Talking to people with hip fractures and their families and providing realistic information on approximate expected recovery trajectories allows them to plan. However, it is complex for clinicians to apply evidence from cohort studies to individual patients as the cohorts are heterogeneous and patients have received varying amounts and types of rehabilitation.

Cohort studies suggest that following hip fracture, only 40–60 % of people who survive are likely to recover their pre-fracture level of mobility [10–12]. Up to 70 % may recover their level of independence for basic activities of daily living [10, 12, 13], but this is variable and less than half of all people experiencing hip fracture may regain their ability to perform instrumental ADLs [10, 14]. In Western nations, approximately 10–20 % of patients are institutionalised following hip fracture [10, 15–17]. The extent to which these outcomes can be improved with greater access to rehabilitation services is not clear.

In a large cohort study where the investigators collected extensive information on recovery for 2 years post-fracture, Magaziner et al. described the sequence of recovery across eight different functional abilities following hip fracture [11]. Upper extremity activities of daily living, depression and cognitive function were the earliest areas to recover and reached maximum recovery within 4 months. Most recovery of gait and balance occurred in the first 6 months, with maximum recovery occurring by 9 months; recovery of instrumental ADLs (such as shopping, preparing meals, house cleaning and handling money) took up to a year. It also took approximately a year for recovery of lower limb function, approximately 10 months for chair rise and walking speed and just over 14 months for walking 3 m without assistance. However, more than half of all patients could not walk 3 m without assistance at this time. It seems that the majority of patients who recover their pre-fracture walking ability or ability to perform basic activities of daily living (such as showering and dressing) do so within the first 6 months after fracture [18], but the role of long-term therapy in recovery pathways is yet to be well investigated.

Some types of patients with hip fracture appear to be at particular risk of poor outcomes – these include male patients, people living in supported accommodation, those with poorer mobility pre-fracture and those with depression or dementia [13, 18, 19]. People with dementia are also less likely to receive rehabilitation [19, 20]. Although mortality following hip fracture has been found to be higher in men than women, recovery of mobility has been reported to be unaffected by gender [19, 21].

Delirium is very common after hip fracture and although it is associated with poorer outcomes, routine assessment by rehabilitation staff remains uncommon [18]. In one prospective study delirium was still present in 39 % of people with hip fracture at discharge from hospital and in 32 % 1 month after fracture [22]. Even after controlling for pre-fracture physical and cognitive frailty those people who suffered delirium were twice as likely to have poor functional outcomes (in terms of mobility and recovery of activities of daily living) than those without [22].

Those who are older are more likely to have poorer mobility, need assistance at home, lose their ability to go outside on their own, cook their own dinner and be unable to prepare their own breakfast [19, 21]. Although a systematic review of nutritional interventions found only weak evidence to support the effectiveness of protein and energy feeds in older people recovering from hip fracture [23], low food intake post-operatively, poor nutrition and malnourishment pre-operatively are associated with worse recovery of mobility and function [24, 25]. Amongst nursing home residents, the factors most strongly associated with death or new total mobility dependence is being aged over 90 years, having very severe cognitive impairment and receiving non-operative management of the hip fracture [26]. Longer lengths of stay, re-hospitalisation, older age, chronic or acute cognitive deficits and depressive symptoms while in hospital are also predictive of poorer recovery of mobility and activities of daily living [18].

After the immediate post-operative period, a rehabilitation pathway should be followed that includes the elements addressed in Table 10.1. In particular, there is a need to assess frailty, establish goals to maximise mobility and other aspects of function, provide occupational therapy services to assess the requirement of aids and determine strategies to support and improve on independence in activities of daily living [27]. Medication management should ensure all prescribed medications are necessary, minimise the use of antipsychotics and sedatives and ensure adequate pain management. Osteoporosis should be treated as appropriate and falls prevention strategies reinforced with both patients and families.

It is widely recognised that a vicious cycle can occur after a hip fracture where pain and hospitalisation result in disuse atrophy of muscles and general deconditioning which increases the risk of immobility and new falls and fractures [28]. While national clinical guidelines recommend providing balance and strengthening exercise [29, 30], it is often unclear how much should be provided, what components of a rehabilitation programme are crucial and how long this programme should be provided for.

A meta-analysis by two of the present authors of randomised controlled trials examining the impact of structured exercise programmes on mobility outcomes, demonstrated that exercise can make significant improvements in overall mobility following hip fracture [6]. We have updated this review for the present chapter without finding additional articles. The overall effect size for all studies in the meta-analysis as identified by systematic review was relatively small (Hedges’ g standardised mean difference (SMD) of 0.35, 95 % confidence interval 0.12–0.58). However, between individual studies the effect size varied widely (I² = 67 %, p = 0.000), from studies that did not demonstrate any significant improvement in mobility, to studies with very large effects (e.g., Sylliiaas et al. 2012 with a SMD of 1.52, 95 % CI 1.06–1.97, or Hauer et al. 2002 with SMD of 1.0, 95 % CI 0.18–1.82) [31, 32]. The characteristics of the studies included in this meta-analysis, and an additional study that demonstrated a significant effect on mobility but could not be included in the meta-analysis [33], are shown in Table 10.2. Our meta-regression suggests that including progressive resistance exercise training in exercise programmes and those that are delivering the programme in settings other than the hospital alone, increases the effectiveness of a programme (SMD increased by 0.58 and 0.50, respectively) [6]. As shown in Table 10.3, the programmes that continued after discharge and were effective were programmes conducted over 12–24 weeks. It is uncertain how much the greater effectiveness of programmes delivered outside the hospital, compared to in hospital alone, is due to a longer duration of the intervention. Regardless, it is clear that exercise programmes must continue to be delivered long after discharge from hospital, ideally for 3–6 months.