Strong evidence supports intensive home physical therapy to improve functional outcomes.

Rationale
Two high strength (Mangione et al 126; Sylliaas et al 127) and two moderate strength (Allegrante et al 128; Ryan et al 129) studies evaluated benefits of intensive exercise training in elderly patients with hip fracture. Studies support that intensive exercise training administered by physical therapy to patients after discharge from hospital care, improves functional outcomes, leg strength and health status. Sylliaas et al127 found that a 3-month leg-muscle strength-training program, performed at 70-80% 1-Repetition Maximum, administered at an outpatient rehabilitation clinic, showed improvement in balance, mobility and instrumental ADLs in home-dwelling hip fracture patients post-surgery. Mangione et al126 found improved leg muscle strength, gait speed, 6-minute walk distance and physical performance scores with intensive leg strengthening exercise training performed by community-dwelling elderly patients, 6-month post hip fracture. Allegrante et al 128 found that high-intensity strength training along with motivational video and peer support, in addition to usual postoperative care, significantly improved SF-36 scores in the role-physical domain functional performance and social functioning. Ryan et al129 found no significant difference in anxiety/depression scores of recently discharged postoperative hip fracture patients, with augmented in-home therapy compared to conventional care.

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. (126) Mangione KK, Craik RL, Palombaro KM, Tomlinson SS, Hofmann MT. Home-based leg-strengthening exercise improves function 1 year after hip fracture: a randomized controlled study. J Am Geriatr Soc 2010;58(10):1911-1917.
  2. (127) Sylliaas H, Brovold T, Wyller TB, Bergland A. Progressive strength training in older patients after hip fracture: a randomised controlled trial. Age Ageing 2011;40(2):221-227.
  3. (128) Allegrante JP, Peterson MG, Cornell CN, MacKenzie CR, Robbins. Methodological challenges of multiplecomponent intervention: lessons learned from a randomized controlled trial of functional recovery following hip fracture. 2007. http://www.nzgg.org.nz/search?search=acute+management;http://www.ncbi.nlm.nih.gov/pubmed /22842835; http://www.kurtis.it/aging/en/previous.cfm
  4. (129) Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age. Clin Rehabil 2006;20(2):123-131.