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.

Background

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.

Methods

  • Design:
    • 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
  • Outreach intervention:
    • 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
  • Assessment procedures
    • Proxy respondents completed outcome measures via telephone interview at three, six, and 12-months post-fracture
    • Outcome measures:
      • FIMphysical domain scale
      • FIMlocomotion scale
      • FIMmobility 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

Findings

  • 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

Discussion

  • 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.”

Limitations

  • 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.


  1. 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.
  2. 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.