Mobility strategies are effective in adults after hip fracture surgery

What’s the issue?

Improving mobility outcomes after hip fracture is key to recovery and health outcomes. Mobility is the ability to move about, including standing up and walking and mobility strategies are treatments that aim to help people move better.

This Cochrane systematic review evaluated the benefits and harms of interventions for improving mobility and physical functioning after hip fracture surgery in adults.

How they carried out the review and what’s new

This Cochrane systematic review included randomised controlled trials or quasi randomised controlled trials that assessed mobility strategies after hip fracture surgery. Eligible trials were identified from eight electronic databases. Trials were included if they investigated the effect of strategies aimed to improve mobility. These could include care programmes, exercise (gait, balance, functional training, strength/resistance/endurance/flexibility training, three-dimensional exercise and general physical activity) or muscle stimulation. Interventions could be compared to usual care (both in-hospital), no intervention, sham exercise or social visits (post-hospital). Outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects, and return to living at pre-fracture residence. 

Two reviewers identified and selected studies, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2.0 tool. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. 

The review included 40 randomised controlled trials (n = 4059 participants) from 17 countries. Patients were mostly elderly (average age 80 years) and female (80%).  All trials had unclear or high risk of bias for one or more domains. 

In the hospital setting, there is low certainty evidence that mobility strategies may lead to a moderate, clinically meaningful increase in mobility compared to usual care (standardised mean difference [SMD]: 0.53, 95% confidence interval [CI] 0.10 to 0.96; n = 360). Post-hospital, there is high certainty evidence that mobility strategies compared to usual care, no intervention, sham exercise or social visit led to a small, clinically meaningful increase in mobility (SMD: 0.32, 95% CI 0.11 to 0.54; n= 761). Adverse events were rarely measured by included trials so the safety of these programmes in the hospital and out of hospital settings remains unknown.

Types of treatments that appear effective in improving mobility target balance, walking and functional tasks. After discharge from hospital, extra strength or endurance training may also improve mobility. The effect of electrical stimulation was not clear.

Why is this important?

Overall, the review found that both in hospital and after discharge, there is enough evidence to say that treatment targeting mobility is probably better than no extra treatment in helping people get safely back on their feet, moving and walking again after hip fracture surgery.

What’s next?

Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies. 

Expert view:

Rene Gray, professional lead for physiotherapy, James Paget University Hospital and honorary fellow at the University of East Anglia

The outcome of this review will come as no surprise to orthopaedic therapists and supports existing evidence for the importance of acute hip fracture rehabilitation to improve patient outcomes (NICE, 2023).

Importantly this review highlights the need for rehabilitation to continue following discharge from hospital and aligns with the hip fracture rehabilitation guidance in physiotherapy practice: From hospital to home standards (2018) and The Community Rehabilitation Best Practice Standards (2022). Ensuring timely and sufficient access to physiotherapy after discharge from hospital will be essential considering the drive to reduce acute length of stay. 

Although there is sufficient evidence for treatment targeting mobility the confidence in the results was low to moderate for the hospital related studies. It will be important for us all as a profession to continue contributing to the existing literature to improve our confidence in our interventions over the next decade, ready for the next Cochrane review update.

NICE Hip fracture: Management Guidance 
Hip fracture rehabilitation in physiotherapy practice
Rehabilitation Best Practice Standards

PEDro

The full PEDro article about this systematic review search can be found here.
The full paper: Fairhall NJ et al. Interventions for improving mobility after hip fracture surgery in adults. Cochrane Database Syst Rev. 2022 Sep 7;9(9):CD001704.