Hip Fractures - Functional assessments and factors influencing in-hospital outcome of patients with hip fracture, a physiotherapeutic perspective

A hip fracture is probably one of the most fatal fractures for the elderly and estimated worldwide to reach 5 million cases annually by the year 2050. Thus, continuing efforts in preventing fractures, with more research and improved treatment strategies for those who do fracture, seem crucial. The primary aims of this thesis, which comprises seven original papers, including a total of 656 patients, were to examine the reliability and validity of functional assessments used by physiotherapists of patients with different types of hip fracture, and to evaluate pre-surgery factors influencing in-hospital performances and outcome. Specifically, the ordinal-scaled prefracture functional level; New Mobility Score (NMS, 0-9), the basic mobility; Cumulated Ambulation Score (CAS, 0-6), and the continuous functional mobility, Timed Up & Go (TUG) test, were evaluated. Furthermore, the focus was on the influence of prefracture function and fracture type in addition to age, gender, mental and health status, on in-hospital performances and discharge destination. The relative intertester reliability of the NMS, and the CAS were, respectively, 0.98 and 0.95, while findings of the absolute reliability expressed by the smallest real difference indicate that a change of one point for both scores signifies a real change for a single person. The prefracture NMS functional level, in addition to age and fracture type, independently predicts or influences the in-hospital CAS-outcome and TUG-scores. Thus, a patient with a low prefracture level (NMS ≤ 6) and/or an inter- or subtrochanteric fracture was, respectively, 18 and 4 times more likely not to regain independency in basic mobility during admittance, compared to a patient with a high prefracture level and a cervical fracture, while the odds against mobility independency increased with 5% for every additional year of age. Correspondingly, patients with a low prefracture NMS and an inter- or subtrochanteric fracture, on average took, respectively, 9 and 6 seconds more to perform the TUG, while scores increased with 0.4 seconds per additional year. TUG scores were strongly influenced by the walking aid used during testing, as patients who performed the TUG with a rollator (a standardised walking aid), required on average 13.6 (95% CI, 11.2-16.1) seconds less than when using their discharge walking aid, a walker. Furthermore, TUG-scores of six subsequent timed trials, performed with a rollator, improved significantly up to and including the third trial. Finally, patients with intertrochanteric fractures presented significantly larger thigh oedema (11% increase) in the fractured limb compared with cervical fractures (4%), and the oedema was significantly correlated to scores of basic CAS-mobility (r = -0.61), postural control (sway, r = 0.67), and fractured limb knee-extension strength (% non-fractured, r = -0.77) ex-plaining between 32% and 59% of the variance (r2) in performances. In conclusion, the NMS, and CAS seem highly reliable with small changes needed to indicate real changes. Findings of the TUG-test indicate that the original TUG-manual needs modification, the fastest of three timed trials performed with a rollator is recommended for testing. The prefracture NMS level, in addition to age and fracture type, provides clinicians with a valid prediction of in-hospital outcome. Finally, our results indicate that the fracture type and the corresponding thigh oedema strongly influence physical performances, including maximal knee-extension strength of the fractured limb. Future research and rehabilitation programmes of patients with hip fracture should accommodate these findings