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Original Investigation |

Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture:  A Randomized Clinical Trial

Nancy K. Latham, PhD, PT1; Bette Ann Harris, DPT, MS2; Jonathan F. Bean, MD, MPH3,4; Timothy Heeren, PhD1; Christine Goodyear, BS, PT5; Stacey Zawacki, DrPH, RD1; Diane M. Heislein, DPT, OCS1; Jabed Mustafa, MD1; Poonam Pardasaney, ScD, DPT6; Marie Giorgetti, PT, MS, NCS2; Nicole Holt, MPH4; Lori Goehring, BA1; Alan M. Jette, PhD, PT1
[+] Author Affiliations
1Boston University, Boston, Massachusetts
2MGH Institute of Health Professions, Boston, Massachusetts
3Harvard Medical School, Boston, Massachusetts
4Spaulding Rehabilitation Hospital, Boston, Massachusetts
5Spaulding Rehabilitation Network, Boston, Massachusetts
6RTI International, Boston, Massachusetts
JAMA. 2014;311(7):700-708. doi:10.1001/jama.2014.469.
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Importance  For many older people, long-term functional limitations persist after a hip fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established.

Objective  To determine whether a home exercise program with minimal contact with a physical therapist improved function after formal hip fracture rehabilitation ended.

Design, Setting, and Participants  Randomized clinical trial conducted from September 2008 to October 2012 in the homes of 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture.

Interventions  The intervention group (n = 120) received functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months. The attention control group (n = 112) received in-home and telephone-based cardiovascular nutrition education.

Main Outcomes and Measures  Physical function assessed at baseline, 6 months (ie, at completion of the intervention), and 9 months by blinded assessors. The primary outcome was change in function at 6 months measured by the Short Physical Performance Battery (SPPB; range 0-12, higher score indicates better function) and the Activity Measure for Post-Acute Care (AM-PAC) mobility and daily activity (range, 23-85 and 9-101, higher score indicates better function).

Results  Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed significant improvement relative to the control group (n=95) in functional mobility (mean SPPB scores for intervention group: 6.2 [SD, 2.7] at baseline, 7.2 [SD, 3] at 6 months; control group: 6.0 [SD, 2.8] at baseline, 6.2 [SD, 3] at 6 months; and between-group differences: 0.8 [95% CI, 0.4 to 1.2], P < .001; mean AM-PAC mobility scores for intervention group: 56.2 [SD, 7.3] at baseline, 58.1 [SD, 7.9] at 6 months; control group: 56 [SD, 7.1] at baseline, 56.6 [SD, 8.1] at 6 months; and between-group difference, 1.3 [95% CI, 0.2 to 2.4], P = .03; and mean AM-PAC daily activity scores for intervention group: 57.4 [SD, 13.7] at baseline, 61.3 [SD, 15.7] at 6 months; control group: 58.2 [SD, 15.2] at baseline, 58.6 [SD, 15.3] at 6 months; and between-group difference, 3.5 [95% CI, 0.9 to 6.0], P = .03). In multiple imputation analyses, between-group differences remained significant for SPPB and AM-PAC daily activity, but not for mobility. Significant between-group differences persisted at 9 months for all functional measures with and without imputation.

Conclusions and Relevance  Among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization. The clinical importance of these findings remains to be determined.

Trial Registration  clinicaltrials.gov Identifier: NCT00592813

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Figures

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Figure 1.
Patient Recruitment, Attrition, and Retention

Individuals who missed the 6-month assessment were still eligible to attend the 9-month assessment. There were 172 individuals who completed both the 6- and 9-month assessments, 20 completed only the 6-month assessment, and 7 completed only the 9-month assessment.

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Figure 2.
Changes in Functional Measures Over Time

The top whisker indicates the maximum value; the bottom whisker, the minimum value; the top of the box, 75th percentile; the bottom of the box, 25th percentile; horizontal line inside the box, median; and circle, mean.

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