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Life after hip fracture

Impact of home rehabilitation versus conventionalcare and patients experiences of the recoveryprocess in a short- and long-term perspective

Lena Zidn

Institute of Neuroscience and Physiologyat Sahlgrenska AcademyUniversity of Gothenburg

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Harry Martinson

i "Dikter om ljus och mrker".

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Abstract

Aim

Method

Results

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Conclusions

Key words

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Svensk sammanfattning

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Contents

Introduction

Background Risk factors for hip fracture

Consequences of a hip fracture The patients perspective Recovery after hip fracture Rehabilitation after hip fracture

What remains to explore?

Aims

Theoretical and methodological viewpoints Life paradigm Self-efficacy

Health-related quality of life Situated learning International Classification of Functioning and Disability (ICF)

Methods Design Settings Participants

Measures (intervention studies I and III)

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Phenomenography (interview studies II and IV) Data collection Data analysis

Ethical considerations

Results The early phase of recovery The latter phase of recovery

Discussion General discussion of the findings

Methodological considerations ICF

What is worth knowing? Ethical aspects

Conclusions and clinical implications

English summary

Acknowledgements

References

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Abbreviations

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Introduction

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Background

Risk factors for hip fracture

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Table 1.Estimated number of fractures, given in thousands, worldwide in men and women in theyear 2000 (F/M female-to-male ratio). From Johnell and Kanis (18).

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Consequences of a hip fracture

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The patients perspective

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Recovery after hip fracture

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Recovery

Personal factors Body functions

age, gender, socio-economic and structuresconditions, experiences, self-efficacy musculo-sceletal function,

cognitive functions, mood

Activity and

Participation Environmental factorsexercise, physical activity, discharge planning, support

social activities, hobbies and rehabilitation, homeand environment

Figure 1. Factors influencing recovery after hip fracture, organized according to the InternationalClassification of Functioning and Health (ICF) within the four components Personal Factors, BodyFunctions and Structures, Environmental Factors and Activity/Participation (85, 86) (see nextsection).

Rehabilitation after hip fracture

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What remains to explore?

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Aims

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Theoretical and methodological viewpoints

Life paradigm

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Self-efficacy

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Health related quality of life

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Situated learning

International Classification of Functioning, Disability and Health (ICF)

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Methods

Design

Table 2. Research design overview.

Study I, III, quantitative II, IV, qualitative

Design Consecutive, randomized controlled Explorative,descriptive

Data collection Assessments and self-reported Semi-structuredmeasures during hospital stay and interviews oneone, six and 12 months after and 12 monthsdischarge after discharge

Setting Acute hospital + participants homes Participants homes

Participants 102 people, 48 in the HR group and 18 people from

54 in the CC group study I

Analysis Descriptive statistics, parametric Phenomenographicand non-parametric statistical analysis method

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Settings

Participants

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1Cognitive impairments (n=16; 8 HR and

8 CC), living in the wrong part of the city(n=10, 7 HR and 3 CC), serious disease//abuse/dead (n=16; 9 HR and 7 CC)wrong diagnosis (n=2)

2No available bed on allocated ward

(n=30; 15 HR and 15 CC)

3Moved from clinic before being asked

to participate , becoming seriously illor deaceased (n=25; 13 HR and 12 CC)

4 Declined (n=11; 5 HR and 6 CC)

(HR = Home rehabilitation, CC = Conventional care)

Dead n=1Drop-out n=1Unreachable n=1

Dead n=1

Follow-up

one month

n=54Interview study:

n=9

Follow-up

six months

Admitted patients with hipfracture betweenNovember 2004and March 2006

n=232

Excluded (n=99):Did not meet inclusion criteria(n=44) 1No bed available onallocated ward (n = 30)2

Other reasons (n = 25)3

-----------------------------------------------------------------Declined to participate (n=11)4

n=48Interview study:

n=9

Home rehabilitation

n=48

Conventional care

n=54

Randomization

and allocationn=212

(105 to HR and107 to CC

Included in thestudyn=102

Missed to randomizen=20

n=51n=47

n=45Interview study:

n=7

n=48Interview study:

n=8

Follow-up

one year

post-discharge

Dead n=3Dead n=2

Figure 2. Flow-chart of the randomization and follow-up occasions

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Table3

.Initialdescriptivecharacteristicsoftheparticipantsinthehomerehabilitationandconventionalcaregro

ups,arrangedbygender.N(%)isg

iven,

exceptforage.

Homerehabilitationgroup

Conventionalcaregroup

All

n=48

Women

n=29

Men

n=19

All

n=54

Women

n=42

Men

n=12

Ageme

an(sd)

median(min-max)

81.2

(5.9

)

81.0

(70.0-94.0

)

82.5

(5.8

)

83.0

(70.0-94.0

)

79.2

(5.6

)

79.0

(71.0-93.0

)

82.5

(7.6

)

83.5

(65.0-99.0

)

82.5

(7.7

)

83.5

(65.0-99.0

)

82.3

(7.2

)

84.0

(69.0-93.0

)

Socialhomeservice

1

1(22.9

)

5(17.2

)

6(31.6

)

20(37.0

)

15(35.7

)

5(41

.7)

Informalhelp

2

7(56.3

)

18(62.1

)

9(47.4

)

38(70.4

)

29(69.0

)

9(75

.0)

Livingalone

2

6(54.2

)

20(69.0

)

6(31.6

)

39(72.2

)

33(78.6

)

6(50

.0)

Walkingaidsindoor

7

(14.6

)

4(13.8

)

3(15.8

)

14(25.9

)

11(26.2

)

3(25

.0)

Walkingaidsout-door

1

3(27.1

)

8(27.6

)

5(26.3

)

23(42.6

)

20(47.6

)

3(25

.0)

Taking

out-doorwalks

4

6(95.8

)

27(93.1

)

19(100.0

)

50(92.6

)

40(95.2

)

10(83.3

)

Alone

3

8(79.2

)

22(75.9

)

16(84.2

)

42(77.8

)

33(78.6

)

9(75

.0)

Withcompany

8

(16.7

)

5(17.2

)

3(15.8

)

8(14.8

)

7(16.7

)

1(8.3

)

Daily

3

1(64.6

)

17(58.6

)

14(73.7

)

25(46.3

)

20(47.6

)

5(41

.7)

onceaweek

1

2(25.0

)

9(31.0

)

3(15.8

)

17(31.5

)

13(31.0

)

4(33

.3)

3

3(6.3

)

0(0.0

)

3(15.8

)

5(9.3

)

2(4.8

)

3(25

.0)

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Table 4.Comparison of the pre-fracture measures between the home rehabilitation group and theconventional care group. Median (min-max) values. FIM = Functional Independence Measure, IAM =Instrumental Activity Measure.

Measurement

Homerehabilitation

groupn = 48

Conventional caregroupn = 54 p-value

Independence in daily activities (FIM, IAM)

FIM total score 90.0 (64-91) 88.0 (52-91) 0.272

Self-care 42.0 (32-42) 41.5 (26-42) 0.472

Sphincter control 14.0 (9.0-14.0) 14.0 (7.0-14.0) 0.756

Mobility 21.0 (15.0-21.0) 21.0 (15.0-21.0) 0.573

Locomotion 14.0 (2.0-14.0) 13.0 (2.0-14.0) 0.053

IAM total score 44.5 (10-56) 39.0 (8, 56) 0.27

Out-door activities 24.0 (4.0-28.0) 19.5 (4.0-28.0) 0.107

Domestic activities 24.0 (4.0-28.0) 21.5 (4.0-28.0) 0.621

Frequency of daily activities

FAI total score 28.0 (0.0-37.0) 24.5 (0.0-40.0) 0.388

Domestic activities 12.5 (0.0-15.0) 12.0 (0.0-15.0) 0.607

Out-door activities 11.0 (0.0-18.0) 9.0 (0.0-17.0) 0.180

Leisure and work 3.5 (0.0-8.0) 3.0 (0.0-9.0) 0.847

P-values are calculated with Mann-Whitneys U-test .

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Table 5. Socio-demographic and clinical characteristics of the participants in the interview studies I andIV.

Sex Age Type of Number of Marital Reported posts-discharge

fracture diagnoses status rehabilitation

M 77 Trochanteric 1-3 Married HRM 81 Sub- 1-3 Widower HR

trochantericF 73 Cervical 1-3 Widow HRF 93 Trochanteric 1-3 Widow HRF 79 Cervical 1-3 Married HRF 81 Cervical 0 Widow HRF 83 Cervical 1-3 Widow HRF 81 Trochanteric 1-3 Widow NoF 66 Sub- 1-3 Married No

trochantericF 91 Cervical 0 Widow NoF 75 Cervical 1-3 Widow NoF 93 Cervical 1-3 Widow NoF 74 Cervical 1-3 Married NoF 78 Cervical 1-3 Widow NoF 77 Cervical 1-3 Married Out-clinic physiotherapy

F 99 Trochanteric 1-3 Widow Short-term nursing homeF 86 Cervical 1-3 Widow HRF 83 Cervical 1-3 Widow No

HR = home rehabilitation

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Measures (intervention studies I + III)

ICF Personal Factors

ICF Activity and Participation

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Ability

ICF Body Functions and Structures

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Phenomenography (interview studies II and IV)

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Data collection

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Table 6. Procedure of all data collection.

Measurements Pre-fracture1

Dis-charge

One month Six months 12 months

Falls Efficacy(FES(S))

- X X X X

Degree of independence(FIM, IAM)

X X X X X

Frequency of daily activities(FAI)

X X X X X

Living conditionsWalking habitsFallsPerceived recoveryHelp at home, walking aids

X

X--X

XX--X

XX-XX

XXXXX

XXXXX

Health-related quality of life(SF-36) - - X X X

Mood(CES-D)

- - X X X

Basic physical mobility(TUG, STS)

--

X-

XX

XX

XX

Semi-structured interview - - X - X1

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Ethical considerations

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Results

The early phase of recovery (study I and II)

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The latter phase of recovery (study III and IV)

Conventional care

0

10

20

30

40

50

60

70

80

90

100

Pre-fra

ctur

e

Discha

rge

One

month

Sixm

onth

s

One

year

Per cent

Self-care

Transfers andlocomotionDomes

Home rehabilitation

0

10

20

30

40

50

60

70

80

90

100

Pre-fra

ctur

e

Discha

rge

One

month

Sixm

onths

One

year

Percent

Self-care

TransfersandlocomotionDomesticactivities

Out-door

Figure 3. Proportion of participants being independent with or without technical aids in self-care (onemonth p

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Conventional care

0

10

20

30

40

50

60

70

80

90

100

Disch ar ge One mo nt h S ix mont hs One ye ar

Per cent

Cleaning

Stair

Home rehabilitation

0

10

20

30

40

50

60

70

80

90

100

Discharge

(NS)

One month

(p 0.0001)

Six months

(p 0.0001)

One year

(p 0.0001)

Per cent

Cleaning

Stair climbing

Out-door walking

Shopping

Figure 4. Proportion (per cent) of participants in the two groups, conventional care and homerehabilitation, reporting totally confident in performing the activities cleaning, stair climbing, out-doorwalking and shopping at discharge and one month, six months and one year after discharge. Chi-2 test.

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Table7b.Balanceconfidence.Comparis

onsbetweengroups,andchangeto

follow-upcomparedtodischargev

alues.FES(S)=Falls

EfficacyScale,Swedishversion.HR=Hom

erehabilitation,CC=Conventional

care.

HR

CC

pvalue

Maximal

HR

CC

pvalue

Follow-updata

score

Median(min-max)cha

nge

Medianvalu

es(min,max)

discharge-follow-up

Dischar

ge(n)

42

39

FES(S)totalscore

88.0(35,130

)75.0(8,124)NS

130

Self-care

50.0(28,60)

43.0(8,60)

NS

60

Stairs

6.0(0,10)

5.0(0,10)

NS

10

Instrumental

36.0(0,60)

28.0(0,60)

NS

60

Onemonth(n)

47

51

FES(S)totalscore

121(85,130)90.0(8,130)