Municipality-based physical rehabilitation after acute hip fracture surgery in Denmark

All patients, who are surgically treated for an acute hip fracture (HF) in Denmark, commence early in-hospital physical rehabilitation conducted as physical therapy exercises (hereafter physical rehabilitation (PR)) in order to regain a minimum of basic mobility skills, if possible [1-3]. Still, most patients are being discharged from the acute hospital with a lower functional status than their prefracture level [4], which indicates a need for outpatient PR. In accordance herewith, more than 95% of patients are referred to further PR following discharge [5]. However, the specifics of PR services after discharge are variable and evidence of best practice remains uncertain [6, 7]. Nonetheless, a few in- or outpatient rehabilitation studies following acute hospitalisation support the effectiveness of exercise programmes that include strength training [4, 8] or cardiovascular exercise [9], and for an extended period of time[10, 11]. This underlines the importance of national surveys that examine whether the PR provided for HF patients is conducted in conformity with these results. In Denmark, there is no knowledge regarding the specifics of municipality-based PR offered to patients who are discharged from hospital following a HF. Such information is important to evaluate the need for future interventions or guidelines. Similar studies have been conducted for long-term care residents in Canada following HF surgery [12], total hip and knee arthroplasty [13, 14] and breast cancer [15].

Thus, the aim of this study was to describe the specifics of municipality-based PR services after HF surgery in Denmark.

METHODS

Study population and design

The present study is a national, cross-sectional study, conducted as a questionnaire survey among municipality-based PR centres treating patients after HF surgery.

Twenty-five major operating hospitals were identified from a national register [5]. We randomly selected 50 municipalities out of a total of 98 municipalities in Denmark, equal to two municipalities per HF-operating hospital. The selection was done by drawing lots between municipalities covered by the catchment areas of each of the 25 hospitals. In case any major municipality was missing, these were subsequently included in the sample. PR centres treating patients with HF were identified by an internet search for each municipality, and 1-3 centres in each municipality were invited to participate in the survey. A total number of 62 PR centres
within 56 municipalities were eligible for the survey (Figure 1). The HF responsible physical therapy clinician or manager at the local PR centre was identified and received the electronic questionnaire by e-mail. The participants were invited to complete the questionnaire and to return relevant documents or links to formal descriptions of procedures and/or specific programmes if treatment was conducted according to such in the PR centre. The survey was conducted from 7 February to 8 April 2013. Three reminders were sent. The reporting of the study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies.

Questionnaire

An online questionnaire (Appendix A), containing ten questions regarding the PR programme, was developed according to previous studies [14, 15]. The questionnaire covered topics including the structure of the post-discharge PR provided and whether it was conducted according to a formal description of procedures (e.g. initiation and duration of rehabilitation) and/or a specialised exercise programme (e.g. specific exercises) for patients with HF. Information was recorded in an Iprix online questionnaire form. The online template only allowed submission of the questionnaire after completion of all questions.

The questionnaire and online procedure was pilot tested in two municipality-based PR centres within two different regions. These data were not included in the final analysis.

Data analysis

Information was gathered on outpatient PR (including one-to-one and group), home-based PR, 24-hour in-patient PR units and nursing homes. Questionnaire responses were categorised according to initiation and
duration of the PR (weeks), frequency (number of treatments per week), and use of formal description of procedures and/or specific programmes (yes, no).

The forwarded formal descriptions of procedures were categorised according to description of aim of PR (yes, no), treatment modalities (training of relevant activities of daily living (ADL) functions, strength training, balance exercise, range of motion exercise and other types of treatment), treatment setting (group/one-to-one exercise) and tests used (yes, no). The name of
the specific tests used in the different centres was also extracted from the forwarded descriptions of procedures.

In the case of missing information or local programmes not being returned, the respondent was contacted by telephone and the programmes obtained where available. The results of the analysis are represented as absolute data and/or as percentages. Fischer’s exact test was used to analyse differences between numbers of weekly sessions in different PR settings. The chi-square test was performed to provide information on differences in contents of exercise in group-exercise versus one-to-one exercise with a significance level of p < 0.05. The statistical analysis was conducted with SPSS 19 software.

Trial registration: not relevant.

RESULTS

Questionnaire

A total of 60 (97%) out of the 62 included PR centres, within 91% of the 56 selected municipalities, completed the survey (Figure 1).

Initiation and duration of physical rehabilitation

The PR was initiated within 1-2 weeks after the municipality had received a referral from the hospital in 97% of the 60 participating centres. The duration of the PR was between 8-12 weeks in 25% of the centres or 4-7 weeks in 60% of the centres. All centres responded that the PR was extended beyond the initial period if needed.

Frequency and setting of physical rehabilitation

The frequency of PR across all types of centres was mainly 1-2 sessions per week, especially in the outpatient PR centres (72%). Therapists employed at an outpatient PR centre sometimes also administered home-based PR or PR at a nursing home unit, and therefore gave more than one response across centre categories (Table 1).

PR provided as home-based, at 24-hour inpatient PR units or nursing homes were more often based on individually adjusted terms regarding sessions per week than PR provided in outpatient centres (Table 1). The number of weekly sessions provided in the different PR settings differed when calculated as outpatient PR centre versus home-based PR (p < 0.01) and 24-hour in-patient PR unit versus nursing home (p < 0.01) (Table 1).

The form of the PR was described mainly as a combination of both group- and one-to-one exercise therapy (78%).

Formal description of procedures and/or specific exercise programmes

Totally, 29 (57%) out of the 56 municipalities responded positively to having a dedicated description of procedure and/or a specific exercise programme for patients after HF surgery. In all, 72% of these 29 municipalities returned a programme; 67% had formulated a general aim for the intervention.

Structure and contents of the physical rehabilitation

All but one (95%) of the forwarded formal descriptions described the PR conducted as a one-to-one exercise, either through the entire PR period or at the beginning of the course.

The modalities constituting the PR were exercises of relevant ADL functions, strength and balance (95%), range of motion (67%) or e.g. reduction of oedema or improvement of outdoor mobility skills (86%). Group-exercise PR was described as offered in 90% of the descriptions, aimed and conducted similarly to that reported in one-to-one PR and with no statistically significant difference (p > 0.05) in the distribution of primary contents between the two types of treatment (one-to-one versus group-exercise) (Table 2).

The contents of the intervention were described in general terms (e.g. regarding modalities and duration) in 76% of the programmes. Still, the majority (86%) lacked information regarding intensity and progression of the PR.

Test and screening in the physical rehabilitation

Test or screening of e.g. basic mobility skills or risk of falls at start of PR was described as being conducted in 76% of the forwarded descriptions, but five of these descriptions had no information that any re-test was being performed. The most frequent test in use was the Timed Up & Go test, Sit To Stand test and the New Mobility Score (Figure 2). Use of other tests were common, e.g. the Tandem test, the Six-Minute Walking Test, the 10 Meter Walking Test, Repetition Maximum, Borg scale, Barthel Score, Muscle Strength Testing (0-5) and the Trendelenburg Test.

DISCUSSION

Almost half of the participating PR centres in this study, representing more than 50% of all municipalities in Denmark, responded that they have no formal description or specific programme for PR in HF patients. Furthermore, 86% of the forwarded formal descriptions lack a specific description of the PR offered. This result suggests that the PR following HF is based on the individual therapist’s estimate; a result which is similar to the results reported in a study of PR after breast cancer surgery [15]. It does, however, invite the question whether the national resources allocated to PR after HF surgery are being utilised optimally? In other words, should the contents of the PR conducted depend on the physical therapist, geography or local agreements? The questions must therefore be what is the most relevant aim of PR for HF patients – short-term or long-term and whether all HF patients have the same need of PR, as highlighted by Beaupre et al [16]. The Cochrane review by Handoll et al is inconclusive concerning early, standard and extended interventions in regards of making exercise recommendations [6]. Studies of early PR remain few and this may reflect a fear of compromising fracture and surgery at the acute stage [17]. Nevertheless, several
studies have found the early exercise interventions with weight-bearing exercises and progressive quadriceps strength training feasible and effective towards functional outcomes [4, 8, 18].

Timing of physical rehabilitation

It seems evident that the timing and contents of the PR are essential to gaining an optimal effect of the PR services provided. Therefore, the next step in targeting the municipality-based PR after HF seems to be to describe and implement best-practice evidence-based guidelines in order to adequately meet the possibly unused PR potential of the patients with a HF.

This survey explored the subjects of timing and contents in several ways. More than 30% of the 24-hour in-patient PR units responded that their patients were offered exercise only 1-2 times per week (Table 1). The effect of 1-2 sessions in a week to patients at a very low level of mobility and with an insufficient level of physical function in order to return to their home can be questioned. Thus, the aim and structure of PR in this setting needs careful consideration as do the issues of cost-effectiveness, knowledge of the value of independent living and mobility, and the patient’s motivation for rehabilitation [19, 20].

Tests

This survey brings forward important knowledge on the use of tests and screening in PR for patients with HF in Denmark. We found that tests of mobility skills are commonly used, but information on re-testing procedures was limited. Use of tests within the early post-operative period as well as the extended PR of HF patients must be considered essential to ensure quality and progression in the PR.

Furthermore, the benefit is the opportunity to communicate important and standardised information between sectors about the patient’s mobility skills at discharge or between different categories of PR centres. Previous studies have demonstrated the feasibility of using standardised tests of mobility skills within patients with HF both in the acute ward and in municipality-based PR [4, 18]. This may aid the recognition of patients in need of personal care or PR of specific skills after HF and optimise the allocation of resources in the field of PR and care for the patient with HF.

Strengths and limitations of the study

The task of providing PR in Denmark is heavily regulated by governmental rules and local arrangements within
regions and municipalities. Consequently, our study is therefore at risk of being biased by respondents completing the survey with answers illustrating procedures performed to meet requirements rather than describing the actual treatment.

The geographical distribution of participants is regarded representative of all regions of Denmark and for small and large municipalities, similar to previous
studies in PR after various surgical procedures [13-15]. Owing to the very high response rate of 91% from randomly selected municipalities, the results are considered likely to represent the current trend in municipality-based PR after HF surgery in Denmark. Still, no final conclusions can rightfully be made based on our data, but hopefully the study may stimulate a professional debate of current and future PR practice.

CONCLUSION

Although 96% of all patients with HF surgery are referred to municipality-based PR in Denmark, this survey found that only three of the 51 participating municipalities had a specific description of the PR conducted after HF surgery regarding contents, use of tests, repetitions and exercise intensity. The remaining respondents had none or only general descriptions of the PR conducted. Thus, the PR after HF in Denmark is initiated shortly after prescription, for a variable duration, and with poorly described exercise intensity and progression, mainly at the discretion of the individual physical therapist conducting the exercise. This calls for a national description and implementation of a formal PR programme reflecting the best available evidence which would be an important step toward a more optimised PR after HF.

Correspondence: Lise Kronborg, Fysio- og Ergoterapien 236, Hvidovre Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark. E-mail: lisekronborg@hotmail.com

Accepted: 9 January 2015

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

Acknowledgements: We thank all of the physical therapists participating in this study for their valuable contribution to produce data for the study. We would like to extend our gratitude to the participating physical therapists, Kajsa Lindgren , Department of Rehabilitation, Municipality of Copenhagen, Jan Overgaard, Department of Rehabilitation, Municipality of Lolland, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), who provided data for the initial pilot testing of the study without any compensation.