| Adunsky 2003138 | Limitations: (1) study design and the non-randomisation of patients; (2) multifactorial background of the patients and the non-inclusion in the analysis of some already well-known predictors of outcome, such as associated comorbidities, pre-fracture ambulating status and pre-fracture level of ADL; (3) the variable time interval from surgery to onset of the rehabilitation period was not analysed because a delay in a patient’s transfer (as well as the timing of surgical intervention) may depend on other medical and non-medical factors; (4) a specific adjustment for coexisting comorbidities was not performed, because patients with significant comorbidities that could affect rehabilitation outcome were excluded a priori; and (5) no cost and cost-effectiveness analysis was carried out because the purpose of the study was to look at functional rehabilitation outcomes rather than at associated expenses. Strengths: provides clinical evidence supporting the implementation of comprehensive orthogeriatric care, which can help manage the use of economic resources and the facilitation of effective treatment strategies | Rehabilitation functional outcomes of elderly hip fracture patients are better for those treated in an orthogeriatric setting than for those treated with the common two-phase model of surgery followed by transfer to a geriatric rehabilitation facility. This model of a comprehensive orthogeriatric ward is a practical and feasible service that covers the various needs of hip fracture patients, results in a shorter length of hospital stay and provides more efficient rehabilitation |
| Israel |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 320; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Al-Ani 2010139 | Limitations: (1) data were collected only from relatives/friends because the patients were selected because of their severe cognitive impairment; no reliability testing of this information was performed; (2) patients discharged to rehabilitation units may differ from those discharged directly to their previous living condition; and (3) although factors that might influence the outcome were adjusted for, data relevant for the decision of discharge to rehabilitation units were not collected. Strengths: (1) the choice of easily recognisable outcome variables: walking outside and inside, ability to walk and Activities of Daily Living – Katz (kADL) index; and (2) fairly low dropout rate | Discharge to the rehabilitation unit was associated with preserved walking ability and ADL in cognitively impaired patients with hip fracture |
| Sweden |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 246; age: ≥ 65 years; gender: both; cognitive impairment: yes |
| Allegrante 200791 | Limitations: (1) high attrition rate largely because of refusal to complete the entire outcome assessment protocol, mainly because of failure to return to hospital; (2) self-selection bias; and (3) inability to blind the surgeons leading to encouragement of control group patients to obtain more physical therapy, diluting the impact of the intervention | Role limitation as a result of physical health was reduced significantly but the results should be interpreted cautiously because of the large number of dropouts. Such results are likely to be expected in community settings when a multicomponent intervention is implemented in rehabilitation after hip fracture |
| USA |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 176; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Arinzon 2005201 | NR | Geriatric rehabilitaion helped the younger age group more than the older age group achieve better results with regard to functional improvement; hence, older groups need more support to obtain better rehabilitation outcomes |
| Israel |
| Quantitative comparative |
| Concurrent cohort study |
| Community |
| Thick |
| Participants: n = 102; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Atwal 2002176 | NR | The key themes identified from the stakeholder interviews were (1) time constraints prevented professionals from completing and reading the multidisciplinary integrated care pathway; and (2) goal-setting was regarded as time consuming. The key findings from the analysis of the interprofessional integrated care pathways were interprofessional differences in the management of the patient caused discharge delays (discharges were not delayed by social services but by organisational aspects). If interprofessional working is to be encouraged, there must be a real commitment to this process. Health-care professionals must be able to state their opinions freely, be willing to share information, set goals with both the patient and other members of the team and be able to understand the value base of other professionals |
| UK |
| Qualitative |
| Qualitative |
| Hospital |
| Rich |
| Participants: n = 48 health professionals; age: NR; gender: both; cognitive impairment: NA |
| Barone 2009177 | NR | This study established that immediate weight-bearing and assisted ambulation is feasible in a high proportion of patients after surgical stabilisation of hip fracture. Neither cognitive impairment nor high comorbidity influenced significantly the adherence to the protocol, indicating that immediate weight-bearing and assisted ambulation may be offered to an unselected population of the elderly with hip fracture. The day of surgery (e.g. pre-holiday or not) was the only variable influencing adherence to the immediate weight-bearing and assisted ambulation protocol, suggesting the importance of maintaining the same standard of daytime care every day of the week |
| Italy |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 469; age: ≥ 70 years; gender: both; cognitive impairment: partial |
| Bäuerle 2004163 (German) | NR | The extent of help and care needed after a hip fracture depends on the subgroup categorisation of patients’ pre-fracture status, including cognitively sound, younger, frailer, very old, living alone or living with family |
| Germany |
| Quantitative non-comparative |
| Historical cohort study |
| Community |
| Thick |
| Participants: n = 332; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Beaupre 2005157 | NR | Standardised rehabilitation and discharge planning did not affect post-operative function or institutionalisation in elderly patients with hip fracture. In intervention patients with low levels of social support, function improved and institutionalisation was reduced |
| Canada |
| Quantitative comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 919; age: ≥ 65 years; gender: both; cognitive impairment: yes |
| Bellelli 2006170 | NR | A body weight-supported treadmill technique was better at improving gait and balance than conventional training |
| Italy |
| Quantitative non-comparative |
| Case report |
| Hospital |
| Thick |
| Participants: n = 1; age: ≥ 80 years; gender: both; cognitive impairment: yes |
| Bellelli 2008141 | Limitations: (1) no formal clinical evaluation of depression; and (2) unclear whether depressive symptoms developed before or after surgery | The co-occurrence of depression and dementia significantly increases the 12-month risk of dying in elderly patients after rehabilitation post-hip fracture surgery |
| Italy |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 211; age: ≥ 65 years; gender: both; cognitive impairment: yes |
| Bellelli 201078 | NR | Action observation treatment is a useful approach in the rehabilitation of post-surgical orthopaedic patients and may be a complementary or an alternative approach to current well-assessed rehabilitation treatments |
| Italy |
| Quantitative comparative |
| RCT |
| Hospital |
| Rich |
| Participants: n = 60; age: ≥ 18 years; gender: both; cognitive impairment: no |
| Binder 200492 | Limitations: (1) results can be generalised only to the subset of people with mild to moderate cognitive impairment or frailty after hip fracture; (2) transportation was provided to maximise study adherence, which may not be practical in many clinical settings, and the study sample may not reflect the eligible individuals who would be able to participate in this type of rehabilitation programme without such support; (3) individuals who dropped out of the control group between 3 and 6 months improved less on the FSQ at 3 months than individuals who continued, which may have biased the estimates of the magnitude of the group difference in FSQ score at 6 months; (4) the lack of a non-exercising control group limits the ability to determine the effect of different intensities of exercise on the functional outcomes and may have reduced the magnitude of the effect size of the physical therapy intervention; (5) physical therapy participants may have had greater social contact than control participants and it is possible that an increased level of socialisation enhanced their motivation more than in control participants and that this may account for some of the improvements observed, particularly in the SF-36 measures; however, the high compliance rate and lower dropout rate among control participants appear to reflect a high level of motivation and it is unlikely that differences in socialisation account for the changes observed in the modified PPT and strength measures, and this is supported by analyses of covariance that included the changes in SF-36 social functioning subscale scores; (6) the study was not designed to answer questions about the optimal timing of intensive physical therapy or weight training, and further study is needed to address this issue; and (7) most patients who had a hemiarthroplasty repair procedure were prescribed range-of-motion restrictions that prohibited them from performing some of the exercises, including lower-extremity weight training, until 10–12 weeks after their fracture | 6 months of extended outpatient rehabilitation that includes progressive resistance training can improve physical function and quality of life, and reduce disability compared with low-intensity home exercise in community-dwelling frail elderly patients with hip fracture |
| USA |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 90; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Bischoff-Ferrari 201093 | Strength: with the high level of frailty after acute hip fracture, the trial was powered for the end points investigated despite its moderate size | Extended physiotherapy was successful in reducing falls but not hospital readmissions |
| Switzerland |
| RCT |
| Hospital |
| Thick |
| Participants: n = 173; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Borgquist 1990188 | NR | Routine follow-up of hip fracture patients in the orthopaedic department after discharge can be omitted. Follow-up in primary health care without radiography and orthopaedic expertise gives good functional results provided that patients with pain and walking problems from the hip are guaranteed rapid specialist treatment. Rapid specialist involvement should be possible because of the outpatient resources released at the hospital |
| Sweden |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 298; age: ≥ 50 years; gender: both; cognitive impairment: no |
| Boyd 1982158 | NR | The rehabilitation ward programme reduced the average length of hospital stay by 18 days (27%), saving 8676 patient bed-days. This also motivated patients to participate in the rehabilitation activities |
| UK |
| Quantitative comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 771; age: NR; gender: female; cognitive impairment: no |
| Buddenberg 199879 | Limitations: (1) small sample size; (2) short follow-up period; and (3) lack of demographic variability in the study population | As participants were similar at baseline and on admission, and received the same number of hours of therapy, it appears that the improvements observed were due to the intervention received |
| USA |
| Quantitative comparative |
| Non-randomised trial/quasi-experimental study |
| Rehabilitation facility (no other details provided) |
| Rich |
| Participants: n = 20; age: ≥ 75 years; gender: female; cognitive impairment: partial |
| Burns 2007197 | NR | After hip fracture surgery, no statistically significant benefits can be achieved from a psychiatric intervention in people who are depressed or a psychological intervention to prevent the onset of depression |
| UK |
| Quantitative comparative |
| RCT |
| Hospital |
| Rich |
| Participants: n = 293; age: ≥ 60 years; gender: both; cognitive impairment: partial |
| Carmeli 2006131 | Limitations: (1) small sample size; (2) high dropout rate; (3) patients from specific government-sponsored hospitals so might not be a representative population; and (4) concerns about the randomisation process | The supervised/class-based exercise group had better outcomes than the non-supervised/home-based exercise group with regard to quality of life and functional performance |
| Israel |
| Quantitative comparative |
| Quasi-randomised trial |
| Hospital and community |
| Rich |
| Participants: n = 63; age: ≥ 75 years; gender: both; cognitive impairment: no |
| Casado 200980 | Limitations: (1) limited generalisability because the participants were mostly Caucasian and willingly participated in the study; (2) only expert aspect of the social support tested in the model; and (3) there was a poor fit of the model to the data and the significant paths explained only a small per cent of the variance in exercise; the consideration of additional variables that explain exercise performance among these individuals is needed | The positive effect of social support for exercise by experts on the outcome expectations for exercise in older women recovering from a hip fracture provides an opportunity for health-care providers to improve physical activity in this population. Age and fear of falling were related to outcome expectations, with those who were younger and had less fear of falling having stronger outcome expectations. Mental health status was related to self-efficacy and depression, as the participants who reported better mental health reported higher self-efficacy and fewer depressive symptoms. Treatment group assignment was related to social support from the experts, such that those exposed to the trainer had stronger social support for exercise. Treatment group assignment (treatment was equivalent to being exposed to any of the treatment groups) also had direct impact on exercise behaviour, indicating that exposure to treatment increased participants’ exercise activities. Social support from experts showed a significant relationship with outcome expectations, such that those who had stronger social support to exercise from the expert reported stronger outcome expectations for exercise. Those who were not exposed to this type of encouragement and who exercised with the trainer only also had improvement in social support for exercise, showing that supervised exercise programmes produce more positive outcomes than unsupervised ones in older adults. There was no significant relationship between expert social support and self-efficacy expectations. Although the significant relationship between social support from experts and outcome expectations may not be influencing current exercise behaviour, it may be important for long-term adherence to exercise. Outcome expectations for exercise have repeatedly been identified as a significant predictor of exercise behaviour over time, pointing to a critical long-term impact of outcome expectations on exercise adherence. The influence of experts on strengthening outcome expectations may therefore have a lasting effect on the hip study participants |
| USA |
| Quantitative comparative |
| RCT |
| Hospital |
| Rich |
| Participants: n = 168; age: ≥ 65 years; gender: female; cognitive impairment: partial |
| Cree 2001175 | Limitation: retrospective nature of the questions | Interventions aimed at improving post-fracture social support could increase health perception following hip fracture |
| Canada |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 222; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Crotty 200094 | Limitations: (1) randomisation and research procedures may have discouraged some people; and (2) patients received conflicting information from practitioners about their ability to manage at home and so were confused about whether or not to consent | Given the choice, hip fracture patients and their carers are less likely to choose early discharge and home rehabilitation, preferring a longer hospital stay and hospital-based rehabilitation, particularly for those living alone. It is necessary to expand these home rehabilitation programmes to educate providers, patients and carers |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 68; age: ≥ 50 years; gender: both; cognitive impairment: partial |
| Crotty 200395 | Limitations: (1) insufficient power to detect differences in many outcome measures because of the small sample size; and (2) the consent process allowed patients with a pre-existing preference for hospital care to refuse the possibility of home rehabilitation and automatically transfer to hospital rehabilitation | The intervention group had greater physical independence and more confidence that they would avoid falling while undertaking ADL. Successful early discharge programmes depend on careful selection of patients (medically stable, assessed as needing, and having adequate physical and mental capacity to participate in, a formal rehabilitation programme, expecting to return home after discharge from hospital, having a home environment suitable for rehabilitation and having adequate social support in the community) and their caregivers, and consultation with families is important to explain the nature of the programme and to relieve their suspicions of the motives for early discharge. With this approach, generally good outcomes for both patients and caregivers can be achieved in 12 months |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 66; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Dai 2002132 | Limitations: (1) a younger and healthier population than most so not representative of the normal hip fracture population; (2) risk of confounding of data collection before and after the study because of changes in hospital practice or policy, although sensitivity analyses showed no significant effects; (3) lack of blinding of outcome assessors; and (4) instead of random assignment, consecutive sampling was used. Strength: follow-up data after hospital discharge were obtained by home visits and direct patient contact, which is more reliable than telephone interviews | A multidisciplinary rehabilitation programme had a continuous positive effect on hip fracture patients and successfully maintained the functional recovery in mobility in elderly patients with hip fracture 6 months after hospital discharge. Earlier discharge from hospital in the intervention group compared with the control group facilitated a better recovery in ADL and mobility 6 months after hospital discharge. Patients with independent mobility before fracture, those patients who did not receive the multidisciplinary rehabilitation programme and women were less likely than others to regain pre-fracture mobility within 6 months of discharge |
| Taiwan |
| Quantitative comparative |
| Quasi-randomised trial |
| Hospital |
| Thick |
| Participants: n = 94; age: ≥ 60 years; gender: both; cognitive impairment: no |
| De Jonge 2001171 | NR | A dedicated team with orthopaedic and geriatric leadership can lead to improved efficiency and quality of care for hip fracture patients |
| USA |
| Quantitative non-comparative |
| Work process and service restructuring |
| Hospital |
| Thick |
| Participants: n = NA; age: NA; gender: NA; cognitive impairment: NA |
| Delmi 199096 | NR | Clinical outcome of elderly patients with femoral neck fracture can be improved by once-daily dietary oral supplementation |
| Switzerland |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 59; age: > 60 years; gender: both; cognitive impairment: no |
| Deschodt 201197 | Limitation: no blinding of participants, health-care professionals or members of the inpatient geriatric consultation team | There were no functional benefits of a recommendation-based and patient-centred inpatient geriatric consultation team model for major outcome parameters such as functional status and length of stay in people with hip fracture |
| Belgium |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 171; age: ≥ 65 years; gender: both; cognitive impairment: partial |
| Di Monaco 2008133 | Limitations: (1) overall population not representative and so the results are not generalisable; (2) large number of dropouts; (3) no blinding of participants and hospital staff; (4) modest study follow-up period (about 6 months); and (5) no record of the time of the first fall and so no survival analysis performed | A single home visit by an occupational therapist after discharge from a rehabilitation hospital significantly reduced the risk of falling in a sample of elderly women following hip fracture. The results suggest that ameliorating adherence to falls prevention advice may result in a further decrease in falls risk. Home visits, mainly targeted at environmental hazards, significantly reduced the risk of falling in the elderly |
| Italy |
| Quantitative comparative |
| Quasi-randomised trial |
| Hospital and community |
| Thick |
| Participants: n = 95; age: ≥ 60 years; gender: female; cognitive impairment: no |
| Dy 2011159 | Limitations: (1) the study included only male patients; (2) the retrospective nature of the study had several inherent limitations – (a) the assessment of comorbidity and post-operative complications was dependent on the clinical evaluation and documentation provided by previous health-care providers, (b) the occurrence of some of the complications, including delirium and decubitus ulcers, was derived from clinical documentation; because of the retrospective nature of the study, it was not possible to use standardised measures to assess for delirium and to grade the severity of decubitus ulcers; however, these limitation are persistent across both study cohorts, which limits its likelihood of influencing the study results, (c) no follow-up of outcomes after discharge, such as return to pre-hospital function, cognition and residence, which are important after sustaining a hip fracture and (d) inability to evaluate the functional impact of the programme at further post-discharge time points; and (3) inclusion of in-hospital outcomes only | Multidisciplinary collaboration for patients with hip fractures can decrease the likelihood of experiencing inpatient complications in male patients. Focused multidisciplinary models of care may improve short-term outcomes for patients with hip fracture but may not yield longer-term benefits |
| USA |
| Quantitative non-comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 74; age: ≥ 55 years; gender: male; cognitive impairment: no |
| Edwards 2004172 | Limitations: (1) issues related to system change; (2) resistance to change among staff – (a) staunch commitment to previous work patterns and relationships, (b) perceived lack of control by the care staff on the acute care units regarding the appropriate timing for referral to rehabilitation because of the consultation team automatically assessing all patients with hip fracture, and (c) patients were assessed within 2 days post-operatively and, in many instances, this may have been too soon to clearly identify rehabilitation potential. Strength: (1) advantages of the streamlined system – (a) potential to improve service coverage in times of staff shortage, (b) opportunity for new learning between two specialty teams, previously functioning separately, (c) this cross-fertilization shared office space and could become enhanced both formal and informal communication, (d) iterative discussions resulted in a more efficient, consolidated service with the potential for staff growth and expertise and (e) client-centred service means a shift in power to enable clients and families to have more control and be partners with service providers; there is greater flexibility in service delivery; thus, services fit the client rather than the reverse | The consolidated model of the HIPP consultation and rehabilitation team has the potential to improve service coverage. It was noted that this cross-fertilisation was facilitated when the staff shared office space and could become acquainted at a more personal level. Although the process of change required iterative discussions regarding both content and process of care, the effort expended resulted in a more efficient, consolidated service with potential for staff growth and expertise within the provision of a client-centred service |
| Canada |
| Quantitative non-comparative |
| Work process and service restructuring |
| Hospital |
| Thick |
| Participants: n = NA; age: NA; gender: NA; cognitive impairment: NA |
| Elinge 200398 | Limitations: (1) high refusal rate; (2) high dropout rate; (3) instruments not always sensitive enough to detect small changes and low levels of disability; and (4) small groups | A hip fracture may disrupt a person’s normal life in several ways and it is therefore important to give those elderly people who do not have the ability to participate in group activities, such as a learing programme, the rehabilitation that they are entitled to. In particular, this may be important for patients with low pre-fracture levels of physical and mental function, factors that strongly influence the rehabilitation outcome. This rehabilitation should be given in the home, so that patients do not have to decline a longer or more intense period of rehabilitation. Self-care and household activity training are important occupational therapy interventions for these patients but measures to support patients’ participation in society must not be disregarded, especially with regard to long-term rehabilitation |
| Sweden |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 35; age: ≥ 50 years; gender: both; cognitive impairment: no |
| Fortinsky 200281 | Limitation: small sample size, limiting the ability to evaluate the self-efficacy measure and preventing analyses that could shed light on important clinical variables that may independently affect reported rehabilitation therapy self-efficacy in the hospital setting, including medical comorbidities and physical symptoms such as pain and weakness | Patients with higher self-efficacy scores had a greater likelihood of locomotion recovery, controlling for pre-fracture locomotion function level and depressive symptoms |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 24; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Fox 1993200 | NR | Resource savings made by early discharge and reduced length of stay will be borne elsewhere in the community and at the expense of significantly reduced numbers returned home and increased numbers placed in nursing homes |
| UK |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 335; age: NA; gender: NA; cognitive impairment: no |
| Fredman 2006142 | NR | High positive affect seems to have a beneficial influence on performance-based functioning after hip fracture |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Community |
| Thick |
| Participants: n = 432; age: ≥ 65 years; gender: both; cognitive impairment: NR |
| Giangregorio 2009134 | Limitations: (1) it was not possible to blind outcome assessors; (2) patients were not randomised: (3) the control group had a longer length of stay on average and so may have received more therapy; and (4) therapists reported that it was easier to deliver hallway walking than body weight-supported treadmill training because of the time taken to put on the harness. Strength: body weight-supported treadmill training was particularly useful for obese patients and those with a great deal of pain on weight bearing | The current study provides preliminary evidence that it may be feasible to implement supported treadmill walking for patients with hip fracture in an inpatient rehabilitation setting. It also provides important feasibility information for future studies of interventions for patients with hip fracture in inpatient rehabilitation with respect to the screening-to-recruitment ratio, the recruitment challenges and the magnitude of loss to follow-up after discharge. Although evaluation of the efficacy of hip fracture rehabilitation interventions is needed, the challenges demonstrated here illustrate the difficulties of conducting rehabilitation research in this population. To optimise future research into hip fracture rehabilitation strategies, trials with sufficient sample sizes and rigorous methods for recruitment and retention are needed, as well as standardisation of outcomes to facilitate comparisons across studies |
| Canada |
| Quantitative comparative |
| Non-randomised trial/quasi-experimental study |
| Hospital |
| Thick |
| Participants: n = 21; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Giusti 2006143 | Limitation: lack of randomisation | Home-based rehabilitation seems to be a feasible alternative to institution-based rehabilitation for hip fracture in older adults previously living in the community with relatives |
| Italy |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 199; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Hagsten 200499 | Limitation: it was not possible to hide the allocation of patients in each group from nursing staff | Individualised occupational therapy training can speed up a patient’s ability to perform ADL on discharge from hospital, which enhances the possibility of the patient returning to independent living at home. Follow-up visits are rational for these elderly patients to make sure that they are performing well and that they are not in need of further medical and/or nursing intervention or rehabilitation |
| Sweden |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 100; age: > 65 years; gender: both; cognitive impairment: no |
| Hauer 2003130 | NR | Improved functional performance in the training group did not lead to an increased level of physical activity after training, which might have preserved the functional improvements. In mobility-restricted, frail geriatric patients, training programmes should continue to keep patients active and prevent the decline in strength and functional performance that precedes loss of autonomy |
| Germany |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 57; age: > 75 years; gender: female; cognitive impairment: no |
| Hoekstra 2011144 | Limitations: (1) not a randomised study; (2) inability to determine the relative effectiveness of different components of the multidisciplinary nutritional care programme; (3) observer and patient bias; (4) intervention provided at different time points; and (5) the seasonal effects (autumn/winter for the control group and spring/summer for the intervention group) could have affected the findings | A multidisciplinary nutritional care strategy increased the intake of energy, protein, vitamin D, zinc and calcium in the immediate post-operative period compared with standard nutritional care. The intervention group experienced a significant beneficial effect on quality of life and nutritional status compared with the control group. The intervention could not prevent a decline in quality of life or nutritional status, but this decline was lower in the intervention group than in the control group |
| The Netherlands |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 127; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Hoenig 1997168 | NR | Surgical repair within the first 2 days of hospitalisation and more than five physiotherapy/occupational therapy sessions per week were associated with better health outcomes in a nationally representative sample of elderly patients with hip fracture |
| USA |
| Quantitative non-comparative |
| Database analysis |
| Hospital |
| Thick |
| Participants: n = 2762; age: ≥ 65 years; gender: both; cognitive impairment: NA |
| Holmberg 1989160 | Limitations: (1) historical cohort; and (2) selection bias | Discharging directly home for rehabilitation reduces the lenth of hospital stay significantly, with similar outcomes |
| Sweden |
| Quantitative comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 170; age: ≥ 65 years; gender: both; cognitive impairment: NA |
| Host 2007153 | Limitations: (1) results can be generalised only to the subset of people with mild to moderate frailty after hip fracture; (2) a precise dose–response relationship could not be assessed for the phase 1 exercises because there was no quantitative measure of intensity, such as the one-repetition maximum (1RM), which was used in the progressive resistance training phase of the programme; and (3) during the progressive resistance training phase of the programme subjects performed bilateral exercises, but isokinetic strength assessments were performed unilaterally; the bilateral measures of exercise intensity (whether as the 1RM, as a percentage of the initial 1RM or as the training volume) were all highly correlated with the unilateral measurement of isokinetic peak torque | In frail elderly people after hip fracture and repair, a 6-month supervised exercise programme can induce gains in strength such that the fractured limb is essentially equivalent to the non-fractured limb. The concept of specificity of training does not apply to the fractured limb. There appears to be a strong relationship between exercise training intensity and functional performance adaptations |
| USA |
| Quantitative non-comparative |
| Controlled before-and-after study |
| Hospital and community |
| Thick |
| Participants: n = 31; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Huang 2005100 | Limitations: (1) this study was limited to one hospital; (2) small size and included a 3-month follow-up period; and (3) potential for compromise of blinding of hospital staff and research assistant | Appropriate discharge planning by a nurse and designed by a multidisciplinary team can improve quality of life, survival and the ability to perform ADL, while reducing readmission rates and length of stay in hospital for older people with hip fracture |
| Taiwan |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 126; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Huang 200982 | NR | Clinicians need to determine how best to foster social support to help older people maintain high levels of a positive sense of self and engage them in conversations about ageing, including the positive and negative aspects of the ageing process, to promote independence |
| Taiwan |
| Qualitative |
| Qualitative |
| Community |
| Thick |
| Participants: n = 15; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Huusko 2000101 | Limitation: no physician or assessor blinding | Hip fracture patients with mild or moderate dementia undergoing active geriatric and intensive rehabilitation can return to the community, have a shorter length of hospital stay, succeed to return to independent living and need less institutional care than hip fracture patients in a standard care programme |
| Finland |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 243; age: ≥ 65 years; gender: both; cognitive impairment: yes |
| Jackson 200183 | Limitations: (1) substantial interpretational problems because of the quasi-experimental design; (2) therapist bias in reporting Functional Independence Measure (FIM) scores because of favour of the occupational adaptation approach; (3) researcher-constructed satisfaction questionnaire has not been subjected to rigorous reliability and validity studies | Occupational adaptation was associated with a more efficient outcome and greater patient satisfaction. The occupational adaptation approach provides one framework for offering an occupation-based intervention that is client-centred and can be efficient, effective and satisfying |
| USA |
| Quantitative comparative |
| Quasi-randomised trial |
| Hospital |
| Rich |
| Participants: n = 24; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Jellesmark 201284 | Limitations: (1) cross-sectional design, which meant that it was not possible to determine the causal association between fear of falling and functional ability; (2) underestimation of the prevalence of fear of falling in patients because of the exclusion of patients who were unable to walk independently at discharge; possibly, fear of stigma and institutionalisation may have prevented participants from admitting to fear of falling; and (3) in the qualitative subset saturation of the data may not have been reached, which is an inherent problem in the explanatory sequential mixed-method design, and this may reduce transferability. Strengths: (1) mixed-methods design that allowed us to investigate the prevalence of fear of falling and associations between fear of falling, avoidance of activities and functional ability and at the same time facilitate a deeper understanding of fear of falling through in-depth interviews with those who experienced a high degree of fear of falling; and (2) the use of validated instruments and conducting the survey face to face improved data collection | Fear of falling was common and significantly associated with activity avoidance and disability, and affected the lives of elderly people recovering from hip fracture. Some patients were physically incapacitated by fear of falling. Fear of falling screening at hospital discharge might be beneficial in tailoring rehabilitation efforts to individual patients. It is assumed that a reduction in fear of falling would enhance self-efficacy and improve physical ability related to balance and strength. Rehabilitation efforts should start early and combine hospital-based training and home training |
| Denmark |
| Mixed methods |
| Mixed methods |
| Hospital and community |
| Thick |
| Participants: n = 33 surveys, n = 4 interviews; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Jensen 1979154 | Limitation: the assessment system applied in this series does not consider walking ability or ADL | More patients discharged to their home maintained their social function than patients discharged to a convalescent home or rehabilitation clinic |
| Denmark |
| Quantitative non-comparative |
| Controlled before-and-after study |
| Hospital and community |
| Thick |
| Participants: n = 518; age: any; gender: both; cognitive impairment: no |
| Johansen 2012145 | NR | Rehabilitation of older, multimorbid and disabled patients in a district inpatient rehabilitation centre improves independency to a higher degree and within a shorter time period than standard community rehabilitation in short-term beds in nursing homes. District rehabilitation centres seem to be an interesting model in societies challenged by increasing needs of primary health-care rehabilitation in an ageing population |
| Norway |
| Quantitative comparative |
| Concurrent cohort study |
| Community |
| Thick |
| Participants: n = 302; age: > 65; gender: both; cognitive impairment: partial |
| Jones 2002195 | Limitations: (1) no data available regarding the quantity and intensity of outpatient therapy; (2) observational study design with no comparable population; (3) large number of patients not analysed at the final outcome measurement point; and (4) no long-term follow-up measurements | Inpatient rehabilitation improved overall functional independence. Relative change indicated that the rehabilitation outcome for locomotion was not maximised, despite patients exhibiting large absolute gains during inpatient rehabilitation. The improvements demonstrated at discharge were maintained at follow-up
Improved locomotion skills and maximising the ability to transfer independently are areas in which inpatient rehabilitation may be targeted to improve function |
| Canada |
| Quantitative non-comparative |
| Controlled before-and-after study |
| Hospital |
| Thick |
| Participants: n = 100; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Jones 2006135 | Limitations: (1) small sample size; and (2) lack of randomisation makes it difficult to generalise the results to a larger population | This study demonstrates the benefits of a functional (task-specific) group exercise programme administered to community-dwelling older adults post hip fracture. The next logical step for future investigations would be to determine, through a RCT, whether or not the exercise intervention will reduce overall mortality and morbidity and improve quality of life for hip fracture patients |
| Canada |
| Quantitative comparative |
| Non-randomised trial/quasi-experimental study |
| Community |
| Thick |
| Participants: n = 25; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Kammerlander 2011178 | NR | The duration of rehabilitation for an optimal outcome in geriatric hip fracture patients is very long, but the results also show that an early geriatric intervention may lead to better function |
| Austria |
| Quantitative non-comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 246; age: ≥ 80 years; gender: both; cognitive impairment: NR |
| Kennie 1988102 | NR | This sudy confirms the effectiveness of geriatric rehabilitative aftercare for elderly women with hip fracture in terms of reducing the hospital stay and improving functional independence and the likelihood of patients returning to an independent life. Both hospital and patient benefited when post-operative rehabilitation was provided in a setting specialising in such care for elderly patients with trauma |
| UK |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 108; age: ≥ 65 years; gender: female; cognitive impairment: no |
| Kerr 2011173 | NR | The conceptual model summarised important experiences and related impacts of hip fracture from the patient’s perspective and demonstrates the wide-ranging effects on other areas of a patient’s life during the recovery process |
| USA |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 21; age: ≥ 50 years; gender: both; cognitive impairment: no |
| Koval 1998146 | Limitations: (1) results not generalisable to previously institutionalised or demented elderly patients; (2) follow-up data collected by telephone interview and so less accurate than data collected face to face; and (3) presence of selection bias because the request for a rehabilitation consultation and the ultimate discharge to the rehabilitation programme were at the physician’s discretion. Strengths: (1) patients were mobilised within 48 hours post-operatively, countering the potential confounding effect of differing weight-bearing protocols; and (2) prospective data collection and small number lost to follow-up | Use of the diagnosis-related-group-exempt rehabilitation programme increased the overall duration of hospitalisation, but decreased acute care hospitalisation. Patients discharged to the rehabilitation programme had no additional benefit with regard to recovering to their pre-fracture level of independence in basic ADL at the 3-month follow-up than patients who were not discharged to the programme |
| USA |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 609; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Kuisma 2002103 | Limitations: (1) treatment bias because of inability to blind health professionals; and (2) results of the study are not generalisable patients living alone or patients not having adequate support at home unless alternative community care is available | Five physiotherapy sessions in the patient’s home after discharge yielded equal or better results in ambulation ability than 1 month of conventional institution-based rehabilitation. All of the patients in the intervention group were able to walk independently in all circumstances at the completion of the study; hence, home-based physiotherapy for patients with hip fracture is an effective alternative to institutional care |
| Hong Kong |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 81; age: ≥ 50 years; gender: both; cognitive impairment: no |
| Latham 2006167 | Limitations: (1) use of secondary data generated for the purpose of clinical and utilisation management decision-making, so cautious interpretation required; and (2) external validity, because the study sample consisted only of patients covered under Medicare Advantage for their skilled nursing facilities stay | The pattern of functional change over time differed for ADL and mobility domains and for specific groups of patients. People with severe baseline mobility impairments experienced a slower rate of mobility improvement in the initial stage of rehabilitation, but the rate of change increased in the second phase. This pattern was reversed for patients with higher levels of mobility at baseline. For both domains, executive function and length of stay were associated with the overall rate of change. The results have implications for goal-setting and discharge planning |
| USA |
| Quantitative non-comparative |
| Database analysis |
| Hospital |
| Thick |
| Participants: n = 351; age: any; gender: both; cognitive impairment: no |
| Lauridsen 2002104 | Limitation: high withdrawal rate in the intervention group | Because of the high dropout rate in the intervention group intensive physical therapy may not be the way to reduce the duration of rehabilitation. Patients with hip fracture often have a multitude of problems requiring a multidisciplinary approach. A significant reduction in length of stay is likely to require a modified objective with more emphasis on outpatient rehabilitation |
| Denmark |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 88; age: 60–89 years; gender: female; cognitive impairment: partial |
| Levi 1997147 | Limitations: (1) sample not representative of the hip fracture population (women, community dwelling and mentally and physically fit); and (2) small numbers for multiple regression analyses | Type of post-hospital setting is associated with resource utilisation but not self-care outcome after hip fracture. Discharge to a skilled nursing setting rather than an inpatient rehabilitation setting is associated with more than double the number of days spent in post-hospital institutions, more sessions of physical therapy and more sessions of occupational therapy, and is not predictive of a decreased ability to perform ADL 2 and 6 months after hip fracture |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 123; age: ≥ 65 years; gender: female; cognitive impairment: no |
| Li 2007189 | Limitation: the findings are limited because of the purposive sampling method used, chosen because of financial limitations, and the short follow-up period | The findings provide evidence to support and expand the application of the concept of interdependence in the Taiwanese context regarding the families of an elderly relative with hip fracture during the post-discharge period. The findings of this study may benefit health-care providers in other countries with an elderly Chinese population in terms of developing more culturally relevant discharge plans |
| China |
| Qualitative |
| Qualitative |
| Hospital and community |
| Thick |
| Participants: n = 20; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Lieberman 2002148 | Limitations: (1) selection bias; and (2) outcomes assessed at discharge only and no follow-up | Rehabilitation after proximal femur fracture surgery is much less successful in the ≥ 85 years age group than in the 75–84 years age group, but there were no differences in duration, the rates of most complications or mortality. A substantial percentage of patients in the older age group were rehabilitated successfully and they should not be denied the chance of successful surgery and rehabilitation, although the younger age group improved more than the older age group |
| Israel |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 424; age: ≥ 75 years; gender: both; cognitive impairment: no |
| Lieberman 2006179 | Limitations: (1) not all patients who underwent surgery were included, leading to an inevitable selection bias; and (2) rehabilitation outcome was assessed at the point of discharge from the hospital | The outome of rehabilitation of elderly patients after hip fracture surgery was associated with four correctable clinical and nutritional parameters. The other four associated significant variables cannot be corrected but may help in predicting outcomes and adjusting expectations of all individuals involved in the rehabilitation process |
| Israel |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 946; age: ≥ 65 years; gender: both; cognitive impairment: partial |
| Lin 2004190 | Limitations: (1) correlations between cognitive function and recovery were not studied and therefore the results must be interpreted with caution; and (2) many patients were lost to follow-up after discharge because of incorrect contact details provided or family refusal to answer the telephone or return items by post | Fracture leads to deterioration in physical function despite the high rate of surgical success. In addition, most elderly people suffer from chronic disease and therefore physical function cannot be recovered after 3–6 months of healing. Rehabilitation should be carried out to improve muscle strength and enhance the self-care ability of the elderly. Comprehensive discharge planning, including pre-discharge instruction, referral and home follow-up, is needed to ensure that patients are properly prepared for discharge |
| Taiwan |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 103; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Lin 2009105 | Limitation: small sample size | A comprehensive discharge planning service can improve hip fracture patients’ self-care knowledge, functional recovery and quality of life |
| Taiwan |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 50; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Lindelof 2002180 | Limitations: (1) greater variation between participants would have been desirable; and (2) the design used may have been unnecessarily cautious | The results of this treatment are promising and should offer encouragement to elderly patients with hip fracture to carry out these exercises. Functional training with a weighted belt seems to show broad effects with regard to mobility and could be suitable for frail elderly persons in general |
| Sweden |
| Quantitative comparative |
| Controlled before-and-after study |
| Hospital |
| Thick |
| Participants: n = 3; age: ≥ 78–82 years; gender: female; cognitive impairment: no |
| Long 2002198 | Limitation: the fact that the study is based on fieldwork of contrasting case studies, clients and settings in one region of England may be seen to limit the generalisability, authenticity and credibility of the findings | Key elements of nurses’ contribution within rehabilitation should aim to maximise client choice to enhance independent living in the clients’ future environment. At a nursing educational policy level, nurses need to have a full understanding of the principles and models of rehabilitation. At a practice level, the nurse’s role must be valued and recognised, by nurses themselves and by other team members |
| UK |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 49 health professionals; age: NA; gender: both; cognitive impairment: NA |
| Louie 2012106 | Limitations: (1) small sample size; (2) no intention-to-treat analysis; (3) no outcome measures to investigate whether or not carers could carry out the necessary caregiving skills and the degree of change in carer stress after participating in the carer training sessions; and (4) no long-term follow-up | Participants who underwent the PCEP were more likely to build on the use of their newly adapted ADL skills. PCEP empowered patients to reinforce their skills and knowledge of hip fractures and ADL. The programme encouraged patients to take a more active role in their rehabilitation |
| Hong Kong |
| Quantitative comparative |
| RCT |
| Hospital |
| Rich |
| Participants: n = 134; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Mangione 2010107 | Limitations: (1) small sample size; (2) single, unblinded interventionist; (3) high dropout rate; (4) baseline differences in modified PPT scores; and (5) lack of information regarding activities that participants performed from the end of the intervention period to the end of the trial. Strengths: (1) use of an attentional control for patients after hip fracture made it possible to control for attention and motivation, which physiotherapists are known to provide during treatment; (2) despite the small number in the trial, the strength of the design provides support for the leg-strengthening intervention being effective; (3) attempts were made to minimise bias with concealed randomisation and blinded outcome assessors; (4) outcomes measured several months after the intervention was completed; and (5) baseline differences were controlled for using ANCOVA | A 10-week programme of twice-weekly progressive resistance training for the leg muscles beginning 6 months after hip fracture was effective at improving force production, gait speed and endurance and physical performance 1 year after hip fracture |
| USA |
| Quantitative comparative |
| RCT |
| Community |
| Rich |
| Participants: n = 26; age: > 65 years; gender: both; cognitive impairment: no |
| McKee 200285 | Limitation: small, convenience sample prohibiting the exploration of interactions between a larger number of variables; thus, study findings not generalisable. Strengths: (1) sample representative of the target population; and (2) high recruitment rate and satisfactory response rate for the follow-up assessment | Assessing worry over further falls in hospital may help to identify older people with hip fracture at risk of poor health outcomes |
| UK |
| Mixed methods |
| Controlled before-and-after study |
| Hospital and community |
| Thick |
| Participants: n = 57; age: ≥ 65 years; gender: both; cognitive impairment: no |
| McMillan 201286 | NR | Older people are vulnerable to losing a sense of control after a health trauma; hence, they and their families need tailored information and support to enable them to take control safely and appropriately. This is especially important for those who are able to return to their own home (and who might not have family and/or professional support) and engage in a precarious process of balancing as they strive to take control. Health-care professionals need to understand the perspective of older people and recognise that the efforts that people make to take control are a consequence of balancing. This understanding can enable health-care professionals to enhance their care of older people and will help them to facilitate successful balancing and progression through the recovery trajectory |
| UK |
| Qualitative |
| Qualitative |
| Hospital and community |
| Rich |
| Participants: n = 27; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Mendelsohn 2008108 | Limitations: (1) small sample size; (2) inclusion criteria of relatively high cognitive functioning and high physical functioning affect the generalisability of the results; (3) conflict between scheduled physiotherapy and occupational therapy sessions and the testing and training schedule in the study; and (4) no increase in intensity, duration or frequency of training during the training programme | The upper-body exercise programme had a significant effect on aerobic power and physical function, including mobility and balance; hence, aerobic endurance exercise should be integrated into standard rehabilitation to enhance patients’ aerobic fitness and mobility after hip fracture surgery |
| Canada |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 20; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Mitchell 2001109 | Limitations: (1) low compliance rate (75%); (2) high rate of loss to follow-up; and (3) observer bias as researchers not blinded to treatment allocation. Strengths: (1) populations representative of the general population so the results are generalisable; and (2) study groups well matched in terms of baseline characteristics | A 6-week programme of twice-weekly progressive high-intensity quadriceps training in elderly proximal femoral fracture patients increased leg extensor power and reduced disability, accompanied by an increase in energy. Benefits persisted for at least 10 weeks after finishing the training programme. The programme was well tolerated by frail elderly subjects who are rehabilitating after proximal femoral fracture. The treatment requires only very basic, inexpensive equipment, such as weighted sandbags, which are placed over the ankle |
| UK |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 80; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Moore 1993181 | NR | Functional gains are made through both physiotherapy and occupational therapy during home care of patients with hip fracture |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 32; age: NR; gender: both; cognitive impairment: no |
| Morghen 2011182 | Limitations: (1) the only measure used to assess depressive symptoms was the 15-item GDS, although previous studies have shown this to be reliable; (2) the study was conducted at only one site and it is not known whether patients lost to follow-up died or became institutionalised; and (3) variables with a possible influence on functional recovery, such as fracture site, type of anaesthesia, degree of pre-operative risk and vitamin D levels, were not assessed | Moderate to severe depressive symptoms in post-hip fracture surgery patients, as measured by the GDS, are associated with poor walking recovery after rehabilitation and an increased risk of institutionalisation or death at 1 year. In addition to those of previous studies, these results may provide valuable clues for designing trials of interventions and developing individualised rehabilitation pathways that consider moderate to severe affective disorders as a specific target of interest |
| Italy |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 230; age: > 65 years; gender: both; cognitive impairment: yes |
| Moseley 2009110 | Limitations: (1) insufficient differences between the high- and low-dose exercise programmes; and (2) relatively short duration of the exercise programmes (i.e. 16 weeks). Strengths: (1) trial carefully designed and implemented according to a strict experimental protocol; and (2) adequate sample size, with a very low dropout rate and good compliance with the exercise programmes | There was no benefit (or harm) of the higher-dose, weight-bearing exercise programme with respect to the primary outcome measures. However, patients with cognitive impairment gained greater benefit and there was a statistical and clinically relevant improvement in functioning, mobility, balance, ADL and quality of life from the higher-dose programme than from the lower-dose programme |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 160; age: ≥ 70 years; gender: both; cognitive impairment: yes (if carer available) |
| Munin 2005149 | Limitations: (1) no cost comparison; (2) subjects recruited from one facility, so limited generalisability; (3) incomplete follow-up data for some patients; (4) possible bias by the research occupational therapist, influencing FIM motor data; and (5) selection bias because group selection was based on clinical decision-making rather than on random group assignment. Strength: use of sensitive measures to evaluate cognition and behavioural domains | Hip fracture survivors treated in inpatient rehabilitation facilities had superior functional outcomes, as measured by the FIM motor score, than those treated in skilled nursing facilities. The improved outcomes with inpatient rehabilitation occurred during a significantly shorter rehabilitation length of stay |
| USA |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 76; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Naglie 2002111 | Limitation: limited statistical power | Post-operative interdisciplinary geriatric care in an acute care hospital did not result in a significantly better 3- and 6-month combined outcome of the proportion of patients who were alive and had no change in ambulation, transfers or residence or in significantly better outcomes individually or in significantly better ADL in patients with hip fracture |
| Canada |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 279; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Nicholson 1997136 | Limitations: (1) small sample size; (2) large dropout rate; (3) non-randomisation of study groups; (4) absence of a controlled intervention for the control group; and (5) short rehabilitation intervention of 6 weeks. Strengths: the exercise programme required no special equipment, was easily implemented, was safe and cost-effective and was applicable in a nursing home setting | The intervention contributed to the maintenance of the physical condition of older women temporarily disabled as a result of a fracture and subsequent hip surgery. Frail elderly participants were no worse off for their involvement in the 6-week chair exercise programme and showed some significant improvements in body composition |
| South Africa |
| Quantitative comparative |
| Non-randomised trial/quasi-experimental study |
| Hospital and community |
| Thick |
| Participants: n = 30; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Ohsawa 2007137 | Limitations: (1) small sample size; (2) non-randomised trial; (3) results not generalisable as the programme was indicated only for patients who accepted the programme and was suitable for more active and vigorous patients; (4) unblinded assessment of hip function; and (5) 6-month follow-up only | Assertive rehabilitation was more effective at restoring the ambulatory ability of frail elderly patients with intracapsular fracture of the hip than conventional care. Assertive rehabilitation is recommended as a conservative treatment for displaced intracapsular fractures of the proximal femur in frail elderly patients as it provides better improvements in ADL than conventional therapy and seems to be an alternative to surgery for patients with poor general condition |
| Japan |
| Quantitative comparative |
| Non-randomised trial/quasi-experimental study |
| Hospital |
| Thick |
| Participants: n = 20; age: ≥ 80 years; gender: both; cognitive impairment: no |
| Oldmeadow 200687 | Limitations: (1) patients were not followed up beyond acute care and it is not possible to say if early ambulation, with its associated improved functional outcomes, resulted in shorter lengths of stay overall; given that early ambulation can be uncomfortable and challenging for patients, investigating their experiences would also have been informative; and (2) current clinical practice is to prescribe bed rest in the presence of cardiovascular challenge and so ambulation was not attempted for most of these patients | Early ambulation in the presence of medical stability accelerates functional recovery, contributes to shorter lengths of stay, is associated with more discharges directly home and less to high-level care and results in lower levels of dependency at discharge from acute care. These benefits justify the intense resources required. Cardiovascular stability is a major determinant of successful early ambulation after hip fracture surgery |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 60; age: ≥ 70 years; gender: both; cognitive impairment: no |
| Olsson 200788 | NR | Differences in patients’ perspectives on the rehabilitation process need to be taken into account to enhance outcomes. Inadequate knowledge and engagement on the part of patients with a hip fracture probably have an impact on their rehabilitation outcome, but the degree of this impact is uncertain |
| Sweden |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 13; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Orwig 2011191 | Limitation: study included a select group of female participants who were healthier than the average hip fracture patient and who showed greater physical functioning and a smaller relative decline in bone mineral density. Strength: the intervention was delivered in participants’ homes. Participants were visited by certified trainers early in the intervention period, leading to the high level of acceptance of the intervention and greater level of activity in the intervention group | Patients with hip fracture who participated in a year-long, in-home exercise programme increased their activity level than those receiving usual care; however, no significant changes in other targeted outcomes were detected |
| USA |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 180; age: ≥ 65 years; gender: female; cognitive impairment: no |
| Oude Voshaar 200712 | Limitations: (1) patients with delirium and a severe cognitive impairment or other significant mental health conditions were excluded; and (2) short follow-up period of 6 months. Strengths: (1) large sample size; (2) the measurement of predictive variables at baseline and at 6 weeks and the assessment of different psychological variables within one study; and (3) use of highly validated and reliable outcome variables to measure performance-based functional outcome | Fear of falling and cognitive functioning may be more important than pain and depression in predicting functional recovery after hip fracture surgery. Cognitive impairment, depressive symptoms and a higher fear of falling are related to a less favourable functional recovery independent of age and pre-morbid level of functioning, whereas the effect of pain on functional recovery is less consistent. Depression increases the impact of a hip fracture on patients’ lives more than can be explained by the degree of objective functional impairment |
| UK |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 291; age: > 60 years; gender: both; cognitive impairment: partial |
| Peiris 2012112 | Limitation: the activity monitor recorded only steps with a cadence of ≥ 20 steps per minute and did not record activity in lying or sitting positions and so bed and sitting exercises were not recorded; monitors placed on the affected limb underestimated step counts at slower walking speeds but this was rectified by placing the monitor on the unaffected limb | Additional allied health rehabilitation services at the weekend increased activity levels of patients who received them, not only at the weekend but also on the following days. However, patients’ lower limbs may not be sufficiently active during inpatient rehabilitation as inpatients are most active during physical therapy and occupational therapy sessions and do little habitual physical activity when not under the supervision of therapists |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 105; age: > 18 years; gender: both; cognitive impairment: no |
| Penrod 2004192 | Limitations: (1) observational study design leading to differential provision of physiotherapy and/or occupational therapy to patients based on their likelihood of benefiting from these, as well as differences in timing and frequency; (2) limitation of the locomotion subscale of the FIM in terms of the amount of assistance that patients receive from a person or device to walk and climb stairs and not measuring gait speed or fear of falling that might have improved by early physiotherapy; (3) analysis performed of survivors only, who might have been healthier and hence may not represent the elderly/frail population; and (4) the number of therapy sessions is only one part of the rehabilitative and overall package of services received by patients with hip fracture; little is known about how the timing and intensity of therapy sessions might affect the outcomes and, moreover, the reimbursement policy, rather than clinical judgement or evidence of effectiveness, may largely dictate the prescription of the timing and intensity of therapy sessions | There was a mobility advantage at 2 months post hip fracture for patients who received more physiotherapy between the day of hip fracture surgery and the first 3 post-operative days. However, the association between early physiotherapy and mobility improvement was attenuated at 6 months post fracture. Hence, early mobilisation and physiotherapy sessions are prudent for patients undergoing surgical repair after fracture of a hip |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 443; age: ≥ 50 years; gender: both; cognitive impairment: no |
| Peterson 2004113 | Limitations: (1) the peer visits were not well received and so that component was discontinued; (2) some patients were not discharged directly home but to acute and subacute care facilities, which delayed the start of the intervention; (3) some participants received care at home other than the intervention or standard care; and (4) participants were reluctant to return to the hospital for assessment | Although strength training and balance exercises may improve rehabilitation after hip fracture, it not possible to illustrate an effect from this study. Both intervention and control participants were involved in exercise programmes elsewhere and it was impossible to monitor the type of training received. This study attempted too much in a short time period when participants were showing rapid improvement anyway |
| USA |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 70; age: ≥ 65 years; gender: both; cognitive impairment: NA |
| Petrella 2000169 | NR | There may be a discrepancy between the attention of the rehabilitation programme on functional outcomes and less emphasis being placed on confidence-building behaviours. Restrictions in function from a fear of falling may negate any gains made through rehabilitation and this could limit the long-term success of these programmes and patient outcomes after hip fracture |
| Canada |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 56; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Portegijs 2008114 | Limitations: (1) study was underpowered; and (2) the fractured leg was not always the weaker leg because of potential influences of other diseases and injuries affecting one leg since the hip fracture; the training, specifically aiming to reduce asymmetric deficit, may thus be more effective when targeted to a population with a clear and consistent deficit, such as in the rehabilitation phase after disease or injury affecting one leg only | Intensive resistance training is feasible for people with a hip fracture and helps improve muscle strength and power. The intervention group had better walking ability and outdoor mobility. Patients may be more responsive in the rehabilitation phase after major injury when the asymmetric deficit is likely to be large |
| Finland |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 46; age: 60–85 years; gender: both; cognitive impairment: no |
| Portegijs 2012166 | Limitations: (1) because of the exclusion criteria, participants had a relatively high level of functioning compared with hip fracture patients in general and so generalisation of the results should be carried out with caution; and (2) because of the cross-sectional study design, the chronological order of lack of balance confidence and limitations in mobility and balance performance and the relationship to the hip fracture event remain unclear | In older people with fall-related hip fracture, an independent relaptionship exists between balance confidence and a range of performance-based and self-reported mobility and balance performance measures. In this group of older people, a score of < 85 on the Activities-specific Balance Confidence scale identified those with mobility and balance limitation. Identification of those with a lack of balance confidence seems clinically relevant as it may compromise functional recovery. Potentially, rehabilitation may be more effective when lack of balance confidence is taken into account or targeted. However, further study is needed to develop existing strategies to improve balance confidence and reduce the functional decline associated with hip fracture |
| Finland |
| Quantitative comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 130; age: ≥ 60 years; gender: both; cognitive impairment: partial |
| Proctor 200813 | NR | Psychological interventions should be formulation led and based on the specific individual needs of the person, a core prerequisite to any psychological approach. Therefore, it is essential that clinical psychologists facilitate and disseminate the use of psychological strategies by providing teaching, training and consultation to other professionals within health-care services |
| UK |
| Case studies |
| Historical cohort study |
| Hospital |
| Rich |
| Participants: n = 3 case studies; age: NR; gender: both; cognitive impairment: no |
| Pryor 1988150 | NR | A large proportion of patients need rehabilitation in hospital. The orthogeriatric system would seem most appropriate for such patients, and it can also significantly reduce the length of hospital stay |
| UK |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 200; age: any; gender: both; cognitive impairment: no |
| Resnick 200572 | Limitation: sample was selected based on specific inclusion criteria and hence the results may not be applicable to all hip fracture patients | The Exercise Plus Program had beneficial effects on hip fracture patients and lessons learned can be translated to the development of other motivational interventions to help engage older adults in exercise |
| USA |
| Qualitative |
| Qualitative |
| Community |
| Rich |
| Participants: n = 70; age: any; gender: both; cognitive impairment: no |
| Resnick 200769 | Limitations: (1) the older women in this study were relatively healthy, lived in the community prior to fracture and willingly participated in an exercise intervention study; (2) there was variability in terms of when the intervention was initiated (because of participant willingness to allow the trainer to come out to the home setting) and some group differences in the number of visits to which participants were exposed; (3) there was an inability to control the type and amount of efficacy information that participants were exposed to, limiting interpretation of the findings; (4) multiple measures were based on recall; and (5) differences in time spent exercising cannot be addressed because of the short follow-up. Strength: it was possible to engage these women in a home-based exercise programme and the Plus only, exercise only or combined Exercise Plus Program resulted in the desired outcome of increased time in exercise | Older adults should be helped to realistically assess their self-efficacy and outcome expectations related to exercise. Health-care providers and friends/peers should be encouraged to reinforce the positive benefits of exercise. Fear of falling should be addressed throughout the entire hip fracture recovery trajectory, well after the initial fracture. Interactions with peers, possibly peers who themselves exercise (and who may have experienced a hip fracture), has a positive influence on self-efficacy related to exercise post hip fracture. Practitioners should consider the use of peers to strengthen beliefs and thereby improve exercise behaviour in older adults post hip fracture. There was no evidence of a trainer effect during any of the testing time points. Thus, the benefits of encouraging exercise are not trainer specific and the skills to be an effective trainer may be easily learned. Self-efficacy and outcome expectations had no direct relationship with exercise. Instead, they indirectly related to exercise through stage of change. Thus, the interventions might best be targeted at encouraging self-efficacy related to readiness to adopt exercise behaviour, after which time exercising will increase. Future research is needed to replicate the findings of this study as demonstrating the beneficial impact of the Plus component alone has practical implications in clinical settings |
| USA |
| Quantitative comparative |
| RCT |
| Community |
| Rich |
| Participants: n = 208; age: ≥ 70 years; gender: female; cognitive impairment: no |
| Richards 1998128 | NR | The early discharge hospital-at-home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services |
| UK |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 241; age: > 65 years; gender: both; cognitive impairment: no |
| Roberto 1992165 | Limitations: (1) study design limitations: retrospective and cross-sectional and so has inherent biases; (2) the cross-sectional nature of this study limits the examination of coping to immediately after the hip fracture; it is not known if this strategy continued to be employed over the course of the recovery period; and (3) the women interviewed had survived an incident known for its high mortality rate; no information available about the resources or coping strategies of women who did not survive the trauma or who chose not to participate in the study | Coping with an enduring health condition is a daily challenge for many older adults. A better understanding of the types of strategies commonly used by older individuals to cope with health-related problems will provide greater insight into the reactions and behaviours of older adults |
| USA |
| Quantitative non-comparative |
| Historical cohort study |
| Community |
| Rich |
| Participants: n = 101; age: 65–94 years; gender: female; cognitive impairment: no |
| Roberts 2004155 | Limitation: study design was subject to contamination of the intervention effect, which was addressed by abstracting all data from the medical records prospectively and obtaining audit data from the nearby orthopaedic units for the same time frames to control for external influences during the study; this design represents a pragmatic solution to the difficulties of preventing contamination | The integrated care pathway was associated with improvements in the process and better outcomes of care, such as improved mobility on discharge, fewer infections and pressure sores, and a trend towards fewer admissions to institutional care for a group of patients with complex needs. Care pathways for hip fracture patients can be a useful tool for raising care standards but may require a longer hospital stay and additional resources such as greater occupational therapy use |
| UK |
| Quantitative comparative |
| Controlled before-and-after study |
| Hospital and community |
| Thick |
| Participants: n = 764; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Robinson 1999183 | Limitation: it is possible that the researcher and moderator may have influenced the groups’ interactions; with focus group research, the researcher and moderator are actively involved in the production of data. Strength: both the moderator and the researcher attempted to be sensitive to this issue by ensuring that their interactions were open, authentic and sensitive to the participants | The participating women were confronted with an array of problems, which were labelled function-inhibiting factors. To overcome these problems, they mobilised their adaptive approaches to life. In addition, they identified various interdisciplinary interventions, labelled function-promoting factors, which helped to provide a successful transition. From these findings, a programme of interdisciplinary interventions was identified that could be implemented in subacute units and tested to establish its effectiveness in promoting a successful transition following hip fracture |
| USA |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 15; age: > 70 years; gender: female; cognitive impairment: no |
| Röder 2003151 | Limitations: (1) non-randomised study design; (2) small sample size; and (3) only patients with normal mental status were enrolled in the study, which might have meant that fitter individuals were recruited, and so the results might not be generalisable | After receiving institutional rehabilitation following surgical treatment of hip fracture there was improvement in patients’ activities of daily living and Instrumental Activities of Daily Living scale scores compared with pre-surgical evaluations; patients regained approximately 80–90% of their initial baseline scores (pre-fracture status) within 6 months of rehabilitation; and there was no significant impact on mortality and morbidity in patients of normal mental status |
| Germany |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 142; age: ≥ 65 years; gender: both; cognitive impairment: partial |
| Rolland 2004184 | Limitations: (1) assessments of comorbidity and medication use prone to reporting bias in cognitively impaired patients; (2) small sample size; and (3) underpowered study for analysis | Cognitively impaired elderly patients with hip fracture can benefit from participation in rehabilitation programmes and improve their functional status; this benefit can be small compared with the maximum theoretical functional gain but it is in accordance with their initial functional status |
| France |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 61; age: ≥ 70 years; gender: both; cognitive impairment: yes |
| Rösler 2012152 | NR | Treatment in a specialised cognitive geriatric unit resulted in better mobility of demented patients with proximal fracture of the femur but did not result in significant increases in ADL scores and number of patients discharged back home |
| Germany |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 129; age: any; gender: both; cognitive impairment: yes |
| Ryan 2006115 | Limitations: (1) low recruitment and uptake rate; (2) smaller sample size than calculated for power of the study; (3) large dropout rate (n = 13/58) and so the analysis was performed through simple imputation, which might increase the likelihood of detecting a significant difference; and (4) lack of information regarding the nature of the intervention | A more intensive community-based multidisciplinary therapy service after discharge from hospital following a hip fracture is unlikely to result in short-term benefit in relation to social participation and some aspects of health-related quality of life |
| UK |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 58; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Saltvedt 2012116 | Limitations: (1) study sample; (2) non-blinding of assessors; (3) choice of end points; and (4) content and performance of the experimental intervention programme | A new treatment program for old hip fracture patients was developed, introduced and run in the Department of Geriatrics, the potential benefits of which were compared in a RCT with those of traditional care of hip fracture patients in the Department of Orthopaedic Surgery; the results will be reported later |
| Norway |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 401; age: ≥ 70 years; gender: both; cognitive impairment: yes |
| Shawler 2006174 | Limitations: (1) despite attempts to include an ethnically diverse sample, all mothers and daughters in the study were European American; (2) even with prolonged engagement and multiple interviews, social desirability may have influenced the women’s reports; and (3) because mothers and daughters had to agree to participate together in this study, dyads with problematic relationships may not have been equally represented | Older women are at a much higher risk of disabling conditions as they age. Therefore, it is imperative that nurses recognise and acknowledge the courage needed and used by older mothers and their caregiving daughters during a health crisis. Nurses can reinforce the courage and inner strength of older women so that they may be empowered to manage and grow from the complicated times of the health crisis |
| USA |
| Qualitative |
| Qualitative |
| Community |
| Thick |
| Participants: n = 6 mother–adult daughter dyads); age: 76–85 years; gender: female; cognitive impairment: no |
| Sherrington 1997117 | Limitations: (1) no participant blinding so it is possible that part of the improvement found in the intervention group group may have been a result of the increased motivation and effort expended; (2) experimenter bias, as the investigator who assessed the subjects was not blind to treatment status; and (3) emphasis was placed on simple, portable tests for the measurements of strength, balance and gait; these assessment tools achieved this aim but may have lacked some of the precision of more sophisticated laboratory equipment | The exercise programme improved strength and mobility following hip fracture and significantly reduced fall risk factors, yet was relatively inexpensive as it was carried out in subjects’ home environment with basic equipment. Significant changes were noted in a short time frame and greater improvements may be possible with ongoing exercise of this nature |
| Australia |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 44; age: > 60 years; gender: both; cognitive impairment: no |
| Sherrington 2004118 | Limitations: (1) no assessor blinding; and (2) the exercise programme was conducted in the home with little supervision and so it was not possible to gather reliable information about the actual intensity of training; hence, practice recommendations cannot be made accurately and reliably. Strength: the external validity of the study is likely to be high; subjects were representative of those with fractured hips, people with a wide range of ages (57–95 years) were included and there were few exclusion criteria and, in addition, participants were recruited from several hospitals, both public and private care, and from several different settings (orthopaedic wards, rehabilitation wards, physical therapy departments); participants had received several different treatment approaches before entering the study and represented a range of socioeconomic and ethnic backgrounds | A weight-bearing home exercise programme with limited supervision can improve balance and functional ability to a greater extent than a non-weight-bearing programme or no intervention among older people with a fall-related hip fracture. All participants completed the usual post-fracture care, so it is evident that they had the potential for further improvements in physical functioning |
| Australia |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 120; age: ≥ 55 years; gender: both; cognitive impairment: no |
| Shyu 2008119 | Limitations: (1) older patients with severe cognitive impairment and weak muscle power were excluded and so the effect of the intervention can be generalised only to hip-fractured elders without severe cognitive impairment and with adequate muscle power in their extremities; (2) single-blind design in which the personnel delivering the intervention and assessing the outcomes were not blinded; (3) lack of baseline measures for health-related quality of life before implementing the intervention programme; (4) method of randomisation (coin flip) might have resulted in a dynamic bias; and (5) the effects of the intervention might not be observed if implemented in other countries because of different health systems, limiting the generalisability of the findings. Strength: intention-to-treat and on-protocol analyses had similar results | An interdisciplinary intervention for hip fracture with a geriatric hip fracture programme and a discharge support component benefited elderly patients without severe cognitive impairment by improving their self-care ability, walking ability and health-related quality of life, and decreasing depressive symptoms, number of subsequent falls and emergency department visits during the 2 years after hospital discharge. The results provide quantitative estimates for the trajectories of treatment effects and provide a reference for health-care providers in countries using similar programmes with Chinese/Taiwanese immigrant populations |
| Taiwan |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 162; age: ≥ 60 years; gender: both; cognitive impairment: yes, mild to moderate |
| Shyu 2009196 | Limitations: (1) convenience sample; (2) pre-fracture risk for depression was not assessed; (3) high rate of loss to follow-up; and (4) patients with severe mental impairment and physical disability prior to the fracture were excluded and so the results are not generalisable | Timely psychological interventions are suggested within the first 6 months after discharge. Health-care professionals need to pay attention to older patients with poorer pre-fracture functioning and particularly those with lower emotional–social support. The finding that the prevalence of risk for depression appeared to be high in this sample has several implications for nursing care – nurses should assess older patients for risk of depression during the first year following surgery for hip fracture |
| Taiwan |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Thick |
| Participants: n = 147; age: ≥ 60 years; gender: both; cognitive impairment: yes, mild to moderate |
| Sirkka 2003193 | Limitation: major domains of life satisfaction (e.g. satisfaction with ADL, leisure, financial situation and family life) were not investigated | The contribution of the occupational therapist should be to enable a person to live independently. Rehabilitation programmes should also be provided that focus on individuals’ needs and goals to allow participation in community life |
| Sweden |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital and community |
| Rich |
| Participants: n = 29; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Stenvall 2007120 | Limitations: (1) outpatient rehabilitation after discharge was not as standardised as during the in-hospital stay; in the intervention programme the aim was to have a well-planned discharge followed up with a telephone call and a home visit; (2) patients were offered further rehabilitation after discharge, but the intensity and quality of this outpatient rehabilitation is unknown; and (3) the assessors where not blinded concerning group allocation during the home visits. Strengths: the two groups had a small and similar dropout rate over time; only two people in each group refused the follow-up visits and one person in the control group moved to another part of the country | A multidisciplinary post-operative intervention programme enhances ADL performance and mobility (walking indoors without walking aids) after hip fracture, from both a short- and a long-term perspective |
| Sweden |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 199; age: ≥ 70 years; gender: both; cognitive impairment: yes |
| Swanson 1998129 | NR | Early intervention consisting of early surgery, minimal narcotic analgesia, intense daily therapy and close monitoring of patient needs through a multidisciplinary approach resulted in a shorter length of hospital stay |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital |
| Thick |
| Participants: n = 71; age: ≥ 55 years; gender: both; cognitive impairment: no |
| Sylliaas 2011199 | Limitations: (1) greater social contact in the intervention group; (2) healthier and more motivated people might have participated in this exercise intervention study; (3) exercises, other kinds of interventions or levels of physical activity for the control group were not registered; and (4) inclusion criteria restricted the findings to older people living on their own without cognitive impairment; the frailest patients were not included. Strengths: (1) trial designed and implemented according to a strict experimental protocol; (2) adequte sample size; (3) low dropout rate; (4) good compliance with the exercise programme; (5) use of standardised, validated instruments; and (6) blinded examiner | Home-dwelling hip fracture patients can benefit from an extended supervised strength-training programme in a rehabilitation setting. These patients are capable of high-intensity strength training, which should optimise gains in physical function, strength and balance. Resistance exercise training seems to influence functional performance adaptation |
| Norway |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 150; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Takayama 2001164 | Limitations: (1) retrospective study and so data obtained before fracture and at discharge depended on limited medical records and the memories of patients and their family members, introducing recall bias into the difference in duration between discharge from hospital and the time of investigation; and (2) proxy responses in a large number of patients (n = 121) | The findings of this study provide important information regarding current recommendations for shortening the duration of hospitalisation and the provision of appropriate post-operative rehabilitation programmes to patients with hip fracture, depending on their background factors |
| Japan |
| Quantitative non-comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 189; age: ≥ 60 years; gender: both; cognitive impairment: partial |
| Talkowski 2009194 | Limitations: (1) no surgical or medical complications that may have affected activity were recorded; (2) data on body mass index or comorbidities were not collected; (3) three of the 18 patients did not complete their actigraph journal and therapists daily schedules had to be used to determine session times; (4) it was difficult to draw comparisons between inpatient rehabilitation facility and skilled nursing facility patients because of limted numbers of the latter; and (5) the study possibly suffered a type II error because of p-values being slightly higher than 0.5, but values appeared clinically meaningful. Strengths: (1) the longitudinal study allowed for the association between physical activity and future functional outcomes to be investigated; (2) the use of accelerometers was feasible and easily implemented and none of the accelerometers was lost or broken; and (3) the Pittsburgh Participation Rating Scale was simple to use in both settings and did not require excessive staff training or participant burden | Therapist-rated patient participation was associated with objective measures of patient activity, which added insight into future functional outcomes in patients after hip fracture |
| USA |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 18; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Taylor 2010185 | Limitations: (1) interviews from a small number of physiotherapists; (2) one rehabilitation centre study so findings may not be generalisable; and (3) researchers’ backgrounds as physiotherapists and work colleagues might have influenced the interviews and the interpretation of the data. Strengths: the methods were rigorous as the participants were provided with transcribed interviews to check; transcripts were coded independently by two researchers and themes were developed by subsequent discussion with a third researcher; and the use of direct quotations in the results served to improve internal validity | In planning discharge after rehabilitation for hip fracture, clinicians place more emphasis on the individual needs and goals of the patient than on specifying objective performance criteria that must be met. The expectation that lack of confidence could be a problem after returning home suggests that this factor could be considered more in discharge planning |
| Australia |
| Qualitative |
| Qualitative |
| Hospital |
| Thick |
| Participants: n = 12; age: NR; gender: female; cognitive impairment: NA |
| Tinetti 1999121 | NR | The systematic multicomponent rehabilitation programme was no more effective in promoting recovery than usual home-based rehabilitation. No self-reported functional outcomes were better and only two physical performance outcomes were marginally better in the intervention group than in the usual care group. At 6 months, upper-extremity strength was significantly better in the intervention group than in the usual care group and the intervention group manifested marginally better qualitative gait performance than the usual care group |
| USA |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 304; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Travis 199889 | Limitations: (1) no tape recording of the interviews, therefore missing the chance to capture the richness of the data; and (2) inability to gendralise the findings because the population was quite old | The actions that elderly people take to create opportunities for mentally restorative experiences are related to past patterns of restorative activities, opportunities made available by the facility, especially circumstances of their care, environmental limitations in the immediate care environment and the degree to which external factors (such as family visits) are readily available |
| USA |
| Mixed methods |
| Mixed methods |
| Hospital |
| Rich |
| Participants: n = 8; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Tsauo 2005122 | Limitations: (1) small sample size; and (2) large number lost to follow-up | The home-based physiotherapy programme is associated with earlier functional recovery and better health-related quality of life than usual care |
| Taiwan |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 54; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Uy 2008123 | NR | No definite conclusion can be drawn about the effectiveness of the intervention because of its premature termination. However, the study established that it is feasible to provide interdisciplinary rehabilitation to older people with hip fracture and severe disablement |
| Australia |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 10; age: ≥ 80 years; gender: female; cognitive impairment: no |
| Van Balen 2002140 | Limitations: (1) small sample size because of the time-consuming follow-up; and (2) study design non-randomised, so some variables (e.g. type of treatment and length of hospital stay) may have changed during the study | There was no clear advantage of discharging hip fracture patients 13 days earlier from the acute hospital. Patients who came from home in the early discharge group had better walking ability and improvements in ADL level at 1 month, but there was no difference at 4 months |
| The Netherlands |
| Quantitative comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 208; age: ≥ 65 years; gender: both; cognitive impairment: no |
| van der Sluijs 1991186 | NR | Rehabilitation after hip fracture is predominantly influenced by sociomedical factors, especially mental health status, whereas fracture type, treatment and ability for immediate weight bearing were not associated with success |
| The Netherlands |
| Quantitative non-comparative |
| Controlled before-and-after study |
| Hospital |
| Thick |
| Participants: n = 134; age: any; gender: both; cognitive impairment: NR |
| Vidán 2005124 | Limitations: (1) sample size was estimated based on length of stay assumptions but not on clinical indices and so the study was not powered to detect differences in relevant low-incidence events; (2) this was an open trial and therefore subject to bias, such as changes in clinical management associated with observation; (3) these results may not be replicable in other clinical settings with a different health-care system organisation; (4) the functional evaluation was based on ADL and Functional Ambulation Classification scales. These are the most frequently used scales in clinical practice but probably lack sensitivity to detect subtle changes occurring during recovery from a hip fracture; and (5) this study lacked a cost-effectiveness analysis to help programme implementation | Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery |
| Spain |
| Quantitative comparative |
| RCT |
| Hospital |
| Rich |
| Participants: n = 319; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Visser 2000156 | NR | Loss of muscle strength, but not loss of muscle mass, is an independent predictor of poorer mobility recovery 12 months after a hip fracture |
| USA |
| Quantitative non-comparative |
| Controlled before-and-after study |
| Community |
| Thick |
| Participants: n = 90; age: ≥ 65 years; gender: female; cognitive impairment: NR |
| Vogler 2012125 | Limitation: (1) the study population for this trial consisted of older people recently discharged from hospital, which may limit the generalisability of the findings to the broader community-dwelling population; and (2) given the short-term nature of the follow-up, it is not possible to draw any conclusions about health-care usage, costs or residential status | Balance improvements and fall-risk reductions associated with a 12-week home-based exercise programme in older adults were partially to totally lost 12 weeks after the cessation of the intervention. These significant detraining effects suggest that sustained adherence to falls prevention exercise programmes is required to reduce fall risk |
| Australia |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 180; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Walheim 1990187 | NR | Continued rehabilitation for > 3 months following surgery is absolutely worthwhile, especially in patients with an unstable trochanteric fracture |
| Sweden |
| Quantitative non-comparative |
| Concurrent cohort study |
| Hospital |
| Thick |
| Participants: n = 92; age: > 50 years; gender: both; cognitive impairment: partial |
| Whitehead 2003161 | Limitations: (1) inability to reliably measure pre-fracture disability; (2) London Handicap Scale component measuring economic self-sufficiency may be less relevant in this elderly group and overemphasise their degree of disability; (3) this scale has not previously been validated in an Australian sample; (4) results are not generalisable to the whole hip fracture population because of the exclusion of demented patients and those living in residential care; (5) small sample size; and (6) no assessment of the prevalence of mood disorders in the population, which could be a potential confounder | A clinical focus on the impairments that lead to slowed gait and falls following hip fracture could lead to lower levels of disability in this group. A focus only on self-care and simple ADL will not treat the key problems in this population, such as balance and strength. The range of outcome measures that are collected by rehabilitation wards should be expanded or revised in light of the findings of this study. Falls after hip fracture and slow gait speed lead to greater levels of disability and loss of self-efficacy. Measures of falls and gait speed following hip fracture should be considered as other outcomes in the rehabilitation of patients with hip fracture. Falls prevention following hip fracture should become an important target for the prevention of future disability |
| Australia |
| Quantitative non-comparative |
| Historical cohort study |
| Community |
| Thick |
| Participants: n = 73; age: ≥ 60 years; gender: both; cognitive impairment: no |
| Yu-Yahiro 2009126 | NR | It was possible to develop and implement, and engage a frail older population of post-hip fracture patients in, a home-based programme of aerobic and strength training exercise. The rate of participation in the programme was high |
| USA |
| Quantitative comparative |
| RCT |
| Community |
| Thick |
| Participants: n = 180; age: ≥ 65 years; gender: female; cognitive impairment: no |
| Zabari 2012162 | Limitations: (1) retrospective study; and (2) did not include data following discharge from the rehabilitation hospital | Proactive monitoring and management of pain in surgical hip fracture patients is associated with better outcomes and should be considered a standard in the rehabilitation of elderly patients following hip fracture surgery |
| Israel |
| Quantitative non-comparative |
| Historical cohort study |
| Hospital |
| Thick |
| Participants: n = 144; age: > 65 years; gender: both; cognitive impairment: NR |
| Zidén 2008127 | Limitations: (1) only two men included because of a lack of male candidates and because several men declined to participate; hence, the sample may not be representative of male gender views; (2) biases related to the inherent design of the interview study, making the validity questionable, as there is no way of ensuring that the subjects really shared their profound experiences or that the interpretation of what was said is correct; (3) the length of some of the interviews at 1 year of follow-up was relatively short; the interviews were performed at the end of the follow-up visit, after the completion of several self-report questionnaires and performance tests, which might have influenced their length, as the interviewees might have thought that they had already talked about various aspects of the fracture; (4) one interview was largely inaudible because of technical problems with the tape recorder; and (5) the participants knew the interviewer well as the visit was the last of at least four earlier encounters [one or two in hospital as well as follow-up visits (1 month, 6 months and 1 year after discharge) in the home], which may have led to the patients trying to please the interviewer; however, this familiarity may also mean that the interviewees were less afraid of sharing experiences. Strengths: (1) steps were taken to enhance the trustworthiness, reliability and validity of the results – (a) categories were illustrated with quotations from the interviews, (b) categories were double-checked by an independent assessor by first reading and analysing the interviews separately and then reflecting and discussing together until consensus about the category descriptions was reached and (c) the subjects, or the interviewer, were able to return to topics under discussion earlier if they wished because of the organic nature of the interview | The fracture caused social and existential cracks in sufferers’ thinking in the early phases after the injury, extending patients’ experiences beyond the actual injury. Hence, arranging health care and rehabilitation chains in order to link together different health-care organisations should be given priority. The findings indicate that the negative consequences of a hip fracture are substantial and long lasting. Hence, health professionals need to consider the patients’ own experiences and possible fear and not merely focus on the physical injury and disabilities |
| Sweden |
| Qualitative |
| Qualitative |
| Community |
| Thick |
| Participants: n = 18; age: ≥ 65 years; gender: both; cognitive impairment: no |
| Zidén 200890 | Limitations: (1) patients’ eligibility was not assessed before randomisation and so a considerable number of patients were excluded after randomisation; (2) baseline differences between the home rehabilitation group and the conventional care group; (3) ineffective use of the Falls Efficacy Scale to measure instrumental activities, resulting in weak measurements of confidence and efficacy; and (4) short follow-up duration. Strength: no dropouts and few missing values at the 1-month follow-up | A brief home rehabilitation programme focusing on enhancing self-efficacy improves patients’ balance confidence and makes them more independent and active in the early phase after hip fracture. Patients receiving home rehabilitation need less post-surgery time at health-care facilities. Home rehabilitation helped patients improve their outdoor activities, resume outdoor walking habits and improve balance confidence more quickly than conventional care |
| Sweden |
| Quantitative comparative |
| RCT |
| Hospital and community |
| Thick |
| Participants: n = 102; age: ≥ 65 years; gender: both; cognitive impairment: no |
