Physiotherapy after hip fracture,
going home does not mean full recovery

There is a chance, but expectations need to be realistic. Research shows that about 40% to 60% of older adults regain their pre-fracture mobility and self-care after a hip fracture, and a higher proportion regain independence in basic self-care (Dyer et al., 2016). How much is regained depends largely on whether rehabilitation continues after surgery. Several months of home resistance training improved function and strength (Binder et al., 2004). Saying that after a break the person will never walk again is too pessimistic, and saying that the person will be fine automatically after the operation is just as unrealistic.

In most cases, the earlier the patient bears weight within what can be tolerated (WBAT), the better. A systematic review showed that unrestricted weight bearing, compared with restricted weight bearing, was associated with lower long-term mortality (RR 0.67), with no significant difference in complications, reoperation or length of stay (the level of evidence is low, and each case needs individual assessment). Moving early helps to reduce the complications of bed rest. The exact weight-bearing limits must be set by the orthopaedic doctor according to the type of fracture and method of fixation. With extracapsular fractures full weight bearing can often start earlier, while intracapsular fixation may call for protected weight bearing.

No. Discharge is often only the middle of rehabilitation. A randomised controlled trial showed that rehabilitation continued for about six months after hip fracture and including progressive resistance training improved physical function and strength clearly more than low-intensity home exercise (Binder et al., 2004). The gap after discharge, when public hospital rehabilitation beds are scarce and the patient has limited mobility and can hardly go out, is when a home visit is most needed.

It helps to separate what physiotherapy can do from what belongs to the doctor. Medical follow-up of bone health is the attending doctor's area, assessed from bone density and the patient's overall condition. What physiotherapy can act on directly is the other half: progressive resistance and balance training, progression of gait and walking aids, and home changes to prevent falls (bathroom grab rails, thresholds, floors, lighting), with the aim of reducing the next fall. It is also worth asking the attending doctor whether a fracture liaison service (FLS) referral is available. An FLS lowered the refracture rate from about 13.4% to 6.4% (NNT about 20, Wu et al., 2018).

Yes, and it is needed even more. Old age is not in itself a contraindication to rehabilitation training. The loss of muscle strength and the lung and skin complications that come with long bed rest carry an even higher risk. Whether to operate, when, and which method of fixation to use are the orthopaedic doctor's judgements according to the type of fracture and the older adult's overall condition, and the physiotherapist does not decide them. Rehabilitation after surgery is what decides whether the person can return to living at home. Ortho-geriatric co-management has been shown to lower in-hospital mortality and shorten the hospital stay (Kammerlander et al., 2010), and the early mobilisation and continuing training within co-management are the physiotherapy part.

Success in hip fracture rehabilitation depends on keeping up continuing training and preventing further falls, while patients find it hard to go out after surgery and public hospital rehabilitation resources are tight. A home visit lets the therapist guide safe weight bearing and walking aid progression at home, strengthen the legs in stages, assess the bathroom and thresholds on the spot and make changes to prevent falls (which directly helps to prevent another fracture), and teach carers correct ways of helping. HK$1,000 for 1 hour and HK$1,300 for 1.5 hours, with no minimum spend, and a registered physiotherapist visits in person.