Question: In community-dwelling frail elderly patients with hip
fracture, does an extended physical therapy program that includes progressive
resistance training improve physical function and reduce disability more than
low-intensity home exercise?
Design: Randomized (allocation
concealed)*, blinded (outcome
assessors), controlled trial with 6-month follow-up.
Information provided by author.
Setting: St. Louis, Missouri.
Patients: 90 community-dwelling patients =65 years of age (mean
age, 81 y; 74% women) who were discharged from standard physical therapy
prescribed for a recent fracture of the proximal part of the femur. Other
inclusion criteria were an evaluation within 16 weeks of hip fracture, a
modified Physical Performance Test (PPT) score of between 12 and 28, and a
difficulty or need for assistance with =1 activity of daily living (ADL).
Exclusion criteria included pathological fracture, bilateral femoral fracture,
or previous contralateral femoral fracture; dementia, cognitive impairment, or
a Short Blessed Test score of =11; an inability to walk 50 feet (15.24
meters) with use of an assistive device; visual or hearing impairments;
cardiopulmonary or neuromuscular disease that would preclude participation in
a weighttraining program; conditions that would not improve with exercise
training; a recent course of medication for osteoporosis or recent hormone
therapy; or a life expectancy of <1 year. Although follow-up was 94%, 24%
of patients did not complete the extended program.
Intervention: Patients were allocated to an extended physical
therapy program (n = 46) or low-intensity home exercises (n = 44). The
training program involved two 3-month phases. In phase 1, a physical therapist
led a group of 2 to 5 patients three times weekly in exercises (45 to 90 min)
designed to enhance flexibility, balance, coordination, movement speed, and
muscle strength. The 22 different exercises became progressively more
difficult and were modified for each person's physical impairments. When
patients could safely do so, they also exercised with use of a stationary
bicycle and treadmill. In phase 2, progressive resistance training with use of
a weight-lifting machine was added to a shortened version of the phase-1
exercise regimen. Exercises included knee extension, knee flexion, seated
bench press, seated row, leg press, and biceps curl. Home exercise involved 9
of the 22 core exercises in phase 1 of the physical therapy program and was
focused on flexibility and did not progress in difficulty. Patients were asked
to do the exercises at home 3 times per week. They were not prohibited from
other types of exercise except weight training.
Main outcome measures: Change from baseline in PPT, Functional
Status Questionnaire (FSQ), and ADL scores. Secondary outcomes were changes in
muscle strength, gait, balance, body composition, and quality of life.
Main results: Analysis was by intention to treat. Patients in the
physical therapy group had greater improvements from baseline in PPT and FSQ
scores than did patients in the home exercise group
(Table). The groups did not
differ with regard to changes in ADL scores. Patients who received physical
therapy also had greater improvements in knee extension, fast walking speed,
balance, single-limb stance time, Hip Rating Questionnaire score, and the
Change in Health and Physical Function subscales of the Short-Form (SF)-36
score.
Conclusions: For community-dwelling frail elderly patients with hip
fracture, an extended physical therapy program that included progressive
resistance training improved physical function and quality of life and reduced
disability more than did low-intensity home exercise.
Previous studies of strength-training programs after hip fracture have not
shown as much improvement in function. This randomized controlled trial by
Binder and colleagues shows that an elaborate, supervised strength-training
program is more effective than an independent home-exercise program for frail
octogenarian patients after hip fracture.
A question not addressed by this study is whether the effectiveness of the
program will continue beyond 6 months. Regression might be expected if
maintenance exercises were discontinued. Furthermore, the authors offer no
information about the actual per-patient cost of the strength-training
program. The extended rehabilitation program is well beyond the scope of the
typical United States Medicare guidelines for rehabilitation after hip
fracture. Future studies might determine the minimum essential aspects of an
extended rehabilitation program for patients after hip fracture. Costs would
be reduced if exercise groups that are conducted in neighborhood gyms and led
by trainers or coaches instead of physical therapists were found to be safe
and effective for this population. A less frequent, supervised but progressive
home strength-training program might also be effective for some patients.
For the surgeon whose older frail patient fails to achieve his or her
desired outcome at 3 to 4 months after hip fracture, this study offers
evidence that significantly improved function, fitness, and quality of life
for selected, noninstitutionalized patients can be achieved by faithful
participation in a well-designed and persistent exercise program that includes
strength training. However, it would be impractical and perhaps wasteful of
scarce resources to recommend this program for all patients after hip
fracture.