Interventions for improving mobility after hip fracture surgery in adults
- PMID: 36070134
- PMCID: PMC9451000
- DOI: 10.1002/14651858.CD001704.pub5
Interventions for improving mobility after hip fracture surgery in adults
Abstract
Background: Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.
Objectives: To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.
Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.
Selection criteria: All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).
Data collection and analysis: Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.
Main results: We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.
Authors' conclusions: Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.
Trial registration: ClinicalTrials.gov NCT00006194 NCT00224367 NCT00389844 NCT04025866 NCT02295527 NCT01129219 NCT01174589 NCT02305433 NCT02407444 NCT02815254 NCT02938923 NCT03030092 NCT04095338 NCT04108793 NCT04207788 NCT04228068.
Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
NF: none SD: none JM: none JD: none WK: none CS: as Catherine Sherrington is an active investigator in several randomised trials in this area, assessment of eligibility of these trials and quality assessment of the four included trials was done independently by two other review authors. Independent data extraction and entry into Review Manager software, presentation and interpretation of these trials were also performed.
Figures
Update of
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Interventions for improving mobility after hip fracture surgery in adults.Cochrane Database Syst Rev. 2011 Mar 16;(3):CD001704. doi: 10.1002/14651858.CD001704.pub4. Cochrane Database Syst Rev. 2011. Update in: Cochrane Database Syst Rev. 2022 Sep 7;9:CD001704. doi: 10.1002/14651858.CD001704.pub5. PMID: 21412873 Updated. Review.
Comment in
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Cochrane in CORR ®: Interventions for Improving Mobility After Hip Fracture Surgery in Adults.Clin Orthop Relat Res. 2023 Mar 1;481(3):438-444. doi: 10.1097/CORR.0000000000002561. Epub 2023 Jan 16. Clin Orthop Relat Res. 2023. PMID: 36728088 Free PMC article. No abstract available.
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- Van Ooijen MW, Roerdink M, Trekop M, Janssen TW, Beek PJ. The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial. BMC Geriatrics 2016;16(1):215. - PMC - PubMed
Williams 2016 {published data only}
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- Williams NH, Roberts JL, Ud Din N, Charles JM, Totton N, Williams M, et al. Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomized feasibility study: fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR). Health Technology Assessment 2017;21(44):1-527. - PMC - PubMed
References to studies excluded from this review
Adunsky 2011 {published data only}
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- Adunsky A, Chandler J, Heyden N, Lutkiewicz J, Scott BB, Berd Y, et al. MK-0677 (ibutamoren mesylate) for the treatment of patients recovering from hip fracture: a multicenter, randomized, placebo-controlled phase IIb study. Archives of Gerontology and Geriatrics 2011;53(2):183-9. - PubMed
Aftab 2020 {published data only}
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- Aftab A, Awan WA, Habibullah S, Lim JY. Effects of fragility fracture integrated rehabilitation management on mobility, activity of daily living and cognitive functioning in elderly with hip fracture. Pakistan Journal of Medical Sciences 2020;36(5):965-70. [DOI: 10.12669/pjms.36.5.2412] - DOI - PMC - PubMed
Beckman 2021 {published data only}
Berggren 2019 {published data only}
Corna 2021 {unpublished data only}
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- NCT04025866. The addition of aerobic training to conventional rehabilitation after proximal femur fracture: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT04025866 (first received 19 July 2019).
Dallimore 2015 {published data only}
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- Dallimore KM. Personal communication. Email to: S Dyer 19 May 2017.
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- Dallimore RK, Asinas-Tan M, Chan D, Hussain S, Willett C, Zainuldin R. A randomised double-blinded clinical study on the efficacy of multimedia presentation using an iPad for patient education of postoperative hip surgery patients in a public hospital in Singapore. Annals of the Academy of Medicine Singapore: Singapore Health and Biomedical Congress (SHBC); 2015 October 2-3 2015;44(10):S58. - PMC - PubMed
Invernizzi 2019 {published data only}
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- Invernizzi M, Sire A, D'Andrea F, Carrera D, Reno F, Migliaccio S, et al. Effects of essential amino acid supplementation and rehabilitation on functioning in hip fracture patients: a pilot randomized controlled trial. Aging Clinical and Experimental Research 2019;31(10):1517-24. - PubMed
Kalron 2018 {published data only}
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- Kalron A, Tawil H, Peleg-Shani S, Vatine JJ. Effect of telerehabilitation on mobility in people after hip surgery: a pilot feasibility study. International Journal of Rehabilitation Research 2018;41(3):244-50. - PubMed
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- Karlsson Å, Berggren M, Gustafson Y, Olofsson B, Lindelöf N, Stenvall M. Effects of geriatric interdisciplinary home rehabilitation on walking ability and length of hospital stay after hip fracture: a randomized controlled trial. Journal of the American Medical Directors Association 2016;17(5):464 e9-e15. - PubMed
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- Karlsson A, Lindelof N, Olofsson B, Berggren M, Gustafson Y, Nordstrom P, et al. Effects of geriatric interdisciplinary home rehabilitation on independence in activities of daily living in older people with hip fracture: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2020;101:571-8. - PubMed
Kim 2020 {published data only}
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- Kim P, Lee H, Choi W, Jung S. Effect of 4 weeks of anti-gravity treadmill training on isokinetic muscle strength and muscle activity in adults patients with a femoral fracture: a randomized controlled trial. International Journal of Environmental Research and Public Health 2020;17(22):1-9. - PMC - PubMed
Lahtinen 2017 {published data only}
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- Lahtinen A, Leppilahti J, Vähänikkilä H, Harmainen S, Koistinen P, Rissanen P, et al. Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities. Clinical Rehabilitation 2017;31(5):672-85. - PubMed
Laiz 2017 {published data only}
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- Laiz A, Malouf J, Marin A, Longobardi V, Caso J, Farrerons J, et al. Impact of 3-monthly vitamin D supplementation plus exercise on survival after surgery for osteoporotic hip fracture in adult patients over 50 years: a pragmatic randomized, partially blinded, controlled trial. Journal of Nutrition, Health & Aging 2017;21(4):413-20. - PubMed
Lehrl 2012 {published data only}
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Scheffers‐Barnhoorn 2019 {published data only}
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- Scheffers-Barnhoorn MN, Van Eijk M, Van Haastregt JC, Schols JM, Van Balen R, Van Geloven N, et al. Effects of the FIT-HIP intervention for fear of falling after hip fracture: a cluster-randomized controlled trial in geriatric rehabilitation. Journal of the American Medical Directors Association 2019;20(7):857-65. - PubMed
Taraldsen 2015 {published data only}
Wang 2020 {published data only}
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- Wang K, Fan J, Li X, Yang S, Ren D, He C. Long-term intensive family rehabilitation training for postoperative functional recovery in elderly hip fracture patients. Chinese Journal of Tissue Engineering Research 2020;24(14):2158-63.
Wu 2010 {published data only}
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- Wu XB, Zhang Q, Song LX, Zhang YZ. Effect of early rehabilitation on the hip joint function in patients with comminuted posterior wall fractures of the acetabulum after internal fixation. Journal of Clinical Rehabilitative Tissue Engineering Research 2010;14(4):732-5.
References to studies awaiting assessment
Che 2020 {unpublished data only}
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- Che X, Zhang X, Li H, Xu P, Zhao D. Therapeutic effect of early rehabilitation training on the recovery of limb function in elderly patients with femoral neck fracture [Abstract]. Basic and Clinical Pharmacology and Toxicology 2020;127 (Suppl 3):300.
Wu XY 2019 {published data only}
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- Wu WY, Xu WG. Evaluation of the effect of early total weight-bearing training after cementless total hip arthroplasty. Chinese Journal of Tissue Engineering Research 2019;23(18):2827-32.
References to ongoing studies
ACTRN12617001345370 {unpublished data only}
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- ACTRN12617001345370. Recumbent bike riding for people with fractured neck of femur: a feasibility trial. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373575 (first received 1 September 2017).
ACTRN12618000903280 {unpublished data only}
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- ACTRN12618000903280. The feasibility of prescribing a walking program to improve physical functioning of people living in the community after hip fracture [The feasibility of prescribing a walking program to improve physical functioning of people living in the community after hip fracture: a phase II randomised controlled trial]. anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618000903280 (first received 25 May 2018).
Heiberg 2017 {unpublished data only}
ISRCTN32476360 {unpublished data only}32476360
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- ISRCTN32476360. Effects of transcutaneous electrical nerve stimulation on acute postoperative pain intensity, ambulation and mobility after hip fracture: a double-blinded, randomized trial. www.isrctn.com/ISRCTN32476360 (first received 05 July 2018). [DOI: 10.1186/ISRCTN32476360] - DOI
jRCTs052190018 {unpublished data only}
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- jRCTs052190018. A pilot study of training using the Balance Exercise Assist Robot for the patients after the proximal femoral fractures surgery at the convalescent rehabilitation ward. rctportal.niph.go.jp/en/detail?trial_id=jRCTs052190018 (first received, unknown. date registered 17 May 2019).
jRCTs052190022 {unpublished data only}
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- jRCTs052190022. A preliminary study of training using the Balance Exercise Assist Robot for the patients after the proximal femoral fractures surgery at the community-based integrated care ward. rctportal.niph.go.jp/en/detail?trial_id=jRCTs052190022 (first received, unknown. date registered 27 May 2019.
KCT0004122 {unpublished data only}
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- KCT0004122. A randomized feasibility study of inpatient rehabilitation using advanced techniques in older people with fragility hip fracture. cris.nih.go.kr/cris/search/detailSearch.do?seq=14311&search_page=L&searc... (first received: unknown; approved 17 June 2019).
Lima 2016 {unpublished data only}
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NCT01129219 {unpublished data only}
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- NCT01129219. Observation and progressive strength training after hip fracture. clinicaltrials.gov/ct2/show/NCT01129219 (first received 24 May 2010).
NCT01174589 {unpublished data only}
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- NCT01174589. Training of patients with hip fracture. clinicaltrials.gov/show/NCT01174589 (first received 3 August 2010).
NCT02305433 {unpublished data only}
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- NCT02305433. Effects of long-term intensive home-based physiotherapy on older people with an operated hip fracture or frailty (RCT) (HIPFRA) [Effects of long-term intensive home-based physiotherapy on older people with an operated hip fracture or frailty (RCT)]. clinicaltrials.gov/ct2/show/NCT02305433 (first received 2 December 2014).
NCT02407444 {unpublished data only}
-
- NCT02407444. Treatment efficacy of leg cycling as part of physiotherapy treatment in elderly patients with hip fracture [A comparison of two physiotherapy treatment protocols, with and without cycling training, in elderly patients with hip fractures at their subacute stage following surgery]. clinicaltrials.gov/ct2/show/NCT02407444 (first received 3 April 2015).
NCT02815254 {unpublished data only}
-
- ANCT02815254. The effect of exercise in elderly hip fracture patients: a clinical randomised trial. clinicaltrials.gov/ct2/show/NCT02815254 (first received 28 June 2016).
NCT02938923 {unpublished data only}
-
- NCT02938923. Starting a testosterone and exercise program after hip injury (STEP-HI) [Combining testosterone therapy and exercise to improve function post hip fracture]. clinicaltrials.gov/ct2/show/NCT02938923 (first received 19 October 2016).
NCT03030092 {unpublished data only}
-
- NCT03030092. Maximal strength training following hip fracture surgery: impact on muscle mass, balance, walking efficiency and bone density. clinicaltrials.gov/ct2/show/NCT03030092 (first received 24 January 2017).
NCT04095338 {unpublished data only}
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- NCT04095338. Assistive robotic in the elderly: innovative models in the rehabilitation of the elderly with hip fractures through technological innovation. clinicaltrials.gov/ct2/show/NCT04095338 (first received 19 September 2019).
NCT04108793 {unpublished data only}
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- NCT04108793. Effectiveness of home-based rehabilitation program in minimizing disability and secondary falls after a hip fracture: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT04108793 (first received 30 September 2019).
NCT04207788 {unpublished data only}
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- NCT04207788. HIP fracture rehabilitation programme (HIP-REP) [HIp fracture rehabilitation programme for elderly with hip fracture]. clinicaltrials.gov/ct2/show/NCT04207788 (first received 23 December 2019).
NCT04228068 {unpublished data only}
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- NCT04228068. The stronger at home study [A home-based rehabilitation program for patients with hip fracture: a pilot randomized trial]. clinicaltrials.gov/ct2/show/NCT04228068 (first received 14 January 2020).
NTR6794 {unpublished data only}
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- NTR6794. Rehabilitation after hip fractures in elderly [COMplex Fracture Orthopedic Rehabilitation (COMFORT) - Real-time visual biofeedback on weight bearing versus standard training methods in the treatment of proximal femur fractures in elderly: a randomized controlled trial]. www.trialregister.nl/trial/6609 (date first received: unclear; date registered 20 October 2017).
UMIN000036379 {unpublished data only}
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- UMIN000036379. Randomized controlled trial with parallel design on the effects of maximum voluntary velocity training in patients after femoral neck fracture surgery. upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041346 (first received 02 April 2019).
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