Moderate evidence supports supervised occupational and physical therapy across the continuum of care, including home, to improve functional outcomes and fall prevention.

Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Moderate Evidence MODERATE EVIDENCE
Rationale
Two high-strength studies (Ziden et al 118, Crotty et al 119) and five moderate-strength studies (Binder et al 120, Hagsten et al 121, Hagsten et al 122, Tsauo et al 123, Bischoff-Ferrari et al 124) support that rehabilitative therapies delivered across the continuum of care have been shown to be effective in improving functional outcomes in the elderly patient with hip fracture, post-surgery. Binder et al 120 demonstrated a supervised home-based Physical Therapy (PT) program to be superior to conventional care in improving physical functioning and mobility. Hagsten et al’s studies121;122) were moderate strength studies that similarly demonstrated utility of Occupational Therapy (OT) (initiated during hospital stay and continued at home) in improving functional outcomes as measured by Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and Health-Related Quality of Life (HRQOL).
 
Four studies including one high strength (Ziden et al 118) and three  moderate strength (Tsauo et al 123; Bischoff-Ferrari et al 124; Ziden et al 125) studies establish the beneficial effects of home-based PT on functional outcomes such as physical and social functioning, ADLs, mobility, HRQOL and patient satisfaction. In addition, Bischoff-Ferrari’s et al 119 study showed reduction in falls although Crotty’s study showed no change in fall rates; however, they demonstrated that accelerated discharge to home-based PT improved level of independence and physical functioning at same levels as hospital-based rehabilitation.

Risks and Harms of Implementing These Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.

Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
 
  1. (118) Ziden L, Kreuter M, Frandin K. Long-term effects of home rehabilitation after hip fracture - 1-year follow-up of functioning, balance confidence, and health-related quality of life in elderly people. Disabil Rehabil 2010;32(1):18-32.
  2. (119) Crotty M, Whitehead CH, Gray S, Finucane PM. Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomized controlled trial. Clin Rehabil 2002;16(4):406-413.
  3. (120) Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE, Schechtman KB. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA 2004;292(7):837-846.
  4. (121) Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy training in 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand 2004;75(2):177-183.
  5. (122) Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability concerning ADL and IADL after hip fracture: a randomized trial. Acta Orthop 2006;77(1):114-119.
  6. (123) Tsauo JY, Leu WS, Chen YT, Yang RS. Effects on function and quality of life of postoperative home-based physical therapy for patients with hip fracture. Arch Phys Med Rehabil 2005;86(10):1953-1957.
  7. (124) Bischoff-Ferrari HA, Dawson-Hughes. Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture: a randomized controlled trial. 2010. http://www.nzgg.org.nz/search?search=acute+management;http://dx.doi.org/10.1001/archinternm ed.2010.67; http://www.ncbi.nlm.nih.gov/pubmed/20458090; http://archinte.ama- assn.org/contents-by-date.0.dtl
  8. (125) Ziden L, Frandin K, Kreuter M. Home rehabilitation after hip fracture. A randomized controlled study on balance confidence, physical function and everyday activities. Clin Rehabil 2008;22(12):1019-1033.