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1237

Systematic Home-Based Physical and Functional Therapy


for Older Persons After Hip Fracture
Mary E. Tinetti, MD, Dorothy I. Baker, PhD, RNC, Margaret Got&chalk, MS, PT, Patricia Garrett, MHS, RNC,
Signian McGeary, MS, OTWL, Daphna Pollack, MPH, Peter Charpentier, MPH
ABSTRACT. Tinetti ME, Baker DI, Gottschalk M, Garrett decreased from 2.1 (SD 1.3) to 0.6 (SD 0.9) (p < .OOOl), while
P, McGeary S, Pollack D, Charpentier P. Systematic home- the mean modified Berg Balance Scale Score increased from
based physical and functional therapy for older persons after 13.0 (SD 4.8) to 20.5 (SD 6.8) (t = 16.6; p < .OOOl). Finally,
hip fracture. Arch Phys Med Rehabil 1997;78:1237-47. the Total ADL Score increased from a mean of 48.2 (SD 15.0)
to 77.7 (SD 18.8) (t = 17.03; p = .OOOl).
Objective: To describe the development, implementation, Conclusions: This systematic assessment and intervention
and results of a home-based rehabilitation protocol for older protocol, targeting impairments and ADL, was feasible, safe,
persons after hip fracture. and effective. Protocols such as the one presented should en-
Design: Demonstration study. hance the ability to implement rehabilitation programs for the
Setting: Community.
increasing number of multiply impaired older persons receiving
Participants: One hundred forty-eight community-living,
home-based therapy and to document the process and outcomes
nondemented participants at least 65 years of age who under-
of this care.
went repair of a fractured hip at two local hospitals.
0 1997 by the American Congress of Rehabilitation Medicine
Intervention: A linked assessment-intervention, home-based
and the American Academy of Physical Medicine and Rehabili-
rehabilitation strategy. The physical therapy (PT) component
of the intervention was designed to identify and ameliorate tation
impairments in balance, strength, transfers, gait, and stair climb-
ing; the functional therapy (FT) component was designed to
identify and improve unsafe and/or inefficient performance of
specific activities of daily living (ADL).
A LMOST 300,000 PERSONS, the majority of whom are 65
years of age or older, suffer a hip fracture each year.’ Most
studieszm6 have found that the majority of older persons do not
Main Outcome Measures: The percentage of participants recover their prefracture level of functioning. Older age and
able to complete each component and the extent of progress poorer prefracture physical and cognitive functioning have been
noted in strength, balance, transfers, gait, and daily functioning. associated with a poor prognosis for functional recovery.2,5,6
Results: A total of 104 of the 148 participants (70%) com- Likely, the location and composition of rehabilitation also in-
pleted the 6-month PT and FT program; 4 completed only PT fluence outcomes after hip fracture. 7-9The location of posthospi-
and 6 refused both PT and FT. The remaining 32 participants tal rehabilitation for community-living persons who experience
(22%) received partial PT and FT that was terminated by death, fractures varies among regions8-” Nationwide, between 10%
hospitalization, or institutionalization. Seventy-seven percent of and 15% of participants are transferred to an acute rehabilitation
participants reported performing at least half of the recom- facility.’ Approximately half are transferred to a skilled nursing
mended daily exercise sessions. Ninety-four percent and 96% facility (SNF), either a traditional SNF or one of the increasing
of participants progressed in upper and lower extremity condi- numbers of subacute or rehabilitation SNFs8~ro More than half
tioning respectively; 33% progressed to the highest level in the of the number of persons discharged either to a traditional or
graduated resisted exercise program. All participants progressed subacute SNF and the majority of those discharged to an acute
in the competency-based graded balance program, with 55% rehabilitation facility return home, where they receive additional
progressing to the fifth (most difficult) level. Similarly, the ma- rehabilitative services.“*‘3 Much of the hip fracture rehabilita-
jority progressed in transfer maneuvers, stair climbing, and out- tion among community-living older persons, therefore, occurs
door gait. One repetition maximum (RM) elbow extension in- at home either immediately after acute hospital discharge or
creased from a mean of 5.8 (SD 4.6) pounds at baseline to 7.2
after an inpatient rehabilitative stay. Several studies”-7-‘0*‘4-‘7
(SD 3.8) pounds at 6mo (t 2.22; p < .02). One RM knee exten-
have reported on rehabilitation after hip fracture in the acute
sion increased from 5.8 (SD 5.8) pounds to 10.8 (SD 5.4) hospital, rehabilitation facility, and SNF setting. Little has been
pounds (t = 8.06; p < .OOOl). The number of gait deviations
reported to date, however, on the process or outcome of home-
based rehabilitation after hip fracture.18
From the Department of Medicine (Dr. Tinetti, Ms. Garrett) and the Department
of Epidemiology and Public Health (Dr. Baker, Ms. Pollack, Mr. Charpentier),
The majority of patients who have had a hip fracture receive
Yale Universitv School of Medicine. and the Deuartment of Rehabilitation Ser- various combinations of conditioning, ambulation, transfer, and
vices, Yale-New Haven Hospital (Ms. Got&chalk), New Haven; and the Depart- balance training by a home-based therapist. The specific compo-
ment of Occupational Therapy, Quinnipiac College. Hamden (Ms. McGeary). CT. nents and intensity of these training programs are largely un-
Submitted for publication November 20, 1996. Accepted in revised form April
15, 1997. studied.” While help with self-care activities of daily living
Supported by grant AG10469 (Claude D. Pepper Older Americans Indepen- (ADL) often is provided by home care agencies,‘,” there is little
dence Center) from the National Institute on Aging. evidence that hip fracture participants receive retraining in self-
No commercial party having a direct financial interest in the results of the care or home management ADL by occupational therapists or
research supporting this xticle has or will confer a benefit upon the authors or
upon any organization with which the authors are associated. rehabilitation nurses9 Because many hip fracture participants
Reprint requests to Mary E. Tinetti, MD, Department of Internal Medicine, have limitations in, and difficulty with, tasks of daily living,
Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New ADL assessment and intervention might be a beneficial comple-
Haven, CT 06520.8025.
ment to the usual postfracture physical therapy (PT).
0 1997 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation Given the diversity and multiplicity of potential problems
0003-9993/97/7811-4277$3.00/O among older persons who have a hip fracture, a comprehensive

Arch Phys Med Rehabil Vol78, November 1997


1238 HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti

assessmentand treatment plan that addresses the full comple- presencemight lead to modifications of intervention recommen-
ment of modifiable impairments, ADL disabilities, and other dations for other impairments and disabilities. The criteria for
impediments may best maximize functional recovery. Such a intervention, based on the baseline assessment, are shown in
comprehensive strategy would be difficult to implement thor- table 1. In our previous study, interrater reliability for the assess-
oughly yet efficiently without a systematic approach. ment items proved high; the Kappa statistic for most of the
As part of an ongoing study of the effectiveness of a 6-month, items was >.6.20,21The assessment was readministered at 2
home-based, multicomponent rehabilitation strategy for older months and at termination of therapy.
participants with hip fracture, we developed an assessmentand Intervention. Interventions for gait, transfers, and bed mo-
intervention protocol. Key features of this protocol include a bility involved instruction in safer, more effective techniques,
systematic and thorough assessment of both impairments and procurement and training in assistive devices, and environmen-
functional tasks, direct linkage of assessmentresults to interven- tal modifications. Progressive, competency-based exercises
tion recommendations, and periodic reassessmentsthat docu- were developed for hip strength and ROM, balance (5 levels),
ment progress in, and adjustment of, interventions. This report and general conditioning (4 levels). Treatment programs for
describes the development, implementation, and results of this specific muscle and joint groups other than the hip were adapted
home-based protocol. from existing sources.22Deconditioning is a common problem
both before and after fracture, so all participants underwent a
METHODS progressive strengthening program using color-coded resistive
bands (Theraband@)unless specifically contraindicated. Mecha-
Participants and Setting nisms for adjusting components of the program for specific
health conditions (eg, cardiac or pulmonary disease)were incor-
Between May 1, 1993 and September 30, 1995, 321 of the
porated into the protocols.
659 participants at least 65 years of age who had surgical repair During the rehabilitation program, which lasted up to 6
of a hip fracture at two local hospitals and returned home within
months, PTs visited participants three times a week for the first
100 days after hospital discharge met preliminary inclusion cri-
1 to 2 weeks, then twice a week for 2 weeks, then once a week
teria for this study. The reasonsfor noninclusion included cogni- for 2 weeks. Frequency of visits then decreased to one to three
tive impairment (n = 127); life expectancy less than 1 year or times a month. The therapists instructed the participants in the
death (n = 76); logistic reasons, most commonly that a study relevant exercises (eg, conditioning, balance), observed their
therapist was not available (n = 53) or lived too far (n = 47);
performance to ensure safe and effective technique, and ad-
and refusal (n = 52). One hundred forty-eight of the eligible vanced the level of exercise if indicated. Exercises were super-
304 participants (49%) were randomly selected to receive our
vised until the participants were able to perform them safely
home-based rehabilitation program. Of these 148 participants, and effectively. They were then instructed to do the exercises
50 went directly home after acute hospital discharge and 98 daily throughout the 6-month intervention. Participants were
stayed less than 100 days at a subacute rehabilitation facility
advanced to a higher level of balance or greater resistance after
before returning home. All procedures were approved by the they had consistently completed the previous level of exercise
Human Investigation Committee. correctly and without significant effort. The resistive bands,
which were set up by the therapist in the best location to facili-
Intervention tate each strengthening program, were left in place throughout
Development of protocol. A team of two physical thera- the intervention. To monitor adherence to the program, partici-
pists, one occupational therapist, one rehabilitation nurse, one pants completed an exercise check list each day.23 After each
home care nurse, and one physician was organized to develop home visit, the PT completed an intervention check list that
a home-based assessment and intervention protocol for older recorded impairments addressedduring the visit and the partici-
persons recovering from hip fracture. The PT component was pant’s level of balance and resistive exercises(table 1). Progress
designed to identify and ameliorate impairments, while the func- was thus documented by advancing levels of exercises.
tional therapy (FT) ~component was designed to identify and FT. Tables 2 and 3 summarize the assessmentsand inter-
modify unsafe and/orineffici&nt performance of functional tasks ventions in the FT component.
performed daily. Since many persons had’multiple impairments Assessment. The assessmentby a rehabilitation nurse spe-
before their fracture, the rehabilitation strategy was geared to- cialist, with consultation from an occupational therapist, began
ward identifying and modifying as many impairments and within 1 week after a participant returned home. The functional
disabilities as possible. The intervention protocol involved in- assessmentwas based on Occupational Therapy Functional As-
struction by the therapist followed by unsupervised (or family- sessmentCompilation (OTFACT), an automated system for in-
supervised) exercises, as is typical in home care. The group tegrating and reporting assessmentinformation.24 The activity
developed algorithms and decision rules directly linking the areaschosen from OTFACT were personal care activities, home
assessmentresults with specific intervention plans. Details for management, and communication. Each activity was separated
each component of the assessment and intervention protocol into prespecified subtasks. Scoring categories for each subtask
were included in a procedure manual for the therapist and reha- included 0 (total deficit), 1 (partial deficit), 2 (no deficit), 3
bilitation nurse (unpublished material, available from authors). (maximum), 4 (deferred), 7 (refused), and 9 (not applicable).
PT. Table 1 summarizes the assessmentsand interventions Concise criteria for scoring each activity and subtask were de-
in the PT component. veloped. Because persons may need to perform an activity in
Assessment. The physical therapist visited the patient within the future even if they do not at present (eg, cooking among
48 hours of the participant’s return home to complete and score older men), participants were encouraged to attempt activities
the baseline assessment.The impairment areas assessedwere: even if they did not usually perform them. “Deferred” was
(1) joint range of motion (ROM); (2) generalized muscle used if the participant was not ready to attempt an activity for
strength conditioning; (3) balance; (4) basic and ADL transfers; physical or psychological reasons or if the participant refused
(5) bed mobility; (6) indoor gait; (7) outdoor gait, ie, curbs and initial attempts at performance. Refusals were assigned only
street crossing; (8) stair climbing; (9) sensation; and (10) tone. after several attempts to encourage the participant. Maximum
Impairments in the last two areas were included because their (3) was used if after at least one re-evaluation and attempt at

Arch Phys Med Rehabil Vol78, November 1997


HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti 1239

Table 1: PT Assessment and intervention

Impairment Criteria for Intervention Intervention*

Joint Impairment
Shoulder Joint impairment interventions are implemented when a Joint-specific exercise programs’
Elbow specific ROM limitation requires specific one-on-one l Performed only with PT, combination of passive
Wrist manual therapy in addition to general conditioning. ROM, active or assisted ROM, passive stretching,
Knee Criteria for intervention based on insufficient active joint mobilization, and contract-relax.3
Ankle ROM for relevant ADL, balance, or gait plus absence l Program(s) continue until participant achieves active
of a neuromuscular, inflammatory, or ROM better than criterion cutoff for the specific joint.
musculoskeletal disorder that would make treatment l Bilateral intervention if meets criteria for either side.
either contraindicated or ineffective (eg, rotator cuff l Performs generalized conditioning exercises as well.
for shoulder, bony end feel, contracture from stroke).

Hand Unable to actively flex fingers to proximal palmar crease l Begins with yellow (light resistance) TheraputtyTM,
or grip strength by dynamometry 570% of age- progresses to red (moderate resistance) when grip
gender norms. strength between 70% and 80% of normal.
l Program ends when participant is able to flex fingers
to proximal palmar crease and/or grip strength
>80% of age-gender norm.

Muscle Conditioning
Upper Extremity All participants unless (I) or (2) Conditioning exercises using Theraband’*
(I) Neuromuscular or musculoskeletal disorder or l Includes a diagonal shoulder abduction exercise and
amputation that would prohibit or limit the exercises to strengthen internal rotators, shoulder
effectiveness of an upper extremity conditioning depressors, and elbow extensors.
program. l Performed daily: 3 sets of 8 exercises (bilateral).
(2) Cardiovascular disorder that would contraindicate l Begins with yellow (light resistance) and progresses
resisted upper extremity exercise. when able to complete without significant effort +
red + green -t blue Theraband unless plateaus at
earlier level plus
l Chair push-ups-number of sets and repetitions
based on endurance.
Lower Extremitv All participants unless a contraindication makes the Conditioning exercises with Theraband”*
strength training program ineffective l Includes resisted ankle dorsiflexion, knee extension,
hip abduction and flexion exercises.
l Begins, performs, and progresses as described for
upper extremity.
l Precautions observed for involved hip.

Unable to sit on edge of bed with hands on lap without Balance protocol
deviation from the vertical for 30 seconds l Progressive exercises incorporating isometrics,
or active ROM (gravity eliminated progressing to
Unable to unilaterally (unaffected leg) stand 5 seconds antigravity), closed and open chain maneuvers, and
without arm support and without constant correction dynamic and static weight shifts.
to the vertical position l Challenges balance by first ling arm support, then
Or by iing base of support, and finally by Ting
Unable in any of the following hip impairment tests on complexity of maneuvers.
either lower extremity: hip extension, supine hip l Levels-Bed (I & II) and Standing (I-V).
flexion, gravity eliminated hip abduction, side lying l Begins at Level I Bed and Standing, number of sets
hip abduction, or seated antigravity hip flexion. and repetitions based on tolerance, strength, ROM.
l Performed once daily.
l Progresses when previous level performed safely,
correctly, without significant effort and as indicated
by weight-bearing status, ROM, strength, endurance.

Basic Transfers Unable to independently transfer in one attempt: Balance protocol plus transfer training*
Stand to sit With controlled rate of descent, and appropriate use of l Therapist demonstrates, assists, and/or provides
arms and ambulatory device. verbal cues for proper technique.
Sit to lie (on bed) Without using arms to assist lower extremities or poor l Participant practices with therapist until
trunk/pelvis alignment supine. demonstrates independence with good safety
Lie to sit Without using arms to assist lower extremities awareness.
(on edge of bed) l Modify chair height with cushions to comply with
Sit to stand Appropriately using upper extremities, demonstrating limited hip flexion/adduction if hemiarthroplasty.
(from chair and/or bed) regard for weight-bearing status and without
extreme forward trunk flexion or lateral sway.

ADL Transfers
Toilet or commode Unable to independently transfer without adaptive l Check existing equipment for sturdiness and
equipment demonstrating appropriate technique he, appropriate height.
no drop sitting; uses only safe objects for support; l Use adaptive equipment until safe/independent.
follows hip precautions) l Instructions-approach toilet or commode, turn away
from toilet, back up until legs touch toilet, follow stand
to sit protocol (see procedure manual).
Tub (I) Uses tub to bathe, and l Follow tub transfer instructions in procedure manual.
(2) Unable to independently lower self to a sitting . Check existing equipment for safety.
position or stand smoothly and safely. l Use adaptive equipment until safe/independent.
Shower (I) Uses shower to bathe and l Follow shower transfer instructions in procedure
(2) Unable to independently transfer into the tub or manual.
shower and stand with good balance and stability. l Use adaptive equipment until safe/independent.
Car Unable to independently transfer including opening the Follow car transfer instructions in procedure manual
door and managing seat adjustment.
(continued)

Arch Phys Mad Rehabil Vol78, November 1997


1240 HOME-BASED THERAPY AnER HIP FRACTURE, Tinetti

Table 1: PT Assessment and Intervention (continued)


Impairment Criteria for Intervention Intervention*
Bed Mobility Unable to independentlv roll or move side to side Follow bed mobility instructions in procedure manual.’
without difiiculty.

Gait
Indoor gait (I) Deviation from weight bearing order or Gait training program”
(2) Uses assistive device incorrectly or Train with appropriate device:
(3) Unequal step length or Bilateral hand support in NWB, TTWB, or PWB.
(4) Unsteady or turns or Bilateral or unilateral hand support if WBAT.
(5) Unable to ambulate 220 feet or Bilateral unilateral, or no hand support if FWB.
(6) Requires assistance/hands on guard or Work on the deviations noted in evaluation.
(7) Pain with ambulation.
Stairs Begin when independent in sit to stand transfers and Stair training per procedure manual with appropriate
ambulation. assistive device.
Outdoor gait Begins when ambulates indoors independently or with Outdoor ambulation training”
supervision. l Begin 50.IOOft (depends on endurance) on sidewalk.
l Increases at own pace or about 2 min per week if not
advancing on own.
l Practices on grass when sidewalks mastered; add
curbs and street crossing; and
l Bus boarding if indicated.

Sensoryflone
Sensory Exhibits either Modify intervention protocols as outlined in the
(1) Numbness/tingling or decreased light touch in procedure manual.
hands or feet or
(2) “Incorrect” response to upper or lower extremity
proprioception test.
Tone Demonstrates either hypertonus or hypotonus in either Modify intervention protocols as outlined in the
arms or legs. procedure manual.
*All interventions described in detail in the procedure manual.
‘Adapted from definitions and techniques described by Kisner and Allen Colby.”
* Participants given illustrated instructions for all independent exercise programs.
“Transfer and gait training performed during PT home visits. Details of training in procedure manual.

intervention, no further improvement was deemed likely. No The reassessmentwas used to document progress and to gen-
deficit (2) was used only if the participant completed the subtask erate a new set of intervention menus reflecting the progress
(assistive devices and adaptive equipment acceptable) in a man- from baseline to 2 months. The final reassessment took place
ner that was deemed safe, effective, efficient, and independent. at 6 months.
Definitions were provided for each of these terms. Partial deficit Interventions. The specific interventions recommended de-
(1) was scored if the participant performed the subtask but did pended on a combination of which subtasks were a problem,
not meet criteria for either 0 or 2. Partial deficits, therefore, plus which impediments were believed to contribute to the prob-
ranged from minimal problems with safety, effectiveness, effi- lem. The FT interventions include the following categories:
ciency, or independence to almost total dependence. A total (1) task (subtask) modifications or behavioral adjustments; (2)
deficit (0) was assigned if the participant was unable to perform adaptive equipment; (3) environmental modifications; (4) psy-
chological interventions; (5) family or caregiver involvement;
the subtask at all, required total assistance, or attempted the (6) referral to PT; and (7) referral to physician or other health
task but performance was hazardous. care provider (table 3). Environmental modifications or adaptive
For each subtask scored 0 or 1, the rehabilitation nurse deter- equipment were implemented in conjunction with direct inter-
mined the impediments contributing to the deficit. Twelve poten- vention on the task performance (eg, task modification).
tial impediments were identified (table 3). Subtasks requiring The rehabilitation nurse visited each participant once or twice
similar skills or movements were aggregated into 12 groups (eg, a week to work on task modification, use of adaptive equipment,
turning the water on for bathing and flushing the toilet). To ensure environmental modifications, and family or caregiver education
that “usual” function was observed, the rehabilitation nurse and as indicated by the intervention menus. She also conferred with
participant agreed on the task to be performed, the subtasks to the physical therapist if physical impairments were determined
be observed, and the equipment to be used. When appropriate to impede a participant’s task performance. If a participant re-
and feasible, the nurse arranged for the home visit to coincide fused an intervention or continued to perform an activity in a
with usual performance of an activity such as dressing, bathing, hazardous manner, the nurse reintroduced recommended strate-
eating, or cooking. The assessmentwas set up, in the order shown gies over time. Thus, while the assessment and intervention
in table 2, so that more basic and essentialactivities (eg, toileting, protocol for functional therapy was standardized, the timing,
eating) were assessedearlier while more complicated activities and methods for task completion were flexible, based on the
such as laundry, housekeeping, and shopping were deferred until participant’s capabilities and preferences.
the participant had mastered earlier activities. Functional therapy assessmentwas repeated between months
Subtask scores were developed for each activity and were 2 and 3, at which time all activities except those that the partici-
the sum of the participants’ scores (0, 1, 2) for each subtask as pant had scored 2 (without deficit) at baseline were observed.
defined above. For scoring, all scores of 3, 4, and 7 were as- Descriptive and Outcome Data
signed a score of 0. The Total ADL Score was the aggregate A trained nurse assessorwho was not part of the therapy team
of the subtask scores for the following activities: medication, obtained self-report and physical performance data from partici-
eating, toileting, oral hygiene, bathing, grooming, dressing, pants before acute hospital dischargeand 6 months after hip frac-
meal preparation, laundry, housekeeping and shopping. The ture. Demographic data and prefracture functioning were ascer-
range of possible Total ADL Scores was 0 to 102. tained by self-report of participants before discharge from the

Arch Phys Med Rehabil Vol78, November 1997


HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti 1241

Table 2: Activities and Their Subtasks Included in FT*

Activity Subtasks’

Manage Medications (1) Opens and closes containers [41.


(2) Takes correct dose on correct schedule 171.
(3) Able to administer medications f61.

Eating (1) Sets up food 141 and (2) manages utensils [41.
(3) Consumes solid foods f61 and (4) liquids [61.

Toileting (I) Bedpan/urinal. (1) Obtains and uses supplies (eg, toilet paper) [41.
(2) Commode. (2) Removes and replaces clothes 151.
(3) Toilet and adaptive equipment. (3) and (4) Achieves and leaves position [21.
(4) Toilet without adaptive equipment. (5) Cleans self 131.
(6) Flushes toilet [Il.

Oral Hygiene (1) Seated in chair or bed using basin. (1) Obtains toothpaste, toothbrush, denture cleaner [41.
(2) Seated at sink. (2) Brushes teeth [41.
(3) Standing at sink.

Bathing (1) Bed bath. (1) Obtains and uses supplies (eg, towel, shampoo, soap) [41.
(2) Sponge bath at sink. (2) Removes clothes [51.
(3) Shower, seated. (3) Turns water on/off and adjusts temperature [Il.
(4) Stand in shower or sit in tub. (4) and (5) Gets into and out of bathing position 121.
(6) Cleans self 131.
(7) Dries self f31.
(8) Shampoos f31.

Grooming (II Seated in chair or bed using basin. (I) Shaves face 141.
(2) Seated at sink. (2) Washes and dries face [41.
(3) Standing at sink. (3) Applies cosmetics [41.
(4) Cares for fingernails 141.
(5) Combs, brushes hair [41.

Dressing (II Bed clothes; robe. (1) Obtains and puts away clothes [41.
(2) Indoor clothes with slippers. (2) Obtains appliances (eg, glasses, hearing aids) [41.
(3) Indoor and outdoor clothes with street shoes. (3) Dons and doffs clothes [51.
(4) Uses fasteners (eg, buttons, laces) [51.

Meal Preparation (1) Meals served by other. (1) and (2) Selects food and plans meals [71.
(2) Retrieves fixed meals. (3) Prepares meal
(3) Prepares cold meals. (uses utensils and appliances, basic food preparation) [4,81.
(4) Prepares heated meals. (4) Clears table and puts food away [4j.

Laundry (1) Handwashes. (1) Launders clothes (washes, dries) [1,4,91.


(2) Uses washing machine at home. (2) Stores clothes (hang in closet, put in drawers, etch [41.
(3) Does laundry out of home.

Housekeeping’ (II Dust. (I) Obtains and replaces supplies 141.


(2) Pick-up. (2) Uses supplies 141.
(3) Make bed. (3) Completes the tasks 131.
(4) Dry mop/sweep.
(5) Vacuum.
(6) Change bed.
(7) Take out trash.
(8) Others.

Yardwork (Optional)’ (I) Mow. (I) Obtains and replaces supplies [41
(2) Shovel or sweep. (2) Uses supplies [41.
(3) Trim. (3) Completes the tasks [31.
(4) Garden.
(5) Water lawn or garden.
(6) Rake.
(7) Others.

Shopping (I) Negotiates around store [IO].


(2) Locates needed items L81.
(3) Carries and transports items [4j.
(4) Handles monev transaction f91.

* Intervention menus are generated based on evaluation of the combination of deficits in subtask performance (groups) and impediments identified.
Ten menus were developed, based on similar movements and skills required to perform the subtask.
’ Prefracture and postfracture levels are recorded. Levels are based on relative difficulty.
* Each subtask is scored 0 = total deficit (cannot do or needs total assistance or unsafe performing task), 1 = partial deficit (performs task but does
not meet criteria for 0 or 2; minimal to moderate problems with safety, effectiveness, or independence; performs task independently but takes a long
time or includes unnecessary steps), 2 = no deficit (performs task safely, effectively, efficiently, and independently; assistive devices and adaptive
equipment allowed), 3 = plateaued at 0 or 1 and no further improvement likely (given only after at least one reevaluation), 4 = deferred (person not
yet ready to attempt task or refuses initial requests), 7 = refused (person continues to refuse to perform tasks after several requests), and 9 = not
applicable. Numbers in brackets after subtasks refer to one or more of the 10 intervention menus based on similar skills and movements required.
’ For these categories of activities, participant selects at least two from list or can select comparable ones not on list. These activities are not considered
hierarchical levels.

Arch Phys Med Rehabil Vol78, November 1997


1242 HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti

Table 3: Impediments to Performance of Specific Subtasks* With Recommended Interventions

Impediment Categories of Interventions Recommended


Memory Task modification (eg, simplify steps; perform repetitively)
Caregiver involvement (eg, supervision, cueing)

Problem-solving Task modification (eg, segment tasks, perform repetitively)


Caregiver involvement (eg, supervision, cueing: provide written instructions)
Environmental (eg, provide environmental cues; simplify environment; reduce background stimuli)

Decreased motivation Psychological


If depressed, referral to MD
If low confidence, follow confidence protocol
If neither, follow adherence protocol

Low confidence (fear) Task modification (eg, start with easy task to ensure “success”; perform repetitively; advance slowly but steadily)
Caregiver involvement (eg, positive encouragement, avoid negative persuasion)
Psychological, follow self-efficacy protocol

Pain+ Task modification (to avoid or reduce painful movements)


Psychological (eg, relaxation techniques; “distraction” techniques)
Referral to PT (eg, heat, cold, exercises)
Referral to MD for medication management; encourage use of prescribed or over-the-counter medications on a short-
term regular basis rather than PRN

Activity tolerance Task modification (to conserve energy, eg, segment task; perform tasks seated rather than standing; frequent rests)
Adaptive equipment (eg, reduce carrying, use lightweight objects)
Environmental (eg, avoid overheated rooms; reduce distances needed to travel)

Vision Task modification (eg, simplify tasks)


Caregiver involvement Leg, constant placement of objects)
Environment (eg, color coding; large visual indicators; remove obstacles; keep supplies in easy reach; increase lighting;
talking clock; preprogrammed telephone, velcro indicators, etc)

Hearing Task modification (eg, stay in kitchen when cooking)


Environment (eg, visual indicators for tasks usually requiring hearing-phone, faucet, smoke detectors)

Coordination (fine motor) Task modification (eg, simplify tasks; allow more time)
Adaptive equipment appropriate to task
Environment (eg, modify handles on faucets, stoves, door knobs etc)

Strength Task modification (eg, lead with stronger side; segment and simplify tasks)
Environmental (eg, modify handles on faucets, stoves, etc.)
Caregiver instructions (assistance with tasks as needed)
Adaptive equipment appropriate to task.
Referral to PT for exercises

ROM Similar to strength recommendations

Balance Task modification (eg, perform tasks seated rather than standing; avoid hazardous tasks (eg, stairs, tub bathing;
simplify tasks)
Environmental (eg, grab bars; organize supplies in easy reach)
Adaptive equipment (eg, reachers, shoe horns, sock donners, etc)

* Subtasks from multiple activities were aggregated into 10 groups based on requirement for similar skills and movements.
’ Based on Agency for’ Health Care Policy Guidelines.

acute hospital. Fracture-related data, including type of fracture one leg, transferring chair to chair, and turning 360” were tested
and repair and weight-bearing status, were ascertained from medi- to show change from baseline to 6 months. Each item was scored
cal chart review. The nurse assessor, blinded to progress with PT 0 to 4. Total score on the modified Berg Balance Scale ranged
or FT, also ascertained participants’ self-reported performance of from 0 to 32. Qualitative assessment of gait, using five items
the following self-care ADL and instrumental ADL (IADL) 6 from the gait component of the Performance Oriented Mobility
months after hip fracture: eating, grooming, toileting, bathing, Assessment (POMA), included step length and symmetry, path
dressing, getting from bed to chair, walking across a small room, deviation, turning, and stepping over an object.** Possible scores
using the telephone, preparing simple meals, doing housework, ranged from 0 to 8. One repetition maximum (1 RM) of the
doing laundry, shopping, using transportation, and handling medi- triceps and knee extensors, using lead-shot pouches, was used to
cation.25,26 Each ADL and IADL was scored 0 (does not do), 1 measure upper and lower extremity strength, respectively. The
(does with some human help), or 2 (does without human help). nondominant arm and nonfractured leg were tested. To accommo-
Composite self-reported ADL-IADL score, the aggregate of the date modifications required because of the fracture, all strength
score on each of these activities, ranged from 0 to 28. The nurse testing was performed in a supine position with a flexion (quad)
assessor performed strength, balance, and gait tests at baseline (in board used for lower extremity testing. One RM was defined as
the hospital, nursing home, or home) and at 6 months (at home). the amount of weight in pounds a participant could lift through
A modified Berg Balance Scale, a reliable and valid measure that a full range of motion.
includes tests of maintenance of position and postural adjustment,
was used to assess balance.” Because several items in the Berg
Statistics
Balance Scale are unsafe or contraindicated after hip fracture or in
persons who have had hemiartbroplasty, only sitting unsupported, Descriptive statistics, means, medians, and standard devia-
transferring sit to stand, standing unsupported with feet together, tions were calculated for all assessment measures. The propor-
standing with eyes closed, transferring stand to sit, standing on tion of participants progressing in the various physical therapy

Arch Phys Mad Rehabil Vol78, November 1997


HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti 1243

regimens was determined. Differences among the measures as- Functional Therapy
sessed at baseline, 2 months, and 6 months were determined Table 5 shows the number and percentage of participants
with the paired t test. The correlation between self-reported receiving interventions for self-care ADL and IADL, the imped-
ADL-IADL at 6 months and the Total ADL Score (defined iments most frequently identified for each activity, and the per-
above) was determined using the Spearman correlation coeffi- formance scores at baseline, 2 months, and 6 months. Among
cient. self-care ADL, as expected, the percentage needing intervention
was higher for more complicated tasks such as dressing and
RESULTS bathing than for simpler activities such as feeding and groom-
ing. Thirty-two percent of participants required intervention for
Eighty-three percent of the 148 participants were women with toileting after PT had worked on the transfer component. The
a mean age of 80.5 (27.0) years. While 89% of participants low percentage of participants receiving intervention for some
had been independent in all their self-care ADL, 80% had re- of the IADL, such as laundry, was partially because many part-
quired help with one or more IADL before the fracture. The cipants had experienced recovery by the time the activity was
majority of fractures (57%) were of the femoral neck; 40% observed. Many other participants however, had already devel-
were intertrochanteric and 3% were subtrochanteric. Surgical oped alternate strategies, eg, family participation, hired help or
repair involved a pin, nail, or screw in 105 participants; the store delivery, that they did not wish to change. In addition,
remaining 43 participants underwent hemiarthroplasty. Among because of serious coexisting health problems such as end-stage
the 148 participants, weight-bearing status at hospital discharge obstructive lung disease, blindness, hemiparesis, and cognitive
was non-weight-bearing for 2, toe touch for 23, partial for 38, impairment, or serious environmental obstacles, the rehabilita-
as tolerated for 59, and full for 26. The median acute hospital tion nurse deemed as unstie laundry chores for 18 participants,
length of stay was 9 days. Among the 98 participants (66%) heavy housekeeping for 17, and shopping for 19 participants.
who experienced a subacute rehabilitation stay before returning There was no intervention related to shopping for an additional
home, average length of stay in the subacute facility was 40.8 25 persons because transportation could not be coordinated.
t 22.3 days (range 1 to 92). A total of 104 participants (70%) The most frequently identified impediments for participants
completed the PT and FT program. An additional four com- receiving FT varied among the activities (table 5). For most
pleted PT but refused all FT and six refused both PT and FT. activities there was a combination of physical (eg, strength,
Two participants were admitted to a nursing home before ther- balance, activity tolerance), psychological (eg, motivation), and
apy could begin. For 32 of the 148 participants (22%), PT cognitive (eg, problem-solving)) impediments cited. The num-
and FT was terminated or interrupted by death (n = 5) or by ber of visits by the rehabilitation nurse per participant ranged
hospitalization for an acute medical or surgical problem (n = from 1 to 22 (median = 5; mean = 7). Each visit averaged 1
17) or an orthopedic problem (n = 9; [failed repair = 4; fracture hour.
other hip = 2; and one each of wrist fracture, knee replacement; For some tasks, including toileting and oral hygiene, most of
and dislocation of other hip]). the improvement occurred between baseline and 2 months; for
other tasks such as housekeeping and shopping, the improve-
ment occurred between 2 and 6 months. For most activities,
Physical Therapy however, improvement as identified by increasing activity
Table 4 shows the number and percentage of participants scores continued throughout the period from baseline (prether-
who received each component of the PT intervention and the apy) to 2 months to 6 months. Total ADL Scores, defined in
progression in each component over the 6 months. Only a small the Methods section, increased from a mean of 48.2 (115.1)
percentage of participants required a specific intervention for from baseline to 67.1 (216.1) at 2 months to 77.5 (-~18.8) at
joint impairments, while almost 20% of participants received a 6 months. Self-reported composite ADL-IADL scores ascer-
hand strengthening exercise program. The majority of partici- tained by an independent assessorwere 24.64 before fracture
pants met criteria and received interventions for each of upper and 22.37 6 months after fracture. The correlation at 6 months
and lower extremity muscle conditioning, balance, transfers, between the rehabilitation nurse score and self-reported score
and gait. From one third to half of participants required interven- reported to a blinded assessorwas .73.
tion in each basic transfer, while a higher percentage required DISCUSSION
ADL transfer training (eg, 91% for toilet and 68% for shower We found that this structured assessment and intervention
transfers). The number of PT visits during which impairment protocol, targeting impairments and ADL disabilities, was feasi-
areas were addressed ranged from 3 for ADL transfers to 16 ble, safe, and effective for use in home-based rehabilitation of
for balance training. The length of the PT intervention ranged older persons after hip fracture. Documentation was deemed
from 1 to 27 weeks with a median of 12 weeks. More than half easier and less time-consuming than for home care participants
of the 148 participants (56%) reported performing at least 70% therapists had cared for under “usual care.” The physical tbera-
of the recommended conditioning and balance exercise sessions; pists noted that they identified and intervened on a broader
77% completed more than half the recommended sessions.No range of impairments than in their previous practice with hip
serious injuries or falls were reported during any sessions. fracture participants. Importantly, participants were able to carry
The majority of participants progressed to higher level re- out the progressive conditioning and balance exercise program
sistive bands and balance exercises and to better categories of independently after instructions from the therapists. Adherence
transfer performance from pretreatment to 6 months (table 4). to the exercise sessions was excellent. The effectiveness of
Improvements in muscle and balance were confirmed by inde- the conditioning exercise program was suggested both by the
pendent assessment of 1 RM elbow and knee extension and increasing proportion of participants using bands with greater
modified Berg Balance Scale, respectively. There was excellent resistance over time and by the significant increase in 1 RM
progression among participants in each parameter of gait includ- testing of elbow and knee extension from baseline to 6 months
ing number of deviations, type of assistive device used, weight- as assessedby a nurse not involved with the participant’s ther-
bearing status, and competency on stairs, curbs, and street cross- apy. Similar to conditioning, participants adhered to, and ap-
ings. peared to benefit from, the progressive balance exercises, with

Arch Phys Med Rehabil Vol78, November 1997


1244 HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti

Table 4: Progress in Impairment-Based PT

No. Receiving Intervention Baseline 2mo &no


Impairment for Impairments Measure of Progress (n = 142)* (n = 133)X (n = 123)*

Color Theraband
Upper extremity conditioning’ 108 Yellow 100% 16% 6%
Red 54% 24%
Green 28% 36%
Blue 2% 33%
1 RM elbow (pounds)* 5.8 (4.6) - 7.2 (3.8)”
Hand strength 27 Dynamometry 11.4 (3.2) - 13.7 (4.6)++
Lower extremity conditioning* 124 Yellow 100% 21% 4%
Red 55% 17%
Green 21% 46%
Blue 2% 33%
1 RM knee (pounds)’ 5.8 (5.8) - 10.8 (5.4)**

Balance 139 Level”


I 94% 8% 0
II 3% 17% 3%
Ill 2% 45% 6%
IV < 1% 27% 35%
V 0 3% 55%
Modified Berg Scale” 13.0 (4.8) - 20.5 (6.8)**

Category”
Transfers
Sit to stand 77 1 14% 0 3%
2 74% 20% 12%
3 11% 80% 85%
Bed mobility 84 1 32% 0 1%
2 52% 24% 13%
3 16% 75% 85%
Toilet 124 1 8% 0 1%
2 83% 57% 28%
3 5% 42% 69%
Shower 100 1 20% 2% 1%
2 76% 74% 55%
3 3% 24% 44%
Tub 26 1 - 10% 6%
2 - 80% 71%
3 - 10% 20%
Car 120 1 - - -
2 - 66% 31%
3 - 31% 69%
Stairs 124 1 - 4% 1%
2 - 49% 14%
3 - 47% 84%
Outdoor gait-curbs and street 130 1 - 9% 3%
2 - 49% 24%
3 - 42% 74%
Gait 139 No. impairments’ 2.1 (1.3) 0.6 (0.9)++
Modified POMA Scale* 4.1 (1.3) 5.9 (1.7)**
Values for 1 RM elbow, dynamometry, 1 RM knee, Modified Berg Scale, impairments, and Modified POMA Scale given as mean (standard deviation).
* Numbers vary because of missing assessments.
’ Four of 12 participants who received shoulder specific interventions gained near full range of motion by 6 months; 3 of 4 participants who received
specific wrist intervention gained near full ROM.
* Seven of 11 participants who received knee specific intervention gained near full ROM at 6 months; 6 of 7 participants who received ankle specific
exercises gained near full ROM at 6 months.
‘See Methods for definitions. These measures were assessed bv a nurse researcher blinded to the progress reported by the PT.
‘I Categories: 1 = severe/moderate deficit; 2 = mild deficit; 3 = nb deficit.
1 p < .05, ++ p < ,001, ** p < .OOOl, baseline versus 6mo, paired t test.

the majority progressing to more difficult exercises over the Implementing the FI assessment and intervention protocols
intervention period. Again, the improvement in balance was was more difficult than implementing the PT component. As the
validated by concomitant improvements in the Berg Balance specific tasks, methods, and personal preference for completing
Scale, basic ADL and IADL vary widely, designing an assessment and
The nurse found most of the FT assessment and intervention intervention protocol that was ’ ‘standardly tailored” was a chal-
feasible, safe, and effective in the majority of participants. She lenge. However, strategies such as assuring participants that we
identified a common set of subtasks for each of the targeted wanted to help them perform tasks more safely and effectively
basic ADL and IADL that were independent of individual within their own “style” or preference, scheduling the visits to
“style.” She observed and rated the safety, effectiveness, and coincide with usual performance (eg, while preparing breakfast
efficiency with which individual participants carried out the or lunch), discussing the tasks ahead of time, and allowing partici-
various subtasks involved in ADL and IADL. Based on these pants to select which tasks would be addressed when, increased
observations and ratings, she was then able to recommend, and their willingness to participate in functional therapy.
instruct in, various combinations of task modifications and envi- The two main barriers to assessing and intervening on self-
ronmental adaptations, as well as implement strategies for en- care ADL were the concerns of some participants that they
hancing motivation or confidence when indicated. would lose their home health aide (covered by Medicare) if

Arch Phys Med Rehabil Vol78, November 1997


HOME-BASED THERAPY AFTER HIP FRACTURE, Tin&i 1245

Table 5: Implementation of FT After Hip Fracture

Activity Score,’ mean (SD) and


median (range)
Received Inlervention, Most Frequent Baseline 2mo 6mo
Activity n (%) Impediments* (n = 1x3* (n = 1271* (n = 11a*

Manage medication 43 (32) Memory 5.4 (1.2) 5.6 (0.9) 5.6 (0.9)
Motivation 6.0 (O-6) 6.0 (O-6) 6.0 (O-6)
Problem solving
Eating 10 (7) Fine motor 7.2Q.2) 7.7 (1.1) 7.9 (0.5)
Strength 8.0 (O-8) 8.0 (O-8) 8.0 (4-8)
Toileting 43 (32) ROM 10.3 (3.1) 11.3 (2.3) 11.2 (2.5)
Problem solving 12.0 (O-12) 12.0 (O-12) 12.0 (O-12)
Balance
Oral hygiene 10 (7) Balance 3.5 (1.2) 3.9 (0.4) 3.9 (0.3)
ROM 4.0 (O-4) 4.0 (O-4) 4.0 (2-4)
Strength
Bathing 107 (79) ROM 8.6 (4.5) 10.5 (5.2) 11.8 (5.5)
Problem solving 10.0 (O-16) 11.5 (O-16) 14.0 (O-16)
Balance
Grooming 19 (14) ROM 3.5 (2.2) 6.5 (1.9) 7.3 (2.1)
Strength 3.3 (O-IO) 6.7 (O-10) 7.5 IO-IO)
Fine motor
Dressing 94 (69) ROM 5.2 (2.3) 6.9 (1.8) 7.3 (1.9)
Problem solving 5.6 (O-8) 8.0 (O-8) 8.0 (O-8)
Strength
Meal Preparation 94 (69) Motivation 2.8 (3.0) 5.1 (3.1) 6.3 (2.6)
Problem solving 1 .O (O-8) 7.0 (O-8) 7.0 (O-8)
Memory
Laundry 21 (15) Activity Tolerance 0.2 (0.7) 1.6 (1.7) 2.5 (1.7)
Environment 0 (O-4) 1.5 (O-4) 4.0 (O-4)
Motivation
Housekeeping 20 (15) Activity tolerance 1.9 (3.4) 8.2 (6.1) 12.3 (6.6)
Motivation 0 (O-18) 10 (O-18) 17 (O-18)
Balance
Shopping 8 (6) Activity tolerance 0.07 (0.7) 0.5 (1.8) 2.2 (3.4)
Motivation 0 (O-8) 0 (O-8) 0 (O-8)
Strength
Total ADL Score 48.2 (15.0) 67.1 (16.1) 77.5 (18.8)
49.6 (3-86) 69 (11-110) 83.5 (18-102)
*The impediments listed most frequently by the rehabilitation nurse during initial observation of the activity.
‘Activity score = sum of scores (0, 1, or 2) for each subtask for an activity. Subtasks are listed in table 2. Criteria for scoring described in Methods.
* Numbers vary because of missing assessments.
’ Total ADL Score = sum of scores for each activity.

they became independent too soon, and embarrassment in per- more complicated IADL such as shopping and housekeeping
forming personal tasks (eg, toileting and bathing) with the nurse. showed little improvement from baseline to 2 months, but
Determining the optimal time to intervene on ADL is crucial marked improvement from 2 to 6 months. These patterns of
to implementing an effective yet efficient home-based strategy. improvement likely reflect a combination of physical and psy-
Waiting might either enhance a participant’s willingness or abil- chological recovery after the hip fracture and acute hospitaliza-
ity to work on specific ADL or, alternatively, the participant tion, plus improvement in strength, balance, gait, and other
might recover sufficiently not to require a specific intervention. impediments through the structured PT, plus the effect of FT
By waiting “too long,” however, the participant may become for specific activities.
“too dependent” and more resistant to change. Timing of obser- The FT component was carried out by a rehabilitation nurse
vation seemed appropriate for IADL such as housekeeping and who had more than 20 years of experience in inpatient and
laundry. By the time the nurse assessed these activities (usually home rehabilitation settings. The study’s occupational therapist
after month 2), many participants who had performed these was integrally involved in developing the assessment and treat-
activities before the fracture were again able to perform them ment components of functional therapy and was available as a
safely and effectively without specific FT intervention. Among consultant through most of the project. We cannot comment on
those who were not able to do so, however, many refused inter- whether results would have been similar to those obtained if
vention because family members or hired help had taken over implemented by an occupational therapist.
these tasks. As expected, intervening illnesses and hospitalizations inter-
In addition to the problems described above for FT, there
were occasional instances in which the PT and rehabilitation rupted PT and FT for many participants. Of note, however, 70%
nurse did not follow the decision rules for interventions com- of these frail older persons were able to complete, to show
pletely or accurately. We are now developing a method to com- progress in, and to benefit from, the home-based rehabilitation
puterize the assessment and the decision rules for intervention program after a hip fracture. Objective evidence of the benefits
to facilitate accurate and consistent implementation of the proto- of rehabilitation in this group remains scant and is essential to
cols and further reduce the burden of documentation. ensuring continued support from third-party payers.
There appeared to be three patterns of functional recovery Although direct comparison is needed to determine whether
among ADL. For some activities (eg, toileting), persons showed a structured, comprehensive PT and FT assessment and inter-
early improvement as suggested by the increase in score from vention protocol such as the one used in this study results in
baseline to 2 months without change from 2 to 6 months. Activi- greater improvement than present usual home care, several
ties represented by bathing and dressing showed steady im- findings support the effectiveness of our approach. First, a high
provement from baseline to 2 months to 6 months. Finally, the proportion of participants improved in each PT parameter (level

Arch Phys Med Rehabil Vol 78, November 1997


1246 HOME-BASED THERAPY AFTER HIP FRACTURE, Tinetti

of resistive and balance training, number of gait impairments, documentation of both process and outcome of care-increas-
safety and effectiveness of transfers and stair climbing) and in ingly required by reimbursers-could be relatively straightfor-
self-care ADL and IADL. Independent assessments of upper ward. A systematic assessmentand intervention protocol should
and lower extremity strength, balance, and gait verified these not constrain therapists’ clinical judgement by forcing confor-
improvements. Further, the proportion of participants reporting mity. Indeed, a successful system requires sufficient flexibility
complete independence in self-care ADL (68%) at 6 months is and individuality to allow the therapist to handle unanticipated
much higher than the 25% to 50% figures reported in several problems and to tailor any treatment plan to the combination
previous observational studies in community-living older per- of comorbidities, contraindications, preferences, and circum-
sons 6 months after a hip fracture? There have been few stances unique to individual participants and households. We
previous studies of rehabilitation after hip fracture. Most investi- found that these systematic, structured, linked assessmentand
gations to date have been of inpatient rehabilitation; results have intervention PT and FT protocols were feasible, safe, and effec-
been inconsistent.4.7,8,14-‘6 In one of the few home-based studies, tive in home-based rehabilitation for older persons after hip
Pryor” found no increase in functional independence 6 months fracture. For the most part, participants were willing and able
after fracture with enhanced home service. The rehabilitation to do the prescribed exerciseprograms and to implement recom-
program did not appear to have been as intense or multifaceted mended task modifications and environmental adaptations for
as ours. various ADL. We were able to implement unsupervised progres-
We realize that this 6-month rehabilitation program does not sive resistive and balance exercises-after careful instruction-
represent “standard practice” for Medicare-covered home care without injuries. We were able to enhance participant’s inde-
participants after hip fracture. Although 6 months was the maxi- pendence in, and safe performance of, a spectrum of ADL,
mum amount of time that participants were seen, intervention although a subset of participants showed resistance to, or were
was discontinued earlier if participants stopped progressing or deemed unsafe in, performing some higher level IADL such as
showed full recovery earlier. The median length of intervention housekeeping and shopping. Protocols such as the one presented
was 12 weeks. The progress shown in every area of PT and here should enhance the capability of rehabilitation therapists
FI between 2 months (the usual termination of home-based to design and implement rehabilitation programs for the ever-
rehabilitation after hip fracture) and 6 months suggests that the increasing number of multiply impaired older persons receiving
longer period of intervention for those who were still improving home-based therapy and to document the process and outcomes
resulted in greater eventual recovery. Although the ability to of this care.
implement longer programs in actual practice will obviously
depend on reimbursement from fee-for-service Medicare, man- Acknowledgments: We acknowledge the efforts of Kathryn Fo-
aged Medicare organizations, or other sources, findings such as garty Trainor, MS, for programming and data management of the proj-
ours should influence decisions concerning coverage of rehabili- ect. We also acknowledge Christine Kasinskas, MS, PT, Marie Koch,
tation programs. Effective and efficient home-based rehabilita- MS, PT, Maria Olsen, MS, PT, and Sally Palumbo, PT, who contributed
tion programs for participants after hip fracture are increasingly their skill and expertise to this project. Therabrandm and Theraputtym
important as acute hospital and subacute stays have shortened were provided by the Hygienic Corporation.
and fewer participants with hip fracture are eligible for acute
rehabilitation. Certainly, if the greater recovery resulting from References
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