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Kronborg L.1, Bandholm T.2, Palm H.3, Kehlet H.4, Kristensen M.T.5
1Copenhagen University at Amager Hvidovre Hospital, Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physio- and Occupational Therapy, Hvidovre, Denmark, 2Copenhagen University at Amager Hvidovre Hospital, Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physical Therapy, Clinical Research Centre, Department of Orthopedic Surgery, Hvidovre, Denmark, 3Copenhagen University at Amager Hvidovre Hospital, Department of Orthopedic Surgery, Hvidovre, Denmark, 4Copenhagen University at Rigshospitalet, Section for Surgical Pathophysiology, Copenhagen, Denmark, 5Copenhagen University at Amager Hvidovre Hospital, Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physical Therapy, Department of Orthopedic Surgery, Hvidovre, Denmark
Background: Patients with a hip fracture (HF) experience knee-extension strength deficit in the fractured limb of more than 50% and impaired physical function immediately after HF surgery. This is likely to contribute to the long term loss of physical function, change of residence and high mortality seen after HF. A recent systematic review provides some evidence for a positive effect on mobility of structured exercise interventions including progressive strength training after HF. Still, it is unclear if systematic strength training in the acute ward as a supplement to functional exercises can reduce the strength deficit in the fractured limb in the acute phase.
Purpose: To determine whether acute in-hospital physiotherapy (PT) with progressive knee-extension strength training of the fractured limb is more efficacious in reducing knee-extension strength deficit at follow-up compared to PT without strength training in patients with a HF.
Methods: The study was a randomized, assessor-blinded efficacy study with parallel assignment to PT with or without strength training after HF surgery following our initial feasibility study. 90 patients with a HF (mean age 79.6 (7.5) years, 69 women, 52 with a trochanteric fracture) admitted to the acute orthopedic Hip Fracture Unit at Hvidovre Hospital between October 2013 and May 2015 were enrolled for the study. The intervention consisted of PT with or without progressive knee-extension strength training (10RM) of the fractured limb using ankle weight cuffs in 3 sets of 10 repetitions, daily during hospital stay. The primary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from 1-3 days after surgery (baseline) to postoperative day 10 or discharge (follow-up). Secondary outcomes were the Timed Up and Go test measured early after surgery and at follow-up, fast speed walking test and concern of falling at discharge, and the time spent upright in the acute ward.
Results: In the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1%, CI (-2.3; 18.4) by additional strength training from baseline to follow-up versus significant improvements by 10.5%, CI (0.3; 20.7) in the per-protocol analysis of non-missing data. No significant between-group differences were found in any other outcome.
Conclusion(s): PT with strength training was not more efficacious than PT without strength training in reducing the knee-extension strength deficit at follow-up in patients with HF and the participants had a substantial strength deficit at follow-up despite targeted early PT. It is debatable whether larger improvements than the observed 8-10% can be expected given that only five exercise sessions, on average, were completed.
Implications: In patients with a HF in the acute phase, where the ability to participate in functional exercise is compromised, we still consider progressive strength training a relevant possibility to improve outcomes, especially if continued after hospital discharge. The present data provides an important basis for future investigations.
Funding acknowledgements: The IMK Foundation, The Research Foundation of the Danish Physical Therapy Organisation, Research Foundation of Hvidovre Hospital, UCSF Lundbeck Foundation.
Topic: Orthopaedics
Ethics approval: The study was approved by the Capital Regions Research Ethics Committee, Denmark (H-A-2007-0127 + 37036)
All authors, affiliations and abstracts have been published as submitted.
