March 2010

Initiate weightbearing early after hip fracture

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The improved outcomes seen with early ambulation in hip fracture patients go beyond gait and function. Because independence is so closely tied to mortality in this population, proper rehab may also help patients live longer.

by Paula Richley Geigle, PT, PhD, Karen Lynn Gordes, PT, DScPT, Kimberly Dodson, and Gene Shirokobrod

More than 350,000 persons over the age of 65 will fracture a hip in the U.S. during the coming year.1 Internationally, hip fracture is identified as the most common type of fracture for persons over the age of 80 and the second most common for persons over the age of 65.2 Following hip fracture, a sudden decline in physical function occurs, particularly manifested by decreased independent walking and slower walking speed.3 Functional recovery continues for a year or more, dependent upon the outcome measure utilized.3,4

At one year post-hip fracture, 50% of individuals who walked independently prior to their fracture are unable to walk independently.3 This means that, with one year of aging factored into the function equation for both groups, 25% more of the post-fracture group do not walk independently compared to their peers with no history of hip fracture. In elderly patients post-hip fracture, the average one-year mortality is 18% to 33%.3,4 The ability to ambulate independently after fracture is a predicting factor of return to pre-morbid functional level,5 underscoring the potential benefits of early ambulation weight-bearing rehabilitation. The duration of recovery and the period of increased mortality risk extends beyond that required for fracture healing, implying that the hip fracture event may trigger other negative physiologic consequences.6

The purpose of this manuscript is to summarize current post hip fracture early ambulation weight-bearing protocols within both the U.S. and Australia. Early weight-bearing ambulation will refer to postoperative day 1 through day 30, in contrast to the previously accepted time frame of six to eight weeks post-fracture.

United States

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The protocol for weightbearing status following hip fracture fixation is not crystal clear.7 Campbell’s Operative Orthopedics textbook states that weight bearing as tolerated (WBAT) is routinely prescribed for individuals with stable fixation, either by intramedullary hip screw nailing or open reduction and internal fixation (ORIF).8 Due to the lack of upper extremity strength in the majority of the hip fracture population, the use of an assistive device to fully unload the repaired extremity is limited. In many cases, surgeons aim for stable fixation to provide early postoperative WBAT.8 Variability in early weightbearing prescription for individuals after femoral ORIF is prevalent in the U.S.;7 however, the move toward early full weightbearing is becoming more parallel to the traditional standard of full weight bearing status by six to eight weeks post-fracture.8

According to a national survey conducted in 2003 and 2004, physical therapists observe a large discrepancy in the prescription of post-hip fracture weight-bearing guidelines across the fracture healing intervention period.9 Forty-two percent of individuals post-hip fracture were full or weightbearing as tolerated, 17% were partial weightbearing, 29% were full, partial, or as tolerated, and 12% were toe-touch or non-weightbearing.

These early (and often ongoing until weeks six to eight) weight bearing restrictions are presumably to decrease the risk of surgical displacement. Koval et al studied the extent of weight distributed through the involved leg when weightbearing was not restricted by the surgeon.10 Early postoperative phase of treatment participants placed 60% to 80% of their body weight through the surgical leg. Post-surgery, patients supported 51% of their body weight in relations to the uninjured limb at one week, 65% at week three, and 87% at week 12.  These weight limits were self-directed by each person’s own pain level. WBAT did not increase the complication rate after surgically repaired hip fracture.

Due to the large percentage of individuals who do not regain full function after a hip fracture, researchers are exploring ways to close the gap in post-hip fracture rehabilitation.11,12 The 2007 study by Host et al aimed to provide clinicians with evidence that a progressive training protocol post-hip fracture can increase function in elderly patients with mild to moderate deficits following hip fracture fixation.11 The interventions included three months of balance, flexibility, and generalized whole-body strengthening followed by three months of progressive resisted exercises focusing on knee extension, knee flexion, and plantar flexion. After six months of physical therapy intervention, the modified PPT (Physical Performance Test) demonstrated a significant clinical increase in function (p value of 0.01 was ambiguous), and the percentage of individuals ambulating without an assistive device increased from 23% to 71%.11

Toussant and Kohia performed a critical review of the international literature regarding the impact of physical therapy upon elders after hip fracture, producing the following evidence summary: Individuals with dementia demonstrate functional  improvement with physical therapy; physical therapy directed treadmill training increased mobility outcomes; therapy should continue beyond pre-fracture functional levels as  individuals demonstrated deconditioning prior to hip fracture; physical therapy improved upon pre-fracture ambulation ability; and therapy should be started sooner than four months.13 All of these findings are important for rehabilitation planning, but of particular importance is the recommendation to start therapy sooner rather than later and the concept that with physical therapy intervention, ambulation ability exceeds pre-fracture ability.

Australia

Current practice in Australia presents a variable approach to managing weight-bearing status for patients immediate to early postoperative surgical management of hip fracture. Sherrington et al conducted a randomized control trial with a four-month follow-up on 120 older people recruited from six hospitals in Sydney.14 The study design included three groups: a WBE group performing set lower extremity exercises in weight-bearing positions (sit-to-stand, lateral step-up, forward step-up-and-over, forward foot taps, stepping grid); a NWBE group completing all selected hip exercises in a supine position (hip abduction, hip flexion, knee flexion/extension and ankle dorsiflexion/plantarflexion); and a non-intervention control group. Strength, balance, gait, and functional performance were assessed pre-intervention and at one month and four months. No significant difference existed for exercise related pain between the exercise groups at one month or at four months. At one month post-intervention, no significant difference was found between the groups across all outcome measures. At the four-month assessment, in the WBE group, a significantly greater number of participants were able to perform a lateral step-up on the affected leg without hand support than in the other two groups. Further, more people in the WBE group were able to ambulate without an assistive device than in the NWBE and control groups, although the difference was not statistically significant.

Oldmeadow et al assessed the impact of time relative to weightbearing by comparing early ambulation to delayed ambulation in patients after hip fracture surgery.2 Early ambulation was defined as first walk postoperative day 1 or 2, and delayed ambulation was first walk postoperative day 3 or 4. Patients whose postoperative orders required a non-weightbearing status were excluded from the study. Outcome measures included distance walked and level of assistance required for transfer from supine-to-sit, sit-to-stand, and negotiation of one step on post-operative day 7. The modified Iowa Level of Assistance Scale (ILAS) measured functional level. Discharge destination (home or rehabilitation facility) and length of stay in the acute care facility were analyzed. The early ambulation group at re-evaluation day 7 walked longer distances (66.0 m versus 29.7 m) and required lower levels of assistance for transfers and ambulation than patients in the delayed ambulation group. A greater number of early ambulation participants returned home directly; 17.2% of the early ambulation group returned directly home versus 3.2% of the delayed ambulation group.

An assessor-blinded randomized trial was conducted in Sydney with 160 people post surgical fixation for hip fracture in which  the impact of a high-dose, weight-bearing exercise program was compared to that of a low-dose, limited weight-bearing exercise program.15 Participants from the inpatient rehabilitation units of three teaching hospitals met the following inclusion criteria: approval for weightbearing or partial weightbearing, tolerate exercise program without medical contraindication, able to take four steps with forearm support, and with discharge plan to return to prior level of living in home or low-care residential facility. Primary outcome measures included knee extensor strength and walking speed.  Additional measures included were Physical Performance and Mobility Examination, sit-to-stand time, Barthel index, standardized balance tests, pain, Modified Falls Efficacy Scale, self-rated subject survey and the Euro-Qol-5D (EQ5D).16

The high-dose exercise program consisted of WBE twice daily, 60 minutes per day for 16 weeks. Specifically, subjects performed five weight-bearing exercises and walked on a treadmill with a partial weight-bearing support harness or completed a walking program. The low-dose exercise program consisted of five non-weight-bearing exercises performed supine or sitting with walking in parallel bars or with an aid. The length of walking and exercise was limited to a total of 30 minutes per day for four weeks. After four weeks, subjects were provided a limited weight-bearing exercise program. The high-dose exercise group demonstrated significantly faster sit-to-stand times at both reassessment time frames (four weeks, 16 weeks post baseline), and completed a greater number of steps in the step test at four weeks than the low-dose exercise subjects; both measures were statistically significant.

Relevant literature does support an association between weight bearing guidelines and patient functional outcomes, but currently variability exists in the prescription of early weight-bearing status post hip fracture. Does the clinical practice of early weight-bearing restriction negatively impact the cost of rehabilitation management? A retrospective review of charts associated with patients 65 years and older after hip fracture surgery addressed this question.17 In a total of 331 patient case notes post-hip fracture, 77% of patients were allowed WBAT, 11% were partial weightbearing (PWB), 4% were touch weightbearing (TWB), and 8% were non-weightbearing (NWB). A significant difference in length of hospital stay was seen between groups. Patients with restricted weightbearing (TWB or NWB) had a longer length of stay than patients in the PWB or WBAT group. For this study hospital, restricted weightbearing added approximately $8400 (AUD) to healthcare cost (based on cost per bed day).17

Implications for clinical practice

Does the conservative approach of delaying full weightbearing following surgically stabilized hip fracture contribute to the large functional deficits observed in elderly individuals? The clinical implications of the available data regarding immediate weight-bearing status after hip fracture appear significant. Delayed weightbearing negatively impacts function, particularly with gait.14 These functional limitations after hip fracture ultimately correlate directly and indirectly to increased healthcare cost. The total global cost of hip fractures by 2050 is anticipated to reach an amount of $131.5 billion annually,15 and more than 95% of all hip fractures are managed surgically.17

Archer et al surveyed approximately 300 surgeon members of the American Trauma Association, finding that this group thinks 57.6% of individuals referred to physical therapy experience a positive encounter, and 26.2% do not.18 Equally important is that 32.6% of this surgeon group stated that patients attain the same functional outcome after lower extremity trauma with a surgeon-prescribed home exercise program as individuals receiving physical therapy. If the individuals do not adequately respond to the surgeon home program, physical therapy becomes a delayed step in the rehabilitation plan. Could improved communication among the rehabilitation team regarding optimal timing of services positively impact hip fracture functional outcomes?

A decision tree cost analysis assessing all aspects of this clinical question is warranted.19 Decision tree factors include but are not limited to costs of extended care for individuals with decreased function after hip fracture; increased staffing needs for immediate WBAT ambulation; surgical failure rate and second surgical procedures; quality of life issues with regard to self-care and independence; and advances in surgical fracture stabilization techniques and materials. Challenging traditional views on early weight-bearing restrictions after surgically repaired hip fracture offers the potential to optimize quality of life and healthcare expenditure.

Paula Richley Geigle, PT, PhD, is an assistant professor of physical therapy and rehabilitation science at the University of Maryland in Baltimore. Karen Lynn Gordes, PT, DScPT, is an assistant professor and director of clinical education, and Gene Shirokobrod and Kimberly Dodson are graduate students in the same department.

References

1. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci  Med Sci 2000;55(9):498-507.

2. Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg 2006;76(7):607-611.

3. Magaziner J, Simonsick EM, Kashner TM, et al. Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. J Gerontol 1990;45(3):101-107.

4. Magaziner J, Fredman L, Hawkes W, et al. Changes in functional status attributable to hip fracture: a comparison of hip fracture patients to community-dwelling aged. Am J Epidemiol 2003;157(11):1023-1031.

5. Shinkai S, Watanabe S, Kumagai S, et al. Walking speed as a good predictor for the onset of functional dependence in rural Japanese community population. Age Ageing 2000;29(5):441-447.

6. Magaziner J, Lydick E, Hawkes W, et al. Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health 1997;87(10):1630-1636.

7. Handoll HH, Sherrington C. Mobilisation strategies after hip fracture surgery in adults. Cochrane Database Syst Rev 2007;(1):CD001704.

8. Canale ST, Beaty JH. Campbell’s Operative Orthopedics. 11th ed. New York: Mosby Publishing; 2007.

9. Mangione KK, Lopopolo RB, Neff NP, et al. Interventions used by physical therapists in home care for  people after hip fracture. Phys Ther 2008;88(2):199-210.

10. Koval KJ, Sala DA, Kummer FJ, Zuckerman JD.  Postoperative weight-bearing after a fracture of the femoral neck or an intertrochanteric fracture. J Bone Joint Surg Am 1998;80(3):352-356.

11. Host HH, Sinacore DR, Bohnert KL, et al. Training-induced strength and functional adaptations after hip fracture. Phys Ther 2007;87(3):292-303.

12.  Talkowski JB, Lenze EJ, Munin MC, et al. Patient participation and physical activity during rehabilitation and future functional outcomes in patients after hip fracture. Arch Phys Med Rehabil 2009;90(4):618-622.

13. Toussant EM, Kohia M. A critical review of literature regarding the effectiveness of physical therapy management of hip fracture in elderly persons. J Gerontol A Biol Sci  Med Sci 2005;60(10):1285-1291.

14. Sherrington C, Lord SR, Herbert RD.  A randomised trial of weight-bearing versus non-weight-bearing exercise for improving physical ability in inpatients after hip fracture. Aust J Physiother 2003;49(1):15-22.

15. Moseley AM, Sherrington C, Lord SR, et al. Mobility training after hip fracture:  a randomised controlled trial. Age Ageing 2009;38(1):74-80.

16. Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001;33(5):337-343.

17. Wu J, Kurrle S, Cameron ID. Restricted weight bearing after hip fracture surgery in the elderly: economic costs and health outcomes. J Eval Clin Pract 2009;1591(1):217-219.

18. Archer KR, MacKenzie EJ, Bosse MJ, et al. Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons. Phys Ther 2009;89(9):893-905.

19. Markov models, Markov analysis, state transition models. Available at:  http://www.treeage.com/learnMore/MarkovModels.html. Accessed January 30, 2010.

4 Responses to Initiate weightbearing early after hip fracture

  1. Rachel Toland says:

    This is so relevant! I am a physiotherapist in a trauma unit in UK. I have often felt frustrated by the general assumption in the medical world that patients lose ’20%’ ability post fracture without evidence that it had ever been tested.

    On another point, we often get instructions for ‘toe-touch weightbearing’. Am I alone in wondering why specifying which part of the body is in contact with the floor is thought to bear any correlation with how much body weight is actually transmitted through the fracture site?

  2. Jane says:

    My elderly father had a fall and a hip fracture, and had surgery. In the hospital and then for a few days at the skilled nursing, they had him walking on a walker for about two weeks. Then the orthopedist decided to have him on non-weight bearing status for 6 weeks. My father spent another 10 days in the skilled nursing, at which time they recorded that he was able to “ambulate 30 feet” and so the health insurance company decided to release him.

    He is now with a relative and has only two more weeks of non-weight bearing.

    My question is – if he was on non-weight bearing status, how was he able to ambulate 30 feet in the physical therapy sessions? Or was this made up and an excuse for the insurance no longer covering him and the skilled nursing being able to release him?

    Since he’s been with the relative and non-weight bearing, he hasn’t been ambulating at all! He’s ‘been getting around just on the wheel chair, and the physical therapist comes and does exercises with him but he’s not walking on a walker or hopping or anything at all.

    Thanks.

  3. Adam says:

    Excellant Article. I run into Hip ORIF’s being toe touch weight bearing. THe problem is the geriatric population is unable to perform this without weight-bearing. Also, one would think that weight-bearing would promote healing in a bone such as the femur. Thank you for this article.

  4. ademil says:

    Nothing beats a carefully and intelligently performed rehabilitation evaluation for management of the hip fracture patient. With all variables taken into consideration, early weight-bearing will always impact optimal outcomes with a more positive note. Delaying weight-bearing with all its supposed “gray areas” almost always is detrimental . Communication with the surgeon is paramount and should prove to be a win-win situation if ever the indication presents itself . In my experience as a therapist, bureaucratic red tape did not start in government but in healthcare.

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