Background: Recovery following hip fractures is limited due to pre-existing falls risk factors, deconditioning post injury and surgery.

Objectives: This study evaluates the effectiveness of group outpatient physiotherapy for community dwelling adults following hip fracture.

Method: An individualised programme of task-specific training was designed. Client’s attended   six one-hour group sessions.  Measures included step length, step test, single leg stance (SLS), sit-to-stand (STS) and the six-minute walk test (6MWT). This was completed initially and after six weeks.

Results: Step lengths and step test (p<0.005) for both legs improved significantly after the training. The 6MWT, chair height for STS and SLS increased (p<0.05) and approached but did not reach statistical significance.

Conclusion: This programme is effective in improving mobility after hip fracture

This project aimed to review an exercise class for clients following a fractured NOF. The goals were to improve function post-op and address pre-morbid falls risk factors.

From 65 years, hospitalised fall related injury rates increase exponentially. Fractures account for 89% of admissions (with 50% of these of the hip) (Peel et al 2002). These fractures are extremely debilitating with few clients returning to their pre-fracture level of mobility and function.

There is insufficient evidence to determine the effects of any particular mobilisation strategy or program started in the rehabilitation period after hip surgery (Handoll et al 2008). Clearly, intervention is required to restore and enhance mobilisation in older people after surgery and for this reason we decided to investigate our current outpatient treatments for this clientele.

The risk of having a fracture is 1.6/1000 men or 3.6/1000 women. The risk of having a second fracture is 15/1000 men and 22/1000 women (Schroder et al 1993).

The one-year survival rate for clients following a NOF fracture is around 55.9% (Kyo et al 1993) to 78.3% (Katelaris et al 1996). For those that survive most do not return to their pre-fracture level of independence (Cumming et al 1996). At 12 months post fracture approximately 50% of patients are unable to walk across a small room independently and 90% are dependent in climbing stairs (Magaziner et al 2000).

The cost for community dwelling older adults increases from $18,523-$20,928 (USD) per year prior to the fracture to $37,250 per year post fracture (Brainsky et al 1997). A large proportion of these costs are due to nursing home admissions that could possibly be prevented with outpatient care.

By 2021 the Australian population of adults >65 years old is projected to increase to 4.02-4.05 million. This equates to an estimated 89% increase in hip fractures (Pocock et al 1999). If 27% of hip fractures (versus 5% controls without hip fractures) are admitted to an aged care institution, the increased demand on the health care budget is immense (Cumming et al 1996).

A person's quality of life correlates with decreased level of physical function and lack of social engagement (Degenholtz et al 2006). We need solutions to prevent and treat the increasing number of hip fractures.

The literature shows inconclusive evidence regarding therapy following a fractured NOF. A number of well-designed trials show that extended outpatient rehabilitation including progressive resistance and functional training in a supervised environment is effective at improving physical function and mobility in our target population. Improvements occurred in muscle strength, gait speed and balance (Binder et al 2004). Supervised high intensity exercises and progressive functional training were also effective (Hauer et al 2002; Host et al 2007).

From this evidence an individualised programme for each client was set up and performed in a group setting for six weeks. The groups were supervised by 2-3 physiotherapists and would have up to eight attendees. Task-specific training was performed addressing problems like lateral pelvic shift and hip extension during STS and walking.

Balance tasks included SLS practice, dual tasking and obstacle courses. Strengthening and stretching tasks included STS, leg press, and hip extension over the side of the bed. Endurance tasks included exercise bike, treadmill and stepper.

Clients completed an individualised home exercise program (HEP) during the period. Some clients were referred to a dietician or occupational therapist to help the client remain at home. Clients attended six one-hour sessions before they were re-assessed. Clients were discharged with a HEP and details for further classes if appropriate.

The measurements recorded before and after training included:

• The 6MWT 
• Step length 
• STS chair height without using hands
• The step test 
• SLS

All tests used were valid and reliable. They were quick and easy for the Physiotherapist to administer as they used readily available equipment and provided immediate feedback about the client's abilities. The mean of the above measurements were performed using two tailed, paired t-tests. An alpha level of 0.01 was used in all analyses.

Step lengths and step test for both legs improved significantly after the training (p< 0.001, Table2). The 6MWT, Chair height for STS and SLS increased but the increase was small (less than 10% of the pre-training mean) and approached but did not reach statistical significance (see table 2, p values). When rehabilitation is organised in a class setting costs are comparatively low.

To sustain change:

• Five physiotherapists are trained in the program.
• There is an information folder containing current research, and assessment/exercise sheets. 
• Yearly reviews of the evidence are planned to see what changes to the exercise and assessment program are required.
• Clients are given a HEP to complete during the class period encouraging independence, and updated to continue on discharge.
• Advice is given on maintaining levels of function after discharge
• Contact details are given if further treatment required.
• Clients will continue to be referred other services including occupational therapy and dietetics as required.

Further studies are being considered including following up clients six weeks post discharge from the class to see if improvements are maintained at a clinically significant level. This class is easy to set-up and run, cost-effective and able to be carried out in hospitals with a small number of staff.

The evidence currently shows that prevention of NOF fractures is possible with balance, diet and mobility training in those with falls risk factors. For this reason falls prevention strategies should be reviewed, implemented and maintained in all GWAHS communities.

Patient Safety & Clinical Quality Manager, Clinical Governance Unit
Greater Western Area Health Service
Ph: 02 6393 3559