Hip Fracture and Long-Term Home Exercise Programs

There are >31,000 hip fracture cases per year in the United States, costing an estimated $14 million to $20 billion. The number of these cases is expected to rise to 700,000 in the United States and from 1.6 million currently worldwide to 4 million by 2050. According to researchers, under the usual care after hip fracture, 16% to 32% of the patients die within a year of the injury. Of the remaining survivors, 50% cannot walk without assistance, and 90% require help in climbing stairs. The patients also undergo significant changes in their physical composition, which include 4% to 7% bone mineral density (BMD) loss and up to 6% decrease in lean body mass (LBM) during the first 2 months, and 3% to 4% higher fat mass within a year after hip fracture. Given these statistics and the vast number of hip fracture cases, an important aspect of postfracture care may be an effective rehabilitative program that the patients can adhere to with relative ease and convenience. Previous research has shown that older adults generally do well with exercise, which potentially increases BMD and strength. Furthermore, it has been shown that weight-bearing aerobic exercises, either independently or accompanied by resistance exercises, can decelerate or stop BMD loss. However, the success rates of these previous programs have varied mainly because the patients did not continue with their program for more than a few months. For the most part, the programs also required patients to travel to participate, because they were either gym- or clinic-based. In Archives of Internal Medicine [2011;171(4):323-331], researchers recently reported results of a study of a year-long exercise program designed for patients’ homes in a randomized clinical trial to determine the feasibility and efficacy of a longer-term, home-based exercise plus program (EPP), which included a self-motivational component. The study included 180 women ≥65 years of age who lived in a community setting, and were admitted to 3 hospitals in the Baltimore Hip Studies network from November 1998 through September 2004. Eligible patients were given dual-energy x-ray absorptiometry within 15 and 22 days of fracture for initial BMD measurements. Patients were then randomized for home exercise intervention (n=91) or usual care (n=89). Follow-up measurements were made and evaluated at 2, 6, and 12 months after fracture to test the hypothesis that the group receiving EPP would show less BMD loss than the usual care group. The researchers also proposed that home exercise intervention would result in other secondary outcomes, such as increased LBM, physical activity, lower extremity performance, grip strength, daily living activities, and quality of living, compared with usual care. Data showed that the EPP group spent more mean time in exercise per week: 0.59 hours at 2 months, 0.77 hours at 6 months, and 0.68 hours at 12 months after fracture (global P=.08). The intervention group also burned more mean calories during their exercise: 184.5 kcal more at 2 months, 249.1 kcal at 6 months, and 169.9 kcal at 12 months (global P=.03). There was no significant difference in adverse events between the 2 groups. Time and calories expended for all physical activities were statistically similar for both groups. Overall, small effect sizes of 0 to 0.2 standard deviations were seen for body composition measures, including femoral neck, trochanteric and total hip BMD, and fat mass. There were also no significant differences in the secondary outcome measurements. “Despite the effectiveness of the delivery system,” the researchers concluded, “the exercise intervention did not result in clinically important or statistically significant changes in targeted outcomes, including BMD, compared with controls.” However, their “low-intensity, home-based exercise program is a feasible delivery strategy and can be used as a model for developing more home-based services that can enhance adherence and promote independence,” the researchers added.