Hip fractures in older adults have a substantial impact on morbidity, mortality, and cost to the individual and society [35
]. Unfortunately, it is anticipated that the numbers of individuals who sustain hip fractures will increase given the current demographics. For older adults who are provided with traditional treatment post-hip fracture, there is on average a 25% reduction in life expectancy, a high likelihood of remaining in nursing facilities, and an average cost of $26,900.00 in the first 6 months after fracture [35
]. In addition, the hip fracture is perceived by many individuals as a stressful life event [36
] and has a substantial impact on quality of life [37
]. The authors believe that interventions such as the Exercise Plus Program not only improve recovery from hip fracture but could help older women post-hip fracture to use this event to change health behaviors focused on optimizing bone and muscle such as exercise.
This exercise intervention was designed in an effort to maximize participation by older hip fracture patients. Design elements such as the one-to-one trainer to subject ratio, selection of a home-based program to eliminate the burden of traveling to a facility, the variety and multiple benefits of including both aerobic and resistance exercises, and the focus on strengthening self-efficacy and outcome expectations related to exercise were all anticipated to help these individuals not only initiate exercise immediately after hip fracture but to adhere to a regular exercise program for the remaining year and beyond.
The one-on-one relationship of the trainer to the subject provided maximum opportunity for trainers to individualize exercise programs, learn the personalities and physical abilities of subjects, and provide motivation and encouragement to not only continue but to increase intensity and amount of exercise. However, the administration and oversight of a one-on-one exercise program compared with exercise in a bigger group setting may be more labor and time intensive. During monthly meetings with the trainers and an investigator exercise physiologist, a month’s worth of exercise logs for all subjects were reviewed and discussed to assure that patients’ exercise programs were being progressed in a standard fashion. Quarterly treatment fidelity visits for each trainer assured that exercises were being administered in a safe and technically correct manner by all trainers.
BHS 4 showed that those subjects receiving the exercise intervention exhibited an increase in the amount of exercise compared with those in the nonexercise group. To determine whether the exercise program alone caused this improvement or whether it could be attributed, at least in part, to the motivation subjects received from their trainer visits, we conducted another study (BHS 5). The 2 studies, BHS 4 and BHS 5, occurred concurrently.
The BHS 5 study also was a randomized, controlled trial and had a 2-by-2 factorial design. The factors were the presence or absence of an exercise trainer, and whether or not the Plus component, a self-efficacy-based motivation intervention, was used. In contrast to BHS 4, participants of BHS 5 received a maximum of 38 supervised sessions by 12 months after hip fracture. The content, timing, and frequency of exercise activities were the same as in BHS 4. A total of 208 female hip fracture patients were enrolled in the BHS 5 trial from 2000 to 2004 [38
]. The BHS 5 investigators found no differences in any of the indices of recovery as a function of the exercise intervention and/or the motivation intervention [39
On the basis of knowledge gained from the authors’ previous 15 years of experience in studying the hip fracture patient, the research team designed a home-based program consisting of a combination of supervised and unsupervised exercise. Only a small number of studies have been conducted that examine the effect of both facility- and home-based exercise after hip fracture [17
]. A wide range of rates of adherence to and drop out from these programs has been reported. Differences in the type and duration of the exercise programs, the time in which they were administered in relation to the time of fracture, and differences in patient populations studied are all possible reasons for the reported variety of adherence and dropout rates.
Five studies of facility-based, supervised exercise programs for hip fracture patients have been reported [17
]. They all involve some type of resistance exercise and vary in duration from 2 weeks [44
] to 18 months [43
]. Subjects in both Nicholson’s and Sherrington’s studies also lived in the facility in which the exercise was conducted. Drop-out rates from these programs ranged from 4% [44
] to 19% [40
] and adherence from 87% [40
] to 96% [17
Home-based exercise programs for hip fracture patients vary in the amount of supervision and instruction that patients receive. Sherrington and Lord’s population [29
] received initial testing and exercise prescription then performed self administered exercise with periodic follow-up visits. Hip fracture patients in studies by Mangione et al [42
] and Tinetti et al [45
] received up to 2 to 3 weekly home exercise sessions administered by physical therapists. Home-based exercise programs varied in length from 12 weeks [42
] to 6 months [40
] and comprised flexibility exercises [40
], physical and functional therapy [45
], weight-bearing activity [29
], and 2 groups performing either aerobic or resistance exercise [42
]. Drop-out rates in these studies ranged from 5% [29
] to 21% [42
] and adherence was 77% [45
] to 131% in the study by Binder et al [40
], in which her patients exceeded the amount of exercise prescribed.
In comparison, the program described here was home-based with patients doing a combination of supervised and unsupervised exercise. The duration of the program, approximately 10 months, was longer than any of the other home-based programs. The number of home visits per week was comparable to that in the studies of Mangione et al [42
] and Tinetti et al [45
], although the total number of visits was substantially greater in the current study, a maximum of 56, compared with 20 in Mangione’s study and up to 24 in Tinetti’s study. Unlike any of the programs undertaken previously, the program discussed in this article included flexibility, resistance, and aerobic types of exercises performed by all of the exercise subjects. In the current study, the drop-out rate of 18% (the percentage of people who were randomized to the exercise program but refused to participate after enrollment) and adherence rate of 78% (completion of 44.5 of the maximum 56 exercise visits) compared favorably with other home-based or community-based exercise programs for hip fracture patients.
There were special challenges to motivation for older adults who sustained a hip fracture. Addressing pain post-fracture and fear of future falls and trauma were particularly important. A major emphasis of the Plus program was to teach these individuals about the importance of exercise and to help them overcome the challenges they faced related to participation in a regular exercise program [46
]. Qualitative findings supported the benefit of the Plus program as participants appreciated the written instructions, identification and articulation of goals, and the rewards and recognition of goal achievements, in addition to the support and encouragement they received from the trainers [48