Research in Focus: Rehabilitation After Hip Fracture for Nursing Home Residents
October 11, 2019
Citation: Beaupre LA, Magaziner JS, Jones CA, Jhangri GS, Johnston WC, Wilson DM, Majumdar SR. Research in Focus: Rehabilitation After Hip Fracture for Nursing Home Residents: A Controlled Feasibility Trial. Journals of Gerontology: Medical Sciences 2019; 74(9):1518-1525.
Hip fractures are common among older adults and are associated with significant morbidity and mortality. Older adults residing in nursing homes are at increased risk of hip fracture.1,2 However, nursing home residents are often excluded from hip fracture rehabilitation research and often receive limited post-fracture rehabilitation and achieve poorer outcomes when compared with community dwelling seniors who sustain a hip fracture.1,2 The purpose of this feasibility study was to determine whether nursing home residents would be able to participate in a structured hip fracture rehabilitation program and to compare their outcomes with nursing home residents who received usual care.
Feasibility study. Non-randomized design.
Participants assigned to outreach or control groups based on the hospital they were admitted to for surgical management.
Clinical assessors and investigators were blinded to group assignment.
Control group intervention:
Usual post-fracture care in their nursing home
Provided by nursing home rehabilitation staff
Three sessions per week for 10 weeks, delivered by one physiotherapist and two physiotherapist assistants
Consisted of bed mobility, transfers, ambulation and functional exercise
Content and difficulty tailored to the patient
Proxy respondents completed outcome measures via telephone interview at three, six, and 12-months post-fracture
FIMphysical domain scale
Euro Quality of Life Five-Dimensions Three-Level (EQ-5D-3L)
Primary Outcome Considered – FIMphysical at three months post-fracture
Secondary Outcomes Considered – FIMphysical, EQ-5D-3L, FIMlocomotion and FIMmobility scales at 12 months post-fracture
77 participants were enrolled in the study; 46 outreach, 31 control
42% of participants were independently walking pre-fracture
55 participants were retained at three-month follow up. (16 deceased, six withdrawn from the study)
At three-month follow-up:
No significant difference in FIMphysical or FIMmobility between outreach and control groups
The outreach group had significantly higher FIMlocomotion scores
Both groups reported significant decline in FIMphysical, FIMlocomotion and FIMmobility compared to pre-fracture status
However, the control group reported greater losses in function and lower independence compared with pre-fracture levels than the outreach group
At 12-month follow-up:
Outreach participants reported significant improvements in all FIM scores and EQ-5D-3L compared with control group
There was no difference in mortality between the two groups
Participation and Retention
84% completed three sessions/week
65% completed the 10-week program (90% of these completed three sessions/week)
Treatment sessions were about 50 minutes in length
Over 10-weeks the intervention shifted from bed mobility and short periods of ambulation to include longer and more frequent ambulation and functional exercises
There were no adverse effects reported
As this was designed as a feasibility study, the participation and retention data are the key outcomes of importance.
The majority of outreach participants completed the 10-week program, and 90% of these were able to complete three sessions/week.
As noted by the authors, “despite lower pre-fracture health status, substantial cognitive impairment, and older age, 76% of Outreach participants commenced the program and 65% completed 10 weeks of structured rehabilitation three times per week.”
Outreach program participants received significantly more rehabilitation intervention than controls.
The “modest benefits achieved [by the Outreach group] during rehabilitation were sustained for 12 months.”
The findings suggest that “ambulatory nursing home residents should be considered potentially eligible for rehabilitation after hip fracture surgery.”
A provincial government policy change one year after participant enrollment began effected how individuals were classified as requiring nursing home level of care. This negatively impacted the premorbid mobility status of participants and study recruitment and may have negatively skewed the study findings.
Due to this change in policy, the study participants were older and had lower premorbid mobility than studies that include community dwelling or supported living facility dwelling seniors. Thus, the findings “may only generalize to older residents of nursing homes who require daily nursing care.”
The study was not randomized. It was a feasibility study to designed to assess treatment fidelity and the impact of the outreach intervention. Future studies should include a randomized trial with an appropriately powered sample size.
Relevance to physiotherapy practice in Alberta
Physiotherapists who work with older adults are familiar with barriers to access to intervention for individuals residing in nursing home facilities following hip fracture. This study provides some evidence that this patient population may benefit from a structured 10-week rehabilitation program post-fracture. This finding may help to inform resource allocation decisions for this patient population.
Disclaimer: The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.
Beaupre LA, Magaziner JS, Jones CA, Jhangri GS, Johnston WC, Wilson DM, Majumdar SR. Research in Focus: Rehabilitation After Hip Fracture for Nursing Home Residents: A Controlled Feasibility Trial. Journals of Gerontology: Medical Sciences 2019; 74(9):1518-1525.
Crotty M, Killington M, Liu E, Cameron ID, Kurrle S, Kaambwa B, Davies O, Miller M, Chehade M, Ratcliffe J. Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomized controlled trial. Age and Ageing 2019; 48:373-380.
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