Systematic home-based physical and functional therapy for older persons after hip fracture

Objective: To describe the development, implementation, and results of a home-based rehabilitation protocol for older persons after hip fracture. Design: Demonstration study. Setting: Community. Participants: One hundred forty-eight community-living, nondemented participants at least 65 years of age who underwent repair of a fractured hip at two local hospitals. Intervention: A linked assessment-intervention, home-based rehabilitation strategy. The physical therapy (PT) component of the intervention was designed to identify and ameliorate impairments in balance, strength, transfers, gait, and stair climbing; the functional therapy (FT) component was designed to identify and improve unsafe and/or inefficient performance of specific activities of daily living (ADL). Main Outcome Measures: The percentage of participants able to complete each component and the extent of progress noted in strength, balance, transfers, gait, and daily functioning. Results: A total of 104 of the 148 participants (70%) completed the 6-month PT and FT program; 4 completed only PT and 6 refused both PT and FT. The remaining 32 participants (22%) received partial PT and FT that was terminated by death, hospitalization, or institutionalization. Seventy-seven percent of participants reported performing at least half of the recommended daily exercise sessions. Ninety-four percent and 96% of participants progressed in upper and lower extremity conditioning respectively; 33% progressed to the highest level in the graduated resisted exercise program. All participants progressed in the competency-based graded balance program, with 55% progressing to the fifth (most difficult) level. Similarly, the majority progressed in transfer maneuvers, stair climbing, and outdoor gait. One repetition maximum (RM) elbow extension increased from a mean of 5.8 (SD 4.6) pounds at baseline to 7.2 (SD 3.8) pounds at 6mo (t 2.22; p < .02). One RM knee extension increased from 5.8 (SD 5.8) pounds to 10.8 (SD 5.4) pounds (t = 8.06; p < .0001). The number of gait deviations decreased from 2.1 (SD 1.3) to 0.6 (SD 0.9) (p < .0001), while the mean modified Berg Balance Scale Score increased from 13.0 (SD 4.8) to 20.5 (SD 6.8) (t = 16.6; p < .0001). Finally, the Total ADL Score increased from a mean of 48.2 (SD 15.0) to 77.7 (SD 18.8) (t = 17.03; p = .0001). Conclusions: This systematic assessment and intervention protocol, targeting impairments and ADL, was feasible, safe, and effective. Protocols such as the one presented should enhance the ability to implement rehabilitation programs for the increasing number of multiply impaired older persons receiving home-based therapy and to document the process and outcomes of this can. (C) 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.