Can elderly patients who have had a hip fracture perform moderate- to high-intensity exercise at home?(Research Report)(Clinical report)

Background and Purpose. The majority of patients after a hip fracture do not return to prefracture functional status. Depression has been shown to affect recovery. Although exercise can reduce impairments, access issues limit elderly people from participating in facility-based programs. The primary purpose of this study was to determine the effects and feasibility of a home exercise program of moderate- or high-intensity exercise. A secondary purpose was to explore the relationship of depression and physical recovery. Subjects. Thirty-three elderly people (24 women, 9 men; [bar.X] = 78.6 years of age, SD = 6.8, range = 64-89) who had completed a regimen of physical therapy following hip fracture participated in the study. Subjects were randomly assigned to a resistance training group, an aerobic training group, or a control group. Methods. Subjects were tested before and upon completion of the exercise trial. Isometric lower-extremity force, 6-minute-walk distance, free gait speed, mental status, and physical function were measured. Each exercise session was supervised by a physical therapist, and subjects received 20 visits over 12 weeks. The control group received biweekly mailings. The resistance training group performed 3 sets of 8 repetitions at the 8-repetition maximum intensity using a portable progressive resistance exercise machine. The aerobic training group performed activities that increased heart rate 65% to 75% of their age-predicted maximum for 20 continuous minutes. Results. Resistance and aerobic training were performed without apparent adverse effects, and adherence was 98%. All groups improved in distance walked, force produced, gait speed, and physical function. Isometric force improved to a greater extent in the intervention groups than in the control group. Depressive symptoms interacted with treatment group in explaining the outcomes of 6-minute-walk distance and gait speed. Discussion and Conclusion. High-intensity exercise performed in the home is feasible for people with hip fracture. Larger sample sizes may be necessary to determine whether the exercise regimen is effective in reducing impairments and improving function. Depression may play a role in the level of improvement attained. [Mangione KK, Craik RL, Tomlinson SS, Palombaro KM. Can elderly patients who have had a hip fracture perform moderate- to high-intensity exercise at home? Phys Ther. 2005;85:727-739.]

Key Words: Exercise, aerobic performance; Exercise, force production; Hip fractures; Home care services.

Hip fracture is a common medical problem that can drastically change the quality of life for the elderly person. More than 300,000 older people are expected to fracture a hip each year (1) at an estimated cost of $5 billion. (2) It has been well established that the majority of patients with hip fracture do not return to prefracture functional status at 1 year after surgery. (3-7) In a study of 120 people, Marottoli et al (5) showed that, 6 months after hip fracture, only 8% climbed a flight of stairs, 15% walked across a room independently, and 6% walked a half mile. Tolo et al (8) reported results from a sample that required no assistive devices for walking before a hip fracture; however, 8 months after a fracture, 42% of the sample required a cane, their walker use tripled, and 56% of the sample reported not walking "as well" as they could before the fracture. Even at a 2-year follow-up, patients with a hip fracture are reported to be 4 times more likely to be homebound, 3 times more likely to be dependent in basic activities of daily living (ADL), and more likely to spend less time on their feet when compared with control subjects. (9)

To varying degrees, exercise and physical activity have been shown to be effective in reducing impairments, functional limitations, and disability in elderly people who are healthy. (10-12) Initiating exercise programs for elderly people with disabilities, however, is reported to be difficult because of problems with access to exercise facilities. (13) Home-based exercise is an approach to address the problem of environmental access for patients after hip fracture.

Only 2 trials in the literature have examined the effectiveness of home-based exercise for patients after hip fracture. Sherrington and Lord (14) examined the effectiveness of performing unsupervised, daily "step-up" exercises in patients 7 months after a hip fracture. A physical therapist determined the number of repetitions and the height of the step that the patients used. After 1 month, isometric force production of the quadriceps femoris muscle improved in the exercise group approximately 3.0 kg and gait speed increased 0.05 m/s.

Tinetti and colleagues (15,16) compared outcomes of "usual care" rehabilitation and "systematic multicomponent rehabilitation (SMR)" at 6 and 12 months in 304 patients receiving rehabilitation in the home after hip fracture. "Usual care" was not defined, but SMR included daily performance of 3 sets of 8 repetitions for seated hip flexion, hip abduction, knee extension, and ankle dorsiflexion. All patients exercised with elastic bands and began with the band of least resistance. Patients also performed transfer, balance and gait training, and range-of-motion (ROM) exercises. There were no differences between groups at either time period when examining recovery of prefracture basic ADL and instrumental activities of daily living (IADL) or in measures of physical performance (gait, muscle force, and balance). Changes in outcomes from the beginning of the intervention to the 6- or 12-month follow-up were not reported.

The studies of home-based exercises reported to date do not provide sufficient detail to determine the intensity of exercise and do not provide guidance to establish exercise protocols for patients after hip fracture. The program described by Sherrington and Lord (14) did not report training intensity, but the results suggest that exercise in people who have had a hip fracture may have positive effects on impairments and functional limitations. Tinetti and colleagues' (15,16) program was comprehensive in scope, but it is not clear whether the training intensity was adequate to improve impairments or functional limitations.

Because there are limited data to guide exercise prescription needed to remediate impairments in patients after hip fracture, applying the evidence from other groups of elderly people appears to be warranted. Highintensity muscle force training improves muscle force production, gait speed, and balance in elderly people who are healthy and those who are frail. (11,17) Training typically involves 3 sets of 8 repetitions at 80% of the one-repetition maximum for 8 to 16 weeks. (18,19) Training has been directed to single muscle groups, such as the knee extensors, and groups of functionally related muscles, such as the hip and knee extensors together. Likewise, endurance training has been examined in elderly people who performed 20 to 40 minutes of exercise for 12 to 16 weeks ranging from low to high intensity (40% to 70% of heart rate reserve). (12,20) The types of training performed by elderly people who are healthy and those who are frail include walking, cycling, and water and land aerobics. Training has been shown to improve maximal oxygen consumption and 6-minute-walk distance as well as measures of health status. Because the fracture site is healed, it appears safe to apply the principles emerging from the rapidly growing body of knowledge regarding exercise prescription in elderly people who are healthy or frail to patients with hip fracture.

Many factors, including depression, have been cited as determinants of recovery after a hip fracture. Depression in people with hip fracture has been associated with greater physical disability and the need for longer rehabilitation. (21,22) For example, in one study that followed 196 Caucasian women 1 year after fracture, women with persistently elevated depressive symptoms were 3 times less likely to achieve independence in walking and 9 times less likely to return to prefracture function than women reporting few depressive symptoms. This study controlled for age, prefracture physical function, and cognitive status. (22) A recent study by Scaf-Klomp et al (23) examined the effect of incomplete recovery and depression 1 year after fall-related injury. Unlike previous studies, this investigation tracked changes in depression during recovery and showed that depressive reactions occurred only when physical function appeared to stagnate. (23) These findings emphasize an important link between depression and physical recovery after hip fracture and have led investigators to suggest that clinicians should screen for depression and initiate appropriate medical intervention. (24) It is also important to further explore the role that depression plays in measures of physical performance after hip fracture.

The primary purpose of this study was to determine the effects of a 12-week program of high-intensity, supervised resistance training or moderate-intensity aerobic training on specific impairments, functional limitations, and disabilities in people after hip fracture. The primary outcome variables were maximum voluntary isometric lower-extremity force, 6-minute walk distance, free gait speed, and self-reported physical function. A secondary purpose was to determine the feasibility of such an exercise program. Feasibility, or ability to perform the exercises at home, was defined as adherence to scheduled appointments, number of sessions the subject was able to achieve the target…