Interventions for improving mobility after hip fracture surgery in adults

Hip fractures are breaks in the continuity of the proximal femur usually arising from a simple fall. The majority of these fractures occurs in people with an average age of around 80 years, with a 4:1 female to male ratio. The majority of hip fractures are treated surgically either with internal fixation or by prosthetic replacement, enabling early mobilization.

Between 5% and 10% of people die within one month of the fracture, and among survivors, most fail to recover their earlier mobility and independence, eventually moving into residential care. In this scenario, rehabilitation aims to increase strength, walking performance, and weight bearing, thus increasing overall functional independence. Many strategies are adopted in physiotherapy to rehabilitate these patients, with mobilisation being a major component.

This review investigated whether interventions aimed at improving mobility and physical functioning after hip fracture surgery are helpful and safe compared to usual in-hospital care or non-provision control.

Given the increasing number of older people worldwide, with increasing estimates of hip fractures together with an overall burden to society, this review is important to respond to the urgent need to improve care services after a fragility fracture and to prevent additional events.

Outcomes of this review

This is an update of Cochrane Systematic Reviews (CSRs) published in 2000 and 2011. The outcomes analysed were mobility and its individual categories of outcome measures such as balance, sit to stand, reaching and stepping, use of aids or need of assistance, walking velocity, functioning, quality of life, mortality, and adverse effects. Further outcomes analysed were muscle strength, activities of daily living, subjective measures of function and satisfaction, and acceptability of interventions.

The CSR included 40 randomised controlled trials (RCTs) published and/or registered up to March 2021, with 4,059 participants from 17 countries. On average, participants were 80 years old, and the great majority were women. Results show that at four months, compared to usual care, mobility treatment undertaken in hospital may moderately increase people’s mobility and probably slightly increase walking speed. Mobility treatment probably makes little or no difference in rehospitalization, discharge at home, or mortality. It is uncertain whether this treatment improves physical functioning or well-being. On the other hand, mobility treatment started at hospital discharge and continued at home or elsewhere produced a slight but clinically relevant improvement in mobility and walking speed, and a slight but not relevant improvement in functioning. Compared to functional control, mobility treatment probably produces a slight but not relevant improvement in well-being. Mobility treatment probably makes little or no difference to readmission to hospital or death.

The types of treatment that appear effective were balance, walking functional, and strength or endurance exercises in addition to standard physiotherapy. The effect of electrical stimulation was not clear. Overall, there is enough evidence to conclude that mobility training, both in hospital and at discharge, is probably better than no extra treatment to help people reclaim their walking autonomy safely after hip fracture.

These results must be interpreted with caution because (i) differences in healthcare models in the countries where the studies were conducted may affect the effectiveness of some interventions and the applicability in the local context; (ii) some trials did not provide accurate descriptions of interventions, controls, study inclusion, or outcomes, limiting applicability or result details; (iii) the majority of trials excluded high-risk patients with cognitive impairment and a history of immobility; thus, the results are not applicable to these patients; (iv) the timing of outcome measurement was suboptimal in the majority of studies; and (v) compliance was not always reported.

Author’s conclusion of the review

Compared with conventional care, interventions to improve mobility after hip fracture may lead to a slight but relevant improvement in mobility and walking speed.

Among the interventions, those that include gait training, balance, and functional tasks are particularly efficacious. Mobility interventions may make little or no difference on mortality, adverse events, hospital readmission, and returning to before-injury residence. It is uncertain whether mobility interventions improve functioning or health-related quality of life.

Future recommendations

Priority questions and areas need to be identified, and this is still an area of open debate. The authors recommended that large-scale, multi-centre RCTs are needed, particularly to find out (a) the long-term effect of the interventions, assessed with one year or more follow-up. Those studies should (b) collect validated and patient-oriented outcome measures, and (c) evaluate economic outcomes such as cost effectiveness. (d) Moreover, the effect of each type of exercise programme should be assessed, as well as (e) whether the priority of the assessment should be on multi-component interventions, not only mobility.

Robin Kuruvila Sentinella