Continuing physical therapy Once the patient leaves the hospital, the patient is not done with physical therapy. Very few- if any - patients attain their prior level of function while in the acute stages of healing. (Patients who were dependent with all mobility prior to hip fracture are the exception.) Ongoing physical therapy will be indicated so that each patient can reach either the prior level of function (or the maximum level of function) after surgery. This ongoing therapy in whatever the setting is- outpatient, home health, inpatient rehab Prevention of hip fracture 95 percent of hip fractures are caused by falls. A fracture is more likely if osteoporosis is present. The most important strategies to prevent hip fracture will focus on the prevention of falls and treat - ment of osteoporosis. There are many strategies to prevent falls. Every patient should be asked if he or she has fallen within the last year. If there has been a fall (or falls), the cause and circumstances should be determined. Then the gait and balance should be screened. If the patient has had only one fall and has had no issues with gait and balance, then no further assessment is indicated. However, if there have been multiple falls, or if the patient is unsteady with gait or demonstrates balance deficits, a multi-factorial fall risk assessment should be per- formed. Medications should be reviewed for side effects that con- tribute to dizziness, and chronic illnesses such as osteoporosis and urinary incontinence should be explored. Lower extremity muscle strength should be assessed, and the patient should be screened for visual acuity and appropriate footwear. If specific deficits are found, the doctor should be notified. If issues are found with the patient’s gait or balance, physical therapy orders can be requested for that purpose. Once the orders are received, the patient’s gait and balance can be assessed with an assessment tool like the dynamic gait bal- ance to assess risk of falls. The patient should also be observed during his or her daily living activities because the patient may be most likely to fall while focusing on another task. The patient’s perceived risk of falls should also be assessed - some patients are not as mobile as they could be, simply because they are afraid of falling (the American Geriatrics Society, 2016). Interventions will vary depending on the individual cause of each fall, but will likely focus on balance and gait. A regular exercise program should be included; participation in a regular exercise program has been shown to decrease the risk of hip fracture. Recommendations should also be made regarding the patient’s environment: There should be adequate lighting and all clutter, electrical cords, and throw rugs should be removed. The above focuses on the prevention of falls in a home environ- ment; yet a large percentage of falls occur in a nursing home set- ting. Fall prevention in a nursing home setting will also require strength training, balance training, gait assessment as well as screening for medications, dizziness, and illnesses that may in- crease the risk of a hip fracture (such as osteoporosis). Many resi- dents in nursing homes will be on multiple medications that may increase the risk of falls. It is estimated that 50 percent of nursing home residents are incontinent (Leung & Schnelle, 2008). The risk of falls is even higher for patients who have cognitive defi- cits, which are often more common in the nursing home than in the general population. In addition to the above recommendations, environmental modifications may include: Using low beds to re- duce injury if the patient falls out of bed, hip protectors, anti-tip mechanisms for wheelchairs, as well as very close supervision from the staff. It is common for patients to fall when they are trying to reach for something, or when they are trying to get up to go to the Conclusion The role of physical therapy is very important in the prevention of hip fractures, as well as in returning patients to their prior level of function after surgery. A physical therapist may be spending as much as one hour a day with each patient after surgery and as such, is in a good position to screen for some very common
or a skilled nursing unit- will need to progress the program already established on acute. Neuromuscular stimulation of the quadri- ceps should begin within one week after surgery. Strength and weight bearing activities are important to rebuild the hip mus- culature after surgery. If possible, balance activities should also be incorporated so that if prior level of function included walking without an assistive device, the goal of walking without an assis- tive device can be attained. bathroom without assistance. A patient with dementia, speech dif- ficulties or other cognitive deficits may not be able to adequately express the need to go to the bathroom, so it will be up to the staff members to set up a plan to prevent a fall. This may neces- sitate a toileting schedule, or perhaps issuing a “reacher” tool that would allow the patient to grasp for what they need without trying to stand (or bend down) when they are not physically able to do so. Alert staff members will take the time to discover the cause of each individual fall and will take appropriate steps to prevent them. The treatment of osteoporosis focuses on medication, calcium and vitamin D supplements. The physical therapist does not pre - scribe these; however, if a physical therapist notices deficits in these areas when performing a chart review of an inpatient that is at a high risk of hip fracture, the therapist can speak to the doctor about these findings. A physical therapist can greatly assist in the management of os- teoporosis by training the patient in weight bearing and muscle strengthening exercises. Strengthening the muscles at a steady, slow rate will create stresses on the bones. The body’s natural reaction is to build more bone- something that is greatly needed in a patient with osteoporosis. It is important that each and every patient continues with a weight bearing and a strength training exercise program, even after formal therapy has been completed. This is difficult for many people as it is out of their regular routine. Education should be provided to both the patient and family on the importance of a regular exercise routine - it may be helpful to set up regular reminders on their phone to help ensure that they do not forget. How therapy can be helpful in prevention of hip fracture can be illustrated by the following example: A 76 year old female presents to an outpatient therapy clinic with orders for back pain. The patient has very kyphotic posture and ambulates from the waiting room to the therapy gym with a straight cane. While reviewing the patient’s history, it is revealed that she has osteoporosis. She is taking both calcium and vitamin D supplements. Although this patient has orders for the treat- ment of low back pain, it is obvious that this patient is at a high risk for a hip fracture. As a treating therapist, it would be prudent to question this patient about any falls that may have occurred within the last year, and perform a quick balance and gait assess- ment - in addition to the prescribed treatment of back pain. If any deficits are found, the doctor can be called and orders may be requested for the treatment of a balance disorder. It is likely that this patient lives at home - she came in for outpatient therapy - so addressing strength and balance deficits and encouraging a regular weight bearing exercise program may enable this patient to prevent a hip fracture and live at home for a longer period of time. Preventing a hip fracture could even save her life; it is important to complete these screenings and treat the whole per- son, not just assess the one issue that a patient has been sent to therapy for.
conditions that can interfere with the post-fracture healing pro- cess. These include: Observing for the signs of depression (such as appetite changes and decreased interest in hobbies or partici- pation in therapy) and screening for delirium (which can include both lethargy and agitation, depending on the type of delirium).
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