Maximising functional recovery following hip fracture in frail seniors




Abstract


This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations – those with cognitive impairment, residing in nursing homes or males – also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.


Introduction


Hip fracture represents a global public health issue with 1.6 million hip fractures reported worldwide in 2000 . Loss of function is common after hip fracture and many patients who survive are unable to return to independent community living . Ongoing long-term care costs when patients are unable to return to the community are one of the largest components of the total costs associated with the ongoing care of hip fracture patients .


Increasing age is accompanied by loss of bone and muscle mass , and increases the risk of falls leading to fracture . Hip fractures most commonly occur in the older population, following a simple fall from standing height in the presence of osteoporosis; 70% occur in women . In addition, many patients with hip fracture present with multiple concomitant medical issues that can adversely affect recovery .


There are also sub-populations of patients who may be at a risk of poor functional recovery after hip fracture, may require different treatments and therefore require special consideration. These include patients with pre-existing functional and cognitive limitations, those residing in nursing homes or other permanent long-term care settings at the time of hip fracture and men .


Pharmacologic management for osteoporosis has been shown to be an effective secondary prevention strategy in reducing the risk of subsequent fractures . Exercise also appears to be beneficial following hip fracture, although some findings are as yet equivocal and more evidence is needed to determine optimal components, timing, intensity and duration . Areas of treatment currently under exploration are treatment of sarcopenia, the use of different modes of exercise, nutritional supplementation and pharmacologic management. Only limited attention has been given to multimodal interventions that consider these interventions as potentially complementary treatment strategies.


This chapter will discuss pre-existing factors that affect recovery following hip fracture as well as interventions that have been shown to restore functioning and independence after a hip fracture. Gaps in current knowledge will be outlined with directions for future research.




Prefracture factors affecting functional recovery


There is good evidence that patients’ health status at the time of hip fracture has an impact on recovery. ‘Reduced prefracture functional independence’ has consistently been shown to adversely affect recovery following hip fracture . Those patients who are more limited in daily activities or ambulation at the time of their fracture are more likely to experience more significant functional loss in the first year after hip fracture than those who were independent in daily activities and ambulation. For example, in a cohort analysis of 571 subjects, Eastwood et al. reported that of those who were independent in locomotion prior to fracture, 10% were dependent in locomotion within 6 months of fracture. By contrast, of those who required assistance with locomotion prior to hip fracture, 31% were dependent in locomotion at 6 months after fracture.


‘Co-morbid conditions’, common in the medically compromised hip fracture patient population , delay or reduce recovery and may lead to increased medical care and costs . Leibson et al. reported that 45% of hip fracture patients had a Charlson Comorbidity Index >1 compared to 30% of matched controls, and multiple studies have demonstrated that those with a greater co-morbid disease burden at the time of fracture do more poorly in the years following the fracture .


One of the most common pre-existing conditions is ‘cognitive impairment’, with which approximately 42% (95% confidence intervals (CI) 37, 46%) of the hip fracture population will present . People with dementia have higher odds of falling than those without cognitive impairment ; thus, people with cognitive impairment or dementia have a higher risk of hip fracture. In turn, recovery after hip fracture has been shown to be negatively impacted by the presence of cognitive impairment. Morgen et al. reported that at 1 year after hip fracture, subjects without cognitive impairment needed little supervision to walk, whereas 50% of subjects with impaired cognition required human assistance to walk. Further, 25% of cognitively impaired subjects also required assistance in transfers and self-care while almost all of the subjects without cognitive impairment had returned to full independence in those tasks .


Affective status or ‘depression’ can adversely affect recovery after hip fracture as well . Depression can augment behavioural symptoms of cognitive impairment and may affect the capacity to participate in rehabilitation . For example, even after adjustment for covariates and potential confounders, patients with moderate to severe depressive symptoms were more likely to not be able to walk independently at hospital discharge (odds ratio (OR) 3.2; 95% CI 1.3, 7.8) and to be institutionalised or die by a year after their fracture . Conversely, positive affect can lead to improved recovery after hip fracture. Fredman et al. reported that at 6 months, even after risk adjustment, those with a positive affect had a mean usual walking pace of 0.06 m s −1 faster than those with depressive symptoms.


‘Poor nutritional status’, which is associated with increased mortality after hip fracture, may also negatively impact functional recovery . In a multivariate analysis in one study, poor nutritional status at the time of fracture was associated with lower odds of walking independently 6 months after hip fracture (OR 0.77, 95% CI 0.66, 0.90) .


The role of ‘social support’ is another factor that affects recovery following hip fracture. Subjects with good social support systems are more likely to return to independent living arrangements than those with poor social support . Shuyu et al. reported that those subjects who had family members who sought further information on both caregiving and related health-care needs were more likely to recover their walking ability than those who did not.


All of these aforementioned factors often interact and coalesce under the concept of frailty. ‘Frailty’ is a term and concept that is widely applied clinically. There is general agreement that it is a state associated with impaired homoeostatic mechanisms that predisposes older people to unfavourable health and social outcomes . Hip fracture is a consequence of impaired homoeostasis with reference to maintaining an upright posture and therefore many older people with hip fracture meet the definitions of frailty.


An understanding of frailty is useful in programmes that aim to restore functioning and independence in a person following a hip fracture because it suggests that there are multiple factors to be addressed. These can be identified systematically using the well-established techniques of geriatric evaluation and management . Through this process, it may be feasible to identify intervention targets, for example, previously undiagnosed cognitive impairment, in addition to instituting multi-component programmes that aim to improve functioning broadly .


The presence of frailty is starting to guide treatment for some health conditions because it has been shown that frailty can predict response to treatment and likelihood of adverse complications . The extent of frailty has also been shown to be associated with outcome in people with hip fracture , but to our knowledge, this information has not been used to guide treatment and rehabilitation approaches.




Prefracture factors affecting functional recovery


There is good evidence that patients’ health status at the time of hip fracture has an impact on recovery. ‘Reduced prefracture functional independence’ has consistently been shown to adversely affect recovery following hip fracture . Those patients who are more limited in daily activities or ambulation at the time of their fracture are more likely to experience more significant functional loss in the first year after hip fracture than those who were independent in daily activities and ambulation. For example, in a cohort analysis of 571 subjects, Eastwood et al. reported that of those who were independent in locomotion prior to fracture, 10% were dependent in locomotion within 6 months of fracture. By contrast, of those who required assistance with locomotion prior to hip fracture, 31% were dependent in locomotion at 6 months after fracture.


‘Co-morbid conditions’, common in the medically compromised hip fracture patient population , delay or reduce recovery and may lead to increased medical care and costs . Leibson et al. reported that 45% of hip fracture patients had a Charlson Comorbidity Index >1 compared to 30% of matched controls, and multiple studies have demonstrated that those with a greater co-morbid disease burden at the time of fracture do more poorly in the years following the fracture .


One of the most common pre-existing conditions is ‘cognitive impairment’, with which approximately 42% (95% confidence intervals (CI) 37, 46%) of the hip fracture population will present . People with dementia have higher odds of falling than those without cognitive impairment ; thus, people with cognitive impairment or dementia have a higher risk of hip fracture. In turn, recovery after hip fracture has been shown to be negatively impacted by the presence of cognitive impairment. Morgen et al. reported that at 1 year after hip fracture, subjects without cognitive impairment needed little supervision to walk, whereas 50% of subjects with impaired cognition required human assistance to walk. Further, 25% of cognitively impaired subjects also required assistance in transfers and self-care while almost all of the subjects without cognitive impairment had returned to full independence in those tasks .


Affective status or ‘depression’ can adversely affect recovery after hip fracture as well . Depression can augment behavioural symptoms of cognitive impairment and may affect the capacity to participate in rehabilitation . For example, even after adjustment for covariates and potential confounders, patients with moderate to severe depressive symptoms were more likely to not be able to walk independently at hospital discharge (odds ratio (OR) 3.2; 95% CI 1.3, 7.8) and to be institutionalised or die by a year after their fracture . Conversely, positive affect can lead to improved recovery after hip fracture. Fredman et al. reported that at 6 months, even after risk adjustment, those with a positive affect had a mean usual walking pace of 0.06 m s −1 faster than those with depressive symptoms.


‘Poor nutritional status’, which is associated with increased mortality after hip fracture, may also negatively impact functional recovery . In a multivariate analysis in one study, poor nutritional status at the time of fracture was associated with lower odds of walking independently 6 months after hip fracture (OR 0.77, 95% CI 0.66, 0.90) .


The role of ‘social support’ is another factor that affects recovery following hip fracture. Subjects with good social support systems are more likely to return to independent living arrangements than those with poor social support . Shuyu et al. reported that those subjects who had family members who sought further information on both caregiving and related health-care needs were more likely to recover their walking ability than those who did not.


All of these aforementioned factors often interact and coalesce under the concept of frailty. ‘Frailty’ is a term and concept that is widely applied clinically. There is general agreement that it is a state associated with impaired homoeostatic mechanisms that predisposes older people to unfavourable health and social outcomes . Hip fracture is a consequence of impaired homoeostasis with reference to maintaining an upright posture and therefore many older people with hip fracture meet the definitions of frailty.


An understanding of frailty is useful in programmes that aim to restore functioning and independence in a person following a hip fracture because it suggests that there are multiple factors to be addressed. These can be identified systematically using the well-established techniques of geriatric evaluation and management . Through this process, it may be feasible to identify intervention targets, for example, previously undiagnosed cognitive impairment, in addition to instituting multi-component programmes that aim to improve functioning broadly .


The presence of frailty is starting to guide treatment for some health conditions because it has been shown that frailty can predict response to treatment and likelihood of adverse complications . The extent of frailty has also been shown to be associated with outcome in people with hip fracture , but to our knowledge, this information has not been used to guide treatment and rehabilitation approaches.




Functional recovery after hip fracture


Functional recovery appears to follow a sequence that may inform an approach for patient management to maximise recovery. Magaziner et al. reported that patterns of recovery vary by functional domain with depression, cognitive function and upper extremity activities of daily living (ADLs) reaching maximum recovery within 4 months of fracture, while balance and gait can take up to 9 months after fracture to recover. Instrumental and physical ADLs are slower to recover, if indeed, subjects are able to regain these higher levels of function, and may take up to 1 year following fracture. These findings align with the process of disablement proposed by Verbrugge and Jette and may have implications for determining appropriate interventions and timing of interventions to promote maximal recovery.




What do we know about restoring function and independence?


Following hip fracture, the early perioperative recovery period focusses on establishing medical stability and commencing early mobilisation strategies to prevent common postoperative complications. Multidisciplinary care that includes medical, rehabilitative and nursing interventions is recommended during this early recovery phase . However, recovery after hip fracture continues throughout the first postoperative year and beyond, and more consideration should be given to post-acute management after the acute hip fracture episode to maximise functional recovery and return to the highest level of independence possible. Treatment strategies during this phase include exercise interventions as well as secondary prevention of future fractures through pharmacologic management of osteoporosis.


Benefits of exercise


There is now strong evidence that well-designed exercise and physical training interventions can enhance muscle strength and balance and prevent falls in older people. There is also mounting evidence that exercise and physical training can enhance recovery of function and independence in older people after hip fracture. However, optimal intervention programmes to maximise post-hip fracture functioning are yet to be established. Thus, although most current hip fracture guidelines indicate the need for rehabilitation, they do not outline key components of rehabilitation programmes that should be delivered . As many of the trials in this area are small and inconclusive, they do not provide clear evidence to guide practice and, as a result, the conclusions of the relevant Cochrane review are that there is “ insufficient evidence from randomised trials to establish the best strategies for enhancing mobility after hip fracture surgery .” .


Despite limitations of prior studies, an inspection of the exercise components of interventions in trials that demonstrated enhanced physical functioning after hip fracture provides useful information. Interventions that used a higher dose of exercise tended to show stronger effects on important outcomes . Examples of programmes found to be effective in individual trials are discussed below and the findings of randomised trials testing these programmes are summarised in Table 1 .



Table 1

Trials showing benefits from exercise programs after hip fracture.
















































































Author, date, Country Interventions Results Sample size PEDro scale quality score
Interventions started in the inpatient setting
Bischoff-Ferrari et al., 2010 ; Switzerland Comparison of extended physiotherapy (PT) (supervised 60 min/day during acute care plus an unsupervised home program) versus standard PT (supervised 30 min/day during acute care plus no home program; single-blinded). All patients also received cholecalciferol. The PT interventions were provided for approximately 7 days.

  • •

    Extended versus standard PT reduced the rate of falls by 25% (95% CI -44%, −1%) but had no effect on hospital readmissions.

173 6/10
Sherrington et al., 2003 ; Australia Comparison of either weight-bearing ( n = 40) or non-weight-bearing ( n = 40) exercise prescribed by a physiotherapist. Both interventions were conducted on a daily basis for 2 weeks.

  • •

    Both groups improved markedly (in the order of 50%) on measures of physical ability however there was no significant difference between the groups in the extent of improvement


  • •

    Additional strength benefits were found for the non-weight-bearing group and additional functional benefits were found for the weight-bearing group who also needed less supportive walking aids ( p = 0.045).

80 7/10
Mitchell et al., 2001 ; Scotland Randomised controlled trial comparing the addition of 6 weeks quadriceps training (training; n = 40 patients) with standard PT alone (control; n = 40 patients). The training group exercised twice weekly for 6 weeks, with 6 sets of 12 repetitions of knee extension (both legs), progressing up to 80% of their one-repetition maximum.

  • •

    Leg extensor power increased significantly in the training group compared with the control group. Significant benefits were maintained at 16 weeks.


  • •

    Quadriceps training resulted in a greater increase in elderly mobility scale score compared with standard rehabilitation (between-group difference of 2.5 (95% CI 1.1, 3.8) at week 6 and 1.9 (0.4, 3.4) at week 16).


  • •

    Barthel score increased significantly from week 0–6 in the training group compared with controls (Mann–Whitney U -test p = 0.05).


  • •

    Patients in the training group scored significantly better in the energy sub-score of the Nottingham Health Profile at the end of follow-up (Mann–Whitney U -test p = 0.0185).

80 5/10
Trials started after discharge from hospital or at the end of usual care
Sylliaas et al., 2012 ; Norway The intervention group ( n = 48) underwent a 3 month progressive strength training program with one session at an outpatient clinic and another session at home. The control group ( n = 47) was asked to maintain their current lifestyle.

  • •

    There were no statistically significant differences between groups in the primary outcome Berg Balance Scale.


  • •

    The intervention group showed significant improvements in strength, gait speed and gait distance, instrumental activities of daily living and self-rated health.

95 8/10
Sylliaas et al., 2011 ; Norway The intervention group ( n = 100) received a 3-month strength training program conducted by a physiotherapist twice a week with a home session to be completed once per week. The control group was asked to maintain their current lifestyle.

  • •

    At follow-up, the intervention group showed highly significant improvements both in the primary endpoint (Berg Balance Scale, mean difference 4.7 points) and in secondary end- points of sit-to-stand, 6 min walk test, gait speed, step height, timed up and go and instrumental activities of daily living.

150 8/10
Mangione et al., 2010 , USa Exercise and control participants received interventions by physical therapists twice weekly for 10 weeks. The exercise group received high intensity leg strengthening exercises. The control group received transcutaneous electrical nerve stimulation and mental imagery.

  • •

    Isometric force production ( p < 0.01), usual and fast gait speed ( p = 0.02 & 0.03, respectively), 6 min walk distance ( p < 0.01), and modified physical performance test ( p < 0.01) improved at one year post fracture with exercise.


  • •

    Effect sizes were 0.79 for strength, 0.81 for modified physical performance test scores, 0.56 for gait speed, 0.49 for 6 min walk, and 0.30 for SF-36 scores.

26 7/10
Portegijs et al., 2008 ; Finland 12 week intensive progressive strength-power training program twice a week for 1–1.5 h ( n = 24) Control group ( n = 22) encouraged to maintain their pre-study level of physical activity during the 12-week trial.

  • •

    Asymmetric leg extension power deficit decreased ( p = 0.010) after training compared with the control group.


  • •

    Leg extension power of the stronger leg, asymmetric knee extension strength deficit, walking speed, and balance performance were not significantly affected by training.


  • •

    Self-reported ability to walk outdoors improved after training.

46 6/10
Mard et al., 2008 ; Norway The intervention group ( n = 23) underwent a 12-week supervised and progressive muscle strength and power training program twice a week. The control group ( n = 20) was encouraged to maintain their pre-study level of physical activity during the 12-week trial.

  • •

    14 subjects in the training group and only 2 controls felt that their mobility had improved during the intervention period ( p = 0.002).


  • •

    Training had no significant effect on TUG, chair rise and stair climbing time and walking time.

43 7/10
Sherrington et al., 2004 ; Australia Compared the effects of weight-bearing ( n = 40) and non-weight-bearing ( n = 40) home exercise programs and a control program ( n = 40). 5 and 8 exercises were prescribed to be carried out daily for a period of 4 months.

  • •

    At the 4-month retest, there were between-group differences compared to the initial assessment for the measures of balance and functional performance but not for strength or gait.


  • •

    The weight-bearing exercise group showed the greatest improvements in measures of balance and functional performance (between-group differences of 30%–40% of initial values).

120 7/10
Binder et al., 2004 ; USA Participants were randomly assigned to 6 months of supervised PT and progressive resistance exercise training ( n = 46) or home exercise control ( n = 44). The exercise intervention sessions lasted for 45–90 min and were conducted 3 times per week. Control participants were instructed to complete their home program of flexibility exercises 3 times per week also.

  • •

    PT participants had improved physical performance and less self-reported disability than control participants at the final follow-up evaluation.


  • •

    Changes over time in the Physical Performance Test (PPT) and Functional Status Questionnaire (FSQ) scores favoured the PT group ( p = 0.003 and p = 0.01, respectively).


  • •

    PT also had significantly greater improvements than the control condition in measures of muscle strength, walking speed, balance, and perceived health but not bone mineral density or fat-free mass.

90 7/10
Hauer et al., 2002 ; Germany Intervention group ( n = 15) performed progressive resistance and functional training to improve strength and functional performance 3 days a week for 12 weeks. Control group ( n = 13) met 3 times a week for 1 h and engaged in placebo motor activities such as seated calisthenics, games and memory tasks.

  • •

    Training significantly increased strength, functional motor performance and balance and reduced fall-related behavioural and emotional problems.


  • •

    Some improvements in strength persisted during 3-months follow-up while other strength variables and functional performances were lost after cessation of training.


  • •

    Patients in the control group showed no change in strength, functional performance and emotional state during intervention and follow-up.

28 6/10


More intensive physiotherapy followed by a home programme has shown positive outcomes after hip fracture. Bischoff-Ferrari et al. compared extended physiotherapy (60 min per day during acute care plus an unsupervised home programme after discharge) with standard physiotherapy (30 min per day during acute care without a home programme). Individuals receiving the more intensive programme had a 25% lower rate of falls in the 12 months after hospital discharge compared to those in the control group.


Intensive outpatient centre-based rehabilitation has been found to enhance recovery after hip fracture in several trials. Binder and colleagues compared 6 months of supervised physical therapy and exercise training with home exercise and found significantly better physical performance, functional status, muscle strength, walking speed, balance and perceived health in the more intensive group. The exercise intervention sessions lasted for 45–90 min and were conducted three times a week. Control participants were instructed to complete a home-based programme of flexibility exercises three times a week. Similarly, Hauer et al. found 12 weeks of progressive resistance and functional training three times a week to improve strength and functional motor performance and balance and reduced fall-related behavioural and emotional problems when compared to placebo motor activities such as seated calisthenics, games and memory tasks undertaken three times a week for 1 h.


Several studies have found particular types of exercises to be beneficial. Progressive resistance training has been found to be safe and effective in people after hip fracture when delivered in inpatient or outpatient settings or as a supervised home programme . Outcomes that have been improved by progressive resistance training have included muscle strength, gait speed, endurance, overall physical functioning and self-reported health.


It may also be possible to enhance physical functioning without resistance training. Exercises undertaken in upright positions (i.e., standing and walking) have been found to have greater impacts on functional recovery than more passive seated or bed exercises in inpatient rehabilitation as well as in home-based situations . There is an indication of ‘specificity of exercise’ in these results.


A number of trials have demonstrated important improvements from interventions started after the completion of usual care . This suggests that the exercise interventions delivered as a part of usual care are not generally of sufficient intensity and/or duration to maximise recovery. This appears to be the case even in more affluent countries with generally good health-care systems. It is likely that the deficit between the extent of hip fracture that can be achieved and the level of recovery that is generally achieved is even greater in resource-poor settings.


Exercise is probably even more effective if delivered as part of a multidisciplinary rehabilitation programme. A trial by Singh et al. found a reduced risk of death and nursing home admission, better ADL performance and less assistive device use after 12 months of high-intensity progressive resistance training with the targeted addition of multidisciplinary treatment of frailty.


We have summarised trials of exercise interventions found to improve physical functioning after hip fracture. There have been a number of other trials that have not demonstrated the effects of exercise. Many had small sample sizes, so they possibly lacked the statistical power to detect effects. However, one relatively large trial ( n = 180) failed to find an impact on the physical functioning of home-based aerobic and resistive exercise delivered by an exercise trainer although the intervention group showed increased overall physical activity. This finding indicates the need for further large-scale trials to investigate key components and optimal intervention doses and delivery methods. The more effective interventions seem to involve visits to specialised outpatient clinics and higher intensity of exercise. This intensive form of exercise programme may not be acceptable to some older people and their caregivers and will be more expensive to deliver on an ongoing basis to the millions of people suffering hip fractures across the globe each year. Further studies need to investigate costs and effects of different exercise programmes as well as investigate participant views of exercise. The global challenge for hip fracture research and clinical practice is how to deliver high-dose mixed interventions in a manner that is cost effective and acceptable to participants, their families, providers and payers.


Secondary prevention through pharmacologic management for bone health


Hip fractures are well recognised as a consequence of bone fragility, which is caused by decreased bone mass. Low bone mineral density (BMD) is common in older persons and is a risk factor for hip fracture ; on average, BMD at the hip declines 0.5–1% per year among elderly women who have not fractured a hip . By contrast, the decline in BMD is 4–7% in the year following hip fracture , contributing to the higher risk of subsequent fractures in these patients . Additionally, hip fractures are associated with an 8.4–36% excess mortality within the year following the fracture .


Treatment options for osteoporosis encompass lifestyle modification including vitamin D supplementation and adequate calcium intake, weight-bearing exercise, smoking cessation and reduction in alcohol intake as well as prescription medications. The two major categories of pharmacologic treatment of osteoporosis are: (1) antiresorptive and (2) anabolic medications. Antiresorptive medications include alendronate, risendronate, ibandronate, zoledronic acid, calcitonin, oestrogen agonist/antagonist, oestrogens and/or hormone therapy, raloxifene, denosumab and strontium ranelate. Teriparatide is the only anabolic medication approved for the treatment of osteoporosis.


The detection and treatment of osteoporosis has been found to be cost effective and showed lower mortality in both women and men . Only zoledronic acid has been tested and approved by the Food and Drug Administration (FDA) and other regulatory bodies for use in hip fracture patients after showing benefits in reducing subsequent fractures, increasing BMD and reducing mortality .


New guidelines advise that pharmacologic therapy should not be considered indefinite in duration, and there is limited evidence of efficacy beyond 5 years . There should be a comprehensive risk assessment after the initial 3- to 5-year treatment period. Despite these recommendations and the proven benefits of the medications, most hip fracture patients do not receive definitive pharmacologic treatment, nor is osteoporosis evaluation generally performed . Osteoporosis diagnosis, which increases the likelihood of treatment , is made in <20% of women who sustain a hip fracture, even after the event . General treatment rates under 20% are typical, even as long as 1 year after the fracture , and less aggressive vitamin D supplementation with or without calcium is the most commonly used treatment .

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Nov 10, 2017 | Posted by in RHEUMATOLOGY | Comments Off on Maximising functional recovery following hip fracture in frail seniors

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