http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(2): 158–164 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2014.911968
ASSESSMENT PROCEDURE
Measuring rehabilitation outcome in post-acute hip fractured patients Avital Hershkovitz1,2, Riki Brown1,2, Arie Burstin1,2, and Shai Brill1,2 Geriatric Rehabilitation Ward, ‘‘Beit Rivka’’ Geriatric Rehabilitation Center, Petach Tikva, Israel and 2Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
1
Abstract
Keywords
Purpose: To present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the patients’ various disability levels and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument. Methods: A retrospective study performed in a postacute geriatric rehabilitation center. Three hundred and eighty-seven hip fractured patients admitted from January 2010 to May 2012 were included in this study. Patients were evaluated by the Functional Independence Measure (FIM), the Timed Get Up and Go (TUG) test and ‘‘bed to chair’’ transfer FIM parameter. The study population was divided into three disability groups according to their admission disability level: high (admission FIM score 540), moderate (FIM 40–79) and low (FIM 80). The Mann–Whitney U, ANOVA and Chi square tests analyzed the data. Results: The FIM instrument was found most sensitive in identifying functional change in patients with moderate disability. Low disability patients received more physio- and occupational-therapy treatment time, yet achieved a lower mean FIM score change compared to moderately disabled patients. The smallest real difference (SRD ¼ 13) for the FIM score was achieved by 60% of patients with moderate disability. When assessed by the TUG test, most patients (94%) improved their score. The SRD% of 31% was achieved by 71.7% of the patients. Nineteen patients (35.9%) achieved a discharge score of 520 s. The high disability group achieved the lowest mean FIM score change. On admission, 52/64 (81%) patients required considerable help in transferring from bed to chair (FIM 1–2), however, upon discharge, the majority (69.2%) improved to the level of a one man transfer (FIM 3). Forty-one (64.1%) patients were discharged home. Conclusion: Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited; therefore, it is advisable to use an instrument most suitable to the patients’ disability level.
Hip fracture, older people, outcome measures, rehabilitation History Received 1 May 2013 Revised 29 March 2014 Accepted 1 April 2014 Published online 23 April 2014
ä Implication for Rehabilitation
Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited. It is advisable to use an instrument most suitable to the patients’ disability level.
Introduction Measuring rehabilitation outcome of hip fractured patients is a crucial element in evaluating different health care system interventions [1]. Assessment of hip fractured patients is complex due to their heterogeneous characteristics which affect short- and long-term prognosis. Previous studies have identified several patient subgroups based on age, pre-fracture function and comorbidity [2,3]. The use of recognized outcome scales for hip fractured patients has recently been discussed [1,4]. Activities of daily living (ADL) scales, particularly the functional Independence Measure (FIM)
Address for correspondence: Avital Hershkovitz, Geriatric Rehabilitation Ward, ‘‘Beit Rivka’’ Geriatric Rehabilitation Center, 4 Hachamisha St, Petach Tikva 49245, Israel. Tel: 972-3-9373841. Fax: 972-3-9373841. E-mail: [email protected]
instrument [5] and Barthel Index [6] have been the most widely used instruments, followed by quality of life scales such as the SF-36 (36-item Short-Form Health Questionnaire) [7] and the Eq5D (Euro QoL) [8]. The choice of instrument depends on its feasibility in a specific setting, population and scoring simplicity [4]. ADL measures were adopted by clinicians in hip fracture trials due to their low burden. Self-reported and performance-based measures were found to assess different constructs and provide complementary information as to physical functioning in hip fractured patients [9,10]. No single unified outcome scale has been found suitable for assessing rehabilitation programs in hip fracture patients. Evaluating rehabilitation achievements in post-acute hip fracture patients presents a challenge. Patients are admitted exhibiting variable functional levels. Many have been functionally and cognitively impaired prior to the current event [11] and may display reduced rehabilitation potential. On admission, many
DOI: 10.3109/09638288.2014.911968
Measuring rehabilitation outcome in post-acute hip fractured patients
patients need assistance in transferring and ambulation; only a few are capable of performing mobility measures such as distance walking tests or the Timed Up and Go (TUG) test [12]. In order to assess functional achievements in this population, a disability measure such as the FIM, are simple to administer. The aims of this study were to present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the various disability levels of these patients; and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument
Methods
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Participants This retrospective study was performed in a university-affiliated 300-bed major post-acute geriatric rehabilitation centre, admitting older patients from nearby acute hospitals. All consecutive hip fracture patients admitted to a 60-bed rehabilitation department from January 2010 to May 2012 were enrolled in this study. Excluded were patients who had not completed the rehabilitation program (died, were admitted to a general hospital due to worsening of their medical condition or unexpectedly left rehabilitation) and patients who had achieved a FIM score change of 0 (severely ill patients, unable to adhere to the rehabilitation program format). Rehabilitation setting The multi-disciplinary team provided medical, nursing, physical, occupational and social work interventions. Rehabilitation care included: (1) 30–45 min of individual physical therapy (PT) [i.e. improving transferring, walking the length of a room, climbing stairs, equilibrium and joint range of motion (ROM)] five times a week; muscle resistance training of major muscles groups was performed twice a week in a fitness room and included two sets of 8–12 repetitions at 8–12 RM (repetition Max); (2) 30–45 min of individual occupational therapy (OT) (improvement of basic and ADL, cognitive evaluation and stimulation, safety education) thricea week; (3) 60 min of group exercise, thrice a week, targeted at improving muscle strength, joint flexibility and ROM; and (4) walking with a trained physiotherapist aide who provided extra walking time with patients capable of walking with walker (FIM 5) according to their needs. Weekly meetings were held with the multi-disciplinary team as to continuance of treatment, as well as a progress review. Measures Functional, clinical and demographic data of patients admitted to rehabilitation were collected from their medical files. Functional variables included the FIM instrument, a disability measure administered on admission and at discharge. The FIM comprises 18 parameters, each rated on a scale of 1–7 according to the degree of assistance required to perform a specific activity in three domains: ADL (8 parameters), mobility level (5 parameters) and cognitive function (5 parameters). The motor FIM (mFIM) includes 13 parameters of ADL and mobility. The patients’ FIM score was assessed during multi-disciplinary team meetings. Patients with an admission FIM score of 80 and ability to walk without assistance (FIM44) were assessed by the TUG test on admission and at discharge. The TUG was measured in all patients using a standard armchair (45 cm) and a front-wheel walker [13]. The patients were instructed to stand up, walk 3 m, turn around, walk back to the starting point and sit down again, as fast as possible. The test was previously performed once by all patients before timing. Physiotherapists measured the TUG.
159
The raters were involved in treating the patients, but blinded to admission score results when rating discharge scores. Patients with an admission FIM score of540 were assessed by the ‘‘bed to chair’’ transfer parameter of the FIM. Cognitive function was measured by the Mini Mental State Examination (MMSE) [14] and administered by occupational therapists. Clinical variables included comorbidity and albumin level on admission. Vascular burden was defined as 3 vascular diseases (ischemic heart disease, congestive heart failure, hypertension, diabetes mellitus, peripheral vascular disease and stroke). Demographic variables included: gender, family status (married; not married), living arrangements (home versus nursing home), presence of a caregiver and education level (elementary 510 years; high 10 years). Data relating to fracture type (intracapsular and extracapsular), fracture side, treatment type (operation, conservative), time from fracture to operation (latency time) and weight bearing instruction were also recorded. Average PT and OT therapy treatment time (min/day) were calculated for each patient. Length of stay (LOS) was defined as the number of days patients resided in the rehabilitation center. Statistics Descriptive statistics were used to obtain major statistics of the independent variables. The standard error of measurement (SEM) was used to calculate real change in FIM and TUG performance during rehabilitation: SEM ¼ SD*(ˇ1 ICC), where SD is the standard deviation and ICC the reliability value. Based on Ottenbacher et al. [15] data, real progress for FIM score (smallest real difference – SRD) with a 95% certainty is expressed as: 1.96 * ˇ2 * (21ˇ1 0.95) ¼ 13.0. As for TUG, we used the data from Kristensen et al. (2011), where the SEM and SRD for TUG times were 2.4 and 6.8 s, respectively. TUG SRD% was calculated as SRD% ¼ (SRD/mean) * 100. The smallest changes that represented a real change for a group and a single patient were 11 and 31%, respectively [16]. The study population was divided into three subgroups according to patient disability level on admission: high (admission FIM score 540), moderate (FIM 40–79) and low (FIM 80) based on a modified version of Garraway et al.’s scale [17–19], originally developed for assessing rehabilitation of stroke patients. A non-parametric test (the Kruskall–Wallis H) was used to assess the significance of difference (of age, albumin level on admission, time from surgery to rehabilitation, MMSE score, FIM score at discharge, FIM score change, PT and OT average treatment time and LOS) between the three disability level groups: high (admission FIM score540), moderate (FIM 40–79) and low (FIM 80). Patients able to perform the TUG test were divided into two subgroups: those who achieved real progress, indicating a 31% real change for a single patient, and those who did not (15). A non-parametric test (the Mann–Whitney U) was used to assess the significance of difference (of age, albumin level on admission, admission and discharge FIM scores, MMSE score, PT and OT average treatment time and LOS) between patients who improved their TUG score by 31% versus the group who did not. The Chi-square test examined the association between the TUG score change groups (real/not real) and the following variables: gender, educational level, presence of caregiver, fracture type and side, NWB instruction and vascular burden. Statistical analyses were performed using SPSS version 19 (SPSS Inc., Chicago, IL) for Windows. Significant level was set at p50.05. This study was approved by the institutional review board (#6035) of the hospital.
160
A. Hershkovitz et al.
Disabil Rehabil, 2015; 37(2): 158–164
Results
groups as to the interval between surgery and admission to the geriatric rehabilitation center.
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Patients’ characteristics From January 2010 to May 2012, 493 hip fractured patients were admitted to our post-acute rehabilitation ward. Seventy-two did not complete the program: 48 patients were readmitted to an acute hospital due to physical deterioration, 5 were transferred to a skilled nursing ward, 18 unexpectedly left the rehabilitation program and 1 died during rehabilitation. Thirtyfour patients deteriorated or did not improve their functional level (FIM score change of 0) during the rehabilitation program (Figure 1). Three hundred and eighty-seven patients were included in this study: 149 (38.5%) with an intracapsular fracture and 238 (61.5%) with an extracapsular fracture. Twenty-two patients received nonweight bearing (NWB) instruction, averaging 33.2 days (±10.3 days). The male to female ratio was 96:291; mean age for males was 82 ± 7 years and 83 ± 7 for females. Clinical and demographic characteristics of patients included and excluded from this study are presented in Table 1. Three hundred and eighteen patients (82.2%) were discharged home; 69 (17.8%) to a nursing home.
TUG
FIM
Sixty-four (16.5%) patients were admitted with a FIM score of 540; 52 (81.2%) needed considerable help in transferring from bed to chair (admission ‘‘bed to chair’’ transfer FIM parameter score 1–2); 8 patients (53%) with an admission ‘‘bed to chair’’ FIM score of 1 and 28 patients (76%) with an admission score of 2 improved in transferring to the level of a one man transfer (FIM 3), 41 (64.1%) patients returned home. The FIM score changes in ‘‘bed to chair’’ from admission to discharge is presented in Figure 2.
Mean and standard deviation for age, albumin level on admission, time from surgery to rehabilitation, MMSE score, discharge FIM score, FIM score change, PT and OT average treatment time and LOS in the three disability groups appear in Table 2. Patients in the lowest disability group were younger and achieved higher MMSE and discharge FIM scores during a shorter LOS (p50.001). These patients received extended PT and OT average treatment time compared with the moderately disabled patients, yet, achieved a lower FIM score change. Following Ottenbacher et al. [15], SRD for the FIM test is 13.0 points and was achieved by 54.3% of all patients (57, 60 and 31% of patients with low, moderate and high disability level, respectively). No significant difference was found between the patient Figure 1. Flow diagram of the study.
Fifty-three patients (75.7%) with an admission FIM score of 80 were assessed by the TUG test [nine needed support in ambulation (FIM55) and were unable to perform the test, two refused to cooperate and six were missing data]. Most patients (50, 94.3%) improved their TUG score. The SRD% (31%) was achieved by 71.7% of patients. Nineteen patients (35.9%) achieved a discharge score of 520 s. No significant differences were found between patients who achieved 31% improvement in their TUG score and those who did not, relating to age, albumin level on admission, admission and discharge FIM score, FIM score change, discharge TUG score, MMSE score, PT and OT average treatment time and LOS (Table 3). Yet, patients who achieved 31% improvement in their TUG score had significantly longer admission TUG scores (p50.001). No significant differences were found between the above TUG groups as to demographic and clinical variables (Table 4) ‘‘Bed to chair transfer’’ FIM parameter
Discussion Hip fracture patients admitted to a post-acute rehabilitation setting are often older and at a greater disability level than patients referred to home rehabilitation or inpatient rehabilitation
493 patients with a proximal hip fracture during 2010-12 72 patients did not complete rehabilitation program
34 patients with a FIM score change of ≤0 387 patients were included in the study Admission FIM
ASSESSMENT PROCEDURE
Measuring rehabilitation outcome in post-acute hip fractured patients Avital Hershkovitz1,2, Riki Brown1,2, Arie Burstin1,2, and Shai Brill1,2 Geriatric Rehabilitation Ward, ‘‘Beit Rivka’’ Geriatric Rehabilitation Center, Petach Tikva, Israel and 2Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
1
Abstract
Keywords
Purpose: To present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the patients’ various disability levels and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument. Methods: A retrospective study performed in a postacute geriatric rehabilitation center. Three hundred and eighty-seven hip fractured patients admitted from January 2010 to May 2012 were included in this study. Patients were evaluated by the Functional Independence Measure (FIM), the Timed Get Up and Go (TUG) test and ‘‘bed to chair’’ transfer FIM parameter. The study population was divided into three disability groups according to their admission disability level: high (admission FIM score 540), moderate (FIM 40–79) and low (FIM 80). The Mann–Whitney U, ANOVA and Chi square tests analyzed the data. Results: The FIM instrument was found most sensitive in identifying functional change in patients with moderate disability. Low disability patients received more physio- and occupational-therapy treatment time, yet achieved a lower mean FIM score change compared to moderately disabled patients. The smallest real difference (SRD ¼ 13) for the FIM score was achieved by 60% of patients with moderate disability. When assessed by the TUG test, most patients (94%) improved their score. The SRD% of 31% was achieved by 71.7% of the patients. Nineteen patients (35.9%) achieved a discharge score of 520 s. The high disability group achieved the lowest mean FIM score change. On admission, 52/64 (81%) patients required considerable help in transferring from bed to chair (FIM 1–2), however, upon discharge, the majority (69.2%) improved to the level of a one man transfer (FIM 3). Forty-one (64.1%) patients were discharged home. Conclusion: Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited; therefore, it is advisable to use an instrument most suitable to the patients’ disability level.
Hip fracture, older people, outcome measures, rehabilitation History Received 1 May 2013 Revised 29 March 2014 Accepted 1 April 2014 Published online 23 April 2014
ä Implication for Rehabilitation
Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited. It is advisable to use an instrument most suitable to the patients’ disability level.
Introduction Measuring rehabilitation outcome of hip fractured patients is a crucial element in evaluating different health care system interventions [1]. Assessment of hip fractured patients is complex due to their heterogeneous characteristics which affect short- and long-term prognosis. Previous studies have identified several patient subgroups based on age, pre-fracture function and comorbidity [2,3]. The use of recognized outcome scales for hip fractured patients has recently been discussed [1,4]. Activities of daily living (ADL) scales, particularly the functional Independence Measure (FIM)
Address for correspondence: Avital Hershkovitz, Geriatric Rehabilitation Ward, ‘‘Beit Rivka’’ Geriatric Rehabilitation Center, 4 Hachamisha St, Petach Tikva 49245, Israel. Tel: 972-3-9373841. Fax: 972-3-9373841. E-mail: [email protected]
instrument [5] and Barthel Index [6] have been the most widely used instruments, followed by quality of life scales such as the SF-36 (36-item Short-Form Health Questionnaire) [7] and the Eq5D (Euro QoL) [8]. The choice of instrument depends on its feasibility in a specific setting, population and scoring simplicity [4]. ADL measures were adopted by clinicians in hip fracture trials due to their low burden. Self-reported and performance-based measures were found to assess different constructs and provide complementary information as to physical functioning in hip fractured patients [9,10]. No single unified outcome scale has been found suitable for assessing rehabilitation programs in hip fracture patients. Evaluating rehabilitation achievements in post-acute hip fracture patients presents a challenge. Patients are admitted exhibiting variable functional levels. Many have been functionally and cognitively impaired prior to the current event [11] and may display reduced rehabilitation potential. On admission, many
DOI: 10.3109/09638288.2014.911968
Measuring rehabilitation outcome in post-acute hip fractured patients
patients need assistance in transferring and ambulation; only a few are capable of performing mobility measures such as distance walking tests or the Timed Up and Go (TUG) test [12]. In order to assess functional achievements in this population, a disability measure such as the FIM, are simple to administer. The aims of this study were to present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the various disability levels of these patients; and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument
Methods
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Participants This retrospective study was performed in a university-affiliated 300-bed major post-acute geriatric rehabilitation centre, admitting older patients from nearby acute hospitals. All consecutive hip fracture patients admitted to a 60-bed rehabilitation department from January 2010 to May 2012 were enrolled in this study. Excluded were patients who had not completed the rehabilitation program (died, were admitted to a general hospital due to worsening of their medical condition or unexpectedly left rehabilitation) and patients who had achieved a FIM score change of 0 (severely ill patients, unable to adhere to the rehabilitation program format). Rehabilitation setting The multi-disciplinary team provided medical, nursing, physical, occupational and social work interventions. Rehabilitation care included: (1) 30–45 min of individual physical therapy (PT) [i.e. improving transferring, walking the length of a room, climbing stairs, equilibrium and joint range of motion (ROM)] five times a week; muscle resistance training of major muscles groups was performed twice a week in a fitness room and included two sets of 8–12 repetitions at 8–12 RM (repetition Max); (2) 30–45 min of individual occupational therapy (OT) (improvement of basic and ADL, cognitive evaluation and stimulation, safety education) thricea week; (3) 60 min of group exercise, thrice a week, targeted at improving muscle strength, joint flexibility and ROM; and (4) walking with a trained physiotherapist aide who provided extra walking time with patients capable of walking with walker (FIM 5) according to their needs. Weekly meetings were held with the multi-disciplinary team as to continuance of treatment, as well as a progress review. Measures Functional, clinical and demographic data of patients admitted to rehabilitation were collected from their medical files. Functional variables included the FIM instrument, a disability measure administered on admission and at discharge. The FIM comprises 18 parameters, each rated on a scale of 1–7 according to the degree of assistance required to perform a specific activity in three domains: ADL (8 parameters), mobility level (5 parameters) and cognitive function (5 parameters). The motor FIM (mFIM) includes 13 parameters of ADL and mobility. The patients’ FIM score was assessed during multi-disciplinary team meetings. Patients with an admission FIM score of 80 and ability to walk without assistance (FIM44) were assessed by the TUG test on admission and at discharge. The TUG was measured in all patients using a standard armchair (45 cm) and a front-wheel walker [13]. The patients were instructed to stand up, walk 3 m, turn around, walk back to the starting point and sit down again, as fast as possible. The test was previously performed once by all patients before timing. Physiotherapists measured the TUG.
159
The raters were involved in treating the patients, but blinded to admission score results when rating discharge scores. Patients with an admission FIM score of540 were assessed by the ‘‘bed to chair’’ transfer parameter of the FIM. Cognitive function was measured by the Mini Mental State Examination (MMSE) [14] and administered by occupational therapists. Clinical variables included comorbidity and albumin level on admission. Vascular burden was defined as 3 vascular diseases (ischemic heart disease, congestive heart failure, hypertension, diabetes mellitus, peripheral vascular disease and stroke). Demographic variables included: gender, family status (married; not married), living arrangements (home versus nursing home), presence of a caregiver and education level (elementary 510 years; high 10 years). Data relating to fracture type (intracapsular and extracapsular), fracture side, treatment type (operation, conservative), time from fracture to operation (latency time) and weight bearing instruction were also recorded. Average PT and OT therapy treatment time (min/day) were calculated for each patient. Length of stay (LOS) was defined as the number of days patients resided in the rehabilitation center. Statistics Descriptive statistics were used to obtain major statistics of the independent variables. The standard error of measurement (SEM) was used to calculate real change in FIM and TUG performance during rehabilitation: SEM ¼ SD*(ˇ1 ICC), where SD is the standard deviation and ICC the reliability value. Based on Ottenbacher et al. [15] data, real progress for FIM score (smallest real difference – SRD) with a 95% certainty is expressed as: 1.96 * ˇ2 * (21ˇ1 0.95) ¼ 13.0. As for TUG, we used the data from Kristensen et al. (2011), where the SEM and SRD for TUG times were 2.4 and 6.8 s, respectively. TUG SRD% was calculated as SRD% ¼ (SRD/mean) * 100. The smallest changes that represented a real change for a group and a single patient were 11 and 31%, respectively [16]. The study population was divided into three subgroups according to patient disability level on admission: high (admission FIM score 540), moderate (FIM 40–79) and low (FIM 80) based on a modified version of Garraway et al.’s scale [17–19], originally developed for assessing rehabilitation of stroke patients. A non-parametric test (the Kruskall–Wallis H) was used to assess the significance of difference (of age, albumin level on admission, time from surgery to rehabilitation, MMSE score, FIM score at discharge, FIM score change, PT and OT average treatment time and LOS) between the three disability level groups: high (admission FIM score540), moderate (FIM 40–79) and low (FIM 80). Patients able to perform the TUG test were divided into two subgroups: those who achieved real progress, indicating a 31% real change for a single patient, and those who did not (15). A non-parametric test (the Mann–Whitney U) was used to assess the significance of difference (of age, albumin level on admission, admission and discharge FIM scores, MMSE score, PT and OT average treatment time and LOS) between patients who improved their TUG score by 31% versus the group who did not. The Chi-square test examined the association between the TUG score change groups (real/not real) and the following variables: gender, educational level, presence of caregiver, fracture type and side, NWB instruction and vascular burden. Statistical analyses were performed using SPSS version 19 (SPSS Inc., Chicago, IL) for Windows. Significant level was set at p50.05. This study was approved by the institutional review board (#6035) of the hospital.
160
A. Hershkovitz et al.
Disabil Rehabil, 2015; 37(2): 158–164
Results
groups as to the interval between surgery and admission to the geriatric rehabilitation center.
Disabil Rehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Patients’ characteristics From January 2010 to May 2012, 493 hip fractured patients were admitted to our post-acute rehabilitation ward. Seventy-two did not complete the program: 48 patients were readmitted to an acute hospital due to physical deterioration, 5 were transferred to a skilled nursing ward, 18 unexpectedly left the rehabilitation program and 1 died during rehabilitation. Thirtyfour patients deteriorated or did not improve their functional level (FIM score change of 0) during the rehabilitation program (Figure 1). Three hundred and eighty-seven patients were included in this study: 149 (38.5%) with an intracapsular fracture and 238 (61.5%) with an extracapsular fracture. Twenty-two patients received nonweight bearing (NWB) instruction, averaging 33.2 days (±10.3 days). The male to female ratio was 96:291; mean age for males was 82 ± 7 years and 83 ± 7 for females. Clinical and demographic characteristics of patients included and excluded from this study are presented in Table 1. Three hundred and eighteen patients (82.2%) were discharged home; 69 (17.8%) to a nursing home.
TUG
FIM
Sixty-four (16.5%) patients were admitted with a FIM score of 540; 52 (81.2%) needed considerable help in transferring from bed to chair (admission ‘‘bed to chair’’ transfer FIM parameter score 1–2); 8 patients (53%) with an admission ‘‘bed to chair’’ FIM score of 1 and 28 patients (76%) with an admission score of 2 improved in transferring to the level of a one man transfer (FIM 3), 41 (64.1%) patients returned home. The FIM score changes in ‘‘bed to chair’’ from admission to discharge is presented in Figure 2.
Mean and standard deviation for age, albumin level on admission, time from surgery to rehabilitation, MMSE score, discharge FIM score, FIM score change, PT and OT average treatment time and LOS in the three disability groups appear in Table 2. Patients in the lowest disability group were younger and achieved higher MMSE and discharge FIM scores during a shorter LOS (p50.001). These patients received extended PT and OT average treatment time compared with the moderately disabled patients, yet, achieved a lower FIM score change. Following Ottenbacher et al. [15], SRD for the FIM test is 13.0 points and was achieved by 54.3% of all patients (57, 60 and 31% of patients with low, moderate and high disability level, respectively). No significant difference was found between the patient Figure 1. Flow diagram of the study.
Fifty-three patients (75.7%) with an admission FIM score of 80 were assessed by the TUG test [nine needed support in ambulation (FIM55) and were unable to perform the test, two refused to cooperate and six were missing data]. Most patients (50, 94.3%) improved their TUG score. The SRD% (31%) was achieved by 71.7% of patients. Nineteen patients (35.9%) achieved a discharge score of 520 s. No significant differences were found between patients who achieved 31% improvement in their TUG score and those who did not, relating to age, albumin level on admission, admission and discharge FIM score, FIM score change, discharge TUG score, MMSE score, PT and OT average treatment time and LOS (Table 3). Yet, patients who achieved 31% improvement in their TUG score had significantly longer admission TUG scores (p50.001). No significant differences were found between the above TUG groups as to demographic and clinical variables (Table 4) ‘‘Bed to chair transfer’’ FIM parameter
Discussion Hip fracture patients admitted to a post-acute rehabilitation setting are often older and at a greater disability level than patients referred to home rehabilitation or inpatient rehabilitation
493 patients with a proximal hip fracture during 2010-12 72 patients did not complete rehabilitation program
34 patients with a FIM score change of ≤0 387 patients were included in the study Admission FIM
