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

Hip fractures are associated with high mortality rates, substantial functional decline and the consequences have been identified as one of the most serious health care problems in elderly people [1]. At present, the age-standardized incidence for females with hip fracture in developed countries is over 150/100000 inhabitants per year, with the highest rates found in Denmark and Sweden at approximately 560/100000. However, due to demographic changes over the coming decades these numbers are expected to increase [2].

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

There is evidence that early admission to a dedicated geriatric unit can reduce mortality and morbidity after hip fracture [13], that an interdisciplinary approach results in better outcomes than standard care [14, 15], and result in improved mobility at 4 and 12 months following fracture [11]. CGC is however not without its limitations. Two recent reviews described how the heterogenous way models of CGC have been organized and put into practice make it difficult to interpret results, compare studies and determine best practice [16, 17]. Rehabilitation research generally includes multiple outcomes, addressing ICF classifications of body function, body structures and activities, however the aspect of patient participation is less commonly studied despite being described as the outcome most important to people with disabilities, their families and society [18]. Encouraging patients with complex health care needs to take a more active role in their health care has shown patients reporting increased motivation and improved outcomes [19], experiencing higher quality of care, with fewer mistakes, and a more positive impression of the health care system [20]. However, the structured nature of care following hip fracture, despite many benefits, has also been described as a factor that can limit patients’ participation due to staff focusing on following care pathways and not allowing time to reflect over and recognise the patients’ personal needs [21].

Factors that may further limit patient participation after hip fracture are impaired functional balance and fear of falling, which not only affect patients’ ability to perform activities of daily living [22], but are considered the most common risk factors for future falls and fractures [23]. Furthermore, reduced balance confidence and impaired functional balance may delay patients’ recovery after hip fracture [24].

At Sahlgrenska University Hospital patients with hip fracture are treated from admission to discharge in a CGC. To our knowledge no study has been performed within a CGC unit to compare rehabilitation programmes during the acute phase after hip fracture with focus on improving patients’ perceived participation and the effect on patients’ function.

The primary aim was therefore to evaluate a modified programme of coordinated inpatient rehabilitation during the acute phase after hip fracture surgery with focus on patients’ perceived participation. Secondary aims were to investigate effect on activities of daily living, functional balance and confidence and physical performance. A further aim was to investigate level of recovery at 1 month follow-up including risk for future falls.

Based on clinical assumptions and the results of previous studies [39, 40] assuming a power of 80% and ∝ of 0.05, and a difference between groups of 13 points in the Falls Efficacy Scale with SD = 20, a total sample size of n = 76 was estimated. With an approximated drop-out rate of 20%, a total sample size of n = 92 was necessary. Descriptive statistics are reported as means and standard deviations (SD) or median (min-max) as appropriate. For comparison between the groups at discharge and at 1 month Chi-square was used for analysis of self-rated degree of participation, and P- and I-ADL. Mann-Whitney U Test was used for the analysis of BBS, FES, SPPB and TUG.

Baseline characteristics of the 126 patients recruited to this study are presented in Table 1, with 63 patients in the intervention and control group, respectively. The patients in the intervention group (IG) had an average age of 82.0 years and control group (CG) 80.5 years, with approximately 75% women in both groups (Table 1). No statistically significant differences were found between the groups at baseline apart from type of surgery, with a higher proportion of patients with a hemiarthroplasty in the IG and I-ADL activity of cooking in which the CG was more independent than the IG.

Of the 237 patients admitted to the unit, 144 patients fulfilled the inclusion criteria. The main reason for exclusion was cognitive impairment and dependency in more ADL activities than just bathing. Eighteen patients declined participation giving a total of 126 patients. There was a further drop-out of 8 patients before discharge, and 12 patients at 1 month, leaving a total of 106 patients completing the follow-up assessment, 52 patients in the IG and 54 in the CG respectively (Fig. 1). Reasons for drop-out prior to discharge included: partial weight-bearing (2), new fracture (3), medical reasons (1), discharged before measurements could be performed (1) and declined (1). Prior to one month follow-up; declined (6), deceased (5), and admitted to hospital (1). This resulted in a 4% mortality and a 16% drop-out rate at 1 month follow-up, (Fig. 1).

This study shows that by modifying existing CGC in-patient rehabilitation routines and intensity, whilst retaining existing staffing levels, positive results concerning patient participation and recovery of ADL can be obtained. There is a lack of studies investigating patient participation during acute phase after hip fracture. However, our physical performance outcomes are similar to those reported by Prestmo et al. who compared orthopedic care and CGC [11]. They found no difference between groups at 1 month concerning physical performance [11]. In our study both groups improved beyond the recommended MDC levels for both balance and physical performance measures between discharge and 1 month. However, despite these improvements, approximately 40–80% of patients remained at risk for future falls at 1 month.

This model of OT and PT coordinated inpatient rehabilitation had a positive effect on patients’ perceived participation in their rehabilitation and ADL but did not appear to affect level of recovery or risk for future falls at 1 month. A large proportion of patients in both groups remained at risk for future falls at 1 month highlighting the need for continued rehabilitation.