review article home-based multidisciplinary rehabilitation

Hindawi Publishing CorporationRehabilitation Research and PracticeVolume 2013, Article ID 875968, 10 pageshttp://dx.doi.org/10.1155/2013/875968

Review ArticleHome-Based Multidisciplinary Rehabilitation following HipFracture Surgery: What Is the Evidence?

Kathleen Donohue,1 Richelle Hoevenaars,1 Jocelyn McEachern,1

Erica Zeman,1 and Saurabh Mehta2

1 School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada L8S 1C72 School of Physical Therapy, Marshall University, 2847 5th Avenue, Huntington, WV 25705, USA

Correspondence should be addressed to Saurabh Mehta; [email protected]

Received 30 July 2013; Revised 2 October 2013; Accepted 14 October 2013

Academic Editor: Eva Widerstrom-Noga

Copyright © 2013 Kathleen Donohue et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Objective. To determine the effects of multidisciplinary home rehabilitation (MHR) on functional and quality of life (QOL)outcomes following hip fracture surgery. Methods. Systematic review methodology suggested by Cochrane Collboration wasadopted. Reviewers independently searched the literature, selected the studies, extracted data, and performed critical appraisalof studies. Summary of the results of included studies was provided. Results. Five studies were included. Over the short-term,functional status and lower extremity strength were better in the MHR group compared to the no treatment group (NT). Overthe long-term, theMHR group showed greater improvements in balance confidence, functional status, and lower extremity musclestrength compared toNTgroup,whereas the effect onQOLandmobilitywas inconsistent across the studies. Severalmethodologicalissues related to study design were noted across the studies. Conclusion. The MHR was found to be more effective compared to theNT in improving functional status and lower extremity strength in patients with hip fracture surgery. Results of this review do notmake a strong case for MHR due to high risk of bias in the included studies. Further research is required to accurately characterizethe types of disciplines involved in MHR and frequency and dosage of intervention.

1. Introduction

Hip fracture is common across all age groups but is morecommon in older adults. Most hip fractures are treatedsurgically [1]. Hip fractures place tremendous burden onhealth care systems [2, 3]. Individuals with hip fractureshave increasedmortality, long-term disability, and functionaldependence since most older adults do not attain pre-injuryfunctional levels [4]. Moreover, impairment in quality of life(QOL), psychological and social domains, and fall relatedefficacy are also reported following a hip fracture [5, 6].Specific interventions have been designed to reduce theimpact of hip fracture on these domains. The components ofan intervention depend on targeted outcome.

Individuals with hip fracture consider increase in mobil-ity and functions to be the preferred outcomes when askedabout their recovery expectations following hip fracture [7].Postsurgical rehabilitation programs aim to reduce disability

and improve mobility, functions, balance, strength and QOLfollowing hip fracture [8]. They are implemented in varietyof settings such as inpatient, outpatient, or home-basedrehabilitation. Posthip fracture rehabilitation may involvemultidisciplinary care, which includes services provided bymultiple health disciplines such as physiotherapy (PT), occu-pational therapy (OT), nursing, social work, and dieteticsunder the supervision of a geriatrician or rehabilitationphysician. Previous systematic reviews have indicated thatmultidisciplinary rehabilitation leads to superior outcomes inindividuals following hip fracture surgery [8–10].

While there is evidence to believe that multidisciplinaryrehabilitation is effective in individuals following hip fracturesurgery, whether the recovery patterns differ depending onthe setting (inpatient, outpatient, or home) in which it isprovided is yet to be determined. Literature thus far haslargely focused on examining the benefits of multidisci-plinary rehabilitation rather than specifically investigating

2 Rehabilitation Research and Practice

the influence of treatment setting in which such rehabil-itation is delivered. Home-based rehabilitation presents aviable option compared to rehabilitation services deliveredin inpatient or outpatient rehabilitation setting. Home-basedrehabilitation typically occurs when a patient is dischargedfrom an inpatient setting (acute care or subacute rehabilita-tion) and receives further rehabilitation at home to maintaincontinuum of care. Home-based rehabilitation programsfacilitate early discharge from hospital, thereby reducing thefinancial burden associated with hip fractures. They are alsosafe and efficient in managing individuals following hip frac-tures [11]. Some of the previous studies have demonstratedthat home-based rehabilitation improves physical function,health related quality of life (HRQOL), and balance confi-dence [11, 12]. However, these studies largely incorporate onlyPT services where the intervention is notmultidisciplinary innature. With distinct advantages of managing individuals intheir home setting, it is important to examine the benefits ofmultidisciplinary home rehabilitation (MHR). In particular, acomprehensive reviewof literature to assess the effect ofMHRon functions, mobility, balance, and HRQOL can facilitateunderstanding of appropriate discharge setting following hipfracture surgery.

The purpose of this study was to conduct a systematicreview of randomized control trials (RCTs) to determinethe effects of MHR on outcomes such as functional status,HRQOL, mobility, lower limb muscle strength, and balancefollowing hip fracture surgery.

2. Methods

2.1. Criteria for including Studies. This review considered allparallel RCTs comparing MHR to inpatient, outpatient, orno treatment (NT) in patients following hip fracture surgery.We defined NT as the groups of patients who receivedconventional acute postsurgical care in hospital and wassent home with no further rehabilitation. In contrast, theinpatient and outpatient groups received multidisciplinaryrehabilitation in inpatient and outpatient setting, respectively,following conventional acute care. The home-based groupreceived multidisciplinary rehabilitation at home followingtheir stay in acute care. Functional status, HRQOL, andbalance confidence were the patient reported outcomes con-sidered for this review. Physical mobility, functional status,lower limb strength, ambulation ability, and balance were theperformance-based outcomes considered for the review.

Only RCTs in which one of the groups received MHRfollowing hip fracture surgery were included. Prospectivecohort and case-control studies were excluded from thereview. Studies with patient groups other than those with hipfracture surgery, those with cost comparison as the primaryoutcome, or those with single-discipline home-based rehabil-itation as the experimental group were also excluded. Trialslooking at the effectiveness of multidisciplinary inpatientrehabilitation and those that examined the benefits of home-based physiotherapy alone were also excluded. Studies whichexamined the effects of MHR after elective hip surgery (suchas total hip arthroplasty) were also excluded.

2.2. Search Techniques for Identifying Relevant Studies. Acomprehensive literature search was performed on multipledatabases to identify studies relevant to this review. Fourstudent investigators (Kathleen Donohue, Richelle Hoeve-naars, Jocelyn McEachern, and Erica Zeman) agreed uponthe search terms to be used in each of the databases a priori.Two reviewers (Kathleen Donohue and Richelle Hoevenaars)performed the searches on the Ovid MEDLINE, EMBASE,PubMed, Cochrane Central Register of Controlled Trials,PEDro, CINHAL, and REHABDATA databases in isolation.ProceedingsFirst was searched to identify any relevant con-ferences and workshops abstracts suitable for this review.Relevant masters and/or doctoral theses were searched onProQuest Dissertations and Thesis. The reference lists ofrelevant studies and systematic reviews were also searchedand studies that appeared relevant in these lists were included.

2.3. Data Collection and Analysis

2.3.1. Selection of Studies. The citations obtained from thesearch were screened by two independent reviewers (JocelynMcEachern and Erica Zeman). A final list of eligible studieswas prepared for full text review. Disagreements between thereviewers were resolved by discussion to reach a consensus.Agreement between the reviewers was assessed by examiningunweighted kappa (𝜅).

2.3.2. Data Extraction andManagement. Data extraction wasperformed independently by two reviewers (JocelynMcEach-ern and Erica Zeman). Both reviewers were in the finalyear of their entry-level physiotherapy program at McMasterUniversity, Hamilton, Canada. A standardized data collectionform was generated for this study. Descriptive data regardingnumber of participants, their age and sex, and the studysetting were extracted. Methodology regarding generation ofrandomization sequence, allocation concealment, blinding,and completeness of outcome data were extracted to gaugethe risk of bias [13]. Information related to the interventionsuch as types of rehabilitation, frequency of visits, andduration of treatments was also extracted.

2.3.3. Assessment of Risk of Bias. An assessment of the risk ofbias in the included studies was completed. Bias was definedas a systematic error in the truth of results or inferences[13]. A domain-based evaluation was used for the risk of biasassessment. The domains included were, random sequencegeneration, allocation concealment, blinding of outcomeassessment and incomplete outcome data.

2.3.4. Measurement of Treatment Effect. The outcomes weredivided and examined as being short-term (the first fourmonths) and long-term (12 months) in order to avoid theunit of analysis issues while performing analysis [14]. We hadplanned to examine standardized mean differences for all theoutcomes (patient reported and performance-based) if thedata across the included studies was deemed to be suitablefor pooling. However, we chose to provide the summary ofresults and provide point estimates of treatment effects given

Rehabilitation Research and Practice 3

that themeta-analysis was not feasible due to heterogeneity inthe study design, participants, outcomes, interventions, anddata reporting.

2.3.5. Assessment of Reporting Biases. To determine anyinfluence on the nature or direction of results, reportingbiases were assessed [15]. A funnel plot to assess publicationbias could not be plotted since only five studies were includedin this review. We used comprehensive search including greyliterature such as conference proceedings, dissertations, andmaster and doctoral theses to ensure that the possibility of thepublication bias was minimized. Citation bias was limited asbibliographies of relevant systematic reviews were searched.Location and language biases were minimized by avoidinglocation and language limitations for the literature search.

2.3.6. Subgroup Analysis and Investigation of Heterogeneity.Due to the nature and intensity of the multidisciplinaryrehabilitation provided in different settings, we did not findit appropriate to combine the results and assess the treatmenteffect of MHR versus other comparison groups combinedtogether. Rather, we opted to create subgroups and assess thetreatment effect of the MHR (MHR versus institution-basedrehabilitation and MHR versus NT).

Sensitivity Analysis was not required since no data impu-tations were done.

3. Results

The literature search strategies are outlined in Figure 1. Thepreliminary search identified 2987 citations. Twenty-twostudies were selected for full text review. Five studies metthe predefined inclusion/exclusion criteria and were chosenfor this review. The process used to identify and select thestudies used in this review is depicted in a flow diagramin Table 1. The raw agreement between two independentreviewers (Jocelyn McEachern & Erica Zeman) for inclusionof studies in this review was 86% with an unweighted 𝜅 of0.73, which is considered acceptable [16].

3.1. Description of Included Studies. Of the five studiesincluded, two were conducted in Sweden [17, 18], two in Aus-tralia [11, 19], and one in Hong Kong [20]. Comparator groupwas inpatient hospital-based setting in one [20] andNT in theother four studies [11, 17–19].The treatment groups within allstudies were discharged from inpatient hospital care to homewhere they received MHR. The number and disciplines thatcomposed the multidisciplinary rehabilitation team variedbetween studies but all of them included physiotherapy (PT).The follow-up period varied between 1 month and 12 monthsbetween studies. A detailed description and characteristics ofall included studies are expressed in Table 1.

3.2. Description of Excluded Studies. Nineteen studies wereexcluded after full text review.The reasons for exclusion werethat the intervention was not provided by a multidisciplinaryteam (𝑛 = 11), participants had elective hip replacementsurgery (𝑛 = 3), comparator group of interest was lacking

Articles identified on preliminary search

N = 2987

Reasons: not treatment of interest, not comparison of interest, not hip fracture surgery, and not RCTs

Potentially relevant articlesN = 1389

Duplicates (exact and close match) removed

N = 1598

Studies included for the full-text review N = 22

Studies included in the review N = 5

Studies excluded after full-text review N = 19

Excluded N = 1367

Figure 1: Flow Diagram.

(treatment and control group both had home-based inter-vention) (𝑛 = 2), treatment group did not have home-basedintervention (𝑛 = 1), there was no RCT design (𝑛 = 1). Arecent study conducted by Tseng et al. [21] was also excludedafter careful review. The objective of their study was toassess the effects of interdisciplinary intervention on differenttrajectories of recovery (poor, moderate, and excellent) inindividuals with hip fractures and not necessarily provide adirect comparison between the MHR group and the usualcare group.

3.3. Risk of Bias in Included Studies. The agreement betweenreviewers for assessing the risk of bias was substantial, withan unweighted 𝜅 of 0.70 and a raw agreement of 84% [16].Table 2 summarizes risk of bias assessment for the includedstudies.

Despite the assumption that the original and follow-uparticles would have identical protocols, the risk of bias in theincluded studies was assessed for Crotty et al. [11, 19] studiesas well as the Ziden et al. [17, 18] with both the pairs reportingshort-term and long-term results of their respective projects.This is because some of the aspects of the publication such asthe blinding of outcomes assessors at different time points,incomplete outcome data reporting, and selective outcomereporting could be different for the same study for whichthe results were reported in two separate publications. WhileCrotty et al. [19] had very low risk of bias, their earlierpublication [11] had risk of bias due to inadequate details ofallocation concealment and incomplete data reporting. The

4 Rehabilitation Research and PracticeTa

ble1:Ch

aracteris

ticso

fthe

Inclu

dedStud

ies.

Stud

yMetho

dParticipants

Interventio

nOutcomes

Results

Kuism

a[20]

Parallelgroup

rand

omized

controlledequivalencetria

l;MHRversus

inpatie

ntrehabilitation

(i)𝑁=81(40in

theM

HR

grou

pand41

inthe

inpatie

ntgrou

p);

(ii)L

ocation—

Hon

gKo

ng;

(iii)Inclu

sion/exclu

sion

criteria

specified—partially;

(iv)A

ge(y)—75±8.3for

both

grou

ps;

(v)S

ex—49

females

(60%

)and32

males

(40%

);(vi)Durationsin

cehip

fracture

orsurgery—

not

repo

rted;

(vii)

Com

orbiditie

srepo

rted—no

MHRgrou

p(i)

Nodescrip

tionprovided

forthe

nature

ofexercises.

(ii)A

verage

of4.6±2.2PT

visitsa

ndaverageo

f1.5±0.6commun

itynu

rse

visits.

Inpa

tient

grou

p(i)

Nodescrip

tionprovided

forthe

nature

ofexercises.

(ii)A

verage

stayin

rehabilitationho

spita

lwas

36.2±14.6days

with

daily

PTvisits.

PRO

Non

eused

PBO

Ambu

latory

capacity

Measuredacrossfive

categorie

s:commun

ityam

bulatory,hou

se-hold

ambu

latory,w

alking

onflat

surfa

ce,transferfrom

bed

tochair,bedto

chair

boun

d.(scorin

g:4=

independ

entw

ithou

taids,3

=independ

entw

ithaids,2

=ableto

walkwith

minim

umassistance/supervision

,1=

ableto

walkwith

maxim

umassistance,0=un

ableto

walk)

(i)Lo

stto

follo

wup

was

9in

theM

HRgrou

pand16

intheinp

atient

grou

p.Ca

uses

ofattrition

weren

otprovided.

(ii)A

dverse

eventsno

trepo

rted.

(iii)Com

mun

ityam

bulatory

abilitywas

bette

rintheM

HRgrou

p.Flat-le

velambu

latory

abilitywas

similarinbo

ththeg

roup

s.

Crotty

etal.[11]

Parallelgroup

rand

omized


l;MHRversus

NT

(i)𝑁=66(34in

theM

HR

grou

pand32

intheN

Tgrou

p;(ii)L

ocation—

Australia;

(iii)Inclu

sion/exclu

sion

criteria

specified—yes;

(iv)A

ge(y)—

median81.6

(IQR:

78.2,85.4)

inthe

MHRgrou

pandmedian

83.5(IQ

R:76.6–85.5)

inthe

NTgrou

p;(v)S

ex—21

females

(62%

)in

theM

HRgrou

pand24

females

(75%

)inNTgrou

p;(vi)Av

eraged

urationsin

cesurgery—

notreported;

(vii)

Com

orbiditie

srepo

rted—no

MHRgrou

p(i)

Hom

evisittoorganize

mod

ificatio

nsandinsta

llequipm

entp

riorto

discharge.

(ii)V

isitedby

therapists

(team

coordinator,PT

,OT,

SLP,SW

,and

therapyaid)

with

in48

hourso

fdischarge.

(iii)Frequencyof

therapy

was

tailo

redfor

individu

alized

needs.

Structured

practic

esessio

nsencouraged

betweenvisits.

(iv)S

ervicessuchas

podiatry,nursin

gcare

and

assistancew

ithlight

domestic

tasksw

ere

provided

asrequ

ired.

NTgrou

p:Re

ceived

routineh

ospital

care:inp

atient

services

and

thed

evelo

pmento

fcare

pathwaysa

nddischarge

planning

.

PRO

BalanceC

onfid

ence

ABC

Scale

Functio

nalStatus

(i)MBI

(ii)L

HS

HRQ

OL

(i)LH

S(ii)S

F-36

(PCS

andMCS

)PB

OBa

lance

BBS

Physica

lmobility

TUG

Falls

Frequencyof

falls

andfalls

thatrequ

ireho

spita

lization

(i)Attrition

orcauses

ofattrition

weren

otspecified.

(ii)A

dverse

eventsweren

otrepo

rted.

(iii)Patie

ntsintheM

HR

grou

pdidno

tsho

wim

provem

entinph

ysical

health

butreported

improvem

entinADL.

(iv)M

HRgrou

palso

had

greaterc

onfid

ence

inavoiding

falls

atfour

mon

ths.


Table1:Con

tinued.

Stud

yMetho

dParticipants

Interventio

nOutcomes

Results

Zidenet

al.[17]

Parallelgroup

rand

omized


l;MHRversus

NT

(i)𝑁=102(48in

MHR

grou

pand54

inNTgrou

p);

(ii)L

ocation—

Sweden;

(iii)Inclu

sion/exclu

sion

criteria

specified—yes

(iv)A

ge(y)—81.2±5.9in

MHRgrou

pand82.5±7.6

inNTgrou

p;(v)S

ex—29

females

(60.4%

)intheM

HRgrou

pand42

females

(77.8

%)in

theN

Tgrou

p;(vi)Com

orbiditie

srepo

rted—yes.

MHRgrou

p(i)

Threew

eeks

ofrehabilitationthatinclu

ded

PTto

encourage

self-effi

cacy

andOTto

encouragea

ctivity

and

independ

ence

inADL.

(ii)P

artic

ipantsreceived

ameanof

4.9(±0.4)

multip

rofessionalh

ome

visits;2.4PT

(±1.7

)and

1.6OT(±1.7

)visits.

(iii)Ev

eryfourth

patie

ntreceived

avisitb

yan

urse.

NTgrou

pNoadditio

naltreatment

after

beingdischarged

from

hospita

l.

PRO

BalanceC

onfid

ence

Swedish

versionof

theF

ES(S)

Functio

nalStatus

(i)FIM

motor

scale

(ii)Instrum

entalA

ctivity

Measure

(measuresd

egree

ofindepend

ence

ineight

advanced

activ

ities)

(iii)Frenchay’sAc

tivity

Index(determines

the

frequ

ency

ofperfo

rming

socialandcomplex

daily

activ

ities)

PBO

Physica

lMobility

TUG

Lowe

rExtremity

Strength

STStest

(i)Lo

stto

follo

wup

was

6in

theM

HRgrou

p;causes

ofattrition

werep

rovided.

(ii)N

oadversee

ventsw

ere

repo

rted

(iii)Th

eMHRgrou

pshow

edsig

nificant

improvem

entson

theF

ES,

TUG,STS

,FIM

,Instr

umentalA

ctivity

Measure,and

the

Frenchay’sAc

tivity

Index

onem

onth

after

discharge

comparedto

theN

Tgrou

p.

Zidenet

al.[18]

Parallelgroup

rand

omized


l;MHRversus

NT

(i)𝑁=102(48in

theM

HR

grou

p,54

intheN

Tgrou

p);

(ii)L

ocation—

Sweden;

(iii)Inclu

sion/exclu

sion

criteria

specified—partially;

(iv)A

ge(y)—81.2±5.9in

MHRgrou

pand82.5±7.6

inNTgrou

p;(v)S

ex—29

females

(60.4%

)intheM

HRgrou

pand42

females

(77.8

%)

females

intheN

Tgrou

p;(vi)Av

eraged

urationsin

cesurgery—

notreported;

(vii)

Com

orbiditie

srepo

rted—yes

MHRgrou

p(i)

Threew

eeks

ofrehabilitationthatinclu

ded

PTto

encourage

self-effi

cacy

andOTto

encouragea

ctivity

and

independ

ence

inADL.

(ii)M

edianof

visits4

.5(w

ithmedianof

3PT

visits

and1.5

OTvisits,11patie

nts

werev

isitedby

anurse).

NTgrou

pNoadditio

naltreatment

after

beingdischarged

from

hospita

l.

PRO

BalanceC

onfid

ence

FES(S)

Functio

nalStatus

(i)FIM

(ii)Instrum

entalA

ctivity

Measure

(iii)Frenchay’sAc

tivity

Index

HRQ

OL

SF-36

Mood

Centre

forE

pidemiological

Stud

iesD

epressionScale

(screening

instr

umentto

measure

depressiv

esymptom

s)PB

OPh

ysica

lMobility

TUG

Lowe

rExtremity

Strength

STS

(i)One

participantinthe

MHRgrou

pand3in

the

NTgrou

pwerelostat

6-mon

thfollo

wup

;additio

nal3

participantsin

theM

HRgrou

pand4

participantsin

theN

Tgrou

pwerelosttofollo

wup

at1-y

ear(reason

sfor

attrition

werep

rovided).

(ii)Th

eMHRgrou

phad

greaterb

alance

confi

dence

andph

ysicalfunctio

nthan

theN

Tgrou

pover

1year

perio

daft

erhipfracture.

(iii)One

year

after

discharge2

9%of

thep

eople

intheM

HRgrou

pconsidered

them

selves

fully

recovered,comparedto

only9%

intheN

Tgrou

p.


Table1:Con

tinued.

Stud

yMetho

dParticipants

Interventio

nOutcomes

Results

Crotty

etal.

[19]

Parallelgroup

rand

omized


l;MHRversus

NT

(i)𝑁=56(not

clear

abou

tho

wmanyin

each

grou

p);

(ii)L

ocation—

Australia;

(iii)Inclu

sion/exclu

sion

criteria

specified—yes

(iv)A

ge(y)—

meanof

81.8±7.2forb

othgrou

pscombined;

(v)S

ex—41

(73%

)fem

ales

forb

othgrou

pscombined;

(vi)Av

eraged

urationsin

cesurgery—

notreported;

(vii)

Com

orbiditie

srepo

rted—no

.

MHRgrou

p(i)

Hom

evisitsby

PT,O

T,SLP,SW

,and

therapyaides.

(ii)S

ervicessuchas

podiatry,nursin

gcare,and

assistancew

ithlight

domestic

tasksw

ere

provided

asrequ

ired.

NTgrou

p:Re

ceived

routineh

ospital

care,inp

atient

services,

developm

ento

fcare

pathways,anddischarge

planning

.

PRO

Functio

nalStatus

Mod

ified

BarthelInd

exHRQ

OL

SF-36(M

CS&PC

S)PB

OPh

ysica

lMobility

TUG

(i)Tenpatie

ntsu

navailable

for12-mon

thfollo

wup

(reasons

fora

ttrition

were

provided).

(ii)A

t12mon

ths,there

weren

odifferences

betweentheg

roup

sfor

scores

ontheM

BI,T

UG,or

SF-36ou

tcom

es(PCS

and

MCS

).

MHR:

multid

isciplin

aryho

merehabilitation;

IQR:

interquartile

range;NT:

notre

atment;PT

:physio

therapist;O

T:occupatio

naltherapist;

SLP:

speech

lang

uage

pathologist;SW:socialw

orker;ADL:

activ

ities

ofdaily

living;PR

O:patient-reportedou

tcom

e;PB

O:perform

ance-based

outcom

es;A

BC:activity

-specific

balancec

onfid

ence

scale;MBI:M

odified

BarthelInd

ex;LHS:Lo

ndon

HandicapScale;SF-36:Sh

ort-F

orm-

36;P

CS:physic

alcompo

nent

summary;MCS

:mentalcom

ponent

summary;BB

S:Be

rgbalances

cale;T

UG:tim

edup

andgo

test;

FES:falls

efficacy

scale;FIM:fun

ctionalind

ependent

measure;STS

:sit-to-stand

.


Table 2: Risk of bias assessment of included studies (Yes—No risk of bias, No—clear risk of bias, Unclear—indicates that risk of bias isunclear).

Random sequencegeneration

(selection bias)

Allocationconcealment(selection bias)

Blinding of outcomeassessment (detection

bias)

Incompleteoutcome data(attrition bias)

Selectivereporting

(reporting bias)Crotty et al. 2002 [11] Yes Unclear Yes Unclear YesCrotty et al. 2003 [19] Yes Yes Yes Yes YesKuisma 2002 [20] Unclear Yes Yes No NoZiden et al. 2008 [17] Unclear Yes No Yes YesZiden et al. 2010 [18] Unclear Yes No Yes Yes

overall risk of bias was low in one study [19], unclear in threestudies [11, 17, 18], and high in one study [20].

3.4. Effects of Interventions. After comparing the results ofoutcomes reported either on the same scale or across differentscales that measure the same construct, it was determinedthat pooling the results was not possible or appropriate.Therefore, a narrative summary of results was provided forshort- and long-term time frames. The study by Kuisma [20]is being excluded from the following summary of results dueto high risk of bias and lack of reporting of outcomes ofinterest.

3.4.1. Patient Reported Balance Confidence. The effect ofMHR on balance confidence over short-term was inconsis-tent across two studies [11, 17]. Crotty et al. [11] assessedbalance confidence using the Activity Specific Balance Con-fidence (ABC) Scale and the FES. No significant differenceswere reported between the MHR group and the NT groupon the ABC scale at 4 months (MHR median: 61.3, IQR:45.5, 75.2; NT median: 53.3, IQR: 26.8, 74.6; 𝑃 > 0.05);significant improvements in the FES scores were reported(MHR median: 90.5, IQR: 80.5, 98.0; NT median: 79.5, IQR:40.0, 92.5; 𝑃 < 0.05). Ziden et al. [17] measured patientreported balance confidence using the FES and found that theindividuals in MHR group had increased balance confidencecompared to those of the NT group at one-month followup(MHRmean (SD): 30.6 (19.3), NTmean (SD): 13.5 (20.9), and𝑃 = 0.0004).

Only Ziden et al. [18] measured patient reported balanceconfidence using the FES in the long-term (1 year afterdischarge). The FES scores indicated significantly higherbalance confidence inMHRgroup compared to theNTgroup(MHR median (min-max): 128 (61–130); NT median (min-max): 102 (13–130); 𝑃 < 0.001).

3.4.2. Patient Reported Functional Status. The effect of MHRon functional status over short-term was also inconsistentacross two studies [11, 17]. Crotty et al. [11] found no differencein functional status between theMHR and theNT groups at 4months as measured by the London Handicap scores (MHRmedian: 0.70, IQR: 0.63,0.77; NT median: 0.65, IQR: 0.58,0.73; 𝑃 > 0.05). Ziden et al. [17] measured patient reportedfunctional status using Frenchay’s Activity (FAI). The resultsindicated that the scores on the FAI domestic activities

subscale were significantly higher in the MHR group (MHRmean (SD): 9.0 (5.0); NT mean (SD): 6.4 (5.3); 𝑃 = 0.0119).Similarly, the scores on the outdoor activities subscale werealso significantly higher in theMHRgroup (MHRmean (SD):5.7 (4.8); NT mean (SD): 2.7 (3.8); 𝑃 = 0.0007). However, thescores on the leisure and work activity subscale did not differbetween the groups at the one-month followup (MHR mean(SD): 3.4 (2.3); NT mean (SD): 2.6 (2.3); 𝑃 = 0.1057).

3.4.3. Patient Reported Functional Status (Long-Term). Zidenet al. [18] evaluated functional status using the FAI in thelong-term (1 year after discharge). Significantly higher scoresin favour of the MHR group were found (𝑃 = 0.028) at 12months (MHR median: (min-max), 27 (0–40); NT median:(min-max) 20 (0–42)).

3.4.4. Patient Reported QOL (Short-Term). Crotty et al. [11]evaluatedQOL at 4months using the LondonHandicap Scaleand the SF-36 and found no significant differences betweengroups. (London Handicap Scale (MHRmean (95% CI): 0.70(0.63–0.77), NT mean (95% CI): 0.65 (0.58–0.73); SF-36 onboth the PCS component (NT mean (95% CI): 26.9 (10.2–42.0), MHR mean (95% CI): 38.3 (27.9–48.7), 𝑃 > 0.05) andthe MCS component (NT mean (95% CI): 42.8 (31.2–54.4);MHR mean (95% CI): 46.4 (36.2–56.6); 𝑃 > 0.05).

Crotty et al. [19] and Ziden et al. [18] evaluated QOL overa longer term using SF-36. The effect of MHR on QOL wasinconsistent across both studies. Crotty et al. [19] found nosignificant differences between groups on the SF-36 for boththe PCS component (mean difference (95% CI): −2.3(−7.6–3.0), 𝑃 = 0.386) and the MCS component (mean difference(95%CI): 0.7 (−3.8–5.3);𝑃 = 0.733). Ziden et al. [18] reporteda significant improvement in the SF-36 domains of physicalfunctioning (𝑃 = 0.001) and bodily pain (𝑃 = 0.042) in theMHR group at one-year followup.

3.4.5. Mobility. The effect of MHR on mobility as assessedby the timed up and go (TUG) over a short-term periodwas inconsistent across two studies [11, 17]. Crotty et al. [11]found no significant difference in TUG scores at four monthsbetween the MHR and the NT groups (MHR median: 23.0,IQR: 15.3, 33.0; NTmedian: 28.0, IQR: 18.0, 42.5). In contrast,Ziden et al. [17] found significant differences in the TUGscores in favor of the MHR group compared to the NT group


at one month (MRR mean (SD): 24.9 (15.4); NT mean (SD):30.8 (6.0); 𝑃 = 0.0139).

3.4.6. Mobility (Long-Term). Similar to the short-term fol-lowup, the effect of MHR onmobility as assessed by the TUGwas also inconsistent across two studies [18, 19]. Crotty etal. [19] found that the median difference between the TUGscores of the MHR and the NT groups at 12 months was notsignificant (median difference (95% CI): −3.0 (−11.0 to 3.0);𝑃 = 0.314), while Ziden et al. [18] reported that TUG scoresin the MHR group were significantly better than NT group(𝑃 = 0.005) at 12 months.

3.4.7. Lower Extremity Functional Strength (Short-Term andLong-Term). Ziden et al. [17] found that lower extremitystrength assessed by the Sit-to-Stand (STS) test was signifi-cantly better the MHR group (𝑃 = 0.011) in comparison tothe NT group in. This improvement was sustained over the12-month followup as well and the MHR group continued toshow significantly better lower extremity strength comparedto the NT group (𝑃 < 0.001) [18].

3.4.8. Balance (Short-Term). The balance was assessed atfour-months followup using the Berg Balance Scale in onlyone study [11]. The result indicated that the MHR group hadhigher scores indicating greater improvement compared tothe NT group at four months; however the difference was notsignificant (MHR median: 43.5, IQR: 34.3, 52.5; NT median:37.5 IQR: 26.3, 45.3; 𝑃 > 0.05).

3.4.9. Adverse Events. No adverse effects of the MHR groupwere reported in any of the studies reviewed [11, 17–19].

4. Discussion

In the short-term, the MHR group showed greater improve-ments in functional status and lower extremity strengthbut no difference in balance and HRQOL compared to theNT group. The effect of MHR on balance confidence andmobility was inconsistent across the studies, and thereforeno inferences can be made whether MHR is effective inimproving these outcomes.

In the long-term, the MHR group showed greaterimprovements in balance confidence, functional status, andlower extremity muscle strength compared to NT group.Theeffect of MHR on HRQOL and mobility was inconsistentacross the studies.

The studies evaluated within this review suggest a trendtowards positive outcomes from MHR program of carecompared to no treatment following hip fracture surgery.Due to the low number of studies that fit the criteria for thisreview, robust conclusions cannot be made. Meta-analysisallows combining data across many studies and enables toderive “pooled” effect.However, the lack of consistency acrossoutcome measures used in the studies limited our ability toperform meta-analysis. Furthermore, applying the evidenceincluded in this review will be difficult, as the studies did notprovide clear descriptions of the interventions administered.

Thoughwe realize that itmay be unrealistic to provide explicitprotocols, as treatment in a MHR setting will naturally varybetween geographical areas, at least a detailed informationregarding the specific roles of health care providers involvedin the MHR plan would have been useful.

Althoughwe only included the studies that reflect the bestevidence into this review by deciding, a priori, to limit oursearch to RCTs alone, the quality of the included studies waslimited both by risk of bias and methodological issues. Someof the keymethodological issues observed across the includedstudies such as unclear in reporting methods of randomsequence generation, lack of blinding of outcome assessment,and incomplete outcome data reporting can highly influencethe results. Furthermore, many of these studies did notadequately describe the MHR provided, which further limitsthe generalizability of the results.Therefore, the results of thisreview do not allow us to make robust conclusions regardingthe usefulness of the MHR following hip fracture surgery incomparison to no treatment.

A comprehensive search strategy performed in duplica-tion, an assessment of agreement for selection of studies, andrisk of bias assessment for included studies all contributed tothe strength of this review. Criteria for inclusion/exclusion ofstudies were determined a priori and two reviewers extracteddata from the studies using a previously developed andstandardized data extraction form.

The comprehensive search strategies utilized in thisreview helped to minimize potential bias in the reviewprocess. Having two reviewers independently performingliterature searche on a multitude of databases helped toensure that all relevant articles were located and includedin this review. However, outside of the reviewer’s control,publication bias may still have influenced our outcomes.Although we set out to locate all studies on the topic ofinterest, it is possible that unpublished studies exist that mayor may not have changed the results of our review.

In the study selection and data collection processes,we again minimized bias by performing these processes induplicate. In the end there was some disagreement amongstreviewers as to which studies to include in the review and onthe quality of included studies. Although this was resolvedthrough discussion amongst all reviewers, it is possible thatthe subjectivity of this processmay have introduced somebiasinto the review.

Lastly, studies did not clearly report details of the treat-ment delivered to the MHR group. Therefore, it is possiblethat the treatments varied in terms of content, duration,and frequency among the MHR groups across studies. Wedid not account for this variation when determining thetreatment effect of MHR after hip fracture surgery. This mayhave introduced bias into the review, however we determinedthat the variation amongst home-based treatments could beoverlooked as this is likely a realistic representation of theapproach taken to home-based treatments in the community.

This systematic review expands on our systematic reviewby Mehta and Roy [22], which concluded that home-basedphysiotherapy was effective in improving patient reportedhealth related QOL following hip fracture surgery. Theoutcomes investigated in this review were different from


those of other similar reviews that assessed outcomes suchas mortality or admission to long-term care homes [23, 24].Moreover, the objective of our review was different in that itcompared multidisciplinary rehabilitation provided in homeversus that provided in institution as well as no treatmentfollowing discharge from acute hospital setting. However, ourresults agree with those of Handoll et al. [8] who suggestedthat multidisciplinary rehabilitation may have some benefitto patients following hip fracture but emphasized the need forhigh quality RCT to comprehensively examine the benefits ofmultidisciplinary rehabilitation.

5. Conclusions

Our findings show a trend to support MHR compared toNT following hip fracture surgery. In all instances, MHRwas found to be at least as effective as, if not more than,NT. However, no conclusive directives can be made to adoptMHR following hip fracture surgery due to risk of biasacross included studies and insufficient details regarding thecomponents of the MHR in the studies. The poor method-ological quality of studies included in this review underscoresthe need to conduct studies with superior methodologicalquality to investigate the effects of MHR in comparison withNT or institution-based care (inpatient or outpatient) inindividuals with hip fracture surgery. Furthermore, futurestudies can accurately characterize the types of disciplinesinvolved in MHR and frequency and dosage of intervention.Moreover, researchers involved in assessing the outcomes ofhip fracture surgery can develop a core set of measures fordifferent constructs (e.g. functional status, balance) relevantto hip fracture population. This will facilitate use of similarmeasures across future studies allowing meta-analysis andassessment of pooled effect of an intervention in individualswith hip fracture. Lastly, a cost analysis comparing NT orinstitution-based rehabilitation to home-based is necessary toascertain the cost benefits of each mode of treatment.

Acknowledgments

The authors report no conflict of interests. The authors aloneare responsible for the content and writing of the paper.Authors Donohue, Hoevenaars, McEachern, and Zemanwere enrolled in the entry-level Physical Therapy programat McMaster University (M.S. (PT)) while performing thissystematic review. This review was part of their Research &Evidence Based Practice (REBP) Project which they com-pleted under the mentorship of Saurabh Mehta.

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