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com/esps/ World J Orthop 2013 October 18; 4(4): 248-258

[email protected] ISSN 2218-5836 (online)
doi:10.5312/wjo.v4.i4.248 © 2013 Baishideng. All rights reserved.

ORIGINAL ARTICLE

Feasibility of progressive strength training shortly after hip

fracture surgery

Jan Overgaard, Morten T Kristensen

Jan Overgaard, Department of Rehabilitation, Municipality of test, assessed before and after the programme.
Lolland, Physical Medicine and Rehabilitation Research-Copen-
hagen (PMR-C), DK-4930 Maribo, Denmark RESULTS: Weight loads in kilograms in the fractured
Morten T Kristensen, Physical Medicine and Rehabilitation Re- limb knee-extension strength training increased from
search-Copenhagen (PMR-C), Departments of Physiotherapy and
3.3 ± 1.5 to 5.7 ± 1.7 and from 6.8 ± 2.4 to 7.7 ± 2.6,
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre,
DK-2650 Hvidovre, Denmark respectively, in the first and last 2 wk (P < 0.001). Cor-
Author contributions: Overgaard J and Kristensen MT con- respondingly, the weight loads increased from 50.3 ±
tributed to the study conception and design, data interpretation, 1.9 to 90.8 ± 40 kg and from 108.9 ± 47.7 to 121.9
manuscript preparation and final approval of the manuscript; ± 54 kg in the bilateral leg press exercise (P < 0.001).
Overgaard J contributed to the data collection; Kristensen MT Hip fracture-related pain was reduced, and large im-
contributed to the data analysis. provements were observed in the functional outcome
Supported by The Danish Physical Therapist’s Research Fund measurements, e.g. , the 6-min walk test improved
Correspondence to: Jan Overgaard, PT, Department of Re-
from 200.6 ± 79.5 to 322.8 ± 68.5 m (P < 0.001). The
habilitation, Municipality of Lolland, Physical Medicine and Re-
habilitation Research-Copenhagen, Sdr. Boulevard 84, DK-4930 fractured limb knee-extension strength deficit was re-
Maribo, Denmark. [email protected] duced from 40% to 17%, compared with the non-frac-
Telephone: +45-611-21191 Fax: +45-546-76948 tured limb. Ten patients reported knee pain as a minor
Received: May 15, 2013 Revised: July 15, 2013 restricting factor during the last 10 RM knee-extension
Accepted: September 4, 2013 strength-training sessions, but with no significant influ-
Published online: October 18, 2013 ences on performance.

CONCLUSION: Progressive strength training, initiated

shortly after hip fracture surgery, seems feasible and
Abstract does not increase hip fracture-related pain. Progressive
strength training resulted in improvement, although a
AIM: To investigate the feasibility of a 6-wk progressive
strength deficit of 17% persisted in the fractured limb
strength-training programme commenced shortly after
compared with the non-fractured limb.
hip fracture surgery in community-dwelling patients.
© 2013 Baishideng. All rights reserved.
METHODS: This prospective, single-blinded cohort
study evaluated 31 community-dwelling patients from
Key words: Hip fracture; Resistance training; Feasibility;
four outpatient geriatric health centres aged 60 years
or older, who started a 6-wk programme at a mean of Repetition maximum; Pain
17.5 ± 5.7 d after hip fracture surgery. The interven-
tion consisted primarily of progressive fractured knee- Core tip: The recovery of strength and function in pa-
extension and bilateral leg press strength training tients with hip fractures is an on-going challenge. We
(twice weekly), with relative loads commencing at 15 aimed to evaluate the feasibility of a 6-wk progres-
and increasing to 10 repetitions maximum (RM), with sive lower limb strength-training programme. To our
three sets in each session. The main measurements in- knowledge, this was the first study to implement such
cluded progression in weight loads, hip fracture-related a program successfully in an outpatient geriatric setting
pain during training, maximal isometric knee-extension within 2-3 wk after hip fracture surgery. Training loads,
strength, new mobility score, the timed up and go test, muscle strength and functional performances improved
the 6-min walk test and the 10-meter fast speed walk without an increase in hip fracture-related pain, which

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 Overgaard J et al . Strength training shortly after hip fracture

is considered new and important knowledge for all related pain influenced strength and functional testing.
professionals aiming to improve the rehabilitation out-
comes of patients with hip fractures.
MATERIALS AND METHODS
Patients
Overgaard J, Kristensen MT. Feasibility of progressive strength Thirty-nine community-dwelling geriatric patients with
training shortly after hip fracture surgery. World J Orthop
hip fractures were included in this study (Table 1) and
2013; 4(4): 248-258 Available from: URL: http://www.wjg-
began the exercise programme at a mean of 17.5 ± 5.7 d
net.com/2218-5836/full/v4/i4/248.htm DOI: http://dx.doi.
after surgery. The types of surgery included hip pins (n =
org/10.5312/wjo.v4.i4.248
3), screws (n = 10) and hemiarthroplasty (n = 10) for the
23 patients with intracapsular cervical femoral fractures,
whereas the patients with extracapsular intertrochanteric
fractures underwent surgery with dynamic hip screws (n
INTRODUCTION = 8) or short intra-medullar hip screws (IMHS, n = 4).
Hip fractures are associated with poorer survival[1], a Four patients with subtrochanteric fractures all under-
greater than 50% loss of fractured lower limb strength went surgery with long IMHS. All of the patients were
within a few week after surgery[2-4] and the return of only cleared by the orthopaedic surgeon at the hospital for im-
poor functional mobility within 4 mo[5]. Knee exten- mediate weight bearing as tolerated on the operated limb,
sor muscle strength is an independent predictor of falls and with the exception of those with hemi-arthroplasty,
within 6 mo of hip fracture[6]. Thus, reducing strength the patients were under no other restrictions during
deficits should be a high priority in rehabilitation, as the rehabilitation. Patients with hemiarthroplasty were not
incidence of falls is higher with asymmetrical lower ex- allowed to perform > 90° flexion, adduction or internal
tremity power[7]. Some trials have suggested the benefits rotation of the hip. Before inclusion, all of the patients
of exercise after hip fracture[8], but studies have most followed a short in-hospital physical therapy programme
often commenced as extended programmes after stan- without strength training, focused on the regaining of
dard physical therapy has ceased, 6 to 8 wk after fracture basic mobility activities[18,19], before being discharged to
at the earliest[9-16]. To our knowledge, only one study has their own homes. Patients were recruited from four out-
evaluated the effects of early 6-wk (median of 15 d post- patient geriatric municipality health centres from Septem-
surgery) strength training after hip fracture as an in- ber 2010 to August 2011. The inclusion criteria were as
patient rehabilitation programme[3]. However, no similar follows: age greater than or equal to 60 years; intra- or ex-
studies have been conducted in community-dwelling geri- tracapsular hip fracture; no post-surgical restrictions for
atric patients with hip fractures or have succeeded in pro- weight bearing; living in their own homes; and ability to
moting the regaining of symmetrical lower limb muscle walk independently, according to an indoor new mobil-
strength. In addition, most strength intervention studies ity score[20,21] (NMS) ≥ 2 points. The exclusion criterion
have based their training intensity on the one repetition was as follows: adverse medical conditions, such as neu-
maximum (RM) level[3,10-12,15-17], which requires further rological impairment (e.g., history of stroke with residual
calculations before use in clinical practice, as well as new hemiplegia) or uncontrolled cardiac diseases that could
one-RM measurements for the subsequent adjustment potentially influence the patient’s ability to participate in
of training intensity. Such one-RM-based programmes the programme. The ethics committee of the Sealand
challenge progressive exercise in comparison with, e.g., region (study no. SJ-145) and the Danish data protection
programmes that start with 12 repetitions and a 12-RM agency approved this study. All of the patients provided
intensity, which in principal, allows physiotherapists to written informed consent, according to the Declaration
adjust weight loads after each set. That is, weight loads of Helsinki Ⅱ.
should be increased in the next set for a patient able to
perform, e.g., 14 repetitions for such a programme to Procedure
be called progressive. In summary, there is only limited The patients were asked to follow a standardised 6-wk
knowledge regarding the feasibility and effects of a non- rehabilitation programme with sessions twice weekly
one-RM-based progressive strength-training programme (12 sessions in total), which included progressive lower
commenced within a few wk after hip fracture surgery. limb strength training. Before the first training session
The primary purpose of this prospective cohort and after the last training session, all of the patients
study was to evaluate the feasibility of a 15- to 10-RM performed the following objective examinations: the
programme, based on a 6-wk early progressive strength- timed up-and-go (TUG) test[22]; the 10-m fast speed walk
training programme, after hip fracture. Feasibility was test (10mWT)[23]; the tandem balance test[24]; the 6-min
indicated if the absolute strength-training loads increased walk test (6MWT)[25]; and the maximal isometric knee-
progressively and if hip fracture-related pain during train- extension strength test for each limb. The pre-fracture
ing remained the same or decreased over time. The sec- functional level was assessed using the questionnaire of
ondary purpose was to report functional adaptations, the the modified[26], functionally validated[27] and reliable[21]
details of specific weight loads and whether hip fracture- NMS (0-9 points, a score of 9 indicating a fully indepen-

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 Overgaard J et al . Strength training shortly after hip fracture

Table 1 Baseline data of patients with hip fractures included

walk tests (TUG, 10mWT and 6MWT), both at baseline
in a 6-wk rehabilitation programme and at follow-up testing. The best of three timed trials
was used for the TUG (performed as previously de-
All Dropout Followed P scribed)[34], the 10mWT and the tandem balance test (no
within 6-wk value
6 wk, program,
walking aid used), whereas one timed trial was used for
n =8 n = 31 the 6MWT.
Age (yr) 77.7 ± 8.7 77.2 ± 8.3 77.9 ± 9.0 0.8
Women 33 (85) 7 (21) 26 (79) 1.0 Gait speed
Men 6 (15) 1 (17) 5 (83) Fast speed walking was measured with the 10mWT[23].
Cervical femoral fracture 23 (59) 4 (17) 19 (83) 0.8
Intertrochanteric fracture 12 (31) 3 (25) 9 (75)
Patients were instructed to “walk as fast as safely pos-
Subtrochanteric fracture 4 (10) 1 (25) 3 (75) sible without running” from a standing position, starting
New mobility score (0-9): behind a line drawn on floor. A stopwatch was started on
Pre-fracture functional level 9 (9-9) 9 (8.5-9) 9 (9-9) 0.8 the command “3-2-1-GO” and was then stopped when
Baseline functional level 4 (3-4) 4 (3-4) 4 (3-4) 0.9
the patient’s leading foot crossed a line 10 m away. The
Barthel-20 (0-20) 18 (17-20) 8 (17-19.5) 18 (17-20) 0.9
Balance, tandem test (0-30) 30 (23-30) 27 (24-30) 30 (22-30) 0.5
results are reported in meters walked per second (m/s).
Timed up and go test, seconds 21.0 ± 7.2 22.4 ± 10 20.2 ± 6.0 0.4
Ten-meter fast speed walk, m/s 0.72 ± 0.22 0.65 ± 0.31 0.74 ± 0.19 0.3 Balance
Six min walk test, meters 198 ± 79 189 ± 80 201 ± 80 0.7
Static balance was assessed with the tandem test[24] with
Fractured, knee-extension 0.47 ± 0.16 0.39 ± 0.16 0.49 ± 0.16 0.1
strength, Nm/kg
a score from 0 to 30 points (a score of 30 points indicat-
Non-fractured, knee- 0.79 ± 0.22 0.69 ± 0.29 0.81 ± 0.28 0.2 ing no balance problems). The first position was standing
extension strength, Nm/kg with the feet together, the second was placing the feet in
semi-tandem, and the last position was setting the feet
Data are presented as mean ± SD, as medians (25%-75% quartiles) or as n
in a full tandem position. The time was measured with
(%).
a stopwatch, and up to 10 points (one per second) were
assigned for maintaining balance in each of the three
dent pre-fracture walk level)[20] and activities of daily liv- positions.
ing, using the Barthel-20[28]. Health-related quality of life
was assessed using the 36-item short form health survey Isometric knee-extension strength
(SF-36) and was reported as SF-36P (physical) and SF- Maximal isometric knee-extension strength was assessed
36M (mental)[29]. The patients were instructed to take for both limbs with a fixated hand-held dynamometer[36]
their prescribed pain medication before the testing and (Power Track Ⅱ Commander). The patients were seated
training. on an examination couch with their arms crossed (as in a
Physiotherapists involved in the testing of the pa- previous study[37], personnel communication with the first
tients before and after the rehabilitation were blinded to author), their knees at a 90° angle and their upper limb
the patients’ participation and progress during the 6-wk fixed with a strap to the examination couch during test-
rehabilitation programme, and the physiotherapists did ing. The transducer (placed 5 cm above the lateral malle-
not supervise training the sessions. oli) was positioned under a fixation belt that was fastened
to the examination couch. After familiarisation with the
Hip pain and restricting factors procedure, the patients performed five voluntary isomet-
Hip fracture-related pain was measured with a 5-point ric knee extensions for each limb (non-fractured limb
verbal ranking scale (VRS) (0 = none, 1 = light, 2 = mod- first) with strong verbal encouragement, separated by a
erate, 3 = severe, 4 = intolerable pain) during all of the minimum of a 30-s pause. Maximal isometric strength
strength and performance testing, as well as during all of was expressed in Nm/kg and was derived from the units
the strength-training sessions (patients were asked imme- of force in newtons (N) multiplied by the corresponding
diately after). The VRS has proved most appropriate for lever arm (distance from lateral epicondyle of the femur
measuring pain in patients with hip fractures[30] and has to the transducer) measured in meters (m), divided by the
been used in previous hip fracture studies[2,31,32]. weight (kg) of the patient[37].
During each strength-training session, the patients were
asked about any factors restricting their performance. Endurance
The 6MWT was performed according to recommenda-
Walking aids and number of trials tions of the American Thoracic Society[25], using a 30-m
The TUG, performed as fast as safely possible, has course with a cone marking each end. The patients were
proved highly reliable in patients with hip fractures[33] instructed to walk as far as possible, and Borg dyspnoea
when using a standardised four-wheeled rollator[34] and and fatigue levels[38] were recorded immediately after fin-
selecting the best of three timed trials[35]. Accordingly, ishing. No practice trial was conducted, but the patients
as all of the patients used some kind of walking aid, a performed the other objective outcome measurements
standardised four-wheeled rollator was used for all of the before the 6MWT.

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 Overgaard J et al . Strength training shortly after hip fracture

A B

Figure 1 The progressive strength training included unilateral (fractured limb) knee-extension (A) and bilateral leg presses (B).

Rehabilitation programme examination couch with his or her hands to assure a stan-
The patients who entered the programme were of dif- dardised position. The patient was connected to a weight
ferent ages (range, 61-96 years) and pre-fracture func- load system with a strap around the ankle, and a success-
tional levels (NMS, 6-9) and therefore exhibited different ful single repetition was defined as movement from the
functional levels at start of the programme. Accordingly, 90° knee angle to as close as possible to a maximal knee
walking and balance exercises were chosen and pro- extension (Figure 1A).
gressed on an individual level to ensure that each exercise The bilateral leg press strength training was started
was conducted with the same intensity for all of the pa- with maximum allowed flexion in the hip (90° for pa-
tients. The exercises began with warm-up on a stationary tients who underwent surgery with hemi- or total arthro-
bicycle (intensity according to the Borg 10) for 10 min plasty) and the knee to a full possible knee extension, and
and were followed by functional exercises focused on the patients were instructed to press equally with both
improving walking forward, backward and sideways and limbs (Figure 1B).
stair climbing with the maximal tolerable weight bearing Strong verbal encouragement was given during all of
on the operated limb, with or without the use of walking the strength exercises, and the patients were instructed to
aids, for 15 min. continue each set until failure/fatigue. The patients were
The balance training was conducted for approximate- instructed not to perform additional training during the
ly 10 min with the patient standing with both legs on the 6-wk programme.
floor and on different surfaces, e.g., an Airex pillow/mat-
tress, an ankle disk or a trampoline, with or without support. Statistical analysis
The progressive strength training included unilateral Descriptive statistics were utilised for baseline character-
(fractured limb) knee extension (Figure 1A) and bilateral istics. We used Student’s t test for normally distributed
leg presses (Figure 1B). For each exercise, three sets of data, the Mann Whitney U test for non-normally distrib-
approximately 15 repetitions with a relative weight load uted data and the χ 2 test or Fisher’s exact test for cat-
of 15 RM were performed for 2 wk (four sessions). egorical data to evaluate differences between patients and
This period was followed by 2 wk with three sets of 12 dropouts over the 6-wk programme. We used the paired
repetitions (12 RM) and 2 wk with three sets of 10 rep- t test and Wilcoxon’s test to examine changes from base-
etitions (10 RM). To determine the relative weight load, line to 6 wk, whereas Pearson’s product moment or Spear-
the supervising physiotherapist adjusted the weight load, man’s rho was used for correlation analyses of normally
so the patient reached fatigue at the respective RM level. and non-normally distributed data, respectively. Addition-
Accordingly, the weight loads were adjusted after each of ally, intention-to-treat analysis was performed, including
the three training sets in each of the 12 sessions if the dropouts with baseline data. The data are presented as
patient was able to perform more than the planned rep- mean ± SD when normally distributed and are otherwise
etitions, to ensure training at the respective RM level. The presented as medians (25%-75% quartiles) or as numbers
reduction in the number of repetitions from 15 to 12 to with percentages. All of the data analyses were conducted
10 during the 6-wk strength-training programme was fol- using SPSS, version 19.0. The level of significance was
lowed by a corresponding increase in intensity from 15 to set at P less than 0.05.
12 to 10 RM. The largest difference in kilograms between
the starting point and endpoint was used in the final anal-
ysis. The total exercise programme lasted approximately RESULTS
60 min per session. Eight of the 39 patients included in this study did not
The fractured limb knee-extension strength training complete the 6-wk programme for the following reasons:
was performed with the patient seated on an examination back pain (n = 2, already present before study inclu-
couch with a 90° hip and knee angle. In the seated posi- sion); second surgeries (n = 2); withdrawal of consent (n
tion, the patient was instructed to grasp the edge of the = 2); and death (n = 2). Both patients who underwent

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 Overgaard J et al . Strength training shortly after hip fracture

11
Table 2 Changes in function, knee-extension strength, and A RM-L
b
10 RM-F 4 sessions
weight loads within six week of rehabilitation (n = 31) b
9
4 sessions
Baseline 6 wk Percen P value 8

Weigth loads in kilograms

tage b
7
change
4 sessions
New mobility score (0-9) 3.7 ± 1.1 5.9 ± 1.6 59 < 0.001 6
Barthel (0-20) 18 (17-20) 20 (18-20) 11 < 0.001 5
Balance, tandem test (0-30) 30 (22-30) 30 (29-30) 0 < 0.001
4
Timed up and go test, seconds 20.2 ± 6.0 13.9 ± 3.2 -31 < 0.001
Ten-meter fast speed walk, m/s 0.74 ± 0.19 0.99 ± 0.2 34 < 0.001 3
Six-min walk, meters 200.6 ± 79.5 322.8 ± 68.5 61 < 0.001 2
Short-form 36, physical 33.8 ± 9 37.1 ± 8 10 0.035
1
component summary
Short-form 36, mental 45.5 ± 11.1 46.4 ± 9.6 2 0.639 0
15RM-F 15RM-L 12RM-F 12RM-L 10RM-F 10RM-L
component summary
Strength training intensity
Fractured knee-extension 0.49 ± 0.16 0.82 ± 0.32 67 < 0.001
strength, Nm/kg
Non-fractured knee-extension 0.82 ± 0.28 0.99 ± 0.34 21 < 0.001 B 200 RM-L
strength, Nm/kg RM-F b
180
Weight loads in kilograms First Last b 4 sessions
160

Weigth loads in kilograms

(kg), fractured knee-extension: session session 4 sessions
15 RM sessions, n: 34 3.3 ± 1.5 5 ± 1.7 52 < 0.001 140 b
12 RM sessions, n: 32 5.3 ± 1.9 6.6 ± 2.3 25 < 0.001
120 4 sessions
10 RM sessions, n: 31 6.8 ± 2.4 7.7 ± 2.6 13 < 0.001
Weight loads (kg), bilateral leg press: 100
15 RM training sessions 50.3 ± 13.4 90.8 ± 40.0 81 < 0.001 80
12 RM training sessions 91.2 ± 38.8 108.9 ± 47.7 19 < 0.001
10 RM training sessions 108.9 ± 47.7 121.9 ± 54.0 12 < 0.001 60

40
Data are presented as mean ± SD, as medians (25%-75% quartiles) or as
20
percentages. RM: Repetition maximum.
0
15RM-F 15RM-L 12RM-F 12RM-L 10RM-F 10RM-L
Strength training intensity
a second operation exhibited dislocated intracapsular
fractures (classified as Garden 3 and 4, respectively). One Figure 2 Feasibility of the programme. A: Absolute weight load over 12
of these patients did not start the program due to luxa- fractured knee-extension strength-training sessions; B: Absolute weight load
tion of a hemi-arthroplasty in her own home, whereas over 12 bilateral leg press strength-training sessions. bP < 0.001 vs RM-F. RM:
the other patient, who underwent surgery with hip pins, Repetition maximum; F: First session; L: Last session.
participated in three training sessions. Only three out of
the eight dropout patients commenced the training pro- ing. Nonetheless, these 10 patients exhibited similar im-
gramme after baseline testing, of whom one underwent provements in all strength and functional performances
a second surgery (hip pins), one died within the first 2 (P > 0.1) and walked a greater distance (P = 0.04) in the
wk, and one withdrew consent within 4 wk of beginning 6MWT at follow-up compared with the 21 reporting no
training due to an acute illness of the spouse. However, knee-pain. The number of patients who expressed knee
those who did not start (n = 5) or complete the training pain as a minor restricting factor was unchanged (n = 4)
programme exhibited similar demographic and baseline during the first and last leg press training session.
data, compared with the 31 patients who completed the
strength-training programme (Table 1), and none of the Hip pain
patients who dropped out cited reasons specific to the Regarding hip pain, only six out of the 39 patients (15%)
programme itself. experienced more than light pain (VRS > 1) in the frac-
tured hip during the baseline knee-extension strength
Feasibility of the programme test, but the performances of these patients did not dif-
Weight loads for the 15, 12 and 10 RM strength training fer from those reporting light or no pain (P = 0.9). Eight
for fractured limb knee extension (Figure 2A) and bilat- patients reported more than light hip pain during the first
eral leg press (Figure 2B) training increased progressively 15-RM strength-training session (Figure 3C), but their
(P < 0.001) from 12% to 81% (Table 2). At the same performances did not differ from those reporting none (n
time, hip fracture-related pain was reduced (Figure 3 A-B). = 18) to light pain (n = 6). Hip fracture-related pain was
Adherence to the programme was noteworthy, with 95% in general very rare in the subsequent strength-training
of possible sessions completed (352 out of 372 possible). and testing sessions and appeared unrelated to perfor-
Of some concern, 10 patients reported knee pain as mance (Figure 3D). In contrast, hip fracture-related pain
a minor restricting factor in the last 10 RM session of was present in 26% of the TUG, 41% of the 10mWT
the fractured limb in the knee extension strength train- and 63% of the 6MWT performances at baseline testing

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 Overgaard J et al . Strength training shortly after hip fracture

A 100
15 RM-F B 100 15 RM-F
15 RM-L 15 RM-L
90 90
12 RM-F 12 RM-F
80 12 RM-L 80 12 RM-L
10 RM-F 10 RM-F
Percentage with hip-pain

Percentage with hip-pain

70 10 RM-L 70 10 RM-L
60 60
50 50
40 40
30 30
20 20
10 10
0 0
No pain Light Moderate Severe Intolerable No pain Light Moderate Severe Intolerable
Fractured hip-pain level Fractured hip-pain level

C 100 At-rest D 100

At-rest
During fractured strength testing During fractured strength testing
90 During functional performances 90 During functional performances
During progressive strength traning During progressive strength traning
80 80

Percentage with hip-pain

Percentage with hip-pain

70 70

60 60

50 50

40 40

30 30

20 20

10 10

0 0
No pain Light Moderate Severe Intolerable No pain Light Moderate Severe Intolerable
Pain level at baseline Pain level after 6 wk training

Figure 3 Hip pain. A: Hip pain over 12 fractured knee-extension strength-training sessions; B: Hip pain over 12 bilateral leg press sessions; C: Hip pain at rest and
at the time of baseline functional testing or at the first strength-training session; D: Hip pain at rest and at the last testing or training session. RM: Repetition maximum;
F: First session; L: Last session.

(Figure 3C). No significant influence was observed for 11% and 59%, respectively, whereas the SF-36P im-
the TUG or fast speed walking tests (P > 0.1), whereas proved by 10% (Table 2, Figure 4A). Further analysis of
patients reporting more than light hip fracture-related the correlations among all of the different outcome vari-
pain during the baseline 6MWT actually walked a signifi- ables after the 6-wk programme revealed that the maxi-
cantly shorter distance of 174 m, compared with 233 m mal isometric fractured limb knee-extension strength was
for those with less pain (P = 0.02), and very few reported significantly correlated with all of the variables (except
more than light pain at the 6-wk follow-up testing (Fig- for the SF-36M) and was superior to that of the non-
ure 3D). fractured limb (Figure 4B).
A conservative intention-to-treat analysis for all 39
Follow-up patients, including baseline data carried forward for the
The patients who completed the 6-wk programme exhib- eight dropouts, demonstrated similar 6-wk functional
ited significant improvements (P < 0.001) in the objective improvements, compared with those patients who com-
walk measurements, ranging from -31% for the TUG to pleted the programme (Figure 4A).
61% for the 6MWT (Table 2, Figure 4A). Twenty-six of
the 31 patients (84%) exhibited improvements of more
than 50 m (range 60-278 m) for the 6MWT, while 81% DISCUSSION
improved by more than 0.1 m/s for the 10mWT. The To our knowledge, this was the first physiotherapy
maximal isometric knee-extension strength improved (P programme including progressive strength training for
< 0.001) in both the fractured and non-fractured limbs, community-dwelling older patients that commenced
by 67% and 21%, respectively. The strength deficit in within a few wk after hip fracture surgery in an outpatient
the fractured limb decreased after rehabilitation, from an geriatric health centre. We determined that 6 wk of lower
average of 40% at baseline to 17% at the study’s conclu- limb strength training in general seems feasible (weight
sion, compared with the non-fractured limb. In addition, loads increased, and only three patients (9%) who started
the Barthel-20 and the NMS improved (P < 0.001) by the programme were not able to complete it), and we

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 Overgaard J et al . Strength training shortly after hip fracture

A 100 Followed 6-wk program (n = 31) B 1.0 Knee-extension strength, fractured

90 Intention to treat analysis (n = 39) 0.9 Knee-extension strength, non-fractured

80 0.8

Correlation coefficient (r)

b
70 0.7
Changes in percentage

b
b b a
60 0.6 a
b b a
a
50 0.5
a
a a a
40 b 0.4 a a
b b
30 b 0.3
b
20 b 0.2
a a
10 a a 0.1

0 0.0
FKES NFKES 10mWT TUG 6MWT SF-36P NMS Barthel Tandom TUG 10mWT 6MWT SF-36P NMS Barthel

Figure 4 Follow up. A: Improvements in function and knee-extension strength after 6 wk of training, bP < 0.001 vs Intention to treat analysis (n = 39); B: Correlations be-
tween knee-extension strength and function after 6 wk of training, aP < 0.05 vs Knee-extension strength, non-fractured. FKES: Fractured knee extension strength; NFKES:
Non-fractured knee extension strength; 10mWT: 10-m walk test; 6MWT: 6-min walk test; SF-36P: Short form-36 physical; NMS: New mobility score.

observed large improvements in objective and patient- 25% of patients experienced moderate to severe hip pain
reported outcome measurements, including a conserva- during the first 15-RM knee-extension training sessions,
tive intention-to-treat-analysis. Systematic registration but the percentage dropped to only 6% reporting moder-
of hip fracture-related pain revealed reduced pain levels ate pain at the last 15-RM session and to 0% at the last
during strength training, indicating that most of the 10-RM session after 6 wk. Similarly, only 4% of patients
patients could tolerate the progressive strength-training reported moderate hip pain as the highest score at the
programme when commenced within 2-3 wk after hip last leg press session. To complete the “pain” picture, up
fracture surgery, without hip pain interfering. to 63% (6MWT) of patients experienced moderate to
Nonetheless, an unexpected and increasing number intolerable pain during the objective outcome measure-
of patients reported knee pain as a minor restricting fac- ments at baseline testing. Nonetheless, hip pain “only”
tor during the fractured knee-extension strength train- influenced the baseline 6MWT performances and did not
ing. Importantly, no dropouts and improvements similar compromise performance after 6 wk of training. Thus,
to those not experiencing this problem were observed. it seems possible to increase weight loads progressively;
Additionally, knee-extension strength training is recom- patients might experience a decrease in hip pain within an
mended nationally for subjects with mild knee osteo- early 6-wk strength-training programme
arthritis in the study country. In addition, clinicians are
provided with the details of specific weight loads used Restricting factors
from the start to the end of the 15- to 10-RM sessions Positively, the pre-defined measurement of hip fracture-
for fractured limb knee-extension and bilateral leg press related pain was of minor influence, but we did find that
training. a number of patients reported knee pain as a minor re-
stricting factor in their fractured knee-extension strength
Weight load training as intensity increased, which was likely related to
The mean absolute weight load increased by ≥ 52%, patella femoral osteoarthritis. Although no dropouts and
19% and 12% within the 15, 12 and 10 RM knee- similar improvements were observed for these patients,
extension and leg press sessions, respectively, with an ac- these reports of knee pain should be noted. Unfortunate-
companying decrease in hip fracture-related pain. These ly, we did not monitor whether these patients reduced
increases emphasise the importance of adjusting weight their pain medications over the 6-wk programme, nor
loads on a set-to-set basis, as reported in previous stud- did we assess information about former or present knee
ies of patients after knee arthroplasty[37], for the strength problems, e.g., knee osteoarthritis, which could potentially
training to be progressive, compared to re-evaluation ev- have explained these changes. We therefore recommend
ery 2-wk[3] or over a longer interval[15,16], using a one-RM the leg press as a more appropriate exercise for patients
estimation for the training. who report knee pain, as fewer patients reported pain
during this exercise, compared with the knee-extension
Hip pain exercise.
Hip fracture-related pain is common and seems to com-
promise functioning in the short and long terms after Objective outcome measures
hip fracture surgery [31,32,39,40]. Critics might therefore The maximal isometric knee-extension strength of the
argue that it is not possible to implement our strength fractured limb increased by a mean of 67%, compared
programme due to pain problems. We found that up to with 21% for the non-fractured limb, but a mean frac-

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 Overgaard J et al . Strength training shortly after hip fracture

tured strength deficit of 17% persisted at the 6-wk less than 10 s at follow-up - a time considered normal for
follow-up. It is possible that initiating a strength-training older individuals[33].
programme even earlier could have reduced this deficit
further, which should be examined in the future. None- Standardised walking aid
theless, these results were better than the previously re- The influence of different walking aids on functional
ported leg extensor power deficit of 26% after another performance has been reported for walking velocity[47],
early 6-wk strength programme that, in addition, required the 2-min walk test[48] and for the TUG[34,49]. Thus, the
standard physical therapy on all week days[3]. Further- effect of rehabilitation could be overestimated if the
more, improvements in our study were much larger than same walking aid were not used during pre- and post-
those reported (11%) for fractured knee-extension torque rehabilitation testing[34]. All patients with hip fractures
in older patients with hip fractures following a late (mean use some type of walking aid in the early period after the
of 1587 ± 736 d after fracture) 12-wk intensive strength- fracture[50,51], and they commonly change to a less sup-
power programme[41]. In the present study, although portive aid, or they eliminate walking aids altogether after
not eliminated, the fractured limb strength deficit was rehabilitation[43,50].
reduced by 23% and reached the non-fractured baseline Thus, functional improvements beyond natural re-
level. Thus, if fractured single-limb leg press training had covery might more truly be related to the rehabilitation
been chosen, instead of bilateral training, this difference programme in the present study, using a standardised
might have been even further diminished. This relation- functional walking aid pre- and post-testing.
ship should be given high priority, as the importance of
reducing asymmetric strength deficits after hip fracture Patient-reported outcome measurements
is further emphasised; the fractured knee-extension Large average improvements were observed for the NMS
strength was correlated with all of the functional assess- (59%), compared with the Barthel-20 and the SF-36.
ments at the follow-up testing and was superior to that However, only three patients reached their pre-fracture
of the non-fractured limb. Similar associations have been NMS functional levels. The ceiling effect seen for the
reported at earlier time points after hip fracture surgery[2]. Barthel-20 at baseline (median of 18, IQR 17-20) was
Performance in the TUG, the 10mWT and the even more obvious in the follow-up testing, as reported
6MWT improved by a mean of 31%-61%, whereas no in two earlier studies[3,15]. Thus, as for the tandem balance
improvement was observed for the median tandem bal- test, the Barthel-20 index cannot be recommended for
ance values. The latter results were probably related to a measuring progress in similar groups of patients with hip
ceiling effect already present at baseline, which indicates fractures.
that the tandem test is probably not suitable for measur- Although significant and correlated with measures of
ing progress in balance within this patient group. knee-extension strength for both limbs upon follow-up,
Natural recovery and/or less hip pain during follow- only small improvements (10%) in self-rated health (SF-
up testing probably should be credited to some of the 36P) were reported, whereas no improvement was ob-
large improvements observed in our study, particularly served for the SF-36M. These results might be related to
with regard to knee-extension strength and the 6MWT. the patients, to some extent, basing their self-rated health
Moreover, our patient group walked a mean of 323 m, on their daily lives and function pre-fracture - a level not
compared with a mean of 297 m in a Norwegian study attained after the 6-wk programme. Similarly, a “later”
that examined patients after ceasing standard rehabili- 3-mo hip fracture intervention programme reported no
tation and after an additional 3 mo of rehabilitation, effect on self-rated health measurements[15].
including strength training twice weekly plus home train-
ing once weekly[15]. In addition, 84% of our patients im- Study weaknesses and strengths
proved by more than 50 m, which has been considered a Functional improvements should be considered in light
meaningful change for the 6MWT in older adults[42] and of the non-randomised design, the level of hip fracture-
in patients with hip fractures (> 54 m)[43]. related pain upon baseline testing and the natural recov-
Different opinions exist regarding what should be ery over this early time period after hip fracture surgery.
considered a meaningful improvement in gait speed after Thus, although we eliminated the potential influence of
hip fracture, ranging from 0.1[44] to 0.26 m/s for a sub- walking aids on the observed functional improvements,
stantial meaningful improvement[45]. We have reported we do not know the exact effect of the progressive
improved gait speed performances, although obtained at strength-training programme. Additionally, the included
the same[3] or at a longer interval post-surgery compared patients exhibited high pre-fracture functional and cog-
with other studies[11,15], and we have demonstrated an av- nitive levels, which thus restrict our findings to patients
erage improvement of 0.25 m/s. More than 80% of the with these characteristics. This limitation is, however,
patients improved by more than 0.1 m/s. Nevertheless, a common problem for research in this patient group,
the patients did not reach the maximum gait speed level and our expectation is that patients with lower levels
considered “normal” for older people in their 70 s[46]. of functioning and cognition would also benefit from
The improvements in the TUG exceeded the standard the programme, which was seen when patients with de-
error of measurement (2.2 s), but only two patients took mentia were provided with an appropriate rehabilitation

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 Overgaard J et al . Strength training shortly after hip fracture

programme[52]. Another limitation was the consumption confirmation in a randomised, controlled trial.
of pain medication before testing and training, as well as Terminology
former knee problems, which were not monitored or re- The feasibility of a progressive strength-training programme: If the absolute
strength training loads increased progressively and if, at the same time, hip
corded. fracture-related pain during training remained the same or if it decreased over
One strength of the study was the systematic record- time. Progressiveness of the strength-training programme: The reduction in
ing of hip fracture-related pain, in addition to other the number of repetitions from 15 to 12 to 10 during the 6-wk strength-training
factors that restricted the progressive strength training. programme is followed by a corresponding increase in the intensity from 15 to
Another strength regarding the large improvements seen 12 to 10 repetitions maximum.
for both objective and subjective measurements was the Peer review
The aim of authors is to investigate the feasibility of a 6-wk progressive
blinding of the physiotherapists who conducted all of strength-training programme commenced shortly after hip fracture.
the baseline and follow-up testing to the progress and
participation in the training programme. Finally, although
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P- Reviewers Emara KM, Sebestyén A S- Editor Gou SX

L- Editor A E- Editor Wu HL

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