hip fracture and home care

8/3/2019 Hip Fracture and Home Care

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Interventions Used by PhysicalTherapists in Home Care for PeopleAfter Hip FractureKathleen Kline Mangione, Rosalie B Lopopolo, Nancy P Neff, Rebecca L Craik,Kerstin M Palombaro

Background and PurposeThe majority of older people who survive a hip fracture have residual mobility

disabilities. Any attempt to systematically reduce mobility disabilities after hip frac-ture, however, requires knowledge of the adequacy of current management prac-tices. Therefore, the purpose of this study was to begin to understand the nature ofphysical therapy home care management by describing usual care for people afterhip fracture.

Subjects and MethodsIn 2003 and 2004, a national survey was conducted of all members of the AmericanPhysical Therapy Association who identified home care as their primary practicesetting (n3,130). Usual care was operationally defined as when more than 50% ofrespondents reported that they always or often use a specific intervention.

ResultsSurvey questionnaires (1,029) were returned with a response rate of 32.9%. Func-tional training activities, including bed mobility, transfer and gait training, balancetraining, safety training, and patient education, were reported very frequently. Active-range-of-motion exercises were performed much more frequently than exercisesinvolving added resistance.

Discussion and ConclusionThis study provides a detailed description of the physical therapy interventionsprovided in the home care setting for patients after hip fracture. The sample size andnational representation increase our confidence that this description accuratelydepicts physical therapist practice.

KK Mangione, PT, PhD, GCS, isProfessor, Department of PhysicalTherapy, Arcadia University, 450 SEaston Rd, Glenside, PA 19038-

3295 (USA). Address all corre-spondence to Dr Mangione at:[email protected].

RB Lopopolo, PT, PhD, MBA, isProfessor, Department of PhysicalTherapy, Arcadia University.

NP Neff, PT, DPT, Cert MDT, isPhysical Therapist, Aquatic andPhysical Therapy Center, Phillips-burg, NJ.

RL Craik, PT, PhD, FAPTA, is Pro- fessor, Department of PhysicalTherapy, Arcadia University.

KM Palombaro, PT, PhD, is Com-munity Engagement Coordinator,Widener University, Chester, Pa.

[Mangione KK, Lopopolo RB, NeffNP, et al. Interventions used byphysical therapists in home care for people after hip fracture. PhysTher. 2008;88:199210.]

2008 American Physical TherapyAssociation

Research Report

Post a Rapid Response orfind The Bottom Line:www.ptjournal.org

February 2008 Volume 88 Number 2 Physical Therapy f 199


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There are more than 325,000hip fractures per year in theUnited States, with an esti-

mated cost to patients, families, andthe health care system of between

$14 billion and $20 billion annual-ly.1,2 The number of hip fractures ispredicted to increase to more than650,000 per year by 2040.3

The majority of people who survivea hip fracture have residual mobilitydisabilities.4,5 For these people, de-pendency in functional activities ofdaily living persist through 2 years ofrecovery, with up to 20% needinghelp putting on pants, 50% needingassistance to walk, and 90% being

dependent in climbing stairs.6 Be-tween 40% and 60% of older people

with hip fracture fail to regain pre-fracture mobility and are unable toreturn to community activities.5,6

The majority of people who sustaina hip fracture receive some form ofphysical therapy intervention in in-patient, home care, or outpatientsettings or a combination of thesesettings.7 Despite physical therapy

interventions, however, mobility dis-abilities and impairments persist longafter the healing of the hip fractureitself. Knowledge of the nature ofphysical therapy interventions afterhip fracture is limited, especially in-terventions that occur in the homecare setting. For example, in one ofthe largest trials of rehabilitation af-ter hip fracture, Tinetti and col-leagues reported, As is typical inhome care, the specific contents andduration of the therapy training pro-gram was left to the discretion ofthe individual therapists.8(p918) Ifphysical therapists want to systemat-ically reduce mobility disabilities af-ter hip fracture and if they believethat their interventions are impor-tant for achieving this goal, then theyneed to understand the nature of cur-rent management practices and de-termine whether they are adequateto meet this goal.

We believe that physical therapy in-terventions after hip fracture aresimilar to those described for strokerehabilitation, which is referred toas a black box, meaning that the

content of what occurs during aphysical therapy session is unde-fined. Defining treatment may bedifficult because interventions aremultifactorial, because substantialclinical variations exist between pa-tients with identical diagnoses, orbecause clinicians rely on experi-ence rather than evidence or theoryfor best practice.9,10 A clearer under-standing of the content of physicaltherapy interventions may enable abetter understanding of the effects of

specific treatments on outcomes.

The least-described component ofmanagement after hip fracture is thecare that occurs in the home. Thecontent provided in the home caresetting is important for several rea-sons. First, because the ultimategoal for most patients is to returnhome,11 knowledge of which physi-cal therapy interventions are crucialto ensuring that a patient is able to

function effectively in the home en- vironment is needed. Second, providing care in the home has beenfound to be the most economical

way in which to provide care, com-pared with acute-stage inpatient re-habilitation or nursing home care.12,13

Insight into best practice for pa-tients treated in this setting is es-sential for determining the efficacyof physical therapy interventions.Third, patients who receive homecare physical therapy after acute-stage rehabilitation are less likely tobe hospitalized and more likely to sur-

vive than those who receive acute-stage rehabilitation alone.14 Finally,home care is associated with greaterimprovements in functional outcomesthan acute care provided in nursinghomes.15

An understanding of which treat-ments are associated with good out-

comes is needed. However, beforethese relationships can be identified,the characteristics of care providedin the home care setting need to beelucidated. Therefore, the purpose

of this study was to describe physicaltherapist practice in the home caresetting for older people after hipfracture. That is, we describe usualcare for this patient populationacross the United States.

Method We conducted a national survey todescribe the nature of usual physicaltherapy care in the home care set-ting for older patients (ie, morethan 65 years of age) after hip frac-

ture. Home care therapists wereasked to participate in the study bycompleting a self-administered ques-tionnaire. Because this was the firststudy to describe the nature of homecare interventions for hip fracturerehabilitation, a multiphase process

was used to develop the question-naire for this study. Initial focusgroups met in spring 2003, and finalsurvey data were collected in spring2004.

To ensure consistency in the respon-dents consideration of what usualcare provided to a patient after hipfracture would be, a description of atypical patient was developed andused throughout all phases of thestudy. This profile of a typical patient

was developed from a composite ofdemographic data collected fromseveral studies.6,8,14,16 The descrip-tion provided was as follows: The

typical individual sustaining a hipfracture is an 81-year-old, whitewoman who is cognitively intact andwas living at home prior to the frac-ture. She had 3 comorbidities at thetime of the fracture and was taking 3medications. The fracture was re-paired surgically. She was hospital-ized for 3 to 4 days and has beenthrough either acute- or subacute-stage inpatient rehabilitation.

Home Care for People After Hip Fracture

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Phase 1: Focus Groups forContent DevelopmentFocus groups were used to ascertainthe nature of usual care for this pa-tient population. We brought to-

gether people experienced in treat-ing the population of interest witha leader who directed the discus-sion. This strategy assists in the earlystages of questionnaire develop-ment by identifying lines of question-ing not obvious to the researcher.17

Eight Philadelphia-based physicaltherapists experienced in the treat-ment of older patients across multi-ple settings participated in 1 of 2focus groups to identify how theymanaged the treatment of this pa-

tient population. The therapistswere selected on the basis of years ofclinical experience and reputationfor professional expertise in treatingthis population. The participants

were, on average, 46 years of age, with 19 years of experience; 89%were women, and 56% had a profes-sional (entry-level) bachelors de-gree. One of the therapists was aGeriatric Clinical Specialist. Thesecharacteristics are similar to those of

the sample of therapists who re-sponded to the final questionnaire.

The framework for identifying inter-ventions was based on the Guide to Physical Therapist Practice, Muscu-loskeletal Practice Patterns 4G and4H: impaired joint mobility, motorfunction, muscle performance, andrange of motion (ROM) associated

with fracture (4G) and with jointarthroplasty (4H).18 The Guide to

Physical Therapist Practice de-scribes the following types of in-terventions for patients after hipfracture: therapeutic exercise, func-tional training, assistive device pre-scription and adjustment, homeexercise prescription, and physicalagents. With open-ended questions,the participants in the focus groups

were asked to describe the types ofphysical therapy interventions thatthey personally provided to their

patients in the target population. Inaddition, information was collectedregarding the time between the frac-ture and the initiation of home care,the typical number of visits, and the

typical initial weight-bearing status.The participants also were asked todescribe typical patient goals andhow they made clinical decisions re-garding choices of interventions,progression of activities, time frames(number of sessions and duration ofsessions), and criteria for the termi-nation of physical therapy services.

The focus group sessions were re-corded, and the recordings weretranscribed to facilitate data ana-

lysis. The responses from both focusgroups were collated and sorted intocategories as defined in the interven-tion section of the Guide to PhysicalTherapist Practice. The organizeddata were then provided to the par-ticipants for review and identifica-tion of necessary additions, changes,or clarifications. On the basis of theirfeedback, the categories and data

were revised and returned to theparticipants for final review. This

2-stage review procedure was usedto ensure that no information hadbeen lost in the data collection andcategorization processes.17

Phase 2: PreliminaryQuestionnaire Testing forCompleteness and ClarityUsing the data provided by the fo-cus groups, the research team con-structed a preliminary questionnaire.To facilitate survey completion anddata analysis, a Likert-type responseformat was used for all interventionquestions. The response format waseither a 5-point scale (never, rarely,sometimes, often, always) or a 2-pointscale (perform, do not perform). A pi-lot test of the preliminary question-naire was conducted to determine

whether there were confusing or am-biguous items or omissions. Thirty-fivephysical therapists from across theUnited States were asked to partici-

pate in this phase of the study. Thispanel was composed of 19 physicaltherapists identified as experts by thePresident of the Home Health Sectionof the American Physical Therapy As-

sociation (APTA) and 16 GeriatricClinical Specialists nominated by a Ge-riatric Clinical Specialist who is a mem-ber of the APTA Section on Geriatricsand is on the research team. Twenty-six physical therapists, 3 to 7 thera-pists from each of 4 geographic re-gions of the United States, participatedin this phase of the study; 1 therapistdeclined to participate, and 8 thera-pists did not respond. Specialists werespecifically targeted for this phase toensure that all possible elements of

practice were included in the final sur-vey. Except for the facts that there wasa higher percentage of specialists inthis phase (60% versus 5%) and thatthese physical therapists had more ex-perience (100% with10 years of ex-perience versus 84% with10 yearsof experience), the participants inphase 2 were similar in age, sex, race,and education to the respondents tothe final questionnaire.

Using the typical patient profile provided and their own clinical ex-perience, the panel members wereasked to complete the questionnaire.

Additionally, they were asked to ex-amine the questions and the avail-able responses and provide feed-back for each question. Specifically,they were asked to identify any pro-cedural interventions that they be-lieved were missing or should be ex-cluded from the questionnaire and tocomment on the appropriateness ofthe responses for each question.

On the basis of the data provided bythe respondents, several questionsand the response formats for specificquestions were modified. For exam-ple, questions were added to addressthe type of surgical fixation used, pa-tient education, breathing exercises,

wound care, discharge planning, andinsurance coverage. Several ques-




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tions, including initial weight-bearingstatus, types of positions used forstrengthening exercises, and the useof weights or resistive bands, were re-

worded for clarification. The response

formats for several questions were re-worded to make the responses mutu-ally exclusive. One question (cardio-

vascular conditioning) was eliminatedbecause of redundancy. Finally, weadded a section for gathering demo-graphic data, such as age, sex, educa-tional level, and specialization of therespondents. The resulting 23-itemquestionnaire was used as the final sur-

vey in phase 3 (Supplemental Appen-dix, available online only at www.ptjournal.org).

Phase 3: Survey Population forDescription of Usual CareThe final questionnaire and a coverletter were mailed to all members of

APTA who had designated homecare as their primary practice setting(n3,130). The respondents wereasked to use the typical patient pro-file provided and their own clinicalexperience to guide their comple-tion of the questionnaire. The re-

spondents were asked to answerthe questions on the basis of theusual care that they provided to thistypical patient, rather than a rare orunusual patient. The questionnaire

was available to be completed eitherby mail or online with a Web-basedprogram (depending on respondentpreference). The wording and in-structions in both versions wereidentical. In both cases, instructionson how to complete the question-naire were provided.

A nominal incentive (organic teabag) was included with the mailedquestionnaire to facilitate its comple-tion and return. A follow-up postcard

was mailed approximately 2 weeksafter the initial mailing to maximizethe return rate.

Data AnalysisThe questionnaire items were codedto facilitate data entry. The data wereentered into a Microsoft Excel 2003*spreadsheet and analyzed with SPSS

version 13.0.

After data entry, thespreadsheet of the results from themailed survey questionnaires waschecked for accuracy. When neces-sary, corrections to data input weremade, and a random sample (10%)of the data was checked again toensure greater than 95% accuracy.Frequency distributions, expressedas percentages, were used to summa-rize responses regarding usual care.

Chi-square analyses were performed

to determine whether relationshipsexisted on the basis of the type ofsurgical repair (open reduction-internal fixation [ORIF] versus hemi-arthroplasty), weight-bearing status(nonweight bearing or toe-touch,full, partial, or as-tolerated weightbearing), and time of initiation ofhome physical therapy after the frac-ture (2 weeks versus 2 weeks andlonger). These analyses were per-formed to determine whether the

type of repair, weight-bearing status,or time after the fracture influencedthe usual care provided for this pa-tient population. In addition, to en-sure that the data represented prac-tice across the United States, theresponses were coded by geo-graphic regions of the country withthe coding scheme described by

APTA (Tab. 1). Chi-square analyses were performed to determine whether the respondents could betreated as a single sample.

We operationally defined usualcare as when more than 50% of re-spondents reported that they oftenor always use a specific interven-tion for questions with a 5-point

Likert-type response format andwhen more than 50% of respondentsreported performing the activity forthe yes (performed)/no (not per-formed) questions.

ResultsA total of 1,029 questionnaires werereturned (965 via mail and 64 via theInternet), for an overall responserate of 32.9%. The mean (SD) ageof the respondents was 46.69.2

years. The majority of the survey re-spondents were women who hadmore than 10 years of experience asphysical therapists. The majority ofthe respondents worked as employ-ees of a home care agency (77%),

and 81% had treated their last patientwith a hip fracture within 3 monthsof completing the questionnaire. Acomparison of the characteristicsof the respondents and those of theentire sample from the APTA data-base showed remarkable similarities(Tab. 1). The APTA sample included72% of therapists with 11 or more

years of experience and another 14% with 6 to 10 years of experience.These data compare favorably with

those for our sample, from which83.9% of therapists reported 10 ormore years of experience.

Chi-Square Analyses ofInfluential FactorsChi-square analyses were performedfor all therapeutic exercises that

were defined as usual care and theclinical variables of interest (type ofsurgical repair, weight-bearing sta-tus, and time of initiation of homephysical therapy). There were nosignificant relationships betweenhemiarthroplasty or ORIF and usual-care therapeutic exercise techniques(Supplemental Table 1, online onlyat www.ptjournal.org). For weight-bearing status (Supplemental Table2, online only at www.ptjournal.org),the significant relationship betweenthe use of active assisted exercise and

weight-bearing status was the re-ported use of active assisted exercise

* Microsoft Corp, One Microsoft Way, Red-mond, WA 98052-6399. SPSS Inc, 233 S Wacker Dr, Chicago, IL60606.




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Table 1.Comparison of American Physical Therapy Association (APTA) Sample of Physical Therapists Who Reported Home Health as TheirPrimary Practice Setting and Our Survey Respondents

APTASample ofTherapists (%)

Our SurveyRespondents(%)

Age range (y)

2024 0.3 0.2

2529 4.7 3

3034 10.5 8.1

3539 13.8 12.8

4044 13.3 13.8

4549 17.4 21.1

5054 19.2 21.4

5559 11.3 12.4

6064 5.4 5.765 4.1 1.5

Sex

Women 75.5 79.5

Men 24.5 20.5

Race

American Indian or Alaskan native 0.3 0.4

Asian, Pacific Islander, or

Hawaiian native

3.8 2.2

African American or black 2.5 1.5

White 90.0 93.5

Hispanic/Latino 2.3 2.2

Other 1.1 0.2

Highest earned degree

Associate 0.2 NA a

Baccalaureate 59.2 58.6

Masters 37.8 34.2

Doctor of Physical Therapy 1.4 0.8

Other doctorate 0.8 0.7

Other 0.6 NA

Certificate NA 5.7

Region

Northeast 29.4 29.7

Midwest 19.9 22.7

South 34.4 30.3

West 16.3 14.9

Puerto Rico NA 0.2

Not answered NA 2.2

a NAnot asked.




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more frequently when the patient wasnot weight bearing versus when thepatient was weight bearing (83% and79% usual care, respectively). Fortime of initiation of home therapy, sig-nificant relationships were found forisometric exercises and resisted exer-cises (Supplemental Table 3, onlineonly at www.ptjournal.org). Patients

who started home physical therapy within 2 weeks of surgery used iso-metric exercises more often thanthose who started home physical ther-apy after 2 weeks (90.3% and 86.1%usual care, respectively). In contrast,those who started home physical ther-apy within 2 weeks of surgery wereless likely to use resisted exercisesthan those who started home physicaltherapy later (59.9% and 66.7% usualcare, respectively).

Because weight-bearing status couldbe related to the time when physicaltherapy is initiated, additional chi-square analyses were performed toexamine this relationship. Weight-bearing status was significantly re-lated to the start and stop times forhome physical therapy (Tab. 2), sug-gesting that physical therapy startedand ended later for patients who

were not weight bearing than forthose who were allowed to bear

weight. There was no relationshipbetween weight-bearing status andthe total number of visits.

Regional AnalysesThe percentages of responses fromthe 4 geographic regions were ap-proximately equal (range27%33%). Chi-square analyses were per-

formed to examine the relationshipsbetween geographic regions andusual-care therapeutic exercises. Theonly type of usual care that showeda significant relationship with re-gion was stretching (P.01), sug-gesting that respondents in thenortheast used stretching exercisesmore frequently than physical thera-pists in the other regions. Chi-squareanalyses demonstrated significantrelationships between geographicregion and insurance coverage, be-ginning and ending time frames forphysical therapy, and number of

visits, suggesting that therapistswho practiced in the western regiontreated a larger percentage of pa-tients with a Medicare health main-tenance organization as their pri-mary medical insurance and that

Table 2.Frequency Distributions and Results of Chi-Square Testing for Relationships Between Temporal Aspects of Care and Number of

Visits and Weight-Bearing Status

NonWeight Bearing orToe-Touch WeightBearing

Full, Partial, or As-ToleratedWeight Bearing

P

Weeks after fracture until

start time for home

physical therapy

n127 n893 .00

2 44.9% 47.4%

23 34.6% 42.6%

45 17.3% 9.4%

67 0.8% 0.7%

8 2.4% 0%

Weeks after fracture until

stop time for home

physical therapy

n127 n886 .00

4 8.7% 12.4%

46 46.5% 55.3%

79 29.9% 26.6%

1012 11.0% 4.9%

12 3.9% 0.8%

Total no. of visits n127 n893 .22

6 4.7 7.2

68 18.9 26.7

912 44.1 38.0

1214 26.0 23.9

15 6.3 4.4




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these patients appeared to have fewerphysical therapy visits (Tab. 3).

On the basis of the overwhelmingsimilarity among the respondents(ie, the very small number of signif-icant relationships found), we used asingle sample to describe usual care.Given the typical patient profile pro-

vided, the majority of respondentsindicated that the surgical repair forthis patient would have been eitherhemiarthroplasty or ORIF (59%) andthat most patients would be allowed

to be weight bearing (71%) (Tab. 4).The broad categories of therapeuticexercise techniques that were partof usual care (50% of respondentsreported that they often or alwaysperformed the techniques) includedROM, stretching, and isometric, ac-tive assisted, active, resisted, and bal-ance exercises (Tab. 5). In terms ofROM and stretching exercises forspecific muscle groups and posi-tions, usual care included stretchingfor the hip flexor, knee flexor, andplantar-flexor muscles. Isometric ex-

ercises were used for the gluteal andquadriceps femoris muscle groups.

As shown in Table 6, active exer-cises were performed much morefrequently than exercises involvingadded resistance. Exercises for mul-tiple muscle groups, including bridg-ing, straight leg raises, and squatting,

were performed very frequently.

Although usual care included usingresisted exercises as a general cate-gory of exercise (64% of therapists;Tab. 5), further questioning revealed

Table 3.Frequency Distributions of Responses for Insurance Coverage and Visits

Parametera Percentage of Respondents by Regionb

Total Northeast Midwest South West

Insurance (P.001) N1,019 n305 n233 n310 n151

Medicare 92 90 98 98 76

Medicare health maintenance organization 7 9 1 2 22

Other 1 1 1 0 2

Begin physical therapy, wk (P.036) N1,020 n304 n233 n311 n152

2 47 38 51 49 54

23 42 47 37 41 40

45 10 14 10 10 5

67 1 1 1 0 1

8 0 0 1 0 0

Total no. of visits (P

.001) N

1,020 n

304 n

233 n

311 n

1526 7 6 7 4 14

68 26 24 29 18 37

912 39 44 34 42 29

1214 24 21 26 31 16

15 4 5 4 5 4

End physical therapy, wk (P.007) N1,013 n303 n233 n307 n151

4 12 8 13 10 21

46 54 54 56 53 54

79 27 30 23 31 20

1012 6 8 5 5 4

12 1 0 3 1 1

a Significant P values (P.05) are reported (determined with the Pearson chi-square statistical test).b The numbers for the regions do not always add up to the total number because of missing data for some responses and because the 2 respondents fromPuerto Rico were not grouped regionally. Regions were as follows: NortheastConnecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont,New Jersey, New York, and Pennsylvania; MidwestIllinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, NorthDakota, and South Dakota; SouthDelaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia,

Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas; and WestArizona, Colorado, Idaho, Montana, Nevada, NewMexico, Utah, Wyoming, Alaska, California, Hawaii, Oregon, and Washington.




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Table 6.Percentages of Respondents Who Reported That They Often or Always Perform Specific Therapeutic Exercises

Exercise Percentage Who Responded Often or Always

ActiveAssisted

Active Resisted,Manual

Resisted,Weights

Resisted,Bands

Hip flexion

Supine 80a 92a 22 20 8

Side lying 12 15 3 2 1

Sitting 21 68a 17 22 12

Standing 10 93a 5 25 10

Hip extension

Prone 13 23 3 4 1


Standing 11 94a 7 22 14

Hip abduction

Supine 81a 92a 27 18 15

Side lying 30 49 8 11 3

Sitting 12 45 17 5 21

Standing 12 94a 8 26 17

Hip adduction

Supine 43 70a 15 9 2


Sitting 9 38 16 3 6

Standing 5 38 3 9 6

Knee flexion

Sitting 24 76a 27 18 23

Standing 14 87a 7 27 9

Knee extension

Sitting 40 94a 34 47 22


Ankle plantar flexion

Sitting 12 84a 16 5 15

Bilateral standing 5 87a 4 5 1

Unilateral standing 4 38 2 3 1

Ankle dorsiflexion

Sitting 18 91a 19 8 14


Multiple joints

Bridging 16 78a 7 2 0

Straight leg raise 49 79a 8 20 2

Squats 6 80a 1 2 1

Step-ups 8 70a 0 2 0

a Usual care, that is, when 50% of respondents indicated that they perform this specific exercise.




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to what was reported in the 1980sfor both acute-care physical therapytreatment and subacute care providedin nursing care facilities.2,19,20 Jetteand colleagues19 described their inter-

ventions as breathing exercises, quadsets (isometric quadriceps femorismuscle exercise), active assisted ROM,

and ambulation and transfer training.Barnes and Dunovan2 reported that atypical treatment included active as-sisted ROM, active and resisted exer-cises, transfer and ambulation training,and occasionally physical modalityuse. However, our results provide amuch richer description of the spe-

cific interventions that are used todayfor this population.

Our findings suggest that usual careprovided in the home care setting is

very different in timing, intensity,and duration from that provided inintervention studies reported in theliterature, which demonstrated im-provement in impairments and func-tional limitations in older patients af-ter hip fracture.2123 These reportedstudies used high-intensity resistancetraining with specialized equip-ment2123 after usual care was com-pleted (3 to 6 months after frac-ture).2224 In these studies, programslasted for several months, and the

total number of sessions ranged from20 to 60.2123 The results of theseinvestigations suggested that exer-cise with more resistance over alonger period of time at some pointin the recovery process is needed toreduce mobility disabilities after hipfracture. The question of optimaltiming for this level of exerciseneeds be investigated.

It is possible that one way to reduce

persistent mobility disabilities andimpairments is for usual care to in-clude some underutilized interven-tions, such as aerobic conditioning,transfers from the floor to a standingposition, picking items off the floor,perturbation training, and the use ofhigh-intensity resistance, which areused by a minority of home care ther-apists. Elements of these interven-tions have been used successfully inexercise trials,2123 but no study todate has shown a patient to progressfrom acute-stage recovery to full in-tegration into the community withthese types of therapeutic exercises.

A combination of functional training,aerobic training, balance training, andstrength (force-generating capacity)training may be the comprehensiveapproach that is missing from currentpatient management, and the lack ofsuch a comprehensive approach maybe contributing to the persistence of

Table 7.Percentages of Respondents Who Reported That They Often or Always PerformSpecific Therapeutic Activities

Activity Percentage WhoResponded Oftenor Always

Balance training

Weight shifting 87a

Marching 88a

Unilateral stance 66a

Self-perturbation 45

External perturbation 38

Picking items off floor 30

Activities of daily living training

Bed mobility 99a

Stand from sitting position 100

a

Tub or shower transfers 83a

Car transfers 74a

Transfer from floor to standing position 16

Gait training

Indoor surfaces 100a

Outdoor surfaces 96a

Curbs 67a

Stairs 94a

Walker to 4-point cane 38

Walker to single-point cane 73a

Walker to crutches 5

Walker or cane to no device 40

Physical agents, manual therapies, and

wound care

Cold packs 32

Hot packs 8

Soft-tissue massage or mobilization 22

Wound care, except for scar massage 9

Scar massage or mobilization 28

a Indicates usual care, that is, when 50% of respondents indicated that they perform this specificactivity.




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mobility disabilities and impairmentsafter the healing of the hip fractureitself. Future research needs to de-termine whether a specific interven-tion or a combination of interven-

tions is more effective in improvingthe function of older people after hipfracture. We believe that our descrip-tion of current usual care practicescan be useful in the design of suchintervention studies.

The question that remains is why thecare provided in the home care set-ting is similar to categories of inter-

ventions described for acute careand subacute care in the 1980s, thatis, less advanced or demanding for

the patient. One possible explana-tion is that physical therapists who

work in the home care setting andbegin therapy with patients within21 days of surgery may view the pa-tients as still being in the acute stageof recovery. This explanation is con-sistent with the finding that the av-erage length of stay in the acute caresetting was almost 22 days in the1980s,19 whereas it was reported tobe only 6.5 days in 2003.25 Thus, the

question remains as to whether pa-tients currently being seen in thehome care setting are ready for moreintensive treatment.

A second possible explanation is thata reduction in the number of homecare visits that have been reportedmay be contributing to the provisionof less therapeutic programming. Themean number of home care visits (allservices) for patients after hip frac-ture in 1996 was 47.8, and that figuredecreased to 25.6 visits in 2001.26

The results of our survey suggest thatpatients typically are being treated inthe home sooner (less than 3 weeksafter hip surgery) and are typicallyreceiving between 6 and 12 visits,depending on the geographic re-gion. The majority of patients, there-fore, are discharged from home carephysical therapy at approximately 6

weeks after surgery. This number of

visits is at the shortest end of theexpected range of visits listed in theGuide to Physical Therapist Prac-

tice Practice Pattern for joint arthro-plasty (1260 visits)18 and is shorter

than the 8 to 12 weeks of treatmentpreviously reported.27 The clinicallyrelevant question is whether 6 to 12

visits in the 6 weeks after hip frac-ture surgery provide sufficient ther-apy to return older patients to theirprior level of function.

The chi-square analyses suggestedthat therapists are providing verysimilar levels of care across theUnited States. We hope that theblack box of physical therapist prac-

tice in the home care setting forhip fracture has been illuminatedmore by the results of this descrip-tive study. Although standardizationof physical therapist practice is agoal for many aspects of care,28 it ishoped that the standardization isbased on evidence or expert consen-sus. It is not clear whether currentpractice, which appears to leave thepatient ambulating with a cane andable to perform functional activities

in the home, is evidence based. Be-cause so few patients are being re-ferred for outpatient therapy, thisminimal level of function is all thatmany older patients may achieve af-ter hip fracture.

There are several limitations to thepresent study. First, we sampledonly physical therapists who weremembers of APTA for ease of ob-taining a sample of participants whopractice in the home care setting.This sampling strategy could haveresulted in an underrepresentationof all physical therapists in theUnited States and does not accountfor the opinions of those who chosenot to respond. However, a com-parison of responders and nonre-sponders suggests that the demo-graphic characteristics of thesegroups were incredibly similar. Sec-ond, although a return rate of 33%

would be considered modest for theidentification of usual care, a returnrate of this magnitude is not uncom-mon in survey research.17 We be-lieve that the sample was large

enough (n

1,029) and distributedwell enough geographically to sup-port the credibility of the findings.Third, the typical patient scenariothat was used to focus respondentsconsiderations was relatively uncom-plicated in clinical presentation. Al-though the instructions presentedasked the respondents to indicate

what they would do with the patientpresented and not what should bedone, we could not prevent the lat-ter from occurring. Clinical scenar-

ios have been shown to be valid mea-sures of what physicians do duringclinical encounters29; however, wedid not test whether what therapistssay they do is actually what is per-formed in the home. In addition, therelative simplicity of the scenario it-self may have left room for differ-ences in the interpretation of the pa-tients condition or prior level offunction by the respondents, whichcould have produced variability in

the responses. Additional research isneeded to answer questions thatguide clinicians in making decisionsabout which interventions to chooseand at what times these interven-tions should be used to restore pa-tients to their prior functional levels.

ConclusionThe present study provides a com-posite description of the physicaltherapy interventions provided inthe home care setting for patientsafter hip fracture. The sample sizeand national representation increaseour confidence that this descriptionaccurately depicts practice. The ma-

jority of therapists have patients per-form active exercises and basic func-tional skills, and almost all therapistsprovide patient and caregiver educa-tion and home exercise programs.Our hope is that this research willspur further study into designing in-




12/12

terventions that will achieve themaximum benefit possible for pa-tients after hip fracture.

Dr Mangione, Dr Lopopolo, and Dr Craik

provided concept/idea/research design andwriting. Dr Neff provided data collection.Dr Mangione, Dr Lopopolo, Dr Neff, andDr Palombaro provided data analysis. DrMangione and Dr Neff provided projectmanagement. Dr Mangione, Dr Lopopolo,Dr Neff, and Dr Craik provided fund pro-curement. All authors provided consultation(including review of manuscript beforesubmission).

The study protocol was approved by theInstitutional Review Board of ArcadiaUniversity.

This research was supported, in part, by sev-

eral grants, including NIH/NICHD grant 1R21 HD043269-01 (principal investigator:Dr Craik; investigator: Dr Mangione), a grant from the Pennsylvania Physical Therapy As-sociation (principal investigator: Dr Neff; in-vestigators: Dr Mangione, Dr Lopopolo, andDr Craik), and a grant from the Arcadia Uni-versity Faculty Development Fund 200405(principal investigator: Dr Mangione).

This article was received January 19, 2007,

and was accepted October 12, 2007.

DOI: 10.2522/ptj.20070023

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