CONSISTENT WITH INTERNATIONAL trends, the population

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1 1953 ORIGINAL ARTICLE Effects on Function and Quality of Life of Postoperative Home-Based Physical Therapy for Patients With Hip Fracture Jau-Yih Tsauo, PhD, PT, Wen-Shyang Leu, MS, Yi-Ting Chen, BS, Rong-Sen Yang, MD, PhD ABSTRACT. Tsauo J-Y, Leu W-S, Chen Y-T, Yang R-S. Effects on function and quality of life of postoperative homebased physical therapy for patients with hip fracture. Arch Phys Med Rehabil 2005;86: Objective: To evaluate the effects of a 3-month home-based physical therapy (PT) program for patients with hip fracture after surgery. Design: Randomized controlled trial. Setting: Home. Participants: Twenty-five patients recently discharged from an acute orthopedic department. Interventions: Patients were randomized to the homebased PT group, where they received home-based PT 8 times from discharge to month 3 postdischarge, or to the control group. The home-based PT program included exercises for muscle strengthening, range of motion (ROM), balance, and functional training. Patients in the control group were instructed to practice the exercise program given at bedside before discharge. Main Outcome Measures: Patients were evaluated for hip ROM, strength, walking velocity, Harris hip score, and healthrelated quality of life (HRQOL) at the week of discharge and at 1, 3, and 6 months after discharge. Results: The baseline characteristics showed no difference between the 2 groups. Harris score of the home-based PT group progressed from to at month 3, whereas Harris score of the control group progressed from to (P.01). Scores of the psychologic domain of HRQOL for the home-based PT group were significantly better at month 1 (P.05) and month 3 (P.01) after discharge. Moreover, the physical domain score of the home-based PT group was also significantly better (P.05) at 3 months after discharge. Conclusions: Home-based PT programs could help patients regain function and HRQOL earlier. Key Words: Hip fractures; Physical therapy; Quality of life; Rehabilitation. From the School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei (Tsauo); Department of Physical Medicine & Rehabilitation, Min-Sheng General Hospital, Taoyuan (Leu); Department of Physical Therapy, Chung Shan Hospital, Taipei (Chen); and Department of Orthopaedics, College of Medicine, National Taiwan University and Hospital, Taipei (Yang), Taiwan. Supported by the National Science Council (grant nos. NSC B M5, NSC B M56). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Rong-Sen Yang, MD, PhD, Dept of Orthopaedics, College of Medicine, National Taiwan University and Hospital. No. 7, Chung-Shan S Rd, Taipei, Taiwan, yang@ha.mc.ntu.edu.tw /05/ $30.00/0 doi: /j.apmr by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation CONSISTENT WITH INTERNATIONAL trends, the population of Taiwan is aging: 9.22% of the population was over 65 years old at the end of These demographic changes present significant health challenges, both in public health and medicine. Not only does the incidence of hip fracture increase with age, 2 but so do the mortality 3 and morbidity 4-6 of this condition. There is a pressing need to understand and improve the process of functional recovery after hip fracture. Several studies suggest that patients generally regain their independence within 6 months after hip fracture. 6,7 Early recovery of function and independence in daily life is very important to patients and their familes, both for financial relief and quality of life (QOL). Today, hospital stays are shortened; thus, subacute care in the early stage after discharge plays an important role in promoting functional recovery. Typical subacute care includes a rehabilitation facility, a skilled nursing facility, and home-based physical therapy (PT) Moreover, Binder et al 11 suggested an extended outpatient rehabilitation program. Pryor and Williams 8 demonstrated that early discharge and a home-based PT program could reduce bed occupation compared with the inpatient PT program and promoted early recovery. Hollingworth et al 9 also showed a reduced medical cost for patients receiving PT at home compared with at an inpatient program. Kelly and Ackerman 10 demonstrated that patients with hip fractures receiving subacute intensive in-hospital PT or home-based PT had good recovery, but the cost for the subacute in-hospital program was higher than for the home-based PT program. The benefits of such a program included increased functional and emotional benefits and reduced cost. In Taiwan, most patients with hip fractures undergoing surgery do not receive PT after the hospital stay because there is no reimbursement for home-based PT in the insurance system. 12 Therefore, the effect of homebased PT needs to be shown. Although many studies have shown the effects of homebased PT on the parameters of impairment (eg, strength, balance) and function (eg, gait, velocity), little is known concerning these patients health-related QOL (HRQOL) after hip fracture with or without home-based PT. The purpose of this study was to compare the outcomes (including the impairments, functions, and HRQOL) of patients with hip fractures receiving a home-based PT program with those of controls. METHODS Participants Patients with hip fracture having surgery in our hospital from October 1, 2000, to September 30, 2001, were recruited with

2 1954 HOME-BASED PHYSICAL THERAPY FOR HIP FRACTURE, Tsauo the agreement of each patient and his/her surgeon. The exclusion criteria included (1) patient or family rejected further treatment and follow-up after discharge, (2) patient was unable to complete the entire follow-up because of transportation problems (this study recruited patients who lived in the neighborhood of our hospital), (3) patient was unable to cooperate because of mental or cognitive problems (eg, psychiatric disorders, senile dementia), and (4) ongoing medical litigation. The study protocol was approved by the Research Ethics Committee of National Taiwan University Hospital. All patients gave written informed consent. Study Design Patients were randomized into the home-based PT group or the control group. A bedside PT program was arranged for all patients once a day during their hospital stays. Patients in the home-based PT group were visited by an experienced physical therapist 8 times at the week of discharge and at 1, 2, 3, 4, 6, 8, and 12 weeks after discharge for education and practicing the proper exercise program. All patients were assessed 4 times: at the week of discharge and at 1, 3, and 6 months after discharge. Interventions The home-based PT program was an individualized training program that encompassed (1) strengthening exercises mainly for hip flexors, extensors, abductors, and knee extensors; (2) range-of-motion (ROM) exercises, mainly for the hip joint; (3) balance training; (4) functional training such as sit-to-stand training, ambulation training, and stair climbing, if needed in the home environment; (5) practice of safe and efficient transfer techniques; (6) adjustment of walking aids; and (7) adaptation and modification of the home environment. The exercise items were given according to the individual capacity and general medical condition of each patient. In general, 5 exercise items were taught at each visit, initially in 3 sets of 10 repetitions a day for each item. The number of repetitions or sets increased if patients tolerated them well based on the home visit evaluation by the physical therapist. In most circumstances, a 1-kg sandbag was used as resistance. However, patients could discontinue the exercise whenever they experienced any discomfort. To improve the accuracy and compliance of the exercise prescription, the physical therapist provided an exercise brochure and record sheet at each visit. The exercise brochure listed the possible problems and proper exercise protocols in the different stages after surgery. The amount of daily exercise was recorded every day by patients or their families, and a reminding telephone call was given every week. Patients in the control group were instructed to practice the exercise program given at bedside before discharge. Outcome Measures Information collected from the medical charts included age, sex, preexisting systemic diseases, prefracture functional status, causes of fracture, types of operation (eg, operation procedures, fixation device, postoperative complications), and functional status before discharge. Patients were evaluated for hip ROM with a goniometer, muscle strength of the hip and knee with a hand-held dynamometer, a walking velocity with patients comfortable speed, Harris hip score, 16 and HRQOL. 17 Walking velocity was measured at home according to the distance each patient walked and time he/she took to complete the task. Harris hip score. The Harris hip score 16 was used to evaluate functional recovery after hip surgery. The parameters include pain (44 points), function (gait and functional activities, 47 points), absence of deformity (4 points), and ROM (5 points). Total scores ranged from 0 to 100 points, with a higher score indicating better function. The Harris total score and 2 subscores Harris pain score and Harris total pain score (total score minus pain score) were analyzed at different stages after discharge. Health-related quality of life. HRQOL was assessed with an abbreviated version (WHOQOL-BREF) of the World Health Organization Quality of Life Questionnaire (WHOQOL-100). 17 It consists of 4 domains: physical health, psychological health, social relationships, and environment. Domain score, with 20 as the highest score, was presented instead of a total score. When patients were interviewed at discharge, we asked them to recall their prefractured conditions and fill out one more questionnaire. Statistical Methods We analyzed data with SPSS, version b The distributions and means of parameters were presented, and we used 2-way analysis of variance (ANOVA) with repeated measures to compare the differences between the 2 groups and among the different stages. The significance level was set at.05. RESULTS Patient Flow A total of 54 patients were recruited in this study. Twentyeight were in the home-based PT group, and 26 were in the control group. Because of the loss of follow-up and poor exercise compliance, there were ultimately only 13 patients in the home-based PT group and 12 in the control group (fig 1). Participants Baseline Data Table 1 lists the basic demographic and medical data of both groups. The preadmission parameters (age, sex, prefracture function, causes and types of fracture, waiting time for operation), length of hospital stay, and functional status before discharge showed no difference between these 2 groups. Except for diabetes (P.05), there was also no significant differ- Fig 1. Patient flow diagram.

3 HOME-BASED PHYSICAL THERAPY FOR HIP FRACTURE, Tsauo 1955 Table 1: Demographic and Medical Data of Both Groups Variables Home-Based PT Mean age SD (y) Sex Male 3 (23.1) 2 (16.7) Female 10 (72.9) 10 (83.7) Prefracture functions Able to walk Unable to walk 0 0 Causes of fracture Falling 9 (69.2) 9 (75.0) Traffic collision 2 (15.4) 2 (16.7) Others 2 (15.4) 1 (8.3) Types of fracture Femoral neck 8 (61.5) 8 (66.7) Intertrochanter 3 (23.1) 4 (33.3) Others 2 (15.4) 0 (0.0) Mean preoperative waiting time SD (d) Types of operation Internal fixation 4 (30.8) 3 (25.0) THA/hemiarthroplasty 9 (69.2) 9 (75.0) Postoperative complication None 9 11 Infection 1 1 Dislocation 0 0 Refracture 2 0 Others 1 0 Mean hospital stay SD (d) Function before discharge Walk with walker 12 (92.3) 11 (91.7) Unable to walk 1 (7.7) 1 (8.3) NOTE. Values are mean standard deviation (SD), n (%), or n. Abbreviations: THA, total hip arthroplasty; SD, standard deviation. ence in the comorbidities between these 2 groups. During the 6-month follow-up after discharge, 1 patient in each group had wound infection after the operation. In the home-based PT group, 2 patients refractured their hips and 1 had gastric tract bleeding. One patient in each group transferred to a nursing home because their families could not take care of them, and the others went home directly after discharge. The baseline ROM, muscle strength, walking speed, and Harris scores (total score, Harris pain score, Harris total pain score) did not differ significantly between the 2 groups (table 2). Similar findings were also noted in the domain scores of QOL before fracture and at discharge (table 3). Outcomes The results of the 2-way ANOVA are shown in tables 2 and 3. The therapeutic effects were different between the 2 groups and between different stages within the same group (see tables 2, 3). Comparison between 2 groups at different stages. ROM, muscle strength, and walking speed did not differ significantly at 1, 3, and 6 months after discharge between the 2 groups (see table 2). However, all the Harris hip scores of the home-based PT group were better than those of the controls at 1 month (P.05) and 3 months (P.01) after discharge. The Harris pain scores of the 2 groups differed significantly at 1 month (P.05) and at 3 months (P.01) after discharge. The Harris total pain scores differed statistically at 3 months and 6 months after discharge (P.01) between the 2 groups. Comparing domain scores of QOL between these 2 groups at different stages (see table 3) showed that the scores of psychological domain of the home-based PT group were higher both at 1 month (P.05) and 3 months (P.01). The score of physical health domain of the home-based PT group was also higher than that of the controls (P.05) at 3 months after discharge. The domain scores in social relationships and environment showed no difference between the 2 groups at different stages. Comparison at different stages within group. The comparisons of different stages within each group are also shown in tables 2 and 3. The home-based PT group showed major improvement of Harris total score during 1 to 3 months, from to (P.01). However, obvious progress in the control group occurred during 3 to 6 months, from to (P.01). Table 3 shows the difference of domain scores of HRQOL at different stages in these 2 groups. Other than the social relationship domain score, the other 3 domain scores all were worse at hospital discharge compared with those before fracture (P.01). In the home-based PT group, the scores of the Table 2: ROM, Muscle Strength, Walking Speed, and Harris Hip Scores 16 Between 2 Groups of Patients at Different Stages Variables At Discharge 1 Month After Discharge 3 Months After Discharge 6 Months After Discharge Range of hip flexion (deg) Hip flexor strength (N) Hip extensor strength (N) Hip abductor strength (N) Knee extensor strength (N) Walking speed (m/min) Harris hip score * Harris pain score * Harris total pain score NOTE. Values are mean SD. Abbreviation:, home-based PT. *Comparison between 2 groups (P.05). Comparison between 2 groups (P.01). Comparison with previous assessments (P.05). Comparison with previous assessments (P.01).

4 1956 HOME-BASED PHYSICAL THERAPY FOR HIP FRACTURE, Tsauo Table 3: Different Categories of QOL Assessed by the WHOQOL-BREF 17 Between 2 Groups of Patients Before Fracture At Discharge 1 Month After Discharge 3 Months After Discharge 6 Months After Discharge Domains Physical health * Psychological * Social relationship Environment NOTE. Values are mean SD. *Comparison between 2 groups (P.05). Comparison between 2 groups (P.01). Comparison with previous assessments (P.05). Comparison with previous assessments (P.01). physical health domain improved continuously at every stage after discharge (P.01). The scores of the psychological and environmental domains improved at 1 month and 3 months after discharge (P.05). In the control group, the scores of the physical health domain improved at 1 month and 6 months (P.01), and scores of the environmental domain improved at 3-month follow-up (P.05); others showed no significant improvement. DISCUSSION The functional outcome and HRQOL were significantly better in the home-based PT group at follow-up. Patients in the home-based PT group recovered earlier and most of their recovery was found between 1 and 3 months after discharge, but patients in the control group recovered mostly between 3 and 6 months after discharge. The study by Meeds and Pryor 13 investigated the speed and degree of recovery of preinjury independence and returning to residence, and their home rehabilitation group recovered significantly better at 6 weeks. However, comparison with their study is impossible because of different measures and different culture almost all of our patients went directly home after discharge. Sherrington and Lord 14 gave a weight-bearing exercise for 1 month; their subjects ranged from 64 to 94 years and were, on average, 7 months after hip fracture. Although the training program was not exactly the same as ours, the 21 exercisers showed increased quadriceps strength and faster walking velocity, the same as in our home-based PT group. Tinetti et al 15,18 conducted a randomized trial with a systemic home-based PT and functional therapy program for older people with hip fractures. There was no difference between the intervention and control groups at 6 and 12 months after fracture. 18 However, the intervention group showed improvements at 6 months compared with their baselines. 15 Our patients receiving the home-based PT program improved earlier, from 1 month after discharge. This study is consistent with previous research 6,7,19,20 that functional recovery after hip fracture is usually achieved at 6 months after surgery. It is reasonable to assume that earlier recovery would have beneficial effects on HRQOL and the prevention of secondary comorbidity. The large number of subjects lost to follow-up was a limitation of this study. However, the number and characteristics of patients lost to follow-up were similar in both groups; thus, this factor might not influence our conclusions. The large amount of loss to follow-up suggested that although the home-based PT program was effective in promoting functional recovery and HRQOL, only those who can actively participate in the program can benefit. This might be considered in policy-making. CONCLUSIONS The home-based PT program is associated with earlier functional recovery and HRQOL than usual care in Taiwan. These findings may have implications not only for clinical practice but also for public health and insurance policy. Acknowledgment: We appreciate the kind help from the Department of Orthopaedics, National Taiwan University Hospital, for their referral of patients. References 1. Department of Health, Executive Yuan. Health and vital statistical annual, Taipei: Department of Health, Executive Yuan; Nickens HW. 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