Kronborg_japa.2015-0071-in press

“Physical Activity in the Acute Ward Following Hip Fracture Surgery is Associated With Less Fear of Falling”

by Kronborg L et al.

Journal of Aging and Physical Activity

© 2016 Human Kinetics, Inc.

Note: This article will be published in a forthcoming issue of

the Journal of Aging and Physical Activity. This article

appears here in its accepted, peer-reviewed form; it has not

been copy edited, proofed, or formatted by the publisher.

Section: Original Research

Article Title: Physical Activity in the Acute Ward Following Hip Fracture Surgery is

Associated With Less Fear of Falling

Authors: Lise Kronborg1, Thomas Bandholm1, 2, 3, Henrik Palm3, Henrik Kehlet4, and

Morten Tange Kristensen1, 3

Affiliations: 1Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),

Department of Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark. 2Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark. 3Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark. 4Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark.

Running Head: Physical activity in the acute ward after hip fracture surgery

Journal: Journal of Aging and Physical Activity

Acceptance Date: January 13, 2016

©2016 Human Kinetics, Inc.

DOI: http://dx.doi.org/10.1123/japa.2015-0071

http://dx.doi.org/10.1123/japa.2015-0071





Title: Physical activity in the acute ward following hip fracture surgery is associated with

less fear of falling

Section: Original Research

Authors: Lise Kronborg, Msc1, Thomas Bandholm, PhD1, 2, 3, Henrik Palm, MD3, Henrik

Kehlet, PhD4, Morten Tange Kristensen, PhD1, 3

Affiliations:

1) Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of

Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark

2) Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark

3) Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark

4) Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark.

Running head: Physical activity in the acute ward after hip fracture surgery

Corresponding author: Lise Kronborg, Department of Physical Therapy 236, Hvidovre

Hospital, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark. Phone: work: +45 3862 6634.

Mobile: +45 4051 1710. E-mail: [email protected]

Reprints can be obtained from the corresponding author.

mailto:[email protected]





Abstract

Early mobilization following hip fracture surgery reduces medical complications and

mortality, but may increase the risk of falling. The aim was to measure objectively the

physical activity (time spent upright) the first week after hip fracture surgery, and relate it to

functional performance and fear of falling at discharge. The 24-hour upright time was

measured for a median of 6 days using a thigh-worn accelerometer in 37 patients (mean 80

years 8.4) and increased from median 13 (IQR 6-31) minutes to 46 (11-107) minutes at day

7. More upright time at discharge was associated with less fear of falling (r=-0.48, p=0.01,

n=27), which also was associated with fast gait speed (r=-0.50, p=0.02, n=23) and a faster

Timed Up and Go test time (r=0.54, p < 0.01, n=22), indicating a need for further studies on

motivation and limitations for more physical activity following hip fracture surgery.

Keywords: physical activity, accelerometers, hip fracture, basic mobility, fear of falling





Introduction

Immobilization following hip fracture surgery is associated with slow recovery, long-

term loss of function, change of residence, medical complications and long-term mortality

(Kristensen, 2011; Gill, Murphy, Gahbauer, & Allore, 2013; Rosell & Parker, 2003; Ariza-

Vega, Kristensen, Martin-Martin, & Jimenez-Moleon, 2015; Resnick et al., 2011). Early

ambulation involving weight bearing and walking has been found efficient to improve short-

term outcomes after hip fracture surgery and is therefore recommended (Foss, Kristensen, &

Kehlet, 2006; Sherrington, Lord, & Herbert, 2003; Oldmeadow et al., 2006; Siu et al., 2006).

The beneficial effects of physical activity (PA) are undisputable, especially in frail older

adults where days of bed rest can have a huge impact on functional capacity (Kortebein et al.,

2008; Zisberg et al., 2011). Still, for hip-fracture patients in the acute ward, potentially

affected by pain (Foss, Kristensen, Palm, & Kehlet, 2009), pain medication (Foss, Kristensen,

Kristensen, Jensen, & Kehlet, 2005) and postoperative delirium after surgery (Robertson &

Robertson, 2006), PA such as standing or walking is also associated with a potentially greater

risk of falling and compromising the newly acquired orthopedic treatment. This presents a

dilemma of patient safety to the ward staff and may affect staff behavior and perspective on

promotion of PA to the patients (Grant, Granat, Thow, & Maclaren, 2010; Doherty-King,

Yoon, Pecanac, Brown, & Mahoney, 2014; Brown, Williams, Woodby, Davis, & Allman,

2007). Overcoming perceived barriers to mobility for the older patient such as fear of falling,

pain and perspectives towards exercise and PA as a way to recover as opposed to bed rest

may require behavior change and be associated with the motivation for PA immediately after

surgery (Franco et al., 2015; Visschedijk, van, Hertogh, & Achterberg, 2013; Schiller et al.,

2015; Schwarzer, Lippke, & Luszczynska, 2011; Bandura, 1977). Fear of falling has been

recognized as a common problem among elderly, especially those with a history of falls, as it

can activate a negative trajectory of avoiding activities that lead to a subsequent negative





impact on the level of physical function and quality of life in patients with a hip fracture

(Visschedijk et al., 2013). Thus, fear of falling is considered important to target at an early

stage in the rehabilitation after hip fracture (Jellesmark, Herling, Egerod, & Beyer, 2012).

Studies of medical (Brown, Redden, Flood, & Allman, 2009; Doherty-King &

Bowers, 2011; Pedersen et al., 2013) or geriatric in-hospital, non-surgical patients (Brown et

al., 2009; Villumsen, Jorgensen, Andreasen, Rathleff, & Molgaard, 2014) have found low

amounts of time spent standing or walking (upright time), down to a median of 43 minutes

per day during admission. Some of these results in non-surgical patients suggest that an

increase in upright time is associated with achieved independent basic mobility skills

(Pedersen et al., 2013; Villumsen et al., 2014). In hip fracture patients hospitalized in the

acute orthopedic ward, even lower levels of activity - down to an average of 16 minutes of

standing and walking per day - have recently been reported (Davenport et al., 2014). This

emphasizes the relevance of an early, targeted rehabilitation towards independent mobility

and walking skills for the hip-fracture patient to prevent excessive functional decline.

A usual gait speed below 0.6 m/s has been associated with an increased risk of

mobility disability in a general population (Cummings, Studenski, & Ferrucci, 2014).

Furthermore, risk thresholds of maintaining in-hospital walking independence in acutely ill

older adults has been identified to be usual gait speeds down to 0.30 to 0.35 m/s, which may

serve as a relevant target value of independent mobility in a population of hip-fracture

patients (Graham, Fisher, Berges, Kuo, & Ostir, 2010; Kronborg, Bandholm, Palm, Kehlet, &

Kristensen, 2014). Thus, the physical function even at the very early stage after hip-fracture

surgery seems vital to future perspectives for the individual patient.

Objective measurement of 24-hour PA together with functional tests during admission

will provide useful knowledge of the relation between the level of basic mobility skills and

the actual time spent upright by the individual throughout the day (Grant et al., 2010; Ostir et





al., 2013). Combined with fall-related self-efficacy data we aimfor a better understanding of

factors affecting PA in hip fracture patients right after surgery. Consequently, in this study we

measured the 24-hour PA (upright time) and associations with physical function and fear of

falling in older adults ( 65 years old) the first week in the acute orthopedic ward after hip-

fracture surgery, in order to generate knowledge towards planning of optimal recovery

programs for hip-fracture patients in the acute ward.

Method

Study Design and Population

In this observational study, a sample of 38 older adults ( 65 years old) admitted to

the acute orthopedic hip fracture unit at a university hospital was recruited from 40 patients

enrolled in another study concerning feasibility of strength training (Kronborg et al., 2014)

(Figure 1. For original, detailed enrollment, see Kronborg et al.). No compensation for

participation was given, but patients were instructed that mobilization was considered

beneficial for the recovery. All patients were home residing with an independent pre-fracture

ability to walk indoor, according to a modified and reliable (Kristensen, Bandholm, Foss,

Ekdahl, & Kehlet, 2008; Kristensen & Kehlet, 2012) indoor New Mobility Score (NMS)

(Parker & Palmer, 1993) of 2 or more. The NMS evaluates the pre-fracture functional level

with a score from 0 (no walking ability) to 9 (fully independent) consisting of sub-scores

within 3 activities; indoor walking, outdoor walking and walking during shopping. Each

activity provides a score from 0 to 3 (0: not at all, 1: with help from another person, 2: with a

walking aid or 3: no difficulty and no aid) (Kristensen & Kehlet, 2012). All patients were

allowed full weight-bearing immediately after surgery and followed an optimized,

multimodal, in-hospital treatment program (Kehlet, 2011) that included a daily regular

physical therapy program at postoperative day 1-3 and most often daily on weekdays





hereafter. A previous study evaluating the physical activity level (monitored with an ActivPal

body-worn sensor) in older people with impaired function reported difficulties in registration

of walking activity, and especially at slow gait speeds (Taraldsen et al., 2011). Physical

activity (ActivPal) data evaluated in the present study were therefore collected as an

amendment to the feasibility study (Kronborg et al., 2014). The study was approved by the

Capital Region’s Research Ethics Committee (H-A-2007-0127) and conducted according to

the Declaration of Helsinki. The reporting of the study adheres to the Strengthening the

Reporting of Observational Studies in Epidemiology (STROBE) guidelines, using the

checklist for cohort studies (Vandenbroucke et al., 2007) (Checklist S1).

Data Collection and Outcomes

One trained physical therapist from the Department of Physical Therapy with more

than 10 years of clinical experience handled the data collection. Patients were included at the

first day or no later than the 3rd day after surgery. The primary outcomes were the time spent

standing and walking (upright time) and the number of daily up right events (sitting to

standing) per 24 hoursand measured by one thigh-worn, accelerometer-based, activity

monitor (ActivPal3TM, PAL Technologies Ltd., Glasgow, UK). Corresponding with the day

of patient inclusion the monitor was set to record for 10 days non-stop, wrapped waterproof

and attached by an adhesive pad (PALstickie) mid-line on the quadriceps region of the non-

fractured limb and 1/3 of the way from the hip to the knee.

The ActivPal3TM accelerometer, measuring physical activity as time spent in the sit/lie

position (X-axis), standing (Y-axis) and walking (Z-axis), has been validated in several

studies in healthy adults (Godfrey, Culhane, & Lyons, 2007) and in older adults with a hip

fracture (Taraldsen, Vereijken, Thingstad, Sletvold, & Helbostad, 2013; Taraldsen et al.,

2011). Still, the default setting of the monitor for registration of walking is a limitation to our

sample, since walking is defined as an activity in the Z-axis with a cadence of more than 20





steps per minute. For an older adult right after hip fracture surgery, this level of gait speed is

most often not possible to achieve. This means that some of the time actually spent walking is

not registered as walking or step count, but as time spent standing. We performed several

tests to determine the accuracy of registrations of step count and time spent walking in

conditions similar to the sample of older adults with impaired walking ability. The tests

showed a huge discrepancy between the monitor’s registration of step count and walking time

and the actual performance with a loss of counts up to 60% in a single bout of non-stop slow

walking. Based on this and related findings by others (Taraldsen et al., 2011; Grant et al.,

2010), we chose not to analyze data on step count and the time spent walking as single

outcomes. Instead, we analysed data from time spent standing and walking as one outcome –

upright time – as done in related studies (Taraldsen et al., 2013; Taraldsen et al., 2013).

The ActivPal3TM software (v.7.2.29) was used to reduce data from the ActivPal

monitor having visually inspected all data for irregularities. The summary results of complete

days of data were exported to SPSS statistical software and filed as upright time (minutes

spent standing and walking) and number of upright events (sitting to standing) during 24

hours each day, between days 2 and 7 postoperatively, and used in the data analysis of

upright time and upright events per day, respectively.

Secondary outcomes included the Cumulated Ambulation Score (CAS) assessing the

basic mobility skills (getting in and out of bed, sit-to-stand-to-sit from a chair and walking,

with a maximum score of 6 = independent mobility) on a daily basis (Kristensen et al.,

2009). The day of independent mobility was determined as the first day postoperatively that

the participant achieved the maximum score of CAS = 6 and used in the data analysis

(Kristensen, Foss, Ekdahl, & Kehlet, 2010). Functional performance was measured by the

Timed Up-and-Go (TUG) test (fastest of 3 attempts used) and the 10 Meter fast speed

Walking Test (10MWT) 1 time, using a rollator as the standardized walking aid the day





before discharge as described in Kronborg et al. (Kronborg et al., 2014). Hip fracture-related

pain was assessed once before (at rest) and once during functional performance tests using a

five-point Verbal Ranking Scale (VRS 0–4 points; 0 = none, 1 = light, 2 = moderate, 3=

severe and 4= intolerable pain) (Bech, Lauritsen, Ovesen, & Overgaard, 2015). Fear of falling

at discharge was assessed by the Short Falls Efficacy Scale International (Short FES-I, 7-28

points, high scores indicating a high degree of fear of falling) and used in the data analysis

(Kempen et al., 2008). The Short FES-I questionnaire was administered as interviewer-

assisted, completed by paper and pencil. Demographic data included age, gender, type of

fracture, cognitive function measured in the emergency room by Hindsoe’s Test (Kristensen

M T, 2010) and postoperatively by the Mini Mental State Examination (MMSE) (Folstein,

Folstein, & McHugh, 1975), the postoperative day of discharge and discharge destination.

Data Analysis

All data were examined for normality of distribution (Kolmogorov-Smirnov and Q-Q

plots). Descriptive statistics was used to report characteristics of the study sample and the

differences were presented as mean SD when normally distributed, otherwise as medians

(first-third quartile, (IQR)) values, or as numbers with percentages. Subgroups of participants

with and without complete activity data samples – but with independent mobility at discharge

- were examined for differences using the Student t-test, Mann-Whitney U Test, Chi-square

test or the Fischer’s exact test, as appropriate. Changes in upright time and upright events

before and after achievement of independent mobility were examined using the Wilcoxon

Signed-Rank test. Correlations between upright time, the number of upright events, day

achieving independent mobility, TUG time, Fast gait speed and Short FES-I at discharge

were examined by the Spearman rho Correlation test. According to Portney & Watkins’

classification of relationship, correlation coefficients from 0 - 0.25 indicates little or no

relationship, 0.26 - 0.50 a fair degree of relationship, 0.51 - 0.75 a moderate to good degree





and 0.76 – 1.0 a good to excellent degree of relationship (Portney & Watkins, 2009). The

level of significance was set at p < 0.05. No formal sample size calculation was made, as the

study was considered explorative. All statistical analyses were conducted with the SPSS

statistical software (version 19; SPSS inc. Chicago, Illinois, USA).

Results

Thirty-eight patients agreed to participate and were included in the study. One

participant who lost the monitor due to detachment during an early postoperative stage of

confusion and delirium was excluded from further analysis. Otherwise, no episodes of

postoperative delirium were noted in the study sample. Characteristics of the remaining 37

participants; mean age of 80 8.4 years, 19 with a cervical hip fracture and 29 (78%) women

are presented in Table 1. These participants wore an activity monitor continuously the first

week after surgery for a median of 6 (5-6) days (Table 2). The majority of participants (n =

22) used no walking aid before hospitalization. Out of the remaining 15 participants, 11 used

a rollator or crutches for indoor activity, 7 used a walking aid or personal assistance for

outdoor activities, while 5 participants needed a walking aid or assistance for shopping.

Thirty participants (81%) achieved independent basic mobility before discharge using a

walking aid (walker or crutches). Of these, complete activity data was available for 20 (54%)

participants at the day before and after independent mobility was achieved (mean of 6.7 2.4

days postoperatively) (Table 3). Incomplete samplings occurred in 10 participants as 2

monitors had technical errors, 2 samplings were stopped due to transfer to a different ward, 1

monitor was removed due to isolation of the patient, 1 patient died during hospitalization and

4 samplings were incomplete (< 24 hours) due to discharge on the day of achieving

independent mobility (Figure 1). There were no significant differences in the characteristics

between subgroups of participants who achieved independent mobility and had complete





activity data (n = 20) or incomplete activity data sampling (n = 10) (Table 1). Twenty-nine

participants (78%) were discharged to their home, 6 (16%) to inpatient rehabilitation and 1

(3%) to another hospital while 1 participant died during admission (Table 4).

Primary Analyses

Upright time for all participants, irrespective of whether they achieved independent

mobility or not during the hospital stay, increased from a median of 13 (6;31) min/day in

patients monitored at day 2 (n = 26) to 46 (11;107) min/day at day 7 (n = 29). Likewise, the

median number of upright events per day increased from 7 (4;16) at day 2 to 18 (8;34)

upright events at day 7 (Table 2, Figure 2-3).

In the subgroup of participants with complete activity data (n = 20), the median time

spent upright increased from 60 (39;112) to 91 (72;119) min/day (z = -2.315, p = 0.021) from

the day before compared to the day after achieving independent mobility, and with a variation

from 14 to 205 minutes upright on day 7. The median number of upright events increased

from 23 (20;33) at the day before to 35 (29;44) upright events at the day after achieving

independent mobility (z = -2.708, p = 0.007) (Figure 2-3, Table 3).

Secondary Analyses

The mean TUG time was 31.2 (20.9) seconds (n = 25) while the mean fast gait speed

was 0.63 (0.32) m/s (n = 23) at discharge in the subgroup of participants who achieved

independent mobility (Table 4). There was no significant difference in results on TUG

performance (p = 0.231) and fast gait speed (p = 0.816) between subgroups of participants

who achieved independent mobility and had complete activity data or not (Table 4). Hip

fracture-related pain at rest was reported to none or light pain while 4 patients reported more

than light pain during functional performance tests. No significant differences were found

between subgroups of complete or incomplete data (pain at TUG, p = .057 and pain at

10MWT, p = 1.00). Significant differences (p = 0.001) were found in pre-fracture level of





function (NMS) between participants that did and did not achieve independent mobility. No

significant differences were found between these subgroups in any other outcome.

Correlation analyses revealed that earlier achievement of independent mobility after surgery

was associated with more upright time before (r = -0.451, p < 0.05) and after (r = -0.574, p <

0.01) achieving independent mobility, as well as on the day before discharge (r = -0.596, p <

0.01). More upright time at discharge was associated with less fear of falling (r = -0.48, p =

0.01, n = 27), which also was associated with fast gait speed (r = -0.50, p = 0.02, n = 23) and

a faster Timed Up and Go test time (r = 0.54, p < 0.01, n = 22.

Discussion

The primary aim of this study was to report the 24-hour PA and associations with

physical function and fear of falling in older adults one week after hip fracture surgery.

Improvements in PA were mainly observed in patients achieving independent mobility skills

and with fair to moderate associations connecting more PA with a lower degree of fear of

falling. Large variations between subjects were seen in the upright time, differing from 14 to

205 minutes in 24hours, measured 7 days after surgery.

A large variation is common to find in studies of PA in older adults, which might also

relate to differences in early recovery programs (e.g., comprehensive geriatric care compared

to orthopaedic care), as found in a Norwegian study (Taraldsen et al., 2013). Thus, the

upright time at postoperative day 4 reached a mean of 52 (63.7) minutes and 21.8 (19.9)

upright events for the sample of patients receiving comprehensive geriatric care as compared

to 45.1 (57.7) minutes upright time and 19 (16.5) upright events in the orthopedic care sample

(Taraldsen et al., 2013). In comparison, the mean upright time at postoperative day 4 in our

sample (n = 35) was 52.1 (52.5) minutes per day and number of upright events 18.5 (15.7),

placing the sample in the present study in alignment with these care-modalities.





The significant association between the physical performances (TUG and 10MWT),

upright time at discharge and fear of falling (Short FES-I) is interesting. This underlines the

importance that adequate attention is given to inform, motivate and empower, the patient as

well as the ward staff, to maximize the patients’ confidence to engage in PA shortly after hip

fracture surgery. A potential action to this could be an increased mutual recognition of

Bandura’s social cognitive theory of behaviour change (Bandura, 1977). In this terminology,

such a behavior change could for our patients begin with verbal encouragement from the

health professionals to facilitate motivation and strategies to challenge possible pain and fear

of falling and engage in physical activity. To the patient, this will be the potential way to an

experience of success (i.e. mastery experience) and regain of further physical function by

addressing the different sources of self-efficacy (Bandura, 1977; Schwarzer et al., 2011;

Warner et al., 2014). Corresponding with this, the understanding of factors affecting PA in

hospitalized older adults have been studied and explained as highly multifactorial including

complications, lack of resources, unit expectations to ambulate patients as well as the

decisions made by the nurses and the patient’s relatives (Doherty-King & Bowers, 2011). The

patterns of sedentary behavior during hospitalization have been found to continue the patterns

of PA in community-dwelling hip fracture patients the first year after surgery (Fleig et al.,

2015; Resnick et al., 2011). The limitations, as well as the possibilities for PA in the acute

setting, are many, as illustrated by Zisberg et. al (Zisberg, Shadmi, Gur-Yaish, Tonkikh, &

Sinoff, 2015). The findings from these studies add to the understanding of the low levels of

PA recorded in our study and underline the need for tailored recovery programs for older

adults after hip fracture surgery.

The achievement of independent mobility at an early stage after surgery was found to

have a positive association withupright time in the present study. Thus, patients that achieved

independent mobility later after surgery spent significantly less time upright and had more





fear of falling at discharge, compared to those who achieved independent mobility at an

earlier day after surgery. Since the importance of PA as a way to prevent complications for

older adults during hospital stay has been established, these findings are considered important

to address specifically as a part of the early recovery program after a hip fracture as

highlighted in recent studies (Davenport et al., 2014; Jellesmark et al., 2012).

The very low levels of hip fracture-related pain reported during functional

performance tests indicate that pain as such was no limitation to PA in the present study.

However, these tests were performed on the day before discharge and may not reflect the

levels of pain experienced before this day. Cummings et al. found that usual gait speed below

0.6 m/s is equal to increased risk of mobility disability (Cummings et al., 2014). These results

show how disposed our sample of older adults with a low mean fast speed gait of 0.63 0.32

m/s are to the risk of further mobility disability and loss of vital physical function.with This is

further underlined by the no-falls cut-point of 24 seconds to perform the TUG test at

discharge as identified by Kristensen et al. (Kristensen, Foss, & Kehlet, 2007), categorizing

the majority of participants in the present study at increased risk of new falls within the

following 6 months. Thus, continuous rehabilitation and fall prevention is still highly

necessary post-discharge, despite an optimized in-hospital treatment program (Kehlet, 2009).

Strength and Limitations

The ActivPal monitor was well tolerated by the participants in the present study, and

no adverse events were reported. However, the monitor had a tendency to detach during the

up to 10 days of non-stop wear either due to wear-out of the adhesive tape or to removal by

staff during treatment or personal care. The monitor that was lost during our study

disappeared due to detachment by the participant during a stage of confusion and delirium.

Our study sample was small and was minimized further by some incomplete activity

data samples. Nevertheless, no significant difference was found in characteristics between the





subgroups of participants who achieved independent mobility but had complete or incomplete

activity data sampling (Table 1). Still, the interpretation of our findings are limited to a

population treated in an optimized in-hospital treatment program (Kehlet, 2009).

The data collection was performed in the acute ward, providing important knowledge on the

actual in-hospital PA and the associations with mobility skills and fear of falling in hip

fracture patients at this early time point after surgery. To our knowledge, this is the first study

on this topic and, thus, adds to the understanding of how to further optimize future recovery

programs for older adults after hip fracture surgery.

Conclusion

In this study, patients with a hip fracture increased the upright time during the first

week postoperatively, while following an enhanced recovery program in an acute orthopedic

ward. More time spent upright was significantly associated with less fear of falling and

mainly observed in patients achieving independent mobility skills during their admission. The

low amount of physical activity and the associations between the time spent upright,

independent mobility skills and fear of falling at discharge indicate a need of actions to

further motivate both patients and health professionals towards behavior changes that

facilitate increased physical activity immediately after hip fracture surgery.

ACKNOWLEDGMENTS

Additional contribution: We thank all the patients in this study for their valuable

contribution. A special thank to the participating physical therapists, Maria Svennergren (B.

Pt.), Kirsten Aunskjær Pedersen (Pt.), Kirsten Juel Nielsen (Pt.), Maria StokholmVan (B. Pt.)

and Sanne Busk Stie (B. Pt.), nurse staff and doctors from the Hip Fracture Unit and the

Department of Orthopedic Surgery at Hvidovre Hospital, whom provided essential

cooperative assistance with the study without any compensation.





Funding

The study was supported by grants from The IMK Foundation, The Research Foundation of

the Capital Region, The Research Foundation of the Danish Physical Therapy Organization,

The Research Foundation of Hvidovre Hospital and The UCSF Lundbeck Foundation. The

funding agencies had no influence on the study design, methods, subjects, data collection,

analyses or manuscript.

Disclosures

The authors have declared that no competing interests exist.





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Figure 1. Flow chart of data completeness.

1 monitor lost during hospital stay

20 participants with a complete activity data sampling 10 incomplete activity data samplings

Technical error n = 2

Transfer to different unit, isolation, death, discharge n = 8

30 participants achieved independent mobility 7 patients did not achieve independent mobility

37 participants

38 patients with a hip fracture





Figure 2. Time spent upright day 2 and 7 after hip fracture surgery (n = 37) and on the day

before and after achieving independent mobility skills (CAS = 6, n = 20). Data are given in

median (IQR) and minimum to maximum range. * = Maximum of data range.

Abbreviations: CAS = Cumulated Ambulation Score; Post opr. = Postoperative.





Figure 3. Number of upright events day 2 and 7 after hip fracture surgery (n = 37) and on the

day before and after achieving independent mobility skills (CAS = 6, n = 20). Data are given

in median (IQR) and minimum to maximum range. * = Maximum of data range.

Abbreviations: CAS = Cumulated Ambulation Score; Post opr. = Postoperative.





Table 1. Participant demographic and descriptive characteristics.

Characteristics

Total

(n = 37)

Independent

mobility

(n = 30)

Complete

activity data

(n = 20)

Incomplete*

activity data

(n = 10)

P**

Age (years) mean SD 80 8.4 78.8 8.0 79.4 8.4 77.6 7.2 0.580

Women, n (%) 29 (78) 23 (77) 15 (75) 8 (80) 0.760

Men, n (%) 8 (22) 7 (23) 5 (25) 2 (20)

Cervical fracture n (%) 19 (51) 16 (53) 10 (50) 6 (60) 0.605

Trochanteric fracture, n (%) 18 (49) 14 (47) 10 (50) 4 (40)

Type of surgery, n (%):

0.422

Parallel pins 3 (8) 2 (7) 1 (5) 1 (10)

Dynamic Hip screw 7 (19) 6 (20) 5 (25) 1 (10)

Femoral intra-medullary nail 13 (35) 10 (33) 7 (35) 3 (30)

Hemi-arthroplasty 11 (30) 9 (30) 5 (25) 4 (40)

Total hip replacement 3 (8) 3 (10) 2 (10) 1 (10)

ASA (1-5), median (IQR) 2 (2-3) 2 (1-3) 2 (1-3) 2 (1.75-3) 0.779

Hindsoe’s Test (0-9), median (IQR) 9 (8-9) 9 (8-9) 9 (8-9) 9 (7.75-9) 0.846

NMS (0-9), median (IQR) 9 (4.5-9) 9 (5.75-9) 9 (5.5-9) 9 (5.75-9) 0.983

MMSE (Max score 30) mean SD (n

= 35) 25.9 4.5 26.1 4.6 26.0 4.8 26.3 4.1 0.868

Postoperative day of MMSE score 5 (4-7) 5 (4-7) 5 (4-7) 5 (3.75-8.75) 0.948

*No physical activity ActivPal sampling available before or after achieved independent mobility.

**Students t-test, Mann-Whitney U Test, Chi-square or Fischer’s exact test was used, as appropriate, to analyze differences between sub groups of participants with

independent mobility at discharge with complete versus incomplete activity data samples.

ASA = American Society of Anesthesiologists physical status classification system; Hindsoe’s Test = Test of cognition (≤ 6: Low cognitive function); NMS = New Mobility

Score; MMSE = Mini Mental State Examination.





Table 2. Physical Activity data for participants (n = 37).

Day after surgery

Variable 2

(n = 26)

3

(n = 34)

4

(n = 35)

5

(n = 35)

6

(n = 31)

7

(n = 29)

24h Upright time

(minutes)

median (IQR) 13 (6-31) 21 (8-47) 42 (9-79) 48 (16-102) 46 (7-103) 46 (11-107)

24h upright events

(n) median (IQR) 7 (4-16) 11 (5-22) 14 (6-30) 20 (8-32) 20 (6-33) 18 (8-34)

Participants with

incomplete 24h

activity data (n)

11 3 2 2 6 8

Reason for incomplete data:

Day of monitor

appliance (n) 11 2

Technical error (n) 1 1

Participant

discharged (n) 1 2 6 8





Table 3. Physical Activity data for participants with independent mobility achieved and

complete data sampling (n = 20).

Participants with independent

mobility achieved and complete

data sampling (n = 20)

Day after surgery

Variable 2

(n = 14)

3

(n = 20)

4

(n = 20)

5

(n = 20)

6

(n = 18)

7

(n = 18)

Upright time,

median (IQR)

(min/day) 11 (5-29) 24 (9-44) 54 (17-85) 79 (33-113) 81 (37-124) 80 (39-121)

24h upright events

(n) median (IQR) 8 (3-16) 12 (8-23) 19 (12-29) 24 (20-35) 28 (22-35) 30 (17-45)

Reason for incomplete data:

Day of monitor

appliance (n) 6

Participant

discharged (n) 2 2





Table 4. Descriptive characteristics of functional performance outcome measures and discharge destination.

Outcome

Total

(n = 37)

Independent

mobility

(n = 30)

Complete

activity data

(n = 20)

Incomplete*

activity data

(n = 10)

P**

Short FES-I

mean SD

16.2 6.8

(n = 29)

15.3 6.6

(n = 25)

14.7 6.5

(n = 16)

16.4 6.9

(n = 9) 0.534

Postoperative day of independent

mobility, mean SD NA 6.8 3.5 6.7 2.4 7.0 5.2 0.830

TUG (seconds) mean SD 31.2 20.9

(n = 25)

31.2 20.9

(n = 25)

27.7 17.1

(n = 17)

38.7 27.2

(n = 8) 0.231

Fast gait speed (m/s) mean SD 0.62 0.32

(n = 24)

0.63 0.32

(n = 23)a 0.62 0.33

(n = 15)

0.65 0.32

(n = 8) 0.816

Postoperative day of discharge, mean

SD (n = 36)b 12.6 6.5 11.7 6.0 12.1 5.8 11.0 6.5 0.658

Discharge destination (n = 36): 0.095

Own home, n (%) 29 (78) 26 (87) 19 (95) 7 (70)

Inpatient rehabilitation, n (%) 6 (16) 4 (13) 1 (5) 3 (30)

Another hospital, n (%) 1 (3)

*No physical activity ActivPal sampling available before or after achieved independent mobility.

**Students t-test, Chi-square or Fischer’s exact test was used, as appropriate, to analyze differences between sub groups of participants with independent mobility at discharge

with complete versus incomplete activity data samples.

Short FES-I = Short Falls Efficacy Scale International (Max score 28); TUG = Timed Up-and-Go test.

aOne patient was unable to rise from a chair independently but capable of completing the Fast gait speed test.

bOne patient died during admission.

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