Clinical Practice Guidelines CHRISTINE M. MCDONOUGH, PT, PhD • MARCIE HARRIS-HAYES, PT, DPT, MSCI MORTEN TANGE KRISTENSEN, PT, PhD • JAN ARNHOLTZ OVERGAARD, PT, MSc • THOMAS B. HERRING, DPT ANNE M. KENNY, MD • KATHLEEN KLINE MANGIONE, PT, PhD, FAPTA Physical Therapy Management of Older Adults With Hip Fracture Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and the Academy of Geriatric Physical Therapy of the American Physical Therapy Association J Orthop Sports Phys Ther. 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301 SUMMARY OF RECOMMENDATIONS ................................CPG2 INTRODUCTION ...............................................................CPG4 METHODS ........................................................................CPG6 CLINICAL PRACTICE GUIDELINES: Impairment/Function-Based Diagnosis ......................CPG10 Examination ..................................................................CPG13 Interprofessional Management ....................................CPG19 Interventions ................................................................ CPG22 DECISION TREE ............................................................... CPG33 AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS ... CPG39 Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on February 2, 2021. For personal use only. No other uses without permission. Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. REFERENCES ..................................................................CPG40 APPENDICES (ONLINE) ...................................................CPG48 For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2021 Academy of Orthopaedic Physical Therapy, American Physical Therapy Association (APTA), Inc, and the Journal of Orthopaedic & Sports Physical Therapy. The Academy of Orthopaedic Physical Therapy, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to reproducing and distributing this guideline for educational purposes. Address correspondence to Clinical Practice Guidelines Managing Editor, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: [email protected] Hip Fracture: Clinical Practice Guidelines Summary of Recommendations* ACROSS THE ENTIRE EPISODE OF CARE Short-Form Health Survey (SF-36) to measure physical function- Examination – Outcome Measures: Body Functions and Structures/ ing in all settings. Physical Impairment Measures Physical therapists may use the SF-36 in all settings to Physical therapists must test and document knee exten- C A measure health-related quality of life. sion strength across all settings. Examination – Outcome Measures: Body Functions and Structures/ POSTACUTE PERIOD: POSTACUTE SKILLED-NURSING Self-reported Measures AND COMMUNITY SETTINGS A Physical therapists must administer and document the Examination – Outcome Measures: Body Functions and Structures/ verbal rating (ranking) scale for pain in all settings to Physical Impairment Measures monitor pain. B Physical therapists should test and document hip exten- Examination – Outcome Measures: Activity Limitations/Physical sor and abductor muscle strength in postacute clinical Performance Measures settings. A Physical therapists should use the gait speed test in all Examination – Outcome Measures: Activity Limitations/Physical settings when patients do not require human assistance Performance Measures to walk. Documentation should include the features of test ad- B Physical therapists should conduct and document the ministration: comfortable or maximum speed, walking aid, and 5-times sit-to-stand or 30-second sit-to-stand test in rolling start or static start. postacute inpatient, home, and outpatient settings to measure mobility and fall risk. A Physical therapists should use the Cumulated Ambulation Score in the acute and postacute clinical settings to mea- B Physical therapists should use the 6-minute walk test in sure basic mobility until independent ambulation has been postacute inpatient and community settings when the reached. patient does not require the therapist’s physical assistance to walk and when there is an adequate length of corridor to con- A Physical therapists should use the timed up-and-go test in all settings to measure mobility and risk for falls when duct the test. patients do not require human assistance. Documentation should C Physical therapists may use the Functional Independence include the features of test administration: comfortable or maxi- Measure in postacute inpatient settings if they have been mum speed and walking-aid use. trained and have a license to use this measure. Physical therapists may use the Short Physical Perfor- C C Physical therapists may use the de Morton Mobility Index mance Battery in all settings, though completion may not in postacute inpatient and outpatient settings. be feasible in the early postoperative period, depending on ability. ACROSS THE ENTIRE EPISODE OF CARE Examination – Outcome Measures: Activity Limitations/Self- Interprofessional Management – Prevention and Identification reported Measures of Delirium Physical therapists should use the New Mobility Score in B A Physical therapists should participate in multicompo- the early period/inpatient setting to assess prefracture nent nonpharmacological intervention programs deliv- Journal of Orthopaedic & Sports Physical Therapy® status, and in the postacute and community settings to assess Downloaded from www.jospt.org at on February 2, 2021. For personal use only. No other uses without permission. Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. ered by an interprofessional team (including physicians, nurses, current status and recovery of prefracture status. and possibly other health care professionals) for the entire hos- pitalization for at-risk older adults undergoing surgery to pre- B Physical therapists in all settings should use the Falls Effi- cacy Scale-International to measure concern about falling. vent delirium. Interprofessional Management – Pain Assessment and Management C Physical therapists may use the Activity Measure for Post- Acute Care in all settings. F Physical therapists must assess hip fracture–related pain at rest and during activity (eg, walking) and implement C Physical therapists may use the 3-level version of the Eu- strategies to minimize the patient’s pain during the treatment roQol-5 dimensions scale in all settings to measure session to optimize the patient’s mobility. Strategies may include health-related quality of life. appropriate timing of medication, consultation with the interpro- fessional team, and psychologically informed physical therapy C Physical therapists may use the 10-item physical func- tioning scale of the Medical Outcomes Study 36-Item approaches for nonpharmacological pain management. cpg2 | february 2021 | volume 51 | number 2 | journal of orthopaedic & sports physical therapy Hip Fracture: Clinical Practice Guidelines Interprofessional Management – Prevention of Pressure Ulcers EARLY POSTOPERATIVE PERIOD: INPATIENT SETTING Interprofessional Rehabilitation Programs F Clinicians must screen for risk of pressure ulcers. Risk factors include significantly limited mobility, significant A Older adults with hip fracture should be treated in a multi- loss of sensation, a previous or current pressure ulcer, nutritional disciplinary orthogeriatric program, which includes physi- deficiency, the inability to reposition themselves, incontinence, cal therapy and early mobilization. and significant cognitive impairment. Interventions – Frequency of Physical Therapy Interprofessional Management – Prevention of Falls B Patients should be offered high-frequency (daily) in-hospital A Physical therapists must assess and document patient physical therapy following surgery for a hip fracture, with risk factors for falls and contribute to interprofessional duration as tolerated, including instruction in a home program. management. Physical therapists should use published recom- Interventions – Early Assisted Transfers and Ambulation mendations from the Academy of Geriatric Physical Therapy of Clinicians must provide assisted transfer out of bed and the American Physical Therapy Association to guide fall-risk A ambulation as soon as possible after hip fracture surgery management in patients with hip fracture to assess and manage and at least daily thereafter, unless contraindicated for medical fall risk. or surgical reasons. Interprofessional Management – Secondary Fracture Prevention Interventions – Aerobic Exercise Added to Structured Exercise Physical therapists should contribute to interprofessional F Physical therapists may provide upper-body aerobic train- care to ensure that older adults with hip fracture are ap- C ing in addition to progressive resistive, balance, and mo- propriately evaluated and treated for osteoporosis and risk of fu- bility training in the early postacute period (inpatient setting) for ture fractures. older adults after hip fracture. Interprofessional Management – Determination and Communication Interventions – Electrical Stimulation for Quadriceps Strengthening of Functional Assistance Requirements Physical therapists may use electrical stimulation for Physical therapists must provide guidance to the interpro- C F quadriceps strengthening