Development, feasibility, and evaluation of HIP fracture REhabilitation Program based on daily activities for older adults with hip fracture

Introduction
The ability to perform activities of daily living (ADL) is essential in maintaining an independent lifestyle and participating in meaningful activities. However, for older adults with hip fractures (HFs), loss of independence and a further decrease in ADL ability often persists beyond 3 months after surgery. This increases the risk of social isolation, depression, and thereby results in a decrease in health-related quality of life (HRQoL). Therefore, a rehabilitation intervention aimed at reducing decreases in ADL ability is crucial for elderly individuals with HFs. Danish clinical guidelines recommend that rehabilitation begins at the hospital in the acute phase and continues after discharge to a municipal rehabilitation center while securing a seamless transition from one sector to the other. In Denmark, rehabilitation often includes a multidisciplinary team consisting of physiotherapists, OTs, doctors, nurses, and health care assistants, where the focus on rehabilitation in the performance of ADL tasks often is a challenge for many older adults with HF. Rehabilitation for the older adults aged 65 years or older with HF, based on ADL (e.g., performing activities such as bathing and dressing) and home visits, has shown some promising results in performing ADL. Achieving a functional habitual level for the older adult with HF is a challenge and therefore there seems to be potential for developing an individually tailored cross-sectoral intervention program, as an add-on to usual rehabilitation, based in ADL among older adults with HF. 

Objective 
The overall aim of this Ph.D. thesis is to develop a rehabilitation program for older adults with HF that focuses on enabling them to perform ADL safely and independently and enhance their HRQoL. The objectives for Study I: To develop a rehabilitation program for older adults with HF using a participatory client-centered and dialogue-based communication with the collaboration and exchange of information and knowledge about rehabilitation from the perspectives of older adults with HF as well as Health care professionals (HCP) across sectors; Study II: To evaluate the feasibility of the HIP fracture REhabilitation Program (HIP-REP) developed in Study I; Study III: To evaluate the effectiveness of a HIP-REP on the quality and independence of ADL ability (performance) using the Assessment of Motor and Process Skills (AMPS) and HRQoL measures.

Design 
To answer the overarching aim, three studies inspired by the Medical Research Council’s (MRC) Guidelines for Developing and Evaluating Complex Interventions were conducted. A development study (phase I), a feasibility study (phase II), and an evaluation study (phase III). Development of these studies were based on results from the previous ones.

Results 
Study I identified three generic categories: (1) Challenge older adults with goal-oriented ADL tasks, (2) Implement strategies to enhance the independent and safe performance of ADL tasks; (3) Communicate important information to the target group and across sectors. A program was developed and an intervention to enhance usual rehabilitation was designed, comprising an individualized intervention component consisting of five additional therapy sessions based on ADL tasks.
Study II demonstrated that the participant recruitment rate was 4.5 individuals per month. Overall, 13 out of 18 participants completed the study, while three dropped out and two died. Adherence among the 13 remaining participants was 100%. The focus group revealed issues related to coordinating the intervention, ensuring procedural processes across sectors regarding participant recruitment, and documentation in the database. Participants expressed satisfaction with the intervention and felt safe when undergoing the program. AMPS showed an average increase in ADL motor ability (from 0.0 to 0.9) and process ability (from 0.5 to 1.0) measures. 
In Study III, the clinical trial, 80 participants were recruited (39 in the intervention group, 41 in the control group). Only data from 49 participants (61.3%) were analyzed at 3 months, due to large loss to follow-up. Of the 39 participants allocated to the intervention group, 23 (59%) received the intervention. Although there was no difference in improvements between the groups, post-hoc subgroup analysis indicated that participants in the intervention group discharged to rehabilitation center achieved a greater increase in both motor and process scores at 3 months when compared to the intervention group discharged from hospital to own home.

Conclusion
The development of the intervention highlighted the need to set individual goals and challenge older adults with HF through guiding strategies to enhance safe and independent performance of ADL tasks. Furthermore, providing written and oral information about goal setting during the transitional rehabilitation was also crucial. Testing the cross-sectoral intervention showed suitable rates of recruitment, retention, and outcome measure completion. Although, the cross-sectoral intervention based on ADL was perceived as relevant and feasible by older adults with HF and the HCPs, the efficacy of the HIP-REP showed there was no increase patients’ ability to perform ADL.