8] at baseline, 6.2 [SD, 3] at 6 months; and between-group differences: 0.8 [95% CI, 0.4 to 1.2], P < .001; mean AM-PAC mobility scores for intervention group: 56.2 [SD, 7.3] at baseline, 58.1 [SD, 7.9] at 6 months; control group: 56 [SD, 7.1] at baseline, 56.6 [SD, 8.1] at 6 months; and between-group difference, 1.3 [95% CI, 0.2 to 2.4], P = .03; and mean AM-PAC daily activity scores for intervention group: 57.4 [SD, 13.7] at baseline, 61.3 [SD, 15.7] at 6 months; control group: 58.2 [SD, 15.2] at baseline, 58.6 [SD, 15.3] at 6 months; and between-group difference, 3.5 [95% CI, 0.9 to 6.0], P = .03). In multiple imputation analyses, between-group differences remained significant for SPPB and AM-PAC daily activity, but not for mobility. Significant between-group differences persisted at 9 months for all functional measures with and without imputation. CONCLUSIONS AND RELEVANCE Among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization. The clinical importance of these findings remains to be determined.

Effects of a Multicomponent Home-Based Physical Rehabilitation Program on Mobility Recovery After Hip Fracture: A Randomized Controlled Trial

“…Ten previously published multi-component home-based rehabilitation studies after a hip fracture, which investigated the effects of rehabilitation on mobility recovery compared to usual care, were found (Crotty et al 2002, Crotty et al 2003, Latham et al 2014, Shyu et al 2010, Tseng, Shyu & Liang 2012, Tinetti et al 1999, Ziden, Frandin & Kreuter 2008, Ziden, Kreuter & Frandin 2010. The studies include seven different trials, and from those, three trials included two separate papers.…”

“…The studies are summarized in Table 1. Most of the trials started soon after the hip fracture, the earliest in the hospital immediately following a hip fracture (Shyu et al 2010, Tseng, Shyu & Liang 2012 and latest approximately nine months after the fracture (Latham et al 2014). The length of the interventions varied from one month to one year.…”

“…The usual outcome variables of the trials were different composite scores, quality of life, and various modifications of the activities of daily living. Three studies found positive effects of the home-based rehabilitation for the measurements mentioned above (Latham et al 2014, Tinetti et al 1999. Although outpatient rehabilitation usually consists of different mobility tasks and strength exercises, no clear advantages of a multi-component home-rehabilitation over usual care have been found in mobility recovery.…”

“…Ten previous studies on seven different trials have been conducted (Crotty et al 2002, Crotty et al 2003, Latham et al 2014, Shyu et al 2010, Tinetti et al 1999, Tseng, Shyu & Liang 2012, Ziden, Frandin & Kreuter 2008, Ziden, Kreuter & Frandin 2010, but evidence of the effects on mobility limitation and disability remains conflicting.…”

Rehabilitation of Lower Extremity Trauma: a Review of Principles and Military Perspective on Future Directions

“…For patients with hip fracture, loss of strength contributes to rapid deterioration in function and an extremely high rate of repeat falls [54]. Multiple randomized controlled trials show that both community and home-based strengthtraining regimens moderately but significantly improve strength, balance, and functional mobility at 6 to 9 months following hip ORIF [55,56]. Additionally, strength training provides long-term reduction in patient's perceived difficulty completing activities of daily living (ADLs) compared to controls [57].…”