Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: A randomised controlled trial

Abstract

QuestionIs acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up compared to physiotherapy without strength training in patients with a hip fracture?DesignAssessor blinded, randomised controlled trial with intention-to-treat analysis.Participants90 patients with a hip fracture admitted to an acute orthopaedic Hip Fracture Unit at a university hospital between October 2013 and May 2015.InterventionDaily physiotherapy with or without progressive knee-extension strength training (10RM), 3 x 10 repetitions, of the fractured limb using ankle weight cuffs conducted by ward physical therapists during hospital stay.Outcome measuresPrimary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from inclusion to postoperative day 10 or discharge (follow-up). Secondary outcome was Timed Up and Go test measured early after surgery and at follow-up.ResultsIn the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1% (95% CI -2.3; 18.4) by additional strength training from baseline to follow-up. In the per-protocol analysis of non-missing data, significant between-group improvements by 10.5% (95% CI 0.3; 20.7) were found in favour of additional ST. No significant between-group differences were found in any secondary outcome.ConclusionPhysiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture. It is debatable whether larger improvements than the observed 8–10% can be expected given that only five exercise sessions, on average, were completed. In fragile patients with a hip fracture in the acute phase, where the ability to participate in functional exercise is compromised, we still consider early strength training a possibility to improve outcomes of clinical importance, given the results of the per-protocol analysis. The present data provides an important basis and call for future investigations including longer term interventions.Trial registrationClinicaltrials.gov NCT00848913

Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider

“…Sample size of primary studies varied from 6229 participants33 to 70 participants 34. Four studies had a sample size of fewer than 100 participants 34–37…”

“…Three meta-analyses and two RCTs contributed to the evidence synthesis about the effect of exercise on bone health-related outcomes in people who had experienced a vertebral fracture,27 any osteoporotic fracture43 or had undergone hip fracture surgery 28 29 35. Interventions included structured exercise of different types,28 balance training43 and progressive resistance exercise (PRE) 29 35. Outcomes included factors associated with risk of falls, for example, mobility, knee-extension strength and balance.…”

“…After hip fracture surgery, structured exercise, in particular interventions incorporating PRE for 2–3 months, led to statistically significant improvements in mobility compared with usual care or no intervention (standardised mean difference (SMD)=0.501, 95% CI 0.297 to 0.705; p<0.001) 29. Balance and leg strength were also favourably affected by the intervention, although one RCT showed that PRE, in addition to routine physiotherapy delivered between postoperative days 2 and 8, was not advantageous when compared with routine physiotherapy alone 35. For people with vertebral fractures, structured exercise compared with usual daily activities reduced reports of pain and improved QoL, but did not improve risk of falling 27.…”

Orthogeriatrics and Hip Fractures

“…There is emerging evidence that an aggressive long term program including resistance exercise can markedly improve outcomes in older persons following hip fracture (81,82). Importantly it appears that progressive strength training should be started in hospital (83) and carried out into the rehab setting. A 6-week strength training program started after surgery was associated with decreased pain and an increase in 6-minute walk test speed (84).…”

Early coordinated rehabilitation in acute phase after hip fracture – a model for increased patient participation

“…A wealth of research to improve outcomes for patients with hip fracture has been performed. Studies include investigating pre-disposing factors affecting recovery [ 3 , 4 ]; factors associated with increased risk of mortality [ 4 ]; effect of lower limb training [ 5 ]; recovery of walking ability [ 6 , 7 ]; predicting risk for future falls [ 8 , 9 ]; and comparison of orthopaedic versus comprehensive geriatric care (CGC) [ 10 – 12 ].…”