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Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2018;-:-------

REVIEW ARTICLE (META-ANALYSIS)

Effectiveness of Supervised Home-Based Exercise


Therapy Compared to a Control Intervention on
Functions, Activities, and Participation in Older
Patients After Hip Fracture: A Systematic Review and
Meta-analysis
Isolde A.R. Kuijlaars, MSc,a Lieke Sweerts, MSc,b
Maria W.G. Nijhuis-van der Sanden, PhD,b,c Romke van Balen, MD, PhD,d
J. Bart Staal, PhD,b,e Nico L.U. van Meeteren, PhD,f,g Thomas J. Hoogeboom, PhDb
From the aCenter for Physical Therapy Ramaekers, Weert; bRadboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical
Center, Nijmegen; cDepartment of Rehabilitation, Radboud University Medical Center, Nijmegen; dDepartment of Public Health and Primary
Care, Leiden University Medical Centre, Leiden; eResearch Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen;
f
Department of Epidemiology, CAPHRI, Maastricht University, Maastricht; and gHealthwHolland, Top Sector Life Sciences and Health, the
Hague, the Netherlands.

Abstract
Objective: The aim of this review was to investigate whether supervised home-based exercise therapy after hospitalization is more effective on
improving functions, activities, and participation in older patients after hip fracture than a control intervention (including usual care). Further-
more, we aimed to account the body of evidence for therapeutic validity.
Data Sources: Systematic searches of Medline, Embase, and CINAHL databases up to June 30, 2016.
Study Selection: Randomized controlled trials studying supervised home-based exercise therapy after hospitalization in older patients (65y)
after hip fracture.
Data Extraction: Two reviewers assessed methodological quality (Physiotherapy Evidence Database) and therapeutic validity (Consensus on
Therapeutic Exercise Training). Data were primary analyzed using a best evidence synthesis on methodological quality and meta-analyses.
Data Synthesis: A total of 9 articles were included (6 trials; 602 patients). Methodological quality was high in 4 of 6 studies. One study had high
therapeutic validity. We found limited evidence in favor of home-based exercise therapy for short- (4mo) and long-term (>4mo) performance-
based activities of daily living (ADL) and effects at long-term for gait (fast) and endurance. Evidence of no effectiveness was found for short- and
long-term effects on gait and self-reported (instrumental) ADL and short-term effects on balance, endurance, and mobility. Conflicting evidence
was found for strength, long-term balance, short-term gait (comfortable), long-term self-reported ADL, and long-term mobility.
Conclusions: Research findings show no evidence in favor of home-based exercise therapy after hip fracture for most outcomes of functions,
activities, and participation. However, trials in this field have low therapeutic validity (absence of rationale for content and intensity and reporting
of adherence), which results in interventions that do not fit patients’ limitations and goals.
Archives of Physical Medicine and Rehabilitation 2018;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

Therapeutic exercise training after hip fracture is recommended in


clinical guidelines, as part of a multidisciplinary program.1-3
However, many patients with hip fractures never regain their
Disclosures: none. prefracture levels of functioning in various domains of functioning

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.05.006
2 I.A.R. Kuijlaars et al

according to the International Classification of Functioning, Methods


Disability and Health (ICF).4-6 Over the last years, home reha-
bilitation has been encouraged in the Netherlands.7,8 Besides a This systematic review was performed according to Preferred
cost argument, it is conceivable that patients recover better at Reporting Items for Systematic Reviews and Meta-Analyses
home on functional and quality-of-life outcomes, because they can Statement.18 The research proposal is registered in PROSPERO
incorporate what they learn directly into their own context.9 (CRD42015029535).
Furthermore, in an observational study, approximately half of
the patients recovering from a hip fracture chose to undertake Literature search
home rehabilitation. These patients had a higher rate of recovery
compared to patients who chose institution-based rehabilitation. We searched the electronic databases Medline, Embase, and
However, in this observational nonrandomized design, prefracture CINAHL for eligible articles up to June 30, 2016. We used the
functional status in activities of daily living (ADL) was better and high-sensitivity strategy for the search of RCTs.19 The search did
less people lived alone before fracture in this home-based reha- not have language restrictions. The search strategy can be found in
bilitation group.10 Interestingly, home-based exercise in- supplemental table S1 (available online only at http://www.
terventions yield smaller effects than institution-based programs archives-pmr.org/). In addition, reference tracking was per-
as suggested in 2 systematic reviews with searches up to 2012. formed in all eligible studies.
One review focused on supervised and nonsupervised in- Two reviewers (I.K. and L.S.) conducted inclusion of articles.
terventions,11 and 1 review reported only physical function and Initially, articles were screened for eligibility on title and abstract.
quality of life as outcome measures.12 Several new randomized If title and abstract suggested that an article was potentially
controlled trials (RCTs) have been published since 2012 which eligible for inclusion, a full paper copy of the report was obtained.
might shed another light on the topic. See fig 1 for the flow chart of the included studies.
Moreover, previous reviews on the effects of home-based Articles were eligible for inclusion if (1) the design was an
rehabilitation programs for patients after bone fractures have not RCT; (2) older patients were included (65y) after hip fracture
yet accounted for the interventions’ therapeutic validity.13,14 (box 1); (3) the authors compared structured (ie, preplanned
Herbert and Bo (2005) recommended to assess the quality of treatment), supervised (by an exercise trainer or physical thera-
complex exercise interventions,13 known as therapeutic validity. pist), home-based exercise therapy (as primary intervention) with
Therapeutic validity is defined as “the potential effectiveness of a an alternative intervention (including usual care and traditional
specific intervention given the potential target group of rehabilitation) after hospitalization; and (4) the authors reported
patients”15(p.2) that focuses on patient selection, therapist and performance-based or self-reported outcome measures of body
setting selection, rationale and content of the intervention, and functions (ICF domain neuromuscular and movement-related
adherence. Recently, a number of systematic reviews have been functions) or activities and participation (ICF domains mobility,
published using this new approach that aids reviewers to account self-care, domestic life).6 Articles were excluded if they studied a
for the validity of studied interventions to pool the best in- multidisciplinary program.
terventions and their effects rather than just provide evidence.15-17
It appears that interventions rarely meet the requirements for Data extraction
therapeutic validity.15-17 By including studies with limited validity
or nonadequate patient selection, the overall (beneficial) effects For all included studies, we assessed whether a design paper was
may dilute. Therefore, we aim to introduce this methodology available to obtain more information regarding the intervention,
within the literature of exercise therapy in patients after hip which we then used as an additional source in our data extraction.
fracture to explore therapeutic validity in this field. The aim of the If no design paper was available, we contacted the corresponding
present study was to systematically review RCTs on the short- authors of the included studies for additional information. One
(4mo) and long-term (>4mo) effectiveness after hospitalization reviewer (I.K.) extracted data from each study using a self-
on body functions, activities, and participation (conform the ICF) administered standardized extraction form. Another reviewer
of supervised home-based exercise therapy in older patients (L.S.) checked a random portion of 33% of the data extraction. If
(65y) after hip fracture compared with a control intervention any error occurred, a second (and so on) 17% of the data was
(including usual care). We hypothesized that home-based in- checked. Data extracted were author names, publication year,
terventions were superior to control interventions. Furthermore, participants (sample size, age, sex, residence), recruitment rate,
we aimed to account the body of evidence for therapeutic validity. time from fracture to start of the study, prestudy and within study
We hypothesized that studies with higher methodological quality description and exercise parameters, control group description,
and therapeutic validity would demonstrate greater effectiveness. number of participants lost to follow-up, outcome measures, and
study results. Only point estimates were reported in this review for
between-group comparisons. Continuous outcomes were
List of abbreviations: expressed as mean differences (MD) with corresponding 95%
ADL activities of daily living confidence interval (95% CI). Dichotomous outcomes were
CI confidence interval expressed as relative risk with corresponding 95% CI. If this in-
CONTENT Consensus on Therapeutic Exercise Training formation was not presented in the articles, we calculated these
IADL instrumental activities of daily living measures if enough data were available.19 Authors of the RCTs
ICF International Classification of Functioning, were contacted if these data were not reported in the published
Disability and Health article. The outcomes of the different studies were divided in
MD mean difference
domains within the components of functions or activities and
RCT randomized controlled trial
participation to interpret the results. Results were classified into
SMD standardized mean difference
short-term (4mo) and long-term results (>4mo) after baseline.20

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Home-based exercise after hip fracture 3

Fig 1 Flow chart of the included studies.

For strength outcomes of lower extremity muscle strength by trial design to generate unbiased results that are sufficiently pre-
dynamometers, strap with a spring gauge or a leg extension power cise and allow replication in clinical practice.21 The methodo-
rig was included. Step-up tests were not presented in this review. logical quality was scored using the Physiotherapy Evidence
Cadence measures were not presented for gait. Database (PEDro) scale.22 The PEDro scale is a reliable measure
for rating quality of RCTs.21 Scores range from 0 to 10, scores 6
Methodological quality and therapeutic validity indicate moderate-to-high methodological quality.22 The thera-
peutic validity was scored using the Consensus on Therapeutic
Two reviewers (I.K. and L.S.) independently assessed methodo- Exercise Training (CONTENT) scale, developed by Hoogeboom
logical quality (table 1) and therapeutic validity (table 2) of the et al (2012)15 for assessing therapeutic validity of therapeutic
included articles. Methodological quality is the likelihood of the exercise programmes. Scores range from 0 to 9, scores 6

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4 I.A.R. Kuijlaars et al

In case of clinical heterogeneity of the studies, decided by


Box 1 Definition for older patients after hip fracture according to
20 the authors based on the participants residence, content, and
Crotty et al.
time frame of the interventions (I.K., L.S., T.H.), we performed
We used the definition of Crotty et al20 to ensure only studies a best evidence synthesis based on methodological quality.
on older patients after hip fracture were included, namely: Studies were rated as high-quality study when the PEDro score
“The main study population was older people with any type was 6. Studies were rated as low-quality study when the
of fracture of the proximal femur. Most participants were PEDro score was <6.22
aged 65 years or over and had undergone surgery for their For the best evidence, synthesis results of the studies were
hip fracture. Trials that included younger participants were rated on effectiveness (yes or no). A P value of <.05 was
included if the mean age minus one standard deviation was considered statistically significant. Because some studies reported
greater than 65 years. Participants younger than 65 years more results on 1 outcome with both statistically and non-
were included as long as the number of these was relatively statistically significant results, we decided if more outcome
small and there was adequate randomization of younger measures in 1 study were not statistically significant than statis-
patients to intervention and control groups. Studies which tically significant, results were rated as no effectiveness. If an
focused on younger people with hip fracture were excluded, equal number of items were statistically significant as not statis-
as were trials involving people with multiple trauma.”20(p.4) tically significant, the long-term effects were reported in the best
evidence synthesis, as we deemed these most meaningful to
the patients.
reflecting high therapeutic validity.15 Disagreements were The levels of evidence were based on Heymans et al (2004).26
resolved in a consensus meeting. The strength of interrater Evidence was rated as no evidence (no RCTs), limited evidence
agreement was measured by Cohen k coefficient (95% CI), with (only 1 RCT [either high or low quality]), conflicting evidence
kZ0.41-0.60 indicating moderate agreement, kZ0.61-0.80 rep- (inconsistent findings in multiple RCTs), moderate evidence
resenting good agreement, and k0.81 representing very good (generally consistent findings in 1 high-quality RCT plus 1 or
agreement.23,24 more low-quality RCTs, or by generally consistent findings in
multiple low-quality RCTs), and strong evidence (generally
consistent findings in multiple high-quality RCTs).26 Consistent
Data analysis findings was defined as similar results in 75% of the studies.27
A sensitivity analysis was performed to assess the impact of
Data were pooled when studies were clinically homogenous
therapeutic validity, by including only studies with high method-
concerning participants, intervention, and outcome measures.
ological quality (6) and high therapeutic validity (6) in the
Continuous measures of functions, activities, and participation in
best-evidence synthesis.
the home-based exercise and control groups were transformed to
standardized mean difference (SMD) (Hedges g) to cope with
variety of outcome measures.19 For studies with more than 1
home-based exercise group, we chose to include the intervention Results
in the meta-analysis that was most alike the other interventions to
avoid a unit-of-analysis error.19 Calculations were performed Literature search
using a random-effects model. An SMD of 0.2, 0.5, and 0.8 rep-
resents respectively a small, moderate, and large effect.25 An Our search resulted in 913 potentially relevant articles. After
alpha value of <0.05 was considered statistically significant. Stata selection 9 articles met our inclusion criteria,28-36 reporting
13a was used to pool the data. data of 6 trials.28-33 According to the Cochrane Handbook,

Table 1 Methodological quality of the included studies


PEDro Score
Source, y 1 2 3 4 5 6 7 8 9 10 11 Total
Latham et al, 201428 þ þ  þ   þ  þ þ þ 6
Salpakoski et al, 201429 þ þ þ þ   þ þ þ þ þ 8
Orwig et al, 201130 þ þ  þ   þ  þ þ þ 6
Mangione et al, 201031 þ þ þ þ   þ  þ þ þ 7
Mangione et al, 200532 þ þ  þ   þ   þ þ 5
Sherrington et al, 199733 þ þ  þ    þ  þ þ 5
NOTE. One point was awarded when a criterion is clearly satisfied (þ: 1 point was awarded, : criterion was not satisfied). Item 1 was not used to
calculate the PEDro score. Scores range from 0 to 10. The criteria are defined as follows: (1) eligibility criteria were specified; (2) participants were
randomly allocated to groups (in a crossover study, participants were randomly allocated an order in which treatments were received); (3) allocation
was concealed; (4) the groups were similar at baseline regarding the most important prognostic indicators; (5) there was blinding of all participants;
(6) there was blinding of all therapists who administered the therapy; (7) there was blinding of all assessors who measured at least 1 key outcome; (8)
measures of at least 1 key outcome were obtained from >85% of the participants initially allocated to groups; (9) all participants for whom outcome
measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least 1 key outcome was
analyzed by intention to treat; (10) the results of between-group statistical comparisons are reported for at least 1 key outcome; and (11) the study
provides both point measures and measures of variability for at least 1 key outcome.

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Home-based exercise after hip fracture 5

Table 2 Therapeutic validity of the included studies


CONTENT Scale
Source, y A1 A2 B3 C4 C5 D6 D7 D8 E9 Total
Latham et al, 2014 28
þ þ      þ  3
Salpakoski et al, 201429 þ   þ    þ  3
Orwig et al, 201130 þ  þ þ  þ  þ  5
Mangione et al, 201031 þ þ    þ þ   4
Mangione et al, 200532 þ  þ þ þ þ þ  þ 7
Sherrington et al, 199733    þ      1
NOTE. One point was awarded when a criterion is clearly satisfied (þ: 1 point was awarded, : criterion was not satisfied). Scores range from 0 to 9. The
criteria are defined as follows: (1) was the patient selection described?; (2) was the patient selection adequate?; (3) were eligibility criteria for
therapist and setting determined and adequate?; (4) was the therapeutic exercise based on a priori aims and intentions?; (5) was the rationale for the
content and intensity of the therapeutic exercise described and plausible?; (6) was the intensity of the therapeutic exercise described?; (7) was the
therapeutic exercise monitored and adjusted when considered necessary?; (8) was the therapeutic exercise personalized and contextualized to the
individual participants?; (9) was adherence to the therapeutic exercise determined and acceptable?

information from multiple reports of 1 study was collated.19 Two electrical nerve stimulation,31 and biweekly mailings of the Na-
publications reported the same data of a 6-month home exercise tional Institutes of Health Age Pages on a variety of nonexercise
program for hip fracture recovery,28,34 from here cited as Latham topics.32 In 1 study, no description of the intervention in the
et al.28 Three publications reported about the same study of the control group was given.33
promotion mobility rehabilitation program,29,35,36 from here The percentage of participants lost to follow-up after baseline
cited as Salpakoski et al (2014).29 A flow diagram of search and varied from 4.9%29 to 30.8%.31 The number of participants who
selection is shown in fig 1. Design papers were available for the dropped out was equal in the home-based exercise and control
study of Latham et al37 and Orwig et al.38 None of the contacted groups. Only in 1 study a higher dropout rate was reported in the
authors provided additional information regarding their resistance group (6 dropouts of 17 participants) in comparison
interventions. with the aerobic (1 dropout of 12 participants) and control group
(1 dropout of 11 participants), because of hospitalization not
related to the training.32
Study characteristics
A second reviewer extracted 67% of the data. Agreement between Methodological quality
the reviewers indicated no further extraction from a second
reviewer was necessary. Table 1 shows the assessment of methodological quality in indi-
Included studies had a total of 602 patients (range mean age vidual studies. The initial agreement of the reviewers on the
77-83y; 81% women). Table 3 shows the characteristics of assessment of methodological quality was 93.9% (62 of 66 items).
included studies. Three studies included only community-dwelling Cohen k (95% CI) was 0.87 (0.72-0.97). Two studies were
participants29,31,32; the other studies also included participants assessed as having low methodological quality32,33 and 4 as
living in supervised caregiver settings.28,30,33 Five studies having moderate-to-high methodological quality.28-31 Two studies
excluded people with cognitive impairment (Mini Mental Status met the criteria of concealed allocation29,31 and adequate follow-
Examination score <18 or <20).28-32 The interventions started at up.29,33 All studies scored positively for items about eligibility
different times. One study started as soon as possible after criteria, random allocation, similar groups at baseline, between-
discharge to home,29 3 studies started after finishing physical group comparisons, and providing point measures and measures
therapy,30-32 1 trial started after finishing usual care,28 and 1 study of variability.28-33
initiated therapy within 9 months after fracture.33 Mean time from
surgery to the start of the trials ranges from 9.2 weeks29 up to 9.5 Therapeutic validity
months.28 Intervention duration and follow-up time points varied
from 1 month33 till 1 year.29,30 For a visible depiction, see fig 2. In Table 2 shows the assessment of therapeutic validity in individual
5 studies, physical therapists provided the exercise pro- studies. The initial agreement of the reviewers on assessment of
gram.28,29,31-33 In 1 study, exercise trainers were trained to provide therapeutic validity was 90.7% (49 of 54 items). Cohen k (95%
the intervention.30 CI) was 0.81 (0.63-0.96). Five studies showed low therapeutic
In 2 studies, control interventions consisted of usual care.29,30 validity28-31,33 and 1 study reflected high therapeutic validity.32
In one of these studies, all participants received standard care after One study scored yes on items about the rationale for the con-
discharge home; 70% of the participants received written home tent and intensity of the therapeutic exercise (C5) and adherence
exercise program without follow-up.29 In the other study, the (E9).32 Items about adequate patient selection (A2)28,31 and
control group received physician-prescribed postfracture standard monitoring and adjustment of the intervention (D7)31,32 were 2
care, which included relatively short hospital stays and approxi- times scored positively. Items about description of the patient
mately 2-4 weeks of rehabilitation.30 In 3 other studies, the control selection (A1) and a priori aims and intentions for the therapeutic
group received another prescribed treatment, that is, nutrition exercise (C4) were scored respectively 528-32 and 429,30,32,33 times
education for cardiovascular health,28 conventional transcutaneous as positive.

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Table 3 Characteristics of the included studies
Participants Home-Based Exercise Intervention
Mean Age  SD Total Score
Source, y N (I/C) (y) Women n (%) Description of Intervention Exercise Parameters Control Group PEDro/CONTENT
Latham et al, 232 (120/112) I: 77.210.2 I: 83 (69.2) A home-based program with functionally Prestudy intervention: traditional Nutrition 6/3
201428 C: 78.99.4 C: 77 (68.8) oriented exercises. The program included rehabilitation. All participants received education for
repeating simple functional tasks using Thera- some physical therapy after their cardiovascular
Bands for resistance and standing exercises fracture (92.2% home care therapy health based
using steps. The therapists also used cognitive service, 42.4% outpatient therapy). on the Dietary
and behavioral strategies to positively Intervention duration: 6 mo Guidelines for
enhance the attitudes and beliefs of each Weekly frequency: 3 Americans
study participant related to exercise. Session duration:
 Supervised sessions: 1 h
 Unsupervised sessions: unknown
Weekly duration: unknown
Intensity: using Thera-Bands, steps of
varying height and weighted vests
Supervised sessions: 3 or 4 sessions and
monthly telephone call
Salpakoski 81 (40/41) I: 80.97.7 I: 31 (78) Standard care and the ProMo. A multicomponent Prestudy intervention: Inpatient Standard care 8/3
et al, C: 79.16.4 C: 32 (78) home-based rehabilitation, included rehabilitation
201429 evaluation and modification of environmental Intervention duration: 1 y
hazards, guidance for safe walking, individual Weekly frequency:
nonpharmacologic pain management  Strengthening and stretching exer-
evaluation, individual progressive home cises: 3
exercise program (strengthening exercises for  Balance and functional exercises: 2-3
lower limb muscles, balance training, Session duration: 30 min
stretching and functional exercises), and Weekly duration: 150-180 min
physical activity counseling. Intensity:
 Strengthening exercises: using resis-
tance bands of 3 different strengths
 Balance training: reducing hand sup-
port and the base of support
Supervised sessions: 5-6 and 2 telephone
calls
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Home-based exercise after hip fracture


Table 3 (continued )
Participants Home-Based Exercise Intervention
Mean Age  SD Total Score
Source, y N (I/C) (y) Women n (%) Description of Intervention Exercise Parameters Control Group PEDro/CONTENT
Orwig et al, 180 (91/89) I: 82.57.1 Only women Usual care and the home-based exercise plus Prestudy intervention: physician Usual care 6/5
201130 C: 82.36.9 were included. program consisted of an exercise component prescribed postacute physical therapy
and a self-efficacyebased motivational Intervention duration: 1 y
component. The exercise sessions combined Weekly frequency:
strength training for the upper and lower  Strength training: 2
extremities, aerobic stepping exercises, and  Aerobic exercise: 3
stretching exercises. The plus or motivational Session duration:
component included a self-efficacy-based  Warm-up and cool-down: 20-30 min
motivational component, education and  Strength training: 30 min
encouragement, physiologic feedback, cueing,  Aerobic exercise: 20-30 min
and self-modeling. Weekly duration*: 120-150 min
Intensity:
 Strength training: The duration of each
exercise was increased until 3 sets of
10 repetitions on both sides; intensity
was increased using the resistance of
exercise bands and ankle and wrist
weights.
 Aerobic training: Once participants
could perform 20 min, light ankle
weights were added.
Supervised sessions: 56 and telephone
calls
Mangione 26 (14/12) I: 79.65.9 I: 12 (86) A high-intensity leg strengthening home Prestudy intervention: physical therapy Conventional 7/4
et al, C: 82.06.0 C: 9 (75) exercise program. A portable progressive Intervention duration: 10 wk TENS
201031 resistive exercise machine was used for hip Weekly frequency: 2
and knee muscles. Session duration: 30-40 min
Weekly duration: 60-80 min
Intensity: 8-RM, reevaluated every 2 wk, 3
sets of 8 repetitions
Supervised sessions: 20
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Table 3 (continued )
Participants Home-Based Exercise Intervention
Mean Age  SD Total Score
Source, y N (I/C) (y) Women n (%) Description of Intervention Exercise Parameters Control Group PEDro/CONTENT
Mangione 41 A: 79.85.6y A: 9 (75)y A: Prestudy intervention: physical therapy Biweekly 5/7
et al, A:13 R: 77.97.9y R: 7 (64)y A moderate-intensity aerobic home exercise Intervention duration: 12 wk mailings of
200532 R:17 C: 77.87.3y C: 8 (80)y program with walking on level surfaces and on Weekly frequency: 2 (first 2mo) to 1 (third the National
C:11 stairs for 20 min. If the patient was unable, he month) Institutes of
or she had to perform additional exercises. Session duration: 30-40 min Health Age
R: Weekly duration: 60-80 min (first 2mo) to Pages on a
A high-intensity leg strengthening home 30-40 min (third month) variety of
exercise program. A portable progressive Intensity: 65%-75% of predicted nonexercise
resistive exercise machine was used for hip maximum heart rate topics
and knee muscles. Supervised sessions: 20
Intervention duration: 12 wk
Weekly frequency: 2 (first 2mo) to 1 (third
month)
Session duration: 30-40 min
Weekly duration: 60-80 min (first 2mo) to
30-40 min (third month)
Intensity: 8-RM, reevaluated every 2 wk, 3
sets of 8 repetitions
Supervised sessions: 20
Sherrington 42 (21/21) I: 80.08.1 I: 13 (61.9) Home-based weight-bearing exercise on a Prestudy intervention: unknown No description of 5/1
et al, C: 77.18.2 C: 20 (95.2) stepping block Intervention duration: 1 mo the control
199733 Weekly frequency: 7 intervention
Session duration: unknown
Weekly duration: unknown
Intensity: using a stepping block of 1 or 2
telephone books. Maximum number of
repetitions at assessment with slowly
increase the number of repetitions at
least once a day.
Supervised sessions: 2
Abbreviations: A, moderate-intensity aerobic training group; C, control group; I: intervention group; ProMo, promotion mobility rehabilitation program; R: high-intensity supervised resistance group; RM:
repetition maximum; TENS, transcutaneous electrical nerve stimulation.
* Warm-up and cool-down were not included in the weekly duration.
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I.A.R. Kuijlaars et al
y
Mangione et al (2005): Age and sex were only reported for patients who completed the study.
Home-based exercise after hip fracture 9

Fig 2 Time plot of the included RCTs. )Orwig et al (2011) reported no time between fracture and baseline for the control group.

Effectiveness of home-based exercise therapy differences were found after the interventions.31,32 After pooling
the lower extremity strength, a nonsignificant SMD with a cor-
Results are shown in supplemental table S2 (available online only responding 95% CI was found of 0.04 (0.66 to 0.58). In the
at http://www.archives-pmr.org/) for body functions, activities, other study, patients in the home-based exercise group had more
and participation. No point measures were available for the study strength than patients in the control group, in both the affected leg
of Orwig et al (2011). Table 4 shows the best evidence synthesis (MD [95% CI]: 3.1 [0.32-5.88]) and the nonaffected leg (MD
for all outcomes based on methodological quality. [95% CI]: 3.5 [0.01-6.99]).33
Data of Mangione et al (2010)31 and Mangione et al (2005)32 Long-term effects on lower extremity strength were reported in
(resistance group) were pooled for summed lower extremity 2 studies.28,31 Strength did not differ at 6 months in 1 study.28 At 9
strength, gait (comfortable gait speed), and endurance. Other data months, strength was better in the fractured leg (MD [95% CI]: 4.3
were not pooled because of heterogeneity of the studies. [0.30-8.30]) and nonfractured leg (MD [95% CI]: 5.0 [0.97-9.03])
in the home-based exercise group.28 The other study found no
Body functions difference in lower extremity strength.31
All studies reported several outcome measures for body func- There is conflicting evidence for effectiveness on strength at
tions.28,29,31-33 Functions were divided into strength, balance, gait, short- and long-term follow-up.
and endurance. All outcomes were performance based.
Body functions: balance
Body functions: strength Two high-quality studies28,29 and 1 low-quality study33 reported
Two high-quality studies28,31 and 2 low-quality studies32,33 re- outcome measures of balance. Short-term effects on balance were
ported outcome measures for muscle strength. Two studies re- reported in 2 studies.29,33 Both studies found no significant results
ported baseline muscle strength for the fractured and nonfractured in balance.29,33
leg, demonstrating an actual strength deficit in the frac- Long-term effects on balance were reported in 2 studies.28,29
tured leg.28,33 One study reported significant improvement at 6 (MD [95% CI]:
Short-term effects on lower extremity strength were reported in 3.3 [0.28-6.32]) and 9 months (MD [95% CI]: 5.2 [2.04-8.36])
3 studies.31-33 Two studies had an intervention group with an after baseline28; the other study did not find a significant inter-
exercise program specially focused on strength training.31,32 No vention effect.29

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10 I.A.R. Kuijlaars et al

Table 4 Best evidence synthesis based on methodological quality


Was There an Effect?
Outcome Yes No Best Evidence Synthesis
Strength
Short-term Low (33) Low (32) Conflicting evidence
High (31)
Long-term High (28) High (31) Conflicting evidence
Balance
Short-term Low (33) Moderate evidence of no effectiveness
High (29)
Long-term High (28) High (29) Conflicting evidence
Gait (comfortable gait speed)*
Short-term High (31) Low (32,33) Conflicting evidence
Long-term High (31) Limited evidence of no effectiveness
Gait (fast gait speed)*
Short-term High (31) Limited evidence of no effectiveness
Long-term High (31) Limited evidence of effectiveness
Endurance
Short-term Low (32) Moderate evidence of no effectiveness
High (31)
Long-term High (31) Limited evidence of effectiveness
ADLdperformance-based
Short-term High (31) Limited evidence of effectiveness
Long-term High (31) Limited evidence of effectiveness
ADLdself-reported
Short-term Low (32) Strong evidence of no effectiveness
High (29,31)
Long-term High (31) High (28,29) Conflicting evidence
IADLdself-reported
Short-term High (29) Limited evidence of no effectiveness
Long-term High (29) Limited evidence of no effectiveness
Mobilitydperformance-based
Short-term High (29) Limited evidence of no effectiveness
Long-term High (28) High (29) Conflicting evidence
Mobilitydself-reported
Short-term High (29) Limited evidence of no effectiveness
Long-term High (28) High (29) Conflicting evidence
NOTE. Studies were rated as high-quality studies when the PEDro score was 6. Studies were rated as low-quality studies when the PEDro score was <6.
* Results of gait were divided in comfortable and fast gait speed.

There is moderate evidence for no effectiveness on balance at There is conflicting evidence for effectiveness on gait
short-term follow-up and conflicting evidence for effectiveness at (comfortable gait speed) at short-term follow-up, limited evidence
long-term follow-up. for no effectiveness on gait (comfortable gait speed) at long-term
follow-up and gait (fast gait speed) at short-term follow-up, and
Body functions: gait limited evidence for effectiveness on gait (fast gait speed) at long-
One high-quality study31 and 2 low-quality studies32,33 reported term follow-up.
outcome measures of gait. Short-term effects on gait were re-
ported in 3 studies.31-33 The studies reported no significant short- Body functions: endurance
term effect on gait,31-33 in exception of usual gait speed 10 weeks One high-quality study31 and 1 low-quality study32 reported
after baseline in 1 study (MD [95% CI]: 0.11 [0.05-0.27]).31 outcome measures on endurance. Short-term effects on endurance
Short-term data of comfortable gait speed were pooled for both were reported in 2 studies.31,32 No significant short-term effects
studies of Mangione31,32 (SMD [95% CI]: 0.40 [0.18 to 0.98]). were found.31,32 Data were pooled for endurance (SMD [95% CI]:
Long-term effects on gait were reported in 1 study, which re- 0.40 [0.19 to 0.98]) with no statistical significant differences
ported significant results for the home-based exercise group for between both groups.31,32
fast gait speed (MD [95% CI]: 0.22 [0.03-0.41]).31 Usual gait The long-term effect on endurance was reported in 1 study,31
speed did not differ between groups.31 which reported a significant improvement for the home-based

www.archives-pmr.org
Home-based exercise after hip fracture 11

exercise group at 26 weeks after baseline (MD [95% CI]: 80.1 control group (MD [95% CI]: 2.8 [0.28-5.32]).28 In the other
[19.48-140.72]).31 study, more participants were able to negotiate stairs without
There is moderate evidence for no effectiveness on endurance difficulties at 12 months (relative risk [95% CI]: 1.54 [1.06-2.24]).
at short-term follow-up and limited evidence for effectiveness at At 6 months, no significant difference was found.29 Perceived
long-term follow-up. entrance-related barriers and perceived outdoor barriers were not
different between groups in the same trial.29
Activities and participation There is limited evidence for no effectiveness on performance-
Four studies reported outcome measures related to activities and based and self-reported mobility at short-term follow-up. In addi-
participation.28,29,31,32 Activities and participation were divided tion, there is conflicting evidence for effectiveness on performance-
into ADL, instrumental activities of daily living (IADL), and based and self-reported mobility at long-term follow-up.
mobility. Mobility is seen as the ability to move from one place to
another, maintaining posture, walking, and moving objects.6 If Sensitivity analysis
more complex tasks were measured, the outcomes were presented None of the eligible studies had high methodological quality and
by ADL. Outcomes were divided into performance-based and self- therapeutic validity, so the sensitivity analysis yielded no studies.
reported outcomes.

Activities and participation: activities of daily living Discussion


Three high-quality studies28,29,31 and 1 low-quality study32 re-
ported outcome measures for ADL. Short-term performance-based This systematic review did not confirm our hypothesis that home-
effects on ADL were reported in 1 study.31 Patients in the home- based exercise therapy was superior to usual care or a nonexercise
based exercise group performed better than the control group at 10 control intervention in older patients after hip fracture. The results
weeks after baseline (MD [95% CI]: 6.1 [2.38-9.82]).31 demonstrates that there is only limited evidence in favor of home-
Short-term self-reported effects on ADL were reported in 3 based exercise for short- and long-term performance-based ADL
studies.29,31,32 The studies found no significant results and long-term gait (fast gait speed) and endurance, based on only 1
on ADL.29,31,32 study investigating a 10-week high-intensity leg strengthening
One study reported long-term performance-based effects on program.31 The highest level of evidence was found for no effec-
ADL.31 Patients in the home-based exercise group performed tiveness of home-based exercise therapy in comparison with an
better than the control group 26 weeks after baseline (MD [95% alternative intervention (including usual care) for short-term self-
CI]: 7.3 [3.55-11.05]).31 reported ADL.29,31,32 There was limited and moderate evidence of
Long-term self-reported effects on ADL were reported in 3 no effectiveness for short- and long-term self-reported IADL,29
studies.28,29,31 No significant differences were found in 2 short-term balance,29,33 gait (fast gait speed),31 endurance,31,32
studies.28,29 In the other study, self-reported ADL was signifi- self-reported and performance-based mobility,29 and long-term
cantly higher in the home-based exercise group than in the control gait (comfortable gait speed).31 Conflicting evidence was found
group (MD [95% CI]: 18.5 [2.73-34.27]).31 for strength, long-term balance, short-term gait (comfortable), long-
There is limited evidence for effectiveness on performance- term self-reported ADL, and long-term mobility. Pooled data
based ADL at short- and long-term follow-up. In addition, there is showed nonsignificant small SMDs in favor of the home-based
strong evidence for no effectiveness on self-reported ADL at exercise group for short-term endurance and comfortable gait
short-term follow-up and conflicting evidence for effectiveness on speed.31,32 We were unable to confirm our hypothesis that studies
self-reported ADL at long-term follow-up. with high methodological quality and therapeutic validity had
greater effects, because none of the eligible studies met these
Activities and participation: instrumental activities of daily criteria. The latter suggests that interventions are ill adapted to the
living needs and health problems of the individual patients after hip
One high-quality study reported outcome measures for IADL.29 fracture. In addition, included RCTs showed wide clinical hetero-
This study found no significant differences between groups at 3, geneity concerning the residence of participants, start of the study,
6, and 12 months after baseline.29 There is limited evidence for no and content and duration of the intervention. Frequently it was
effectiveness on self-reported IADL at short- and long-term unclear which interventions were provided between the hip fracture
follow-up. surgery and start of the studied rehabilitation intervention. More-
over, most interventions in the RCTs (4/6; 67%) included started at a
Activities and participation: mobility relatively late stage (4-9mo after hip fracture), thereby limiting the
Two high-quality studies evaluated mobility.28,29 Short-term ef- comparability with daily practice, which typically starts earlier after
fects on mobility were reported in 1 study.29 No differences were surgery. There is risk on selection bias, which is higher in the latest
found between the groups on performance-based and self-reported started studies, because patients with appropriate recovery will not
outcomes.29 Long-term performance-based effects on mobility participate in the studies.
were reported in 2 studies.28,29 One study found better perfor- Recently, Diong et al (2015)39 published a meta-analysis about
mances in the home-based exercise group than in the control the effect of structured exercise in all settings on overall mobility
group at 6 (MD [95% CI]: 1.0 [0.15-1.85]) and 9 months (MD in people after hip fracture. The authors concluded that structured
[95% CI]: 1.3 [0.44-2.16]) after baseline.28 The other study found exercise produced small improvements on overall mobility.
no differences between the groups.29 Furthermore, interventions in other settings than hospitals were
The same studies reported long-term self-reported outcomes on more effective.39 Two other reviews did not find enough evidence
mobility.28,29 One study found no difference between groups at 6 to confirm the effectiveness of home-based exercise therapy above
months. At 9 months after baseline, patients in the home-based exercise therapy in other settings.11,12 The somewhat positive re-
exercise group scored significantly higher than patients in the sults in favor of home-based exercise therapy of our review are in

www.archives-pmr.org
12 I.A.R. Kuijlaars et al

line with earlier reviews of RCTs. Furthermore, previous reviews items might have been scored false negative. However, in 2
on home-based exercise therapy did not account their effects for studies, design papers were available and only 1 design paper gave
therapeutic validity of the included interventions. In other sys- extra information to tackle false negative scores.30 In both studies,
tematic reviews that assessed therapeutic validity, CONTENT the CONTENT scores were still low (3 and 5 points).28,30
scores varied from 0-515 to 1-716 in other populations, with 0%- Furthermore, the reliability of this new scale has not been deter-
38% of the studies rated as having high therapeutic validity, in mined but there was good agreement between the assessors
comparison with CONTENT scores of 1-7 and 17% of the RCTs (Cohen k [95% CI]: 0.81 [0.63-0.96]), comparable to the agree-
rated as high therapeutic validity in this systematic review. To ment between assessors in other systematic reviews.15,17 For the
date, the association between therapeutic validity and treatment best evidence synthesis, a cutoff score of 6 was chosen for the
effectiveness has not been confirmed in previous systematic re- PEDro score and CONTENT scale. This literature-based cutoff
views.15-17 In our systematic review, we were also unable to point is dubious because methodological quality and therapeutic
confirm an association, which have been due to the limited validity are far from optimal with a score of 6. Another factor that
number of therapeutically valid studies or perhaps due to an limits our understanding of our findings is that the content of the
overall lack of effectiveness of exercise therapy in this group. comparator is often times not or only partly described. Several
In the present systematic review, methodological quality of the reporting guidelines are available to report the content of in-
included studies was moderate to high in 4 of 6 studies.28-31 terventions; these should not be exclusively used to describe the
Critical items of methodological quality in the included studies experimental intervention under study, but also its counterpart(s).
were concealed allocation and adequate follow-up. No study
blinded the participants and therapists who administered the
Strengths
therapy, because this is not possible in exercise interventions. The
limited number of studies that met the criterion of concealed Strengths of this study were the data extraction and assessment of
allocation29,31 increased the risk of selection bias and could affect methodological quality and therapeutic validity by 2 reviewers,
the generalizability of the results. Furthermore, only 2 studies had which contributed to the accuracy of the review. Furthermore, the
an adequate follow-up of at least 1 key outcome29,33 which could exploration of the content of the intervention by using the CON-
have biased the results. TENT scale (see table 2), a comprehensive table of patients’
The assessment of therapeutic validity is seen as an added characteristics (see table 3), and the time plot of the RCTs (see fig
value to earlier published reviews on exercise therapy after hip 2) were a valuable addition to earlier reviews in this field.
fracture.11,12 Only in 1 trial the authors argued the content and
intensity of the intervention which are necessary to achieve ef- Implications
fects.32 Despite within-group effects, no significant between-group
effects on the outcome measures were found in this study because Although multidisciplinary rehabilitation after hip fractures is
of the small sample size. In addition, this was the only study with recommended,1-3 the content of the components to optimize
acceptable adherence to the intervention,32 which included a effectiveness is still unclear, as well as for exercise therapy and the
description of the number of sessions and achievement of target best context of its delivery. Because of low therapeutic validity in
intensity. For other studies adherence was not described suffi- the current RCTs, it is still unclear whether a specific manner of
ciently and the real training intensity was unclear which could home-based exercise therapy could be an effective training in this
have resulted in lower training effect. In only 2 trials, the goals of older population. It is important to provide patients an exercise
the therapeutic exercise matched the participants’ problems28,31 program that matches the individual patients’ problems and with
and the treatment was monitored and adjusted for an optimal adequate intensity. In the future, investigators of trials should be
exercise intensity.31,32 Furthermore, only 3 studies provided an attentive to therapeutic validity of their research and the reporting
individual personalized and contextualized exercise program.28-30 of this, possibly in design articles. Well-designed therapeutic in-
This seems to be quintessential for successful physical therapy terventions focused on patients’ problems and in the daily context
interventions in the frail elderly population,40,41 which is in line could be more effective than those studied in the RCTs in
with the value of task-specific training in some other patients (eg, this review.
poststroke).42 In summary, the therapeutic validity of included
studies was low and no RCT could be included in our sensitivity
analysis. This indicated that in most of the studies a home-based Conclusion
exercise program was provided that may have had limited op- In this systematic review, we found primarily RCTs with low
portunity to a priori be effective (regardless of the premise therapeutic validity (ie, absence of rationale for exercise content
whether or not exercise is effective in this population). In addition, and intensity and unclear adherence to the exercise program),
in most studies patients were selected on their injury and not on which may have resulted in interventions that suboptimally
the basis of their limitations, even though limitations underlie the address patients’ abilities and capacities. The article with suffi-
request for care. Structured interventions, like the included RCTs, cient therapeutic validity had low methodological quality and only
lack a patient-centered approach which enables a customized se- within-group effects were found. Furthermore, clinical heteroge-
lection of exercises and goal-directed training for the individual neity was high for the starting point, content, and duration of the
goals of the patient on predefined decision rules.40,41 trials. Perhaps the low therapeutic validity explains why there is
only limited evidence in favor of supervised home-based exercise
Study limitations therapy in older patients 2-10 months after hip fracture in com-
parison to usual care or a nonexercise control interventions. For
A limiting factor of this review was that the CONTENT scale only future research, it is essential to improve both the methodological
reviews what is written down in articles. By doing so, possibly and therapeutic quality.

www.archives-pmr.org
Home-based exercise after hip fracture 13

Supplier joint replacement: a systematic review and meta-analysis. PLoS One


2012;7:e38031.
16. Vooijs M, Siemonsma PC, Heus I, Sont JK, Rövekamp TA, van
a. Stata, version 13; StataCorp. Meeteren NL. Therapeutic validity and effectiveness of supervised
physical exercise training on exercise capacity in patients with chronic
obstructive pulmonary disease: a systematic review and meta-analysis.
Clin Rehabil 2016;30:1037-48.
Keywords 17. Snoek JA, van Berkel S, van Meeteren N, Backx FJ, Daanen HA.
Effect of aerobic training on heart rate recovery in patients with
Community health services; Elderly; Exercise; Hip fractures; established heart disease; a systematic review. PLoS One 2013;8:
Rehabilitation e83907.
18. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. J
Clin Epidemiol 2009;62:1006-12.
Corresponding author 19. Higgins JP, Green S; The Cochrane Collaboration. Cochrane Hand-
book for Systematic Reviews of Interventions version 5.1.. Available
Thomas J. Hoogeboom, PhD, Radboud Institute for Health at: http://handbook.cochrane.org/. Accessed August 1, 2016.
Sciences, IQ Healthcare, Radboud University Medical Center, 20. Crotty M, Unroe K, Cameron ID, Miller M, Ramirez G, Couzner L.
P.O. box 9101 (114), 6500 HB Nijmegen, the Netherlands. E-mail Rehabilitation interventions for improving physical and psychosocial
address: thomas.hoogeboom@radboudumc.nl. functioning after hip fracture in older people. Cochrane Database Syst
Rev 2010;(1):CD007624.
21. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M.
Reliability of the PEDro scale for rating quality of randomized
References controlled trials. Phys Ther 2003;83:713-21.
22. Physiotherapy Evidence Database (PEDro). Centre for Evidence-
1. Beaupre LA, Cinats JG, Jones CA, et al. Does functional recovery in Based Physiotherapy. Downloads.. Available at: http://www.pedro.
elderly hip fracture patients differ between patients admitted from org.au/english/downloads/. Accessed August 1, 2016.
long-term care and the community? J Gerontol A Biol Sci Med Sci 23. Landis JR, Koch GG. The measurement of observer agreement for
2007;62:1127-33. categorical data. Biometrics 1977;33:159-74.
2. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture 24. van Tulder MW, Suttorp M, Morton S, Bouter LM, Shekelle P.
in eight areas of function. J Gerontol A Biol Sci Med Sci 2000;55: Empirical evidence of an association between internal validity and
M498-507. effect size in randomized controlled trials of low-back pain. Spine
3. American Academy of Orthopaedic Surgeons (AAOS). Management (Phila Pa 1976) 2009;34:1685-92.
of hip fractures in the elderly. 1st ed. Rosemont, IL: American 25. Cohen J. Statistical power analysis in the behavioral sciences. 2nd ed.
Academy of Orthopaedic Surgeons; 2014. Hillsdale: Lawrence Erlbaum Associates, Inc; 1988.
4. Van Vugt AB, Van Balen R, Van der Cammen TJ, et al. Richtlijn 26. Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW.
Behandeling van de proximale femurfractuur bij de oudere mens. Back schools for non-specific low-back pain. Cochrane Database Syst
2008. Rev 2004;(4):CD000261.
5. National Institute for Health and Care Excellence (NICE). The man- 27. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European
agement of hip fracture in adults. London: National Clinical Guideline guidelines for the management of chronic nonspecific low back pain.
Centre; 2011. Eur Spine J 2006;15:s192-300.
6. World Health Organization. International Classification of Func- 28. Latham NK, Harris BA, Bean JF, et al. Effect of a home-based ex-
tioning, Disability and Health (ICF). Available at: http://www.who.int/ ercise program on functional recovery following rehabilitation after
classifications/icf/en/. Accessed August 1, 2016. hip fracture: a randomized clinical trial. JAMA 2014;311:700-8.
7. Zorginstituut Nederland. Geriatrische revalidatiezorg. Available at: 29. Salpakoski A, Tormakangas T, Edgren J, et al. Effects of a multi-
https://www.zorginstituutnederland.nl/pakket/zvw-kompas/ component home-based physical rehabilitation program on mobility
geriatrischeþrevalidatiezorg. Accessed August 1, 2016. recovery after hip fracture: a randomized controlled trial. J Am Med
8. Rijksoverheid. Langer zelfstandig wonen ouderen. Available at: http:// Dir Assoc 2014;15:361-8.
www.rijksoverheid.nl/onderwerpen/ouderenzorg/ouderen-langer- 30. Orwig DL, Hochberg M, Yu-Yahiro J, et al. Delivery and outcomes of
zelfstandig-wonen. Accessed August 1, 2016. a yearlong home exercise program after hip fracture: a randomized
9. Stolee P, Lim SN, Wilson L, Glenny C. Inpatient versus home-based controlled trial. Arch Intern Med 2011;171:323-31.
rehabilitation for older adults with musculoskeletal disorders: a sys- 31. Mangione KK, Craik RL, Palombaro KM, Tomlinson SS,
tematic review. Clin Rehabil 2012;26:387-402. Hofmann MT. Home-based leg-strengthening exercise improves
10. Giusti A, Barone A, Oliveri M, et al. An analysis of the feasibility of function 1 year after hip fracture: a randomized controlled study. J Am
home rehabilitation among elderly people with proximal femoral Geriatr Soc 2010;58:1911-7.
fractures. Arch Phys Med Rehabil 2006;87:826-31. 32. Mangione KK, Craik RL, Tomlinson SS, Palombaro KM. Can elderly
11. Auais MA, Eilayyan O, Mayo NE. Extended exercise rehabilitation patients who have had a hip fracture perform moderate- to high-
after hip fracture improves patients’ physical function: a systematic intensity exercise at home? Phys Ther 2005;85:727-39.
review and meta-analysis. Phys Ther 2012;92:1437-51. 33. Sherrington C, Lord SR. Home exercise to improve strength and
12. Mehta SP, Roy JS. Systematic review of home physiotherapy after hip walking velocity after hip fracture: a randomized controlled trial. Arch
fracture surgery. J Rehabil Med 2011;43:477-80. Phys Med Rehabil 1997;78:208-12.
13. Herbert RD, Bo K. Analysis of quality of interventions in systematic 34. Chang F, Latham NK, Ni P, et al. Does self-efficacy mediate func-
reviews. BMJ 2005;331:507-9. tional change in older adults participating in an exercise program after
14. Hoogeboom TJ. Meta-analyses on therapeutic physical exercise: time hip fracture? A randomized controlled trial. Arch Phys Med Rehabil
for a new direction. Phys Ther Rev 2013;18:219-20. 2015;96:1014-10.e1.
15. Hoogeboom TJ, Oosting E, Vriezekolk JE, et al. Therapeutic validity 35. Edgren J, Salpakoski A, Sihvonen SE, et al. Effects of a home-based
and effectiveness of preoperative exercise on functional recovery after physical rehabilitation program on physical disability after hip

www.archives-pmr.org
14 I.A.R. Kuijlaars et al

fracture: a randomized controlled trial. J Am Med Dir Assoc 2015;16: 39. Diong J, Allen N, Sherrington C. Structured exercise improves
350.e1-7. mobility after hip fracture: a meta-analysis with meta-regression. Br J
36. Portegijs E, Rantakokko M, Edgren J, et al. Effects of a rehabilitation Sports Med 2015;50:346-55.
program on perceived environmental barriers in older patients recov- 40. de Vries NM, van Ravensberg CD, Hobbelen JS, et al. The Coach2-
ering from hip fracture: a randomized controlled trial. Biomed Res Int Move approach: development and acceptability of an individually
2013;2013:769645. tailored physical therapy strategy to increase activity levels in older
37. Sipilä S, Salpakoski A, Edgren J, et al. Promoting mobility adults with mobility problems. J Geriatr Phys Ther 2015;38:169-82.
after hip fracture (ProMo): study protocol and selected baseline 41. de Vries NM, Staal JB, van der Wees PJ, et al. Patient-centred physical
results of a year-long randomized controlled trial among therapy is (cost-) effective in increasing physical activity and reducing
community-dwelling older people. BMC Musculoskelet Disord frailty in older adults with mobility problems: a randomized controlled trial
2011;12:277. with 6 months follow-up. J Cachexia Sarcopenia Muscle 2015;7:422-35.
38. Yu-Yahiro JA, Resnick B, Orwig D, Hicks G, Magaziner J. Imple- 42. French B, Thomas LH, Leathley MJ, et al. Repetitive task training for
mentation of a home-based exercise program post-hip fracture: the improving functional ability after stroke. Cochrane Database Syst Rev
Baltimore hip studies experience. PM R 2009;1:308-18. 2007;4:CD006073.

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Home-based exercise after hip fracture 14.e1

Supplemental Table S1 Searchstring


Searchstrings Medline, Embase, CINAHL up to June 2016
Searchstring e Medline 30-06-2016
ID Search Hits
#7 #3 AND #4 AND #5 AND #6 352
#6 ((((((((((ambulatory care[MeSH Terms]) OR ambulatory care[Title/Abstract]) OR community health 696017
services[MeSH Terms]) OR community based[Title/Abstract]) OR community dwelling[Title/Abstract])
OR community program[Title/Abstract]) OR primary health care[MeSH Terms]) OR primary health care
[Title/Abstract]) OR outpatient*[Title/Abstract]) OR out-patient*[Title/Abstract]) OR home[Title/
Abstract]
#5 ((((((((exercise[MeSH Terms]) OR exercise[Title/Abstract]) OR modalities, physical therapy[MeSH Terms]) 2266182
OR physical therapy[Title/Abstract]) OR physiotherapy[Title/Abstract]) OR rehabilitation[MeSH
Terms]) OR rehabilitation[Title/Abstract]) OR therapy[Title/Abstract]) OR training[Title/Abstract]
#4 (hip fractures[MeSH Terms]) OR (((((hip[Title/Abstract]) OR collum[Title/Abstract]) OR ((((femoral 33161
[Title/Abstract]) OR femur[Title/Abstract])) AND ((neck[Title/Abstract]) OR proximal[Title/
Abstract])))) AND fracture[Title/Abstract])
#3 #1 NOT #2 3306959
#2 (animals[MeSH Terms]) NOT humans[MeSH Terms] 4233866
#1 (((((((randomized controlled trial[Publication Type]) OR controlled clinical trial[Publication Type]) OR 3833673
randomized[Title/Abstract]) OR placebo[Title/Abstract]) OR drug therapy[MeSH Subheading]) OR
randomly[Title/Abstract]) OR trial[Title/Abstract]) OR groups[Title/Abstract]
Searchstring e Embase 30-06-2016
ID Search Hits
#9 #3 AND #4 AND #5 AND #8 660
#8 #6 OR #7 724377
#7 outpatient*:ab,ti 191872
#6 ‘ambulatory care’/exp OR ‘ambulatory care’:ab,ti OR ‘community care’/exp OR ‘community based’:ab,ti OR 558778
‘community dwelling’:ab,ti OR ‘community program’:ab,ti OR ‘primary health care’/exp OR ‘primary
health care’:ab,ti OR ‘out-patient’:ab,ti OR ‘home care’/exp OR home:ab,ti
#5 ‘exercise’/exp OR exercise:ab,ti OR ‘physiotherapy’/exp OR physiotherapy:ab,ti OR ‘physical therapy’:ab,ti 2933519
OR ‘kinesiotherapy’/exp OR ‘rehabilitation’/exp OR rehabilitation:ab,ti OR ‘training’/exp OR
training:ab,ti OR therapy:ab,ti
#4 ‘hip fracture’/exp OR ((hip:ab,ti OR collum:ab,ti OR ((neck:ab,ti OR proximal:ab,ti) AND (femoral:ab,ti OR 48850
femur:ab,ti))) AND fracture:ab,ti)
#3 #1 NOT #2 6102310
#2 ‘animal’/exp NOT ‘human’/exp 4686549
#1 ‘randomized controlled trial’/exp OR ‘randomized controlled trial’ OR ‘controlled clinical trial’/exp OR 6906409
‘controlled clinical trial’ OR ‘randomized’ OR ‘placebo’/de OR ‘placebo’ OR ‘drug therapy’/exp OR ‘drug
therapy’ OR ‘randomly’ OR ‘trial’ OR ‘groups’
Searchstring e CINAHL 30-06-2016
ID Search Hits
S7 S3 AND S4 AND S5 AND S6 214
S6 (MH “ambulatory care”) OR (MH “community health servicesþ”) OR (MH “primary health care”) OR (TI 363889
“ambulatory care”) OR (TI “community based”) OR (TI “community dwelling”) OR (TI “community
program”) OR (TI “primary health care”) OR (TI outpatient*) OR (TI out-patient*) OR (TI home) OR (AB
“ambulatory care”) OR (AB “community based”) OR (AB “community dwelling”) OR (AB “community
program”) OR (AB “primary health care”) OR (AB outpatient*) OR (AB out-patient*) OR (AB home)
S5 (MH “exerciseþ”) OR (MH “rehabilitationþ”) OR (TI exercise) OR (TI "physical therapy") OR (TI 428987
physiotherapy) OR (TI rehabilitation) OR (TI therapy) OR (TI training) OR (AB exercise) OR (AB
"physical therapy") OR (AB physiotherapy) OR (AB rehabilitation) OR (AB therapy) OR (AB training)
S4 (MH “hip fractures”) OR (((TI hip) OR (TI collum) OR (((TI femoral) OR (TI femur)) AND ((TI neck) OR (TI 6828
proximal)))) AND (TI fracture)) OR (((AB hip) OR (AB collum) OR (((AB femoral) OR (AB femur)) AND
((AB neck) OR (AB proximal)))) AND (AB fracture))
S3 S1 NOT S2 656585
S2 (MH animals) NOT (MH humans) 30282
S1 (PT “randomized controlled trial”) OR (PT “clinical trials”) OR (TX randomized) OR (TX placebo) OR (MM 662825
“drug therapy”) OR (TX randomly) OR (TX trial) OR (TX groups)

www.archives-pmr.org
14.e2 I.A.R. Kuijlaars et al

Supplemental Table S2 Results of individual studies on functions, activities and participation


Results of Individual Studies with Strength as Outcome Measure
Source, Outcome* Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)y
Short-term
Mangione et al., 2010
Summed mean (SD) isometric force (electromechanical dynamometer and handheld dynamometer), N
10 weeks 949 (207) 887 (274) 62 (-132.90;256.90)
Mangione et al., 2005
Summed mean (SD) isometric force (handheld digital strain-gauge dynamometer), kg, in subgroup aerobic
12 weeks 67.1 (22.3) 67.7 (22.2) -0.6 (-20.48;19.28)
Summed mean (SD) isometric force (handheld digital strain-gauge dynamometer), kg, in subgroup resistance
12 weeks 59.6 (18.2) 67.7 (22.2) -8.1 (-26.57;10.37)
Sherrington et al., 1997
Mean (SD) quadriceps strength (strap with a spring gauge), kg
Affected leg
1 month 10.4 (4.9) 7.3 (3.7) 3.1 (0.32;5.88)
Non-affected leg
1 month 12.9 (5.7) 9.4 (5.2) 3.5 (0.01;6.99)
Long-term
Latham et al., 2014
Mean (SD) isometric strength of knee extensors (strain gauge dynamometer), lb
Fractured leg
6 months 27.7 (12.8) 26.7 (14.3) 1.0 (-2.83;4.83)
9 months 29.9 (12.9) 25.6 (14.2) 4.3 (0.30;8.30)
Non-fractured leg
6 months 29.4 (13.3) 28.8 (13.9) 0.6 (-3.24;4.44)
9 months 30.8 (13.7) 25.8 (13.6) 5.0 (0.97;9.03)
Mangione et al., 2010
Summed mean (SD) isometric force (electromechanical dynamometer and handheld dynamometer), N
26 weeks 1073 (167) 927 (354) 146.0 (-72.68;364.68)
95%-CI: 95% confidence interval; SD: standard deviation.
* Short-term is  four months and long-term is > four months.
y
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

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Home-based exercise after hip fracture 14.e3

Results of Individual Studies with Balance as Outcome Measure*


y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Short-term
Salpakoski et al., 2014
Mean (SD) BBS
3 months 43.63 (6.22) 45.53 (6.98) -1.89 (-4.87;1.07)
Sherrington et al., 1997
Mean (SD) postural sway on floor, mm
1 month 124 (69) 136 (87) -12 (-62.26;38.26)
Mean (SD) postural sway on foam, mm
1 month 298 (161) 285 (159) 13 (-114.72;140.72)
Mean (SD) functional reach, cm
1 month 15.7 (7.9) 16.9 (7.7) -1.2 (-6.19;3.79)
Long-term
Latham et al., 2014
Mean (SD) BBS
6 months 44.4 (10.7) 41.1 (10.7) 3.3 (0.28;6.32)
9 months 45.6 (10.0) 40.4 (11.4) 5.2 (2.04;8.36)
Salpakoski et al., 2014
Mean (SD) BBS
6 months 44.26 (6.22) 45.72 (8.07) -1.45 (-4.71;1.80)
12 months 44.81 (6.14) 44.15 (9.92) 0.66 (-3.10;4.42)
95%-CI: 95% confidence interval; BBS: Berg Balance Scale; SD: standard deviation.
* Results of Orwig et al. (2011) were not presented because they published only change scores.
y
Short-term is  four months and long-term is > four months.
z
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

Results of Individual Studies with Gait as Outcome Measure*


y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Short-term
Mangione et al., 2010
Mean (SD) gait speed usual, m/s
10 weeks 0.81 (0.17) 0.70 (0.22) 0.11 (0.05;0.27)
Mean (SD) fast gait speed, m/s
10 weeks 1.07 (0.23) 0.91 (0.25) 0.16 (-0.03;0.35)
Mangione et al., 2005
Mean (SD) gait speed free, m/s, in subgroep aerobic
12 weeks 0.79 (0.26) 0.65 (0.23) 0.14 (-0.08;0.36)
Mean (SD) gait speed free, m/s, in subgroep resistance
12 weeks 0.71 (0.28) 0.65 (0.23) 0.06 (-0.18;0.30)
Sherrington et al., 1997
Mean (SD) comfortable gait speed, m/s
1 month 0.51 (0.34) 0.50 (0.35) 0.01 (-0.21;0.23)
Long-term
Mangione et al., 2010
Mean (SD) gait speed usual, m/s
26 weeks 0.81 (0.17) 0.67 (0.21) 0.14 (-0.01;0.29)
Mean (SD) fast gait speed, m/s
26 weeks 1.11 (0.22) 0.89 (0.24) 0.22 (0.03;0.41)
95%-CI: 95% confidence interval; SD: standard deviation.
* Results of Orwig et al. (2011) were not presented because they published only change scores.
y
Short-term is  four months and long-term is > four months.
z
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

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14.e4 I.A.R. Kuijlaars et al

Results of Individual Studies With Endurance as Outcome Measure*


y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Short-term
Mangione et al., 2010
Mean (SD) 6MWT, m
10 weeks 295.7 (79.8) 242.7 (83.0) 53.0 (-13.0;119.0)
Mangione et al., 2005
Mean (SD) 6MWT, m, in subgroup aerobic
12 weeks 321.1 (101.7) 266.2 (82.4) 54.9 (-28.62;138.42)
Mangione et al., 2005
Mean (SD) 6MWT, m, in subgroup resistance
12 weeks 278.9 (114.6) 266.2 (82.4) 12.7 (-79.34;104.74)
Long-term
Mangione et al., 2010
Mean (SD) 6MWT, m
26 weeks 299.5 (80.0) 219.4 (67.8) 80.1 (19.48;140.72)
6MWT: six minutes walk test; 95%-CI: 95% confidence interval; SD: standard deviation.
* Results of Orwig et al. (2011) were not presented because they published only change scores.
y
Short-term is  four months and long-term is > four months.
z
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

Results of Individual Studies with ADL as Outcome Measure*


y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Short-term, performance-based
Mangione et al., 2010
Mean (SD) mPPT
10 weeks 27.4 (3.2) 21.3 (5.8) 6.1 (2.38;9.82)
Short-term, self-reported
Salpakoski et al., 2014
Mean (SD) Evergreens activities of daily living index ADL
3 months 3.4 (3.2) 3.0 (3.0) 0.4 (-1.03;1.83)
Mangione et al., 2010
Mean (SD) SF-36 physical function score
10 weeks 50.4 (15.6) 40.4 (14.2) 10.0 (-2.16;22,16)
Mangione et al., 2005
Mean (SD) SF-36 physical function score, in subgroup aerobic
12 weeks 57.5 (24.3) 48.0 (18.9) 9.5 (-10.18;29.18)
Mean (SD) SF-36 physical function score, in subgroup resistance
12 weeks 57.7 (21.1) 48.0 (18.9) 9.7 (-8.67;28.07)
Long-term, performance-based
Mangione et al., 2010
Mean (SD) modified Physical Performance Test
26 weeks 27.6 (2.6) 20.3 (6.2) 7.3 (3.55;11.05)
Long-term, self-reported
Latham et al., 2014
Mean (SD) AM-PAC daily activity
6 months 61.3 (15.7) 58.6 (15.3) 2.7 (-1.68;7.08)
9 months 63.0 (15.9) 59.0 (14.9) 4.0 (-0.56;8.56)
Salpakoski et al., 2014
Mean (SD) Evergreens activities of daily living index ADL
6 months 3.0 (3.2) 3.4 (3.7) -0.4 (-1.97;1.17)
12 months 3.6 (4.1) 3.0 (3.7) 0.6 (-1.20;2.40)
(continued on next page)

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Home-based exercise after hip fracture 14.e5

(continued )
Results of Individual Studies with ADL as Outcome Measure*
y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Mangione et al., 2010
Mean (SD) SF-36 physical function score
26 weeks 56.8 (19.6) 38.3 (19.2) 18.5 (2.73;34.27)
95%-CI: 95% confidence interval; ADL: activities of daily living; AM-PAC: Activity Measure for Post-Acute Care; mPPT: Modified Physical Performance
Test; SD: standard deviation; SF-36: Medical Outcomes Study 36-Item Short Form Health Survey.
* Results of Orwig et al. (2011) were not presented because they published only change scores.
y
Short-term is  four months and long-term is > four months.
z
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

Results of Individual Studies with IADL as Outcome Measure*


y
Source, Outcome Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)z
Short-term, self-reported
Salpakoski et al., 2014
Mean (SD) Evergreens activities of daily living index IADL
3 months 7.1 (7.1) 5.5 (6.0) 1.6 (-1.42;4.62)
Long-term, self-reported
Salpakoski et al., 2014
Mean (SD) Evergreens activities of daily living index IADL
6 months 6.4 (6.6) 7.2 (7.8) -0.8 (-4.08;2.48)
12 months 6.8 (7.7) 6.5 (7.1) 0.3 (-3.11;3.71)
95%-CI: 95% confidence interval; IADL: instrumental activities of daily living; SD: standard deviation.
* Results of Orwig et al. (2011) were not presented because they published only change scores.
y
Short-term is  four months and long-term is > four months.
z
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

www.archives-pmr.org
14.e6 I.A.R. Kuijlaars et al

Results of Individual Studies with Mobility as Outcome Measure


Source, Outcome* Home-Based Exercise Group Control Group Mean Difference or Relative Risk (95%-CI)y
Short-term, performance-based
Salpakoski et al., 2014
Mean (SD) SPPB
3 months 6.69 (2.89) 7.26 (2.37) -0.57 (-1.76;0.61)
Short-term, self-reported
Salpakoski et al., 2014
Number (%) able to negotiate stairs without difficulties
3 months 23 (64) 28 (72) 0.89 (0.65;1.22)
Number (%) no perceived entrance-related barriers
3 months 23 (59) 28 (70) 0.84 (0.61;1.17)
Number (%) no perceived outdoor barriers
3 months 13 (33) 11 (28) 1.21 (0.62;2.37)
Long-term, performance-based
Latham et al., 2014
Mean (SD) SPPB
6 months 7.2 (3.0) 6.2 (3.0) 1.0 (0.15;1.85)
9 months 7.6 (2.9) 6.3 (2.9) 1.3 (0.44;2.16)
Salpakoski et al., 2014
Mean (SD) SPPB
6 months 7.18 (2.70) 7.36 (2.42) -0.18 (-1.33;0.98)
12 months 7.18 (2.93) 7.22 (2.51) -0.04 (-1.28;1.20)
Long-term, self-reported
Latham et al., 2014
Mean (SD) AM-PAC basic mobility
6 months 58.1 (7.9) 56.6 (8.1) 1.5 (-0.76;3.76)
9 months 59.5 (9.3) 56.7 (7.6) 2.8 (0.28;5.32)
Salpakoski et al., 2014
Number (%) able to negotiate stairs without difficulties
6 months 28 (76) 23 (62) 1.22 (0.89;1.66)
12 months 27 (75) 19 (49) 1.54 (1.06;2.24)
Number (%) no perceived entrance-related barriers
6 months 28 (72) 26 (67) 1.08 (0.80;1.45)
12 months 29 (76) 31 (79) 0.96 (0.76;1.22)
Number (%) no perceived outdoor barriers
6 months 19 (49) 12 (31) 1.58 (0.90;2.80)
12 months 18 (47) 16 (41) 1.15 (0.70;1.91)
95%-CI: 95% confidence interval; AM-PAC: Activity Measure for Post-Acute Care; SD: standard deviation; SPPB: Short Physical Performance Battery.
* Short-term is  four months and long-term is > four months.
y
Results were presented in bold if the mean difference or relative risk is statistical significant (p<0.05).

www.archives-pmr.org