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Meta-analysis
ACE Report #4204

Extended rehabilitation programs improve physical function after hip fracture


Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A

Extended Exercise Rehabilitation After Hip Fracture Improves Patients' Physical Function: A Systematic Review and Meta-Analysis

Phys Ther. 2012 Nov;92(11):1437-51. doi: 10.2522/ptj.20110274. Epub 2012 Jul 19.

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OE EXCLUSIVE

Mohammad A. Auais (International Centre for Health Innovation, Western University) discusses the effect of extended exercise rehabilitation after hip fracture.

Synopsis

This meta-analysis included 13 randomized controlled trails (1107 fractures) that assessed the effects of an extended exercise rehabilitation program on the physical functioning of patients with hip fractures. The results of the meta-analysis and systematic review indicate that an extended exercise rehabilitation program improves knee extension strength, balance, physical performance based tests, the Timed "Up and Go" test, and fast gait speed when compared with a standard rehabilitation program for patients with hip fractures.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
Canadian Institutes of Health Research
Conflicts:
None disclosed

Risk of Bias

10/10

Reporting Criteria

19/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

4/4

Analysing Data

4/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Hip fractures are the most serious form of osteoporotic fracture. When these fractures are sustained, the goals of treatment include returning patients to a pre-event functional level and preventing recurrent fractures. Unfortunately, only 50% of survivors regain their former levels of mobility. Interest in the effects of an extended rehabilitation period has increased due to the fact that functional status of patients seem to decline after rehabilitation services are stopped. However, the long-term effects of this program are unclear, as findings have been conflicting. This study aimed to determine whether an extended exercise rehabilitation program offered improvement over the regular rehabilitation program with regard to the physical functioning of patients who have undergone surgical repair of a hip fracture.

What was the principal research question?

Does an extended rehabilitation program improve the physical function of patients who have undergone surgical repair of a hip fracture when compared to usual care?

Study Characteristics -
Data Source:
A search of the Cochrane libraries, PubMed, CINAHL, PEDro, and EMBASE were conducted from inception until April 2012. The Current Controlled Trials Registry, the ClinicalTrials.gov registry, the Australian New Zealand Clinical Trials Register, weekly downloads from AMEDEO of "fracture" articles in new issues of 15 journals, the bibliographies of all eligible articles and related reviews, and recurrent conference proceedings were also searched.
Index Terms:
(post acute OR home based OR home health care OR home rehab* OR post-rehab* OR post operation OR transfer care OR home physical therapy OR home program OR Outpatient* Service* OR After Care OR Ambulatory Care Facilities OR community based OR community dwelling OR community health services OR community program OR Post Discharge OR Outpatients [MeSH] OR out-patient* OR outpatient* OR Ambulatory Care) [MeSH] AND (Physical therapy OR Physical Therapy Modalities [MeSH] OR therapy OR extended rehabilitation OR physiotherapy OR physical therapy service* OR Exercise [MeSH] OR exercise OR Exercise Therapy [MeSH] OR Rehabilitation [MeSH] OR rehab* OR rehab) [subheading] AND (Hip Fractures) [MeSH] AND Randomized Controlled Trial) [ptyp].
Study Selection:
Inclusion criteria were randomized controlled trials that included community dwelling patients who had sustained a hip fracture, an intervention that included an extended home or community-based exercise rehabilitation program that was extended for more than a regular rehabilitation period, and outcomes reflecting physical function constructs.
Data Extraction:
Identification of studies for inclusion was conducted by two independent reviewers. Discrepancies were discussed and if a consensus was not reached, a third reviewer was consulted.
Data Synthesis:
13 randomized controlled trials were identified using the search criteria that included a total of 1107 fractures. The Hedges g effect size (ES) and 95% confidence intervals (CI) were used to describe the effect of each intervention and the standard Q and I squared statistics were used to determine heterogeneity among comparable trials. Data were pooled across studies (and reported under the random effect theory) when similar outcomes were presented.

What were the important findings?

  • Extended rehabilitation programs significantly improved knee muscle strength on the affected (ES=0.47, 95% CI=0.27 to 0.66, p<0.001) and nonaffected side (ES=0.45, 95% CI=0.16 to 0.74, p=0.002), balance (ES=0.32, 95% CI=0.15 to 0.49, p<0.001), physical performance-based tests (ES=0.53, 95% CI=0.27 to 0.78, p<0.001), timed "Up and Go" test (ES=0.83, 95% CI=0.28 to 1.4, p=0.003), and fast gait speed (ES=0.42, 95% CI=0.11 to 0.73, p=0.008) when compared to standard rehabilitation programs.
  • Results from the 6 Minute Walk Test (ES=0.22, 95% CI=0.12 to 0.57, p=0.21), normal gait speed (ES=0.16, 95% CI=0.17 to 0.48, p=0.35), activities of daily living (ES=0.14, 95% CI=0.07 to 0.35, p=0.2), instrumental activities of daily living (ES=0.2, 95% CI=0.07 to 0.48, p=0.14), and the physical function subscale of the 36-Item Short-Form Health Survey (ES=0.2, 95% CI=0.03 to 0.44, p=0.09) were not significantly different between the patients that completed extended rehabilitation programs and the patients that completed standard rehabilitation programs.

What should I remember most?

The data suggests that extended rehabilitation programs result in significantly greater improvement than standard rehabilitation programs with respect to knee muscle strength on the affected and nonaffected side, balance, physical performance-based tests, timed "Up and Go" test, and fast gait speed among patients who required surgical intervention for a fracture of the hip.

How will this affect the care of my patients?

Extended rehabilitation programs may improve physical functioning of the hip when compared to standard rehabilitation programs for hip fractures. However, in order to reach a definite conclusion regarding extended rehabilitation programs, randomized controlled trials with larger sample sizes are required, as well as cost analyses.

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