How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a critical appraisal

This blog is a critical appraisal of the following randomized controlled trial: How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture.

Background

Hip fractures are a common and severe problem for both the patient and the National Health Service (NHS); most occur when an elderly person has a fall. The Royal College of Physicians (RCP) (2017) reported that in 2016 Britain treated over 65,000 hip fractures in those aged 60 or older. Most spent an average of three weeks in hospital, costing the NHS over one billion pounds.

Within the research base there is a lack of evidence on which treatment method and outcome measure is best to assess for a fully functional recovery following surgery (Unnanuntana et al. 2018). In addition, there is a high level of mortality and comorbidity following a broken a hip. Regaining baseline mobility level may never be possible which can have a massive effect on a person’s quality of life (QoL) (RCP 2017). There is research suggesting that by using balance task-specific rehabilitation compared to active range of motion (AROM) and strengthening exercises will improve a patients confidence and mobility levels (Monticone et al. 2018).

What was the study?

There were 52 participants and a specific inclusion and exclusion criteria, focusing on elderly adults who were over the age of 70 who had suffered a hip fracture and had a surgical intervention.  19 participants were excluded due to issues such as stroke, chronic lung diseases, previous lower limb surgery and cognitive impairments. The participants were split evenly by a MATLAB blinded treatment code; both the biostatistician and lead researcher were blinded from the process. The physiotherapist and patients were not blinded to the different interventions, however they were blinded to the study’s hypothesis.

The intervention group were given balance specific tasks that involved proprioceptive exercises, motor-cognitive exercise and activities of daily living (ADL’s) exercises, compared to the control group who were given closed-chain exercises to improve AROM and muscle strength.  The primary outcome measure was functional ability which was assessed by a self-report Western Ontario and McMaster University Osteoarthritis Index (WOMAC).  Secondary outcomes measured pain, balance, ADLs and QoL.  The questionnaires were distributed by the same secretary pre-treatment, before hospital discharge and at the 12 month follow up.

What were the results?

The researchers demonstrate that by focusing on balance task-specific training in rehabilitation, it can improve functional ability, reduce pain, and assist in the regaining of ADL and QoL within the elderly population after a hip fracture. There was a significant difference between the two groups, with a 95% confidence interval with primary outcome and the secondary outcome measures, with a P- <0.001. The study claims that balance task-specific training was better than general rehabilitation exercises for, at a minimum, 12 months post-surgery.

Strengths and weakness of the study?

Evaluating the study using the CASP tool, and by following the guideline and answering questions about the study, will aid a deeper understanding of the study and demonstrate whether the results can be used in a clinical environment.

The sample size of the study was small (52 Italian participants with a hip fracture) which can lead to a small number of outcome events. This, in turn, can lead to reduced confidence that any difference between the groups reflects the differences in the treatments rather than the effects of chance.

However, the recruitment was very similar between both groups. The intervention and control group were split very evenly using the MATLAB program, having similar age range, gender, BMI, social class, comorbidities and physical function/activity level as their baseline. The largest difference in the whole sample size was that 15 out of 52 were male; this is more likely due to women having a longer life expectancy compared to males (Sanders 2018). Furthermore, the exclusion criteria limits the ability to generalise due to other comorbidities and the high mortality rates following a hip fracture (Monticone et al. 2018).

Interestingly, in the study, it suggests that you can generalise within the same population and condition, using balance task-specific exercises during treatment (Monticone et al. 2018). This could be due to using strong outcome measures such as WOMAC and the Berg Balance Scale.

The intervention and control treatments were different between groups. Therefore, for the results to be valid, both groups had the same number and amount of treatment sessions over the three weeks of rehabilitation. Additionally, all mobility equipment and gait re-education was the same for both groups otherwise it would create an ethics issue which in turn would affect the validity of the results. The method of treatment in the control group was lying in supine, performing closed chain exercises. However, by not weight-bearing post surgery, this can have a negative effect on the rehabilitation and the functional ability outcome (Sherrington 2003).

Conclusion

The study demonstrates that there is a significant difference between using balance task-specific training in elderly adults who have had a broken hip, for up to a 12-month period post surgery. Yet we still need further research into this topic due to the high mortality rates following a fractured hip (RCP 2017).

References

CRITICAL APPRAISAL SKILLS PROGRAMME (CASP)., 2018. CASP Checklists – CASP – Critical Appraisal Skills Programme [online]. [viewed 3 December 2018].

MONTICONE, M., AMBROSINI, E., BRUNATI, R., CAPONE, A., PAGLIARI, G., SECCI, C., ZATTI, G. and FERRANTE, S., 2018. How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial. Clinical Rehabilitation [online]. vol. 32(3):340-351 [viewed 4 December 2018].

SANDERS, S., 2018. National life tables, UK – Office for National Statistics [online]. [viewed 6 December 2018].

SHERRINGTON, C., LORD, S. and HERBERT, R., 2003. A randomised trial of weight-bearing versus non-weight-bearing exercise for improving physical ability in inpatients after hip fracture. Australian Journal of Physiotherapy [online]. vol. 49(1):15-22 [viewed 4 December 2018].

THE ROYAL COLLEGE OF PHYSICIANS (RCP)., 2017. National Hip Fracture Database annual report 2017 [online]. [viewed 6 December 2018].

UNNANUNTANA, A., JARUSRIWANNA, A. and NEPAL, S., 2018. Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture. Archives of Orthopaedic and Trauma Surgery [online]. vol. 138 (12):1671-1677 [viewed 5 December 2018].

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