Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: A randomised controlled trial.

Lise Kronborg,Henrik Kehlet,Morten Tange Kristensen,Henrik Palm,Thomas Bandholm,Catherine Sherrington

doi:10.1371/journal.pone.0179867

Lise Kronborg, Henrik Kehlet + Show 4 more

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https://doi.org/10.1371/journal.pone.0179867

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Journal: PloS one	Publication Date: Jun 29, 2017
Citations: 32	License type: CC BY 4.0

Affiliation: Copenhagen University Hospital, Rigshospitalet

Abstract

QuestionIs acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up compared to physiotherapy without strength training in patients with a hip fracture?DesignAssessor blinded, randomised controlled trial with intention-to-treat analysis.Participants90 patients with a hip fracture admitted to an acute orthopaedic Hip Fracture Unit at a university hospital between October 2013 and May 2015.InterventionDaily physiotherapy with or without progressive knee-extension strength training (10RM), 3 x 10 repetitions, of the fractured limb using ankle weight cuffs conducted by ward physical therapists during hospital stay.Outcome measuresPrimary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from inclusion to postoperative day 10 or discharge (follow-up). Secondary outcome was Timed Up and Go test measured early after surgery and at follow-up.ResultsIn the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1% (95% CI -2.3; 18.4) by additional strength training from baseline to follow-up. In the per-protocol analysis of non-missing data, significant between-group improvements by 10.5% (95% CI 0.3; 20.7) were found in favour of additional ST. No significant between-group differences were found in any secondary outcome.ConclusionPhysiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture. It is debatable whether larger improvements than the observed 8–10% can be expected given that only five exercise sessions, on average, were completed. In fragile patients with a hip fracture in the acute phase, where the ability to participate in functional exercise is compromised, we still consider early strength training a possibility to improve outcomes of clinical importance, given the results of the per-protocol analysis. The present data provides an important basis and call for future investigations including longer term interventions.Trial registrationClinicaltrials.gov NCT00848913

Highlights

Patients with a hip fracture (HF) experience knee-extension strength deficit in the fractured limb of more than 50% compared to the non-fractured limb [1,2,3] and impaired physical function immediately after HF surgery [4]
Physiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture
It is debatable whether larger improvements than the observed 8–10% can be expected given that only five exercise sessions, on average, were completed

Summary

Introduction

Patients with a hip fracture (HF) experience knee-extension strength deficit in the fractured limb of more than 50% compared to the non-fractured limb [1,2,3] and impaired physical function immediately after HF surgery [4]. A recent systematic review with meta-analysis and meta-regression provides some evidence for a positive effect on mobility of structured exercise interventions including progressive strength training (ST) after HF [18]. The efficacy of very early interventions including standard care rehabilitation are much less studied in patients with HF, promising results have been found after hip replacement surgery [19] and recently regarding the feasibility of ST initiated within the first days after HF surgery [20] It remains unclear if systematic ST in the acute ward as a supplement to functional exercises, such as walking, rising from a chair and stairclimbing, can reduce the strength deficit in the fractured limb. The hypotheses of this study were that it would be

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