Accepted Manuscript

Title: Physiotherapy following fragility fractures

Authors: Monica R. Perracini, Morten Tange Kristensen,

Caitriona Cunningham, Cathie Sherrington

PII: S0020-1383(18)30319-X
DOI: https://doi.org/10.1016/j.injury.2018.06.026
Reference: JINJ 7728

To appear in: Injury, Int. J. Care Injured

Received date: 3-5-2018

Accepted date: 21-6-2018

Please cite this article as: Perracini MR, Kristensen MT, Cunningham C,
Sherrington C, Physiotherapy following fragility fractures, Injury (2018),
https://doi.org/10.1016/j.injury.2018.06.026

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Physiotherapy following fragility fractures

Monica R Perracinia, Morten Tange Kristensenb, Caitriona Cunninghamc, Cathie

Sherringtond

a
Master’s and Doctoral Programs in Physical Therapy, Universidade Cidade de

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São Paulo, Brazil

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b
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),

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Department of Physical Therapy, and Department of Orthopedic Surgery,

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Amager-Hvidovre Hospital, University of Copenhagen, Denmark.
c
Associate Dean of Teaching and Learning, School of Public Health,

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Physiotherapy and Sports Science, University College Dublin, Ireland
Head, Ageing and Physical Disability Program, Musculoskeletal Health
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Sydney, School of Public Health, The University of Sydney, Australia
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Corresponding author:
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Monica R Perracini, Master’s and Doctoral Programs in Physical Therapy,

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Universidade Cidade de São Paulo, Brazil.

Rua Cesáreo Galeno, 448 – Tatuapé – São Paulo, Brazil, Zip Code: 03071-000
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e-mail: monica.perracini@unicid.edu.br
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Abstract
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Physiotherapy can play a vital role in the pathway of care of people after fragility fracture
and includes interventions of early mobilisation and prescription of structured exercise
programmes for maximising functional recovery and reducing the risk of falls and future
fractures. Although the optimal nature of physiotherapist interventions after hip and vertebral
fracture requires further investigation in large-scale trials, evidence supports the prescription
of high-intensity and extended exercise interventions. This article will overview interventions
in the acute and chronic phases after hip fractures, interventions after vertebral fracture and
the role of physiotherapy in the prevention of further fractures.

Key-words: Fragility fractures; Physical therapy; Exercise; Rehabilitation

Introduction
Fragility fractures are a major and increasing global public health issue, affecting one in two
women and one in five men aged over 50 [1, 2]. Recommendations from international

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evidence-based guidelines regarding best practice care after hip fracture include early

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mobilisation, multidisciplinary care and interventions to reduce the risk of future fractures
that include fall prevention strategies as well as bone protection [3]. In many countries,

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physiotherapists play a key role in post-hip fracture mobilisation. The physiotherapist’s

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responsibility for post-hip fracture mobilisation is outlined in evidence-based guidelines.
from the Australia and New Zealand [4] and the United Kingdom [5]. These guidelines also

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recommend multidisciplinary care and fall prevention interventions to prevent further
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fractures (see Appendix 1 for guidelines relevant to physiotherapy after hip fracture).
Although, the optimal nature of physiotherapist interventions after hip fracture requires
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further investigation in large-scale trials, recent existing evidence shows that interventions
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that include progressive resistance training produce improvements in overall mobility after
hip fracture [6]. However, the Cochrane review on this topic concludes that there is not
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enough evidence to guide practice, although it is currently being updated [7]. The
intervention that had the largest effect on mobility and function in individual trials to date
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was delivered with high intensity (three times per week) and close supervision in a centre-
based setting [8]. Such programs are resource intensive and further investigation is indicated
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to assess whether such gains are possible with less costly interventions. Encouragingly, a
recent high-quality randomised trial found a six-month home exercise program, taught by a
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physiotherapist and undertaken with minimal supervision, improved mobility in older people
after hip fracture [9]. Further trials are currently investigating the impact of sustained home
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exercise programs on outcomes after hip fracture [10, 11] For example, the RESTORE trial
in Australia [10] (n=340) is the largest home-based trial to date of an exercise program taught
by a physiotherapist and using a motivational interviewing approach to investigate the
effectiveness on improving mobility and reducing falls. The CAP trial in the USA (n=210) is
the first large trial of home-based strength training in hip fracture survivors that is measuring
the impact on restoring community ambulation [12].
As for hip fracture, physiotherapy has a major role to play in the management of vertebral
fragility fractures (VFF), given the associated pain and loss of function. Once accepted that
the fracture is stable, early mobilisation is recommended [13, 14]. However, diagnostic and
therapeutic recommendations for VFF, including those related to physiotherapy, are generally
inconsistent with limited quantity and quality of evidence available to guide professionals
[15]. The physiotherapist’s first point of contact with the VFF patient is usually following
hospital admission, but unlike hip fracture, management is usually conservative. Although
kyphoplasty and vertebroplasty may be offered when patients do not respond well to initial

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non -invasive management [16].

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Braces are commonly prescribed and fitted for acute vertebral fracture, despite the lack of

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high quality evidence to support this practice [15]. Physiotherapists can support the related

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clinical decision-making that requires having a clear rationale for the use of brace and taking
account of patient preferences and likelihood of adherence. Exercise should include postural
and spinal extensor strength exercise [17, 18] combined with a general strength and balance
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programme [19-21] to improve physical function, quality of life and reduce risk of falls.
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Overall, physiotherapists’ biopsychosocial approach contributes with the expertise in spinal
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assessment, pain management, biomechanics, posture and movement education, exercise
prescription and orthosis fitting, taking into consideration individual lifestyle, social supports
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and preferences.
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There is now strong evidence that exercise as a single intervention can prevent falls in the
general older community [22]. Few trials have evaluated the effect of exercise programs on
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the prevention of further falls in fracture survivors and the results are conflicting. Bischoff-
Ferrari and colleagues found prescription of home-based exercise by physiotherapists prior to
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hospital discharge was feasible and reduced falls in the following 12 months [23]. Orwig et al
did not detect a between-group difference in fallers when a home exercise program was
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compared to usual care [24].

There is meta-analysis evidence that exercise can have a similar effect on injurious falls [25]
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and fractures [26] as on falls. However, there is yet to be a single adequately powered trial to
show the role of exercise in the prevention of fractures. This will soon change when the
results of the PreFIT trial in the UK (n=9821) are published [27]. This is the first trial to be
powered to detect an impact of a fall prevention program on fractures. It tests the the
comparative effectiveness of advice, exercise and a multi-factorial fall prevention programme
on peripheral fractures incidence among older people living in the community.
Physiotherapy in the acute care setting after hip fracture
As recommended in international guidelines [3-5] early mobilisation and physiotherapy play
an important role as part of a multidisciplinary approach providing enhanced recovery
programs [28] for patients with hip fracture (HF). A first goal for the acute care
physiotherapy should be focused on patients regaining independence in three basic mobility
activities; getting in and out of bed, sit to stand to sit from a chair with arms, and walking
with an assistive device, considered essential for an older adult returning to their pre-fracture

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living situation [29, 30] without 24-hour care [31], and associated with increased physical
activity [32]. In that view, the Cumulated Ambulation Score (CAS) [29], that can be used for

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all patients independent of their pre-fracture living situation and function, was specifically

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developed to plan and monitor progress of these activities during a daily acute hospital

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physiotherapy program, until independence was reached [33]. However, to do that
physiotherapists need to take into consideration a number of pre-fracture factors, that
consistently seem to influence the early ambulatory level [34]; the pre-fracture functional

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level seems to be the strongest predictor [31-38]. Thus, the odds of regaining basic mobility
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independence in the acute setting, evaluated with the CAS, was markedly reduced for those
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with a low pre-fracture function [35, 36], when assessed by the modified [39, 40] New
Mobility Score (NMS) [15]. At the same time, physiotherapists should be aware of several
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post-surgery factors [34], e.g. hip fracture-related pain [41-43], anaemia [35, 44], lower limb
muscle power/strength [45, 46], fracture type [36, 44, 45, 47] and the ability to complete the
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planned physiotherapy program early after surgery [35], that also seem to influence the early
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mobility level.

Thus, patients who experienced moderate to severe pain (evaluated with the Verbal Rating
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Scale (VRS) [48] when performing the standardised Timed Up and Go (TUG) test [49], used
on average 8.7 seconds more than those with less pain, and related to having a trochanteric
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hip fracture [42]; the fractured limb power/strength was a strong determinant of walking
speed [45, 46], while those not able to complete early physiotherapy as planned were at
greater risk of not regaining their pre-fracture CAS level during acute hospitalisation [35].
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Please see appendix 2 for a more detailed description of the CAS, NMS, TUG and VRS. At
the same time, participation in early physiotherapy seems limited by hip fracture-related pain
[43, 50], and patients on average lose more than 50% of their fractured limb muscle power/
strength (%non-fractured) within the first post-surgery weeks [45, 46, 51], and with the
greatest loss seen for those with a trochanteric fracture [45, 52]. Ultimately, both the short
[33]- and long-term [53-55] mortality rates seem associated with the early post-surgery
ambulatory level. Altogether, this underlines the complexity of treating patients with HF in
the acute care setting, and the necessity for all healthcare professionals, including
physiotherapists, to be aware of the many factors potentially influencing the early recovery.
Especially physiotherapist have an obligation to include pain scoring in their daily sessions
and communicate their findings to nurses and doctors if the pain medication is not sufficient,
as they commonly are the ones challenging the patients the most, and experiencing pain as a
limitation for their physiotherapy [43, 50].

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The negative consequences of a low post-surgery ambulatory status [33, 53, 55] and also with
a post-surgery non-weight bearing status [38] leave no room for questioning the importance

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of early mobilisation of patients with HF. Further, a number of studies support the frequency

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of (more) physiotherapy in the acute care setting in relation to enhanced recovery [31, 56-
58], e.g. functional recovery was accelerated, more patients were discharged home and with
less to high-level care, for patients that followed a daily and early physiotherapy ambulation
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program versus delayed ambulation (walking first commenced at day 3 or 4) [57].
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Correspondingly, patients following a high-intensity physiotherapy program (3 daily
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sessions) in the acute ward, on average reached functional discharge criteria 10 days earlier
compared to the usual care physiotherapy group (1 daily session) [56]. Importantly, no
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patients withdrew from the latter study, and the intensive program was reported as safe.
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As mentioned, early loss of fractured limb muscle power/strength after HF is extensive [2,
45, 46, 51], associated with performances [45, 46], and although reduced, seems to persist at
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two months post-fracture [59], underlining the importance of physiotherapy targeted at

counteracting these strength losses. Importantly, the latest meta-analysis concluded that
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interventions that included progressive strength training were more effective, but delivered in
other settings than the acute care [6]. However, fractured limb knee-extension strength
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training has recently proven feasible when started a few days post-surgery in an acute hip
fracture unit [52]. The regular physiotherapy program included a daily session focused on
independence in the essential basic mobility activities [2-4], combined with balance and 12
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specific exercises [60]. On top of that, one extra daily session of progressive fractured limb
knee-extension strength training using ankle weight cuffs in 3 sets of 10 repetition maximum
loadings, with the patient seated on the bedside, was added on weekdays [52]. No adverse
events were reported, weight loads were progressed without hip fracture-related pain
interfering, and fractured limb strength deficits on average were reduced from 50% to 32%,
at time of acute hospital discharge[52]. A subsequent RCT with the same programme (plus
weekends) showed a 10% reduction in strength deficits in favour of the intervention group
[60].

Physiotherapy in the sub-acute, post-acute and late stages of recovery after hip fracture
After hospital discharge, three periods of rehabilitation after HF can be highlighted: sub-acute
or early post-discharge rehabilitation (up to 3 months postoperatively), post-acute
rehabilitation that usually include programmes that start soon after completion of standard

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physical therapy (from 3 months postoperatively up to 6 months after fracture), and late stage

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rehabilitation (from 6 months up to 2 years after fracture). Although there is little consensus
about these periods of rehabilitation [7], they appear to be supported by the extensive

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information on functional recovery after hip fracture [61-63]. Gait and balance function is

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recovered in the first 6-9 months, but by large, most patients will take a longer period
(approximately 10-14 months) to recover lower limb function [61, 64]. Of the patients who

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recover pre-fracture walking ability, the majority do so within the first 6 months after fracture
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[62]. Although very old persons may show no improvement in ambulation within 6 months
due to underlying frailty, reduced physiologic capacity and cumulative impairments from the
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disablement process already existing at the time of the fracture [65], they can still improve
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substantially over a 12-month period and beyond [65]. Thus, highlighting the need for
enlarging physiotherapy intervention to maximise functional recovery and return to the
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highest level of independence [63]. However, the impact of intensive rehabilitation to

accelerate recovery of ambulation or the impact of continuing rehabilitation for longer
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periods on recovery trajectories is yet to be well investigated [12, 65, 66].

The scope of physiotherapy provided in the sub-acute period is in line with the intervention
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initiated at the hospital and is commonly provided in inpatient rehabilitation (IR) or skilled
nursing (SN) facilities. At this stage physiotherapy is focused on enhancing safe mobility and
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on improving muscle function. Encouraging patients to keep as active as possible and to

avoid too much sitting [67-69] is also a key role of physiotherapists. Low levels of activity
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during hip fracture rehabilitation in IR and SN, even during therapy sessions, were monitored
[68] and the results suggest that those who were more active reported better functional
abilities at 3- and 6-month time points. Patients may experience fear of falling, pain and be
afraid of transferring weight to the fractured leg, spending too much time sitting or lying [69],
reinforcing the need to address inactivity at an early stage of rehabilitation [67]. High-
intensity progressive resistance training added to conventional physiotherapy [70] initiated 15
days postoperatively conducted in IR (from 50% up to 80% of 1 RM, 3 sets and 12
repetitions) during 6 weeks or high-intensity resistance training added to functional training
[71] started immediately upon hospital discharge conducted in the community (up to 70% to
90% of 1 RM) during 12 weeks [71], were able to improve muscle strength and mobility.

At the post-acute rehabilitation stage, once the fracture has healed, it would be plausible to
devote more attention to enhancing physiotherapy intensity on other exercise components
such as balance, functional activities and endurance, along with keeping the progressive

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resistance training that, in general, had started in a previous stage. A recent meta-regression

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analysis provided evidence that greater improvements in overall mobility are better achieved
if exercise interventions include progressive resistance training (random effects Hedges’ g

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standardised mean difference=0.35, 95% CI 0.12 to 0.58, p= 0.002) and are delivered in

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settings other than only in hospital [6]. These exercise regimens significantly improved gait
speed, activities of daily living, self-reported mobility, mobility assessed using the Timed up
and go test and balance assessed using the Berg Balance Scale. However, components other
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than resistance training have been little investigated and the optimal intervention programmes
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to maximise post-hip fracture functioning are yet to be established in terms of care setting
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(outpatient or home-based), components, frequency, intensity and duration [7, 63]. Another
systematic review and meta-analysis suggested that extended exercise programmes, offered
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beyond the regular rehabilitation period, seem to have a positive impact on balance, physical
functioning (including fast gait speed) and on mobility [72].
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Interventions initiated after 6 months postoperatively are heterogeneous in terms of exercise

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components and limited in number [9, 73, 74] but also observed positive results in
functioning, indicating that there is some plausibility to offer exercises in the period where
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the recovery in ambulation and in activities of daily living is still occurring. Although Binder
and colleagues [8] initiated intervention within 16 weeks after surgery, they extended
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intervention for more 6 months and showed the strongest effects for improving physical
performance when a progressive resistance training (65% up to 100% 1 RM, 3 sets of 8-12
repetitions) conducted 3 times a week in a gym-based regimen was added to other exercises
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such as, balance, coordination, flexibility and movement speed. Sherrington and Lord [73]
included patients with 7 months postoperatively and even offering a short intervention (only
four weeks) of daily lateral step up exercises were able to observe minor improvements in
quadriceps strength and gait speed. Mangione and colleagues [74] delivered a 10-week leg-
strengthening program of progressive resistance exercise (80% 1 RM, 3 sets of 10
repetitions) twice a week, starting six months after hip fracture in a home-basis and observed
an improvement on muscle strength and functional performance one year after hip fracture.
Participants who performed leg-strengthening exercise made meaningful changes in walking
speed, endurance, and physical function. Recently Latham and colleagues [9] conducted a
trial with older adults who had completed traditional rehabilitation after hip fracture (mean of
9.5 months after fracture) and received 3 home visits from a physiotherapist who taught
simple functional tasks to be conducted with resistance, standing exercises using steps of
varying heights and with weighed vests. A DVD was provided to support behavioural

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strategies. Their results showed a significant but still modest improvement in physical

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function (SPPB score) at 6 months of follow-up.

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Although, there is strong evidence that progressive high-intensity balance exercises can

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prevent falls [22], the majority of studies after hip fracture included unspecific balance
exercises, without clearly reporting the progression and not covering all balance dimensions,
hindering conclusions about the effect of balance exercises in improving safe locomotion and
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mobility in a long-term basis. However, in trials that have conducted exercises in weight-
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bearing positions, addressing balance (stability and anticipatory postural adjustment), such as
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chair stands, lateral step-up and forward step-up-and-over and progressively used less hand
support, improvements in measures of balance and functional performance were observed
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[51, 75].
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Understanding chronic pain, in terms of intensity and characteristics in the post-acute and late
stage care of hip fracture older patients is critically important for physiotherapists, since it
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negatively impacts on the ability to walk outdoors [76], and as a result may restrict social
participation and reinforce inactivity. Pain experience, not only intensity but also quality,
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should be better investigated in future studies to offer relevant information for maximising
functional recovery [77].
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Physiotherapy for dementia hip fracture patients has so far been supported by limited
evidence based on a small number of studies [78]. However, is possible to suggest that
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intensive rehabilitation and exercise activities are beneficial for these patients. Moseley and
colleagues included patients with cognitive impairment since there was a caregiver who was
able to supervise a progressive weight bearing and walking exercise programme that was
initiated at the inpatient facility and was followed by a structured home-based exercise
programme over 16 weeks. Study results showed that these patients gained greater benefit
from the higher dose programme and spent more time exercising, reaffirming the importance
of engaging caregivers in physiotherapy interventions for these patients.

The optimal timing and dosage of specific physical therapy intervention, and the impact of
other functional tasks and physical activity encouragement outside of therapy sessions (e.g.,
walking and participating in social and recreational activities) need to be clarified by further
studies.[78]

Conclusions:

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After hip and vertebral fracture, patients benefit from high-intensity exercise interventions to

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optimise recovery of function. This is particularly true if they start from an early stage with

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mobilisation strategies and go beyond the completion of usual physiotherapy, particularly
from 6-12 months. For hip fracture patients, greater improvements in overall mobility are

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achieved if exercise interventions include progressive resistance training. Further studies
should investigate the optimal nature of physiotherapy for hip and vertebral fracture patients

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in terms of exercise components, intensity, frequency and duration.
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