By Sylviane Duval, contributing writer
Older women who receive rehabilitation services after hip surgery from a variety of health care professionals as inpatients are slightly more likely to do better than those who receive usual hospital care are, according to a review in the most recent issue of The Cochrane Library. The authors suggest that such multidisciplinary rehabilitation also might help if applied in patient or caregiver homes.
“Because hip fracture is so common, the possible improvement for these 10% of patients represents a large number of people,” said review co-author Ian Cameron, PhD, at the University of Sydney, Sydney, Australia. “The trend towards better functioning for people who had rehab is most important, especially since older people fear disability as a result of hip fracture.”
The Cochrane Library is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The authors analyzed 13 studies conducted in Australia, Canada, Spain, Sweden, Taiwan, and the UK involving 2,498 senior—mostly female—patients who had undergone surgery following hip fracture.
In 11 studies where care was mainly in-hospital or inpatient and the authors were better able to pool the statistics, they found a marginal improvement in the death rate, hospital readmissions, and number of people able to stay in their homes — instead of being placed in institutions — between the groups receiving multidisciplinary rehab versus those receiving usual care. The data at least do confirm that multidisciplinary rehab does no harm.
According to the American Academy of Orthopaedic Surgeons, 350,000 hospital admissions each year and 60,000 nursing home admissions are the result of hip fractures. Over 4% of these patients die during their initial hospitalization; 24% die within a year, and 50% never walk again.
Generally, hip rehab involves a wide range of treatments in a hospital ward under the supervision of orthopedic staff. Some treatments aim to restore mobility and the ability to perform basic tasks such as dressing and bathing independently. Occasionally, help from geriatricians, physiotherapists, and other health professionals supplements these programs. Often, family and caregivers are involved. The level of rehab depends greatly on the patient’s health and, because of this, can take place in a hospital setting or externally.
For this review, the authors defined multidisciplinary rehab as that delivered by a multidisciplinary team supervised by a geriatrician or rehab physician. Since “usual care” varied so widely among the studies, the authors were only able to define it as orthopedic or medical care of lesser intensity or with different components than multidisciplinary rehab.
The disparity of the data collected in the individual studies, such as the age gap between patients, the definition of usual care, and the duration of hospital stay, did not allow the authors to pool all of the findings. Such variations precluded the authors from stating conclusively that multidisciplinary rehab— in-hospital or out—after hip surgery is beneficial, although slight tendencies do point in that direction.
“Because a broad range of treatments were applied in diverse settings to patients in different states of health, an effective treatment can be lost in the mix,” said Karim Khan, MD, Centre for Hip Health and Mobility, Vancouver, British Columbia.
For instance, said Khan, who had no connection with the review, clinicians rarely employed resistance-training programs to prevent subsequent falls in this population until very recently. “The authors prove convincingly that a ‘shotgun approach’ will not prevent death or deterioration of function leading to increased dependency or institutional care. As is often the case with a complex medical condition such as fall-related hip fracture, there is no magic bullet.”
The authors found inconclusive evidence from three studies that multidisciplinary rehab does not place an extra burden on caregivers. In fact, in the only study that compared home-based multidisciplinary rehab with usual inpatient rehab, caregivers of the home-based patients reported a significantly lower long-term burden — even though the duration of the rehab was longer.
Another study showed that doubling the number of weekly home-based rehab visits had no effect on patients’ eventual mobility.
The authors say that the limitations of the findings are partly because of the difference in populations studied and the fact that the studies do not represent some patient groups fully, such as those with dementia or those living in nursing homes. Khan said that well over half of all people who have hip fractures have cognitive impairment — dementia and pre-dementia — which can have a big effect on outcome and compliance with rehabilitation.
Handoll HHG, et al. Multidisciplinary rehabilitation for older people with hip fractures. The Cochrane Database of Systematic Reviews 2009, Issue 4.
[Source: Health Behavior News Service]
