hip fracture rehab protocol pdf

Hip fracture rehabilitation is a crucial process, guided by evolving clinical guidelines and protocols, aiming to restore function and independence post-surgery for optimal patient outcomes.

Understanding Hip Fractures

Hip fractures commonly result from falls, particularly in older adults with osteoporosis, though high-impact trauma can also be a cause. These fractures disrupt the normal anatomy of the hip joint, significantly impacting mobility and independence. Understanding the specific fracture type – intracapsular (within the hip joint capsule) or extracapsular (outside the capsule) – is vital, as it influences the rehabilitation approach and expected recovery timeline.

The severity of the fracture, alongside pre-existing health conditions (co-morbidities), and the chosen surgical fixation method (e.g., hip replacement, internal fixation) all play a role in shaping the rehabilitation plan. Effective rehabilitation protocols, informed by guidelines from organizations like NICE, SIGN, and the Australia and New Zealand Hip Fracture Registry, are essential for maximizing functional recovery and minimizing long-term complications.

The Importance of Rehabilitation

Rehabilitation following a hip fracture is paramount for restoring lost function, reducing disability, and improving quality of life. A well-structured program, adhering to established clinical guidelines, aims to regain strength, balance, and mobility, enabling patients to return to their pre-fracture activity levels. Early mobilization, initiated in the acute care setting, is crucial to prevent complications like muscle weakness, joint stiffness, and pressure ulcers.

Comprehensive rehabilitation encompasses pain management, progressive exercise, and functional training, often utilizing assistive devices initially. Assessments like the 5TSS and 30-second sit-to-stand tests, alongside the 6-Minute Walk Test, objectively measure progress and identify fall risks. Adherence to evidence-based protocols, considering individual patient factors, optimizes outcomes and promotes successful community reintegration.

Phase 1: Acute Care & Early Mobilization (0-7 Days Post-Op)

Initial focus centers on pain management, assessment, and gentle bed mobility and range of motion exercises to initiate recovery safely.

Pain Management Strategies

Effective pain management is paramount during the initial post-operative phase, directly influencing a patient’s ability to participate in rehabilitation. A multi-modal approach is typically employed, combining pharmacological interventions with non-pharmacological techniques. Pharmacological options include prescribed analgesics, carefully titrated to manage pain levels while minimizing side effects.

Non-pharmacological strategies are equally vital. These encompass positioning techniques to alleviate pressure, ice or heat application to reduce inflammation and discomfort, and gentle range of motion exercises within pain-free limits. Psychological support and relaxation techniques, such as deep breathing exercises, can also contribute to pain reduction.

Regular pain assessments, utilizing standardized scales, are crucial to monitor effectiveness and adjust the treatment plan accordingly. Proactive pain control facilitates early mobilization and participation in rehabilitation, ultimately improving functional outcomes.

Initial Assessment & Goals

A comprehensive initial assessment is fundamental to tailoring a rehabilitation program; This evaluation encompasses the patient’s medical history, fracture characteristics (type and location), surgical fixation method, pre-fracture functional status, and current pain levels. Physical therapists assess range of motion, muscle strength, balance, gait, and functional mobility – including bed mobility and transfers.

Based on this assessment, individualized goals are collaboratively established with the patient and their healthcare team. Short-term goals focus on pain control, edema management, and achieving basic functional skills like safe transfers. Long-term goals center around restoring independence in activities of daily living (ADLs), improving gait and balance, and facilitating a return to prior levels of function.

Realistic and measurable goals are essential for motivating the patient and tracking progress throughout the rehabilitation journey.

Bed Mobility Exercises

Bed mobility exercises are initiated early, even within the first 24-48 hours post-operatively, to prevent complications and prepare the patient for more advanced activities. These exercises begin with gentle ankle pumps and quadriceps sets to promote circulation and muscle activation. Progressing, patients practice supine to side-lying turns, maintaining hip precautions to protect the surgical site.

Emphasis is placed on maintaining proper body mechanics and avoiding hip flexion, adduction, and internal rotation. Bridging exercises are introduced to strengthen gluteal muscles, crucial for hip stability. Patients then work on scooting and repositioning in bed, gradually increasing independence.

The goal is to establish a solid foundation of bed mobility skills before progressing to sitting and transfers, ensuring patient safety and maximizing functional recovery.

Early Range of Motion Exercises

Early range of motion (ROM) exercises are carefully implemented, adhering strictly to post-operative precautions to avoid dislocation. Gentle ankle pumps, knee bends, and hip abduction/adduction (within safe range) are initiated to maintain joint mobility and prevent stiffness. These movements are performed passively by the therapist initially, then progressed to active-assisted and active ROM as tolerated.

Emphasis is placed on pain management and monitoring for any signs of instability. Heel slides and gentle hip flexion exercises are introduced cautiously, always respecting the surgical fixation. The focus is on restoring a functional ROM gradually, avoiding forceful movements or positions that compromise the healing process.

Regular ROM exercises are vital for preventing contractures and optimizing long-term functional outcomes.

Phase 2: Subacute Rehabilitation (7-21 Days Post-Op)

Subacute rehab focuses on regaining independence with transfers, initiating gait training with assistive devices, and building strength in key muscle groups.

Transfer Training (Bed to Chair, Chair to Standing)

Transfer training is a cornerstone of subacute rehabilitation, typically initiated between 7-21 days post-operatively. The initial focus is on safe and efficient transfers from the bed to a chair, progressing to chair to standing. This phase emphasizes proper body mechanics and utilizes assistive devices as needed, ensuring patient safety and minimizing fall risk.

Physical therapists carefully assess the patient’s strength, balance, and cognitive ability to tailor the training program. Strategies include verbal cues, tactile guidance, and demonstration. Emphasis is placed on weight-bearing precautions dictated by the surgical fixation method.

Progression occurs as the patient demonstrates improved control and stability. The goal is to achieve independent transfers with minimal assistance, preparing them for more advanced mobility tasks like gait training and functional activities. Regular monitoring and adjustments are crucial throughout this phase.

Gait Training with Assistive Devices

Gait training, commencing within the subacute phase (7-21 days post-op), utilizes assistive devices – walkers, canes – to provide stability and support during ambulation. Initial training focuses on proper weight-bearing, step length, and cadence, adhering to surgeon’s protocols. The physical therapist carefully monitors for compensatory patterns and addresses them promptly.

Progression involves gradually decreasing reliance on the assistive device, starting with partial weight-bearing and advancing to full weight-bearing as tolerated. Emphasis is placed on maintaining good posture and balance.

Environmental factors, such as surface texture and obstacles, are incorporated to simulate real-world walking conditions. Regular assessment of gait parameters, including speed and stride length, guides treatment adjustments. The 6-Minute Walk Test can be used to measure endurance.

Strengthening Exercises (Focus: Glutes, Quads, Hamstrings)

Strengthening exercises are paramount during the subacute phase (7-21 days post-op), targeting the gluteal muscles, quadriceps, and hamstrings – key stabilizers for hip function. Initial exercises are often isometric, minimizing stress on the fracture site, progressing to active-assisted and then active range of motion.

Examples include gluteal sets, quad sets, hamstring curls, and short arc quads. Resistance is gradually increased using ankle weights or resistance bands.

Bridging exercises are introduced to strengthen the glutes and hamstrings synergistically. Proper form and controlled movements are emphasized to prevent compensatory strategies. Regular assessment of muscle strength guides progression, ensuring patient safety and optimal recovery.

Balance Training (Static & Dynamic)

Balance training is integral to hip fracture rehabilitation, reducing fall risk and enhancing functional mobility. Initially, static balance exercises are performed, such as maintaining a stable stance with a narrow base of support, progressing to single-leg stance with minimal support.

Dynamic balance exercises are then introduced, including weight shifting in multiple directions, tandem stance, and reaching activities. Perturbations can be added gradually to challenge stability.

Assistive devices are used as needed, and the environment is carefully monitored for safety. The 5TSS (Five Times Sit-to-Stand) test is a valuable tool for assessing lower extremity strength and balance, providing objective data to guide progression.

Phase 3: Intermediate Rehabilitation (21-42 Days Post-Op)

This phase focuses on improving gait, strength, and proprioception, with an emphasis on reducing reliance on assistive devices and preparing for stair negotiation.

Advanced Gait Training (Reducing Assistive Device Dependence)

As patients progress, the focus shifts towards maximizing independence in ambulation. This involves a systematic reduction of assistive device use, guided by the patient’s functional abilities and safety. Initially, exercises concentrate on improving weight-bearing symmetry and step length, often utilizing parallel bars for support.

Progressive challenges are introduced, such as walking with a cane, then transitioning to walking without any assistive device for short distances. Careful monitoring of gait parameters – speed, stride length, and base of support – is essential.

The 6-Minute Walk Test (6MWT) can be utilized to objectively assess endurance and functional capacity during this phase. Clinicians should observe for compensatory strategies and address any gait deviations to prevent secondary complications. Regular reassessment and adjustments to the gait training program are crucial for optimal outcomes.

Progressive Strengthening Exercises

Building upon the foundational strength gained in earlier phases, this stage emphasizes progressively increasing resistance and complexity. Exercises target key muscle groups – gluteals, quadriceps, hamstrings, and hip abductors – crucial for hip stability and function.

Examples include resisted hip abduction/adduction, knee extensions, hamstring curls, and bridging exercises, utilizing resistance bands or light weights.

Functional exercises, like step-ups and single-leg stance, are incorporated to challenge balance and proprioception. The intensity is carefully monitored, ensuring patients can maintain proper form and avoid exacerbating pain.

Regular assessment of strength using manual muscle testing or dynamometry helps guide progression. The goal is to achieve sufficient strength to support independent ambulation and functional activities.

Proprioceptive Exercises

Restoring proprioception – the body’s awareness of its position in space – is vital after a hip fracture, as surgery and immobilization can disrupt this sense. These exercises aim to improve joint position sense and dynamic stability, reducing fall risk.

Activities include weight shifting exercises, single-leg stance with eyes open and closed, and perturbation training (controlled imbalances). Utilizing unstable surfaces like foam pads or wobble boards further challenges the neuromuscular system.

Progressive difficulty is key; start with simple exercises and gradually increase the challenge as the patient improves.

Focus is on controlled movements and maintaining balance. Regular assessment using tools like the Star Excursion Balance Test can track progress and guide exercise selection.

Stair Climbing Training

Stair climbing is a functional activity often limited after a hip fracture, requiring strength, balance, and coordination. Training should begin in a controlled environment with appropriate assistive devices, such as a cane or walker, and supervision from a physical therapist.

Initially, focus on ascending and descending one step at a time, emphasizing leading with the stronger leg. Progress to reciprocal stair climbing, alternating legs on each step, as strength and confidence improve.

Ensure proper form: maintain an upright posture, use handrails for support, and avoid twisting the hip.

Gradually increase the number of stairs climbed and reduce reliance on assistive devices. Regular assessment of gait and balance is crucial to ensure safety and effectiveness.

Phase 4: Late Rehabilitation & Return to Function (42+ Days Post-Op)

This phase prioritizes regaining independence in daily activities, enhancing endurance, and minimizing fall risk through functional exercises and community reintegration planning.

Functional Exercises (ADL Simulation)

Functional exercises are paramount in late-stage hip fracture rehabilitation, bridging the gap between clinical exercises and real-world activities. These exercises directly simulate Activities of Daily Living (ADLs), such as dressing, bathing, toileting, and meal preparation, fostering independence. Patients practice these tasks with increasing complexity, initially in a controlled environment and progressing to home-like settings.

Emphasis is placed on safe techniques, incorporating adaptive equipment when necessary. For example, practicing getting in and out of a chair mimicking a home chair, or reaching for objects at varying heights. Simulating kitchen tasks, like retrieving items from cupboards, builds strength and coordination. The goal is to build confidence and competence in performing essential self-care tasks, ultimately enabling a safe and successful return to a fulfilling lifestyle. Regular assessment and modification of these exercises are crucial to meet individual patient needs and progress.

Endurance Training (6-Minute Walk Test)

Endurance training is vital for regaining functional capacity after a hip fracture, and the 6-Minute Walk Test (6MWT) serves as a valuable performance-based measure. This test assesses walking endurance in older adults during post-acute and outpatient rehabilitation, reflecting their ability to perform activities requiring sustained ambulation. Patients walk as far as possible for six minutes on a 12-meter walkway, utilizing assistive devices if needed.

The distance covered in meters is meticulously recorded, providing a quantifiable metric of progress. Regular 6MWT assessments help monitor improvements in cardiovascular fitness and lower limb strength. Training protocols involve gradually increasing walking duration and distance, incorporating rest periods as required. This approach enhances stamina, reduces fatigue, and prepares patients for the demands of daily life, ultimately promoting a higher quality of life post-fracture.

Fall Risk Assessment & Management (5TSS/30-Second Sit-to-Stand)

Fall risk assessment is paramount in hip fracture rehabilitation, as falls can significantly impede recovery and lead to re-injury. Physical therapists utilize standardized tests like the 5 Times Sit-to-Stand (5TSS) and the 30-Second Sit-to-Stand test to objectively measure lower limb strength, balance, and functional mobility. These tests are administered across various care settings – inpatient, home, and outpatient – to track progress.

The 5TSS measures the time taken to repeatedly rise from a seated position, while the 30-second test counts the number of stands completed within the timeframe. Results inform targeted interventions, including strengthening exercises, balance training, and gait re-education. Addressing identified deficits minimizes fall risk and promotes safe, independent mobility, crucial for successful reintegration into the community.

Community Reintegration Planning

Community reintegration planning is a vital final phase of hip fracture rehabilitation, focusing on enabling patients to safely resume their pre-injury lifestyle. This involves a holistic assessment of the patient’s home environment, social support network, and functional abilities. Addressing potential barriers, such as home modifications (e.g., grab bars, removing trip hazards), is crucial for preventing falls and promoting independence.

The plan should incorporate strategies for managing activities of daily living (ADLs), transportation, and social engagement. Collaboration with occupational therapists ensures patients can confidently perform essential tasks. Furthermore, providing education on energy conservation techniques and fall prevention strategies empowers patients to maintain long-term well-being and participate fully in their community.

Specific Considerations

Rehabilitation plans must be individualized, accounting for fracture type, co-morbidities, and surgical fixation methods to optimize recovery and patient-specific outcomes.

Fracture Type & Rehabilitation Adjustments

Hip fracture rehabilitation protocols necessitate adjustments based on the specific fracture type – intracapsular versus extracapsular – significantly influencing recovery trajectories. Intracapsular fractures, involving the femoral neck, often present a higher risk of avascular necrosis, demanding a more cautious and gradual progression of weight-bearing exercises. Conversely, extracapsular fractures, such as intertrochanteric or subtrochanteric fractures, generally allow for earlier weight-bearing, but require focused strengthening of the gluteal muscles and careful monitoring for malunion.

The chosen surgical fixation method – hip hemiarthroplasty, total hip arthroplasty, or internal fixation – also dictates rehabilitation modifications. Post-arthroplasty patients typically require a more extensive range of motion and strengthening program compared to those with internal fixation. Furthermore, the presence of other injuries alongside the hip fracture necessitates a holistic approach, prioritizing stabilization and addressing all impairments concurrently to ensure a safe and effective rehabilitation process.

Impact of Co-morbidities on Rehab

The presence of co-morbidities profoundly impacts hip fracture rehabilitation, demanding individualized protocol adjustments. Conditions like cardiovascular disease, respiratory illness, and diabetes can limit exercise tolerance and delay healing, necessitating a slower, more carefully monitored progression. Cognitive impairment can hinder a patient’s ability to follow instructions and participate actively in therapy, requiring simplified exercises and increased caregiver involvement.

Osteoporosis, frequently co-existing with hip fractures, increases the risk of further fractures and necessitates careful weight-bearing precautions. Pre-existing arthritis can exacerbate pain and limit range of motion, requiring pain management strategies and modified exercises. A comprehensive assessment of all co-morbidities is crucial to tailor the rehabilitation program, optimizing safety and maximizing functional recovery while accounting for individual limitations and medical complexities.

Surgical Fixation Method & Protocol Modifications

The chosen surgical fixation method significantly influences the hip fracture rehabilitation protocol. Internal fixation with screws, plates, or intramedullary nails generally allows for earlier weight-bearing compared to hemiarthroplasty or total hip arthroplasty. However, the stability of the fixation dictates the progression of exercises and weight-bearing restrictions;

Protocols must be modified based on fracture type and surgeon’s preferences. For instance, unstable fractures require longer periods of protected weight-bearing. Post-operative protocols often specify phases with increasing weight-bearing percentages. Careful adherence to these guidelines is vital to prevent implant failure or non-union. Regular communication with the surgical team ensures appropriate protocol adjustments, optimizing healing and functional recovery based on individual patient factors and surgical outcomes.

Clinical Guidelines & Resources

NICE, SIGN, and AHRQ provide comprehensive clinical guidelines for hip fracture management, informing evidence-based rehabilitation protocols and best practices.

NICE Guidelines (CG124)

The National Institute for Health and Care Excellence (NICE) guideline CG124 offers comprehensive recommendations for the care of individuals experiencing hip fractures. This guideline emphasizes a multidisciplinary approach, integrating medical management with specialized rehabilitation programs. It stresses the importance of early mobilization and individualized rehabilitation plans tailored to the patient’s specific needs and fracture characteristics.

CG124 advocates for prompt surgical intervention, followed by a structured rehabilitation pathway. Key areas addressed include pain management, prevention of complications like pressure ulcers and deep vein thrombosis, and the progressive restoration of mobility and function. The guideline highlights the role of physiotherapy in assessing functional abilities, implementing exercise programs, and providing education on fall prevention strategies; Furthermore, it underscores the necessity of ongoing assessment and adjustment of the rehabilitation plan based on the patient’s progress and response to treatment, ensuring optimal outcomes and quality of life.

Scottish Intercollegiate Guidelines Network (SIGN) 111

The Scottish Intercollegiate Guidelines Network (SIGN) guideline 111 provides robust recommendations for managing hip fractures within the Scottish healthcare system. Similar to NICE CG124, SIGN 111 champions a multidisciplinary team approach, prioritizing rapid assessment, surgical intervention, and a structured rehabilitation pathway. It emphasizes the significance of standardized care protocols to minimize variations and optimize patient outcomes.

SIGN 111 details specific guidance on pre-operative assessment, surgical techniques, and post-operative rehabilitation. It advocates for early mobilization, individualized exercise programs, and comprehensive pain management. The guideline also addresses the importance of addressing co-morbidities and optimizing nutritional status. Furthermore, SIGN 111 stresses the need for ongoing monitoring of functional progress and adaptation of the rehabilitation plan to meet individual patient needs, promoting independence and reducing the risk of complications and falls.

Australia and New Zealand Hip Fracture Registry Guidelines

The Australia and New Zealand Hip Fracture Registry (ANZHFR) provides crucial data-driven guidelines for improving hip fracture care across both nations. These guidelines emphasize a standardized approach encompassing all phases of care, from admission to discharge and beyond, focusing on minimizing time to surgery and optimizing rehabilitation. The registry’s recommendations advocate for early mobilization and a structured rehabilitation program tailored to individual patient needs and fracture characteristics.

ANZHFR guidelines highlight the importance of multidisciplinary collaboration, including surgeons, physicians, nurses, and allied health professionals. They promote the use of evidence-based interventions, such as progressive strengthening exercises, balance training, and gait re-education. The registry also emphasizes the need for comprehensive fall risk assessment and management strategies to prevent re-fractures and enhance long-term functional outcomes, contributing to improved quality of life for patients.

Agency for Health Research and Quality (AHRQ) Guidelines

The Agency for Health Research and Quality (AHRQ) contributes to hip fracture rehabilitation through comprehensive guidelines focused on enhancing the quality and effectiveness of healthcare delivery. AHRQ’s resources emphasize a patient-centered approach, advocating for shared decision-making and individualized treatment plans. These guidelines support the implementation of evidence-based practices throughout the rehabilitation continuum, from acute care to community reintegration.

AHRQ promotes the use of standardized assessment tools and outcome measures to track patient progress and identify areas for improvement. Their recommendations highlight the importance of addressing co-morbidities and optimizing medication management to maximize rehabilitation potential. Furthermore, AHRQ guidelines emphasize the role of interdisciplinary teams in coordinating care and ensuring seamless transitions between healthcare settings, ultimately aiming to improve functional outcomes and reduce long-term disability.