Key messages
Mobility is the ability to move about, including standing up and walking. Mobility strategies are treatments that aim to help people move better.
Mobility treatment undertaken in hospital may moderately improve people's mobility four months after their hip was fractured. The effect of mobility treatment on other main outcomes was unclear. Mobility treatment undertaken after discharge from hospital after a fractured hip improves mobility, probably increases walking speed, improves functioning slightly and reduces falls.
Future studies should focus on which types of treatments work best and whether the treatments work in poorer countries.
What can people do to improve their mobility after a hip fracture?
A key aim of care after surgery for hip fracture is to get people safely back on their feet, moving and walking again. Initially, people may be asked to rest in bed and restrict weight bearing. Then various strategies to improve mobility, including walking retraining, exercise programmes and electrical stimulation, are used during hospital stay and often after discharge from hospital.
What did we want to find out?
We wanted to find out:
- whether mobility treatments delivered in the hospital or after discharge from hospital help people move around better;
- what type of treatments help people move well after hip fracture.
We also wanted to know if mobility treatments can cause unwanted effects.
What did we do?
We searched for studies that compared:
- mobility training against no mobility training; or
- different methods and times of mobility treatments.
We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 40 studies that involved 4059 people with hip fracture, most of whom were over 65 years old, with an average age of 80. The smallest study involved 26 people and the largest involved 336 people. The studies were conducted in 17 countries. Many of the studies had weak methods. Twenty-seven studies received funding, mostly from government and research funding organisations.
Main results
Eighteen studies evaluated mobility strategies that started in the hospital within a week after hip fracture surgery. Mobility treatment undertaken in hospital may moderately increase people's mobility four months after their fracture and probably increases walking speed to a small but meaningful degree. Mobility treatment probably makes little or no difference to re-admission to hospital, return to living at home, or death. We are not certain if mobility treatment affects physical functioning (the ability to move around and function in one’s environment) or well-being.
Twenty-two trials evaluated longer-duration mobility strategies that started after discharge from hospital and were undertaken in homes, retirement villages and outpatient clinics. In these settings, mobility treatment increases mobility to a small but meaningful degree, meaningfully increases walking speed, and leads to a small but non-meaningful increase in functioning. Compared to no treatment, social visits or usual care, mobility treatment probably slightly improves people's well-being but not to a meaningful level. Mobility treatment probably makes little or no difference to re-admission to hospital or death.
The types of treatment that appear effective in improving people’s mobility are exercises in additional to standard physiotherapy. Both in the hospital and after discharge from hospital, the helpful exercises target balance, walking and functional tasks. After discharge from hospital, extra strength or endurance training may also improve mobility. The effect of electrical stimulation was not clear.
Overall, the review found that both in hospital and after discharge, there is enough evidence to say that treatment targeting mobility is probably better than no extra treatment in helping people get people safely back on their feet, moving and walking again after hip fracture surgery.
What are the limitations of the evidence?
We have low to moderate confidence in the results of the studies in hospitals. Our confidence was lowered because: some of the studies did not report all their results; they used different ways of delivering treatments; and many of the studies were small.
We are more confident in the results of the studies conducted after discharge from hospital, including the finding that mobility training improves movement and walking. We are less confident in the results for unwanted effects, because of the low number of unwanted effects reported.
How up to date is this evidence?
This review updates our previous review. The evidence is up to date to March 2021.
Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.
Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.
To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.
All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).
Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.
We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%).
In-hospital setting, mobility strategy versus control
Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low.
Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes.
Post-hospital setting, mobility strategy versus control
Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence).
Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.