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CPG for Hip Fracture RehabilitationINTRODUCTIONHip fractures are common among older adults, with increasing incidences occurring as the population ages [1].In 1997, there were 1.26 million hip fractures worldwide,which is expected to double in 2025 and reach 4.5 millionin 2050 [2]. In a population-based study using the KoreanNational Health Insurance claims data, the annual incidence was 104.06 hip fractures (female 146.38 and male61.72) per 100,000 people aged 50 in 2003 [3].The hip joint is located between the proximal femurand the acetabulum. A hip fracture refers to a fracture inthe proximal femur that can be divided into femoral neck,intertrochanteric, and subtrochanteric fractures [4]. Hipfractures are classified as intracapsular or extracapsularfractures based on the relationship between the fracturesite and the hip joint capsule. Since the joint capsulestarts at the femoral neck and connects to the pelvis, femoral neck fractures are intracapsular, while intertrochanteric or subtrochanteric fractures are extracapsular [5]. Asthe period of immobilization after surgery increases, previous comorbidities worsen and new complications arelikely to occur. Therefore, early rehabilitation treatment isessential for promoting postoperative recovery.Hip fractures are common fragility fractures usuallycaused by low-energy trauma, such as falls, primarily inolder people with osteoporosis [6]. Hip fractures result inhigh morbidity rates and seriously impair mobility andthe ability to perform daily activities [7]. The mortalityrate within one year after the occurrence of a hip fractureis reported to be 18%–31%. In the long term, only half ofthe patients were able to walk without assistance and approximately one-fifth required care services [8]. Despiteconventional rehabilitation treatments, significant mobility limitations have been reported [9]. With hip fractures, the life expectancy of people aged 80 years wasshortened by 1.8 years, and the life expectancy of thosewith hip fractures decreased by 25% compared to theage-matched people without hip fractures [10]. When ahip fracture occurs in women aged 70 years, the excessmortality rate is 9 per 100 patients [11]. In a study of hipfracture surgery (HFS) (n 2,208), intensive rehabilitationafter surgery significantly reduced the mortality rate at 6months [12]. One study showed that 50% of postoperative deaths could be avoided [13]. As the population ages,more hip fractures occur, and the socioeconomic burdenis increased [14,15]. Through rehabilitation treatmentafter HFS, gait, physical function, muscle strength, andbalance were improved. The number of hospitalizationsand frequency of falls also decreased [16].Appraisal of other clinical practice guidelines for hipfracture rehabilitationClinical guidelines (CGs) focused on rehabilitationcomprising physical and occupational therapies and themanagement of comorbidities/complications after HFShave not yet been developed. Currently accessible clinicalpractice guidelines (CPGs) that cover the diagnosis of hipfracture to surgery and postoperative rehabilitation include: National Institute for Health and Care Excellence(NICE) CG124 [17], Blue Book [18], Scottish Intercollegiate Guidelines Network (SIGN) 111, Scottish Standardsof Care for Hip Fracture Patients [19,20], the guidelines ofAustralia and New Zealand Hip Fracture Registry and National Health and Medical Research Council [21,22], andthe Agency for Health Research and Quality (AHRQ) ofthe United States [23]. Postoperative rehabilitation guidelines were referred from these to develop the currentguidelines (Table 1). A CPG for physical therapy in olderadults with hip fractures was recently published [24].Purpose of CPGsThis guideline presents evidence for fracture rehabilitation proven by scientific methods to clinicians and otherhealthcare professionals. We aimed to systematicallyprovide the information necessary for decision-makingon issues related to hip fracture rehabilitation: (1) the importance of multidisciplinary management after HFS, (2)components and effects of rehabilitative treatments afterHFS, (3) community-based rehabilitation following intensive rehabilitation after HFS, and (4) combined medical problems after HFS (pain, venous thrombosis, urinarytract infection [UTI], osteoporosis, and nutrition). Theguideline will contribute to restoring maximum mobilityand physical ability, improving the quality of life (QoL),and ultimately reducing the refracture and mortality ratesin patients who undergo HFS.Scope of CPGRehabilitation treatment after HFS in adults was presented with physical and occupational therapies, and theissues related to community care, associated comorbidi-www.e-arm.org227

ilizationScottish Standards of care forhip fracture patients [20], 2018SIGN 2009 [19]Standard 8 Mobilisation has8.5 Early mobilizationbegun by the end of the first- If the patient’s overall mediday after surgery and everycal condition allows, mobilipatient has physiotherapy as- sation and multidisciplinary1.7.2 at least once a day andensure regular physiotherapysessment by end of day two.rehabilitation should beginreview (2011)within 24 hours postoperatively. (Good practice points)1.6.1 Operate on patients with-W eight-bearing on the inthe aim to allow them to fullyjured leg should be allowed,unless there is concern aboutweight bear (without restricquality of the hip fracturetion) in the immediate postrepair (e.g., poor bone stockoperative period. (2011)or comminuted fracture).(Good practice points)1.8.1 From admission, ofStandard 7: Every patient who 9.2.3 Medical managementfer patients a formal, acute,is identified locally as beingand rehabilitationorthogeriatric or orthopaedic frail, receives comprehensive - A multidisciplinary teamward-based Hip Fracturegeriatric assessment withinshould be used to facilitateProgramme. (2011)three days of admission.the rehabilitation process.- Rehabilitation after hipfracture incorporating theStandard 11: Every patient’sfollowing core componentsrecovery is optimised by aof assessment and managemulti-disciplinary team apment: medicine; nursing;proach such that they are disphysiotherapy; occupationalcharged back to their originaltherapy; social care. Adplace of residence within 30ditional components maydays from the date of admisinclude: dietetics, pharmacy,sion.clinical psychology.Standard 9: Every patient hasa documented OccupationalTherapy Assessment commenced by the end of daythree post admission.NICE 2017 [17](NICE 2011 [176] updateversion)1.7.1 Mobilisation on the dayafter surgery (2011)Table 1. Summary of CPGs of hip fracture management19. Rehabilitation-P atients with hip fractureshould be offered a coordinated multidisciplinaryrehabilitation program withthe specific aim of regainingsufficient function to returnto their prefracture living arrangements.-E arly multidisciplinarydaily geriatric care reduces inhospital mortality and medical complications in olderpatients with hip fracture,but does not reduce length ofstay or functional recovery.-18. Mobilisation-E arly assisted ambulation(begun within 48 hours ofsurgery) accelerates functional recovery.Mak et al. [22], 2010Kyunghoon Min, et al.

NICE 2017 [17]Scottish Standards of care for(NICE 2011 [176] updatehip fracture patients [20], 2018version)Standard 7: Every patient whoComorbidities and Referral to Clinical guidelineis identified locally as beingcomplications(CG103)frail, receives comprehensiveDelirium: prevention, diagnogeriatric assessment withinsis and managementthree days of admission: fallshistory and assessment inReferral to NICE guidelinecluding an ECG and lying and(NG89)standing blood pressures,Venous thromboembolism inassessment of co-morbiditiesover 16sand functional abilities,medication review, cogniReferral to Clinical guidelinetive assessment, nutritional(CG146)assessment, assessment forOsteoporosis: assessing thesensory impairment, contirisk of fragility fracturenence review, assessment ofbone health and dischargeReferral to Clinical guidelineplanning.(CG32)Nutrition support for adultsStandard 10: Every patientwho has a hip fracture has anassessment of, or a referralfor, their bone health prior toleaving the acute orthopaedic ward.Table 1. Continued 1Mak et al. [22], 20108.1 Pain relief5. Thromboprophylaxis- Regular assessment and for- - L ow molecular weight hepamal charting of pain scoresrin and mechanical devicesshould be adopted as routinepractice in postoperative6. Pressure gradient stockingscare. (Recommendation B)8. Type of analgesia8.7 Urinary catheterization-F emoral nerve block-U rinary catheters should be- I ntrathecal morphineavoided except in specificcircumstances. (Good prac15. Urinary catheterisationtice points)- I ntermittent catheterization-W hen patients are catheteris preferableised in the postoperativeperiod, prophylactic antibi16. Nutritional statusotics should be administered - P rotein and energy suppleto cover the insertion of thementcatheter. (Good practicepoints)17. Reducing postoperativedelirium9.2.1 Nutrition-P rophylactic low-dose halo-S upplementing the diet ofperidolhip fracture patients in rehabilitation with high energy20. Osteoporosis treatmentprotein preparations con- Vitamin D supplementation,taining minerals and vitaannual infusion of zoledronicmins should be considered.acid(Recommendation A)-P atients’ food intake shouldbe monitored regularly, toensure sufficient dietary intake. (Good practice points)SIGN 2009 [19]CPG for Hip Fracture Rehabilitationwww.e-arm.org229

230www.e-arm.orgCPG, clinical practice guideline; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network.Community careTable 1. Continued 2NICE 2017 [17]Scottish Standards of care for(NICE 2011 [176] updateSIGN 2009 [19]Mak et al. [22], 2010hip fracture patients [20], 2018version)19. Rehabilitation9.4 Discharge management1.8.5 Only consider intermedi- A program of accelerated- Supported dischargeate care (continued rehabilidischarge and home-based reschemes with liaison nursetation in a community hoshabilitation may lead to funcfollow up can monitor papital or residential care unit)tional improvement, greaterif length of stay and ongoingtient progress at home andconfidence in avoiding subseobjectives for intermediatehelp to alleviate some ofquent falls, improvements inthese fears.care are agreed. (2011)- Liaison between hospital and health-related quality of lifecommunity (including socialand less caregiver burden.1.8.6 Patients admitted fromwork department) facilitates - Extended outpatient rehabilicare or nursing homes shouldtation that includes progresthe discharge process.not be excluded from rehasive resistance training canbilitation programmes in thealso improve physical functioncommunity or hospital, orand quality of life comparedas part of an early supportedwith home exercise alone.discharge programme. (2011)Kyunghoon Min, et al.ties, complications, and nutrition were also addressed.Diagnosis and surgical techniques for hip fractures, metastatic fractures due to tumors, and pediatric fractureswere not covered. This guideline does not limit physicians’ medical practices and is not used to evaluate them.METHODSAcknowledgement and independenceThis guideline was developed with financial supportfrom the Korean Academy of Rehabilitation Medicine(KARM) and the Korean Academy of Geriatric Rehabilitation Medicine (KAGRM). However, the developmentwas not affected by the supporting academies and wasnot supported by other groups. All members involved inthe development of the guideline (43 members of a development committee) had no conflicts of interest (COI)related to this study. The COI was required to indicatewhether or not to be involved in the development ofsimilar guidelines, employment, financial interests, andother potential interests.CPG development groupThe guideline development group consisted of a development committee, an advisor, and an advisory committee (two methodology experts and two geriatricians).Forty-three development committee members wereresponsible for determining the level of evidence andrecommendation level for each key question (KQ), consisting of 36 physicians (34 physiatrists and 2 orthopedicsurgeons), 3 nutritionists, 1 nursing staff, 1 occupationaltherapist, and 2 physical therapists.Formation of KQs Perspectives of the targets to be applied and the groupsusedThe Steering Committee prepared a draft by referringto questions related to rehabilitation from the previousguidelines for hip fracture treatment. In order to reflectthe perspectives and preferences of patients and theirguardians after HFS, the results of a questionnaire surveyconducted on 152 patients ( 65 years) at a university hospital from September 2016 to May 2017 were reviewed.They were interested in rehabilitation after surgery andwere highly anxious about postoperative pain, treatmentcosts, falls, and refractures [25].

CPG for Hip Fracture RehabilitationMoreover, in 2017, 15 orthopedic surgeons and rehabilitation physicians were surveyed regarding the perceptionof the rehabilitation process after HFS. The following twopoints were identified. First, most of them agreed that hipfracture rehabilitation was not well-organized due to lowmedical care costs and limited hospital stay, and second,they recognized the lack of collaboration in rehabilitationafter HFS.PICO selectionA total of 15 KQs reflecting the perspectives of theguideline users and patients were created consisting offour categories: (1) multidisciplinary approach (1 KQ), (2)rehabilitation treatment (6 KQs), (3) community care (2KQs), and (4) comorbidities/complications (6 KQs). TheKQs were structured according to the population, intervention, control, and outcomes (PICO) principle and aresummarized in Tables 2 and 3.Previously, the effectiveness of HFS was evaluated interms of mortality and surgical implant success directlyrelated to surgery; however, comprehensive aspectsshould be considered because of the complex clinicalfeatures and complications of hip fractures [26]. Whenmaking PICOs, all items should be specific; an increasein sensitivity of the literature regarding the outcome ofPICO is required. As to 10 KQs, such as multidisciplinarysystem (KQ1), rehabilitation treatment (KQ2, 3, 4, 5, 6),local community (KQ8, 9), and nutrition-related KQs(KQ14, 15), the outcomes were evaluated in various aspects, including functional recovery (lower extremitymuscle strength, mobility ability, and physical ability),mortality, activities of daily living (ADLs), hospital stay,and living facilities after discharge. The outcomes of hipfracture rehabilitation were evaluated in five areas: (1)mobility, and physical performance, (2) QoL, (3) ADLs, (4)disease-specific scales, and (5) hip-specific scales [27].Delirium is a common problem after HFS, but we decided to follow the 2019 treatment guidelines alreadydeveloped (SIGN157, risk reduction and managementof delirium, a national clinical guideline) [28]. Positionchange and aspiration pneumonia screening tests wereexcluded due to a lack of evidence. CPGs for venousthromboembolism (VTE) have been developed. VTE isa serious medical complication that could be directlyrelated to mortality during rehabilitation after HFS, andthe guidelines of the American College of Chest Physi-cians (ACCP) and the Korean Society on Thrombosis andHemostasis (KSTH), which were evaluated according toAGREE-II, have been partly adapted for the contents regarding hip fracture surgeries [29,30].Selection and grading of evidenceA literature search was conducted on PubMed (https://pubmed.ncbi.nlm.nih.gov/), EMBASE (http://embase.com), Cochrane Library (http://cochranelibrary.com),and one domestic database of KoreaMed (http://koreamed.org). MeSH (for PubMed and Cochrane Library)and Emtree (for Embase) terms were used after establishing a highly sensitive search strategy in combination withnatural language (Supplementary Data 1).Documents searched for each KQ were collected usingEndNote. Two researchers per KQ selected articles andexcluded the literature on hip fractures related to cancerous or pathological fractures. Furthermore, paperswritten in languages other than English and Korean, casereports, technical reports, and documents that existedonly in abstract form were excluded. If opinions differed,an agreement was reached, or a final decision was madethrough arbitration by a third party (Supplementary Data2).The selected documents were subjected to a risk of biasassessment; Cochrane risk-of-bias (RoB) 2.0 (randomizedcontrolled trials [RCTs]) and the risk-of-bias assessmenttool for non-randomized studies (RoBANS) (non-RCTs)were used [31,32]. The methodological quality of the systematic reviews (SRs) was assessed using AMSTAR 2.0—ameasurement tool to assess the methodological quality of systematic reviews [33]. The level of evidence andrecommendation grade were determined according tothe GRADE method (grading of recommendation assessment, development, and evaluation) [34]. For each KQ, ifthere was a recently published systematic review literature, the level of evidence was determined by combiningthe systematic review literature and subsequent randomized controlled studies. Systematic review documentswere evaluated in an integrated manner consideringincluded articles based on (1) study limitation accordingto the study design, (2) indirectness of evidence, (3) inconsistency of results, (4) the imprecision of results, and(5) publication bias [35,36]. In addition to the systematicreview literature, randomized control studies and nonrandomized control studies also evaluated the degree ofwww.e-arm.org231

232www.e-arm.orgComorbidities andcomplicationsCommunity ryapproach15121314High protein intakeHome-based rehabilitation duringmaintenance phaseRegional anesthesiaAnticoagulant/antithrombotic drugs,compression treatmentIntermittent catheterizationBisphosphonateNutritional plan91011Early treatmentSupervised gradual strengtheningWeight-bearing exerciseBalance trainingSupervised ADL trainingMultidisciplinary rehabilitationHome-based rehabilitation duringrecovery phaseInterventionMultidisciplinary rehabilitation2345678No.1General careOther pain treatmentsAnticoagulant/antithrombotic drugs,compression treatment unusedIndwelling catheterizationWithout bisphosphonateGeneral careConventional treatmentDelayed treatmentConventional treatmentConventional treatmentConventional treatmentConventional treatmentConventional treatmentConventional treatmentComparisonConventional treatmentTable 2. PICOs for key questions (P: patient, I: intervention, C: Comparison, O: Outcome)Urinary tract infectionRefracture rate, mortality① Mobility and physical performance,② Quality of life,③ ADLs,④ Disease specific scales,⑤ Hip specific scalesSame aboveSame above and pain reliefVenous thromboembolismOutcome① Mobility and physical performance,② Quality of life,③ Activities of daily living (ADLs),④ Disease specific scales,⑤ Hip specific scalesSame aboveSame aboveSame aboveSame aboveSame aboveEconomic benefits① Mobility and physical performance② Quality of life,③ ADLs,④ Disease specific scales,⑤ Hip specific scalesSame aboveKyunghoon Min, et al.

CPG for Hip Fracture RehabilitationTable 3. Key questions (KQs) for clinical guidelines for postoperative rehabilitation

University Seoul Hospital, Ewha Womans University School of Medicine, Seoul; 36Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang; 37Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea Objective The incidence of hip fractures is increasing worldwide with .