Keywords

1 The Need for Increased Provision of Rehabilitation Worldwide

The World Health Organization has recently highlighted a substantial unmet need for rehabilitation worldwide, with a 2017 Call-to-Action to increase the role of rehabilitation in health care as an essential component of integrated health services [1]. It was acknowledged that there is a profound unmet need for rehabilitation, particularly in LMICs. There was a call for greater access to rehabilitation services recognising it as an essential part of the health system rather than an optional extra. Rehabilitation is “an investment in human capital that contributes to health, economic and social development” and there is under-prioritisation by governments with an absence of planning for services at a national and subnational level. The call to action includes “greater awareness and advocacy, increased investment into rehabilitation workforce and infrastructure, and improved leadership and governance structures”. This includes increasing networks and partnerships in rehabilitation, particularly between LMICs and high-income countries.

2 The Principles of Rehabilitation Programmes after Hip Fracture

After a hip fracture operation, an older person’s recovery is enhanced if they are provided with an optimistic, well-coordinated rehabilitation programme. Recovery after hip fracture starts on admission when the patient and family receive realistic information on the likely course and time of discharge. The earlier patient goals and expectations can be explored and information on barriers or supports for recovery of independence identified, the more likely it is that an individual will retain a sense of control and self-efficacy which is likely to be associated with better outcomes [2, 3]. Consistent information on the planned rehabilitation programme is important as most people will have a recovery pathway which extends for several months across hospital and community settings [4].

During the acute hospital stay (ideally on an orthogeriatrics ward), along with secondary prevention treatments for osteoporosis, a rehabilitation pathway should be established and outlined to the patient and family. Rehabilitation involves diagnosing and treating impairments, preventing and treating complications, slowing loss of function and where this is not possible, compensating for lost functions (e.g. prescribing walking aids, bathroom adaptations, additional home help) [5]. Several systematic reviews and meta-analyses have demonstrated that rehabilitation programmes improve outcomes for patients after hip fracture compared to simply letting time take its course [6,7,8]. However, the components of recovery/rehabilitation programmes vary, including the length of time and the settings where programmes are delivered (home, inpatient units, outpatients). Standard management of hip fracture patients also varies between different countries. An audit in the UK reported that 70% of hip fracture patients receive orthogeriatrician assessment and 92% a falls assessment. These figures were only 27% for orthogeriatrician assessment and 4% for falls assessment in a tertiary hospital in Beijing [9].

In clinical practice, the cornerstone of a rehabilitation approach is a team of various disciplines (physiotherapy, occupational therapy, nutrition, social work, psychology, medicine) who meet regularly, set goals, review progress towards these goals with the patient and assess outcomes. The chance of recovery is maximised if the following elements are incorporated into the clinical approach:

  • Assessment: identification of problems to be addressed, which involves understanding the premorbid level of functioning and understanding the current comorbidities (e.g. delirium).

  • Goal-setting: identifying what can be improved and what cannot. In particular, assessing what level of mobility and independence in bathing and dressing is likely to be achieved in the short, medium and long term. Similarly, identifying what informal and formal supports are available to help recovery.

  • Treatment: intervening to improve medical and functional problems (such as pain, vitamin D deficiency, undernutrition, depression) as well as physical and psychosocial interventions to meet the rehabilitation goals.

  • Evaluation: reviewing the effectiveness of interventions (i.e. reassessment).

  • Planning: organising support services; providing self-management strategies for patients and carers.

The World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework provides a standardised framework for the classification and description of health, functioning and disability [10]. It moves away from the idea that disability is simply the consequence of disease or ageing towards an approach that acknowledges factors created by the social environment and it attempts to explicitly identify barriers and facilitators to social inclusion. Functioning and disability are seen as multidimensional concepts, relating to:

  • Body functions (physiological and psychological functions of body systems) and structures (anatomical parts of the body such as organs, limbs and their components);

  • Activities people do and the life areas in which they participate;

  • Factors in people’s environment (physical, social and attitudinal) which can be barriers or facilitators to functioning.

If this approach is applied to a person who suffers a hip fracture, their disability will be assessed and ranked according to the ICF framework components of health domains (e.g. seeing, hearing, walking, memory) and health-related domains (e.g. their ability to access transport, their level of education and social interactions). Figure 12.1 shows an individual’s functioning or disability as a dynamic interaction between health conditions and contextual factors, which encompass both environmental and personal factors [10].

Fig. 12.1
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Interactions between the components of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework. Source: WHO 2001 [10]

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3 What Is Known about the Pattern of Recovery Following Hip Fracture?

Talking to people with hip fractures and their families and providing realistic information on approximate expected recovery trajectories allows them to plan. However, it is complex for clinicians to apply evidence from cohort studies to individual patients as the cohorts are heterogeneous and patients have received varying amounts and types of rehabilitation.

Cohort studies suggest that following hip fracture, only 40–60% of people who survive are likely to recover their pre-fracture level of mobility [11]. Up to 70% may recover their level of independence for basic activities of daily living, but this is variable and less than half of all people experiencing hip fracture may regain their ability to perform instrumental ADLs. In Western nations, approximately 10–20% of patients move to a residential care facility following hip fracture. The extent to which these outcomes can be improved with greater access to rehabilitation is not clear.

Magaziner et al. described the sequence of recovery across eight different functional abilities following hip fracture [12]. Upper extremity activities of daily living, depression and cognitive function reached maximum recovery within 4 months. Most recovery of gait and balance occurred in the first 6 months, with maximum recovery occurring by 9 months; recovery of instrumental ADLs (such as shopping, preparing meals, house cleaning and handling money) took up to a year. It also took approximately a year for recovery of lower limb function and just over 14 months for walking 3 m without assistance. It seems that the majority of patients who recover their pre-fracture walking and basic activities of daily living do so within the first 6 months after fracture [13], but the role of long-term therapy in recovery pathways is yet to be well investigated.

In LMICs outcomes may be poorer due to reduced rates of optimal management, particularly due to reduced access to rehabilitation services [1]. In many LMICs standard hip fracture management pathways are not established [14]. Barriers to providing rehabilitation services in LMICs are discussed in more detail in Tables 12.10 and 12.11. An audit of practice in China (considered an upper MIC) demonstrated reduced access to surgery and orthogeriatric services at a Beijing hospital in comparison to the United Kingdom [9]. Since that time a retrospective before–after study has demonstrated that improvements in both time to surgery and orthogeriatric management are possible with implementation of a co-management care plan [15].

4 Factors Associated with Poor Outcomes After Hip Fracture

Some types of patients with hip fracture appear to be at particular risk of poor outcomes – these include male patients, people living in supported accommodation, those with poorer mobility pre-fracture and those with depression or dementia [13, 16, 17]. People with dementia are also less likely to receive rehabilitation [17, 18]. For people with dementia who receive rehabilitation, improvements comparable to other populations are achievable but this may take longer [19]. Although mortality following hip fracture has been found to be higher in men than women, recovery of mobility is unaffected by gender [17, 20].

Delirium is very common after hip fracture and although it is associated with poorer outcomes, routine assessment by rehabilitation staff remains uncommon [13]. In one prospective study, delirium remained in 39% of people with hip fracture at discharge from hospital and in 32% 1 month after fracture [21]. Even after controlling for pre-fracture physical and cognitive frailty those people who had delirium were twice as likely to have poor functional outcomes (in terms of mobility and recovery of activities of daily living) than those without [21].

Those who are older are more likely to have poorer mobility, need assistance at home, lose their ability to go outside on their own, cook their own dinner and be unable to prepare their own breakfast [17, 20]. Low food intake post-operatively, poor nutrition and malnourishment pre-operatively are associated with worse recovery of mobility and function [22, 23]. A systematic review of nutritional interventions found low-quality evidence to support the effectiveness of multi-nutrient supplements started before or soon after surgery in older people recovering from hip fracture to prevent complications [24]. Amongst nursing home residents, the factors most strongly associated with death or new total mobility dependence are being aged more than 90, having very severe cognitive impairment and receiving non-operative management of the hip fracture [25]. Longer lengths of stay, re-hospitalisation, older age, chronic or acute cognitive deficits and depressive symptoms while in hospital are also predictive of poorer recovery of mobility and activities of daily living [13].

5 Key Elements of a Rehabilitation Pathway

After the immediate post-operative period, a rehabilitation pathway should be followed that includes the elements addressed in Table 12.1. In particular, there is a need to assess frailty, establish goals to maximise mobility and other aspects of function, assess the requirement of aids (using occupational therapy services where available) and determine strategies to support and improve independence in activities of daily living [26]. Medication management should ensure all prescribed medications are necessary, minimise the use of antipsychotics and sedatives and ensure adequate pain management. Osteoporosis should be treated as appropriate and falls prevention strategies reinforced with both patients and families.

Table 12.1 Key elements of a typical rehabilitation pathway, based on the Alberta Hip Fracture Restorative Care Pathway [26]
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6 What Programmes Should We Recommend to Help with Recovery?

It is widely recognised that a vicious cycle can occur after a hip fracture where pain and hospitalisation result in disuse atrophy of muscles and general deconditioning which increases the risk of immobility and new falls and fractures [27]. While national clinical guidelines recommend providing balance and strengthening exercise [28, 29], it is often unclear how much should be provided, what components of a rehabilitation programme are crucial and how long this programme should be provided for. Analysis of the components of interventions found to be effective in randomised trials can assist in addressing this uncertainty.

The characteristics of all randomised controlled trials of multidisciplinary rehabilitation approaches reporting impact on patient-centred outcomes or mortality (Table 12.2) and exercise and mobility training programmes (Table 12.3), within different settings as identified by systematic review to 2019, are presented below [30, 31]. The quality of the trials is represented with the Physiotherapy Evidence Database (PEDro) score (see https://www.pedro.org.au/), which scores ten items reflecting trial design including randomisation, blinding, balance in baseline characteristics and follow-up. Details of the components of the programmes that have been demonstrated to be effective at improving mobility or function in randomised controlled trials are shown in Table 12.4 (multidisciplinary interventions in hospital or hospital and community setting), Table 12.5 (exercise programmes conducted in hospital settings), Table 12.6 (community-based multidisciplinary interventions) and Table 12.7 (community-based exercise programmes).

Table 12.2 Characteristics of trials of multidisciplinary rehabilitation approaches reporting impact on patient-centred outcomes or mortality
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Table 12.3 Characteristics of trials of exercise and mobility training programmes reporting impact on mobility or function outcomesa
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Table 12.4 Trials of hospital- and hospital-plus community-based multidisciplinary rehabilitation interventions with demonstrated effectiveness
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Table 12.5 Trials of hospital-based exercise and mobility training programmes with demonstrated effectiveness on mobility or functiona
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Table 12.6 Characteristics of community-based multidisciplinary rehabilitation interventions in trials with demonstrated effectiveness
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Table 12.7 Trials of community-based exercise and mobility training programmes with demonstrated effectiveness on mobility or functiona
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6.1 In-hospital Rehabilitation

Multidisciplinary programmes have been researched over a long period of time with significant changes to the components of treatment programs. Some trials provide a comparison to a usual care control group while others have a standard rehabilitation programme as the control group. Furthermore, some multidisciplinary programs begin soon after admission (e.g. Prestmo et al. [40]) and others include both in hospital rehabilitation and community components (e.g. Cameron et al. [45]). A 1988 trial demonstrated improvements in function on discharge for provision of multidisciplinary care in comparison to standard orthopaedic care [37].

Table 12.4 shows the characteristics of hospital-based and hospital-plus community-based multidisciplinary rehabilitation interventions in studies with demonstrated effectiveness. Four trials of programmes delivered solely in a hospital setting have demonstrated effectiveness on patient-centred outcomes overall (Table 12.4). One effective in-hospital programme with comprehensive, multidisciplinary geriatric care including early mobilisation, and daily training and a follow-up assessment at 4 months, demonstrated improvements in function at 1 year [42]. Another trial demonstrated improvements in mobility with orthogeriatric care for a subgroup who were living at home [44]. A third trial demonstrated reduced rates of delirium with daily geriatrician visits [38].

A more recent hospital-based trial has demonstrated effectiveness on a range of person-centred outcomes including mobility, function and quality of life at 1-year follow-up in comparison to standard orthopaedic care [40]. This programme provided comprehensive interdisciplinary care, early mobilisation and rehabilitation and also addressed psychosocial aspects of care through a focus on social situation and mental health.

Two exercise programmes that have demonstrated effectiveness in terms of improving mobility or function were delivered completely in an in-hospital (rehabilitation) setting (Table 12.5) [30, 31]. One study added progressive resistance training in the form of additional early post-operative, high-intensity bilateral quadriceps muscle strengthening to conventional physiotherapy. A significant improvement in the Elderly Mobility Scale, leg extensor power of the fractured leg and functional reach was reported at 16 weeks, which was 10 weeks after the end of the intervention [30]. The other programme which delivered a high dose of in-patient rehabilitation including supervised balance exercises (five times weekly for 90 min, over 3 weeks), also demonstrated improvements in mobility and function compared to standard rehabilitation on discharge [31].

6.2 Rehabilitation in the Community

Six multidisciplinary interventions delivered across both hospital and community settings have demonstrated improvements in patient-centred outcomes in comparison to usual orthopaedic care (Table 12.4) [37, 50,51,52,53, 55]. Four of these trials were conducted in high income countries [37, 52, 53, 55] and two were conducted in Taiwan [51, 81]. In general, multidisciplinary programmes that emphasise early assessment through comprehensive geriatric assessment with appropriate early surgery, early mobilisation, higher doses of mobility training and an emphasis on regaining functional independence are more effective. Multidisciplinary rehabilitation programmes (including those with a focus on multidisciplinary factors where specialist teams are not available) should also begin soon after hospital admission and continue for a long period, including after hospital discharge.

It remains unclear what is the best link between orthogeriatric services and hip fracture rehabilitation services to improve coordination for patients, but common governance structures, shared staff, shared information systems or formal arrangements for handovers are all options. These services should treat patients with dementia and delirium and also include patients who are living in, or will live in, residential aged care facilities. High intensity and prolonged multidisciplinary rehabilitation programmes (e.g. Singh et al. [52]) are effective for a selected group of people with hip fracture.

There is an emerging view that hip fracture rehabilitation programmes should also be available to people with significant dementia who live in long-term care, or at home, with severe disabilities. A recent trial of a four-week multidisciplinary programme delivered as a hospital outreach programme within long-term care demonstrated improvements in mobility at the end of the programme, which was not maintained over 12 months, but a small improvement in quality of life was observed at 12 months (Table 12.6) [56]. Whilst the programme was found not to be cost-effective, it demonstrates that improvements in patient-centred outcomes can be made after hospital discharge in a population living in long-term care.

As shown in Table 12.7, the exercise programmes that continued after discharge and were effective were programmes conducted over 12–24 weeks. At least for some individuals, there are benefits from exercise programmes delivered after discharge from hospital. One of the most effective programmes identified in our review of trials of exercise and mobility training programmes was implemented as twice-weekly sessions with a physiotherapist in an outpatient clinic for the first 3 months, then once weekly for a further 3 months (Table 12.7) [77, 78]. This was supplemented with exercises once a week at home. The exercise programme involved prolonged progressive resistance training, fitness warm-up and lower limb strength exercises, compared to a control group of the participant’s usual lifestyle, without any restrictions placed on the amount or type of exercise undertaken. This programme significantly improved patient’s mobility after 3 months [77], but the magnitude of the effect was even greater after 6 months [78]. While the strength of effect in this study may partly be due to a comparison against patients with no structured exercise programme, two other community-based programmes of progressive resistance training in small groups also demonstrated large effects in comparison to alternative programmes [65, 66]. Another study has demonstrated that extra progressive resistance exercises in addition to a 12-week standard daily physiotherapy programme can provide additional benefits for mobility and function [76].

However, long-term provision of exercise programmes through outpatient clinics for whole populations may not be feasible, even in developed countries, as this would require an enormous expansion of rehabilitation services with associated costs. Greater provision of community exercise options in liaison with health professionals may help to meet this gap, as has been recommended for people with neurological impairments [82].

6.3 Rehabilitation in Low Resource Settings

A trial conducted in Taiwan has demonstrated significant improvements in mobility and self-care extending to 2 years post-hip fracture from interdisciplinary rehabilitation programmes in comparison to usual care with no formal rehabilitation programme [81]. A further trial demonstrated additional benefits of a comprehensive care programme addressing nutrition, depression management and falls prevention in addition to interdisciplinary care in the same setting [51]. Whilst the same interdisciplinary care may not be possible in low resource and LMIC settings, rehabilitation programmes that address these principles using professionals with competencies in geriatrics, orthopaedics, physiotherapy, occupational therapy, nutrition, social work and psychology should be the aim.

Supervised exercise programmes may present access difficulties for people in remote locations or in low resource settings so home exercise, wider family involvement or tele-rehabilitation options may be required.

A home-based exercise programme of simple, functionally oriented tasks with minimal supervision had a moderate effect on improving physical function [68]. In this programme, a physical therapist taught the exercises and used cognitive and behavioural strategies to enhance attitudes and beliefs about the benefits of exercise and to overcome fear of falling during three home visits of 1 h (Table 12.7). Monthly telephone calls were also made by the therapists and an additional visit was provided if necessary. The participants were provided with a DVD of the programme to watch and a DVD player if necessary. Participants performed the exercises independently in their own home three times a week for 6 months, supported by a monthly telephone call from the physical therapist. The intervention also included a cognitive-behavioural component in order to improve adherence. A secondary analysis of this trial indicates that self-efficacy may partially mediate the effects of this intervention on longer term functional outcomes [83]. Whilst physical therapists may not be available in all resource settings, this trial demonstrates the potential effectiveness of home-based therapy. Alternative professionals with skills in physical therapy could provide training. Including caregivers in this training, where resources for watching a DVD and follow-up phone calls are not available, appears promising and warrants investigation.

7 Rehabilitation and Cognitive Impairment

Rehabilitation for people with dementia after hip fracture is complex. Approximately 40% of patients who sustain a hip fracture have dementia [85, 86]. These patients have more complex care needs, with greater risks of complications, physical disabilities and social care requirements compared to people without dementia [87]. This is due to a number of factors. Firstly, people with dementia are often more disorientated in hospital environments, being more prone to delirium. They often have difficulty expressing problems of pain, nausea and dizziness which impact on physical performance. Many people with dementia have movement limitations, which when combined with hip fracture, makes simple tasks like learning how to use walking aids and equipment very difficult. They often have a critical relationship with informal caregivers (family/friends) which is strained after a hip fracture; greater considerations for supporting the patient–caregiver dyad may be required than for patients without dementia. Daily proactive geriatrician visits starting before or within 24 h of hip fracture surgery, with application of multiple types of treatment, has been demonstrated to reduce delirium occurrence by 36%, and severe delirium by 60% [38]. Similar principles could be followed in LMIC settings with lesser intensity of inputs.

A number of research reports and guidelines recommend intervention with specific strategies including enhanced rehabilitation and care pathways to support recovery from hip fracture for people living with dementia. However, the evidence base for these is sparse. Five trials have investigated enhanced rehabilitation models for this population; evaluating strategies designed specifically for people with dementia following hip fracture surgery. These are larger trials of patients following hip fracture surgery which have presented data specifically for the subgroup of patient with cognitive impairment. These trials have tested two types of interventions: enhanced interdisciplinary inpatient rehabilitation and care models versus conventional inpatient rehabilitation and care models [43, 88, 89] and secondly, enhanced interdisciplinary inpatient and home-based rehabilitation and care models versus conventional rehabilitation and care models [90, 91]. The characteristics of these trials and interventions are presented in Table 12.8. The enhanced models generally offer multidisciplinary programmes with greater intensity or length of programmes.

Table 12.8 Characteristics of trials of enhanced rehabilitation for people with dementia following hip fracture
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7.1 Enhanced Interdisciplinary Inpatient Rehabilitation and Care

The clinical outcomes of enhanced inpatient rehabilitation care compared to conventional care are summarised in Table 12.9. It appears there was no benefit of enhanced interdisciplinary inpatient rehabilitation over conventional care for outcomes including personal ADL independence at four-month or 12-month follow-up, walking independence without an aid or assistance at four-month or 12-month follow-up or the number of drugs prescribed on discharge. Similarly, there were no differences in outcomes for mortality or hospital length of stay for enhanced inpatient rehabilitation models over conventional care.

Table 12.9 Clinical outcomes of enhanced rehabilitation interventions for people with dementia following hip fracture
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There was no benefit of an enhanced inpatient rehabilitation programme over conventional rehabilitation for complications including pneumonia, pressure ulcers, post-operative fracture or whether participants were living in care facilities at 4 months or 12 months. However, there was a reduction in the enhanced interdisciplinary rehabilitation care model group for complications including urinary tract infection, nutritional problems, recurrent falls and post-operative delirium. Freter and colleagues also reported greater cognitive function for those who received the enhanced intervention 5 days post-operatively compared to conventional rehabilitation [88].

7.2 Enhanced Interdisciplinary Inpatient and Home-Based Rehabilitation

The clinical outcomes of enhanced rehabilitation inpatient and home-based rehabilitation care compared to conventional care are summarised in Table 12.9. Findings suggest that enhanced inpatient and community-based interventions for people with cognitive impairment provide promising early outcomes, but do not differ to conventional rehabilitation models longer term. Whilst people allocated enhanced interdisciplinary rehabilitation were less likely to be living in institutional care at 3 months, this was less certain at 12 months. One trial conducted in Taiwan reported that patients who received enhanced rehabilitation strategies until 3 months post-discharge had improvements in regaining pre-fracture walking levels and better ADL performance at 3 and 12 months, but did not differ from conventional rehabilitation at 24 months [91]. The evidence suggests no benefit of the enhanced inpatient and home-based intervention for outcomes including frequency of hospital admissions, attendance at the emergency room/accident and emergency, incidence of falls or mortality at 4 or 12 months post-operatively.

Whilst the current evidence-base provides a basis, the data remain very low in quality due to the small number of participants and the serious risk of bias in trial designs. The evidence underpinning the rehabilitation of people with dementia following hip fracture is based on subgroup analyses of randomised controlled trials of people with and without cognitive impairment who have a hip fracture. Consequently, the evidence-base is underpowered. No data were provided on behaviour, quality of life, pain or complications. No trials have investigated interventions which have been specifically designed for people with cognitive impairment. It remains unclear whether rehabilitation models are more effective if they include dementia-focused interventions such as provision of cues, reminiscence therapy, the adoption of familiarised routines or the use of assistive technologies. These are areas of research priority. Following this, it is hoped that health professionals will be able to be more evidence-based in addressing the complex care needs for this subgroup of the hip fracture population.

Nevertheless, it is clear that patients with cognitive impairment also benefit from rehabilitation approaches and these patients should not be excluded from rehabilitation following hip fracture.

8 Psychosocial Factors and Rehabilitation

Within the WHO ICF framework, psychosocial factors can be environmental or personal “contextual” factors (e.g. social support, self-efficacy, fear of falling) or psychological “body function” factors (e.g. mental health) that interact with health conditions to impact on a person’s functioning and recovery. Psychosocial factors are predictors of hip fracture recovery and their role in functional recovery after hip fracture has been acknowledged as important [92]. Depressive symptoms post hip fracture increase the likelihood of poorer mobility, function and psychological outcomes [92,93,94]. Fear of falling is common in people with hip fracture and is associated with poorer recovery, decreased mobility, anxiety and falls-related self-efficacy [95,96,97]. Social support and caregiver responses also appear to play a dynamic role in recovery [98, 99]. However, the relationships between psychosocial factors, rehabilitation programmes and outcomes are complex and inadequately understood.

Clinicians need to support patients’ adjustment to residual disability when providing rehabilitation to people with fragility fractures. Hip fractures are common and many older people in the community hold the fear that a hip fracture will precipitate a move into a residential aged care facility. In an Australian time–trade-off study, 80% of community-dwelling women at risk of hip fracture said they would rather die rather than suffer a hip fracture requiring relocation into a residential aged care facility [100]. The participants of this study commonly believed that they were living on “borrowed time” having survived beyond usual life expectancy. They perceived any threat to their ability to live independently in the community as potentially catastrophic.

When individuals experience changes in their health states, they often alter their internal standards, their values and concept of quality of life which is sometimes described as a “response shift” [101]. After a hip fracture, many people are left walking with an aid, with restrictions in the use of public transport, hobbies and roles, thus a significant loss of quality of life may occur. Maximising functional recovery is important but providing adequate support for older people to make “response shifts” and adjustments and to identify ways to compensate for changes is equally important e.g. by acknowledging losses in mobility but providing access to alternatives.

A randomised controlled trial of a home-based hip fracture rehabilitation intervention which included psychological strategies improved mobility outcomes for patients [68, 83]. The study found that the intervention protected against the loss of self-efficacy. As self-efficacy appears to play a crucial role in maintaining exercise long-term, a focus on self-efficacy in hip fracture interventions may mean that patients are more likely to continue activity independently [83]. Qualitative studies indicate that hip fracture patients recognise the importance of their own psychological outlook and the need for social support in their recovery. Support from health professionals provides not only information and exercises but also emotional and motivational support and confidence boosting. Support from informal caregivers, family and friends is also seen as invaluable to help with ADLs, emotional support, encouragement and companionship [95, 102, 103]. Thus, inclusion of psychological and social interventions in hip fracture rehabilitation programmes is likely to be beneficial. However, the specifics of how to best design such programmes to improve outcomes are yet unclear [92].

9 Delivery of Rehabilitation Following Hip Fracture in LMICs

The prevalence of hip fracture is expected to increase dramatically in middle-income countries in Asia and Latin America, presenting a major challenge to rehabilitation care in coming years. By the year 2050, around 30% of the world’s hip fractures will occur in Asia, mostly in China and India. Although the rate of increase in incidence of hip fracture has been attenuated in Hong Kong and Taiwan, it has markedly increased for almost all age groups in both genders in mainland China [104]. India lacks a systematic data registry for fragility hip fractures, but a report in 2004 estimated an annual prevalence of 600,000 hip fractures, which will substantially increase, since the population over 60 years in 2026 will reach nearly 170 million people [105].

Overall hip fractures in the Latin America region will increase by 700% in the population 65 and over with an estimated cost of $13 billion [106]. Based on population ageing estimates in Brazil the increase of hip fracture prevalence is estimated to be nearly 250% between 2015 and 2040 [107]. In Mexico, another highly-populated country, hip fracture rate estimates are sparse, but one study showed similar rates to southern countries in Europe [108].

The impact of hip fractures is unfavourable for patients and their families in LMICs as many do not have health care systems which are able to deliver integrated services including rehabilitation. Barriers exist in terms of human resources capability, infrastructure, cultural and social influences and environmental context.

While research on barriers and facilitators for rehabilitation following hip fracture is still scarce in most LMICs, Tables 12.10 and 12.11 describe known barriers to prompt in-hospital and community rehabilitation following hip fracture surgery in LMICs.

Table 12.10 Barriers to prompt in-hospital rehabilitation following hip fracture surgery in LMICs
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Table 12.11 Barriers to rehabilitation in the community in LMICs
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9.1 Key Evidence-Based Recommendations and Their Implementation in LMICs

Implementation of evidence-based recommendations in LMICs is challenging but should not be interpreted as a wasted effort. Table 12.12 lists some key evidence-based recommendations and suggestions for implementation of in-hospital rehabilitation and community rehabilitation following hip fracture surgery in LMICs, based on expert opinion. Suggestions with limited formal evidence but apparent face validity include involving families as partners early and explicitly including them in the care plan and ensuring that ward nurses and therapists jointly commit to delivering the mobility goals.

Table 12.12 Implementation strategies in LMICs, based on expert opinion
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With limited infrastructure (rehabilitation units and trained therapists) and rapidly growing demand, disruptive approaches to rehabilitation are needed in LMICs. WHO’s Integrated Care for Older People (ICOPE) programme for older people is a community-based primary care health ageing approach which focuses on ways of optimising a community dwelling older person’s function. However, many of the tools and resources provided in this programme allow community workers to design individualised programmes for older people. Available as an app or on-line some of these practical approaches (e.g. on nutrition, polypharmacy, carer support) could be helpful for primary care workers once a patient with a hip fracture returns home (available from www.who.int/ageing/health-systems/icope/en/).

Access to rehabilitation with the associated opportunity to maximise function and quality of life is increasingly recognised as a human right. Efforts to increase therapist numbers and optimise older patients’ access to evidence-based hospital rehabilitation programmes have been strengthened by WHO’s recent Rehabilitation 2030: Call to Action [1]. But as the pressure increases for health systems to provide universal coverage with access to rehabilitation it is likely that community-based rehabilitation will become more important as a cost-effective way to deliver services. Globally, community rehabilitation is also likely to become the focus for future research efforts to maximise recovery, partly because of the long trajectories of recovery (particularly of mobility) after hip fracture and partly because older people are increasingly vocal about prioritising returning home as quickly as possible.

10 Conclusion

  • A rehabilitation pathway includes: (1) early and intensive mobility and self-care retraining with medical minimisation of complications and problems from comorbidities; (2) chronic care interventions (including dementia and frailty assessment and falls prevention) and (3) access to community services, including aged care support services and allied health therapies.

  • Patients with cognitive impairment should not be excluded from rehabilitation following hip fracture.

  • Recovery time for different functional domains varies from less than 6 months for many activities of daily living and cognitive function to over a year for walking 3 m without assistance.

  • Rehabilitation programmes should be multidisciplinary with integration of orthogeriatric and rehabilitation services, or include professionals with multidisciplinary competencies. They should include early comprehensive geriatric assessment, surgery and mobilisation, with higher doses of mobility training and an emphasis on regaining functional independence. Programmes should also begin soon after hospital admission and continue after hospital discharge.

  • In-patient rehabilitation programmes should include goal-directed mobilisation practice with balance and functional exercises.

  • Structured exercise programmes should continue beyond the hospital setting for at least 12 weeks and may include progressive resistance training.

  • Exercise programmes should incorporate components targeting self-efficacy to support patients to build their confidence to undertake exercise programmes post-discharge.

  • Where possible a chronic disease self-management approach should be used with patients and families to promote self-efficacy and adherence to falls prevention strategies, osteoporosis treatment and exercise programmes.

  • Self-efficacy, social support and caregiver responses play a role in recovery and can assist in rehabilitation in hospital and at home. Caregivers should be included in every phase of the recovery e.g. during care and discharge planning.

  • Whilst there are many barriers to providing rehabilitation services in lower to middle income countries, implementation of evidence-based recommendations should not be viewed as futile. Health care professionals at all levels should not accept cognitive and physical functioning limitations as a normal age-related pathway for older patients after hip fracture surgery.