Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture

• Autores: Nancy K. Latham, Bette Ann Harris, Jonathan F. Bean, Timothy Heeren, Christine Goodyear
• Localización: JAMA: the journal of the American Medical Association, ISSN 0098-7484, Vol. 311, Nº. 7, 2014, págs. 700-708
• Idioma: inglés
• Enlaces
  • Texto Completo Ejemplar
• Dialnet Métricas: 1 Cita
• Resumen

  • Importance For many older people, long-term functional limitations persist after a hip fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established.

    Objective To determine whether a home exercise program with minimal contact with a physical therapist improved function after formal hip fracture rehabilitation ended.

    Design, Setting, and Participants Randomized clinical trial conducted from September 2008 to October 2012 in the homes of 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture.

    Interventions The intervention group (n = 120) received functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months. The attention control group (n = 112) received in-home and telephone-based cardiovascular nutrition education.

    Main Outcomes and Measures Physical function assessed at baseline, 6 months (ie, at completion of the intervention), and 9 months by blinded assessors. The primary outcome was change in function at 6 months measured by the Short Physical Performance Battery (SPPB; range 0-12, higher score indicates better function) and the Activity Measure for Post-Acute Care (AM-PAC) mobility and daily activity (range, 23-85 and 9-101, higher score indicates better function).

    Results Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed significant improvement relative to the control group (n=95) in functional mobility (mean SPPB scores for intervention group: 6.2 [SD, 2.7] at baseline, 7.2 [SD, 3] at 6 months; control group: 6.0 [SD, 2.8] at baseline, 6.2 [SD, 3] at 6 months; and between-group differences: 0.8 [95% CI, 0.4 to 1.2], P < .001; mean AM-PAC mobility scores for intervention group: 56.2 [SD, 7.3] at baseline, 58.1 [SD, 7.9] at 6 months; control group: 56 [SD, 7.1] at baseline, 56.6 [SD, 8.1] at 6 months; and between-group difference, 1.3 [95% CI, 0.2 to 2.4], P = .03; and mean AM-PAC daily activity scores for intervention group: 57.4 [SD, 13.7] at baseline, 61.3 [SD, 15.7] at 6 months; control group: 58.2 [SD, 15.2] at baseline, 58.6 [SD, 15.3] at 6 months; and between-group difference, 3.5 [95% CI, 0.9 to 6.0], P = .03). In multiple imputation analyses, between-group differences remained significant for SPPB and AM-PAC daily activity, but not for mobility. Significant between-group differences persisted at 9 months for all functional measures with and without imputation.

    Conclusions and Relevance Among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization. The clinical importance of these findings remains to be determined.

    Trial Registration clinicaltrials.gov Identifier: NCT00592813 More than 250 000 people in the United States fracture their hip each year, with many experiencing severe long-term consequences.1- 3 Two years after a hip fracture, more than half of men and 39% of women are dead or living in a long-term care facility.4 Many of these patients are no longer able to independently complete basic functional tasks that they could perform prior to the fracture, such as walking 1 block (>80% unable) or climbing 5 steps (90% unable) 2 years after a fracture.5 In 2003, the lifetime attributable cost of a hip fracture was estimated to be $81 300, with nearly half (44%) of these costs the result of long-term care expenses.6 A 2004 study7 found that a 6-month intensive extended rehabilitation program conducted in an outpatient setting resulted in significant improvements in function, mobility, and other outcomes. Since this study, systematic reviews have concluded that intensive, supervised exercise programs can result in additional functional gain following hip fracture.8,9 Although these studies demonstrate the potential for patients with hip fracture to improve their function, most efficacious programs are in essence a continuation of standard rehabilitation with close supervision and frequent visits. Given the increase in postacute care costs for hip fracture, it would be difficult to add a large amount of extended therapy to hip fracture treatment.10,11 The aim of this study was to determine the efficacy of a 6-month, functionally oriented, home exercise hip rehabilitation program with modest in-person contact with a physical therapist intended to extend the benefits of the initial hip fracture rehabilitation. Our primary objectives were to determine whether an extended hip rehabilitation intervention improved overall function at 6 months and to determine if the effects of the program persisted 9 months after randomization.