Rehabilitation after hip fracture: the role of progressive strength training


Principal investigator: Lise Kronborg          

Principal supervisor: Morten Tange Kristensen

Co-supervisor(s): Thomas Bandholm, Henrik Palm, Henrik Kehlet

Research initiative: (1) Department of Physical Therapy, (2) Clinical Research Centre, (3) Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, and PMR-C.

Time frame: March 2013-Feb 2016.

Background: Around 10.000 elderly Danish citizens are treated for an acute hip fracture each year. Subsequently many fail to regain basic mobility activities, experience recurrent injurious falls or new fractures, resulting in a decreased level of physical function, increased need of supportive care and a high mortality. Previous studies have found that patients with a hip fracture loose more than 50% of their fractured limb knee-extension muscle strength compared to the non-fractured limb within one week of surgery and with large fracture-type related differences. However, evidence on feasibility and effect of strength training commenced immediately after surgery is lacking.

Most patients are referred to further in- or outpatient rehabilitation after hospital discharge, but we do not know of content and to which extend these rehabilitation programs follow evidence-based guidelines.

Purpose: The purpose of this PhD project is to examine 1) the feasibility and 2) the effect of progressive strength training based on pre-specified criteria for feasibility when commenced immediately after hip fracture surgery in the acute orthopedic ward, and 3) to evaluate the content of community based rehabilitation programs for patients with a hip fracture and to evaluate to which extend these programs follow evidence-based guidelines. The hypothesis is that (1) progressive knee-extension strength training commenced immediately after surgery is feasible (2), the effect of physical therapy including strength training will be greater than physical therapy without strength training and (3), that the content of community based rehabilitation programs for patients with a hip fracture vary considerably in the different municipalities and that they do not follow evidence-based guidelines.

Experimental approach:

Study 1) the first study is planned for  20 patients with a cervical and 20 with a trochanteric hip fracture, admitted to an acute orthopedic hip fracture unit. Patients receive a daily (on weekdays) program of progressive knee-extension strength training for the fractured limb, starting within the first 3 days after surgery, using ankle weight cuffs as loading. At each session, patients perform 3 sets of 10 repetition maximum (RM) loadings (adjusted on a set-by-set basis). Maximum voluntary isometric knee-extension strength is measured using a handheld fixated dynamometer at baseline (day after surgery) and at day before discharge. Key measurements are changes in training loads (kg), evaluated in relation with changes in hip fracture-related pain, and strength deficits in the fractured limb in percentage of the non-fractured limb.

Study 2) In the second study patients are to be included in a single-blinded randomized controlled trial and allocated to physical therapy with or without progressive strength training, as conducted in Study 1. Patients are assessed as in Study 1 and at 4 months postoperatively. Primary outcomes are change in maximum voluntary isometric knee-extension strength, strength deficits in the fractured limb in percentage of the non-fractured limb and functional performances (10m fast speed walking and Timed Up and Go test).

Study 3) The third study is a nationwide questionnaire survey, studying the contents of community based rehabilitation programs for patients with a hip fracture and to which extend these programs follow evidence-based guidelines. Participants are physical therapists at rehabilitation clinics in 56 randomly selected municipalities. Key measurements are presence of a local diagnose-specific guideline or program for the rehabilitation given to patients with hip fracture.

Additional information:

Study 1:

Study 2:


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