Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: A randomised controlled trial

Abstract

Question: Is acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up compared to physiotherapy without strength training in patients with a hip fracture?

Design: Assessor blinded, randomised controlled trial with intention-to-treat analysis.

Participants: 90 patients with a hip fracture admitted to an acute orthopaedic Hip Fracture Unit at a university hospital between October 2013 and May 2015.

Intervention: Daily physiotherapy with or without progressive knee-extension strength training (10RM), 3 x 10 repetitions, of the fractured limb using ankle weight cuffs conducted by ward physical therapists during hospital stay.

Outcome measures: Primary outcome was the change in maximal isometric knee-extension strength in the fractured limb in percentage of the non-fractured limb from inclusion to postoperative day 10 or discharge (follow-up). Secondary outcome was Timed Up and Go test measured early after surgery and at follow-up.

Results: In the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1% (95% CI -2.3; 18.4) by additional strength training from baseline to follow-up. In the per-protocol analysis of non-missing data, significant between-group improvements by 10.5% (95% CI 0.3; 20.7) were found in favour of additional ST. No significant between-group differences were found in any secondary outcome.

Conclusion: Physiotherapy with addition of 5 sessions of ST yielded no additional improvements compared to physiotherapy without strength training in reducing the knee-extension strength deficit at follow-up in patients with a hip fracture. It is debatable whether larger improvements than the observed 8-10% can be expected given that only five exercise sessions, on average, were completed. In fragile patients with a hip fracture in the acute phase, where the ability to participate in functional exercise is compromised, we still consider early strength training a possibility to improve outcomes of clinical importance, given the results of the per-protocol analysis. The present data provides an important basis and call for future investigations including longer term interventions.

Trial registration: Clinicaltrials.gov NCT00848913.

Fig 1. CONSORT flow diagram.

ST = strength training group, PT = physiotherapy group.

Fig 2. Mean (SD) weight load (kg) applied at first and last strength training session.

Fig 3. Percentage of patients with hip fracture-related pain recorded at rest and during strength training (ST) by Verbal Ranking Scale (None to intolerable pain).

Fig 4. Mean (SD) fractured limb strength (MVT, Nm/kg) in percentage of the non-fractured limb for strength training group (ST group) and physiotherapy group (PT group).

Fig 5. Change in the primary outcome (MVT Nm/kg), fractured limb in percentage of non-fractured from baseline to follow-up, with (ST) or without (PT) strength training.