Effects of the ActiveHip+ mHealth intervention on the recovery of older adults with hip fracture and their family caregivers: a multicentre open-label randomised controlled trial.

Background: Mobile health (mHealth) systems are a promising alternative for rehabilitation of hip fracture, addressing constrained healthcare resources. Half of older adults fails to recover their pre-fracture routines, which imposes a burden on caregivers. We aimed to test the effectiveness of the 3-month ActiveHip + mHealth intervention on physical and psychological outcomes of older adults with hip fracture and their family caregivers. Methods: In a multicentre open-label randomised controlled trial conducted across 3 hospitals in Andalusia (Spain), patients older than 65 with a hip fracture, who were previously independent and lacked cognitive impairment were recruited alongside with their caregivers. Participants were randomly allocated (1:1) to the intervention group (ActiveHip+) or control (usual care) group. The intervention group underwent a 12-week health education and tele-rehabilitation programme through the ActiveHip + mHealth intervention. The primary outcome, physical performance, was assessed using the Short Physical Performance Battery at three time points: at hospital discharge (baseline), 3-month after surgery (post intervention) and 1-year after surgery follow-up. Primary analyses of primary outcomes and safety data followed an intention-to-treat approach. This study is registered at ClinicalTrials.gov, NCT04859309. Findings: Between June 1st, 2021 and June 30th, 2022 data from 105 patients and their caregivers were analysed. Patients engaged in the ActiveHip + mHealth intervention (mean 7.11 points, SE 0.33) showed higher physical performance compared with patients allocated in the control group (mean 5.71 points, SE 0.32) at 3 months after surgery (mean difference in change from baseline 1.40 points, SE 0.36; puncorrected = 0.00011). These benefits were not maintained at 1-year after surgery follow-up (mean difference in change from baseline 0.19 points, SE 0.47; puncorrected = 0.68). No adverse events, including falls and refractures, were reported during the tele-rehabilitation sessions. At 3-months, the intervention group had 2 falls, compared to 4 in the control group, with no observed refractures. At the 1-year follow-up, the intervention group experienced 7 falls and 1 refracture, while the control group had 13 falls and 2 refractures. Interpretation: This study suggests that the ActiveHip + mHealth intervention may be effective for recovering physical performance in older adults with hip fracture. Importantly, the implementation of ActiveHip + into daily clinical practice may be feasible and has already been adopted in 18 hospitals, mostly in Spain but also in Belgium and Portugal. Thus, ActiveHip + could offer a promising solution when rehabilitation resources are limited. However, its dependence on caregiver support and the exclusion of participants with cognitive impairment makes it necessary to be cautious about its applicability. In addition, the non-maintenance of the effectiveness at 1-year follow-up highlights the need of refinement the ActiveHip + intervention to promote long-lasting behavioural changes. Funding: EIT Health and the Ramón y Cajal 2021 Excellence Research Grant action from the Spanish Ministry of Science and Innovation.

Association of the @ctivehip tele-rehabilitation with the fear of falling of older adults with hip fracture and their family caregivers: Secondary analysis of a non-randomised controlled trial.

INTRODUCTION: Osteoporotic hip fracture is a major health problem. Falls, the primary cause, might lead to a persistent fear of falling (FoF) among older adults, affecting their daily activities and rehabilitation. While in-person interventions exist, limited research is available on the effects of tele-rehabilitation on the FoF after a hip fracture. Thus, this study aims to test the association of the @ctivehip tele-rehabilitation programme on reducing the levels of FoF experienced by both older adults with hip fracture and their family caregivers. METHODS: A non-randomised controlled trial (ClinicalTrials.gov; Identifier: NCT02968589) that compared a webpage-based tele-rehabilitation (@ctivehip) against usual care. Fear of falling was assessed using the Short Falls Efficacy Scale-International. Patients' functional status was evaluated using the Functional Independence Measure. Physical performance was assessed by the Timed Up and Go test and Short Physical Performance Battery. We conducted a per-protocol analysis as the primary outcome, and an intention-to-treat approach as secondary analysis. RESULTS: A total of 71 patients with hip fracture (78.75 ± 6.12 years, 75% women) and their family caregivers participated. Participants in the intervention showed a higher decrease in FoF in comparison to those in the usual care (0.5 Cohen's d; p = 0.042). The reduction in FoF resulting from participation in the tele-rehabilitation programme was mediated by improvements in functional status by 79%. The @ctivehip programme did not decrease FoF of family caregivers. DISCUSSION: @ctivehip is associated with a reduction of the FoF in older adults with hip fractures, but not in their family caregivers, with the reduction being mostly explained by improvements in the patients' functional status. Although the intervention seems promising, it should not be applied in clinical settings until confirmed by appropriate-designed randomised clinical trials.

Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: A systematic review and meta-analysis.

BACKGROUND: Internet-based telerehabilitation could be a valuable option for the treatment of musculoskeletal disorders, with the advantage of providing rehabilitation from anywhere. However, there is no solid and updated evidence demonstrating its effectiveness on relevant clinical and cost outcomes. OBJECTIVE: This systematic review aims to determine the clinical and cost-effectiveness of internet-based telerehabilitation during the recovery of musculoskeletal disorders. METHODS: Medline, Web of Science, Scopus and Cochrane databases were systematically searched from inception to June 2023. Trials investigating the effects of internet-based telerehabilitation in any musculoskeletal disorder were selected. Nonoriginal articles and grey literature were excluded. Two independent reviewers conducted the study selection and data extraction. Random effect meta-analyses (standardized mean difference) and further sensitivity analyses were performed. RESULTS: We selected 37 clinical trials (33 randomized and 4 non-randomized) and 5 health economics studies, which included a total of 4,288 participants. Telerehabilitation was more favourable than control treatments in improving all studied clinical outcomes, although the effectiveness varied depending on the type of musculoskeletal disorder. The standard mean differences (SMD) ranged from 0.24 to 0.91. For physical function, the primary outcome, superior effectiveness was found only in people with hip fractures (SMD, 0.87; 95 % CI, 0.34 to 1.41). The effects for joint replacement, osteoarthritis, and spine pain were similar to those of control treatments. However, the favourable outcomes for telerehabilitation became insignificant when compared specifically to face-to-face rehabilitation. Some results displayed publication bias and a lack of robustness, necessitating cautious interpretation. In terms of health economics studies, telerehabilitation was 89.55$ (95 % CI 4.6 to 174.5) cheaper per individual than conventional treatments. CONCLUSIONS: Telerehabilitation should be considered in the recovery process of musculoskeletal disorders when optimal face-to-face rehabilitation is not feasible. Moreover, telerehabilitation reduces costs and time. PROSPERO NUMBER: CRD42022322425.

ActiveHip+: A feasible mHealth system for the recovery of older adults after hip surgery during the COVID-19 pandemic.

Objective: Half of older adults undergoing hip surgery do not recover their previous functional status. mHealth is a promising tool for rehabilitating older adults after hip surgery. This study aimed to test the feasibility of the ActiveHip+ mHealth system in older adults after hip surgery. Methods: Sixty-nine older adults who had undergone hip surgery and their family caregivers were recruited from hospitals in Spain and Belgium and used the ActiveHip+ mHealth system for 12 weeks. Assessments were made during hospital stay and 3 months after surgery. Feasibility assessment included: adoption (participation proportion), usage (access to the app), satisfaction with the app (Net Promoter Score) and user perception of the quality of the app (Mobile App Rating Scale). Clinical assessment included: patient-reported outcomes, such as functional status (Functional Independence Measure) and performance-based outcomes, such as physical fitness (Short Physical Performance Battery). Results: The ActiveHip+ mHealth system obtained satisfactory feasibility results in both countries. In Spain, we observed 85% adoption, 64% usage, 8.86/10 in satisfaction with the app and 4.42/5 in perceived quality of the app. In Belgium, we observed 82% adoption, 84% usage, 5.16/10 in satisfaction with the app and 3.52/5 in app's perceived quality. The intervention had positive effects on levels of functional status, pain and physical fitness. Conclusions: The ActiveHip+ mHealth system is a feasible tool to conduct the rehabilitation in older adults after hip surgery. Although the intervention seemed beneficial clinically, we do not recommend its implementation in clinical settings until appropriately designed randomised clinical trials confirm these results.

Co-creation of mHealth intervention for older adults with hip fracture and family caregivers: a qualitative study.

PURPOSE: Hip fracture results in an older person's loss of independence. Limited healthcare resources make mobile Health (mHealth) an alternative. Engaging key stakeholders in health technology development is essential to overcome existing barriers. The aim of this study was to establish perspectives of older adults with hip fracture, family caregivers and health professionals (stakeholders) on the development of a mHealth system. MATERIALS AND METHODS: Qualitative study guided by user-centered design principles with focus groups to engage stakeholders during the development. Seven focus groups were conducted [older adults with hip fracture (n = 2), caregivers (n = 3), and health providers (n = 2)] with 45 participants (14 older adults, 21 caregivers and 10 health providers). Inclusion criteria were older adults ≥ 65 years who sustained a hip fracture in the previous 3 months; family caregiver of a person with hip fracture; and health providers with 2+ years of clinical experience working older adults with hip fracture. We followed standard methods for focus groups, including recording sessions, transcription and conducting an inductive content analysis. The same moderator, with clinical and research experience, conducted all focus groups. RESULTS: Three themes were generated to consider for a future mHealth intervention: (1) user-friendly design; (2) content to include recovery and prevention information; and (3) implementation factors. Our mHealth system was developed based on feedback from participants. CONCLUSIONS: Co-creating mHealth technology with stakeholders is essential for uptake and adherence. We provide an overview of the development of ActiveHip+, an mHealth system for the clinical care of older adults with hip fracture.

Designing mHealth tools through a co-creation process with the main stakeholders is a way of facilitating the use of health information and communication technology, especially for older adults.Creating a user-friendly and intuitive mobile application is a critical point for a feasible implementation.Including relevant information about the entire process of a hip fracture recovery and an easy way of communicating with health providers are important aspects for patients and caregivers' support.

An m-Health telerehabilitation and health education program on physical performance in patients with hip fracture and their family caregivers: Study protocol for the ActiveHip+ randomized controlled trial.

Telerehabilitation interventions administered via a smartphone may provide new feasible and effective rehabilitation options at home for patients with hip fracture. However, to date, no such interventions have been shown to be effective in the recovery key health outcomes of these patients. The present multicentre randomized controlled trial (RCT) aims to test the effect of the ActiveHip+ m-Health system in the recovery of physical performance, functional level, quality of life, and other health-related outcomes in both patients with hip fracture and their family caregivers. A total of 104 patients older than 65 years, with hip fracture, and their family caregivers will be randomized into the ActiveHip+ rehabilitation (N = 52) or the control group (N = 52). ActiveHip+ is a 12-week smartphone-based rehabilitation program conducted in Granada and Cádiz (Spain) that includes: (1) 24 sessions of physical exercise and 12 sessions of occupational therapy; (2) seven educational modules for patients and for caregivers; and (3) general recommendations in activities of daily living. The control group will receive the usual rehabilitation protocol offered by the Andalusian Public Healthcare System. The primary outcome is the patient's physical performance, while the secondary outcomes are the patient's functional level, quality of life, pain, fear of falling, fitness perception, pre-fracture functional level, emotional status, and caregiver burden. The present project will substantially contribute to the existing knowledge by testing for the first time the efficacy and feasibility of a multidisciplinary m-Health system in the rehabilitation of patients with hip fracture.

Effects of the @ctivehip telerehabilitation program on the quality of life, psychological factors and fitness level of patients with hip fracture.

INTRODUCTION: Telerehabilitation has emerged in the last decade as a promising alternative to conduct the rehabilitation process at home. However, there are no studies testing the effects of telerehabilitation interventions for patients with hip fracture on quality of life nor psychological factors, whereas the evidence on fitness level is scarce. Thus, the aim of this study is to test the effects of the @ctivehip telerehabilitation program on the quality of life, psychological factors and fitness level of patients who had suffered a hip fracture. METHODS: The present study is a non-randomized clinical trial that includes patients older than 65 years old with a hip fracture and their family caregivers (ClinicalTrials.gov; Identifier: NCT02968589). Per-protocol (64 participants) and intention-to-treat (71 participants) analyses were performed, the first being the main analysis. The intervention group received a home-based multidisciplinary telerehabilitation intervention, called @ctivehip, that lasted 12 weeks. The control group received the traditional care and rehabilitation provided by the Andalusian Public Health Care System. The outcomes measured were the patients' quality of life through the EuroQol Quality of Life Questionnaire (EQ-5D), physiological factors (anxiety and depression) using the Hospital Anxiety and Depression Scale (HADS) and the fitness level, assessed with the International Fitness Scale. RESULTS: The quality of life of the telerehabilitation group increased, while the control group scored worsened at the 3-month follow-up (medium effect size: 0.66 SDs; p = 0.006). The telerehabilitation group demonstrated a greater decrease than the control group in the total HADS score (medium effect size: -0.50 SDs; p = 0.015). Lastly, the telerehabilitation group recovered a fitness level close to the pre-hip fracture in comparison with the control group (small effect size: 0.49 SDs; p = 0.022). DISCUSSION: The @ctivehip telerehabilitation program seems to be a promising treatment to improve the quality of life and psychological factors (i.e. anxiety and depression) of older adults after a hip fracture, as well as to recover their previous fitness level.

Development and Evaluation of a Post-Hip Fracture Instructional Workshop for Caregivers.

BACKGROUND AND PURPOSE: A hip fracture is an unexpected traumatic event. Caregivers of patients with an acute hip fracture have only short time to learn the new skills of postoperative care and handling of the patient. This sudden responsibility changes the life of the caregivers who perceive a higher level of preoccupation about the care of their family member/friend. The objective of this study was to develop and test feasibility for a post-hip fracture inpatient instructional workshop for caregivers of older adults with hip fracture and to establish their knowledge of hip fracture recovery and perceptions of the utility and satisfaction with the workshop. METHODS: This 2-part study was conducted at the University Hospital of Granada, Spain, from September 2016 to April 2017. We invited caregivers of patients (60 years of age or older) hospitalized for a surgically treated fall-related hip fracture to attend an informational and skill development hospital-based workshop (60-90 minutes in duration) on postdischarge management strategies. Following the workshop, we invited caregivers to complete a questionnaire to obtain their knowledge about care after hip fracture and their perceived concerns. Furthermore, we requested that they provide feedback on workshop utility and satisfaction (0-10 points) and suggestions for improving the workshop. RESULTS AND DISCUSSION: We delivered 42 workshops over an 8 month period. One hundred three caregivers attended the sessions and enrolled in the study, mean (SD) age: 52.1 (12.8) years. Sixty-nine percent of the caregivers were women. Caregivers' main concern was apprehension for delivering physical care to their family member/friend (75%), followed by lack of time (42%). Caregivers who were employed were 3.16 times as likely to be concerned about time availability to provide care for their family member/friend. The median (Q1, Q3) of both workshop utility and satisfaction was 10 (10, 10), minimum-maximum: 7 to 10. CONCLUSIONS: Caregivers in this study stated that the workshop was useful and satisfactory. Because caregivers play such a vital role in recovery after hip fracture, providing knowledge and skill development as part of health care delivery may support more person-centered care.

Translation, inter-rater reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation score in patients after hip fracture.

Purpose: To translate the Cumulated Ambulation Score into Spanish, and to examine its inter-rater reliability, agreement and internal consistency.Materials and Methods: Two occupational therapists independently used the Spanish version of the Cumulated Ambulation Score (three activities scored from 0-2 points) to assess 60 consecutive patients with hip fracture within the first post-surgery week at a traumatology service of a public hospital. We used linear weighted kappa (κ) statistics to determine inter-rater reliability, percent agreement to assess measurement error, Cronbach's α coefficient to establish the internal consistency, and the McNemar-Bowker test to evaluate for systematic between-rater differences.Results: The κ was ≥ 0.83 for the three individual activities and the total score, the percent agreement was ≥ 0.87, and Cronbach's α was 0.89 with no observed systematic between-rater difference.Conclusions: This study provides evidence for almost perfect inter-rater reliability, excellent internal consistency, and high percent agreement of the Spanish version of the Cumulated Ambulation Score. Due to the strong psychometric properties, and its ease of use, we suggest it be used in Spanish speaking countries to assess early basic mobility status of patients with hip fracture until independence is reached.Implications for rehabilitationThe Spanish version of the Cumulated Ambulation Score is a reliable outcome measure to assess basic mobility of patients with hip fracture.We suggest the Spanish version of the Cumulated Ambulation Score be used in Spanish speaking settings to indicate small changes in basic mobility of patients with hip fracture until an independent level is reached.The Spanish version of the Cumulated Ambulation Score can be used with a high reliability by experienced and inexperienced occupational therapists, corresponding to the already established reliability when used by physicians and physiotherapists.

A home-based tele-rehabilitation protocol for patients with hip fracture called @ctivehip.

Home-based tele-rehabilitation programs are under development and may be a future option for some patients. The objectives of this non-randomized clinical trial are to design a home-based multidisciplinary tele-rehabilitation protocol for patients with hip fracture, and to compare this protocol versus the home-based usual outpatient rehabilitation protocol. Seventy patients treated for an acute hip fracture, aged 65 years or older, with a high pre-fracture functional level (Functional Independence Measure score >90), without severe cognitive impairment, absence of terminal disease, discharged to their own home or a relativés home postoperatively, allowed weight-bearing, and with signed informed consent, will be allocated into a tele-rehabilitation group (n = 35) or a control group (n = 35). The inclusion criterion for the intervention group will be to have a caregiver with the ability to access the Internet who is willing to perform exercises and activities with the patient at home. The intervention includes a program of physical exercise and occupational therapy (five weekly sessions during 12 weeks), and recommendations for patients and their caregivers, all delivered through a website. The patient's functional level (Functional Independence Measure), quality of life (Euro-Qol), physical performance (Timed Up and Go), caregiver burden (Zarit Interview), and other descriptive data will be assessed at hospital discharge, 4 weeks, and 12 weeks. This project will add to the knowledge concerning the feasibility of tele-rehabilitation as an option to promote recovery of the pre-fracture functional level for some patients with a hip fracture. ClinicalTrials.gov Identifier: NCT02968589NCT.