Review of the Impact of Exercise Interventions on Function Post Hip Fracture and Recommendations for Future Interventions

Barbara Resnick, Gregory E. Hicks, Denise Orwig, Janet Yu-Yahiro and Jay Magaziner

Abstract

Hip fractures continue to be a significant problem among older adults, and approximately half of those who are able to walk independently before their fracture are not able to do so by 12 months post fracture. In addition, approximately 25% of individuals post hip fracture can not perform all basic activities of living independently. Exercise interventions have been used as a strategy to improve recovery among older adults following a hip fracture. Unfortunately, even those exposed to exercise have not completely recovered basic activities of living. The authors review 12 published exercise intervention studies implemented with older adults post hip fracture, as well as recent findings from the Baltimore Hip Studies. In considering the results obtained from the studies, the Functional Training Program Post Hip Fracture (FTPPHF) was developed and is described.

Introduction

By the year 2030, over 650,000 hip fractures will occur annually in older adults living in the United States and as many as one third of these individuals will die within the first year of their fracture (Agency for Health Care Policy and Research, 1999; Cauley, Thompson, Ensrud, Scott, & Black, 2000; Haentjens, Autier, Barette, & Boonen, 2001; Johnson, Kramer, Lin, Kowalsky, & Steiner, 2000; Rose & Maffulli, 1999; Van Balen, et al, 2001). Unfortunately approximately 25% of individuals who sustain a hip fracture have significant functional decline in activities of living (AL) such as bathing and dressing (Magaziner, et al, 2000). Among these individuals, 20% need help with lower extremity dressing and 90% require help climbing the stairs (Magaziner, Simonsick, Kashner, Hebel & Kenzora, 1990). Individuals who have had a hip fracture are noted to be impaired in their ability to independently rise from an armless chair or to step symmetrically (Gruber-Baldini, et al., 2003), and approximately 38% to 50% need assistance to walk or are unable to walk at 12 months post hip fracture (Binder, et al, 2004; Mangione, Craik, Tomlinson & Palombaro, 2005).

Researchers conducting longitudinal studies have shown that recovery of function continued for a year or more following a hip fracture (Magaziner et al., 2000). Unfortunately, half of those who were able to walk independently before their fracture were not able to do so after the fracture (Gruber-Baldini et al., 2003). In one cohort of 674 community dwelling older adults individuals living in the United States function post hip fracture declined such that they needed help with four lower extremity ALs. The activities in which the greatest majority of participants needed assistance included climbing stairs (90.5%), shower and bath transfers (83%), walking one block (52.5%), car transfers (50.2%), and getting up from an armless chair (54.4%) (Magaziner et al, 2000).

Multiple approaches have been used to optimize recovery post hip fracture such as: (1) multidisciplinary clinical pathways; (2) early home discharge with home therapy; and (3) high intensity occupational and physical therapy in inpatient and outpatient settings; (Chudyk, Jutai, Petrella & Speechley, 2009). There are wide variations in practices and study designs making it difficult to compare approaches and establish best practices for recovery post hip fracture. There is some evidence, however, that exposing older adults post hip fracture to exercise interventions will improve recovery (Chudyk et. al., 2009). Regular exercise, even at low levels of intensity, improves physical fitness in older adults. In meta-analyses of exercise intervention studies strength training and walking programs improved function, enhanced strength and aerobic capacity, and prevented disability (Sherrington & Lord, 1997; Tsauo, Leu, Chen & Yang, 2005). In addition, exercise improved overall health (Sherrington, Lord & Finch, 2004), decreased bone and joint problems (Carmeli, Sheklow & Coleman, 2006; Sherrington, Lord & Herbert, 2003), decreased falls (Hauer, Specht, Schuler, Bartsch & Oster, 2002), improved endurance (Trudelle-Jackson & Smith, 2004), improved sleep (Jones, Jakobi, Taylor, Petrella,& Vandervoort, 2006; Resnick et al, 2007), improved mood and quality of life (Resnick, Orwig, Inguito & Xi, 2007) and improved balance (Distefano, Clark & Padua, 2009).

Exercise Interventions Post Hip Fracture

A review of 12 studies (see Appendix A) focused on testing exercise interventions with older adults post hip fracture was done. Reviewers concluded there was limited support for the effectiveness of exercise with regard to basic performance of ALs. Our recent work (Resnick, et al, 2007) implementing a 12 month home based exercise program post hip fracture similarly did not result in improvements in basic ALs beyond that achieved by those in the no treatment control group. The purpose of this review is to describe the exercise interventions implemented and subsequent outcomes from these studies and consider future interventions that might positively influence performance of ALs among older adults who have sustained a hip fracture.

Binder and her team of investigators (2002) completed a randomized controlled trial in which 119 community dwelling older adults were randomized to a supervised exercise training program (n=69) provided by a physical therapist versus a low-intensity home exercise program (n=50). The supervised exercise intervention incorporated strengthening exercises focused on 22 muscle groups. In addition, a stationary bike or treadmill was initiated when the participant was ÒableÓ. Progressive resistance was added to the training program at 6 week intervals using six basic exercises (knee extension, knee flexion, seated bench press, seated row, leg press and biceps curl). Participants started with 1-2 sets of 6-8 repetitions at 65% of their one repetition maximum [(1-RM) which is the maximum amount of weight one can lift in a single repetition for a given exercise], and progressed to 3 sets of 8 to 12 repetitions at 85 to 100% of the initial 1-RM. Participants were exposed to 72 (87%) of the total number of possible supervised sessions. Although scores and p values were not reported in the published data, it was noted that there was no improvement in scores from the Older American Resources and Services (OARS) questionnaire (Fillenbaum & Smyer, 1981) and the authors concluded there was no treatment effect on ALs.

Similarly, Mangione et al (2005) tested a supervised, facility based intensive exercise program for older adults post hip fracture. Their program was also implemented by a physical therapist and continued for a 12 week period, with a total of 20 visits. A total of 33 older adults living in the community were randomly assigned to a resistance training group (n=17), an aerobic training group (n=13) or a control group (n=11). Resistance activities focused on bilateral hip extensors and abductors, and plantar flexors. A portable resistive exercise machine and the resistance of the individual's body weight were use for resistive activities. Progression occurred at 2 week intervals and was based on the participants' ability to complete 8 repetitions on a given weight. Three sets of 8 repetitions were done during the training activity. Aerobic activity was performed for 20 minutes. There was 98% adherence to the classes. Based on the Barthel Index (Mahoney & Barthel, 1965) and Instrumental Activities of Daily Living Questionnaire (IADL) (Lawton & Brody, 1969) there was no treatment effect based on either outcome measure. Mean baseline scores on the Barthel Index were 96.8 (SD=9.0) for the aerobic group, 95.0(SD=5.9) for the resistance training group, and 92.0 (SD=10.3) for the control group. Scores post exercise were not reported in the published manuscript. The high baseline scores, however, mean that there was likely a ceiling effect in terms of measuring AL outcomes. A high total score for complete independence on the Barthel Index is 100, thus the mean scores in the 90's left little opportunity for participants to improve. IADL scores at baseline were lower with a mean score of 5.5 (SD=2.4) for the aerobic training group, 3.9 (SD=2.5) for the resistance training group, and 4.2 (SD=3.9) for the control group. IADL scores range from 1 to 8 with 8 indicative of independent IADL function.

Sherrington, Lord, and Herbert (2003) tested an in-patient exercise program implemented by a physical therapist over a 4 month period. A total of 80 older adults were randomized to non weight-bearing (n=39) or weight-bearing exercise groups (n=41). There was 96% adherence to these sessions which focused on a stepping exercise. A functional measure that also includes some timed activities, the Physical Performance Mobility Exam (PPME), did not support a treatment effect across any ALs. Scores for the nonweight bear group ranged from 4.5 (SD=2.5) at baseline to 6.8 (SD=2.8) post intervention and for the weight bear group they ranged from 5.4 (SD=3.0) at baseline to 7.5 (SD=2.7) post exercise (p=.74).

Sherrington, Lord, and Herbert (2004) also tested home based exercise activities that included stepping. The study done in 2004 included 120 older adults living in the community and these individuals were randomized to one of 3 groups: A weight-bearing exercise (n=40), a non-weight bearing exercise (n=40) and a control group (N=40). The intervention was similar to the inpatient intervention with the exercise program implemented by a physical therapist. Adherence to the exercise activities was 80-89% at 1 month and decreased to 69-73% adherence at 4 months. As noted in the inpatient study, the home based exercise intervention (Sherrington, et al, 2004) did not demonstrate a treatment effect on ALs based on PPME scores (scores range from 0 to 12 with higher scores indicating better function). In the weight bear group the mean PPME score at baseline was 9.4 (SD=2.1) and this increased to 10.3 (2.3) post treatment, the mean baseline score for PPME in the non weight bear group was 9.5 (2.0) and this increased to 10.5 (SD=1.5) post treatment, and the control group was 9.8 (1.8) at baseline and increased to 10.1(SD=1.8) post treatment.

Tinetti and her research team (2002) tested a 6 month physical and occupational therapy initiated intervention that was based on individual needs of participants. A randomized controlled trial was done in which 304 older adults living in the community were randomized to systematic multicomponent rehabilitation (SMR, n=148) versus usual care (UC, n=156). In the SMR group, an occupational therapist implemented a functional training program that focused specifically on ALs and IALs such that tasks were broken down and intervention directed to areas in which the individual was unable to complete the task. The OARS was used to measure basic ALs (Fillenbaum & Smyer, 1981) and IALs using self report (Lawton & Brody, 1969). Participants were exposed to 72% of the intended sessions and there was no significant treatment effect on ALs. At baseline 131 (89%) of the SMR group and 136 (87%) of the participants in the UC group were independent in all selfcare and at 12 months 98 (73%) of those in the SMR group and 95 (69%) of those in the UC group were independent in all self care (p=.49). At baseline 30 (20%) of the SMR group and 35 (22%) of the UC group were independent with IALs and at 12 months this decreased some to 25 (19%) of those in the SMR group and 34 (25%) of those in the UC group (p=.23).

The intervention by Tsauo and his research team (2005) was the only intervention to have a small treatment impact on ALs. A group of 54 older adults post hip fracture were randomized to a 3 month home-based physical therapy group (n=28) or usual care (n=26). The home based intervention focused on functional training. Despite only 50% exposure to the intended number of sessions, the participants in the treatment group demonstrated improvement in ALs based on Harris Hip Scores. Harris Hip Scores, which include ALs such as walking and putting on shoes, were low in the treatment group at baseline with a mean of 58.6 (SD=8.5) and increased to 90.1 (SD=5.4) at the end of the intervention and those in the control group increased from 54.6 (SD=14.5) at baseline to 77.4 (SD=10.0) post intervention (p<.01). Harris Hip scores range from 0 to 100 with higher scores indicative of better function. The remaining studies that implemented exercise interventions post hip fracture (Hauer, et al, 2002; Jones et al, 2006; Peterson, Ganz, Allegrante & Cornell, 2004; Sherrington & Lord, 1997) listed in Appendix A did not measure ALs.

Additional Lessons Learned from the Baltimore Hip Studies (BHS)

The Baltimore Hip Studies (BHS) include a series of 6 studies that recruited approximately 2500 older adults post hip fracture over the past 25 years. Two of the recently completed studies were randomized controlled trials that tested a home based exercise program. These studies, BHS-4 and BHS-5, have been described in detailed elsewhere (Resnick, et al, 2007). Briefly BHS-4 and BHS-5 tested the impact of the Exercise Plus Program, a home based program that combined an exercise and motivational intervention. Outcomes focused on exercise behavior and recovery post hip fracture. A combined total of 389 female hip fracture patients (BHS-4 N = 180 and BHS-5 N = 209), 65 years of age and older who were communityÂ-dwelling at the time of fracture were consented within 15 days post hip fracture. The exercise component of the Exercise Plus Program was implemented by exercise trainers and included an aerobic exercise program using a Stairstep (Yu-Yahiro et al, 2009), a comprehensive strengthening program that covers the main muscle groups relevant to hip fracture recovery, and stretching exercises (these were part of the warm up and cool down periods). Participants were encouraged to perform aerobic activity at least three days per week and strength training two days per week for 30 minutes.

Function was measured at baseline, 2, 6 and 12 months post fracture and included a subjective report of ALs using a modified form of the Functional Status Index (Jette, 1980) revised to specifically address ALs relevant to patients post hip fracture.

Table 1 provides a description of ALs among one of the BHS cohorts, BHS-5. Mean function among participants, regardless of randomization status, improved over the course of the 12 month hip fracture recovery period (i.e. from 2 to 12 months). As noted in the majority of the prior exercise intervention studies with hip fracture patients, the participants in the BHS cohort did not return to baseline function. Table 2 provides the percentages by treatment group of individuals that needed human assistance with each functional activity. Based on repeated measure analyses there was not a statistically significant difference by group in terms of functional changes from baseline to 12 month follow up. Transferring into the bathtub and climbing stairs were the two areas in which there was the greatest percentage of individuals that did not regain function. On average, across all treatment groups, 29% (N = 155) at 12 months versus 11% (N=208) of the sample prior to hip fracture needed human assistance to climb stairs and 13% (N=155) at 12 months versus 7% (N=208) prior to hip fracture needed human assistance to transfer into the tub or shower. Similar findings were noted in the BHS-4 cohort (Resnick, Orwig, Inguito & Xi, 2007).

Next Steps in Optimizing Recovery of ALs Post Hip Fracture

All of the studies reviewed with hip fracture patients tested traditional resistance exercise activities which may have demonstrated some physical improvements among these individuals, but did not result in improvements or full recovery of ALs. To establish the optimal path to improve recovery of ALs in older adults after hip fracture, consideration should be given to the Nagi Recovery Model (Nagi, 1976) and the revised model developed by Verbrugge-Jette referred to as the Disablement Model (Verbrugge & Jette, 1994). According to these models, pathology leads to impairment (loss of anatomic structure and/or function) which then leads to functional limitation. Ultimately, disability occurs and the individual is unable to independently perform ALs. For example, if an older adult has an osteoporotic hip fracture, then functional limitations might include muscle weakness, range of motion (ROM) limitations and pain. Limitations in ALs might include inability to climb stairs or to transfer into and out of a car independently, which then might result in an inability to perform IALs such as obtaining groceries or doing the laundry. These recovery models have been further modified by Magaziner et al. (2000) for recovery in hip fracture patients. By examining the sequence by which recovery naturally occurs in hip fracture patients, Magaziner and colleagues (2000) hypothesized that in order to demonstrate recovery in AL disability, improvement in muscle strength, range of motion (ROM), balance, affective state and cognitive ability are all needed.

In rehabilitation research there is an underlying assumption that, by increasing muscle strength, ROM and decreasing pain, the individual will regain the ability to independently perform ALs. This philosophy assumes that there is a direct linear relationship between impairments and patient outcomes (Jette, Branch, & Berlin, 1990). Based on the prior work done with hip fracture patients (Hauer et al, 2002; Mangione et al, 2005; Resnick, et al, 2007; Sherrington & Lord, 1997; Sherrington et al, 2003; 2004; Tsauo et al, 2005) however, the assumption of a linear relationship is faulty in that improvements in impairments (e.g. muscle strength, ROM) do not necessarily lead to improvement in the ability to perform ALs. It is possible, therefore, that post fracture exercise interventions for hip fracture patients should incorporate a functional training approach that addresses underlying capability to do a specific ALs (e.g. the necessary muscle strength to stand from a chair) as well as practice performing the task.

Functional Training Programs

Functional training is a form of exercise that focuses on repetitive practice of a task to improve performance in a relevant AL. The theory behind functional training is that direct improvement of functional task performance (e.g., rising from a chair) is best achieved by practicing that task repeatedly rather than solely focusing on a specific impairment (e.g., quadriceps muscle weakness). In light of the models of disablement and recovery, the functional training approach moves the training focus from the organ/body system level (i.e., improving muscular impairments through strength training) to the person/society level (i.e. improving functional performance through task-specific training) (Krebs, Scarborough & McGibbon, 2007). In the non-hip fracture geriatric literature (Alexander et al, 2001; Bean, et al, 2004; De Vreede, Samson, van Meeteren, Duursma & Verhaar, 2005; Hoffmeyer, Nyquist, Medell & Koreishi, 2002; Krebs, Scarborough & McGibbon, 2007; Manini, Clark, Tray, Burke & Ploutz-Snyder, 2005), there is some evidence that functional training may improve performance of ALs. It is anticipated, therefore, that deficits in ALs commonly noted in hip fracture patients can be influenced by this principal of functional training by utilizing exercise activities that specifically address underlying abilities needed for task completion and by practicing these in real world settings.

The benefits of functional training have been best demonstrated in stroke rehabilitation (Chan, Chan & Au, 206). This work, referred to as Òmotor relearningÓ (Carr & Shepherd, 1987), focused on practicing the motor tasks involved within a context that is task or environment specific. Step one involved identification of the missing performance components of the task; step two initiated training using remedial exercises; step three incorporated training using functional task components; and step four transferred the skills practiced to ALs.

Based on our prior work (Magaziner et al, 1990; 2000; Resnick, et al, 2007) we are well informed as to which ALs need to be targeted in a functional training program. We anticipate there could be many benefits to implementation of a functionally focused training program post hip fracture, such as a greater likelihood of improvements in ALs with persistent task practice. Further we hypothesize neuroplastic changes that occur with functional training will last for longer periods of time than impairment-based training (de Vreede, et al, 2005) and be more likely to improve underlying impairments such as muscle weakness.

Given the low level of physical activity noted among older adults post hip fracture (Magaziner et al, 1990; 2000; Resnick, et al, 2007), it may be challenging to engage these individuals in the necessary practice periods needed to improve performance of ALs. We have, however, extensive experience in motivating older adults to engage in regular exercise using a self-efficacy approach (Resnick, Orwig, Zimmerman, Simpson & Magaziner, 2005), and have successfully been able to demonstrate that those exposed to these motivational interventions increase the time they spend in exercise (Resnick, et al, 2007). The motivational intervention focuses on education about the benefits of exercise, establishing goals, providing verbal encouragement and reinforcement, using role models and self-cueing, and decreasing the unpleasant sensations associated with exercise. In addition, we utilize a comprehensive approach to pain management (pharmacological and nonpharmacological) and a repeated exposure approach to decrease fear and anticipation of pain (de Jong, et al, 2005; George, et al, 2008; Resnick, et al, 2005; Resnick, et al, 2007; Shaw, Linton & Pranksy, 2006; Vlaeyen, De Jong, Geilen, Heuts, Van Breukelen, 2002).

Potential Functional Training Program for Hip Fracture Patients

The Functional Training Program Post Hip Fracture (FTPPHF) has been developed based on our current and prior work evaluating AL recovery of hip fracture patients in the first year post hip fracture (Magaziner et al. 2000). The FTPPHF focuses on four specific tasks (chair transfers, bath transfers, walking and stair climbing) as well as balance. A licensed physical therapist evaluates the patient for major strength limitations, defined as an inability of the muscle to perform normal action in an against-gravity position. For example, due to quadriceps weakness a patient may be unable to fully extend the knee from a seated position. In this case, a focused, impairment-based approach to increasing quadriceps strength may be necessary to achieve a baseline level of strength to then be able to practice getting up from the chair. If the patient has a major limitation in ROM of a joint that would prevent ÒnormalÓ movement, then joint mobilizations or a stretching program may be needed prior to practicing the specific AL. When there is evidence of limitations in such things as ROM it is critical to avoid the use of compensatory patterns to perform functional tasks that might result in muscle or joint trauma and/or increased risk of falls.

The next step in the FTPPHF involves evaluating each component of individual ALs as delineated in Table 4. Training is then matched to the component that the patient is unable to perform. If the patient is able to complete all components necessary for the AL, then training focuses on the complete task. Practice then progresses by increasing load, speed, and complexity of the task. Table 5 provides an outline of functional training progressions for each AL and for improving balance.

Although the baseline and follow up evaluations of the patient post hip fracture should be done by a licensed physical therapist, the FTPPHF can be implemented by trained healthcare professionals such as physical therapy assistant, exercise trainers, or nursing assistants. Supervised functional training should be implemented two to three times per week for approximately 12 weeks (de Vreede et al., 2005), with home exercises encouraged on the days in which there is no supervised one-on-one training. The physical therapist should communicate with the health care professional implementing the training activities on a weekly basis regarding the patient's status and re-evaluate the patient every two weeks to assess progress and make appropriate adjustments in training. At completion of the 12 week FTPPHF, a maintenance exercise program is given to the patient and Òtune-upsÓ or inoculation sessions provided every 6 months to prevent deconditioning and/or a decline in function. Given that prior exercise interventions and traditional interventions provided by physical and occupational therapists have not demonstrated optimal improvement in ALs among older adults post hip fracture, the FTPPHF is proposed as an alternative way in which to improve ALs and decrease care needs among hip fracture patients. Ongoing research is needed to extensively test this approach.

Table 1 Comparison of the Katz Activities of Living Scores Across Treatment Groups Based on Generalized Estimating Equations

Treatment Group

N

Mean

Std. Deviation

95% Confidence Interval for Mean

P

Baseline

0.17

Control

51

.41

1.00

.13

.69

Exercize

51

.35

1.00

.13

.69

Exercize Plus

54

.37

1.03

.08

.65

Plus

52

.38

.86

.14

.63

Total

208

.37

.92

.25

.51

2 month

Control

41

2.65

1.61

2.05

3.09

Exercise

40

2.57

1.57

2.16

3.16

Exercise Plus

43

3.13

1.59

2.64

3.63

Plus

38

3.07

1.51

2.58

3.58

Total

162

2.86

1.58

2.62

3.11

6 month

Control

42

1.88

1.62

1.37

2.39

Exercise

39

1.56

1.91

.94

2.18

Exercise Plus

46

1.65

1.55

1.19

2.11

Plus

41

2.29

1.66

1.77

2.82

Total

168

1.85

1.69

1.58

2.10

12 month

Control

40

1.80

1.87

1.20

2.39

Exercise

35

1.28

1.56

.75

1.82

Exercise Plus

43

1.48

1.33

1.08

1.89

Plus

154

1.63

1.59

1.38

1.89


Table 2 Description of BHS-5 Cohort: Percentage of Individuals Able to Perform Specific Activity of Daily Living Without Human Assistance

Variable

Exercise Only

Plus Only 4

Exercise Plus

Routine Care

(p)*

N(%)N/group

N(%)N/group

N(%)N/group

N(%)N/group

Walking 10 feet

.10

Baseline

0(0%) 51

0(0%) 54

0(0%) 52

0(0%) 51

12-month

0(0%) 35

1(3%) 36

1(2%) 43

2(4%) 40

Walking 1 block

Baseline

1(2%) 51

3(6%) 54

3(6%) 51

6(12%) 51

.21

12-month

0(0%) 35

4(11%) 36

2(5%) 43

7(17%) 41

Climb 5 stairs

Baseline

8(10%) 51

5(10%) 54

8(15%) 52

4(8%) 51

.51

12-month

6(17%) 35

14(39%) 36

11(26%) 43

14(34%) 41

Car Transfer

Baseline

0(0%) 51

0(0%) 52

1(2%) 54

0(0%) 51

.71

12-month

4(11%) 35

4(11%) 36

3(7%) 43

7(17%) 41

Bed Transfer

Baseline

0(0%) 51

1(2%) 51

2(4%) 52

1(2%) 50

.70

12-month

1(3%) 35

2(6%) 36

1(2%) 43

1(2%) 41

Put on pants

Baseline

0(0%) 51

1(1%) 51

1(1%) 53

0(0%) 51

.63

12-month

2(6%) 35

2(5%) 36

2(4%) 43

2(5%) 41

Put on socks & shoes

Baseline

3(6%) 48

4(8%) 48

1(2%) 52

0(0%) 50

.24

12-month

3(9%) 35

5(14%) 36

2(4%) 43

4(9%) 41

Toilet transfer

Baseline

0(0%) 51

0(0%) 50

0(0%) 54

1(2%) 51

.43

12-month

1(3%) 35

1(3%) 36

1(2%) 43

2(5%) 40


Table 3: Critical Components for Specific Functional Tasks

Chair Transfers

Bath Transfers

Balance

Walking

Stair Ascent & Descent

Seated trunk extension with wand

Triceps dip (concentric and eccentric)

Reaching tasks in different directions with feet shoulder width apart (i.e. reach overhead, sideways, behind, floor)

Standing hip hike

Step ups/downs with hand support (standard step height)

Wall Sit

Deep squat with hand hold assist

Reaching tasks in different directions with feet side by side

Modified lunge with wide base of support

Step ups/downs without hand support (standard step height)

Buttock raise from chair (avg. height)

Stepping over an obstacle (tub height)

Reaching tasks in different directions with feet in semi-tandem position

Modified lunge with narrow base of support

Step ups/downs with hand support (increased step height)

Sit ’ Stand with proper form (avg. height chair)

Turning within a small radius with a narrow base of support

Walking in a narrow path

Walking at variable speeds with stops and starts, as well as directional changes

Step ups/downs without hand support (increased step height)

Buttock raise from chair (toilet seat height)

Practice whole task

Obstacle Course

Walking while carrying a laundry basket

Stair negotiation (step over step) with railing

Sit ’ Stand with proper form (toilet seat height)

Four square stepping

Treadmill walking to focus on timing and endurance

Stair negotiation (step over step) without railing

Sit ’ Stand under variable conditions (i.e. holding a glass, standing and walking to one side, start and stop in different parts of range

Stair negotiation (step over step) with weighted vest


Table 4: Progression of Exercises for Performing Functional Tasks

Chair Transfers

Bath Transfers

Balance

Walking

Stair Ascent & Descent

Standing Phase

  • Move feet backwards
  • Lean forward at trunk with spine extended
  • Move knees foward
  • Extend hips and knees

Standing Phase

  • Elbow extension
  • Hip & knee extension from deep squat
  • Turning within a small radius with a narrow base
  • Hip & knee flexion to step over tub wall

Ability to weight shift from one extremity to the other

Stance Phase

  • Controlled knee flexion after heel strike
  • Hip extension through-out

Stance Phase-Ascent

  • Hip and Knee Extension
  • Ankle DF
  • Forward shift of trunk

Sitting Phase

  • Lean forward at trunk with spine extended
  • Move knees forward
  • Flex knees

Sitting Phase

  • Hip and knee flexion
  • Turning within a small radius
  • Deep Squat with significant hip & knee flexion
  • Controlled elbow flexion

Ability to handle postural disturbances (i.e. dual task situations)

Swing Phase

  • Knee flexion & hip flexion
  • Knee extension at heel strike with ankle DF

Swing Phase-Ascent

  • Hip and Knee Extension

Swing Phase-Descent

  • Controlled hip and knee flexion
  • Maintain trunk over supporting leg

References

Agency for Health Care Policy and Research. (1999). Hospital Inpatient Statistics, 1996. Washington, DC: US Department of Health and Human Services (AHCPR publication 99-0034).

Alexander NB, Galecki AT, Grenier ML, Nyquist LV, Hofmeyer MR & Grunawalt JC. (2001). Task-specific resistance training to improve the ability of activities of daily living-impaired older adults to rise from a bed and from a chair. Journal of the American Geriatric Society, 49(11), 1418-1427.

Bean JF, Herman S, Kiely DK, Frey IC, Leveille SG & Fielding RA. (2004). Increased Velocity Exercise Specific to Task (InVEST) training: A pilot study exploring effects on leg power, balance, and mobility in community-dwelling older women. Journal of the American Geriatric Society, 52(5), 799-804.

Binder E, Schechtman K, Ehsani A, Steger-May K, Brown M, Sinacore D, Yarasheski K. & Holloszy J. (2002). Effects of exercise training on frailty in community dwelling older adults: Results of a randomized, controlled trial. Journal of the American Geriatric Society, 50, 1921-1928.

Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE & Schechtman KB. (2004). Effects of extended outpatient rehabilitation after hip fracture: A randomized controlled trial. Journal of the American Medical Association, 292(7), 837-846.

Carmeli E, Sheklow SL, & Coleman R. (2006). A comparative study of organized class based exercise programs versus individual home-based exercise programs for elderly patients following hip surgery. Disability and Rehabilitation, 28(16), 997-1005.

Carr JH, & Shepherd RB. (1987). A motor relearning programme for stroke London: Butterworth-Heinemann Physiotherapy.

Cauley JA, Thompson DE, Ensrud KC, Scott JC & Black D. (2000). Risk of mortality following clinical fractures. Osteoporosis International, 11(7), 556-561.

Chan DY, Chan CC, & Au DK. (2006). Motor relearning programme for stroke patients: a randomized controlled trial. Clinical Rehabilitation, 20(3), 191-200.

Chudyk, AM, Jutai JW, Petrella RJ & Speechley M. (2009). Systematic review of hip fracture rehabilitation practices in the elderly. Archives of Physical Medicine and Rehabilitation, 90, 249-253.

de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen M, Mulder H. (2005). Fear of movement/(re)injury in chronic low back pain: education or exposure in vivo as mediator to fear reduction? Clinical Journal of Pain, 21(1), 9-17.

de Vreede PL, Samson MM, van Meeteren NL, Duursma SA, & Verhaar HJ. (2005). Functional-task exercise versus resistance strength exercise to improve daily function in older women: a randomized, controlled trial. Journal of the American Geriatrics Society, 53(1), 2-10.

Distefano LJ, Clark MA & Padua DA. (2009). Evidence Supporting Balance Training in Healthy Individuals: A Brief Review. Journal of Strength Conditioning Research. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19910803?itool

Fillenbaum GG & Smyer MA (1981). The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire. Journal of Gerontology, 36(4), 428-434.

George SZ, Zeppieri G. Jr., Cere AL, Cere MR, Borut MS, Hodges MJ, Reed DM, Valencia C, Robinson ME. (2008). A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain. Pain, 140(1), 145-157.

Gruber-Baldini A, Zimmerman S, Morrison R, Grattan L, Dolan M & Hebel J. (2003). Cognitive impairment in hip fracture patients: Timing of detection and longitudinal follow-up. Journal of the American Geriatrics Society, 51(9), 1227-1236.

Haentjens P, Autier P, Bärette M & Boonen S. (2001). The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohort study with matched-pair analysis Belgian Hip Fracture Study Group. Journal of Bone and Joint Surgery 83-A(4), 493-500.

Hauer K, Specht N, Schuler M, BŠrtsch P & Oster P. (2002). Intensive physical training in geriatric patients after severe falls and hip surgery. Age & Ageing, 31(1), 49-57.

Hofmeyer MR, Alexander NB, Nyquist LV, Medell JL & Koreishi A. (2002). Floor-rise strategy training in older adults. Journal of the American Geriatrics Society, 50(10), 1702-1706.

Jette AM. (1980). Functional Status Index: Reliability of a chronic disease evaluation instrument. Archives of Physical Medicine and Rehabilitation, 61(September), 395-401.

Jette AM, Branch LG & Berlin J. (1990). Musculoskeletal impairments and physical disablement among the aged. Journal of Gerontology: Medical Sciences, 45(6), M203-M208.

Johnson MF, Kramer AM, Lin MK, Kowalsky JC & Steiner JF. (2000). Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke. Journal of the American Geriatrics Society, 48(11), 1389-1397.

Jones GR, Jakobi JM, Taylor AW, Petrella RJ, & Vandervoort AA. (2006). Community exercise program for older adults recovering from hip fracture: A pilot study. Journal of Aging and Physical Activity, 14, 439-455.

Krebs DE, Scarborough DM, & McGibbon CA. (2007). Functional vs. strength training in disabled elderly outpatients. American Journal of Physical Medicine and Rehabilitation, 86(2), 93-103.

Lawton MP & Brody EM. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179-186.

Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M. (2000). Recovery from hip fracture in eight areas of function. Journal of Gerontology: Medical Sciences, 55A(9), M498-M507.

Magaziner J, Simonsick EM, Kashner TM, Hebel JR & Kenzora JE. (1990). Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. Journal of Gerontology: Medical Sciences, 45(3), M101-M107.

Mahoney F & Barthel D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14(2), 61-66.

Mangione KK, Craik KL, Tomlinson SS & Palombaro KM. (2005). Can elderly patients who have had a hip fracture perform moderate- to high-intensity exercise at home? Physical Therapy 85(8), 727-739.

Manini TM, Clark BC, Tracy BL, Burke J, & Ploutz-Snyder L. (2005). Resistance and functional training reduces knee extensor position fluctuations in functionally limited older adults. European Journal of Applied Physiology, 95(5-6), 436-446.

Nagi, S. (1976). An epidemiology of disability among adults in the United States. Milbank Memorial Fund Quality Health Soc., 54, 439-467.

Peterson MGE, Ganz SB, Allegrante JP & Cornell CN. (2004). High intensity exercise training following hip fracture, Topics in Geriatric Rehabilitation, 20(4), 273-284.

Resnick B, Orwig D, Inguito P, & Xi BB. (2007). The Baltimore Hip Studies Projects: Prevention of Fracture Through Intervention. Symposium. Gerontological Society of America. The Gerontologist, 47(1), 203.

Resnick B, Orwig D, Yu-Yahiro J, Hawkes W, Shardell M, Hebel JR & Magaziner J. (2007). Testing the Effectiveness of the Exercise Plus Program in Older Women Post-Hip Fracture. Annals of Behavioral Medicine, 34(1), 67-76.

Resnick B, Orwig D, Zimmerman S, Simpson M, & Magaziner J. (2005). The Exercise Plus Program for Older Women Post Hip Fracture: Participant Perspectives. The Gerontologist, 45(4), 539-544.

Rose S & Maffulli N. (1999). Hip fractures: an epidemiological review. Bulletin Hospital Joint Disease, 58(4), 197-201.

Shaw WS, Linton SJ & Pransky G. (2006). Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors? Journal of Occupational Rehabilitation, 16(4), 591-605.

Sherrington C & Lord SR. (1997). Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 78(2), 208-212.

Sherrington C, Lord SR & Finch CF. (2004). Physical activity interventions to prevent falls among older people: update of the evidence. Journal of Science Medicine and Sport, 7(1Supp), 43-51.

Sherrington C, Lord SR & Herbert RD. (2003). A randomized trial of weight-bearing versus non-weight-bearing exercise for improving physical ability in inpatients after hip fracture. Australian Journal of Physiotherapy, 49(1), 15-22.

Sherrington C, Lord SR. & Herbert RD. (2004). A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Archives of Physical Medicine and Rehabilitation, 85(5), 710-716.

Tinetti ME, Baker D, Gallo WT, Nanda A, Charpentier P & O'Leary J. (2002). Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care. Journal of the American Medical Association, 287(16), 2098-2105.

Trudelle-Jackson E & Smith S. (2004). Effects of a late-phase exercise program after total hip arthroplasty: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 85(7), 1056-1062.

Tsauo J, Leu W, Chen Y & Yang R. (2005). Effects on function and quality of life of postoperative home-based physical therapy for patients with hip fracture. Archives of Physical Medicine and Rehabilitation, 86(10), 1953-1957.

Van Balen R, Steyerberg E, Polder J, Ribbers T, Habbema J & Cools HJ. (2001). Hip fracture in elderly patients: outcomes for function, quality of life and type of residence. Clinical Orthopedics, 390, 232-243.

Verbrugge LM & Jette AM. (1994). The disablement process.Social Science Medicine,38(1), 1-14.

Vlaeyen JW, de Jong J, Geilen M, Heuts PH, & van Breukelen G. (2002). The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clinical Journal of Pain, 18(4), 251-261.

Yu-Yahiro J, Resnick B, Orwig D, Hicks GE, Magaziner J. (2009) Design and Implementation of a Home-Based Exercise Program Post-Hip Fracture: The Baltimore Hip Studies Experience. Physical Medicine & Rehabilitation, 1(4), 308-318.

Acknowledgements

Support for this project was provided by National Institute on Aging (NIA) grants R37 AG09901, R01-AG18668, R01 AG17082, and the Claude D. Pepper Older Americans Independence Center P60-AG12583. Authors also would like to thank Thera-Band Academy for their generous contribution of Thera-Band¨ resistive bands used by study participants; hospitals and personnel participating in the Baltimore Hip Studies; and research staff who worked with study patients and their families.

Authors would also like to thank hip fracture patients and their families for volunteering their time and information for this work.

Contributors:

Corresponding Author: Barbara Resnick, PhD, CRNP, FAAN, FAANP
Email: barbresnick@aol.com

Sonya Ziporkin Gershowitz, Chair in Gerontology, Professor, University of Maryland, 655 West Lombard Street, Baltimore, MD 21201

Gregory E. Hicks, PT, PhD, University of Delaware

Denise Orwig, PhD, University of Maryland School of Medicine, Dept of Epidemiology, Redwood Street, Baltimore, MD 21201

Janet Yu-Yahiro, Union Memorial Orthopaedics, The Johnston Professional Building, #400, 3333 North Calvert Street, Baltimore, MD 21211

Jay Magaziner, PhD, University of Maryland School of Medicine, Dept of Epidemiology, Redwood Street, Baltimore, MD 21201

 

International Journal of Disability, Community & Rehabilitation
Volume 9, No. 1
www.ijdcr.ca
ISSN 1703-3381