Longer rehabilitation by six months helps elderly patients to more fully recover from hip fractures

Extending supervised outpatient rehabilitation by six months helps elderly patients more fully recover from hip fractures, according to the first controlled study of its kind. The study also showed for the first time that these patients, previously thought to be too frail for weight training, can benefit from progressive resistance exercise training.

The study, conducted by researchers at Washington University School of Medicine in St. Louis, challenges the current standard therapy. It will appear in the Aug. 18 issue of the Journal of the American Medical Association.

“Hip fractures are a very prevalent problem in the elderly, and research shows that most patients have significant difficulty performing daily activities even after the standard four to 16 weeks of home-based therapy,” says principal investigator Ellen F. Binder, M.D., assistant professor of medicine in the Division of Geriatrics and Nutritional Sciences and staff physician at Barnes-Jewish Hospital. “Our goal is to help elderly hip fracture patients live independently in their own homes for as long as possible, which is usually an important component of their quality of life.”

Typically, rehabilitation, covered by Medicare and most third-party insurance plans, involves up to 16 weeks of therapy conducted in the home, but most patients do not get referred to outpatient facilities after that.

Binder’s team randomly assigned 90 hip fracture patients who had just completed the standard course of acute therapy to one of two groups: One group received six months of supervised physical therapy and exercise training, while the other group received instructions and brief training in exercises to be performed at home for six months.

The supervised rehabilitation program consisted of two consecutive phases that lasted a total of 6 months. Participants attended three exercise sessions per week on site at Washington University in both phases of the program.

Exercises in the first phase were conducted in a group format and focused on flexibility, balance, coordination, motor speed and, to a modest extent, strength. Therapists adapted exercises for each individual’s needs and made them progressively more difficult as patients improved.

During the second exercise phase, progressive resistance training using weight machines was added.

The home-based therapy group received a prescribed home-exercise program based on standard approaches to hip-fracture rehabilitation. After a one-hour training session, participants were instructed to perform a series of exercises on their own at home at least three times per week, with one follow-up training session per month. This group did not perform any weight-training exercises.

Participants in both groups were prescribed standard dosages of calcium and vitamin D replacement therapy.

The researchers not only took measurements of the participants’ muscle strength, balance and flexibility, they also evaluated functional improvements using standardized tests of daily tasks and physical abilities directly relevant to mobility. They also took measurements of bone density.

Participants who received supervised rehabilitation therapy that included resistance training improved on functional, strength, balance, mobility and quality of life measures significantly more than those who received a prescribed, home-based regimen. In addition, for participants in both groups, bone density did not decline over the course of the study. Previous research has shown that bone density declines up to four percent in the first year after a hip fracture.

“The most important thing about our study is that we show functional improvements,” Binder says. “It’s great to improve strength and balance, but the key is whether that translates into being able to do more with less outside help.”