Keywords

14.1 Introduction

Following a fragility fracture, especially a hip fracture, patients face a long journey to recovery [1]. Older people with fragility fracture are often medically complex, presenting with concomitant conditions including frailty that require extended care from multiple carers/providers in both hospital and community settings. Beyond the physical challenges to recovery, social and psychological factors, including fear of falling, can also affect the rehabilitation and recovery process. Although hip fracture is one of the most common and devastating fragility fracture, the rehabilitation concepts discussed in this chapter are also applicable to patients experiencing other fragility fractures. Previous chapters discussed frailty, early mobility, remobilization and exercise, and falls prevention. This chapter will focus on rehabilitation across the care continuum, including interprofessional care, for patients following a fragility fracture. The aim of the chapter is to promote the role of nurses and other practitioners in progressing mobility through the rehabilitation process in patients with fragility fractures.

14.2 Learning Outcomes

At the end of the chapter, and following further study, the practitioner will be able to:

  • Define the goals of rehabilitation for patients with fragility fractures transitioning back to their community settings

  • Describe the role of the nurse and other practitioners in empowering the family to participate in and enhance rehabilitation processes.

  • Outline the evidence and make pragmatic suggestions for including older adults with dementia and fragility fractures in all rehabilitation processes

  • Apply strategies to encourage full return to function and participation in the community.

14.3 Long-Term Outcomes Following Significant Fragility Fracture

Many older adults who experience a low trauma fall and fragility fracture will experience a decline in physical mobility, basic and instrumental activities of daily living, and quality of life in the year following fracture. The risk of institutionalization is increased, but this is not significantly different after fragility fractures of the hip, pelvis, and spine—suggesting increasing disability among all those with fragility fractures [2].

Older adults who sustain a fragility fracture after a fall are likely to fall again. In an Australian study of 336 older adults who sustained a lower extremity fragility fracture, 43% of the participants fell again during the following year and approximately 10% sustained a second fracture [3]. In 161,000 older USA residents who had sustained a hip fracture, the risk of subsequent fracture was approximately 5.5% and most likely to be another hip fracture. The risk of further fractures increased with age, being female, and having comorbid conditions [4]. A critical review of disability outcomes following hip fracture found that older adults in New Zealand were four times more likely to be unable to mobilize in the community 2 years after fracture [5]. By 6 months post fracture, 42–71% of surviving patients recovered basic ADLS. In instrumental ADLs, of the 34% who were independent prior to the fracture, only 14% were independent after a year. Across the globe, decline in quality of life (QoL) measures (EQ. 5D) was in the region of 10–20% at both 4- and 12-months post fracture. The review also reported studies which noted the need for increased domestic services in the home and reported decline in both cognitive and physical health the year post fracture [5]. The studies in the critical review could only include the survivors under usual care conditions. The review did not address potential for recovery for a given patient or for those who receive optimal care.

14.4 Post-acute Rehabilitation

Most older adults who sustain a significant fragility fracture (e.g., hip or pelvis) will receive post-acute rehabilitation. This rehabilitation may occur in multiple settings, making care complex [6, 7]. In-patient acute rehabilitation centers provide patients with daily physical and occupational therapy. Nursing homes can also provide daily rehabilitation services, but usually at less intensity than acute rehabilitation centers. Rehabilitation can occur in patients’ homes (including assisted living facilities or group homes) and at out-patient centers, but the frequency of visits is usually two to three times per week at best [7]. While the ultimate goal of rehabilitation services is to restore patients to the highest level of function and/or return patients to their level of function prior to the fracture, the care is often fragmented by the transition in settings and by the multiple professionals communicating with patients.

14.5 Rehabilitation and Exercise

Rehabilitation combines the key features of exercise science with functional training for basic and instrumental activities of daily living. Although exercise and remobilization are considered in detail in Chap. 8, it is important to consider these as part of the rehabilitation process. For rehabilitation to be successful, gradually rebuilding strength and endurance in activity is important. Supporting patients in exercise for rehabilitation is an interdisciplinary team’s responsibility. In particular, the nursing and therapy teams need to work closely together to support patients in undertaking exercise and other rehabilitation activities. Rehabilitation needs to be incorporated into care activities so that it is performed several times a day, rather than only when a physiotherapy, an occupational therapist or a rehabilitation nurse is present.

In terms of exercise science, “progressive overload,” “specificity,” and “reversibility” are key principles that are applied to all types of exercise affecting muscle, bone, and function which will impact on rehabilitation:

  • Progressive overload is that an individual needs to provide a load to the tissue (muscle or bone) that is “more than the customary load” for there to be an increase in muscle strength or bone formation. Lifting the leg or extending the knee may be an appropriate exercise day 1 after hip surgery but, for the muscle to get stronger as the exercise becomes easier, a greater load (weight) is needed to continue to increase muscle strength.

  • Specificity is defined as adaptions made by muscle that are specific to the type of stimulus applied. For example, performing a holding contraction of the thigh muscles (quadriceps set) will not increase the ability to rise from a chair. The muscle needs to be stronger while moving through either “cuff weights” or practicing the specific activity. The location and type of stimulus are important. The third principle of exercise science is reversibility of training.

  • Reversibility suggests that when the stimulus/load is discontinued, the gains are diminished.

In practical terms, the discontinuation of rehabilitation must be associated with a plan to continue exercise and movement so that gains made are not lost. Exercise, like medication, is prescribed at a specific dose. “Dosing” of exercise is done by identifying the frequency (how often an individual should do the exercise), intensity (at what level of exertion or effort the exercise should be performed), and duration (how many repetitions, or for how many minutes, the exercise should be done). By manipulating these dosing characteristics, rehabilitation providers create individualized and progressive programs for their patients.

These principles are supported by recommendations in clinical practice guidelines for hip fracture and other fragility fractures [7, 8]. Multimodal exercises are recommended for older adults post fracture. Multimodal exercises include progressive resistive exercises for gaining strength, weight-bearing exercises, balance exercises, and functional mobility training. These recommendations are consistent with the WHO’s guidelines for older adults:

“… as part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity, on 3 or more days a week, to enhance functional capacity and to prevent falls” [9].

Examples of potential exercises, dosing and rationales are provided in Table 14.1.

Table 14.1 Training type, possible exercises, dosing, and rationale
Full size table

In the acute hospital setting, an assessment will be needed of whether patients are physically fit to conduct prescribed exercise, even with support. Frailer patients, for example, may take longer to be able to undertake exercises and other physical activity.

14.5.1 Functional Rehabilitation

In the early weeks post fracture (regardless of setting), the rehabilitation provided by an interdisciplinary team made up of physiotherapists, occupational therapist, and/or rehabilitation nurses/practitioners (“The rehabilitation team”) will focus on getting the patient to be able to safely, and independently walk using an assistive device (such as a walking frame or stick/s). They will also focus on patient ability to get in and out of bed, how to rise from a chair and toilet, and how to balance for short periods of time without holding on to the assistive device. Practitioners can achieve these functional goals by educating patients, and instructing them in proper techniques, while working on increasing muscle strength, range of motion, and standing balance.

As recovery progresses in the next several weeks, the rehabilitation team will encourage the patient to walk and move frequently for an increasing amount of time each day. Frequent and sustained movement helps to prevent muscle atrophy and decreases fall risk while enhancing wound healing, bowel function, and bone healing.

Rehabilitation will become more intensive as progressive resistive exercises will be part of the routine to increase muscle strength. Balance exercises will also become more challenging, and functional training will include walking on various indoor and outdoor terrains, getting on and off the floor, and up and down steps. Ultimately, as the patient becomes more independent with household activities and community engagement, the rehabilitation team will recommend a life-long physical activity plan for the patient.

14.6 Interprofessional Rehabilitation Following Fragility Fracture

For patients to achieve maximum recovery and return to pre-fracture function and living arrangements, the support of multiple healthcare providers and disciplines is required. Where human health resources might be limited, all available healthcare providers, including nurses, may offer a broad spectrum of care to meet the patients’ needs across the care continuum, including the community and home. Evidence suggests that patients should be offered a coordinated interdisciplinary care approach to care and rehabilitation from the time of admission to improve their recovery [10].

Nurses play a pivotal role in engaging with patients and their families as they are the primary provider in many locations in terms of time spent with patients involving multiple interactions with patients (and their families) throughout each day [11]. Providing positive, consistent messages around recovery, rehabilitation, and promoting the importance of early mobility is a role for all team members, with nurses playing a leading role. Early goal setting with patients and their family and/or support system can help patients anticipate their recovery, but also allows acute care providers to identify gaps in care that need to be addressed before or during discharge transitions. Communication within and across team members and care settings is critical to successful recovery [12].

Not only can nurses and other practitioners assist with goal setting, they can also help coordinate healthcare team communication across disciplines so that the care provided addresses individual patient needs in a coordinated manner. Advanced practice nursing roles are emerging to ensure a patient-centered coordinated approach to care [13].

Having the healthcare team provide consistent messaging to patients and their families about the importance of movement and mobilization early after surgery and continuing to progress their mobility increases the likelihood of patients becoming partners in their own healthcare. Patients and their families may have difficulty perceiving the benefits of early mobility and movement as fear of falling is highly prevalent following a fragility fracture; >90% of fragility fractures occur with a simple fall from a standing height [14] (see Chap. 4). Providing information about how to safely mobilize and emphasizing how early mobility will help patients recover and return to their pre-fracture home is an important role for all healthcare providers.

Nurses and other practitioners frequently assist patients to transfer out of bed and should encourage them to be out of bed as much as possible. Positive feedback about daily progress as patients regain the ability to perform daily tasks with decreasing assistance can facilitate patient motivation, an important contributor to full recovery [15]. A recent UK study using the UK “Physiotherapy Hip Fracture Sprint Audit” reported that patients who received more frequent and intensive physiotherapy in the first week after surgery had shorter acute care length of stays [16], so early mobility support from all team members may have benefits for both patients and healthcare system.

Appropriate pain management is also an important part of early acute care, as it is associated with delirium, sleep disturbances, and reduced mobility [17,18,19]. Patients with altered cognition may have difficulty communicating about their pain and are often under-treated for pain [20]. Using non-verbal cues/assessments of pain [21, 22] are important to improve their pain control and remove barriers to patients’ participation in mobility activities. Nurses play a central role in managing pain, particularly in acute settings [12]. But pain management remains an important consideration throughout the recovery process and during rehabilitation as patients are much more likely to engage in mobility and rehabilitation activities when their pain is well-controlled. Nurses (and all members of the care team) who work outside of acute care settings, including the community, should continue to monitor pain to ensure it is not a barrier to rehabilitation progression.

Special consideration must also be given to those patients who present with cognitive impairment. The 3Ds that can affect patient rehabilitation and recovery are Dementia, Delirium, and Depression [23]. In particular, patients with pre-existing dementia or who present with delirium during their hospital stay represent up to 40% of patients who experience a hip fracture [24], but are often considered poor candidates for rehabilitation. They are less likely to be mobilized early after surgery, typically receive fewer rehabilitation services in hospital and are less frequently discharged to rehabilitation facilities [24]. Research evidence is limited in these patient sub-groups, as they are often excluded from clinical research studies and trials [25].

However, limited evidence supports that patients with cognitive impairment experience similar relative gains in function as those without cognitive impairment. An Advanced Nurse Practitioner-led interprofessional rehabilitation approach for patients with cognitive impairment recovering from hip fracture surgery demonstrated that patients who received the program were significantly more likely to return home than those who received usual care in a risk-adjusted model (p < 0.02) [26]. Adaptations to programs to engage patients with cognitive impairment in mobility include performing functional tasks of interest to the patient, such as ambulating or getting out of a chair rather than structured exercises [27]. Increasing the distance walked and the number of sit to stand activities performed over the day can help achieve progression in function and independence.

Patients who live in residential care settings at the time of the fracture represent the frailest sub-set of those experiencing fragility fracture and frequently present with concomitant cognitive impairment [28]. Even in this group, limited research suggests that patients experience at least short-term benefits from rehabilitation. An Australian randomized trial of 240 nursing home residents who received a 4-week rehabilitation program reported improved mobility at 4 months and better quality of life at 12 months [29]. A controlled trial in Canada reported sustained functional gains in mobility and ambulation at 12 months after a 10-week rehabilitation program delivered in the nursing home [30]. Further research is underway, but principles of mobility and rehabilitation should be applied to allow these fragile patients to try to regain their pre-fracture functional levels. (See Box 14.1 for issues to consider optimizing recovery).

Box 14.1 Issues Requiring Management to Optimize Rehabilitation and Recovery

  • Early engagement of patient and family to set goals for recovery and facilitate discharge planning

  • Nutrition (both in-hospital and at home) (Chap. 11)

  • Management and prevention of delirium (Chap. 12)

  • Pain management

  • Management of dementia and adaptation to include patients with altered cognition in rehabilitation

  • Progressive exercise and mobility, including physical activity (Chap. 8)

  • Falls prevention and appropriate use of assistive devices (Chap. 4)

  • Social support including community re-engagement where possible (Chap. 13)

  • Caregiver support (Chap. 16)

14.7 Case Application

Encouraging movement and physical activity after a fragility fracture is essential for continued recovery in terms of bone growth around the fracture, for keeping joints lubricated (decreasing stiffness), for maintaining and improving muscle strength, and for maintaining motor control and functional activities. In the home environment, there are several cues and tasks that can be easily added to a day to increase the total amount of physical activity. The following cases illustrate how this can be done.

Case 1: Mrs. Herrera

Mrs. Herrera is an 84-year-old woman who fell and fractured her hip and after her in-patient rehabilitation, now lives with her daughter. She is functionally independent in that she can get up from the chair or bed or toilet alone and walk within the home with a rollator, but she spends most of her day sitting in the living room. Both mother and daughter are fearful that she will fall and fracture again. The Rehab Team left exercises for her to perform but is not visiting the patient on a regular basis.

Consider:

How can the nurse help educate the patient and daughter and encourage a message of movement and activity?

Think of the normal full body activities that an older adult performs each day: rising from a bed/chair/toilet, walking from room to room, perhaps ascending and descending stairs, or walking outdoors. To encourage enough physical activity to achieve the physiologic goals mentioned above, one needs to build the physical activity around normal routine. Mrs. Herrera may get up in the morning, walk to the toilet, walk to the kitchen for breakfast, and then settle in a living room chair until lunch. To increase the number of times, she needs to move from the living room chair, the practitioner could try the techniques listed below. The key for all the suggestions is to make the initial opportunities successful, not associated with “exercise” or anything medical, and enjoyable.

  • Educate the daughter to encourage greater intake of liquids at meals (for increased trips to the toilet).

  • Designate a chair that is for “exercise”—firm seat and back and have Mrs. Herrera do some of the exercises.

  • Take her blood pressure in a different room than where she currently sits.

  • Educate the daughter to have Mrs. Herrera come to the kitchen table for tea or mid-morning snack or even medications if they don’t all have to be given at specific time.

  • Cue Mrs. Herrera and her daughter to stand up during commercials on TV or when a clock chimes.

  • Consider a short afternoon nap in the bedroom so that Mrs. Herrera has to get into and out of bed again, go to a different room, and stretch out. While in bed, she may be able to do a few bridging exercises or other exercises the Rehabilitation Team recommended.

  • Walking outdoors, initially accompanied by the daughter, should be promoted daily. Initially getting fresh air and sunlight can help motivate patients and continued performance can help it become a routine like it may have been prior to the fracture. Time or distance doesn’t need to be addressed initially, but if Mrs. Herrera had a neighbor to chat with or an animal to pet, it may help in the initial stages.

  • Music is a powerful motivator for movement. Playing Mrs. Herrera’s favorite music will likely get her moving in her chair and the ultimate goal would be for her to get out of the chair and begin dancing or moving. This activity may be a great precursor for walking outdoor.

Case 2: Miss Loke

Miss Loke is an 87-year-old woman who lived alone prior to falling and fracturing her hip. She has had rehabilitation and will remain in the residential facility since she has no one to help her at home. She can ambulate independently with a rollator, but the institution is very fearful of residents falling.

Consider:

The approach to promoting movement and physical activity with Miss Loke will vary slightly due to the environment. Many of the suggestions listed above for Mrs. Herrera could apply, in addition, consider:

  • Have her assist in the transport of a wheelchair bound resident to meals or activities.

  • Allow her to be a peer leader in activities that involve dance or movement or exercise.

  • Provide adequate seating in hallways, etc. so that if she will be encouraged to walk to all meals and activities. If she becomes tired, she could rest without worrying about finding a place to sit.

  • Encourage the development of a walking club for staff and residents.

Case 3: Mr. Sale

Mr. Sale is an 85-year-old man who lived in a care home prior to falling and fracturing his hip. He has pre-existing dementia requiring full time residential care but ambulated independently without aids before his fracture and required only stand by assistance to get out of bed. He is now 2-days postoperative but has not been mobilized as he has been very sleepy and non-communicative. His family thinks he just needs to rest and rehabilitation can start later.

Consider:

What should the care team do to increase the likelihood of Mr. Sale returning to independent ambulation?

  • It is not uncommon for people with dementia to also experience delirium postoperatively, which can present with hypo-activity. Assess his cognitive status for delirium (including asking family members about his pre-fracture cognitive status). If delirium seems present, assess for other reasons for delirium (dehydration, urinary retention/UTI, etc.) and treat as necessary.

  • Explain to the family how important it is for him to be awake during the day, and in upright positions to encourage alertness. Educate the family about the importance of early mobility, including walking, to enhance the likelihood of returning to independent ambulation. Discuss the harms of prolonged bed rest.

  • Turn the lights on in his room, sit him up in bed and when more alert, move Mr. B into a chair. Rather than explaining the whole process of the transfer for Mr. B, which is common practice for those without dementia to reduce their anxiety, use short 1-step instructions for Mr. B. Short-term memory loss is common with dementia, so although patients will not remember a 3-step command, they can follow a 1-step command. Tell Mr. B each step that is going to happen and then immediately perform that action.

  • If possible, try ambulating a short distance. Frequently, people with dementia will ambulate more readily post fracture than those without dementia as walking is a familiar activity and they may not remember that they have sustained a fracture.

  • Ensure that Mr. Sale sits in a chair for brief periods throughout the day, including for meals and continue daily ambulation, increasing the distance and reducing the assistance as able.

  • On discharge back to his nursing home, provide detailed instructions as to his current level of mobility and the need for this to continue so that Mr. B can return to independent ambulation.

Summary of Main Points for Learning

  • Decline in mobility after a fragility fracture is common and should be directly addressed by the Rehabilitation Team (rehabilitation nurse, physiotherapist, and/or occupational therapist).

  • Intentionally making exercises more difficult (progressive overload), choosing exercises and activities specific to the patient’s goals and functional level (specificity), and a targeted and concrete plan for continued activity and movement after discharge are all essential to return the patient to their pre-fracture functional level.

  • Patients with cognitive impairment should also receive rehabilitation postoperatively to increase their likelihood of returning to their pre-fracture functional status.

14.8 Suggested Further Study

Determine your team’s educational needs in terms of patient rehabilitation and consider how these needs might be addressed. Examples of educational resources include:

Cadel L, Kuluski K, Wodchis WP, Thavorn K, Guilcher SJT (2022) Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review. PLoS One. 17(8):e0273038.

Handoll HHG, Cameron ID, Mak JCS, Panagoda CE, Finnegan TP (2021) Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev. 11.

FFN Resources—https://fragilityfracturenetwork.org/ffn-resources/

Discuss with patients, caregivers, and other staff members the factors they believe can delay or enhance rehabilitation. Consider the implications of these ideas for patient-centered care aimed to rehabilitation and family participation.

14.9 How to Self-Assess Learning

Following reading this chapter and additional study, consider the following options for determining how what you have learned pertains to your individual practice and that of your team:

Discuss the knowledge you gained from this chapter with your colleagues and determine and discuss how your team could improve local patient rehabilitation practice.

Search regularly about recent new practices, guidance, knowledge, or evidence related to rehabilitation.

Meet with specialists and other team members to keep current on new evidence and disseminate it to colleagues.

Consult and be mentored by other expert clinicians.