Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: A systematic review

The influence of communal spaces on patient activity in rehabilitation: a mixed methods study

PURPOSE

This study aimed to determine whether patients are more active in communal spaces compared to their bedrooms and explore patient perspectives on communal spaces for activity, rest, and wellbeing.

MATERIALS AND METHODS

A prospective study observed participants via behavioural mapping in a mixed inpatient rehabilitation unit for up to three days. Physical, social, and cognitive activity levels in communal spaces were compared with activity in bedrooms using independent t-tests. Three focus groups explored participants' perspectives on communal spaces for activity, rest and wellbeing using thematic analysis.

RESULTS

Thirty-three participants (age 71.6 ± 13years, 39%male) were observed, and a subset (n = 12) (age 67.3 ± 16.9, 50%male) participated in focus groups. Participants spent a greater proportion of time being physically active (mean difference 22.7%, 95%CI 8.7-36.6, p = 0.002) and socially active (mean difference 23.6%, 95%CI 9.1-38.1, p = 0.002) in communal spaces than bedrooms. No difference in cognitive activity was found. Participants perceived communal spaces to positively influence mood and activity. Reduced independence was a barrier, while visitors, activities, and an inviting design attracted people to communal areas.

CONCLUSION

Communal spaces may positively influence patient activity and mood during inpatient rehabilitation. Future studies should seek strategies to optimise engagement in communal environments.IMPLICATIONS FOR REHABILITATIONOptimising patient activity throughout the day in inpatient rehabilitation is important to support recovery.Communal spaces in inpatient rehabilitation hospitals can positively influence patient activity and mood.Strategies to promote use of communal spaces in the inpatient rehabilitation hospital are needed.

Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures

BACKGROUND

As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients.

AIM

To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs.

METHODS

A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses.

RESULTS

The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL.

CONCLUSION

The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

Additional saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation: a prospective cohort study

Background

The first aim of this study was to investigate the impact of providing an additional four hours of Saturday occupational therapy to patients receiving Saturday physiotherapy in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday occupational therapy service in addition to physiotherapy resulted in a net cost savings for the rehabilitation facility.

Methods

A prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit from 2015–2017. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs.

Results

A total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (receiving Saturday occupational therapy and physiotherapy) had 192 participants and the historical control group (receiving Saturday physiotherapy only) had 174 participants. On admission, intervention group participants had higher cognitive (p < 0.01) and total (p < 0.01) Functional Independence Measure scores. Participation in weekend therapy by the intervention group was 11% higher, attending more sessions (p < 0.01) for a greater length of time (p < 0.01) compared to the historical control group.

After controlling for differences in admission Functional Independence Measure scores, rehabilitation length of stay was estimated to be reduced by 1.39 (p = 0.08) days. The economic evaluation identified potential cost savings of AUD1,536 per patient. The largest potential savings were attributed to neurological patients AUD4,854. Traumatic and elective orthopaedic patients realised potential patient related cost savings per admission of AUD2,668 and AUD2,180, respectively.

Conclusions

Implementation of four hours of Saturday occupational therapy in addition to physiotherapy results in a more efficient service, enabling a greater amount of therapy to be provided on a Saturday over a shorter length of stay. Provision of multidisciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07727-7.

Progressive Resistance Training Program Characteristics in Rehabilitation Programs Following Hip Fracture: A Meta-Analysis and Meta-Regression

Introduction: Older adults often experience incomplete recovery after a hip fracture. Rehabilitation programs with progressive resistance training are associated with improved functional recovery. This systematic review and meta-analysis with meta-regression a) evaluated resistance training characteristics reported in hip fracture rehabilitation programs, b) performed meta-analysis of resistance training impact on strength (primary outcome), gait and physical activity (secondary outcomes), and c) explored resistance training program characteristics associated with improved outcomes using meta-regression. Materials and Methods: Medline, EMBASE, CINAHLPLUS, and Web of Science Core Collection databases were searched (January2000–February2021). Randomized controlled trials including progressive resistance training rehabilitation programs after hip fracture surgery in adults ≥50 years old were included. Meta-analyses and exploratory meta-regression were performed. Results: Meta-analysis showed significant increases in strength (10 trials-728 participants; Standardized Mean Difference (SMD) [95%CI]; .40 [.02, .78]) immediately following program completion in intervention relative to control participants. Meta-analysis on 5 trials (n = 384) with extended follow up found no significant group differences (SMD = .47 [-.28, 1.23]) in strength. Center-based relative to home-based programs were associated with significantly greater improvements in strength (P < .05) as were programs where resistance training intensity was prescribed using one-repetition maximum relative to other exercise prescription methods (P < .05). In gait meta-analysis (n = 10 trials-704 participants), gait speed in intervention participants immediately after the program was significantly higher than control (SMD = .42 [.08, .76]) but this finding was not maintained in extended follow-up (n = 5 trials-240 participants; SMD = .6 [-.26, .38]). Higher resistance training intensity was associated with significant improvements in gait speed (P < .05). No meta-analysis was performed for the 3 heterogeneous studies reporting physical activity. Discussion: Progressive resistance training improved muscle strength and gait speed after hip fracture surgery in adults ≥50years old immediately after the program ended, but the longer-term impact may be more limited. Conclusions: Higher resistance training intensity and center-based programs may be associated with more improvement, but require further research.

Mapping Knowledge Structure and Themes Trends of Post-operative Rehabilitation of Hip Fractures in the Elderly: A Bibliometrics and Visualization Study

Background

Hip fractures are a common type of fracture in the elderly and are characterized by many complications and high mortality. Many topics concerning postoperative rehabilitation of hip fracture in elderly people still remain controversial, and the global research trend in this field has not yet been well studied. The aim of the present study was to illustrate the overall knowledge structure, development trends, and research hot spots of postoperative rehabilitation of hip fracture in elderly people.

Methods

Articles and reviews regarding postoperative rehabilitation of hip fracture in elderly people from 2001 to 2021 were identified from the Web of Science database. An online bibliometric platform, CiteSpace, and VOSviewer software were used to generate visualization knowledge maps, including annual trends of publications, contributions of countries, institutions, authors, funding agencies, and journals, and clustering of keywords.

Results

A total of 1,724 publications were identified from Web of Science Core Collection (WoSCC). In the past 20 years, the number of published studies on the rehabilitation of hip fracture in the elderly has exhibited an overall upward trend. The USA was the leading contributor in this field, with the largest number of publications (354, 20.65%) and the most citations (13,786 times). The international cooperation map among relevant countries/regions indicated that the USA collaborated most closely with Canada and China. The University of Maryland and Professor Marcantonio were the most prolific institution and influential author, respectively. Injury: International Journal of the Care of the Injured was the most productive journal concerning the research of postoperative rehabilitation of hip fracture in elderly people. The keyword co-occurrence analysis identified six clusters: quality of life study, rehabilitation and outcomes study, cognitive impairment study, operative approaches study, mortality study, and osteoporosis study.

Conclusions

There will be an increasing number of publications on the research of postoperative rehabilitation of hip fracture in elderly people, and the United States will stay ahead in this field. Our findings could offer practical sources for scholars to understand the current status and trend of studies on rehabilitation of hip fracture in the elderly and provide references and suggestions for the development of related research in future.

Correlation between neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture: a meta-analysis

Introduction

The neutrophil-to-lymphocyte ratio (NLR) is a crucial prognosis predictor following several major operations. However, the association between NLR and the outcome after hip fracture surgery is unclear. In this meta-analysis, we investigated the correlation between NLR and postoperative mortality in geriatric patients following hip surgery.

Method

PubMed, Embase, Cochrane library, and Google Scholar were searched for studies up to June 2021 reporting the correlation between NLR and postoperative mortality in elderly patients undergoing surgery for hip fracture. Data from studies reporting the mean of NLR and its 95% confidence interval (CI) were pooled. Both long-term (≥ 1 year) and short-term (≤ 30 days) mortality rates were included for analysis.

Result

Eight retrospective studies comprising a total of 1563 patients were included. Both preoperative and postoperative NLRs (mean difference [MD]: 2.75, 95% CI: 0.23–5.27; P = 0.03 and MD: 2.36, 95% CI: 0.51–4.21; P = 0.01, respectively) were significantly higher in the long-term mortality group than in the long-term survival group. However, no significant differences in NLR were noted between the short-term mortality and survival groups (MD: − 1.02, 95% CI: − 3.98 to 1.93; P = 0.5).

Conclusion

Higher preoperative and postoperative NLRs were correlated with a higher risk of long-term mortality following surgery for hip fracture in the geriatric population, suggesting the prognostic value of NLR for long-term survival. Further studies with well-controlled confounders are warranted to clarify the predictive value of NLR in clinical practice in geriatric patients with hip fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02831-6.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Cross-sectional survey of rehabilitation service availability for stroke and hip fracture in Australian public hospitals

OBJECTIVE

To describe the rehabilitation services available for people with stroke and hip fracture across New South Wales/Australian Capital Territory metropolitan and rural/regional public hospitals in Australia.

DESIGN

A cross-sectional study design was used.

SETTING

New South Wales/Australian Capital Territory public hospital providing rehabilitation services for stroke and hip fracture.

PARTICIPANTS

Delegates from 59 eligible hospitals.

INTERVENTION

Information about the type, number and availability of inpatient and outpatient rehabilitation services at each hospital was collected via survey.

MAIN OUTCOME MEASURES

Counts, percentages, mean (SD), median (IQR) were used to quantify the number and type of inpatient and outpatient services available.

RESULTS

Across inpatient rehabilitation units, reduced availability was noted in the number of clinical disciplines available, availability of neuropsychology and social work in rural units. Across outpatient rehabilitation services, reduced availability was noted in the number of disciplines available, availability of occupational therapy, psychology, rehabilitation physicians, specialist nursing, geriatricians, and podiatry in rural services. Five rural hospitals had no access to outpatient rehabilitation.

CONCLUSION

There was reduced availability of rehabilitation services and health disciplines in rural/regional settings. A follow-up study is underway investigating relationships between reduced outpatient service availability and inpatient length of stay in rural/regional versus metropolitan hospitals.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities

OBJECTIVE

To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes.

DATA SOURCES

Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014.

STUDY DESIGN

We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions.

DATA EXTRACTION METHODS

We identified Medicare beneficiaries discharged from a hospital to IRF.

PRINCIPAL FINDINGS

In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals.

CONCLUSIONS

Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

Factors Associated with Mechanical Complications in Intertrochanteric Fracture Treated with Proximal Femoral Nail Antirotation

Purpose

Although proximal femoral nail antirotation (PFNA; Synthes, Switzerland) has demonstrated satisfactory results when used for the treatment of intertrochanteric fractures, mechanical complications may occur. To better quantify the risk of mechanical complications when proximal femoral nail antirotation is used to treat intertrochanteric fractures, this study aimed to: (1) characterize the frequency of mechanical complications and extent of blade sliding and their correlation with reduction quality and (2) identify factors associated with mechanical complications.

Materials and Methods

A review of medical records from 93 patients treated for intertrochanteric fractures with a minimum of 6-months of follow-up between February 2014 and February 2019 was conducted. Blade position was evaluated using Tip-apex distance (TAD) and Cleveland index. The extent of blade sliding was evaluated using the adjusted Doppelt's method for intramedullary nailing. Individuals were classified as having or not having mechanical complications, and reduction quality and radiologic outcomes were compared between the two groups.

Results

Mechanical complications occurred in 12 of 94 hips (12.8%), with 11 out of 12 being from the intramedullary reduction group. There was no significant difference in TAD between groups; however, there were significant differences were noted in Cleveland index, AO/OTA classification, reduction quality and extent of blade sliding. The mean blade sliding distance was 1.17 mm (anatomical group), 3.28 mm (extramedullary group), and 6.11 mm (intramedullary group), respectively (P<0.001). Data revealed that blade sliding was an associated factor for mechanical complications (odds ratio 1.25, 95% confidence interval 1.03–1.51).

Conclusion

The extent of blade sliding determined using the adjusted Doppelt's method was significantly associated with mechanical complications suggesting that prevention of excessive sliding through proper intraoperative reduction is important to help achieve satisfactory treatment outcomes.

Association of the intraoperative peripheral perfusion index with postoperative morbidity and mortality in acute surgical patients: a retrospective observational multicentre cohort study

Background

We hypothesised that in acute high-risk surgical patients, a lower intraoperative peripheral perfusion index (PPI) would indicate a higher risk of postoperative complications and mortality.

Methods

This retrospective observational study included 1338 acute high-risk surgical patients from November 2017 until October 2018 at two University Hospitals in Denmark. Intraoperative PPI was the primary exposure variable and the primary outcome was severe postoperative complications defined as a Clavien–Dindo Class ≥III or death, within 30 days.

Results

intraoperative PPI was associated with severe postoperative complications or death: odds ratio (OR) 1.12 (95% confidence interval [CI] 1.05–1.19; P<0.001), with an association of intraoperative mean PPI ≤0.5 and PPI ≤1.5 with the primary outcome: OR 1.79 (95% CI 1.09–2.91; P=0.02) and OR 1.65 (95% CI 1.20–2.27; P=0.002), respectively. Each 15-min increase in intraoperative time spend with low PPI was associated with the primary outcome (per 15 min with PPI ≤0.5: OR 1.11 (95% CI 1.05–1.17; P<0.001) and with PPI ≤1.5: OR 1.06 (95% CI 1.02–1.09; P=0.002)). Thirty-day mortality in patients with PPI ≤0.5 was 19% vs 10% for PPI >0.5, P=0.003. If PPI was ≤1.5, 30-day mortality was 16% vs 8% in patients with a PPI >1.5 (P<0.001). In contrast, intraoperative mean MAP ≤65 mm Hg was not significantly associated with severe postoperative complications or death (OR 1.21 [95% CI 0.92–1.58; P=0.2]).

Conclusions

Low intraoperative PPI was associated with severe postoperative complications or death in acute high-risk surgical patients. To guide intraoperative haemodynamic management, the PPI should be further investigated.

What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews

BACKGROUND

Hip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place.

METHODS

In a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available.

RESULTS

Three interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment.

CONCLUSIONS

Three interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Longitudinal changes in physical activity levels and fear of falling after hip fracture

BACKGROUND AND PURPOSE

Due to global ageing, more people will suffer from hip fracture in the future, and many will be left with permanent physical impairments. The care burden for people post hip fracture is high. The aim of this study is to measure longitudinal changes in physical activity levels and fear of falling in people after hip fracture who return home after inpatient rehabilitation.

METHODS

Longitudinal observational study. Participants were recruited from three rehabilitation centres in Victoria, Australia. Self-reported fear of falling (Short Falls Efficacy Scale - International) and physical activity levels (Human Activity Profile - Adjusted Activity Score and Frenchay Activity Index) were assessed at 2 weeks, 3 and 6 months after discharge. Mobility (walking speed) and balance (Timed Up-and-Go test and Step Test) were measured at discharge from rehabilitation.

RESULTS

Thirty-four participants (mean age: 82 years [SD 8]; 62% female) with unilateral hip fracture were recruited. Participants had moderately impaired balance and mobility at discharge compared to age-matched normative data; they were all discharged with a walking aid and were 40% slower in their walking speed. Participants had increased fear of falling and reduced physical activity 2 weeks after discharge, which improved significantly (p < 0.01) over the following 6 months, but scores were still lower than the normative values. At 6 months, participants also had moderate to high levels of fear of falling and were less active than the general population of similar age.

DISCUSSION

Although fear of falling and physical activity improved in the 6 months following discharge, both remained negatively affected compared to normative data. Rehabilitation post hip fracture should include routine assessment of fear of falling as a potential barrier for return of physical activities.

Hip fractures

In the UK the incidence of hip fractures is nearly 76 000 cases per year, with the vast majority of these fractures occurring in patients over the age of 70 years. Most patients who sustain a hip fracture will have significant comorbidities and up to 40% will have cognitive impairment. For patients, sustaining a hip fracture can potentially be a devastating event. This article provides an overview of the presentation, assessment and management of hip fractures for core surgical, acute care common stem and emergency medicine trainees.

Translation, reliability, agreement and validity of the Turkish version of Cumulated Ambulation Score in patients with hip fracture

OBJECTIVES

This study aims to translate and investigate the inter- rater reliability, agreement and validity of the Turkish version of the Cumulated Ambulation Score (CAS-TR) in patients with hip fracture.

PATIENTS AND METHODS

This study included patients with a hip fracture of the femoral neck between July 2019 and March 2020 at the Dr. Lütfi Kırdar Kartal Training and Education Hospital, Department of Orthopedics and Traumatology, Istanbul. The CAS manual and score-sheet were translated into Turkish. An orthopedician and a physiotherapist independently administered the CAS-TR to 36 patients (12 males, 24 females; mean age 78.7 years; range, 65 to 90 years) at postoperative days one, two, three and 30. Weighted Cohen's kappa coefficient was used to measure inter-rater reliability. Turkish version of modified Barthel Index was used for analysis of validity.

RESULTS

The majority of the patients had type III fracture (72.2%) according to Garden's classification. The kappa value was ≥0.90 for days one-three, the total and 30th day score of CAS-TR. The observed agreement ranged between 91.6% and 100% for all assessments. Validity analysis showed a significantly positive correlation between day two and day 30 CAS-TR and Barthel scores.

CONCLUSION

We found almost perfect reliability, high percentage agreement and acceptable convergent validity of the CAS-TR. We recommend the CAS to be used as an easily applicable instrument to assess basic mobility status in Turkish patients with hip fracture. Orthopedic and geriatric patients and patients undergoing any type of surgery can be assessed with CAS for early evaluation of mobility status.

Are people in residential care entitled to receive rehabilitation services following hip fracture? Views of the public from a citizens' jury

BACKGROUND

Access to rehabilitation services for people living in residential care facilities is frequently limited. A randomised trial of a hospital outreach hip fracture rehabilitation program in residential care facilities has demonstrated improvements in mobility at four weeks and quality of life at 12 months but was not considered cost-effective by standard health economic metrics. The current study aimed to explore the general public's views on issues involved in the allocation of rehabilitation resources for residents of care facilities.

METHODS

A citizens' jury comprising 13 purposively sampled members of the general public, representative of the South Australian age, gender and household income profile. The jury considered the questions "Should there be an investment of physical rehabilitation services in residential care for older people following a hip fracture? If so, what is the best way of providing this service (considering funding, models of service delivery and equity)?" Deliberations were in the context of a state-wide health reform program. The jury was conducted over two days with an experienced independent facilitator, addressing questions developed by a steering group of research academics and clinicians.

RESULTS

The mean age of the citizens' jury members was 43 (range 26 to 61). Eleven members voted for investment in outreach hospital rehabilitation services in residential aged care. All jurors agreed a number of strategies in addition to investment should be implemented, including health care planning and decision making, increased emphasis on hip fracture prevention, training of aged care staff in rehabilitation and routine provision of hospital discharge summaries to families. The jury further advocated for an increased focus on rehabilitation in residential care, potentially through accreditation criteria, increasing health literacy of residents and families, implementation of age friendly environment strategies and improving connections of care facilities with community, hospital and tertiary services.

CONCLUSIONS

This citizens' jury representative of the general public recommends that regardless of dementia and frailty, people who live in residential care and are walking and fracture their hips should have access to hospital outreach rehabilitation and recovery services.

Association between longitudinal clinical outcomes in patients with hip fracture and their pre-fracture place of residence

BACKGROUND

Clinical outcomes of patients with proximal femoral fracture within 1 year after hospitalization are presented. In particular, associations between the patients' clinical status and their pre-fracture residence were evaluated (community-dwelling vs nursing home).

METHODS

Patients aged ≥60 years with proximal femoral fractures were included in a prospective, single-centre observational study and followed for 12 months. Patients' clinical status at baseline was compared to their health status at follow-up 12 months later. Several standardized questionnaires were used to evaluate the patients' functional and cognitive capacity (e.g. Lawton Instrumental Activities of Daily Living Scale, Barthel Index, and Mini-Mental State Examination), mobility (timed up-and-go test, Tinetti Test, and Harris Hip Score), quality of life (EuroQol-5 Dimensions index and EuroQol Visual Analogue Scale), and psychological status (Geriatric Depression Scale).

RESULTS

This study included 402 patients (mean age: 81.3 ± 8.2 years, 72% women). Patients stayed in hospital for 13.7 ± 6.1 days on average. The comparison of patients' clinical status at baseline and at 12-month follow-up revealed that the Mini-Mental State Examination and Charlson Comorbidity Index remained unchanged (P = 0.527 and P = 0.705), the level of depression (Geriatric Depression Scale) significantly decreased (P < 0.001), and quality of life (EuroQol-5 Dimensions index) diminished (P < 0.001). Although patients' mobility increased after 12 months (P < 0.001 for timed up-and-go test and Harris Hip Score), their functional capacity was significantly reduced (P < 0.001 for Barthel Index and Lawton Instrumental Activities of Daily Living Scale). Nursing home residents showed a significantly higher impairment at baseline than community-dwelling individuals and less improvement in functional and cognitive tests at 12-month follow-up.

CONCLUSIONS

Clinical outcomes after hip fracture are significantly associated with patients' pre-fracture residence status. Place of residence as well as functional and cognitive status on admission may lead to differences in functional recovery and affect therapeutic and rehabilitative decision-making.

Urban-Rural Differences in Hip Fracture Mortality: A Nationwide NOREPOS Study

Higher hip fracture incidence in urban than in rural areas has been demonstrated, but urban–rural differences in posthip fracture mortality have been less investigated, and the results are disparate. Hence, the aims of the present register‐based cohort study were to examine possible urban–rural differences in short‐ and long‐term mortality in Norwegian hip fracture patients and their potential associations with sociodemographic variables, and to investigate possible urban–rural differences in excess mortality in hip fracture patients compared with the general population. Data were provided from the NOREPOS hip fracture database, the 2001 Population and Housing Census, and the National Registry. The urbanization degree in each municipality was determined by the proportion of inhabitants living in densely populated areas (rural: <1/3, semirural: 1/3 to 2/3, and urban: >2/3). Age‐adjusted mortality rates and standardized mortality ratios were calculated for hip fracture patients living in rural, semirural, and urban municipalities. A flexible parametric model was used to estimate age‐adjusted average and time‐varying HRs by category of urbanization with the rural category as reference. Among 96,693 hip fracture patients, urban residents had higher mortality than their rural‐dwelling counterparts. The HR of mortality in urban compared with rural areas peaked during the first 1 to 2 years postfracture with a maximum HR of 1.20 (95% CI, 1.10 to 1.30) in men and 1.15 (95% CI, 1.08 to 1.21) in women. The differences were significant during approximately 5 years after fracture. Adjusting for sociodemographic variables did not substantially change the results. However, absolute 30‐day mortality was not significantly different between urban and rural residents, suggesting that health‐care quality immediately postfracture does not vary by urbanization. The novel findings of a higher long‐term mortality in urban hip fracture patients might reflect disparities in health status or lifestyle, differences in posthip fracture health care or rehabilitation, or a combination of several factors. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Short-Term Outcomes of Interdisciplinary Hip Fracture Rehabilitation in Frail Elderly Inpatients

Objective

To investigate short-term outcomes of an interdisciplinary rehabilitation program for elderly inpatients who underwent surgical treatment for hip fractures.

Methods

This is a prospective cohort study of fifty older inpatients who were admitted to a geriatric rehabilitation unit. Clinical and functional outcomes were assessed at admission, at discharge, and one month postdischarge.

Results

Patients mean age was 84.1 ± 4.7 years. Proportions of study population with risk factors of frailty were cognitive impairment (64%), Charlson comorbidity index > 1 (72%), and protein malnutrition (59.2%). Before fracture, Barthel median was 90 (IQR 85, 100), and functional ambulation classification (FAC) score was ≥ 4 for 90% of study participants. One month after concluding rehabilitation, Barthel median was 80, 1 month postdischarge FAC ≥ 4 – prefracture FAC ≥ 4 mean change was – 8% (95% CI, -21.5%, 3.4%), and average for gait speed was 0.48 ± 0.18 m/s (95% CI, 0.43, 0.54). Significant correlation was found between admission Barthel score and 1 month postdischarge Barthel score (ρ= 0.27, p=0.05), and between prefracture FAC score and FAC score 1 month postdischarge (ρ = 0.57, p = 0.05). According to regression analysis, age, cognitive status, prefracture Barthel, prefracture FAC, type of surgery, and length of stay were associated with short-term recovery outcomes.

Conclusion

An early interdisciplinary rehabilitation management was insufficient to recover prefracture functional status. Future studies should investigate the best therapeutic strategies to optimize functional recovery, according to clinical and prefracture frail conditions of these patients.

Pre-operative haemodynamic monitoring and resuscitation in hip fracture patients: Protocol for a prospective observational study

BACKGROUND

In a frail patient group often suffering from dehydration, hip fracture is potentially fatal partly because of the blood loss and thus deteriorated circulation. An important goal for haemodynamic monitoring and resuscitation is early detection of insufficient tissue perfusion. "The peripheral perfusion index" reflects changes in peripheral perfusion and blood volume. We hypothesize that hip fracture patients are hypovolaemic with poor peripheral perfusion and accordingly respond to controlled fluid resuscitation. The peripheral perfusion index might reflect restricted tissue perfusion in spite of stable central haemodynamic variables.

METHODS

This prospective observational study assess to what extend hip fracture patients suffer from hypovolaemia and respond to a stroke volume-guided fluid challenge. The secondary objectives are to evaluate correlation between the non-invasive peripheral perfusion index and minimally invasive measures of stroke volume, changes in blood volume and near-infrared spectroscopy determined tissue- and cerebral oxygenation and to compare results to prevalence of post-operative complications including mortality. We will include 50 patients (>65 years) presenting a hip fracture and treated in a multimodal fast-track regimen when written informed consent is available.

DISCUSSION

This is likely the first study to address pre-operative haemodynamic monitoring and resuscitation in hip fracture patients where adequate resuscitation is easily missed. We aim to evaluate feasibility of pre-operative stroke volume-guided haemodynamic optimization in the context of minimally- and non-invasive monitoring of peripheral perfusion and measure of blood volume.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Comparisons of mortality and rehospitalization between hip-fractured elderly with outpatient rehabilitation and those without: A STROBE-compliant article

Geriatric patients with hip fractures have high mortality. This study aimed to compare the mortality and rehospitalization of recipient and nonrecipient of outpatient rehabilitation in hip-fractured elderly.This retrospective cohort study used nationwide claims data in Taiwan and included 3585 senior citizen patients admitted for hip fractures between January 1, 2005, and December 31, 2012. Patients were divided into the recipient (717) and nonrecipient (2868) of outpatient rehabilitation during the first 3 months after hospital discharge. Each patient was followed up for 1 year. Mortality rates of hip-fractured elderly after discharge during the first 3-month period in different groups were analyzed with Chi-square test. Cox proportional hazards regression model was employed for both death and rehospitalization risk analyses.The mortality rate of the rehabilitation group was lower than that of the nonrehabilitation group (12.69% vs 16.70%, P < .05). A more beneficial effect was observed for patients receiving continuous rehabilitation. The rehabilitation group had a lower adjusted risk of death [hazard ratio (HR) = 0.74; 95% confidence interval (95% CI): 0.59-0.94] than that of the nonrehabilitation group. However, the rehabilitation group was at a higher risk of rehospitalization (HR = 1.37; 95% CI: 1.22-1.55).Hip-fractured elderly receiving outpatient rehabilitation have a lower risk of death but a higher risk of rehospitalization than those not receiving rehabilitation within 1 year after fracture.

Determinants of Functional Outcomes Using Clinical Pathways for Rehabilitation After Hip Fracture Surgery

Background

This study evaluated functional outcomes using newly established clinical pathways after hip fracture surgery in older adults and analyzed the major determinants of successful functional outcomes in rehabilitation programs using standardized clinical pathways.

Methods

This was a retrospective cohort study performed in a tertiary rehabilitation facility. A total of 220 patients who had received unilateral hip fracture surgery were followed up from immediately after surgery to 6 months postoperatively. Clinical pathways for rehabilitation included early, individualized rehabilitation, education for activities of daily living, review of general medical conditions, and arrangement of discharge settings. One rehabilitation specialist consecutively checked ambulatory function using 3-level grading, and patients were classified into good recovery and poor recovery groups based on ambulatory function at 6 months postoperatively. Logistic regression analysis was performed using 7 representative variables (age, sex, bone mineral density, Mini-Mental Status Examination [MMSE], Berg Balance Scale [BBS], premorbid ambulatory function, and length of hospital stay).

Results

A total of 86.8% of patients could walk with or without assistance at 6 months after surgery and 75.5% of patients involved in the rehabilitation program were classified into the good recovery group in this study. the good recovery group showed higher mmse and bbs scores compared with the poor recovery group. the factors in the model most strongly correlated with recovery were mmse and bbs.

Conclusion

This study showed that a well-designed rehabilitation program could improve ambulatory function in older patients after hip fracture surgery and that cognitive impairment and poor balance control may inhibit the recovery of ambulatory function.

The incidence and factors of hip fractures and subsequent morbidity in Taiwan: An 11-year population-based cohort study

Hip fractures are a major problem to elder population, but subsequent morbidity is unclear about environmental factors and socioeconomic conditions. The study aims to investigate the incidence of hip fractures treated by the surgery; to compare the sequelae and temporal trends of hip fractures; to evaluate the seasonal effects in the subsequent short-term and long-term morbidities after hip fractures. A cohort study design is conducted using national health research datasets between 2000 and 2010. The ICD-9-CM diagnostic codes were utilized to investigate the incidence of hip fractures and the corresponding treatments. Hierarchical modeling was used to analyze the factors associated with various types of hip fractures. The results indicated that females had a lower incidence in the 30–44 age group, but a significantly higher incidence than males among those aged 60 years or older (adjusted rates 232.1 vs. 100.3 per 100,000 persons, p<0.001). The incidence of hip fractures in the low-income group showed no significant difference compared to that in the general population. There was a temporal trend of a 8.6% increase in the incidence of all types of hip fractures over the period of 2000–2010. A summer-winter variation is observed among the elderly. Hip fractures and subsequent morbidity are increasing in Taiwan’s aging society. Older age, female gender, and time periods were independent risk factors for subsequent morbidities after surgical treatment. The result of this study is useful to the healthcare policy makers and to raise the public awareness of hip fractures.

Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups

OBJECTIVES

To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture.

DESIGN

Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams.

SETTING

North Wales.

PARTICIPANTS

Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13).

RESULTS

The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring.

CONCLUSIONS

A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III).

TRIAL REGISTRATION NUMBER

ISRCTN22464643, Pre-results.

Home Health Agency Characteristics and Quality Outcomes for Medicare Beneficiaries With Rehabilitation-Sensitive Conditions

OBJECTIVE

To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely.

DESIGN

Retrospective analysis.

SETTING

Home health agencies.

PARTICIPANTS

Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge.

RESULTS

Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88-.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77-.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18-1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10-1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70-.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03-1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07-1.28).

CONCLUSIONS

As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Rehabilitation of Older Adults with Dementia After Hip Fracture

OBJECTIVES

To evaluate the effects of postoperative rehabilitation on the outcomes of older adults with dementia who experienced hip fracture.

DESIGN

Retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Community-dwelling adults with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized as no rehabilitation, complex continuing care (CCC), home-care based rehabilitation (HCR), and inpatient rehabilitation (IPR).

MEASUREMENTS

Time to long-term care (LTC) placement, mortality, and risk of repeat hip fracture and falls.

RESULTS

Of 11,200 individuals with dementia who experienced a hip fracture during the study period, 4,494 (40.1%) received no rehabilitation, 2,474 (22.1%) were admitted to CCC, 1,157 (10.3%) received HCR, and 3,075 (27.4%) received IPR. HCR and IPR were associated with less risk of LTC admission after discharge from hospital than no rehabilitation. All three forms of rehabilitation were associated with lower risk of mortality than no rehabilitation, with the greatest effect observed with IPR. HCR was associated with a higher risk of falls than no rehabilitation (P=.03); there were no other significant between-group differences in risk of falls or repeat fractures (P>.05).

CONCLUSION

Postfracture rehabilitation for older adults with dementia is associated with lower risk of LTC placement and mortality. Improving access to rehabilitation services for this vulnerable population may improve postfracture outcomes.

Dedicated orthogeriatric service reduces hip fracture mortality

BACKGROUND

Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture.

AIMS

We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency.

METHODS

A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N = 206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N = 248).

RESULTS

Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (χ² = 13.34, P < 0.001), length of acute hospital stay (U = -3.77, P < 0.001) and requirements for further rehabilitation (χ ² = 26.59, P < 0.001). Patients in the pre-service establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (χ ² = 5.34, P = 0.021).

CONCLUSIONS

A multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes.

Establishing well-being after hip fracture: a systematic review and meta-synthesis

PURPOSE

This study aimed to identify, appraise, aggregate and synthesize findings of experiences of self-confidence and well-being after hip fracture.

METHOD

The systematic review followed the Joanna Briggs Institute (JBI) guidelines. A three-step literature search strategy was followed. Included studies were critically appraised using the JBI critical appraisal tool. Data were analyzed into a meta-summary and a meta-synthesis using a hermeneutic approach.

RESULTS

Twenty-nine studies were included in the analysis. The category "balancing a new life" was illustrated through older people's "adaptations", "adjustments" and "worries". The second category "striving for interaction with new life possibilities" was built on experiences of "supportive interaction", "missing interaction" and "obstacles". The abstraction of the categories into the meta-synthesis "establishing well-being described the process of older people gradually coming to terms with new life conditions". It was a process of building confidence through cooperation with staff.

CONCLUSIONS

Experiences of well-being were possible after hip fracture. Self-confidence enhanced adaptations and adjustments. Older people strived for an active everyday life where they had a sense of identity. Health professionals can facilitate the establishing of well-being through supportive interaction being aware of vulnerabilities and possibilities. This study provides information that may help in the development of interventions taking into account what is meaningful for older people. Implications for Rehabilitation Both staff and significant others play a significant role during rehabilitation after hip fracture and can give rise to both well-being and suffering. During rehabilitation, experiences of self-efficacy can be important as they support progress and adaptation towards a new way of living. After hip fracture, older people may have worries and can experience a diversity of obstacles. A sensitivity towards these experiences by health care professionals can be a support for older people striving to establish well-being after hip fracture. To enhance functional ability and experiences of independency, it may be important to consider what it is about activities that are meaningful in the lives of older people after a hip fracture.

Community-Based Hip Fracture Rehabilitation Interventions for Older Adults With Cognitive Impairment: A Systematic Review

BACKGROUND

A hip fracture in older adulthood can result in function and mobility decline. The consequences are debilitating and place a great burden on patients, caregivers, and the health care system. Although inpatient rehabilitation programs have proven effective, the best practices for community-based rehabilitation required to maintain the gains in function and mobility post hospital discharge are currently unknown.

OBJECTIVE

The aim of this systematic review is to identify and evaluate the evidence on the effectiveness of community-based rehabilitation post hospital discharge interventions for older adults with cognitive impairment (CI) following a hip fracture, and to identify the physical recovery outcomes and measures used in previous studies.

METHODS

The methods outlined in the Cochrane Handbook for Systematic Reviews of Intervention were followed and findings were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search strategy included a combination of text words and subject headings relating to the concepts of CI, dementia, delirium, cognitive reserve, and hip fractures. For a study to be included in the review, it had to involve participants with CI who underwent hip fracture surgery, and consisted of an outpatient intervention that occurred in the participant's home or community. Peer-reviewed journal articles were identified by searching various databases. Two independent reviewers screened the titles and abstracts to determine which articles comprising of a rehabilitation intervention within a community setting prior to being included for a full article review. A data extraction form and an evidence and quality checklist were used during the full article data analysis and synthesis. A meta-analysis was not conducted due to heterogeneity of measures and outcomes.

RESULTS

The original search resulted in over 3000 articles. Of those, three studies satisfied the necessary criteria to be included in the systematic review. All studies included inpatient and outpatient physiotherapy, with some including a cognitive component, family education, and a discharge assessment.

CONCLUSIONS

The findings from this review suggest that community-based rehabilitation post hospital discharge interventions show promising results towards improving various physical function outcomes, mobility, and activities of daily living for older adults with CI following a hip fracture. This review also demonstrates and discusses the current lack of outpatient rehabilitation interventions targeted towards older adults with CI post-hip fracture. Additionally, several substantive gaps that require attention to move this field forward are highlighted.

Management of hip fracture

INTRODUCTION

Hip fracture poses a significant global challenge both to healthcare systems and to patients themselves. We outline the management of this injury, highlight areas where the evidence is deficient and discuss research efforts towards improving the quality of the evidence base.

SOURCES OF DATA

We searched MEDLINE, PubMed and the Cochrane Library, using the core search terms 'hip fracture' and 'proximal femoral fracture'. In addition we reviewed national treatment guidelines for hip fracture care and references from relevant articles. Only articles published in English from inception to March 2015 were included.

AREAS OF AGREEMENT

Modern hip fracture management should consist of a coordinated multidisciplinary approach with orthogeriatrician input, early surgery, adequate analgesia and liaison with related services to facilitate safe supported discharge.

AREAS OF CONTROVERSY

The optimum thromboprophylaxis to reduce venous thromboembolism remains a topic for debate. The use of bone cement has received much attention recently with concerns about its safety in the frailest of hip fracture patients.

GROWING POINTS

An increasing understanding of the severity and impact of sustaining a hip fracture upon quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Strategies to improve postoperative mobility, postoperative nutrition and the role of home-based rehabilitation. There is a need to identify the optimum analgesic regimes and assessment tools for hip fracture patients with cognitive impairment.

After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review

QUESTION

In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults participating in an inpatient rehabilitation program.

INTERVENTION

Additional rehabilitation provided after hours (evening or weekend).

OUTCOME MEASURES

Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores.

RESULTS

Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD -1.8 days, 95% CI -5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10).

CONCLUSION

Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay.

REVIEW REGISTRATION

PROSPERO CRD42014007648. [Scrivener K, Jones T, Schurr K, Graham PL, Dean CM (2015) After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review.Journal of Physiotherapy61: 61-67].

Can geriatric hip fractures be managed effectively within a level 1 trauma center?

OBJECTIVES

To determine whether geriatric hip fractures can be managed effectively within a level 1 trauma center.

DESIGN

A prospective observational cohort study with a historical control group.

SETTING

Level 1 trauma center.

PATIENTS

A total of 199 patients admitted under our hip fracture service were prospectively identified from 2011-2012. These were compared with 191 hip fracture patients who were admitted before the service.

INTERVENTION

The hip fracture service includes coadmission under an orthopaedic and a geriatric team. A daily, consultant-led operating list was made available for hip fracture surgery. A "neck of femur" nurse was employed to coordinate patient care.

MAIN OUTCOME MEASUREMENTS

Time to surgery, length of stay, discharge destination, and mortality. A cost-benefit analysis and a comparison with a lower acuity hospital were also performed.

RESULTS

Since the hip fracture service, more patients underwent surgery within 48 hours (67% vs. 52%; P = 0.004), the length of stay significantly decreased from 26 to 22 days (P = 0.004), significantly more patients were admitted to the rehabilitation unit (58.7% vs. 3.5%; P < 0.001) and ultimately discharged to their own residence (51.6% vs. 40.5%; P = 0.034). Inpatient mortality rates did not change significantly (7.5% vs. 6.8%; P = 0.780). The estimated cost saving in 2011 was $981,040.

CONCLUSIONS

Only minor changes are required to significantly improve the management of geriatric hip fracture patients. These patients can be managed effectively within a level 1 trauma center when an organized service prioritizing these patients is used.

LEVEL OF EVIDENCE

Therapeutic level III. See Instructions for authors for a complete description of levels of evidence.

Variation in the Use of Therapy following Distal Radius Fractures in the United States

Background:

Distal radius fractures (DRFs) are one of the most common injuries among the elderly, resulting in significant expense and disability. The specific aims of this study are (1) to examine rates of therapy following DRFs and (2) to identify those factors that influence utilization of therapy and time span between DRF treatment and therapy among a national cohort of elderly patients.

Methods:

We examined national use of physical and occupational therapy among all Medicare beneficiaries who suffered DRFs between January 1, 2007, and October 1, 2007, and assessed the effect of treatment, patient-related, and surgeon-related factors on utilization of therapy.

Results:

Overall, 20.6% of patients received either physical or occupational therapy following DRF. Use of therapy varied by DRF treatment, and patients who underwent open reduction and internal fixation were more likely to receive therapy compared with patients who received closed reduction. Patients who received open reduction and internal fixation were also referred to therapy earlier compared with patients who received external fixation, percutaneous pinning, and closed reduction. Surgeon specialization is associated with greater use of postoperative therapy. Patient predictors of therapy use include younger age, female sex, higher socioeconomic status, and fewer comorbidity conditions.

Conclusion:

Use of therapy following DRF varies significantly by both patient- and surgeon-related factors. Identifying patients who benefit from postinjury therapy can allow for better resource utilization following these common injuries.

The management of hip fracture in the older population. Joint position statement by Gruppo Italiano Ortogeriatria (GIOG)

This document is a Joint Position Statement by Gruppo Italiano di OrtoGeriatria (GIOG) supported by Società Italiana di Gerontologia e Geriatria (SIGG), and Associazione Italiana Psicogeriatria (AIP) on management of hip fracture older patients. Orthogeriatric care is at present the best model of care to improve results in older patients after hip fracture. The implementation of orthogeriatric model of care, based on the collaboration between orthopaedic surgeons and geriatricians, must take into account the local availability of resources and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention. The position paper focused on eight quality standards for the management of hip fracture older patients in orthogeriatric model of care. The GIOG promotes the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture.

Community-based rehabilitation post hospital discharge interventions for older adults with cognitive impairment following a hip fracture: a systematic review protocol

Background

Hip fractures among older adults remain a public concern. Consequences of a hip fracture include the subsequent decline in function and mobility for the older adult, and an increased burden placed upon their caregivers and the health care system. The consequences may be more challenging if an older adult also has a compromised cognitive reserve. Although rehabilitation programs have proven effective, the best practices and resources required to maintain the gains in function and mobility, to negate diminution of effect, and to enable this patient population to continue living at home are currently unknown.

Objective

The objective of this study is to develop a systematic review protocol focused on identifying the evidence and evaluating the effectiveness of post discharge rehabilitation programs for older adults with a cognitive impairment following a hip fracture.

Methods

The search strategy will include a combination of text words and subject headings relating to the concepts of cognitive impairment, dementia, delirium, cognitive reserve, and hip fractures. Searching various databases will identify peer-reviewed journal articles. There will be two independent reviewers who will screen the titles and abstracts to determine which articles comprise a rehabilitation intervention within a community setting prior to being included for a full article review. A data extraction form and an evidence and quality checklist will be used during the full article data analysis and synthesis. It is expected that there will be a paucity of studies that focus on post discharge rehabilitation interventions for older adults with cognitive impairment following a hip fracture, and few studies that use the same or similar outcome measures. However, if possible, a meta-analysis will be conducted on studies that used similar outcome methods.

Results

This review will synthesize knowledge focusing on activities to maintain and restore function in older adult patients with cognitive impairment once they have completed their active rehabilitation program and return home. A synthesis of the findings will be conducted to determine which components of the interventions identified were the most advantageous to the patient population. The results will be used to develop a multi-faceted post discharge rehabilitation intervention aimed at enabling older adults to return and remain living at home after a hip fracture.

Conclusions

The aim of this systematic review is to generate results that can be used to create interventions that focus on the care necessary to enable older adults to remain living at home post discharge from acute or inpatient rehabilitation care for a hip fracture. With the support and contributions by our associated knowledge users, this systematic review will be used to help inform procedures and policies to facilitate the necessary care and resources required by our patient population.

Postoperated Hip Fracture Rehabilitation Effectiveness and Efficiency in a Community Hospital

Introduction: This study aims to determine the inpatient rehabilitation effectiveness (REs) and rehabilitation efficiency (REy) of hip fracture in a Singapore community hospital (CH), its association with socio-demographic variables, medical comorbidities and admission Shah-modified Barthel Index (BI) score as well as change in independent ambulation from discharge to 4 months later. Materials and Methods: A retrospective cohort study using data manually extracted from medical records of all patients who had hip fracture within 90 days and admitted to a CH after the operation for rehabilitation. Multiple linear regressions are used to identify independent predictors of REs and REy. Results: The mean REs was 40.4% (95% Confidence Interval (CI), 36.7 to 44.0). The independent predictors of poorer REs on multivariate analysis were older age, Malay (vs non-Malay) patients, fewer numbers of rehabilitative therapy sessions and dementia. The mean REy was 0.41 units per day [CI, 0.36 to 0.46]. The independent predictors of poorer REy on multivariate analysis were higher admission BI and being non-hypertensive patient. The prevalence of independent ambulation improved from 78.9% at the discharge to 88.3% 4 months later. Conclusion: CH inpatient rehabilitative therapy showed REs 40.4% and REy of 0.41 units per day and the optimum number of rehabilitative therapy session was from 28 to 41 in terms of rehabilitation effectiveness and the maximum rehabilitation efficiency was seen in those doing 14 to 27 sessions of rehabilitative therapy. The study also showed improvement in BI at discharge and improvement in the independent ambulation 4 months after discharge from the CH. Key words: Modified Barthel Index, Length of stay, Length of weight bearing

Effects of dementia on postoperative outcomes of older adults with hip fractures: a population-based study

OBJECTIVE

To evaluate the association between dementia and postoperative outcomes of older adults with hip fractures.

DESIGN

Population-based, retrospective cohort study.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

All individuals with hip fractures who underwent hip fracture surgery in Ontario, Canada between April 1, 2003 and March 31, 2010 were identified. Physician-diagnosed dementia, prior to hip fracture, was identified using a diagnostic algorithm in the administrative databases.

MEASUREMENTS

The preoperative characteristics of older adults with and without dementia were compared separately for individuals admitted to hospital from community or long-term care (LTC). Multivariable regression was used to compare postoperative health service utilization, time with LTC admission, and mortality for individuals with and without dementia.

RESULTS

A total of 45,602 older adults had hip fractures and individuals with dementia accounted for 23.9% and 83.5% of all hip fractures from the community and LTC settings, respectively. Compared with those without dementia, individuals with dementia were less likely to be admitted to rehabilitation facilities. Among community-dwelling older adults, dementia was associated with an increased risk of LTC admission [hazard ratio (HR) = 2.49, 95% confidence interval (CI): 2.38-2.61, P < .0001]. Dementia was also associated with a higher mortality for older adults from community (HR = 1.47, 95% CI: 1.41-1.52, P < .0001) and LTC (HR = 1.10; 95% CI: 1.02-1.18, P = .005) settings.

CONCLUSIONS

Dementia is common among older adults with hip fractures and associated with poor prognosis following hip fracture surgery. Specialized services targeting the growing number of older adults with dementia may help to prevent hip fractures and optimize postoperative care for this vulnerable population.

Home-Based Multidisciplinary Rehabilitation following Hip Fracture Surgery: What Is the Evidence?

Objective. To determine the effects of multidisciplinary home rehabilitation (MHR) on functional and quality of life (QOL) outcomes following hip fracture surgery. Methods. Systematic review methodology suggested by Cochrane Collboration was adopted. Reviewers independently searched the literature, selected the studies, extracted data, and performed critical appraisal of studies. Summary of the results of included studies was provided. Results. Five studies were included. Over the short-term, functional status and lower extremity strength were better in the MHR group compared to the no treatment group (NT). Over the long-term, the MHR group showed greater improvements in balance confidence, functional status, and lower extremity muscle strength compared to NT group, whereas the effect on QOL and mobility was inconsistent across the studies. Several methodological issues related to study design were noted across the studies. Conclusion. The MHR was found to be more effective compared to the NT in improving functional status and lower extremity strength in patients with hip fracture surgery. Results of this review do not make a strong case for MHR due to high risk of bias in the included studies. Further research is required to accurately characterize the types of disciplines involved in MHR and frequency and dosage of intervention.

Effect of occupational therapy on functional and emotional outcomes after hip fracture treatment: a randomized controlled trial

OBJECTIVE

To explore whether an occupational therapy intervention combined with physiotherapy rehabilitation improved hip fracture patient outcomes regarding emotional distress, fatigue, independence and function.

DESIGN

Randomized controlled trial.

SETTING

Inpatient trauma ward in a rehabilitation and trauma hospital.

PARTICIPANTS

One hundred and twenty-two patients admitted into hospital for hip fracture.

INTERVENTION

Patients were randomly assigned to a standard care group (SC, n = 61) or a combined treatment group (CT, n = 61). The SC group received conventional hospital care for hip fracture patients and the CT group underwent occupational therapy as well.

MAIN MEASURES

Patients' emotional distress (GHQ-28), perceived fatigue (the first item of the BASDAI using a 0-100 visual analogue scale scale), level of independence (Modified Barthel Index) and function (Harris Hip Score) were measured at baseline and one, three and six months after the intervention.

RESULTS

Patients in the CT group experienced a considerable decrease of emotional distress at three and six months (p = 0.005 and p < 0.001, respectively). A between-group analysis showed significant differences in emotional distress at one, three and six months (p < 0.001). Although fatigue levels decreased in the SC group, the most significant decline was reported by the CT group at six months (p < 0.001, mean difference = 14 points). Regarding independence level, significant differences were found within groups at each stage, but also between groups at one month in favor of the CT group. Function improved in both groups compared with baseline (p < 0.001), but no significant differences were found in functionality between groups.

CONCLUSION

Although both groups reported significant improvements, patients in the CT group had better scores in emotional distress and dependence throughout follow-up and better scores in all measures at six months.