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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
PM R. Author manuscript; available in PMC Feb 10, 2013.
Published in final edited form as:
PMCID: PMC3568511
NIHMSID: NIHMS156462
Design and Implementation of a Home-Based Exercise Program Post-Hip Fracture: The Baltimore Hip Studies Experience
Janet A. Yu-Yahiro, PhD, Barbara Resnick, PhD, Denise Orwig, PhD, Gregory Hicks, PhD, and Jay Magaziner, PhD
Janet A. Yu-Yahiro, Department of Orthopaedic Research, The Union Memorial Hospital, 3333 N. Calvert Street, Suite 400, Baltimore, MD 21218. Disclosure: 7A, Aussio Pharmaceuticals Study; 8A, HIP Fracture Study, NIA-R01AG018668;
Address correspondence to J.A.Y.-Y, c/o Grace Nasrallah, Assistant Editor; grace.nasrallah/at/medstar.net
Objective
The objectives are to describe for the first time a home-based exercise intervention for frail elderly hip fracture patients and to describe the feasibility of this exercise program.
Design
A home-based exercise program was used in a randomized controlled trial in which the authors investigated exercise intervention versus no exercise intervention in patients after hip fracture.
Setting
This program was implemented at the patients’ own home or place of residence after discharge.
Participants
Women 65 years of age or older were recruited within 15 days of hip fracture. Eligible patients were those with a nonpathologic fracture who were admitted within 72 hours of injury, had surgical repair of the hip fracture, and met medical inclusion criteria. Participants initially were randomized to exercise groups and then assigned to exercise trainers.
Intervention
The exercise contained strength training and aerobic components. Participants were expected to exercise 5 days per week by performing a combination of supervised and independently performed exercise sessions. Intensity and duration were increased gradually by trainers in a standardized way. The frequency of the supervised sessions decreased as participants became more independent. Treatment fidelity visits ensured that the intervention was being delivered as intended across trainers and across participants.
Main Outcome Measurement
This work describes the feasibility and challenges of administering an intensive home-based exercise program in this population of older adults.
Results
Of those patients randomized to exercise, 82% were followed by a trainer and almost all advanced to higher levels in both aerobic and strength programs. Overall, participants received an average of 44 (78.5%) of the prescribed visits by the trainer.
Conclusions
This study showed that it was possible to engage a frail older population of post-hip fracture patients in a program of aerobic and strength training exercise with a high rate of participation.
By the year 2030, more than 650,000 hip fractures will occur annually in older adults, and 18–33% of these individuals will die within the first year of their fracture [1]. Many of those patients surviving the hip fracture will have reduced functional performance and consequently be unable to live independently in the community [24]. In the year after a hip fracture, there is a loss in bone mineral density ranging from 2% to 4.6%, and a loss in muscle mass of approximately 6.5% [57]. These changes place individuals at increased risk for falls and subsequent fracture, as does the commonly associated decline in function and physical activity after a hip fracture.
Losses in muscle mass are associated with declines in some specific muscle groups after hip fracture. A rapid decrease in muscle strength, especially of the knee extensors and flexors, is observed during the early post-fracture period [8,9]. Aniansson and Gustafsson [10] found that older male and female hip fracture patients had a decrease in fast-twitch muscle size in the quadriceps muscle compared with a similarly aged healthy population. Fast-twitch fibers are responsible for force development in high-speed contractions and are used in tasks such as regaining balance after a near fall.
Hip abductors also are weak after fracture, and there is a significantly positive correlation between abductor strength and independent ambulation in hip fracture patients [11]. Barnes and Dunovan [11] suggest that hip abductors may be weakened as the result of the insult of hip fracture surgery and that this weakness causes biomechanical changes in gait. Finally, a previous study by the authors’ group found that during the first year of recovery, female hip fracture patients who lost ankle strength in the nonfractured leg had a worse recovery of mobility compared with those who gained strength [12]. Ankle dorsiflexion strength, as well as quadriceps strength, also was found to be lower in fallers compared with non- or one-time fallers when measured in an older nonfracture population [13].
Exercise training after hip fracture is an important strategy with the potential to improve recovery and prevent a decrease in function and subsequent falls in older adults. Regular exercise, even at low levels of intensity, can improve physical fitness in older adults [14,15]. For those who have sustained hip fractures, regular exercise (resistive and/or aerobic) has been reported to improve mobility [15,16], increase walking speed, and improve quadriceps strength [17]. Helping older adults to initiate and adhere to a regular exercise program after hip fracture may have an important impact on recovery and overall quality of life.
Therefore, this study has 2 objectives, which are to describe a home-based exercise intervention for frail elderly hip fracture patients and to describe the feasibility of this exercise program. In addition, the authors provide information comparing the amount of exercise during the year after fracture between the group that received the exercise intervention (exercisers) and a group receiving usual care (non-exercisers). Data are reported from one randomized controlled trial (Baltimore Hip Study [BHS] 4), in which 180 women were enrolled. This work focuses on the feasibility of the exercise program and the comparison made between the exercisers (n = 91) and the nonexercisers (n = 89).
The Baltimore Hip Studies
The current research is part of the BHS, an ongoing program of research conducted by the University of Maryland in Baltimore and dedicated to identifying strategies to enhance recovery from hip fracture. Investigators in the BHS have been conducting observational studies and single-center clinical trials since 1983. The program collaborates with a network of 22 hospitals serving 5 counties that surround and include the Baltimore Metropolitan area, Washington DC, and southern Pennsylvania.
STATOOLS software [18] was used to randomize participants of BHS 4 within blocks for each hospital to eliminate between-hospital biases. Those participants randomized to an exercise group were then assigned to an exercise trainer based on their geographic location and the trainer’s work load at that time.
The BHS 4 study was a randomized, controlled trial of exercise versus usual care post-hip fracture. Usual care in this study is defined as the physician prescribed post-fracture standard of care for hip fracture patients in the greater Baltimore region at the time of the study. This included relatively short hospital stays and approximately 2 to 4 weeks of rehabilitation with follow-up by the orthopedist and primary care provider. The exercise program began at the end of the physician prescribed post-acute physical therapy. The exercise sessions occurred 5 days per week, and participants received 3 trainer-supervised exercise sessions per week in their homes during their first 2 months of the study. The frequency of supervised sessions decreased so that participants received a maximum of 56 supervised sessions by the end of the protocol, 12 months after the fracture. Participants were expected to exercise 5 times per week for 45 minutes. Two sessions per week focused on strength-training exercises performed with resistive bands and cuff weights, whereas 3 sessions per week (alternating days) involved aerobic activity using a specially designed stair step with handles. A total of 180 female hip fracture patients were enrolled in BHS 4 from 1998 to 2004.
Study Participants
The participants in these studies were women 65 years of age and older. They were community-dwelling at the time of fracture and were enrolled in the studies within 15 days of their hip fracture. Eligibility was determined through a medical chart review, a medical assessment, and a cognitive screen. Eligible patients were those with a nonpathologic fracture who were admitted to a hospital within 72 hours of injury and had surgical repair of the hip fracture. Medical exclusions included the presence of cardiovascular disease, neuromuscular conditions limiting exercise (for example, Parkinson disease, amyotrophic lateral sclerosis, multiple sclerosis), respiratory conditions, diseases of the bone (such as Paget disease, osteomalacia), metastatic cancer, cirrhosis, and end-stage renal disease. Other miscellaneous exclusions were considered that would increase the risk of falling while a patient was exercising independently (such as a history of seizures, alcohol abuse, or narcotic or benzodiazepine use) or increase the risk of injury if a fall occurred (such as recent gastrointestinal bleeding or the use of Coumadin). Participants also had to be walking without human assistance (independent ambulation with or without an assistive device) before the fracture and achieve a score of ≥20 on the Folstein Mini-Mental State examination [19]. Institutional review board approvals were obtained from the University of Maryland and study hospitals. All enrolled participants provided their own informed consent. A Data and Safety Monitoring Board met quarterly and reviewed all adverse events and safety reports.
Design of Exercise Program
One of the challenges of the investigative team while designing the intervention was to determine whether the exercise program would be facility-based or home-based. After reviewing the literature and considering the authors’ experience with previous hip fracture patient populations, it was decided that a home-based exercise program would be most successful for this population. The advantages of such a program included increased adherence to the exercise program, because travel would not be necessary to participate, and a greater ability to individualize the program based on physical conditions and abilities.
In addition, it was thought that exercise could be initiated earlier in the post-fracture period and that placing equipment in the patient’s home improved the likelihood of independent exercise between the trainer’s visits and after completion of the study. An in-home program also would afford the opportunity to build a one-on-one relationship between the trainer and the patient. Finally, it would allow the trainer to advance exercise more rigorously over a longer period of time and to optimize motivation, thereby changing the exercise behavior in these individuals beyond the 12-month intervention.
The authors believed the disadvantages of a home-based program would include an initial reluctance on the part of some participants to let the trainers into their homes, cost related to trainer time and travel, and limited space for placement of the exercise equipment in their homes. An institution-based program would offer the camaraderie of group exercise and availability of institutional medical services. Research has shown, however, that home-based and group exercise programs in patients with orthopedic problems are equally effective [20]. Moreover, it was thought that the increased potential for adherence in the home-based program and ability to individualize treatment were most important and that the disadvantages could be overcome with our trained staff and the use of our self-efficacy based motivational component.
The exercise program was designed based on previous investigations of hip fracture patients, previous work with cardiac rehabilitation in a slightly younger population, and knowledge of postsurgical restrictions after various surgical procedures to repair hip fractures. The type, frequency, and intensity of exercise were designed with consideration of the American College of Sports Medicine [21] and the National Osteoporosis Foundation [22,23] guidelines for exercise in older adults. Initially, the program focused on weight-bearing, aerobic-type exercises because previous studies with older adults [24] indicated a slowing or halting of the rate of loss of bone mineral density. However, evidence for the benefits of a strength training program in facilitating ambulation and improving the ability to recover from a near fall was so compelling that a strengthening component was also added [2531].
The exercise program was designed and carefully reviewed by 2 orthopedic surgeon consultants and a group of physical therapists who work with hip fracture patients after their surgeries. The program was then piloted in the homes of several female residents in a retirement community who were of similar age as our population and had previous history of hip fractures. Final exercise programs with descriptions and pictures for all exercises, including warm-up, cool down, and aerobic and strengthening exercises, were printed on sturdy paper and put into flip books and/or posters. The Yale physical activity questionnaire [32] was administered to all subjects at 2, 6, and 12 months after fracture.
Standardization Versus Individualization
One of the greatest challenges of the program was to balance standardization of the exercise protocol with the need to tailor exercises to the individual patient’s medical status and level of conditioning. Although each participant started at her own individual level, all participants were advanced to a higher level according to a standard protocol. Each participant was assessed during her initial visit to identify an appropriate exercise prescription. Exercise trainers documented the level, intensity, and frequency of each exercise during supervised sessions. Participants received a calendar page each month on which they were asked to record all independent exercise. Individual exercises were modified in a standard way, for consistency according to participant limitations such as physical restriction, and were documented. All participants were advanced to a higher level of exercise in a standardized manner using the same equipment.
Exercise Program
Warm-Up and Cool-Down Exercises
All sessions began and ended with a warm-up that included a set of flexibility and range of motion exercises for the upper and lower extremities. These exercises, listed in Table 1, took approximately 10 minutes to complete. Participants were given a flipbook or poster that had explanations and pictures of each exercise for use during unsupervised exercise sessions.
Table 1
Table 1
Exercise Plus Program: Flexibility exercise for warm-up and cool-down exercises
Strength Training
Strength training consisted of a series of 11 exercises for the upper and lower extremities with the use of exercise bands, ankle and wrist cuff weights, and a specially designed 4-inch stair step with handles on either side for support and balance (Figure 1). Participants performed these exercises at various levels (easy, moderate, advanced, and challenging). These exercises are described in detail in Table 2. Generally, the duration of each exercise was increased until the participant could do 3 sets of 10 repetitions on the right and left sides. Intensity was then augmented by increasing the resistance of exercise bands or tubes and/or adding ankle and wrist cuff weights. Specific criteria for progression of exercises are described in Table 3. Padded handles were attached to the bands for comfort for some strength exercises. Participants received either a flipbook or poster illustrating and explaining each exercise.
Figure 1
Figure 1
Four-inch stair step with handles on either side for support and balance.
Table 2
Table 2
Strengthening exercises
Table 3
Table 3
Criteria for progressing the level of exercise for strength training
Aerobic Exercise
Aerobic exercise was performed on a specially designed 4-inch step with handles on either side for support and balance (Figure 1). There was non-skid material on the stepping surface and extra ballast boards along the bottom edges to prevent tipping. Duration of stepping was increased gradually with the goal of completing 30 minutes of continued stepping during each aerobic session. Once participants could perform the step exercise for 20 minutes, light ankle weights were added to increase exercise intensity. Before full weight-bearing activity, some participants did a seated march, or walking with walkers. Alternative aerobic exercise included stepping on a traditional staircase and marching in place.
Safety Assessment
Before initiation of exercise during the supervised sessions, the trainers conducted a brief medical screen including blood pressure, heart rate, observation of clammy skin, cyanosis, and documentation of any new confusion, and hip or chest pain. Criteria were established and taught to participants to indicate when it was not safe for them to exercise (Table 4). Ensuring safety and proper technique were the focus of the early post-fracture visits. After exercise, recovery heart rate and perceived exertion were measured.
Table 4
Table 4
Contraindications to exercise
The Plus or Motivational Component
In addition to the exercises, there was a self-efficacy-based motivational component. This component addressed patient education and encouragement, physiologic feedback, and cuing and self-modeling. The theoretical basis of the motivational intervention has been published previously [33].
Education and Encouragement
To educate patients post-hip fracture, a simple “Exercise After your Hip Fracture” booklet was used (available from authors upon request). The booklet reviewed the benefits of exercise for older adults who have had a hip fracture and acknowledged and addressed the barriers to exercise (such as pain, time constraints) and how to overcome them. In addition, the exercise program was taught to the participant one-on-one by the trainer. Verbal encouragement was provided through identification of individualized goals and reinforcement of progress made towards attaining them. Short-term goals focused on which exercises the individual could do, and long-term goals were individualized based on activities and goals appropriate for the participant. Examples of these were walking without an assistive device, being able to go out with family or on a trip, lifting a grandchild, or carrying a bag of groceries. Goals were written on a special Goal Identification Form and reviewed periodically with the trainer so that reinforcement could be provided and/or goals revised as appropriate. Rewards for goals achieved were given on a weekly basis (such as a pen, refrigerator magnet, pill box, magnifier, or night light).
Physiologic Feedback
The physiologic feedback intervention involved the trainer asking the participants at each supervised exercise session about any pain, fear, or fatigue that they associated with exercise. Standard interventions were implemented to decrease these unpleasant sensations and thereby facilitate increased physical activity and willingness to engage in an exercise program. Table 5 provides an overview of the techniques utilized to address these problems.
Table 5
Table 5
Interventions to decrease unpleasant sensations associated with exercise
Cueing and Self-modeling
The cueing with self-modeling component of the intervention involved the use of written material in the form of a poster, a booklet, and/or large print typed pages that described exactly what exercises the participant should do. During the first trainer visit, a picture of the participant exercising (self-modeling) was taken to serve as a reminder to the participant that they were capable of doing these exercises. Follow-up pictures were taken at 6 and 12 months post-fracture to reflect progress.
An exercise calendar also was given to participants to serve as a reminder to exercise, provide cues for what exercise to do, and help the individual review their own progress and adherence to exercise. The calendar also was useful for friends, family, and other health care providers to see what types of exercise the individual was doing and to provide additional social support and encouragement.
Trainers
After the participants were randomized to the exercise group, a single trainer was assigned to a participant for the duration of the study. The subjects were assigned to a particular trainer based on their geographic location and the trainer’s work load at that time. Trainers had previous experience as physical therapy assistants or were certified exercise trainers and had experience working with older adults. All trainers were taught the Exercise Plus Program, which had been fully articulated in a protocol manual. Trainers demonstrated their ability to correctly implement the entire Exercise Plus Program in a pilot/practice situation before working individually with a participant. All trainers were CPR certified and trained in study emergency procedures.
Trainers met monthly as a group with the exercise physiologist to review all of the participants’ records and discuss any problems. Records were checked for consistency and safety in advancing a participant through different stages of the exercise protocol. In addition, changes in medical status that affected the participants’ ability to exercise were assessed, as well as changes in environmental issues, scheduling difficulties, motivational issues, and other concerns. Finally, the trainers’ workloads were reviewed and modified as needed.
The close monitoring of the intervention done by the trainers and exercise physiologist was part of a larger treatment fidelity plan implemented in these studies [34] that comprehensively evaluated study design, training providers, delivery of treatment, receipt of treatment, and enactment of treatment skills [34]. The delivery of the treatment (ie, the Exercise Plus Program) was based on 70 randomly selected home observations by 2 observers during the entire study intervention period. Checklists related to delivery of the Exercise Plus Program were used to guide the observers, one of which was a nurse researcher and one an exercise physiologist. In addition, during the monthly meeting of the interventionists with the exercise physiologist, each current participant’s exercise log books were monitored to assure that the intervention was being delivered as intended.
The observations were used as an indication of adherence to delivery of the intervention across all of the treatment groups. As appropriate, after the observations, feedback to the interventionist was provided and ranged from specific exercise intervention techniques to reminders to use the exercise calendars, review the exercise booklets, or incorporate verbal encouragement. In so doing deviations from the proposed intervention were addressed and corrected immediately.
Data from the BHS 4 are presented in this section to provide a description of the patient population as well as to demonstrate the willingness of these patients to participate in this type of exercise program. Of the BHS 4 female hip fracture admissions (1276) to the study hospitals, 243 (19%) were eligible for the study, and 180 (74%) of those eligible consented to participate. Ninety-one subjects were randomized to the exercise group and 89 to the nonexercise group. The mean age of the participants was 82 years (range, 66 to 100 years). Among the participants, 94% were white, and 93% had at least an 8th-grade education. The majority of the participants were admitted with intertrochanteric (43.3%) and femoral neck (36.7%) fractures with the remainder of the fractures located in the subcapital (11.7%), subtrochanteric (3.9%), intracapsular (2.8%), and femoral neck base (1.7%) regions of the hip. Table 6 shows the types of surgery received.
Table 6
Table 6
Demographic variables of BHS 4 exercisers and nonexercisers at baseline
At the time of discharge from the acute care site, patients went home, or to skilled nursing homes, rehabilitation hospitals (transitional care units), or assisted living facilities (Table 6). Of the intervention participants, 41 started exercising before 60 days and 51 subjects started exercising before their actual 2-month measurement. Participants were followed at their discharge location and the average time to initiate exercise was 67.8 days (range, 25 to 203 days) after fracture.
Of the 91 subjects randomized to the exercise program, 75 (82%) were actively followed by a trainer and 16 (18%) refused the first visit by the trainer or any further participation in the study. Only 1% refused further participation in the program once they received visits by the trainer. The average number of visits for all those randomized to receive exercise was 36.2 (65%); however, if the participant received at least one trainer visit, the average number of visits the participants received was 44 visits (78.5%) of the possible 56 trainer visits over the post-fracture year. Missed visits were mostly the result of acute illnesses, traveling, schedule conflicts, and rehospitalizations. No serious exercise associated events occurred while the participants were engaged in the exercise program during the course of the 12-month study intervention.
Treatment fidelity visits were performed by 2 investigators on 5 different exercise trainers. Trainers were observed a total of 70 times. Adherence to the delivery of the intervention was 91%, and 92% of participants demonstrated evidence that they received the intended intervention during these observations.
At baseline, exercisers were similar to nonexercisers in all of the demographic variables measured (Table 6). As measured by the Yale physical activity questionnaire, exercise participants tended to report that they spent more time exercising at 2, 6, and 12 months post fracture than non-exercisers, but this trend did not reach significance (P = .08). However, the number of kilocalories expended while exercising as reported on the Yale, was significantly higher than non-exercisers at all time-points measured (P = .03).
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 [17,29,4045]. 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 [17,40,41,43,44]. 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% [17,44].
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 [40,45] 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 [46,47]. 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].
During the design phase of this study, some experts in the field doubted that it would be possible to get such a frail older population to participate in any form of exercise, especially after a hip fracture. The results shown here indicate that it is possible to develop and implement a home-based exercise program for frail older adults after hip fracture. The rate of participation in and enjoyment of the program was high, and patients often complained when it was time for the exercise trainer to decrease the frequency of his or her exercise visits. As the study progressed, the authors of this study continued to learn about the program’s usefulness in a frail older population and about the potential future usefulness of similar programs in other populations.
Acknowledgments
The authors acknowledge the help and support of Dr. Myron Sachs for his invaluable assistance in volunteering in the many aspects of this study; exercise trainers Lauren Holtzman, Becky Boyle, Sharon Opdyke, Teresa Awalt, and Kim Resnick for their dedication to the study and study subjects; and Justine Golden, Gina Shepherd, and Grace Nasrallah for their technical and statistical help with this study. The authors would also like to acknowledge the generous support of Thera-Band® Products and Mr. Phil Page MS, PT, ATC, CSCS, Manager of Clinical Education and Research, The Hygenic Corp, Akron, OH 44310 in providing all of the Thera-Band® exercise band products to our study participants.
This work was supported by the National Institutes of Health NIA Grant RO1 AG17082-01, Principal Investigator Barbara Resnick, PhD, CRNP, FAAN, FAANP, and the National Institutes of Health NIA Grant R37 AG09901, Principal Investigator Jay Magaziner, PhD, MSHyg. The work was also supported by the Claude D. Pepper Center at the University of Maryland (Health, Exercise, and Rehabilitation) and was funded by Grant P60 AG12583 from the National Institutes on Aging.
Contributor Information
Janet A. Yu-Yahiro, Department of Orthopaedic Research, The Union Memorial Hospital, 3333 N. Calvert Street, Suite 400, Baltimore, MD 21218. Disclosure: 7A, Aussio Pharmaceuticals Study; 8A, HIP Fracture Study, NIA-R01AG018668.
Barbara Resnick, Division of Gerontology, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore, MD. Disclosure: nothing to disclose.
Denise Orwig, Division of Gerontology, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore, MD. Disclosure: nothing to disclose.
Gregory Hicks, Division of Gerontology, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore, MD. Disclosure: nothing to disclose.
Jay Magaziner, Division of Gerontology, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore, MD. Disclosure: 2A, Consulted Merck and Navartis, DSMB Member on Hip Fracture Project; 7A, Novartis Zoledronic Acid Study; 8A, Hip Fracture Study NIA-R01-AG018668)
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