Ninlerd et al.

Effect of Home-Based Rehabilitation Exercise

Program for Elderly Patients with Femoral Neck
Fracture after Bipolar Hemiarthroplasty

Chantanee Ninlerd, B.Sc., Sangarun Dungkong, B.Sc., Gonrada Phuangphay, B.Sc., Chutikarn Amornsupak,
B.Sc., Rapeepat Narkbunnam, M.D.
Department of Orthopaedic Surgery, Faculty of Medical Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT
Objective: This study aimed to investigate the effectiveness of a home-based rehabilitation program by examining
recovery time, the risk of falling, improvement in mobility, and improvement in quality of life.
Methods: This prospective cohort study included elderly patients who sustained a primary femoral neck fracture
that required cement less bipolar hemiarthroplasty using posterior approach at the Department of Orthopaedic
Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Time to return to pre-injury
status was the primary outcome. Patient quality of life was evaluated using Short Physical Performance Battery
(SPPB) and EQ5D-5L at three and six months after surgery.
Results: Forty-one patients were included in the final analysis. All patients could return to pre-injury ambulatory
status within six months. The mean SPPB score at six months was significantly higher than the mean score at three
months after surgery. The results of EQ5D-5L showed that quality of life improved from three to six months after
surgery. No postoperative complications were observed, including infections, secondary fractures, or hip dislocations.
Conclusion: The home-based rehabilitation program evaluated in this study was found to be safe and effective for
improving recovery, physical performance, and quality of life. All participating patients could return to their pre-
injury ambulatory status within six months.

Keywords: Femoral neck fracture; bipolar hemiarthroplasty; home-based rehabilitation exercise program; short
physical performance battery (SPPB); EQ5D-5L (Siriraj Med J 2020; 72: 315-320)

INTRODUCTION Asia.2 Health and healthcare are major concerns of older

Since the proportion of elderly population continues people. Consistent with that, osteoporosis has been raised
to increase, the issues that affect aging and aged societies are as one of the most important diseases because it occurs
attracting attention in many countries around the world. in most elderly people. Osteoporosis associates with a
In 2015, 15.8 percent of Thai population were people aged decrease in muscle strength and an increase in fall risk,
60 years and over. That number is projected to increase to which increases the risk of osteoporotic fractures.3 The
23.1% by 2025, and 37.1% by 2050.1 Accordingly, Thailand literature shows that approximately 20 percent of elderly
has one of the fastest growing older adult populations in people could experience a femoral neck fracture, which

Corresponding author: Rapeepat Narkbunnam

E-mail: mai_parma@hotmail.com
Received 7 May 2019 Revised 30 September 2019 Accepted 30 October 2019
ORCID ID: http://orcid.org/0000-0002-3564-1700
http://dx.doi.org/10.33192/Smj.2020.42

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 Original Article SMJ

can cause serious health consequences with approximately dementia, or cognitive impairment. Patients with post-
10 to 20% mortality within six months and significant operative complications that adversely affect the ability
loss of mobility.4,5 A standard of treatment that is now to exercise were also excluded.
used to treat displaced osteoporotic femoral neck fracture Before undergoing surgery, all patients were instructed
is bipolar hemiarthroplasty.5 in how to perform a home-based rehabilitation program
After undergoing this surgical procedure, patients for femoral neck fractures by a physiotherapist. The
have to attend a rehabilitation program to improve their program was designed to help patients recover and
ability to physically perform daily activities to the same to improve their mobility so they can return to their
level they did prior to their fracture, and to minimize pre-fracture status. Each patient had to perform the
their risk of falling and mortality.6,7 General resistance postoperative exercise once a day for six months. The
exercise and aerobic practice can improve patient mobility.8 rehabilitation program includes both lying and standing
However, participation in a rehabilitation program may exercises. Lying exercises consisted of hip abduction and
be inconvenient for some patients for several possible hip flexion. Standing exercises included hip abduction,
reasons. For instance, most rehabilitation programs require hip extension, and hip flexion.14 Patients were advised
a patient to travel to the hospital or rehabilitation center, to perform each exercise 10-15 reps/set, 2 sets/time, 3
and this involves higher cost of rehabilitation, travel- times per day (Table 1). Each patient received an exercise
related expenses, the inconvenience of travel, and often booklet and daily record sheet. From six weeks to the
the need for a caregiver. Home-based exercise programs three month after surgery, participants would receive a
were established to reduce the cost of rehabilitation, phone call every week to encourage the rehabilitation
and to help patients regain physical functions.9,10 Many program and to assess their pain level and their ability
studies support the benefit of having exercise at home to walk. From the three months to the six months after
– particularly for patients with femoral neck fractures. surgery, patients would get a phone call once every two
In Thailand, various exercise programs have been weeks.
implemented. A few studies have evaluated the effectiveness
of home-based rehabilitation for stroke patients.11,12 Data collection
For patients with knee osteoarthrosis, Chaipinyo and Demographic and clinical data of recruited patients
Karoonsupcharoen studied home-based strength and were collected, including age, gender, side, number of
balance training.13 Our review of the literature revealed that days before surgery, weight, height, and body mass index
no studies have assessed the effectiveness of home-based (BMI). Patients were appointed for follow-up at six
program for elderly patients with femoral neck fracture weeks, three months, and six months after receiving the
who received bipolar hemiarthroplasty. Accordingly, operation. At follow-ups, postoperative complications,
the aim of this study was to investigate the effectiveness such as fracture, dislocation, and wound complication,
of a home-based rehabilitation program for elderly were investigated. Time to return to pre-injury ambulatory
patients with femoral neck fracture who received bipolar status was measured as the primary outcome. Time to
hemiarthroplasty by examining recovery time, the risk return to pre-injury status was indicated as six weeks,
of falling, improvement in mobility, and improvement three months, or six months after the operation date.
in quality of life. Physical performance and quality of life was assessed
using Short Physical Performance Battery (SPPB) and
MATERIALS AND METHODS EQ5D-5L, respectively. The SPPB test consists of three
This study was approved by Human Research sections, including the ability to rise from sitting on a
Protection Unit, Faculty of Medicine Siriraj Hospital, chair, standing balance test, and walking speed test, with
Mahidol University (Si 400/2016). Patients aged from 60 scores that range from 0 (worst performance) to 12 (best
to 85 years who required treatment for primary femoral performance).15 The EQ5D-5L is a standardized tool used
neck fracture and who underwent cementless bipolar for describing health-related quality of life. It consists
hemiarthroplasty using posterior approach were enrolled of two parts associated with health status: EQ5D and a
starting in January 2016. Included patients had to have visual analogue scale (EQ-VAS), which range from 0
had the ability to walk independently or walk with a gait to 100. The maximum score indicates the best health
aid for at least 10 meters prior to sustaining their fracture. status.16,17 This tool was proven to be reliable and valid
Patients were excluded from this study if they had a for assessing the health status of elderly patients with
disease that affects exercise, such as severe cardiovascular femoral neck fractures.18
disease, severe respiratory disease, psychiatric disease,

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Ninlerd et al.

TABLE 1. The rehabilitation program for patients with femoral neck fracture after bipolar hemiarthroplasty

Hip abduction exercise Move your leg out to the side as far as you can and
then back to the starting position.

Lying position
∙ Repeat 10-15 reps/set,
2 sets/time,
and 3 times per day

Heel slide Bend your knee while keeping your heel on the bed. Do
not let your knee roll inward or bend over 90˚.

Hip flexion exercise Lift your operated leg toward your chest.
Do not lift your knee higher than your hip.

Hip abduction exercise Keep your body straight and lift your leg out to the side.
Standing position
∙ Repeat 10-15 reps/set,
2 sets/time,
and 3 times per day

Hip extension exercise Lift your operated leg backward slowly, keep your body
straight and then return your foot.

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 Original Article SMJ

Statistical analysis After undergoing this procedure, all patients need to

Patient demographic and clinical characteristics participate in a rehabilitation program to leverage their
were summarized using descriptive statistics. Continuous recovery. Home-based exercise programs were developed to
variables are expressed as mean ± standard deviation, reduce the cost of treatment and improve the effectiveness
and categorical variables are presented as frequency and of patient rehabilitation.9,10
percentage. Chi-square test was used to compare time This prospective cohort study showed the recovery
to return to pre-injury ambulatory status. Paired t-test of patient functions following bipolar hemiarthroplasty
was used to compare the results of SPPB, EQ5D, and to be improved after performing the recommended
EQ-VAS. All data was analyzed using SPSS Statistics rehabilitation program for six months. Patient physical
(SPSS, Inc., Chicago, IL, USA). A p-value less than 0.05 functions, quality of life, and time to return to pre-
was considered statistically significant. injury status were evaluated using SPPB and EQ5D-5L.
Similar to previous studies, we found the SPPB scores
RESULTS at six months to be significantly higher than the scores
There were 53 patients with femoral neck fracture at three months after surgery.10,20
who underwent cementless bipolar hemiarthroplasty, Several studies have evaluated new rehabilitation
as shown in Fig 1. The first patient was recruited in programs that associated with intensive supervision,
January 2016, and the last followed-up patient visited equipment, and progressive resistance exercises at hospitals.
our clinic in April 2018. Eleven patients were excluded Those programs were found to have improved the capacity
due to one of the following reasons: age over 85 years, of conventional rehabilitation.21-23 In contrast, the present
conservative treatment, or inability to walk more than study evaluated a newly designed home-based rehabilitation
10 meters. One patient was withdrawn from the study program that involved patients following a prescribed
because two follow-up visits were missed. program and three physical therapist follow-up visits
Patient demographic and clinical characteristics are within six months. The advantages of this home-based
shown in Table 2. The mean age of participants was 76.4 rehabilitation program are lower cost and no requirement
± 8.4 years, and 34 patients (82.9%) were women. Average for the patient to travel to the hospital.
BMI was 22.2 ± 3.2 kg/m2. No patients had postoperative Although older patients with femoral neck fractures
complications, including infections, secondary fractures, had asymmetric strengths of lower extremities and impaired
or hip dislocations. postural balance24,25, the program evaluated in this study
After evaluating the outcome parameters, the included standing exercises to improve strength and
proportion of participants who returned to pre-injury balance in elderly patients. The efficacy of this program
ambulatory status within six weeks, three months, and was demonstrated by improvement in SPPB scores.
six months after surgery was 24.4%, 82.9%, and 99.9%, The results obtained from the EQ5D-5L show
respectively (Table 3). As a result of this rehabilitation that quality of life was improved from three months
program, all included patients were able to return to to six months. Moreover, 39 participants in this study
their pre-injury ambulatory status within six months. had an EQ-VAS score of zero at six months. Neither
As shown in Table 3, the mean SPPB scores was recurrent fracture nor dislocation occurred during the
6.7 ± 1.3 at three months, and 8.5 ± 1.9 at six months rehabilitation period. No evidence of falling case found
(p < 0.000). According to the EQ5D questionnaires, in this study. Thus, it can be concluded that this home-
health-related quality of life was improved from the based rehabilitation program could safely and effectively
three months to the six months. EQ-health state scores promote health-related quality of life.
were 0.9 ± 0.0 and 1.0 ± 0.0 at three and six months The key limitation of this study is that although
(p < 0.000), respectively. For the pain scores, the average patients were instructed in the exercises to perform and
of EQ-VAS was 69.4 ± 12.1 at three months, which was when and for how long, there is no way to know for
improved to 85.9 ± 8.5 at six months (p < 0.000). At six certain that the exercise program was strictly followed.
months, 39 patients (95.1%) had an EQ-VAS score of To enhance the likelihood of compliance, we provided
zero on the prosthesis side. No patients experienced any each patient with a logbook so they could record their
limitations of physical function after six months. daily rehabilitation exercises and activities. The strengths
of this study are its prospective design, the six months
DISCUSSION duration of rehabilitation, and the fact that validated
Bipolar hemiarthroplasty is a conventional surgery assessment tools were used to evaluate recovery.
for treating elderly people with femoral neck fracture.19 In conclusion, the home-based rehabilitation program

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Ninlerd et al.

TABLE 2. Patient demographic and clinical characteristics

Characteristics Mean ± SD or % (n)

Age, year 76.4 ± 8.4

Gender, % (n)

Male 17.1 (7)

Female 82.9 (34)

BMI, kg/m2 22.2 ± 3.2

Affected side, % (n)

Right 43.9 (18)

Left 56.1 (23)

ASA

2 56.1 (23)

3 43.9 (18)

Days before surgery, day 10.3 ± 11.3

Abbreviations: ASA = American Society of Anesthesia Score, BMI = body mass index

TABLE 3. Results of the rehabilitation program

Variables Mean ± SD or % (n) P-value

Patients returned to pre-injury ambulatory status, % (n)

Within 6 weeks 24.4 (10)

Within 3 months 58.4 (24)

Within 6 months 17.1 (7)

Mean SPPB scores

At 3 months 6.7 ± 1.3 <.000

At 6 months 8.5 ± 1.9

EQ-health state scores

At 3 months 0.9 ± 0.0 <.000

At 6 months 1.0 ± 0.0

EQ-VAS scores

At 3 months 69.4 ± 12.1 <.000

At 6 months 85.9 ± 8.5

p-value < 0.05 indicates statistical significance

Abbreviations: SPPB = Short Physical Performance Battery; EQ5D-5L questionnaire = EQ-health state score and EQ-VAS score

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 Original Article SMJ

evaluated in this study was found to be safe and effective Zawacki S, et al. Effect of a home-based exercise program on
for improving patient recovery, physical performance, functional recovery following rehabilitation after hip fracture:
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11. Chaiyawat P, Kulkantrakorn K. Randomized controlled trial of
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months. The results of this study suggest that exercise upon disability and elderly depression. Psychogeriatrics
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ACKNOWLEDGMENTS 13. Chaipinyo K, Karoonsupcharoen O. No difference between
This research study was support by the Routine home-based strength training and home-based balance training
to Research Unit, Faculty of Medicine Siriraj Hospital, on pain in patients with knee osteoarthritis: a randomised
Mahidol University (R2R: 15R00017/038/15). We trial. Aust J Physiother 2009;55(1):25-30.
would like to thank Miss Nichakorn Khomawut for her 14. Bray A. Essentials of physical medicine and rehabilitation:
Musculoskeletal disorders, pain, and rehabilitation: Oxford
assistance with data collection in this study. We thank
University Press UK; 2017.
Assist. Prof. Pakdee Thipthavee, Assist. Prof. Vipawan 15. Simonsick EM, Guralnik JM, Ferrucci L, Glynn RJ, Berkman
Chewachutirungruang and Mr. Thitipan Vichaiya for LF, Blazer DG, et al. A Short Physical Performance Battery
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