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Life after hip fracture
Impact of home rehabilitation versus conventional
care and patients experiences of the recovery
process in a short- and long-term perspective
Lena Zidn
Institute of Neuroscience and Physiology
at Sahlgrenska Academy
University of Gothenburg
2
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ISBN 978-91-628-7604-3
Printed by Intellecta DocuSys AB, V Frlunda









LIIe aIter hIp Iracture LIIe aIter hIp Iracture LIIe aIter hIp Iracture LIIe aIter hIp Iracture

mpact oI home rehabIIItatIon versus conventIonaI care
and patIents' experIences oI the recovery process
In a short- and Iong-term perspectIve


Lena ZIden Lena ZIden Lena ZIden Lena ZIden









Department oI CIInIcaI NeuroscIence and RehabIIItatIon
nstItute oI NeuroscIence and PhysIoIogy
at SahIgrenska Academy
UnIversIty oI Cothenburg
Sweden


























OmsIagsIoto: SergIo ]oseIovsky




Lena ZIden, 2008-09-09

lSN 978-91-628-7604-3

Irinled by InleIIecla DocuSys A
Vslra IrIunda Sveden











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Harry Martinson
i "Dikter om ljus och mrker".
3


Abstract





Aim
In a shorl and Ionglerm erseclive comare a gerialric home rehabiIilalion rogramme
HR for alienls vilh hi fraclure vilh convenlionaI care CC and lo calure lhe alienls
exerience of lhe consequences of lhe in|ury and lheir concelions of vhal infIuences lhe
recovery rocess

Method
The lhesis is based on lvo quanlilalive and lvo quaIilalive sludies The lvo quanlilalive
sludies vere randomized and conlroIIed IongiludinaI inlervenlion sludies in vhich
communilydveIIing eIderIy alienls vho had received eilher HR n or CC n vere
foIIoved for one year afler discharge The HR rogramme vhich slarled immedialeIy afler
admission lo hosilaI incIuded aclive arlicialion from alienls in selling goaIs and
Ianning discharge The rogramme vas focused on encouraging lhe arlicianls seIf
efficacy and exercising daiIy aclivilies Assessmenl of baIance confidence degree of
indeendence and frequency of daiIy aclivilies heaIlhreIaled quaIily of Iife mood erceived
recovery and basic hysicaI erformance vere made one monlh six monlhs and one year
afler hosilaI discharge In lhe quaIilalive henomenograhic sludies alienls vere
inlervieved one monlh and one year afler discharge aboul hov lhey exerienced lhe
consequences of lhe hi fraclure and lheir concelions of lhe recovery rocess

Results
The main recovery for aII arlicianls look Iace during lhe firsl six monlhs afler discharge
The resuIls shov lhal lhose vho had arlicialed in lhe HR rogramme recovered fasler lhan
lhose vho hade received CC AddilionaIIy in a Ionger erseclive lhey vere more confidenl
and indeendenl lhan lhe CC grou aIlhough lhe differences belveen lhe grous had
diminished al one year OnIy ersons in lhe HR grou and five ersons in lhe CC grou
considered lhemseIves fuIIy recovered afler one year The resuIls from lhe inlervievs shoved
lhal lhe hi fraclure caused sociaI and exislenliaI cracks in lhe individuaIs Iives The hi
fraclure came unexecledIy and resuIled in an exerience of a changed body and a more
reslricled Iife The inlervievees exerienced lhal lhey had increased difficuIlies lo move and
lo manage indeendenlIy One reaclion vas lhal lheir refraclure seIfviev as being heaIlhy
and slabIe had been unclured by lhe in|ury AIlhough osilive exeriences such as being
salisfied vilh lhe recovery vere aIso exressed many of lhe negalive consequences remained
or had even deeened one year afler discharge A dominaling exerience vas lhal lhey vere
4
more caulious afraid of furlher faIIs and feIl more sedenlary and isoIaled lhan before lhe
fraclure

Conclusions
The resuIls shov lhal lhe negalive consequences of a hi fraclure are subslanliaI and Iong
Iasling Hovever lhe HR rogramme had a more significanl imacl lhan CC on lhe
arlicianls funclioning and confidence vhich vas mosl evidenl in lhe earIy hase of lhe
recovery An essenliaI lask for heaIlh care shouId be lo creale conlinued ossibiIilies for
rehabiIilalion afler discharge from hosilaI aIso in a Ionger erseclive and nol rimariIy
focus on lhe medicaI and hysicaI needs The alienls exeriences and sychoIogicaI
reaclions lhal may foIIov a hi fraclure shouId aIso be considered

Key words
Hi fraclure recovery home rehabiIilalion RCT IongiludinaI inlervievs
henomenograhy baIance confidence indeendence suorled discharge
5







Svensk sammanfattning




Hflfraklur r en av de aIIvarIigasle konsekvenserna av en faIIoIycka och r vid sidan av
slroke den vanIigasle orsaken liII s|ukhusvisleIse och rehabiIilering fr Idre ersoner
Iorskning har visal all endasl ell flaI av alienlerna lerlar de fysiska och sociaIa aklivileler
de hade fre frakluren Mnga uIever all de fr svrare all la sig ulanfr hemmel och del
finns en kad risk fr nedslmdhel och inaklivilel Omfallande insalser har g|orls inom
s|ukvrden fr all idenlifiera verksamma rehabiIileringsmodeIIer fr denna alienlgru
och hemrehabiIilering r en modeII som har vunnil vxande inlresse under senare r
ResuIlalen frn sludier om hemrehabiIilering r emeIIerlid molslridiga Del saknas
dessulom kunska om hur alienlerna uIever lerhmlningen och vad skadan inneburil
fr deras dagIiga Iiv

De vergriande syflena med avhandIingen var all |mfra ell gerialriskl s|ukhusanknulel
hemrehabiIileringsrogram med sedvanIig vrd och all fI|a alienlerna under ell r efler
ulskrivning frn s|ukhus saml all fnga alienlernas egna erfarenheler och ufallningar
om skadans konsekvenser och om lerhmlningsrocessen Som en fI|d av del har vi
frulom all mla alienlerna liIIlro liII sin baIans grad av oberoende och frekvens av
dagIiga aklivileler basaI fysisk funklionsfrmga uIevda IivskvaIilel grad av
lerhmlning och sinnesslmning ven inlerv|ual en deI av deIlagarna om deras
erfarenheler av skadans konsekvenser hur den verkal deras dagIiga Iiv Iiksom deras
ufallningar av liIIfrisknandel

I avhandIingen raorleras resuIlal frn en sludie dr alienler Iollades liII all anlingen
deIla i ell hemrehabiIileringsrogram ersoner eIIer i sedvanIig vrd ersoner
HemrehabiIileringsrogrammel var inriklal mol all sld|a alienlernas liIIlro liII sin egen
frmga och baIans saml all lidigl lerula aklivileler ulanfr bosladen som l ex
romenader I genomsnill g|ordes fem hembesk frmsl av s|ukgymnasl och arbelsleraeul
hos dem som fick hemrehabiIilering AIIa deIlagarna fI|des sedan u i hemmel en
mnad sex mnader och ell r efler ulskrivning frn s|ukhus Vid dessa liIIfIIen g|ordes de
6
oIika mlningarna och bedmningarna DeIlagarna fick dessulom genomfra lv enkIa
gng och uresningslesl

I avhandIingen redovisas ocks resuIlal frn lv inlerv|usludier genomfrda en mnad och
ell r efler ulskrivning I sludierna har av deIlagarna i hemrehabiIileringssludierna
inlerv|uals om sina erfarenheler av hflfrakluren viIka konsekvenser den inneburil fr
deras dagIiga Iiv och vad de ufallade verkade Ikningen

I resuIlalen framkommer bI a all den slrsla deIen av lerhmlningen skedde under de
frsla sex mnaderna efler ulskrivning frn s|ukhus In mnad efler ulskrivningen hade
deIlagarna i hemrehabiIileringsgruen hgre grad av lerhmlning i svI liIIlro liII egen
baIans grad av oberoende och frekvens av dagIiga aklivileler som basaI fysisk
funklionsfrmga n de som fll sedvanIig vrd

Sex mnader och ell r efler ulskrivning hade en deI av skiIInaderna meIIan gruerna
ul|mnals men vid ellrsufI|ningen hade deIlagarna i hemrehabiIilering forlfarande
hgre grad av lerhmlning av oberoende i egenvrd frfIyllning och gng liIIlro liII baIans
i dagIiga aklivileler saml hgre s|Ivskallad fysisk funklionsfrmga |mfrl med gruen
som fll sedvanIig vrd Vid ellrsufI|ningen ansg endasl ersoner av
hemrehabiIileringsgruen och fem i gruen som fll sedvanIig vrd all de hade
lerhmlal sig heIl |mfrl med fre frakluren

I inlerv|uerna framkom all frakluren medfrl slora frndringar i individernas Iiv bde i del
korla och Inga erseklivel In dominerande erfarenhel var all oIyckshndeIsen hade
begrnsal frmgan all Ieva som innan Inlerv|uersonerna erfor all de hade svrare all rra
sig obehindral och kIara sig s|Ivslndigl i del dagIiga Iivel viIkel ocks medfrl all de bIivil
mer isoIerade De hade ocks bIivil mer frsikliga och rdda och fr en deI medfrde
hndeIsen all de uIevde all dden kom nrmare och all de inle vgade Ianera framliden
OIyckshndeIsen hade begrnsal deras dagIiga Iiv och mnga av de negaliva
konsekvenserna kvarslod eIIer hade frd|uals ell r efler ulskrivningen

de hIso och s|ukvrd och sociaIl|nsl kan dra Irdom av sludiernas resuIlal Ifler en
hflfraklur r del vikligl all skaa fungerande vrdked|or med forlsall m|Iighel liII
rehabiIilering omedeIbarl efler hemgng och fr dem som behver ven i ell Ingre
lidsersekliv Del r ocks sannoIikl all hemrehabiIileringsrogrammel som slarlade
direkl vid inskrivning s|ukhusel och som innebar all alienlen aklivl deIlog i mIsllning
och ulskrivningsIanering har hafl belydeIse fr hur snabbl alienlerna kunnal lerg liII
sina dagIiga aklivileler i hemmel efler ulskrivning Iflersom en hflfraklur sIr undan
fllerna den som drabbas finns slorl behov av all f h|I och sld all behIIa ho om
liIIfrisknande och all s|Iv bIi akliv i sin rehabiIilering HIso och s|ukvrdsersonaI br
aIIls i samverkan med andra vrd och omsorgsgivare aklivl arbela fr all invoIvera
alienlerna och deras anhriga i vrd och rehabiIilering och d inle enbarl fokusera de
medicinska och rreIsemssiga behoven Kunskaerna om alienlernas erfarenheler och de
7
sykoIogiska reaklionerna som kan fI|a en sdan skada br Iigga som grund fr hur
man bemler och sld|er alienlen genom hennes lerhmlningsrocess

Del lerslr all ulforska hur hIso och s|ukvrdsresurserna ska anvndas ell s olimaIl
sll som m|Iigl fr all skaa vIfungerande och ekonomiskl frsvarbara rehabiIilerings
rogram Dessa rogram br innehIIa samverkan och samarbele meIIan oIika vrd och
omsorgsgivare och slrva efler all undvika all alienlerna faIIer meIIan sloIarna



8


Original papers



This lhesis is based on lhe foIIoving aers vhich viII be referred lo in lhe lexl by lheir Roman
numeraIs

I Ziden L Irndin K Kreuler M Home rehabiIilalion afler hi fraclure A randomized
conlroIIed sludy on baIance confidence hysicaI funclion and everyday aclivilies one
monlh afler discharge Acceled for ubIicalion in CIinicaI RehabiIilalion

II Ziden L Weneslam CG Hansson Scherman M A Iifebreaking evenl earIy exeriences
of lhe consequences of a hi fraclure for eIderIy eoIe CIin RehabiI

III Ziden L Kreuler M Irndin K Longlerm effecls of home rehabiIilalion afler hi
fraclure on funclioning baIance confidence and heaIlhreIaled quaIily of Iife in eIderIy
ersons Manuscril submilled

IV Ziden L Hansson Scherman M Weneslam CG The crack remains eIderIy eoIes
exeriences of a hi fraclure one year afler lhe in|ury Manuscril submilled
9

Contents



Introduction

Background
Risk factors for hip fracture
Osleoorosis
Lack of hysicaI aclivily
IaIIs and fear of faIIing
Consequences of a hip fracture
The patients perspective
Recovery after hip fracture
Rehabilitation after hip fracture
Ihysiolheray
MuIlidisciIinary rogrammes
Home rehabiIilalion
What remains to explore?

Aims

Theoretical and methodological viewpoints
Life paradigm
Self-efficacy
IaIIs efficacy
Health-related quality of life
Situated learning
International Classification of Functioning and Disability (ICF)

Methods
Design
Settings
Participants
Sludy I and III
|an!cnizaiicn
Ccntcniicna| carc
Hcnc rcna|i|iiaiicn
Sludy II and IV
Measures (intervention studies I and III)
aIance confidence
Ierceived recovery
10
Deendence and frequency of daiIy aclivilies
Ierceived recovery
asic hysicaI erformance
Mood
HeaIlhreIaled quaIily of Iife
Iarlicianls characlerislics baseIine
and foIIovu dala
Phenomenography (interview studies II and IV)
Data collection
Data analysis
SlalislicaI melhods
QuaIilalive anaIysis
Ethical considerations

Results
The early phase of recovery
The latter phase of recovery

Discussion
General discussion of the findings
Home rehabiIilalion versus convenlionaI care
Ialienls exeriences and concelions
Iredicling and revenling faIIs and fraclures
Methodological considerations
SlalislicaI consideralions
VaIidily
ReIiabiIily and vaIidily of chosen measuremenls
Truslvorlhiness and credibiIily of
lhe quaIilalive dala
Combining quaIilalive and quanlilalive dale
ICF
What is worth knowing?
Ethical aspects

Conclusions and clinical implications

English summary

Acknowledgements

References

11


Abbreviations




HR Home rehabiIilalion

CC ConvenlionaI care

HRQoL HeaIlhreIaled quaIily of Iife

ADL Aclivilies of daiIy Iiving

IIM IunclionaI Indeendence Measure

IAM InslrumenlaI Aclivily Measure

IAI Irenchay Aclivily Index

IISS IaIIs Ifficacy ScaIe Svedish version

TUG TimedUandGo

STS SilToSland

SI ShorlIorm

CISD Cenler for IidemioIogicaI Sludies of Deression




12


Introduction





Hi fraclure is currenlIy one of lhe mosl serious heaIlh care robIems facing ageing
ouIalions Nol onIy is lhe in|ury accomanied by severe ain and difficuIly lo sland or
vaIk on lhe fraclured Ieg bul aIso by a risk of oor heaIing ConsiderabIe disabiIily and a
decreased caacily for managing aclivilies of daiIy Iiving ADL indeendenlIy may aIso
revaiI desile advances in surgicaI lechniques nursing care and rehabiIilalion
Iurlhermore lhe lraumalic in|ury can bring feeIings of uncerlainly and fear vhich can Iead
lo sociaI isoIalion A beller underslanding of hov lrealmenl of lhis in|ury can maximaIIy
reslore funclioning and heI lhe alienls overcome fear and regain lheir revious abiIilies
and aclivilies is a ma|or chaIIenge for heaIlh care

In lodays coslculling environmenl caulion musl be laken lo revenl shorllerm cosl
saving measures from comromising Ionglerm oulcome for eIderIy eoIe vilh hi
fraclures Irevious research has mainIy deaIl vilh lhe causaIilies and acule lrealmenl of hi
fraclure bul lhe diversily of lhe recovery rocess and lhe voice of lhe individuaI have been
Iess comrehensiveIy described GeneraIIy hysiolheray afler hi fraclure has been
regarded as a rouline maller deaIing mainIy vilh lraining of mobiIily and Ieg muscIe
slrenglh basic daiIy aclivilies such as lransfers lo and from bed or chair and ambuIalion
Hovever in addilion lo lhis lhe alienls ovn exeriences and sychoIogicaI reaclions
such as anxiely and fear and lhe edagogicaI asecls of meeling eoIe vho are
lraumalized afler an acule in|ury are aIso essenliaI lo consider for hysiolheraisls The
Ionglerm effecls of hysiolheray inlervenlions have nol been sufficienlIy evaIualed
vhich have resuIled in dubielies as lo vhich is lhe besl melhod Iurlhermore lhe
conlinuousIy reorled devaslaling and Iasling negalive imacl on alienls funclioning
and daiIy Iives eIucidale lhe deficiencies of lodays rouline hysiolheray lrealmenl

The focus of lhe resenl lhesis is lo enlhrone lhe infIuences of a home rehabiIilalion
rogramme on lhe alienls daiIy Iife as veII as lheir ovn exeriences of going lhrough a
hi fraclure and lhe subsequenl recovery rocess

In lhe foIIoving seclion lhe slale of currenl knovIedge vilhin lhe fieId is resenled This is
foIIoved by a seclion in vhich lheorelicaI and melhodoIogicaI concels vilh reIevance lo
lhe aims of lhe lhesis are resenled
12
13
In lhe foIIoving ackground seclion vhen referring lo an individuaI or a alienl she
viII be used in order lo faciIilale lhe reading Recovery refers lo recaluring lhe IeveI of
funclioning and veIIbeing rior lo lhe in|ury and rehabiIilalion refers lo WHOs
definilion RehabiIilalion of eoIe vilh disabiIilies is a rocess aimed al enabIing
lhem lo reach and mainlain lheir olimaI hysicaI sensory inleIIecluaI sychoIogicaI and
sociaI funclionaI IeveIs RehabiIilalion rovides disabIed eoIe vilh lhe looIs lhey need lo
allain indeendence and seIfdelerminalion


Background




Risk factors for hip fracture

Advanced age and fraiIly are recognized risk faclors for hi fraclure AddilionaIIy
decreased bonemass densily has been found lo be slrongIy reIaled lo hi fraclure
bul aIso olher cIinicaI risk faclors such as faIIs and fear of faIIing Iack of hysicaI
aclivily Iiving in an inslilulion imaired cognilive funclion and imaired
heaIlh have been reorled as rediclors of Ionglerm risk of hi fraclure In lhis seclion
lhree seIecled faclors osleoorosis faIIs and fear of faIIing and Iack of hysicaI aclivily
viII be highIighled

Ostcnpnrnsis
Osleoorosis is defined as a condilion of skeIelaI fragiIily characlerized by reduced bone
mass vilh increased risk of fraclures as a consequence Throughoul lhe vorId
osleoorosis is second afler cardiovascuIar disease as lhe Ieading heaIlh care robIem and
il confines alienls lo a more immobiIe Iife lhan chronic obslruclive uImonary disease
myocardiaI infarclion or cancer One in lhree vomen and one in eighl men viII
deveIo osleoorosis in lheir Iifelime and lhe robIem is groving as lhe number of oIder
eoIe increases The mosl common osleoorosis fraclure is verlebraI fraclure foIIoved by
hi fraclure Among vomen over years aroximaleIy viII exerience a hi
fraclure verlebraI or vrisl fraclure during lhe remainder of lheir Iives Il has been
caIcuIaled lhal osleoorolic fraclures in Iuroe cause more disabiIily ad|usled Iife years
Iosl ie lhe sum of lhe years of disabIed Iife in survivors and lhe Iifeyears Iosl due lo
13
14
remalure morlaIily lhan common cancers vilh lhe excelion of Iung cancer In labIe
lhe eslimaled vorIdvide revaIence of fraclures is shovn


Table 1. Estimated number of fractures, given in thousands, worldwide in men and women in the
year 2000 (F/M female-to-male ratio). From Johnell and Kanis (18).

Sile of fraclure Men Women TolaI Iercenlage IM
Hi
Iorearm
Sine
Humerus
Olher siles


Hi fraclures have become an inlernalionaI baromeler of osleoorosis as lhey are
associaled vilh Iov bone mineraI densily cause exlensive heaIlh care cosls and invoIve
more disabiIily lhan any olher lye of osleoorolic fraclure Iurlhermore hi fraclures
are lrealed in hosilaI and are lherefore easier lo record and comare belveen differenl
counlries lhan for inslance verlebraI fraclures AIlhough osleoorosis is a vorIdvide
robIem lhe highesl incidence of fraclures is currenlIy in Norlhern Iuroe Hovever
aIso in Asia lhe incidence is rising as in lhe IeoIes ReubIic of China vhere hi fraclure
rales have been amongsl lhe Iovesl in lhe vorId Hi fraclure rales in for inslance ei|ing
vere found lo have increased by for vomen and for men belveen and


Given lhe execled increase of lhe eIderIy ouIalion il is anlicialed lhal lhe overaII
incidence of hi fraclures viII conlinue lo rise by er year in mosl areas of lhe vorId
for bolh men and vomen The incidence rales of hi fraclure increase exonenliaIIy
vilh age in bolh men and vomen Iurlhermore lhe increase in faIIs is agereIaled vilh a
higher incidence of faIIs in higher ages Added lo lhe deveIomenl of lhe ouIalion and
lhe reIalion lo age osleoorosis and faIIs lhis exIains al Ieasl of aII hi fraclures

In Sveden aroximaleIy eoIe suslain hi fraclure every year and aboul of
lhe alienls are femaIe As il slrikes Iale in lhe deveIomenl of osleoorosis lhe mean
age of lhe alienls in Sveden is as high as years years for vomen and years for
men There are lvo rinciaI calegories of hi fraclure cervicaI femoraI neck and
lrochanleric incIuding sublrochanleric The surgicaI lrealmenl allern has changed over
lhe Iasl len years eseciaIIy concerning lhe disIocaled cervicaI fraclures of vhich in
vere given hi reIacemenl comared lo in

The Svedish nalionaI quaIily regisler of hi fraclures SAHII reorled lhal in
of lhe alienls vere admilled lo hosilaI from lheir ovn homes look ouldoor vaIks
used frame and vaIked vilhoul vaIking aids before lhe fraclure A quarler of
14
15
lhe alienls vere discharged from hosilaI direclIy lo lheir ovn homes Al lhe four monlh
foIIovu look ouldoor vaIks TolaI morlaIily lhe firsl four monlhs vas in


Lack nI physica! activity
A Iov IeveI of hysicaI aclivily has been found lo be associaled vilh an increased risk of
hi fraclure CouIand and coaulhors found lhal sub|ecls vho did nol veighl
bear reguIarIy or erform muscIe Ioading aclivilies such as cIimbing slairs and gardening
vere aII more lhan lvice as IikeIy lo suslain a hi fraclure vhen comared vilh sub|ecls
vho vere more hysicaIIy aclive This increase in risk remained afler ad|usling for body
mass index smoking aIcohoI consumlion and deendence in daiIy aclivilies
AddilionaIIy Hoidru and coaulhors in a sludy on men and vomen reorled lhal
moderale IeveIs of hysicaI aclivily seemed lo rolecl againsl hi fraclure and lhal decIine
in hysicaI aclivily over lime vas an imorlanl risk faclor for hi fraclure Women
vho vere aclive lhree or more hours er veek during recenl years had haIf lhe risk of
suslaining a hi fraclure as sedenlary vomen vhiIe hysicaI aclivilies during earIier years
shoved no associalion vilh lhe risk of hi fraclure as vas shovn in a sludy by Iahramand
and coaulhors Lov hysicaI aclivily IeveIs arlicuIarIy Ioadbearing aclivilies may
lhus have a slrong bearing on lhe increase in hi fraclure rales reorled by deveIoing
counlries as veII as induslriaI counlries

Fa!!s and Icar nI Ia!!ing
Ior oIder aduIls Iiving in lhe communily fear of faIIing is common Irevious
sludies have eslimaled lhal belveen and of communilydveIIing eIderIy eoIe
in generaI are afraid of faIIing and belveen and in lhose vho have
faIIen Iear of faIIing has been shovn lo reduce hysicaI as veII as sociaI
aclivilies olenliaIIy Ieading lo a decIine in hysicaI funclioning Ioss of
confidence deendency sociaI isoIalion and a decrease in quaIily of Iife
Kressig and coaulhors found lhal among eIderIy vomen lransilioning lo fraiIly
aclivilyreIaled fear of faIIing vas resenl in aImosl haIf of lhe samIe In anolher sludy on
communilyIiving eIderIy eoIe lhose vho reorled reslricled aclivily vere more
hysicaIIy fraiI lhan lhose vho reorled fear of faIIing aIone Il has been suggesled lhal
fear of faIIing couId acl as a sychoIogicaI barrier lo hinder arlicialion in recrealionaI
aclivily

The correIalion belveen faIIs and fear of faIIing has been cIearIy shovn bul il is
uncIear vhich comes firsl Tinelli and coaulhors shoved lhal afler an in|urious faII lhe fear
of faIIing lended lo increase In a ouIalionbased roseclive sludy on oIder
aduIls reorled faIIs al baseIine vas an indeendenl rediclor for lhe onsel of fear of
faIIing afler monlhs and fear of faIIing al baseIine indeendenlIy redicled becoming a
15
16
faIIer Il couId lherefore be suggesled lhal individuaIs vho eilher deveIo fear of
faIIing or exerience reealed faIIs are al risk of deveIoing lhe olher vilh a resuIling
siraIIing risk of faIIs fear of faIIing and funclionaI decIine


Consequences of a hip fracture

The hysicaI consequences of faIIing have been veII documenled AIlhough mosl faIIs do
nol resuIl in severe in|ury five er cenl of faIIs resuIl in a fraclure of vhich hi
fraclure is lhe mosl serious There is an increased risk of dying afler hi fraclure u lo
of alienls arlicuIarIy men and lhose oIder lhan years die during lhe firsl year
afler lheir fraclure Iarl of lhis excess morlaIily is due lo comorbidily As
eoIe vho suffer a hi fraclure have more olher diseases comared vilh lhe generaI
ouIalion il has been eslimaled lhal maybe of dealhs foIIoving hi fraclures are due
lo lhe hi fraclure ilseIf

The ma|orily of alienls suslaining a hi fraclure do nol regain lheir refraclure funclionaI
IeveI Cooer reorled lhal one year afler fracluring a hi of lhe alienls
vere sliII unabIe lo vaIk indeendenlIy Sixly er cenl had difficuIly vilh al Ieasl one
essenliaI aclivily of daiIy Iiving and as many as vere reslricled in olher aclivilies
such as driving or grocery shoing Magaziner and coaulhors concIuded lhal
hi fraclure caused an excess vaIking disabiIily vilhin lvo years afler lhe fraclure of
more lhan in a grou of malched nonfraclured eIderIy eoIe In a caseconlroI sludy by
Norlon and coaulhors on surviving alienls vilh hi fraclure and conlroIs
lhe alienls vilh hi fraclure vere limes more IikeIy lhan conlroIs lo be communily
immobiIe and senl significanlIy Iess hours er day on lheir feel lvo years afler lheir
hosilaI slay

Moreover hi fraclure increases lhe risk of being ermanenlIy inslilulionaIized This vas
described in a caseconlroI sludy in vhich lhe rogress of eIderIy femaIes vas
foIIoved lvo years afler lheir hosilaI slay The aulhors reorled lhal alienls vilh
hi fraclure vere more IikeIy lo have muIliIe faIIs and a furlher hi or eIvic fraclure
used more heaIlh care and home services and lhal of alienls vilh hi fraclure had
enlered a nursing home for lhe firsl lime comared vilh of lhe nonfraclured conlroIs


AIso lhe sychoIogicaI reaclions afler a hi fraclure such as anxiely and fear of nev
faIIs can be exlensive Iurlhermore deressed mood is common afler a hi
fraclure and ils negalive imacl on recovery has been described by severaI aulhors
The resuIls of a recenl sludy in vhich degree of deression erceived hoeIessness
iIIness slress and ain vas measured in eIderIy alienls vilh hi fraclures indicaled
lhal oslin|ury beIiefs and hoeIessness infIuenced IeveIs of deression and anxiely in lhe
acule hase afler a hi fraclure Lenze and coaulhors in one sludy shoved lhal
deression and cognilive imairmenl vere rediclive of negalive oulcomes in eIderIy
16
17
alienls rehabiIilalion from hi fraclure In anolher sludy lhe same aulhors found lhal lhe
grealesl risk for onsel of deression afler hi fraclure vas immedialeIy afler lhe fraclure
and lhal alienls vilh cIinicaI evidence of aalhy vere al higher risk of deveIoing
deression ResuIls from anolher sludy shoved lhal eoIe suffering hi fraclure vho
had fev deressive symloms vere lhree limes more IikeIy lo achieve indeendence in
vaIking and nine limes more IikeIy lo relurn lo lheir rior IeveI of funclioning lhan lhose
vho vere deressed SimiIarIy alienls vilh high osilive affecl shoved beller
erformancebased funclioning afler hi fraclure

Iurlhermore lhe consequences of suslaining a hi fraclure have been reorled lo
exlensiveIy imacl heaIlhreIaled quaIily of Iife HRQoL This vas described by
SaIkeId vho in a sludy of vomen over years shoved lhal Ioss of abiIily lo Iive
indeendenlIy afler a hi fraclure had considerabIe negalive effecls on erceived quaIily of
Iife HaIIberg and coaulhors found lhal verlebraI and hi fraclures had a considerabIy
grealer and more roIonged imacl on HRQoL lhan olher osleoorosis fraclures and lhal
for hi fraclure lhe HRQoL vas beIov normaI even lvo years afler lhe fraclure RandeII
and coaulhors concIude lhal measures of HRQoL shouId be incIuded vhen evaIualing
lhe consequences of hi fraclure

Il couId lhus be summarized lhal revious research highIighls lhe exlensive negalive
consequences of a hi fraclure for lhe individuaI


The patients perspective

In conlrasl lo research on funclionaI recovery and lhe effecls of differenl rehabiIilalion
rogrammes afler hi fraclure sludies on lhe alienls ovn exeriences are fev
orkan and coaulhors found lhal faIIs and faII in|uries forced eIderIy alienls vilh hi
fraclures lo accel lhe Iimilalions of ageing In a aer describing lvo quaIilalive sludies
Iurslenberg conducled elhnograhic inlervievs vilh nine communilydveIIing
eIderIy vho had nol exerienced hi fraclure and hosilaIized alienls vilh hi
fraclure She reorled lhal lhe nonfraclured eIderIy foresav ermanenl disabiIily and
sociaI dealh vere lhey lo suslain a hi fraclure vhiIe lhose aclive in recovery afler hi
fraclure aIlered lheir execlalions osiliveIy or negaliveIy based uon lheir recovery
exerience and cues or suorl from heaIlh care rofessionaIs Iurlhermore ArchibaId
vho inlervieved alienls afler being discharged lo lheir ovn homes afler hi fraclure
surgery reorled lhal lhe alienls feIl disabIed and housebound

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18
eing admilled lo hosilaI due lo an acule in|ury is a dislressing evenl for lhe individuaI
Todays heaIlh care slrives lo minimize hosilaI slay vhich may negaliveIy affecl lhe osl
discharge silualion for lhe eIderIy alienls if lhe discharge Ians and roulines are deficienl
In a sludy in vhich eIderIy vomen vere inlervieved veeks foIIoving
hosilaIizalion lhe aulhors concIuded lhal heaIlh care oflen faiIs lo refIecl lhe comIexily
of lhe alienls silualion afler discharge by focusing rimariIy on basic hysicaI and
medicaI needs ralher lhan on lhose imorlanl lo lhe alienls Iurlhermore alienls
may nol be abIe lo anliciale lheir needs al home vhiIe sliII in hosilaI and hosilaI
rofessionaIs and alienls oflen disagree as lo vhal viII become oslhosilaIizalion needs



Recovery after hip fracture

Differenl faclors such as refraclure cognilive and mood disorders Iov
IeveI of hysicaI aclivily and imaired funclionaI abiIily oor seIfraled heaIlh
resence of diseases Iack of sociaI suorl oslsurgicaI ain aII seem lo
negaliveIy infIuence recovery afler hi fraclure Some sludies have suggesled lhal oId age
couId redicl Iover degree of recovery vhiIe olher sludies have shovn lhal
indeendence and hysicaI funclioning before lhe fraclure vere found lo be more
imorlanl lhan age er se for funclionaI recovery Ceder reorled lhal Iiving
logelher vilh someone and an abiIily lo visil friends before lhe fraclure meanl a grealer
chance of relurning home afler a hi fraclure In conlrasl lo lhis KovaI in an earIier
sludy found lhal indeendence in inslrumenlaI aclivilies before lhe fraclure redicled
faiIure lo recover AIso sychoIogicaI characlers such as seIfefficacy ie eoIes
beIiefs aboul lheir caabiIilies have been slaled as imorlanl faclors in lhe recovery
rocess

ResuIls from a sludy in vhich lvo araIIeI randomized conlroIIed lriaIs vere underlaken
aiming lo revenl and lreal deression afler hi fraclure shoved lhal faIIs efficacy and
cognilive funclion vere more imorlanl lhan ain and deression lo redicl funclionaI
recovery Iurlhermore Whilehead and coaulhors based on lhe resuIls of a sludy
on eIderIy eoIe vilh hi fraclure suggesled lhal rehabiIilalion rogrammes shouId
incIude a variely of oulcome measures incIuding seIfefficacy and lhal more research vas
needed vilhin lhis area NeverlheIess reIaliveIy fev inlervenlion sludies have focused on
lhe seIfefficacy asecl

A modeI of differenl faclors infIuencing recovery afler hi fraclure arranged according lo
lhe InlernalionaI CIassificalion of Iunclioning DisabiIily and HeaIlh ICI modeI see nexl
chaler is shovn in figure

18
19
Recovery
Personal factors Body functions
age, gender, socio-economic and structures
conditions, experiences, self-efficacy musculo-sceletal function,
cognitive functions, mood
Activity and
Participation Environmental factors
exercise, physical activity, discharge planning, support
social activities, hobbies and rehabilitation, home
and environment

Figure 1. Factors influencing recovery after hip fracture, organized according to the International
Classification of Functioning and Health (ICF) within the four components Personal Factors, Body
Functions and Structures, Environmental Factors and Activity/Participation (85, 86) (see next
section).


Ma|or arl of lhe recovery in seIfcare and basic lransfers occurs vilhin lhe firsl six monlhs
afler hi fraclure vhiIe slair cIimbing and inslrumenlaI aclivilies imrovemenl
roceed for al Ieasl one year afler surgery This vas aIso reorled by Magaziner and
coaulhors vho found lhal recovery in gail and baIance vas concenlraled lo lhe firsl
six monlhs vhiIe sociaI funclioning aeared lo increase u lo lvo years oslfraclure
AddilionaIIy for erceived HRQoL lhe ma|orily of recovery seems lo lake Iace by six
monlhs as vas reorled by Ielerson and coaulhors The alienls had allained over
of lheir one year vaIue by six monlhs measured by SI excel for lhe domain of
hysicaI roIe vhich imroved more sIovIy


Rehabilitation after hip fracture

Physinthcrapy
There are many differenl modeIs of rehabiIilalion rogrammes for eoIe vilh hi
fraclures avaiIabIe One is inlensive hysiolheray exercise vhich has been shovn lo
imrove funclionaI recovery afler hi fraclure Hauer and coaulhors found
lhal alienls vho had arlicialed in veeks inlensive rogressive resislance and
funclionaI lraining had significanlIy more increased slrenglh funclionaI erformance and
baIance lhan lhose vho had received Iacebo aclivilies such as memory games or massage
Hovever lhe difference belveen lhe grous had IargeIy disaeared lhree monlhs afler
cessalion of lraining In anolher sludy alienls vho had arlicialed in an inlensive
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20
hi fraclure lraining rogramme al a seciaIized rehabiIilalion vard had significanlIy
shorler Ienglh of slay in hosilaI mean days comared lo significanlIy more
alienls discharged direclIy lo lheir ovn homes comared lo and significanlIy
more alienls vho vere indeendenl in ADL al discharge comared lo lhan
lhe conlroI grou AddilionaIIy Sherringlon and coaulhors reorled lhal a home
based veighlbearing rogramme for alienls vilh hi fraclure imroved baIance and
funclionaI abiIily lo a grealer exlenl lhan a nonveighlbearing rogramme The aulhors
shoved lhal quadrices muscIe slrenglh vas significanlIy associaled vilh imroved
hysicaI erformance Hovever lhe sludies have had reIaliveIy shorl foIIovu lime
and fev sludies used osldischarge direcled rogrammes

Mu!tidiscip!inary prngrammcs
MuIlidisciIinary efforls using skiIIed medicaI nursing and rehabiIilalion lrealmenl have
been slaled lo be a suerior modeI lo maximize rehabiIilalion olenliaI In an
inlervenlion sludy a grou of alienls vilh hi fraclure vho vere randomized lo exlended
muIlirofessionaI rehabiIilalion incIuding aclive revenlion of osloeralive
comIicalions earIy mobiIizalion and four monlh foIIovu lo delecl comIicaling
disorders and lo delermine furlher rehabiIilalion needs vas comared vilh convenlionaI
osloeralive roulines four and monlhs afler surgery The resuIls shoved lhal
desile shorler hosilaIizalion significanlIy more alienls in lhe inlervenlion grou lhan
conlroIs had regained indeendence in ersonaI ADLs al bolh foIIovu occasions
Hovever olher inlervenlion sludies have faiIed lo achieve funclionaI recovery in a Ionger
erseclive Hovever a recenl reviev on randomized lriaIs in vhich
muIlidisciIinary rehabiIilalion vas comared vilh convenlionaI orlhoaedic care in oIder
eoIe vho had suslained a hi fraclure shoved lhal lhere vas subslanliaI suorl for
muIlidisciIinary rogrammes

Hnmc rchabi!itatinn
In Sveden lhere is a Iarge varialion in access lo rehabiIilalion al home for eIderIy eoIe
Many municiaIilies arrange home rehabiIilalion for communilydveIIing eIderIy for
inslance afler an acule hosilaI slay based on lheir need for rehabiIilalion al home
This resuoses lhal lhe alienls cannol lransorl lhemseIves lo lhe rimary heaIlh care
unil Iurlhermore in many cases lhe riorilizalion for home rehabiIilalion is rigorous and
lhe roulines for referraI belveen differenl caregivers deficienl vhich Iimils lhe
accessibiIily for lhe alienls Afler exlensive nalionaI heaIlh care reorganizalions
ambiguily and demarcalion robIems belveen differenl heaIlh and sociaI care
organizalions have been reorled

A syslemalic reviev on homebased care and rehabiIilalion made in by lhe Svedish
CounciI of TechnoIogy Assessmenl in HeaIlh Care SU reorled lhal hosilaI slay
can be reduced by homebased care and rehabiIilalion bul lhal alienl oulcomes vere
simiIar in aIlernalive lyes of rehabiIilalion and lhal cosls vere comarabIe

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21
Home rehabiIilalion HR is frequenlIy offered lo alienls vilh slroke Sludies
have shovn lhal alienls vho afler slroke had arlicialed in a HR rogramme had
significanlIy fever hosilaI days lhan lhose vho had received hosilaIbased rehabiIilalion
Iurlhermore one sludy shoved shorllerm benefil in reIalion lo sociaI
arlicialion and HRQoL vhiIe arlicianls in anolher sludy on HR afler slroke
reorled oorer menlaI heaIlh SI scores lhan lhose vilh convenlionaI rehabiIilalion


IraiI and mobiIilyimaired eIderIy aduIls may benefil from rehabiIilalion al home
In a sludy by Sanford and coaulhors arlicianls vho had received a muIli
facloriaI homebased occualionaI and hysiolheray inlervenlion had imroved lheir
confidence in erforming aclivilies lask seIfefficacy more lhan lhose vho had received
convenlionaI care CC Iurlhermore one sludy described lhal eIderIy vilh a hislory of
faIIs in lhe revious monlhs couId reduce lheir faIIs by afler having arlicialed in
a rogramme aimed al imroving faIIs seIfefficacy encouraging behaviouraI change and
reducing faIIs In a recenl sludy GilIin and coaulhors reorled lhal communily
dveIIing aduIls over years vho arlicialed in a hysiolheray and occualionaI
lheray inlervenlion al home incIuding ADL and confidence in erforming daiIy lasks
had Iess difficuIly vilh inslrumenlaI ADL aclivilies grealer seIfefficacy fever home
hazards and grealer use of adalive slralegies lhan lhe conlroIs and lhal lhis vas
suslained for monlhs Anolher recenl sludy on communilydveIIing eIderIy
shoved lhal an inlervenlion incIuding four oneveekIy occualionaI and hysiolheraisl
sessions largeling mobiIily and lransfers resuIled in a significanlIy higher overaII seIf
efficacy lhan lhose vho had received CC

In Sveden home rehabiIilalion afler hi fraclure vas aIready racliced in lhe earIy s
During recenl years homebased rehabiIilalion for differenl diagnoses has
gained increasing inleresl from differenl heaIlh care roviders One reason for lhis may be
lhe dramalicaIIy shorlened hosilaI slay during lhe Iasl decade

There are many differenl modeIs of home rehabiIilalion one being homebased
hysiolheray aIone In a sludy alienls vilh hi fraclure vho had received eighl sessions
of homebased hysiolheray sessions incIuding exercises for muscIe slrenglhening range
of molion baIance and funclionaI lraining vere comared vilh alienls vho vere
inslrucled lo raclice lhe exercise rogramme given before discharge The sludy
shoved lhal lhe inlervenlion grou lended lo regain lheir hysicaI funclioning and heaIlh
reIaled quaIily of Iife HRQoL fasler lhan conlroIs lhe firsl lhree monlhs osldischarge
vhiIe lhere vas no difference al six monlhs One Iimilalion hovever vilh lhe sludy vas
lhe Iarge amounl of droouls Ieaving fev arlicianls lo foIIovu In anolher sludy
by Crolly and coaulhors on a rogramme vilh acceIeraled discharge afler hi
fraclure and muIlirofessionaI home visils no difference in erceived HRQoL couId be
seen four monlhs afler lhe fraclure On lhe olher hand lhe alienls vho had received
homebased hysiolheray had higher abiIily lo erform daiIy aclivilies and scored higher
21
22
on lhe IaIIs Ifficacy ScaIe al a four monlh foIIovu comared vilh convenlionaI care
When lhe same aulhors Ialer made a monlh foIIovu on lhe same arlicianls
lhey sav a significanl decIine in lhe hysicaI score of lhe SI for bolh grous bul onIy
lhe caregivers of alienls aIIocaled lo receive homebased lheray reorled a significanl
reduclion in burden

Iev sludies on home rehabiIilalion afler hi fraclure have foIIoved lhe alienls for more
lhan six monlhs Kuisma reorled lhal homebased hysiolheray significanlIy
imroved ambuIalion scores for communily and househoId ambuIalion one year afler hi
fraclure surgery comared vilh lhe conlroI grou In conlrasl lo lhis Tinelli and co
aulhors found no differences belveen lhe inlervenlion and conlroI grou regarding
ADL sociaI aclivily IeveIs mobiIily baIance or Iover exlremily slrenglh six monlhs afler
discharge for hi fraclure On lhe conlrary lhere vas a lrend lovards a higher roorlion
of conlroI grou arlicianls reorling comIele indeendence in home managemenl ADL
al six monlhs comared vilh lhe inlervenlion grou

Reorls on home rehabiIilalion afler hi fraclure lhus imIy lhal il oflen brings osilive
effecls for lhe alienls aIlhough lhere is a greal seclrum of resuIls as veII as of
inlervenlion modeIs Iurlhermore lhe Ionglerm effecls of home rehabiIilalion have been
sarseIy sludied


What remains to explore?

Irevious research has reealedIy enlhroned lhal lhe IongIasling robIems and Iimilalions
for lhe alienls are subslanliaI and mosl inlervenlion rogrammes have shovn Iimiled
effecls in a more Ionglerm erseclive Iurlhermore conslanl ressure on hosilaI beds
deficiencies in discharge roulines and Iacking cooeralion belveen hosilaI and
communilies have conlribuled lo suslaining robIems for lhe alienls The Iileralure
reviev has reveaIed lhal many queslions sliII remain on hov lo besl suorl eIderIy eoIe
afler a hi fraclure lhrough lhe recovery rocess and hov lo overcome fear of faIIing in
order lo avoid hysicaI and sociaI Iimilalions even in a Ionger erseclive

During recenl years severaI counlries have vorked oul ambilious oIicy slalemenls
slandards and guideIines The recommendalions are based on besl avaiIabIe evidence
Differenl counlries or regions vilhin a counlry shov greal disarilies concerning
financing and organizing care and rehabiIilalion of eIderIy vhich makes il difficuIl lo
comare and generaIize Iurlhermore lhe voice of lhe alienls has nol been sufficienlIy
heard Research on alienls exeriences of lhe consequences and rehabiIilalion needs afler
a hi fraclure is scarce Il is aIso imorlanl lo gain deeer knovIedge of hov lo
individuaIize rehabiIilalion afler hi fraclure in order lo meel lhe alienls acluaI needs
and heI lhem besl regain lhe abiIilies and aclivilies lhey need and desire
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23

Aims




The overaII aims of lhis lhesis vere in a shorl and Ionglerm erseclive

lo comare a muIlirofessionaI home rehabiIilalion HR rogramme vilh
convenlionaI care CC
lo exIore and describe lhe alienls exeriences of a hi fraclure and lhe recovery
rocess afler lhe in|ury

The hyolhesis vas lhal eoIe vho had arlicialed in a bridging hosilaIbased HR
rogramme vouId have more confidence in lheir ovn abiIily lo manage daiIy aclivilies
and hence be more hysicaIIy and sociaIIy aclive earIy in lhe rehabiIilalion rocess lhan
eoIe vho had arlicialed in convenlionaI care vhich incIuded IillIe or no rehabiIilalion
afler discharge from hosilaI Iurlhermore lhal lhe individuaIs vho arlicialed in HR
vouId be abIe lo resume lheir refraclure daiIy aclivilies earIier in lhe rehabiIilalion
rocess and ossibIy be abIe lo kee lhem over lime lhan lhose vho had received CC

The secific aims of lhe incIuded sludies vere
5tudy I
To sludy if a HR rogramme for eIderIy alienls vilh acule hi fraclure couId Iead lo
imroved baIance confidence indeendence and IeveI of daiIy aclivily and hysicaI
funclioning comared lo CC one monlh afler discharge

5tudy II
To calure lhe ercelions of a grou of eIderIy eoIe vho recenlIy had suslained a hi
fraclure and lo describe lheir exeriences of lhe consequences of lhe hi fraclure in lhe
earIy hase of lhe recovery rocess
5tudy III
To invesligale Ionglerm effecls of a HR rogramme in eIderIy eoIe vilh hi fraclure
regarding indeendence in daiIy aclivilies baIance confidence frequency of daiIy
aclivilies hysicaI funclioning heaIlhreIaled quaIily of Iife and erceived recovery
comared vilh CC
5tudy IV
To exIore eIderIy eoIes exerienced consequences of a hi fraclure and lheir
concelions of vhal infIuences recovery one year afler discharge from hosilaI
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24



Theoretical and methodological viewpoints





The loics sludied in lhis lhesis recovery and rehabiIilalion afler hi fraclure are
muIlidimensionaI and require differenl lheorelicaI keyslones as veII as research melhods
in order lo cover various asecls Wilh lhis background il became vaIuabIe lo seek a
lheorelicaI base insired by medicaI hiIosohicaI sychoIogicaI as veII as educalionaI
areas of knovIedge As lhe basic medicaI slandoinls have been described in lhe seclion
above lhis seclion viII incIude a descrilion of lhe areas vhich form lhe lheorelicaI base
for lhis lhesis


Life paradigm

A raclicing hysiolheraisl oflen comes cIose lo lhe alienls body and feeIings
Avareness aboul vhal haens in such an encounler is essenliaI for deveIoing a good
reIalion belveen lhe lheraisl and lhe alienl The hysiolheraisls ambilion couId be lo
guide lhe alienl lo be avare of her ovn resources and her reerloire of aclion ie vhal
she is caabIe of doing in order lo be abIe lo acl according lo her ovn inlenlions and goaIs
inslead of focusing on deficiencies and disabiIilies

Wilhin lhe area of rehabiIilalion Trnebohm has deveIoed secific lheories aboul
IifevorId and Iife aradigm According lo his lheories a ersons IifevorId conlains
everylhing lhal mean somelhing lo her such as aclivilies significanl olhers and cuIluraI
henomena Wilhin a ersons IifevorId herseIf her body and her Iife aradigm are aIso
incIuded A ersons Iife aradigm comrises her viev on her Iife and Iife ideaIs ie vhal
makes Iife vorlh Iiving her viev on lhe vorId her concelions and knovIedge her viev
on her body her skiII and abiIilies and her areas of inleresl ie vhal drives her aclions As
a ersons Iife aradigm is dynamic il conlains everylhing she has exerienced during Iife
Trnebohm emhasizes lhe urge for heaIlh care rofessionaIs lo exIore lhe alienls Iife
aradigms in order lo be abIe lo meel her differenl needs from her ovn erseclive and nol
onIy from heaIlh cares oinl of viev

Il couId lhus be suggesled lhal hysiolheraisls and olher heaIlh care rofessionaIs have
much lo gain by exIoring lhe alienls Iife aradigm
24
25

Self-efficacy

SeIfefficacy ie an individuaIs beIief aboul lheir abiIily lo coordinale skiIIs and abiIilies in
changing and chaIIenging silualions can have imorlanl imIicalions for successfuI
rehabiIilalion oulcomes Ividence suggesls lhal seIfefficacy is an imorlanl asecl of
rehabiIilalion in lerms of lhe alienls roensily lo engage rehabiIilalion rogrammes
High degree of erceived seIfefficacy has been Iinked lo osilive oulcomes
incIuding beller recovery from lrauma or in|ury and Ionger duralion of recovery in
oIder ersons vilh nevIy acquired disabiIilies Iurlhermore higher seIfefficacy
scores vere found lo be one of lhe fev faclors associaled vilh ADL recovery in a samIe of
lhe oIdesl oId

andura vho deveIoed and described lhe concel seIfefficacy has suggesled lhal
oulcomes lhal eoIe anliciale deend IargeIy on lheir |udgemenl of hov veII lhey viII
be abIe lo erform in given silualions SeIfefficacy is cIoseIy reIaled lo lhe concels
coing ie aclivily aimed al overcoming adversily lo relurn lo an aclive Iife and
Iocus of conlroI ie vhere individuaIs conceluaIIy Iace resonsibiIily choice and
conlroI over evenls in lheir Iives Il is knovn from exerimenls vilh chiIdren Iearning
malhemalics lhal lhose vho regarded lhemseIves as efficacious vere more successfuI in
soIving malhemalicaI robIems lhan vere chiIdren vho doubled lheir abiIilies This
suggesls lhal eoIe vho doubl lheir caabiIilies in arlicuIar areas of aclivily may give u
on difficuIl lasks in lhose domains and inslead focus on lheir ersonaI deficiencies
andura describes hov lhis may Iead lo Iosl failh in ones caabiIilies vhich makes il
easy lo become a viclim of slress and deression In conlrasl lo lhis he slales eoIe vho
have slrong beIiefs in lheir caabiIilies aroach difficuIl lasks as chaIIenges lo be
maslered ralher lhan lhreals lo be avoided Those individuaIs remain laskfocused lend lo
sel lhemseIves chaIIenging goaIs allribule faiIure lo insufficienl efforl more lhan ovn
incaabiIily and recover quickIy lheir sense of efficacy afler faiIure or selbacks vhich in
lurn Iovers vuInerabiIily lo deression If individuaIs do nol beIieve in lheir olenliaI
for successfuI aclion lhey are Iess IikeIy lo alleml adalive slralegies According lo
andura seIfefficacy aIso affecls lhe IeveI of slress and deression exerienced in
lhrealening or difficuIl silualions SeIfefficacy is increasingIy being recognized as an
essenliaI comonenl of veIIbeing In a sludy in fraiI eIderIy eoIe sychosociaI
faclors such as seIfefficacy had a slrong infIuence on lhe HRQoL

Fa!!s cIIicacy
The concel faII seIfefficacy oflen caIIed faIIs efficacy has been deveIoed using lhe
framevork of seIfefficacy Measuring faIIs efficacy can be focused eilher on lhe
asecl of fear of faIIing or on lhe asecl of baIance confidence ie erceived confidence in
lask erformance vilhoul faIIing In lhe inlervenlion sludies I III ve vere rimariIy
inleresled in exIoring lhe confidence asecl of faIIs efficacy

25
26
IaIIs efficacy has been reorled lo be associaled vilh funclionaI abiIily and individuaIs
vilh Iov eslimaled seIfefficacy lend lo reduce lheir hysicaI and sociaI aclivilies
Ior imrovemenl of faIIs efficacy or baIance confidence among lhe eIderIy
differenl lyes of inlervenlions for inslance Tai Chi shorllerm hysicaI exercise
homebased exercise and hi roleclor have been lesled In one singIe case
sludy four oul of five vomen vilh erceived unsleadiness imroved lheir baIance
and increased lheir degree of baIance confidence afler having arlicialed in a veek
rogramme incIuding ouldoor vaIking and baIance lraining Tinelli and coaulhors
reorled lhal faIIs efficacy roved lo be a olenl indeendenl correIale of ADL as veII as
hysicaI and sociaI funclioning and suggesl lhal cIinicaI rehabiIilalion rogrammes shouId
alleml simuIlaneousIy lo imrove hysicaI skiIIs and confidence Some sludies have
shovn lhal among oIder aduIls vilh a fear of faIIing confidence is an imorlanl faclor in
reIalion lo lhe erformance of funclionaI aclivilies Higher IeveIs of seIf
efficacy have been found lo be roleclive againsl funclionaI decIine in basic ADL and sociaI
aclivilies vhereas individuaIs vilh Iov erceived seIfefficacy lended lo avoid cerlain
aclivilies Iorlinsky and coaulhors shoved lhal alienls vilh higher seIf
efficacy scores had a grealer IikeIihood of Iocomolion recovery afler hi fraclure

CIearIy IeveI of seIfefficacy and fear of faIIing are Iinked vilh veIIbeing and quaIily of
Iife of oIder aduIls Moderale fear of faIIing has been associaled vilh a
decrease in Iife salisfaclion a deressed mood and increased fraiIly and severe fear vas
furlher associaled vilh a decrease in mobiIily and in sociaI aclivilies


Health related quality of life

The lerm heaIlhreIaled quaIily of Iife HRQoL refers lo lhose asecls of quaIily of Iife lhal
direclIy reIale lo an individuaIs heaIlh slalus HRQoL measuremenl lhus refers lo lhe
evaIualion of lhe alienls sub|eclive ercelion of his or her heaIlh ie lhe imacl of
disease and lrealmenl on erceived heaIlh slalus infIuenced by his or her exeriences and
execlalions There is no universaIIy acceled definilion of HRQoL and differenl
conceluaI framevorks guide lhe oeralionaIizalion of HRQoL domains and inslrumenls
A videIy used definilion of HRQoL is lhe exlenl lo vhich heaIlh imacls an individuaIs
abiIily lo funclion and her erceived veIIbeing in hysicaI menlaI and sociaI domains of
Iife The funclioning arl of HRQoL incIudes basic aclivilies such as seIfcare and aid
or unaid Iabour Il aIso incIudes lhe exlenl lo vhich a erson is abIe lo inleracl vilh
famiIy or friends The veIIbeing arl of HRQoL is more sub|eclive lhan lhe funclioning
arl as il deaIs vilh lhe resondenls ercelions WeIIbeing ilems incIude vhelher lhe
erson feeIs hay sad deressed or anxious vhelher lhey are in severe ain or have no
ain and vhelher lhey are energelic or nol Comrehensive measures of HRQoL incIude
ilems measuring lhe hysicaI menlaI and sociaI domains of Iife


26
27
Situated learning

One of lhe underIying ideas of lhe home rehabiIilalion sludied in lhis lhesis is lhal of
Iacing rehabiIilalion al home ralher lhan al a cIinic This idea is based on lhe lheory of
silualed Iearning vhich concerns Iearning vhich lakes Iace in lhe same conlexl in vhich
il is aIied An underIying resumlion is lhal Iearning as il normaIIy occurs is a funclion
of lhe aclivily conlexl and cuIlure in vhich il occurs ie il is silualed Silualed
Iearning has ils rools in lhe vorks of Vygolsky concerning sociaI Iearning and in
Deveys lheories on Iearningbydoing According lo Anderson and coaulhors
silualed Iearning has four ma|or remises vhich guide lhe educalionaI aclivilies a
Iearning is grounded in lhe aclions of everyday silualions b knovIedge is acquired
silualionaIIy and lransfers onIy lo simiIar silualions c Iearning is lhe resuIl of a sociaI
rocess encomassing vays of lhinking erceiving robIem soIving and inleracling in
addilion lo decIaralive and roceduraI knovIedge and d Iearning is nol searaled from
lhe vorId of aclion bul exisls in robusl comIex sociaI environmenls made u of aclors
aclions and silualions According lo lhe lheories of silualed Iearning il is suosed
lhal as Iearners acquire addilionaI skiIIs Iess suorl viII be needed Inslruclors change
lheir roIes from conlenl lransmillers lo faciIilalors of Iearning by encouraging rogress
buiIding Iearning environmenls encouraging refIeclion and heIing Iearners become more
avare of conlexluaI cues lo aid underslanding

Irom lhis erseclive il seems referabIe lo reside in lhe alienls ordinary environmenl al
home ralher lhan al a hosilaI vard or rehabiIilalion cenler vhen lraining daiIy aclivilies
and funclionaI abiIilies afler an in|ury Iike a hi fraclure


International Classification of Functioning, Disability and Health (ICF)

The overaII aim of lhe ICI is lo rovide a unified and slandard Ianguage and framevork
for lhe descrilion of heaIlh and heaIlhreIaled slales The domains incIuded in ICI can
be seen as heaIlh domains and heaIlhreIaled domains They are described from lhe
erseclive of lhe body lhe individuaI and sociely Iunclioning is an umbreIIa lerm
incIuding aII body funclions aclivilies and arlicialion and disabiIily serves as an
umbreIIa lerm for imairmenls aclivily Iimilalions or arlicialion reslriclions ICI aIso
Iisls environmenlaI faclors vhich may inleracl vilh aII lhese areas

ICI has lvo arls each vilh lvo comonenls funclioning and disabiIily vilh lhe
comonenls a body funclions and slruclures and b aclivilies and arlicialion and
conlexluaI faclors vilh lhe comonenls a environmenlaI faclors and b ersonaI faclors
Iach comonenl may be exressed in lvo vays On lhe one hand lhey can be used lo
indicale robIems eg imairmenl aclivily Iimilalion or arlicialion reslriclion
summarized under disabiIily and on lhe olher hand lhey can indicale nonrobIemalic
neulraI asecls of heaIlh summarized under funclioning
27
28

ody slruclures are analomicaI arls such as organs Iimbs and lheir comonenls and
imairmenl in body slruclures are robIems in body funclion or slruclure for inslance a
significanl devialion or Ioss of funclion Aclivily is lhe execulion of a lask or aclion by an
individuaI and aclivily Iimilalions are difficuIlies lhe individuaI may have in execuling
aclivilies Iarlicialion is invoIvemenl in a Iife silualion and arlicialion reslriclions are
robIems an individuaI may exerience in invoIvemenl in Iife silualions
InvironmenlaI faclors make u lhe hysicaI sociaI and alliludinaI environmenl in vhich
eoIe Iive and conducl lheir Iives for inslance lechnoIogy naluraI environmenl suorl
from olher eoIe alliludes and services or oIicies IinaIIy ersonaI faclors are lhe
arlicuIar background faclors for an individuaIs Iife and Iiving vhich are nol arl of a
heaIlh condilion or heaIlh slales IxamIes of such faclors are gender race IifeslyIe asl
and currenl exerience coing slyIes or individuaI sychoIogicaI assels vhich may Iay a
roIe in disabiIily al any IeveI IersonaI faclors are nol cIassified in ICI aIlhough lhey may
have an imacl on lhe oulcome of various inlervenlions As ICI is seen as a research
looI lo measure oulcomes heaIlhreIaled quaIily of Iife couId be regarded as a gIobaI
concel of lhe ICI measuring differenl asecls of heaIlh

In lhis lhesis lhe ICI has been used lo slruclurize lhe differenl oulcome measures





28
29


Methods





Design

The research queslions Ieading lo lhe incIuded sludies vere comIex and required muIliIe
melhodoIogicaI aroaches Therefore a randomized conlroIIed nonbIinded design vas
used for sludy I and III and inlervievs according lo lhe henomenograhic melhod vere
used for sludy II and IV An overviev of lhe research design is given in labIe

Table 2. Research design overview.

Study I, III, quantitative II, IV, qualitative


Design Consecutive, randomized controlled Explorative,
descriptive

Data collection Assessments and self-reported Semi-structured
measures during hospital stay and interviews one
one, six and 12 months after and 12 months
discharge after discharge

Setting Acute hospital + participants homes Participants homes

Participants 102 people, 48 in the HR group and 18 people from
54 in the CC group study I

Analysis Descriptive statistics, parametric Phenomenographic
and non-parametric statistical analysis method



29
30
Settings

Al lhe lime of Ianning and commencemenl of our sludies alienls vilh hi fraclures vere
admilled lo aII lhree hosilaIs beIonging lo lhe SahIgrenska Universily HosilaI in
Gleborg lhe SahIgrenska hosilaI lhe slra hosilaI and lhe MIndaI hosilaI We chose
lo use onIy lhe SahIgrenska hosilaI for our sludies of lhe foIIoving reasons

The SahIgrenska hosilaI vas lhe Iargesl of lhe lhree vilh aroximaleIy hi
fraclure surgeries of aII hi fraclure surgery in lhe area every year SurgicaI
and care roulines differed belveen lhe lhree hosilaIs
The onIy hosilaIbased HR rogramme avaiIabIe for alienls vilh hi fraclure al
lhe lime vas Iocaled al one of lhe gerialric vards al lhe SahIgrenska hosilaI
A ma|orily of lhe alienls vilh hi fraclure vho vere admilled lo lhe SahIgrenska
hosilaI Iived in lhe communily dislricls in lhe cenlraI and veslern arls of lhe cily
and lhe HR rogramme vas direcled lo six of lhose dislricls
A caIcuIalion shoved lhal il vouId be ossibIe lo incIude lhe number of alienls ve
needed lo reach slalislicaI over aroximaleIy alienls during monlhs al
lhe SahIgrenska hosilaI
Iurlhermore ve considered lhal il vouId be cIinicaIIy ossibIe lo be in conlroI of aII
sles of lhe sludy if lhe sludies vere concenlraled lo one hosilaI

When considering aII lhese faclors ve came lo lhe concIusion of recruiling aII arlicianls
lo our sludies al lhe SahIgrenska hosilaI Hovever due lo a reorganizalion orlhoaedic
care in Gleborg aII hi fraclure surgery in lhe area of Gleborg vas moved lo MIndaI
hosilaI by lhe end of lhe incIusion eriod As a consequence of lhis lhe Iasl arlicianls
incIuded vere recruiled from gerialric vards al MIndaI hosilaI


Participants

5tudy I and III
|an!cnizaiicn Al SahIgrenska Universily hosilaI in Golhenburg alienls vilh hi
fraclure as a rouline vere referred direclIy from lhe emergency unil lo eilher of lvo
differenl gerialric vards one vilh HR and one vilh CC The sludy randomizalion
lherefore occurred before lhe alienls vere lransferred lo lhe reseclive vard and before
lhey vere informed and asked aboul arlicialion in lhe sludy

When a alienl vilh acule hi fraclure came lo lhe emergency unil lhe resonsibIe nurse
checked lhe basic incIusion crileria years or oIder communilydveIIing from one of six
seIecled cenlraIveslern communily dislricls in Gleborg vilh diagnosis acule hi fraclure
cervicaI lrochanlericaI or sublrochanleric If lhe alienl fuIfiIIed lhese basic crileria lhe
nurse conlacled lhe resonsibIe gerialric doclor in order lo gel an arovaI lhal lhe alienl
vas suilabIe for gerialric rehabiIilalion Afler a osilive resonse from lhe gerialrician lhe
30
31
nurse honed a nurse al one of lhe gerialric vards vho drev a seaIed enveIoe slaling
vhich grou and hence vhich of lhe lvo gerialric vards lhe alienl vas seIecled for If
lhere vas no bed avaiIabIe on lhe randomized vard lhe alienl vas excIuded from lhe
sludy Wilhin lhe firsl lhree hosilaI days lhe invesligalor checked each alienl concerning
lhe delaiIed incIusion and excIusion crileria before informing aboul lhe sludy Ialienls vho
had documenled demenlia for inslance AIzheimers disease a diagnosed severe iIIness
vilh execled survivaI of Iess lhan one year severe drug or aIcohoI abuse or vho couId
nol communicale or undersland lhe Svedish Ianguage vere excIuded Ialienls vho
shoved cognilive robIems or acule confusion vere lesled using lhe MiniMenlaI Slale
Ixaminalion MMSI Those vho reached scores of Iess lhan on lhe MMSI vere
excIuded from lhe sludy

elveen November and Iebruary a lolaI of eoIe vere conseculiveIy
randomized al lhe emergency unil lo lhe HR vard and lo lhe CC vard figure
A lolaI of alienls vere excIuded due lo a Iack of beds al lhe vard lo vhich lhey had
been randomized HR or CC as lhey did nol meel aII incIusion crileria cognilive
imairmenl n Iiving in lhe vrong arl of lhe cily n earIier serious
diseaseabusedead n and finaIIy alienls vho became aculeIy iII or vere moved lo
anolher hosilaI The excIuded alienls vere evenIy dislribuled belveen lhe HR and lhe
CC grou

Of lhe remaining eoIe vho vere given verbaI and vrillen informalion and inviled
lo arliciale in lhe sludy decIined Thus ersons finaIIy signed a vrillen consenl
lo arliciale in lhe sludy vho had been randomized lo lhe HR vard and lo lhe CC
vard figure No sociodemograhic differences vere found belveen lhose vho vere
excIuded and lhose vho arlicialed in lhe sludy

The fIovcharl of lhe sludy arlicianls is described in figure and lhe iniliaI descrilive
characlerislics of lhe arlicianls in labIe
31
32









1
Cognitive impairments (n=16; 8 HR and
8 CC), living in the wrong part of the city
(n=10, 7 HR and 3 CC), serious disease/
/abuse/dead (n=16; 9 HR and 7 CC)
wrong diagnosis (n=2)

2
No available bed on allocated ward
(n=30; 15 HR and 15 CC)

3
Moved from clinic before being asked
to participate , becoming seriously ill
or deaceased (n=25; 13 HR and 12 CC)

4 Declined (n=11; 5 HR and 6 CC)
(HR = Home rehabilitation, CC = Conventional care)

Dead n=1
Drop-out n=1
Unreachable n=1
Dead n=1

Follow-up
one month
n=54
Interview study:
n=9
Follow-up
six months
Admitted patients with hip
fracture between November 2004
and March 2006
n=232
Excluded (n=99):
Did not meet inclusion criteria
(n=44)
1

No bed available on
allocated ward (n = 30)
2
Other reasons (n = 25)
3
-----------------------------------------------------------------

Declined to participate (n=11)
4


n=48
Interview study:
n=9
Home rehabilitation

n=48
Conventional care

n=54
Randomization
and allocation
n=212
(105 to HR and
107 to CC)
Included in the
study
n=102
Missed to randomize
n=20
n=51 n=47
n=45
Interview study:
n=7
n=48
Interview study:
n=8
Follow-up
one year
post-discharge
Dead n=3 Dead n=2
Figure 2. Flow-chart of the randomization and follow-up occasions
32
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g

a
l
o
n
e

2
6

(
5
4
.
2
)

2
0

(
6
9
.
0
)

6

(
3
1
.
6
)

3
9

(
7
2
.
2
)

3
3

(
7
8
.
6
)

6

(
5
0
.
0
)

W
a
l
k
i
n
g

a
i
d
s

i
n
d
o
o
r

7

(
1
4
.
6
)

4

(
1
3
.
8
)

3

(
1
5
.
8
)

1
4

(
2
5
.
9
)

1
1

(
2
6
.
2
)

3

(
2
5
.
0
)

W
a
l
k
i
n
g

a
i
d
s

o
u
t
-
d
o
o
r

1
3

(
2
7
.
1
)

8

(
2
7
.
6
)

5

(
2
6
.
3
)

2
3

(
4
2
.
6
)

2
0

(
4
7
.
6
)

3

(
2
5
.
0
)

T
a
k
i
n
g

o
u
t
-
d
o
o
r

w
a
l
k
s

4
6

(
9
5
.
8
)

2
7

(
9
3
.
1
)

1
9

(
1
0
0
.
0
)

5
0

(
9
2
.
6
)

4
0

(
9
5
.
2
)

1
0

(
8
3
.
3
)


A
l
o
n
e

3
8

(
7
9
.
2
)

2
2

(
7
5
.
9
)

1
6

(
8
4
.
2
)

4
2

(
7
7
.
8
)

3
3

(
7
8
.
6
)

9

(
7
5
.
0
)


W
i
t
h

c
o
m
p
a
n
y

8

(
1
6
.
7
)

5

(
1
7
.
2
)

3

(
1
5
.
8
)

8

(
1
4
.
8
)

7

(
1
6
.
7
)

1

(
8
.
3
)

D
a
i
l
y

3
1

(
6
4
.
6
)

1
7

(
5
8
.
6
)

1
4

(
7
3
.
7
)

2
5

(
4
6
.
3
)

2
0

(
4
7
.
6
)

5

(
4
1
.
7
)

o
n
c
e

a

w
e
e
k

1
2

(
2
5
.
0
)

9

(
3
1
.
0
)

3

(
1
5
.
8
)

1
7

(
3
1
.
5
)

1
3

(
3
1
.
0
)

4

(
3
3
.
3
)

<

o
n
c
e

a

w
e
e
k

3

(
6
.
3
)

1

(
3
.
4
)

2

(
1
0
.
5
)

8

(
1
4
.
8
)

7

(
1
6
.
7
)

1

(
8
.
3
)

N
e
v
e
r

2

(
4
.
2
)

2

(
6
.
9
)

0

(
0
.
0
)

4

(
7
.
4
)

2

(
4
.
8
)

2

(
1
6
.
7
)

T
y
p
e

o
f

f
r
a
c
t
u
r
e
:

C
e
r
v
i
c
a
l



2
6

(
5
4
.
2
)


1
4

(
4
8
.
3
)


1
2

(
6
3
.
2
)


2
8

(
5
1
.
9
)


2
2

(
5
2
.
4
)


6

(
5
0
.
0
)


T
r
o
c
h
a
n
t
e
r
i
c

1
7

(
3
5
.
4
)

1
2

(
4
1
.
4
)

5

(
2
6
.
3
)

2
1

(
3
8
.
9
)

1
6

(
3
8
.
1
)

5

(
4
1
.
7
)


S
u
b
t
r
o
c
h
a
n
t
e
r
i
c

5

(
1
0
.
4
)

3

(
1
0
.
3
)

2

(
1
0
.
5
)

5

(
9
.
3
)

4

(
9
.
5
)

1

(
8
.
3
)

O
t
h
e
r

d
i
a
g
n
o
s
e
s
:



N
o

2

(
4
.
2
)

2

(
6
.
9
)

0

(
0
.
0
)

2

(
3
.
7
)

2

(
4
.
8
)

0

(
0
.
0
)





1
-
3

4
3

(
8
9
.
6
)

2
7

(
9
3
.
1
)

1
6

(
8
4
.
2
)

4
7

(
8
7
.
0
)

3
8

(
9
0
.
5
)

9

(
7
5
.
0
)





>
3

3

(
6
.
3
)

0

(
0
.
0
)

3

(
1
5
.
8
)

5

(
9
.
3
)

2

(
4
.
8
)

3

(
2
5
.
0
)


33
34
There vere no slalislicaIIy significanl differences belveen lhe lvo grous al refraclure
baseIine labIe


Table 4. Comparison of the pre-fracture measures between the home rehabilitation group and the
conventional care group. Median (min-max) values. FIM = Functional Independence Measure, IAM =
Instrumental Activity Measure.

Measurement

Home
rehabilitation
group
n = 48
Conventional care
group
n = 54 p-value
Independence in daily activities (FIM, IAM)
FIM total score

90.0 (64-91)

88.0 (52-91)

0.272
Self-care 42.0 (32-42)

41.5 (26-42)

0.472
Sphincter control 14.0 (9.0-14.0)

14.0 (7.0-14.0)

0.756
Mobility 21.0 (15.0-21.0)

21.0 (15.0-21.0)

0.573
Locomotion 14.0 (2.0-14.0)

13.0 (2.0-14.0)

0.053
IAM total score 44.5 (10-56) 39.0 (8, 56) 0.27
Out-door activities 24.0 (4.0-28.0)

19.5 (4.0-28.0)

0.107
Domestic activities 24.0 (4.0-28.0)

21.5 (4.0-28.0)

0.621
Frequency of daily activities
FAI total score

28.0 (0.0-37.0)

24.5 (0.0-40.0)

0.388
Domestic activities 12.5 (0.0-15.0)

12.0 (0.0-15.0)

0.607
Out-door activities 11.0 (0.0-18.0)

9.0 (0.0-17.0)

0.180
Leisure and work 3.5 (0.0-8.0)

3.0 (0.0-9.0)

0.847
P-values are calculated with Mann-Whitneys U-test .



Ccntcniicna| carc
The eoIe in lhe CC grou received slandard care and rehabiIilalion and vere
discharged lo lheir ovn home vilh no furlher organized rehabiIilalion or lo shorllerm
nursing home vilh varying access lo rehabiIilalion A common rouline for alienls vilh
hi fraclure al lhe gerialric cIinic vas earIy mobiIisalion and aII ersonneI vere invoIved in
lhe everyday rehabiIilalion The CC aIso comrised arlicialion in lhe slandard
rehabiIilalion rogramme incIuding daiIy individuaI exercise of ersonaI ADL lransfers
vaIking slair vaIking and hysiolheray grou lraining sessions The hysiolheraisl and
occualionaI lheraisl made a home visil lo lhe alienl in conneclion vilh discharge vhen
deemed as necessary for examIe if lhe alienl needed lechnicaI aids or home adalalions
in order lo manage safeIy in daiIy aclivilies AII rehabiIilalion measures vere adaled lo
lhe alienls individuaI medicaI and funclionaI slalus and ersonaI goaIs
34
35
Hcnc rcna|i|iiaiicn prcgrannc
eyond vhal lhe CC alienls received lhe alienls al lhe HR vard foIIoved a seciaIIy
designed rogramme consisling of lvo arls one slarled immedialeIy vhen lhe alienl had
been admilled lo lhe HR vard and lhe second arl afler discharge The rogramme incIuded
an earIy goaIselling meeling in vhich lhe alienl a nurse an assislanl nurse and a
hysiolheraisl or an occualionaI lheraisl arlicialed vilhin lhe firsl days afler
admission Al lhis meeling lhe alienls shorllerm and Ionglerm goaIs for lhe
rehabiIilalion described in as much delaiI as ossibIe vere eslabIished and lhe alienl
received a brochure describing lhe HR rogramme and lheir ovn decided goaIs in vriling
The alienls nexlofkin vere invoIved in lhe vhoIe rehabiIilalion rocess if lhe alienl so
desired The aim of lhe earIy slarl of lhe rogramme vas lo reIieve lhe alienls and lheir
reIalives ossibIe anxiely aboul going home inslead of slaying Ionger in hosilaI or being
lransferred lo a shorllerm nursing home

The HR rogramme incIuded muIlirofessionaI aclions aimed al mobiIizing lhe alienls
molivalion and seIfefficacy Iach HR inlervenlion vas individuaIIy designed and invoIved
suorl for a raid relurn home encouraging cues and raclice of daiIy aclivilies vilh
graduaIIy rising comIexily DaiIy grou sessions incIuding vaIking slair vaIking baIance
and muscIe slrenglh exercises as veII as reguIar assessmenl and lraining of ersonaI care
and lransfers vere incIuded for aII alienls CarefuIIy reared and suorled discharge
as veII as cIose cooeralion vilh lhe alienls reIalives and sociaI home services
vere essenliaI ingredienls of lhe inhosilaI arl of lhe rogramme

The second arl of lhe rogramme consisled of a brief inlervenlion eriod of a lhree veeks
maximum incIuding home visils made mainIy by hysiolheraisls and occualionaI
lheraisls To ensure conlinuily lhe same lheraisls vere invoIved in bolh arls of lhe
rogramme In some cases vhen needed nurses or assislanl nurses made visils The
ersons in lhe HR grou received a median of home visils hysiolheraisl median
min max visils occualionaI lheraisl median min max visils and alienls
vere visiled by a nurse The hosilaI gerialrician vas aIso medicaIIy resonsibIe for lhe
alienls care during lhe second arl of lhe HR eriod afler discharge

The focus of lhe hysiolheray inlervenlion vilhin lhe rogramme vas lo encourage seIf
efficacy and hysicaI aclivily vilh seciaI allenlion lo slair cIimbing and ouldoor
ambuIalion and seIf lraining vas anolher key ingredienl The aim vas lo lry lo make every
erson vho had been abIe lo vaIk ouldoors refraclure lo resume vaIking ouldoors
vilhin lhe rehabiIilalion eriod

5tudy II and IV
Iighleen of lhe arlicianls in lhe inlervenlion sludy vere recruiled lo lhe firsl inlerviev
sludy II sixleen vomen and lvo men The aim vas lo incIude individuaIs vilh differenl
backgrounds gender age Iiving condilions such as Iiving aIone or logelher vilh someone
in an aarlmenl or viIIa vilh or vilhoul eIevalor Iiving in differenl communily dislricls
35
36
reviousIy heaIlhy or vilh severaI medicaI diagnoses in order lo gain a varialion of
exeriences Tvo of lhe arlicianls died belveen one monlh and one year foIIovu and
one erson deveIoed serious cognilive difficuIlies
vilh haIIucinalions vhich revenled an inlerviev al one year SubsequenlIy ersons
arlicialed in lhe one year foIIovu inlerviev sludy

TabIe gives an overviev of lhe arlicianls in lhe inlerviev sludies II and IV


Table 5. Socio-demographic and clinical characteristics of the participants in the interview studies I and
IV.

Sex Age Type of Number of Marital Reported posts-discharge
fracture diagnoses status rehabilitation


M 77 Trochanteric 1-3 Married HR
M 81 Sub- 1-3 Widower HR
trochanteric
F 73 Cervical 1-3 Widow HR
F 93 Trochanteric 1-3 Widow HR
F 79 Cervical 1-3 Married HR
F 81 Cervical 0 Widow HR
F 83 Cervical 1-3 Widow HR
F 81 Trochanteric 1-3 Widow No
F 66 Sub- 1-3 Married No
trochanteric
F 91 Cervical 0 Widow No
F 75 Cervical 1-3 Widow No
F 93 Cervical 1-3 Widow No
F 74 Cervical 1-3 Married No
F 78 Cervical 1-3 Widow No
F 77 Cervical 1-3 Married Out-clinic physiotherapy
F 99 Trochanteric 1-3 Widow Short-term nursing home
F 86 Cervical 1-3 Widow HR
F 83 Cervical 1-3 Widow No


HR = home rehabilitation

36
37
Measures (intervention studies I + III)

The oulcome measures have been slruclured according lo lhe InlernalionaI CIassificalion of
Iunclioning DisabiIily and HeaIlh ICI

ICF Personal Factors

Ba!ancc cnnIidcncc
The Svedish version of lhe IISS vas used lo measure baIance confidence
IniliaIIy lhe IIS vas deveIoed by Tinelli and coaulhors and consisled of ilems
vilh a degree scaIe vhere indicaled very confidenl no fear of faIIing and nol
confidenl al aII very afraid of faIIing The Svedish version has been modified inlo an
degree scaIe vilh ilems gel in and oul of bed gel in and off lhe loiIel ersonaI grooming
gel in and oul of a chair gel dressed and undressed lake a balh or shover go u and dovn
slairs vaIk around neighbourhood reach inlo cuboardscIosels housecIeaning reare
simIe meaIs ansver lhe hone simIe shoing of vhich lhe firsl lhree have been added
lo lhe originaI scaIe The IIS has been used lo measure eilher exerienced degree of baIance
uncerlainly ie fear of faIIing or exerienced baIance confidence ie eslimaled confidence in
keeing baIance during erformed aclivilies In lhis lhesis ve chose lo focus on lhe
confidence asecl of faIIs efficacy ie lhe maximaI score corresonding lo maximaI
confidence SubsequenlIy lhe reversed ansvering aIlernalives nol confidenl al aII and
lolaIIy confidenl vere used in lhis lhesis The scaIe comrises lhree arls six ilems
measuring seIfcare six ilems measuring inslrumenlaI ADL lvo of lhem ouldoor and lhe
lhird arl measuring slaircIimbing The maximum score is vilh oinls for basic ADL
oinls for inslrumenlaI ADL and oinls for slair cIimbing

The IIS has been found lo be sensilive lo change in fears foIIoving cIinicaI inlervenlions for
inslance lai chi hi roleclors or differenl grou inlervenlions such as exercise or
educalion The IIS has been found lo have a reIiabiIily and vaIidily of an
accelabIe slandard for communily dveIIing eIderIy eoIe and il has been reorled lo
be sensilive lo change in fear of faIIing foIIoving cIinicaI inlervenlions

Pcrccivcd rccnvcry
The arlicianls reorled erceived degree of recovery vas arl of lhe seciaIIy designed
queslionnaire see beIov The arlicianls ansvered yes or no lo lhe queslion Do you
consider yourseIf fuIIy recovered comared lo before lhe hi fraclure


ICF Activity and Participation

Dcpcndcncc and Ircqucncy nI dai!y activitics
Degree of indeendence in ersonaI daiIy aclivilies IADL vas assessed using lhe
IunclionaI Indeendenl Measure IIM molor scaIe The IIM molor is a ilem
inslrumenl lhal uses a oinl grading scaIe er ilem lolaIIy deendenl and lolaIIy
37
38
indeendenl The maximum score is oinls vilh oinls assessing seIfcare oinls
assessing mobiIily oinls assessing shincler conlroI and oinls for Iocomolion
VaIidily and reIiabiIily have been lesled and demonslraled accelabIe lo high reIiabiIily
across a vide variely of sellings assessors and alienls

Degree of indeendence in inslrumenlaI daiIy aclivily IADL erformance vas assessed
using lhe InslrumenlaI Aclivily Measure IAM vhich is a scaIe deveIoed from lhe IIM
scaIe The IAM assesses lhe degree of indeendence in eighl advanced aclivilies
vaIking m cooking a simIe meaIdinner using common lransorlalion simIe
shoing ma|or shoing cIeaning and vashing The maximum score is oinls vilh
oinls assessing domeslic aclivilies and oinls assessing ouldoor aclivilies Good
reIiabiIily has been reorled in alienls vilh slroke and aIso inlerraler agreemenl has
been found lo be good

Ior some anaIyses ve dicholomized lhe IIMIAM ilems and subscaIes inlo lvo IeveIs
indeendence vas defined as a score of ie lhe individuaI used a device or vas unabIe lo
do lhe aclivily in a safe or limeIy manner or a score of ie lolaIIy indeendenl Deendenl
vas defined as a score of lo

The frequency of sociaI and comIex daiIy aclivilies incIuding Ieisure aclivilies vas
measured using lhe Irenchays Aclivily Index IAI deveIoed by HoIbrook and SkiIbeck
The aclivilies demand a cerlain amounl of inilialive and lhe inslrumenl can be broken
dovn inlo lhree subscaIes domeslic chores Ieisurevork and ouldoor aclivilies The IAI
consisls of ilems each scored never and indicales lhe mosl frequenl vaIue
vhich can be divided inlo domains each conlaining ilems domeslic ouldoor and
Ieisurevork vilh a lolaI maximum score of The IAI has been found lo have good
conslrucl vaIidily arlicuIarIy in middIeaged and oId eoIe and lo be reIiabIe in a
generaI and in slroke ouIalions

Basic physica! pcrInrmancc
The Timed U and Go TUG lesl vas used lo measure abiIily lo erform basic everyday
movemenl The TUG measures lhe lolaI lime for slanding u from a slandard chair vaIking
m lurning
o
relurning and silling dovn The TUG has good inler and inlraraler
reIiabiIily and is a reIiabIe and vaIid measure of funclionaI mobiIily According lo
recommendalions by IodsiadIo and Richardson lhe TUG vas erformed lvice in each lesl
session one lriaI and one limed erformance vilh a brief sealed resl in belveen The
arlicianl vas informed lo vaIk al a comforlabIe seed The TUG is a rediclor for vaIking
abiIily and aclivily IeveI afler hi fraclure and a melaanaIysis shoved lhal mean vaIue
for heaIlhy eoIe aged years of oIder vas seconds The TUG has
aIso been lesled as a measure of idenlifying eIderIy eoIe vho are al risk of faIIing


38
39
Ability lo rise from a chair vas measured by The Sillo Sland lesl STS The besl
oul of lhree lriaIs erformed as quickIy as ossibIe in seconds vas recorded As lhe
measuremenls vere made in lhe arlicianls homes ordinary chairs aroximaleIy cm
referabIy vilh armresls and ordinary vaIking aids vere used if needed The STS had vas
found reIiabIe and vaIid vhen invesligaling Iover exlremily funclion and Iimilalions in
mobiIily of eIderIy eoIe


ICF Body Functions and Structures

Mnnd
The arlicianls mood vas measured by lhe Cenlre for IidemioIogicaI Sludies Deression
ScaIe CISD Svedish version The CISD is a shorl seIfreorl screening inslrumenl
lo measure deressive symlomaloIogy IarlicuIar behaviours or feeIings are described and
arlicianls indicale hov oflen lhey behaved or feIl lhal vay during lhe asl veek IossibIe
ansvers are rareIy or none some or a IillIe occasionaIIy or a moderale amounl of lime
and mosl or aII of lhe lime The scaIe consisls of ilems Iach ilem has a score of and
lhe maximum score is vilh higher scores indicaling more symloms IeoIe vilh
scores vere cIassified as deressed The inslrumenl has been found lo be vaIid and
reIiabIe

Hca!thrc!atcd Qua!ity nI LiIc
HeaIlhreIaled QuaIily of Life HRQoL vas measured by lhe Shorl Iorm HeaIlh Survey
SI vhich is a generic inslrumenl measuring seIfreorled hysicaI and sychoIogicaI
asecls of heaIlh SI incIudes eighl domains IhysicaI funclioning II len ilems
RoIe funclioninghysicaI RI four ilems odiIy ain I lvo ilems GeneraI heaIlh GH
five ilems VilaIily VT four ilems SociaI funclioning SI lvo ilems RoIe funclioning
emolionaI RI lhree ilems and MenlaI heaIlh MH five ilems The lolaI score in each
domain is vhich indicales a higher degree of erceived heaIlh The Svedish version has
been found reIiabIe and vaIid by Iersson and coaulhors and SuIIivan and coaulhors


Wilhin lhe ICI quaIily of Iife has been regarded as an overaII concel incororaled in aII
IeveIs of lhe ICI In lhis lhesis lhe differenl domains of lhe SI couId be associaled
vilh lhe differenl ICI comonenls as foIIovs ICI Aclivily and Iarlicialion IhysicaI
funclioning RoIe funclioning hysicaI RoIe funclioning ImolionaI and SociaI
funclioning ICI IersonaI Iaclors VilaIily ICI ody Iunclions and Slruclures MenlaI heaIlh
and odiIy ain GeneraI heaIlh is considered as an overaII concel

Participant charactcristics basc!inc and In!!nwup data
AII lhe refraclure baseIine dala vas regislered during lhe iniliaI conlacl vilh lhe incIuded
alienls al lhe vard using seciaIIy designed sludy queslionnaires The firsl covers sociaI
and Iiving condilions lhe use of vaIking aids and ouldoor vaIking habils ie frequency of
39
40
ouldoor vaIks vilh or vilhoul comany IeveI of sociaI home serviceinformaI heI and
lransorlalion habils before lhe fraclure Dala concerning lhe fraclure and olher medicaI
condilions vas coIIecled from medicaI records Al discharge from hosilaI lhe second
queslionnaire covering Ienglh of hosilaI slay discharge faciIily and Ians for conlinued
rehabiIilalion vas used The lhird queslionnaire covering Iiving condilions Ienglh of slay al
osldischarge hosilaI or shorllerm nursinghome care number of hysiolheray or HR
visils IeveI of sociaI home serviceinformaI heI and vaIking aids and habils faIIs and
erceived recovery vas used al lhe foIIovu visils

Some arls of lhe background and foIIovu queslionnaires such as received heI from
sociaI home service or reIalives couId be regarded as beIonging lo lhe ICI comonenl
InvironmenlaI faclors


Phenomenography (interview studies II and IV)

The quaIilalive research lradilion is helerogeneous and incIudes a vide range of aroaches
and melhods In conlrasl lo olher quaIilalive research melhods henomenograhy vas
deveIoed vilhin lhe domain of human Iearning vilhin lhe Universily of Golhenburg in lhe
earIy s Ils aim is lo define lhe differenl vays in vhich eoIe exerience inlerrel
undersland erceive or conceluaIize a henomenon or cerlain asecls of reaIily
According lo Marlon lhere are a Iimiled number of quaIilaliveIy differenl vays in
vhich differenl eoIe exerience a cerlain henomenon A basic assumlion in
henomenograhy is lhal vhal eoIe lhink undersland or remember aboul a arlicuIar
henomenon may vary in a quaIilaliveIy meaningfuI vay Anolher assumlion is lhal
human beings in reIalionshi vilh lhe surrounding vorId creale meaning
Ihenomenograhy invoIves idenlifying lhe concelions or exeriences and Iooking for
lheir underIying meaning and lhe reIalionshi belveen lhem Marlon describes lhis as
foIIovs

We are abIe lo oinl nol onIy lo concelions making u ils consliluenls bul aIso lo reIalions
belveen cerlain concelions of one asecl of lhe vorId and cerlain concelions of anolher
asecl Whal ve have in mind is cerlainIy nol mereIy a Iisling of one concelion afler anolher
Some asecls are cerlainIy more basic lhan olhers and differenl and more or Iess fundamenlaI
Iayers of lhe erceived vorId can be reveaIed

In generaI lhe research rocess of lhe henomenograhic melhod agrees vilh mosl of lhe
quaIilalive melhods In a henomenograhic sludy lhe emiricaI oulcome incIudes verbaI
descrilions of cognilive rocessing resuIling in a body of descrilions of lhe arlicuIar
loic invesligaled lhe henomenon vhich conslilules lhe oulcome sace The
oulcome sace defines lhe quaIilalive varialion of lhe individuaIs concelions of lhe
henomenon or lhe loic The oulcome sace is lhe dala ground for furlher anaIysis The
oulcome sace reresenls lhe various meanings a arlicuIar henomenon has among a
cerlain grou of ersons vhich creales a second order descrilion of lhe henomenon The
40
41
second order erseclive is cenlraI in henomenograhy and il conlrasls vilh lhe firsl order
erseclive vhich focuses on invesligaling hov lhings reaIIy are lhal is lhe lrue nalure of
lhe vorId around us vhiIe lhe second order erseclive describes hov a henomenon is
underslood erceived or exerienced

Irom a henomenograhic erseclive il is imorlanl lo gain knovIedge of eoIes
differenl exeriences of a arlicuIar henomenon and lo use such knovIedge in Iearning
silualions in schooI and in heaIlh and medicaI care Ihenomenograhy is
descrilive emiricaI and conlenlorienled The research inleresl in
henomenograhy is lo describe lhe vorId as eoIe see il Iach unique concelion or
exerience is reorled even if il is heId by onIy one or lvo individuaIs arlicialing in a
sludy


Data collection

5tudy I and III
During lhe alienl incIusion eriod mosl of lhe dala coIIeclion vas carried oul by one of lhe
aulhors LZ assisled by cIinicaI hysiolheraisls al lhe vards AII dala coIIeclion al lhe
foIIovu occasions as veII as inlerviev lranscrils and dala inul vere carried oul by lhe
same aulhor

Wilhin one or lvo days afler arrivaI al reseclive vard eilher HR or CC vard aII incIuded
alienls vere inlervieved by a hysiolheraisl ackground dala vas recorded and medicaI
dala vas coIIecled from medicaI records

To ensure olimaI slandardizalion of lhe discharge measuremenls of lhe TUG and lhe IISS
lhe hysiolheraisls vho vere invoIved agreed on lhe rocedures as veII as coracliced lhe
measuring

efore lhe foIIovu lhe arlicianls vere conlacled by leIehone in order lo aoinl a lime
for lhe visil in lheir ovn homes The queslionnaires vere resenled in a redelermined
order and fiIIed oul in cooeralion vilh lhe resondenls The resuIls of lhe differenl lesl
sessions vere recorded in searale documenls and lhe invesligalor had no access lo revious
dala

5tudy II and IV
In lhe quaIilalive sludy of lhe arlicianls in lhe lvo grous nine from each vere
incIuded According lo lhe henomenograhic lradilion lhe arlicianls vere chosen
slralegicaIIy lo achieve a varialion of exeriences Thus an as urosefuI a seIeclion as
ossibIe vas made of individuaIs vilh differenl backgrounds such as marilaI slalus Iiving
condilions age refraclure funclionaI slalus and arlicialion in rehabiIilalion
rogrammes
41
42

The common melhod of dala coIIeclion in henomenograhy is lhe semislruclured
inlerviev efore lhe inlervievs areas of inleresl vilhin lhe chosen henomenon vere
discussed and served as a slarling oinl oinl for lhe inlervievs The resondenls vere
inlervieved and lae recorded in lheir ovn home and each inlerviev Iasled minules
The inlervievs slarled vilh a fev minules of smaII laIk and informalion aboul lhe rocedure
and vere conducled in a conversalionaI manner lhal aIIoved lhe inlervievees lo seak
freeIy and exress lheir ovn exeriences of lhe henomenon under invesligalion As an
inlroduclion lhe sub|ecl vas asked lo describe vhal had haened vhen he or she had
fraclured lheir hi sludy I or laIk aboul lheir resenl silualion comared lo before lhe
fraclure sludy II IoIIovu queslions and romls vere used such as TeII me more aboul
il Whal does lhis mean lo you and Can you cIarify The ambilion vas lo Iel lhe sub|ecls
concrelize lheir exeriences for inslance by describing in as greal delaiI as ossibIe lheir
ordinary daiIy aclivilies before and afler lhe fraclure

In labIe lhe lime scheduIe and lhe lolaI oulcome measuremenls are resenled


Table 6. Procedure of all data collection.


Measurements Pre-
fracture
1

Dis-
charge
One month

Six months 12 months
Falls Efficacy
(FES(S))
- X X X X
Degree of independence
(FIM, IAM)
X X X X X
Frequency of daily activities
(FAI)
X X X X X
Living conditions
Walking habits
Falls
Perceived recovery
Help at home, walking aids
X

X
-
-
X
X
X
-
-
X
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
Health-related quality of life
(SF-36)
- - X X X
Mood
(CES-D)
- - X X X
Basic physical mobility
(TUG, STS)
-
-
X
-
X
X
X
X
X
X
Semi-structured interview - - X - X

1
informalion vas relrosecliveIy coIIecled al hosilaI

IISS The IaIIs Ifficacy ScaIe Svedish version IIM The IunclionaI Indeendence Measure
IAM The InslrumenlaI Aclivily Measure IAI The Irenchay Aclivily Index
SI The ShorlIorm CISD The Cenler for IidemioIogicaI Sludies Deression ScaIe
TUG The TimedUandGo lesl STS The SilToSland lesl

42
43
Data analysis

5tatistica! mcthnds sludy I and III
ased on cIinicaI assumlions and lhe resuIls of revious sludies
assuming a over of and of and a difference belveen grous of oinls in IIM
vilh SD a lolaI samIe size of n vas eslimaled Wilh an aroximaled drooul rale
of a lolaI samIe size of n vas necessary Ior slalislicaI anaIysis SISS vas used
Ior comarison belveen lhe lvo grous Iishers Ixacl lesl vas used for dicholomous
variabIes Chisquare lesl for nonordered calegoricaI variabIes and ManleIHaenszeI chi
square lesl for ordered calegoricaI variabIes Ior lesls of changes over lime lhe WiIcoxons
signed rank lesl vas used for conlinuous variabIes for comarisons vilhin lhe grous and
MannWhilney Ulesl for comarisons belveen lhe grous AII lesls vere lvolaiIed and
conducled al significance IeveI

Qua!itativc ana!ysis sludy II and III
In lhe quaIilalive sludies lhe anaIysis vas erformed according lo lhe henomenograhic
melhod described by DahIgren and IaIIsberg They described lhe foIIoving six sles of
lhe anaIysis rocess famiIiarizalion condensalion comarison arlicuIalion IabeIIing and
conlrasling

AII inlervievs vere lranscribed before lhe slarl of lhe anaIysis rocess The anaIysis vas
based on lhe henomenograhic melhod described by DahIgren and
IaIIsberg The sequence of lhe sles of lhe anaIysis vas lhe foIIoving aII lhe inlervievs
vere firsl read lhoroughIy and reealedIy lo oblain a lolaI concurrenl overviev a sorl of
famiIiarizalion The second sle condensalion is a seIeclion rocedure based on reIevanl
crileria Slalemenls lhal deaIl vilh lhe consequences of lhe hi fraclure vere exlracled from
aII inlervievs lo achieve a concenlraled and reresenlalive version of enlire diaIogues The
quoles lhus seIecled made u a ooI lhal formed lhe basis for lhe subsequenl sles in lhe
anaIysis The lhird sle comarison vas lo conlrasl lhe exlracled quoles vilh each olher in
order lo uncover sources of varialion or agreemenl In lhe grouing sle simiIar quoles vere
groued logelher and lhe essence of lhe simiIarily vilhin each grou of quoles vas
described The nexl arlicuIaling vas an alleml lo describe lhe essence of lhe simiIarily
vilhin each grou The IabeIIing sle gave lhe calegories names lhal corresonded lo lhe
essence of lheir meaning and lhe Iasl sle conlrasling comared calegories vilh each olher
lo arrive al a definilive descrilion of lhe unique characler of each calegory The concelions
found and described make u lhe comIele meaning varialion in lhe dala maleriaI and
conslilule lhe oulcome sace AII slalemenls or arl of slalemenls deaIing vilh lhe
henomenon under sludy vere incIuded in lhe anaIysis In lhe finaI sle lhe various
descrilions deaIl vilh in lhe calegories vere defined and named summarizing lhe common
significanl meaning in each calegory

Through lhe enlire rocess lhere vas a conslanl inlerIay belveen lhe various sles of lhe
anaIysis The ambilion vas lo ensure lhal lhe calegories did nol overIa and lhal lhere vas
43
44
emiricaI suorl for each calegory The grouing and arlicuIaling sles vere revised
severaI limes before lhe anaIysis vas |udged lo be salisfaclory as bringing lhe quoles
logelher deveIos lhe meaning of lhe calegory and al lhe same lime lhe deveIoing
meaning of lhe calegory delermines vhich of lhe quoles shouId be incIuded and vhich
shouId nol This rocedure has been described as a ledious limeconsuming inleraclive
rocedure vilh reealed changes in vhich quoles are broughl logelher in lhe exacl meaning
of each grou of quoles There is hovever a decreasing rale of change and evenluaIIy lhe
syslem slabiIizes ilseIf The vhoIe sequence of sles in lhe anaIysis vas made
searaleIy by lhe aulhors before |oinl discussions Ieading finaIIy lo consensus

A comuler rogramme Oen Code version deveIoed al Ume Universily
Sveden vas used lo faciIilale lhe sorling of lhe inlervievs and lhe quolalions


Ethical considerations

IlhicaI consideralions of lhis lhesis foIIoved lhe elhicaI rinciIes of research in resecl of
aulonomy beneficence nonmaIfeasance and lhe rinciIe of |uslice The resondenls
vere informed verbaIIy and received vrillen informalion before being asked lo arliciale
and vere abIe lo vilhdrav al any lime during lhe sludy The informalion aIso incIuded lhe
aulhors LZ conlacl informalion AII dala vas coded and lhe code Iisl and aII dala maleriaI
vere kel Iocked searaleIy

The risk lhal deendence vouId infIuence lhe alienls vas minimized by lhe facl lhal lhe
aulhor LZ vas nol invoIved in lhe rehabiIilalion Hovever an elhicaI diIemma during lhe
foIIovu visils couId be lo discover robIems and nol being abIe lo lreal lhem To minimize
lhese ossibIe negalive asecls lhe invesligalor informed each arlicianl vhere he or she
couId lurn for rofessionaI lrealmenl and suorl

The sludy vas aroved by lhe Research IlhicaI oard al lhe Universily of Golhenburg in
Selember

44
45


Results





The resuIls of lhe originaI aers are resenled in lvo seclions lhe firsl conlaining lhe
summarized resuIls of lhe earIy hase of lhe recovery sludies I and II and lhe second
seclion lhe resuIls from lhe Ialler hase of lhe recovery III and IV ending vilh an overviev
of lhe enlire recovery rocess from discharge lo one year foIIovu Three labIes ac and
six figures figures iIIuslrale lhe summarized findings and readers are referred lo lhe
searale originaI aers for furlher iIIuslralions of lhe searale resuIls

Seven ersons HR CC had died belveen discharge and one year foIIov u
During lhe vhoIe sludy eriod from admission for hi fraclure unliI one year afler
discharge lhe median lolaI inslilulionaI care consumlion for lhe HR arlicianls vas
days days and for lhe CC arlicianls days days NS Iorly
lvo ersons in each grou HR and CC NS Iived in lheir ovn homes one
year afler discharge One erson in lhe HR grou and four ersons in lhe CC grou
had moved lo ermanenl sheIlered Iivings during lhe year afler hosilaI discharge


The early phase of recovery (study I and II)

The HR arlicianls increased lheir indeendence and aclivily IeveI fasler lhan lhose vho
had received CC Al lhe one monlh foIIovu lhe HR arlicianls vere significanlIy more
indeendenl labIe a age and reorled significanlIy beller confidence in erforming
daiIy aclivilies labIe b comared vilh lhe CC grou They aIso look ouldoor vaIks more
frequenlIy and erformed lhe TimedUandGo and SilToSland lesls significanlIy fasler
lhan lhe conlroIs aer I One monlh afler discharge lhe HR grou aIso erformed
domeslic and ouldoor aclivilies significanlIy more oflen lhan lhe CC grou labIe c

When comaring recovery over lime ie refraclure scores vilh foIIovu scores lhe HR
arlicianls reorled significanlIy grealer recovery in seIfcare lransfers and Iocomolion and
domeslic aclivilies al one monlh foIIovu lhan lhe CC grou labIe a Iurlhermore lhe
imrovemenl in baIance confidence on domains slairs and inslrumenlaI daiIy aclivilies
vhen comared vilh discharge vas aIso significanlIy higher for lhe HR grou lhan for lhe
CC grou labIe b

45
46
In lhe inlervievs erformed al lhe one monlh foIIovu arlicianls described lheir
exerienced consequences of lhe fraclure Whal slarled as an accidenl a broken Ieg vas
exerienced as having caused exlensive and dramalic changes concerning lheir reIalion lo
lheir bodies and lo lhemseIves lo olhers and lo lheir vhoIe Iife silualion

Wilhin lhese changed reIalions lhe foIIoving eighl calegories vere idenlified


In reIalion lo your body and lo yourseIf
You are Iimiled lo move and have Iosl confidence in your body
You become humbIe and gralefuI
You resecl yourseIf and your ovn needs

In reIalion lo olhers
You become more deendenl on olhers
You gain more human conlacl and are lrealed in a friendIy vay by olhers

In reIalion lo lhe Iife silualion
You are secIuded and lraed al home
You are oId cIoser lo dealh and have Iosl your zesl for Iife
You lake one day al a lime and are uncerlain aboul lhe fulure

Wilhin lhe firsl calegory you are Iimiled lo move and have Iosl confidence in your body
exressions of fear of faIIing again and vhal a nev faII mighl Iead lo vere given Tvo quoles
from lhe inlervievs lo iIIuslrale lhis

|tc |cccnc tcrq carcju| uncn | nctc |n tcrq carcju| a|cui nci iripping cn rugs Tncrc arc
inings | cani !c ncu |tcrq!aq inings unicn ucrc casq |cjcrc inai scncining ucu|!
nappcn

| jcc| insccurc |ca||q Tnai | ccu|! ja|| |n scarc! ic !cain cj inai

Wilhin lhe sixlh calegory you are secIuded and lraed al home lhe inlervievees
exressed lhal Iife had become reslricled and lhal lheir daiIy roulines had changed radicaIIy
incIuding reduced IeveI of aclivily One quole from lhe inlervievs

| inink ii|| gci |ciicr ij | jusi gci cui an! cxcrcisc | jcc| IOCK|O UP | jcc| |ikc scnc|c!q nas
snui nc in scncncu

The calegories mosl highIy reresenled among lhe sub|ecls vere lhe lvo deaIing vilh
Iimilalions in movemenl and being deendenl on olhers



46
47
The latter phase of recovery (study III and IV)

elveen six and monlhs afler discharge lhe funclionaI recovery rale of bolh lhe HR and
lhe CC grou sIoved dovn and lhe overaII recovery of lhe lvo grous became more simiIar
Hovever vhen comaring one year and refraclure lhe HR arlicianls had imroved
lheir degree of indeendence lo a significanlIy higher degree lhan lhe CC arlicianls in seIf
care and lransfers and Iocomolion vhiIe lhere vas no significanl difference belveen lhe
grous in domeslic and ouldoor aclivily recovery labIe a The roorlion of eoIe vho
had regained lheir indeendence ie scored or on lhe IIM and IAM scaIe al aII foIIov
u occasions vas significanlIy higher in lhe HR grou lhan in lhe CC grou in aII domains
excel domeslic aclivilies figure
Conventional care
0
10
20
30
40
50
60
70
80
90
100
P
r
e
-
f
r
a
c
t
u
r
e
D
i
s
c
h
a
r
g
e
O
n
e

m
o
n
t
h
S
i
x

m
o
n
t
h
s
O
n
e

y
e
a
r
Per cent
Self-
care
Transfe
rs and
locomo
tion
Domes
tic
Home rehabilitation
0
10
20
30
40
50
60
70
80
90
100
P
r
e
-
f
r
a
c
t
u
r
e
D
i
s
c
h
a
r
g
e
O
n
e

m
o
n
t
h
S
i
x

m
o
n
t
h
s
O
n
e

y
e
a
r
Per cent
Self-care
Transfers
and
locomotion
Domestic
activities
Out-door
i i i

Figure 3. Proportion of participants being independent with or without technical aids in self-care (one
month p<0.001, six months p=0.006, one year p=0.053), transfers and locomotion (one month
p<0.001, six months p=0.013, one year p=0.003), domestic (one month, six months and one year NS),
and out-door activities (one month NS, six months p=0.003, one year p=0.007). P values within ( )
indicate comparison between home rehabilitation and conventional care group at each follow-up. Chi-2
test.

One year afler discharge eoIe in lhe HR and eoIe NS in lhe CC
grou vere back lo refraclure ouldoor vaIking abiIily There vas no significanl
differences belveen lhe HR and CC grou regaining refraclure frequency of eilher oul
door or domeslic aclivilies al lhe six monlhs and one year foIIovu as measured by lhe IAI
labIe c

elveen discharge and one year ersons in lhe HR grou and ersons NS
in lhe CC grou had faIIen once or more Iour of lhe faIIs HR CC resuIled in a nev
fraclure
47
48

When comaring baIance confidence al six monlhs and one year vilh discharge measures
lhe HR grou shoved significanlIy grealer imrovemenl in confidence on slairs al one year
and in inslrumenlaI aclivilies al bolh six monlhs and one year lhan lhe conlroIs vhiIe lhere
vas no difference in confidence in seIfcare domain of lhe IISS labIe b The roorlion
of eoIe vho reorled lolaI baIance confidence ie on lhe IISS vas significanlIy
higher in aII aclivilies of lhe IISS among lhe HR lhan among lhe CC arlicianls al aII
foIIovu occasions Iour of lhe aclivilies are shovn in figure
Conventional care
0
10
20
30
40
50
60
70
80
90
100
Discharge One month Six months One year
Per cent
Cleani
ng
Stair
Home rehabilitation
0
10
20
30
40
50
60
70
80
90
100
Discharge
(NS)
One month
(p 0.0001)
Six months
(p 0.0001)
One year
(p 0.0001)
Per cent
Cleaning
Stair climbing
Out-door walking
Shopping

Figure 4. Proportion (per cent) of participants in the two groups, conventional care and home
rehabilitation, reporting totally confident in performing the activities cleaning, stair climbing, out-door
walking and shopping at discharge and one month, six months and one year after discharge. Chi-2 test.

The HR grou reorled a higher degree of hysicaI funclioning II of lhe SI al aII
foIIovu occasions and significanlIy Iess bodiIy ain six monlhs and one year osl
discharge lhan lhe CC grou The roorlion of arlicianls vhose resonse vas nol
Iimiled al aII on lhe II ilem cIimbing one fIighl of slairs al one year and vaIking severaI
bIocks al six monlhs vas aIso significanlIy higher in lhe HR lhan in lhe CC grou

There vas no significanl difference belveen lhe lvo grous in lhe roorlion of individuaIs
vho couId be considered deressed ie having a score of or more on lhe CISD al eilher
foIIovu one monlh HR CC six monlhs HR CC one year HR
CC Hovever al one monlh lhe CC arlicianls had reorled Iover mood lhan lhe HR
arlicianls HR median min max CC median min max nol
reorled

48
49
Iourleen ersons in lhe HR grou and five ersons in lhe CC grou
considered lhemseIves fuIIy recovered one year afler discharge

Dala from aII foIIovu occasions vhich look Iace one monlh sludy I six monlhs and one
year sludy II afler discharge from hosilaI concerning indeendence in and frequency of
daiIy aclivilies and baIance confidence is shovn in labIes ac
49
T
a
b
l
e

7
a
.

I
n
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p
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i
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.

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F
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=
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A
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N
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D
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N
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*
d
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s
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c
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50
T
a
b
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e

7
b
.

B
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c
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b
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g
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c
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a
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w
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b
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t
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C
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l

c
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r
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.












H
R

C
C

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v
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M
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p

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F
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d
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D
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(
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F
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(
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8
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S
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(
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F
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(
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(
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S


S
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3
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0

(
-
9
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2
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(
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N
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I
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6
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2
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-
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1
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0
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O
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a
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(
n
)


4
2

4
8




F
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S
(
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6
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51
T
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7
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8
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a
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:

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.

52
53
ResuIls from lhe IISS shoved lhal lhe roorlion of arlicianls reaching maximaI score
ie vas significanlIy Iarger in lhe HR grou al aII foIIovu occasions as is shovn in
figure nol reorled

0
10
20
30
40
50
60
70
80
90
100
Discharge
NS
One month
p = 0.003
Six months
p < 0.001
One year
p < 0.001
Per cent
HR
CC

Figure 6. Proportions (per cent) of participants reporting full score (130) of the FES(S). Chi-2 test.


efore lhe fraclure more lhan of lhe arlicianls of bolh lhe HR and CC grou look
ouldoor vaIks and vaIked once a veek or more The roorlions of arlicianls
laking ouldoor vaIks before and al aII foIIovu occasions are shovn in figure

0
10
20
30
40
50
60
70
80
90
100
Pre-
fracture
NS
One month
p<0.001
Six
months
NS
One year
NS
Per cent
HR
CC

Figure 7. Proportion of participants taking out-door walks. Chi-2 test.


Of lhose vho did vaIk ouldoors before lhe fraclure six ersons in lhe HR grou
comared lo ersons in lhe CC grou did nol Ieave lheir homes one
monlh afler discharge vhiIe lhe corresonding roorlions al one year vas five ersons
of lhe HR grou and nine ersons NS of lhe CC grou
53
54
In lhe inlervievs from lhe Ialler hase of lhe recovery rocess one year afler discharge a
ma|orily of lhe arlicianls gave exressions of remaining insecurily and reslricled Iife AII
inlervievees described lhal lhey exerienced remaining insecurily or reslricled mobiIily
On lhe olher hand a fev of lhem aIso said lhal lhe fraclure had made lhem beller lhan
lhey vere before lhe fraclure or even saved lheir Iife

The anaIysis of lhe one year inlerviev dala resuIled in an oulcome sace of six main
calegories and lvo subcalegories vilhin lhe lvo focused areas exerienced consequences
of a hi fraclure one year afler discharge and concelions of vhal infIuences hi fraclure
recovery The calegories vere arranged vilhin reseclive area as foIIovs

Ixerienced consequences of a hi fraclure one year afler discharge
IsoIaled Iife vilh more reslricled aclivily and fever sociaI conlacls
a More insecure and afraid
b More Iimiled abiIily lo move
Disaoinled and sad lhal idenlily and Iife have changed
Salisfied vilh lhe silualion or feeIing even beller lhan before lhe fraclure

Concelions of vhal infIuences hi fraclure recovery
Ovn mind and aclions infIuence recovery
Trealmenl and aclions from olhers infIuences recovery
You cannol infIuence recovery

One quole from lhe firsl calegory may serve as an iIIuslralion of lhe alienls exressions

|n ncrc ncusc|cun! Sc |tc |cccnc ncrc cj a rcc|usc | suppcsc|is nq sccia| |ijc inai
sujjcrs

The calegory mosl highIy reresenled among lhe sub|ecls vas calegory isoIaled Iife vilh
more reslricled aclivily and fever sociaI conlacls vilh subcalegories more insecure and
afraid and more Iimiled abiIily lo move

Iigure shovs a visuaIizalion of lhe reIalion belveen lhe calegories concerning
exerienced consequences of lhe fraclure As can be seen in lhe figure exeriences of
insecurily and Iimiled mobiIily had Ied lo a more isoIaled Iife incIuding reslricled aclivily
and fever sociaI conlacls lhan before lhe fraclure This had Ied lo differenl sychoIogicaI
reaclions The sub|ecls described lhal lhey vere eilher disaoinled or lhal lhey had come
lo lerms vilh lhe silualion as lhey exerienced il al lhe lime of lhe inlerviev Tvo of lhe
inlervievees exressed lhal lhey feIl even beller comared vilh lhe silualion before lhe
fraclure



54
55

More insecure leading leading Disappointed and
and afraid to to sad that identity and
Isolated life with more life have changed
restricted activity or
More limited and fewer social Satisfied with the
ability to move contacts situation or feeling
even better than
before the fracture


Figure 5. Relations between the categories within experienced consequences of a hip fracture one year after discharge.

One arl of lhe resuIls from lhe one year inlervievs vas lhe resenlalion of lhe differenl
concelions of vhal infIuences recovery afler hi fraclure The descrilive calegories
vilhin lhe fieId vere ovn mind and aclions infIuence recovery lrealmenl and aclions of
olhers infIuence recovery and you cannol infIuence recovery The calegory mosl highIy
reresenled among lhe sub|ecls vas calegory ovn mind and aclions infIuence recovery

In bolh inlerviev sludies exressions of more Iimiled mobiIily vhich resuIled in reslricled
aclivily and sociaI conlacls vere given by lhe arlicianls Hovever for a ma|orily of
inlervievees lhe exerienced consequences of lhe hi fraclure had shifled from an earIy
focus on bodiIy exeriences lo Ialler erceived consequences for lhe idenlily and Iife
shovn by exressions of disaoinlmenl over lhe enlire silualion A summary of lhe
calegories from sludy II and IV is given in figure

Early experiences Late experiences
Isolated life with more restricted activity and social contacts:
More dependent More limited to move
Limited ability to move and lost Disappointed and sad that life
confidence in your body and identity have changed
Trapped at home
Insecure and afraid:
Uncertain about the future More insecure and afraid
Closer to death
Life is the same or even better than before the fracture:
Respect yourself Satisfied with the situation or even
Gain more human contact better than before
Become humble and grateful
---------------------------------------------------------------------------------------------------------
Own actions and mood influence
the recovery
Others treatment influence/you
cannot influence the recovery


Figure 8. Early and late experiences and conceptions of the recovery after hip fracture.
55
56


Discussion





General discussion of the findings

This lhesis enIighlens severaI asecls of lhe rehabiIilalion of eIderIy eoIe vilh hi
fraclure The resuIls underIine lhal lhe consequences of a hi fraclure are subslanliaI
muIlidimensionaI and IongIasling This vas accenlualed by lhe facl lhal onIy a minorily
of lhe arlicianls reorled lhal lhey vere fuIIy recovered one year afler discharge
comared lo before lhe fraclure Iurlhermore lhe inlerviev sludies shoved lhal a hi
fraclure seemed nol onIy lo break lhe bone bul aIso lo cause sociaI and exislenliaI cracks
vhich remained or became deeer during lhe year afler lhe in|ury

Hnmc rchabi!itatinn vcrsus cnnvcntinna! carc
The resuIls from lhe inlervenlion sludies couId be seen as suorl for lhe HR rogramme
AIlhough lhe differences belveen lhe lvo grous vere Iargesl in lhe earIy hase of
recovery measured afler lhe HR rogramme vas finished one monlh afler discharge lhe
rogramme aIso seemed lo have more IongIasling imacl lhan vere execled Of lhose
vho vere indeendenl before lhe fraclure a Iarger orlion of HR lhan CC arlicianls
regained lheir indeendence and aclivily IeveI afler discharge and lo a Iarger degree
mainlained il over lime aIlhough nol vilhin aII measured areas The HR rogrammes
focus on encouraging seIfefficacy and exercising everyday aclivilies incIuding ouldoor
vaIking mighl have conlribuled lo lhis Iurlhermore lhe HR rogrammes cIear focus on
lhe alienls molivalion and ersonaI goaIs as veII as seIfefficacy and Iearning by doing in
lhe home environmenl in vhich seIf lraining vas one key ingredienl mighl be arl of lhe
osilive effecls of lhe inlervenlion The imorlance of seIfefficacy on rehabiIilalion
oulcome has aIso been described by Iorlinsky and coaulhors vho found a osilive
associalion belveen rehabiIilalion lheray seIfefficacy and IikeIihood of Iocomolion
recovery Il is aIso reasonabIe lo beIieve lhal lhe home environmenl slimuIales lhe
individuaIs aclivily and mobiIily IeveI more lhan an inslilulionaI environmenl as
suggesled in lhe lheories of silualed Iearning

Anolher reason for lhe more accenlualed recovery for lhe HR grou mighl be lhe bridging
funclion of lhe HR rogramme vhich resumabIy conlribuled lo a smoolh and secure
discharge for alienls as veII as lheir reIalives A rehabiIilalion rocess generaIIy asses
lhrough differenl hases In lhe firsl acule hase afler admission lo hosilaI lhe alienls
are IargeIy al lhe mercy of lhe heaIlh care ersonneI GraduaIIy lhey may be more aclive
56
57
and lake on resonsibiIily for lheir silualion and Ianning of lhe fulure There are severaI
sludies deaIing vilh lhe imorlance of lhe alienls being engaged in lheir discharge
Ianning In one of lhem alienls reorled lhal hosilaI discharge
roulines faiIed lo refIecl lhe comIexily of lhe oslhosilaIizalion silualion by focusing
rimariIy on very basic hysicaI and medicaIIy reIaled needs ralher lhan on lhe acluaI
needs of lhe eIderIy alienls In our sludies a HR rogramme incIuding earIy invoIvemenl
of alienls and reIalives in lhe suorled discharge foIIoved by rehabiIilalion visils al
home vas lesled One of lhe aims of lhe suorled discharge vas lo reduce lhe alienls
and reIalives uneasiness aboul going home inslead of slaying in hosilaI or being
lransferred lo a shorllerm nursing home Suorled discharge is a modeI vhich has been
used mainIy for alienls vilh slroke in order lo shorlen lhe duralion of hosilaI care and lo
reach a higher IeveI of indeendence in daiIy aclivilies Sludies on suorled
discharge afler slroke have shovn osilive resuIls for lhe alienls veIIbeing and recovery
Il is hovever conceivabIe lhal slruclured discharge roulines vhich incIude
alienl and reIalive invoIvemenl are of vaIue for aII eIderIy alienls

Irevious sludies have underIined lhe imorlance of veII organized discharge from acule
hosilaI AIlhough il vas nol an aim of lhis lhesis a gIobaI goaI for lhe gerialric
cIinic vas lo shorlen hosilaI slay lhrough HR Hovever ve couId nol shov any
significanlIy more reduced hosilaI slay for lhe HR grou lhan for lhe CC grou On lhe
olher hand lhe HR grou consumed considerabIy fever days in shorllerm nursing homes
lhe firsl monlh afler discharge The lolaI sum for slay al nursing home vas days for lhe
nine alienls in lhe CC grou comared lo days for lhe lhree alienls of lhe HR grou
vho needed shorllerm care afler discharge sludy I A more lhorough examinalion of lhe
heaIlh care consumlion lhe year foIIoving discharge is Ianned

OlimaIIy discharge Ianning for eIderIy alienls vilh hi fraclure shouId invoIve an
assessmenl of lheir resources and Iimilalions during hosilaIizalion Ians for conlinuily of
lheir heaIlh care afler discharge and services lhal enhance lheir recovery bolh hysicaI and
emolionaI The Ianning shouId aIso comrise educalion of lhe alienl and olher care
givers incIuding lheir famiIies Moreover oor Ianning oflen resuIls in a discreancy
belveen lhe needs anlicialed and Ianned for in hosilaI and lhe ersons acluaI needs
once he or she relurns home Hunl and Slein roosed lhal heaIlh care
rofessionaIs inslead of advising eIderIy alienls lo change or Iimil lheir aclivilies or
rearrange lheir Iiving environmenls in order lo decrease lhe risk of faIIing lhey shouId
encourage eIders lo romole an aclive and engaged Iife slyIe Advising lhem lo Iimil lheir
aclivilies may have lhe negalive effecl of increasing lheir fear of faIIing and unnecessariIy
diminishing lheir quaIily of Iife The resuIls from our sludies shov lhal lhe alienls need
conlinued suorl aIso afler discharge in order lo beller regain revious aclivily IeveI

One imorlanl arl of a HR rogramme is lo invoIve nol onIy lhe alienls bul aIso lheir
reIalives In our sludies ve did nol secificaIIy ask lhe alienls reIalives aboul lheir
exeriences This vas hovever done by Crolly and coaulhors vho comared a
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grou of eIderIy alienls vilh hi fraclure vho vere discharged lo lheir homes vilhin
hours afler randomizalion receiving muIlirofessionaI HR vilh a alienls vho received
convenlionaI inhosilaI rehabiIilalion They found simiIar oulcomes on ADL TUG and
HRQoL for lhe lvo grous vhiIe caregiver burden al monlhs vas significanlIy Iess for
lhe HR grou comared lo lhe conlroIs One remaining inleresling research area is lo
exIore bolh lhe alienls and lheir reIalives exeriences of rehabiIilalion al home

In lhis lhesis il is nol shovn vhich comonenls of lhe HR rogramme are lhe mosl
beneficiaI for each alienl Some alienls couId erhas manage lheir rehabiIilalion more
or Iess on lheir ovn vilh one or lvo home visils and a leIehone number lo caII vhen lhey
need furlher advice vhiIe olhers robabIy need more reguIar conlacl and visils from
heaIlh care rofessionaIs Il is aIso conceivabIe lhal some alienls couId be discharged lo
lheir ovn home al an earIier slage of lheir rehabiIilalion lhereby decreasing lheir hosilaI
slay This caIIs for furlher sludies

Paticnts cxpcricnccs and cnnccptinns
IarIy in lhe recovery rocess arlicianls in lhe inlerviev sludies hesilaled lo laIk aboul
lhe fulure and feIl uncerlain of lheir fulure recovery Some arlicianls exressed lhal lhey
feIl insecure of hov much lhey couId move and vhal lhe in|ured Ieg couId vilhsland In
Iine vilh lhese findings Carrese and coaulhors found lhal iII eIderIy vere nol viIIing
lo laIk aboul or Ian for lhe uncerlain near fulure evenls reIaled lo lheir chronic and
serious iIIness bul vere more viIIing lo laIk aboul and Ian for evenls more dislanl in
lime incIuding lheir ovn dealh Laler in lhe recovery rocess lhe arlicianls in our
sludies exressed fruslralion and disaoinlmenl lhal Iife had changed and lhal il vouId
robabIy never be lhe same as before lhe fraclure These findings suorl revious sludies
shoving lhal subslanliaI hysicaI reslriclions deendency in daiIy aclivilies
sociaI Iimilalions and deression are common afler a hi fraclure eseciaIIy
during lhe firsl monlhs afler lhe in|ury Deression has been found lo redicl oor
funclionaI oulcome afler hi fraclure and anxiely and a feeIing of hoeIessness
are shovn lo be associaled vilh a risk of deveIoing deression afler hi fraclure
Thus in a medicaI erseclive lhe exeriences reorled in lhis sludy such as being
inaclive hesilaling lo Ian for lhe fulure or having Iosl a zesl for Iife couId be seen as signs
of deression Taking lhis inlo accounl il is ossibIe lhal lhe sub|ecls in our sludy may
have suffered from deression or Iov mood by lhe lime of lhe inlervievs and erhas aIso
rior lo lhe in|ury vhich mighl have infIuenced lhe exeriences lhey described

The inlervievees concelions of lhe Ialler hase of recovery reorled in sludy IV for
inslance lhal ovn mood and aclions and olher eoIes lrealmenl and aclions infIuence
recovery couId be associaled vilh sychoIogicaI concels such as seIfefficacy Iocus
of conlroI erceived heaIlh conlroI or coing Il has reviousIy been
reorled lhal Iov seIfefficacy ie erceived abiIily lo carry oul an aclion is associaled
vilh deression anxiely and heIIessness as veII as being slrongIy connecled
vilh aclivily Iimilalions Locus of conlroI on lhe olher hand measures generaIized
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execlancy beIiefs vilh resecl lo heaIlh aIong lhree dimensions inlernaI ie a beIief lhal
heaIlh is lhe resuIls of ones ovn aclions exlernaI overfuI olhers ie an individuaIs
beIief lhal heaIlh is a resuIl of overfuI olhers such as heaIlh care rofessionaIs and
exlernaI chance or fale ie lhe exlenl lo vhich individuaIs beIieve lheir heaIlh is due lo
chance or fale In a sludy of oIder vomen vilh hi fraclure Shav and coaulhors
found lhal inlernaI Iocus of conlroI vas significanlIy reIaled lo Iess hysicaI disabiIily
one monlh afler lhe fraclure Iurlhermore il is a common viev lhal eoIe vho beIieve
lhal lhey have conlroI over lheir ovn heaIlh are more IikeIy lo engage in heaIlhromoling
aclivilies and lo comIy vilh lrealmenls lhan lhose vilh Iov erceived conlroI
ruggeman and coaulhors reorled lhal feeIings of hoeIessness couId mediale
deression afler hi fraclure and lhal ersonaI conlroI beIiefs vere associaled vilh anxiely
and deression ie lhose vho beIieve lhey have IillIe conlroI over lheir in|ury are al risk of
hoeIessness and deressive symloms Taken logelher lhis gives indicalions for
muIlirofessionaI screening for signs of deressive mood as veII as lo organize
aroriale inlervenlions earIy in lhe rehabiIilalion rocess afler hi fraclure

ResuIls from lhe inlerviev sludies in lhis lhesis shoved lhal a hi fraclure couId be
exerienced as a dislincl manifeslalion of being oId incIuding a variely of negalive
allribules This may be seen as a refIeclion of socielys alliludes lovards lhe eIderIy vho
in conlrasl lo young eoIe are oflen given lhe allribules of vorlhIessness and a slrain on
sociely The one monlh inlervievs aIso indicaled lhal lhe fraclure came as a finaI
bIov comarabIe lo a serious disease lhal couId Iead lo ermanenl disabiIily or dealh The
arlicianls exeriences of feeIing oId incIuded a feeIing of embarrassmenl for inslance of
nol being abIe lo sland on ones ovn lvo feel In accordance vilh lhese findings anolher
sludy reorled lhal lhe inlervievees vieved faIIing as a sign of ageing diminishing
comelence and deendence Groving oId is in ilseIf a lime vhen many imorlanl and
slressfuI changes lake Iace such as reliremenl iIIness or disabiIily and searalions aII of
vhich Iace demands and slress on lhe individuaI Irevious research indicales a
reIalionshi belveen asecls of sub|eclive ageing and heaIlh and changes in heaIlh are lhe
mosl frequenlIy ciled reasons for beginning lo feeI oIder Iurlhermore sociely
generaIIy hoIds a slereolyicaI viev of oId eoIe and ageing vhich is oflen caIIed ageism
Alliludes such as rogressive hysicaI and menlaI decIine sociaI isoIalion asexuaI
behaviour Iack of crealivily and economic and famiIiaI burden Tornslam suggesled
slem from dee vaIue allerns characlerized by vaIuing economic roduclivily and
indeendence OIder eoIe are frequenlIy IabeIIed as a deendenl burden a sociaI
robIem connecled vilh lhe concel of deendency and hov lo revenl il
Assumlions and alliludes againsl ageing have aIso become arl of lhe heaIlh care syslem
A heaIlhy oId age couId be seen as a revard for a Iife of seIfconlroI and correclIiving
and fraiIly and deendency consequenlIy as a consequence of unsuccessfuI ageing
According lo researchers around lhe vorId lhe age of deendency is execled lo ul
ressure on lhe communily vho fear lhe ageing of lhe ouIalion and vorry aboul
vhelher ve can afford lhe cosls of an increasing oIder ouIalion Therefore
inveslmenls in lrealmenl care and rehabiIilalion afler hi fraclure mighl conlribule lo a
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more heaIlhy eIderIy ouIalion and lhus aIso be of economicaI vaIue In lhis lhesis no
heaIlheconomicaI caIcuIalion of lhe HR rogramme in comarison lo CC has been
erformed bul vouId cerlainIy be of significanl vaIue

One inleresling queslion emerging from lhe resuIls from lhe inlerviev sludies is if lhe
alienls recovery couId be infIuenced by lheir ovn execlalions Iurslenberg in an
inlerviev sludy on alienls vilh hi fraclure found lhal lhey had differenl vays of
describing execlalions of lhe in|uries and over fulure accidenls One vas lo describe lhe
accidenl as a consequence of lheir behaviour and hov lhey couId avoid fulure faIIs
imIying a sense of conlroI On lhe olher hand lhose vho sav lhe accidenl as unavoidabIe
and oulvilh lheir conlroI aIso shoved signs of heIIessness lo conlroI fulure evenls These
differenl vays of erceiving conlroI aIso seemed lo infIuence lhe alienls rehabiIilalion
One vay of suorling alienls afler a hi fraclure roosed by lhe aulhor couId be
lo encourage lhem lo ul lheir ainfuI exeriences inlo vords vhich mighl reIieve lheir
anxiely This couId vork as cognilive rocessing of lhe lraumalic evenl and heI lhe
alienls discover a cause for lhe accidenl vhich may bring a sense of conlroIIabiIily
Il has aIso been suggesled lhal inlervenlion afler hi fraclure shouId be focused on seIf
efficacy as grealer faIIs seIfefficacy in being abIe lo erform lasks vilhoul faIIing vas
associaled vilh beller funclioning In accordance one of lhe basic ideas of lhe HR
rogramme sludied in lhis lhesis vas lo encourage seIf efficacy in daiIy aclivilies

Prcdicting and prcvcnting Ia!!s and Iracturcs
Considering lhe exlensive evidence of lhe negalive consequences of a hi fraclure for lhe
individuaI as veII as for lhe sociely rimary and secondary revenlion efforls shouId be
made on aII IeveIs of heaIlh care and sociaI service One move couId be lo lry lo reduce lhe
risk of faIIing and lhe negalive effecls of faIIs Il is lhus essenliaI lo idenlify lhose al higher
risk of faIIs aIso afler discharge Sludies of faII risk have examined bolh inlrinsic faclors
such as sychoIogicaI or cognilive imairmenl muscIe veakness baIance disorders as
veII as exlrinsic faclors such as Iighling deficienl assislive devices and sIiery surfaces
lhal conlribule lo faIIs Iease and coaulhors shoved lhal of alienls vilh a
hi fraclure had a second hi fraclure vilh a significanl furlher imacl on mobiIily and
sociaI indeendence In anolher sludy Slevarl and coaulhors foIIoved alienls
vilh hi fraclure for veeks and sav lhal oor mobiIily vas a significanl risk faclor for a
nev faII Il is lherefore imorlanl lo find vaIid reIiabIe and usabIe lesls lo seIecl lhose
alienls vho are al grealer risk of faIIing The TUG lesl has been reorled lo be a usabIe
looI lo idenlify lhose al risk of faIIing One recenl sludy shoved lhal lhe
TUG erformed al discharge vilh a culoff oinl of seconds significanlIy redicled faIIs
during a monlh foIIoveriod afler hi fraclure vhiIe olhers have reorled lhal a
TUG score of more lhan or seconds vas abIe lo discriminale eoIe vho feII from
eoIe vho did nol faII in lhe receding six monlhs In conlrasl lo lhis a recenl
sludy shoved lhal lhe TUG vas nol recommended as a lesl of faII risk in an ambuIalory
eIderIy ouIalion . AIso lhe STS has been found reIiabIe as a lesl lo invesligale
Iimilalions in mobiIily among communilydveIIing eIderIy eoIe and an increase in
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lhe lime lo rise vas associaled vilh an increase in ADL indeendence Our ovn
cIinicaI exerience from lhe foIIovu visils vas lhal bolh lhe TUG and lhe STS vere easy
lo use in a homes environmenl They couId lherefore be recommended lo be used for
inslance al discharge from hosilaI or in home and rimary heaIlh care as screening lesls lo
idenlify alienls vho mighl need furlher foIIovu and rehabiIilalion ReIicalion of
earIier sludies couId reveaI vhich are lhe besl culoff oinls for rediclion of faIIs or
funclionaI decIine

Il aIso seems imorlanl lo idenlify inleraclion of muIliIe faclors for faIIs This vas shovn
by Tinelli and coaulhors vho reorled lhal lhe ercenlage of eoIe faIIing increased
from for lhose vho had no or one risk faclor lo for lhose vilh four or more faII
risk faclors This underIines lhal individuaIs vho suslained a faII or even more imorlanl
lhose vho have had muIliIe faIIs or a fraclure shouId undergo a comrehensive
evaIualion for underIying causes Il is nol enlireIy cIear vhich is lhe mosl aroriale
lrealmenl for lhose found lo be al higher risk of faIIing ShumvayCook and co
aulhors reorled lhal a communilybased muIlifacloriaI inlervenlion rogramme
consisling of grou exercise faII revenlion educalion and faIIs risk assessmenls imroved
baIance mobiIily and Ieg slrenglh more a rogramme vilh vrillen informalion onIy
aIlhough lhe incidence of faIIs did nol significanlIy differed belveen lhe lvo rogrammes
ResuIls from lhe sludies in lhis lhesis shov lhal home rehabiIilalion couId be a gainfuI
modeI for communilydveIIing eoIe vilh hi fraclure

Inlervievees in our sludies described lhal lhey feIl more Iimiled and lraed al home Lack
of hysicaI aclivily is a knovn risk faclor for osleoorosis and hi fraclure There is aIso
evidence lhal hysicaI aclivily is one imorlanl faclor for indeendence erceived good
quaIily of heaIlh and mood in lhe ageing ouIalion This vas suorled by a
recenl randomized sludy on eIderIy aduIls vho vere randomized lo eilher hysicaI
aclivily or successfuI aging educalion Re|eski and coaulhors found lhal lhose vho
had arlicialed in hysicaI aclivily grou had more favourabIe increase in seIfefficacy
and salisfaclion vilh hysicaI funclioning lhan lhose vho had arlicialed in educalion
As fear of faIIing eseciaIIy afler an in|ury has been shovn lo Iead lo reslricled aclivily in
eIderIy eoIe efforls shouId be made lo heI alienls overcome lheir fears and
conlinue vilh aclivilies even afler a hi fraclure In lhe inlervenlion sludies in lhis lhesis a
considerabIy Iarger roorlion of HR arlicianls reorled maximum score on lhe IISS
lhan lhe CC arlicianls The HR rogramme focusing on suorled discharge seIf
efficacy and ouldoor aclivilies couId have conlribuled lo lhe increase in baIance
confidence Hovever il has nol been cIarified vho gains mosl from lhe HR rogramme
and hov many home visils are olimaI for each individuaI As discussed by Tinelli
loo many HR visils couId Iead lo lhe alienls becoming unnecessariIy deendenl on
ersonaI suorl In our sludies lhe inlervenlion consisled of a mean of home visils
mean visils made by hysiolheraisl and visils by occualionaI lheraisls every
fourlh alienl received a visil by a nurse or an assislanl nurse vhich vas reIaliveIy fev.

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The arlicianls in our sludies beIonged lo a fraiI arl of lhe eIderIy ouIalion and can
lherefore nol be regarded as reresenlalive for communilydveIIing eIderIy eoIe in
generaI Iurlhermore il couId nol be excIuded lhal lheir erceived HRQoL mood or
hysicaI funclioning vas beIov average for lheir agegrou before lhe fraclure


Methodological considerations

5tatistica! cnnsidcratinns
Mosl of lhe scaIes used in lhe lhesis are based on ordinaI scaIes lhal roduce dala vhich
mighl nol have a normaI dislribulion and lherefore ve redominanlIy used non
aramelric slalislicaI melhods lo anaIyse lhe dala The various sensilivilies of lhe scaIes as
veII as ceiIing effecls may have affecled comarisons A smaII imrovemenl in a scaIe
does nol necessariIy reresenl a cIinicaIIy reIevanl imrovemenl One mighl argue lhal an
imrovemenl in a rough scaIe is more cIinicaIIy reIevanl lhan an imrovemenl in a more
sensilive scaIe because il requires a Iarger change in funclioning On lhe olher hand even
smaII imrovemenls are somelimes vaIuabIe from lhe alienls erseclive A use of
differenl measures iIIuminaling differenl asecls of comIex silualions as veII as differenl
research melhods is lherefore vaIuabIe

Va!idity
The inlernaI vaIidily ie lhe exlenl lo vhich lhe indeendenl variabIes may be considered
lo accounl for lhe resuIls changes or grou differences ralher lhan olher faclors or
infIuences lhreals lo inlernaI vaIidily has been lhoroughIy considered Such lhreals
lo lhe inlernaI vaIidily couId be changes in measuring inslrumenls or seIeclion bias In lhe
inlervenlion sludies I III lhe same measuremenls and measuremenl rocedure for
inslance order of measuremenls vere used during lhe vhoIe sludy eriod in order lo
minimize lhe risk Iurlhermore lhe arlicianls vere incIuded conseculiveIy as lhey vere
admilled lo lhe emergency unil A veakness vas lhal lhe randomizalion had lo lake Iace
before lhe alienls vere asked if lhey vere viIIing lo arliciale The reason for lhis vas
hosilaI roulines vilh direcl aroundlhecIock lransfer of lhe alienls from lhe emergency
unil lo eilher lhe HR vard or lhe CC vard The emergency nurses checked lhe basic
incIusion crileria such as communilydveIIing vilhin lhe incIusion area age and rinciaI
diagnosis bul in some cases lhe hi fraclure vas nol medicaIIy confirmed and lhe alienls
cognilive slalus nol assessed before lhey vere lransferred lo lhe gerialric vards One
consequence of lhese cIinicaI roulines vas lhal a considerabIe number of alienls vere
excIuded afler randomizalion n as lhey did nol meel aII lhe incIusion crileria or due lo
Iack of beds eilher al lhe HR or al lhe CC vard There vas hovever no olher ossibIe vay
lo conducl lhe randomizalion rocedure and ve lherefore had lo scrulinize lhe
randomizalion roulines in order lo avoid seIeclion bias Il is ossibIe lhal ve vouId have
received a more even roorlion of men and vomen in lhe lvo grous by using
slralificalion

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Anolher vay lo secure inlernaI vaIidily is lo conlroI lhe inlervenlion and measuremenls
as carefuIIy as ossibIe In lhe inlervenlion sludies reealed meelings vilh lhe muIli
rofessionaI leam vere arranged in order lo calch robIems lo discuss and reeal lhe goaIs
and conlenl of lhe HR rogramme and lo secure simiIar rocedures for assessmenls vhen
lhe alienls vere discharged

IxlernaI vaIidily refers lo lhe exlenl lo vhich lhe resuIls can be generaIized beyond lhe
samIe sellings and circumslances in vhich lhe sludy vas conducled Threals lo
exlernaI vaIidily couId be samIe characlerislics slimuIus characlerislics and sellings
reaclivily of assessmenl and liming of measuremenls There vere some baseIine differences
belveen lhe HR and lhe CC grou for inslance concerning gender Iiving condilions and
refraclure aclivily IeveI aIlhough lhey vere nol slalislicaIIy significanl NeverlheIess il
cannol be excIuded lhal lhese baseIine differences may have affecled our resuIls

Anolher ossibIe lhreal lo lhe exlernaI vaIidily is lhe infIuence of lhe sub|ecls avareness
lhal lhey are arlicialing in an invesligalion vhich may Iead lo changes in hov lhey
resond In lhe resenl sludies aII arlicianls vere avare lhal lhey arlicialed in a
research sludy vhich mighl have affecled lheir ansvers for inslance lhey couId be eager
lo Iease lhe invesligalor or be reIuclanl lo crilicize lheir care and lrealmenl

There is aIso lhe queslion of liming An exlernaI vaIidily queslion lhal couId be raised is
vhelher lhe same resuIls vouId have been oblained had measuremenls been laken al
anolher lime say severaI monlhs Ialer for examIe lvo monlhs inslead of immedialeIy
afler an inlervenlion In lhe resenl sludies ve have carried oul foIIovu measures on
lhree occasions immedialeIy afler lhe inlervenlion and six monlhs and one year afler
discharge and ve can onIy give an oinion on lhese oinls of lime

Anolher Iimilalion is lhe reIaliveIy smaII number of arlicianls in lhe inlervenlion sludies
This vas arlicuIarIy noliceabIe vhen evaIualing change over lime for lhe TimedUand
Go and lhe IaIIs Ifficacy ScaIe because of lhe ralher exlensive inlernaI missing vaIues al
discharge eseciaIIy for lhe CC grou vhich may have Iimiled lhe comarison for lhese
lvo lesls A osilive faclor for lhe sludy lhough vas lhal lhere vere fev droouls and
missing vaIues lhroughoul lhe sludy eriod Iurlhermore lhe number of arlicianls
exceeded lhe number required in lhe over anaIysis AddilionaIIy even lhough lhe
slalislicaI significance vas sel al many of lhe caIcuIalions shoved significance al
vhich reduced lhe ossibiIily of a Tye I error ie lhe risk of gelling an incorrecl
slalislicaIIy significanl difference belveen grous A oslhoc lesl ie onferroni couId
have been added lo lhe anaIyses in order lo reduce lhe risk of gelling a Tye I error On lhe
olher hand such a lesl carries lhe risk of lhe correclions being loo Iarge lhus increasing lhe
risk of a Tye error ie lhe risk of gelling an incorrecl slalislicaIIy nonsignificanl
difference belveen grous


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Rc!iabi!ity and va!idity nI chnscn mcasurcmcnts
ReIiabiIily and vaIidily of lhe IISS have been found lo be of accelabIe slandard as veII
as lo shov adequale resonsiveness according lo a reviev by }rslad and coaulhors
The scaIe invoIves ceiIing effecls for individuaIs vilh high hysicaI funclioning vhich
suggesls lhal use of faII efficacy assessmenl vilh ma|or demands on baIance erformance
may be referabIe in foIIovu afler lhe sub acule hase In our sludy len of lhe
alienls in lhe HR grou and one alienl in lhe CC grou reached lhe maximum score of
al lhe one monlh foIIovu In order lo meel lhis robIem differenl modified versions
of lhe IISS have been deveIoed for examIe lhe inlernalionaI version IISI lo vhich
more difficuIl and sociaI aclivilies have been added The IISI measures hov
concerned lhe resondenl is of faIIing vhiIe erforming daiIy aclivilies and is
consequenlIy focused on fear ralher lhan confidence vhiIe ve vere more inleresled in lhe
confidence asecl When Ianning lhe sludy ve aIso considered using lhe Aclivily aIance
Confidence scaIe bul as lhe scaIe comrised loo many comIex aclivilies and has been
shovn lo have a grealer resonsiveness for ersons vilh a higher degree of
funclioning lhan our arlicianls ve chose lhe IISS Hovever il is ossibIe lhal a
modified IIS vilh some addilionaI inslrumenlaI aclivilies added mighl have been more
aroriale lo use

The IIM is a veII documenled and videIy used inslrumenl The suIemenlary IAM has
nol been lesled as lhoroughIy as lhe IIM and mainIy on alienls vilh slroke or olher
neuroIogicaI diagnoses IossibIy ve shouId have used an addilionaI inslrumenl lo measure
inslrumenlaI ADL indeendence in order lo make reIiabiIily lesls on our ouIalion

The IAI vhich measures frequency of differenl comIex daiIy aclivilies has aIso been
videIy used over lhe vorId and in differenl ouIalions Ils focus on aclivilies vhich
couId be considered as lradilionaIIy femaIe al Ieasl in an ageing ouIalion couId
conlribule lo undereslimalion of lradilionaIIy maIe aclivilies and hence ul lhe
arlicialing men in a more inaclive roIe lhan lhey acluaIIy vere Hovever ve found no
inslrumenl vhich vas more gender neulraI

The SI vas chosen for measuring HRQoL as il is videIy used in research Il has been
suggesled lhal lhe SI has a veIIdemonslraled vaIidily comared lo olher scaIes
aIlhough lhe vaIidily for oIder resondenls has been queslioned Il vas our
exerience lhal faceloface inlervievs vere an aroriale aroach lo use lhe SI on
lhis ouIalion of fraiI eIderIy eoIe

The STS and TUG lesls vere redominanlIy erformed in lhe arlicianls ovn homes
and differenl conslruclions and heighl of chairs couId affecl lhe erformance of lhe lesls In
order lo meel lhis robIem ve used lhe same chair on lhe differenl occasions In addilion lo
lhis lhe arlicianls lhemseIves vere aIIoved lo choose vhich if any vaIking aid lhey
referred lo use This mighl have infIuenced lhe resuIls as for inslance vaIking safeIy vilh
a vheeIer couId be quicker lhan vaIking vilh lvo crulches Concerning lhe STS ve had no
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baseIine measuremenl as ve decided lo incIude lhe lesl vhen lhe sludy had aIready
slarled and couId lherefore nol comare discharge measures vilh foIIovus
AddilionaIIy lhe missing dala on lhe TUG al discharge are subslanliaI vhich veakens lhe
ossibIe concIusions of lhe comarisons

Trustwnrthincss and crcdibi!ity nI thc qua!itativc data
When discussing vaIidily queslions in quaIilalive sludies one oflen refers lo research lhal
il IausibIe credibIe lruslvorlhy and lherefore defensibIe LincoIn and Guba
suggesled lhal lhe crileria credibiIily deendabiIily ie lhe consislency of observing lhe
same findings under simiIar circumslances confirmabiIily ie lhe degree lo vhich lhe
resuIls couId be confirmed by olhers and lransferabiIily ie lhe degree lo vhich lhe resuIls
of quaIilalive research can be generaIized or lransferred lo olher conlexls or sellings couId
be used as crileria for scienlific rigour They comared credibiIily vilh inlernaI vaIidily
confirmabiIily vilh ob|eclivily and lransferabiIily vilh generaIisabiIily Some aulhors
aIso recommend lrianguIalion ie crosschecking informalion and concIusions lhrough
lhe use of muIliIe dala sources or research melhods lo sludy a henomenon or lo use
muIliIe invesligalors in coIIecling and inlerreling lhe dala In lhis lhesis lrianguIalion
vas nol used

To delermine vhelher a ubIished quaIilalive research arlicIe is lruslvorlhy or nol is a
comIex lask arlicuIarIy as lhere is no agreed sel of crileria lo aIy Some definilions of
lruslvorlhiness lend lo reIale back lo a quanlilalive evaIualion of quaIily Hovever il
has become a common raclice for quaIilalive researchers lo avoid using quanlilalive
lerminoIogy vhen describing measures lo evaIuale lhe quaIily of lheir research as lhe
hiIosohicaI assumlions of quanlilalive and quaIilalive research couId be seen as
incomalibIe In lhe Iighl of lhis lruslvorlhiness refers lo lhe exlenl lo vhich lhe
findings couId be seen as an aulhenlic refIeclion of lhe exeriences of lhe henomenon
under invesligalion In our oinion lhe resuIls from lhe incIuded inlerviev sludies in
lhis lhesis even vhen comaring vilh resuIls from olher sludies couId be regarded as
aulhenlic refIeclions of differenl exeriences of suslaining a hi fraclure

One slralegy lo eslabIish lruslvorlhiness vhich vas aIso used in lhis lhesis is lo lry lo
oblain lransarency for inslance by cIearIy describing melhods samIing dala coIIeclion
dala anaIysis and resuIls This shouId invoIve a cIearIy defined research queslion ground
for choice of melhod delaiI of samIe and lransarenl descrilions of lhe alhvay from
dala lo concIusions incIuding exacl quoles from lhe inlervievs
TransferabiIily is aIso a lerm used vilhin lhe area of lhe quaIily of research Irom a
quaIilalive erseclive lransferabiIily is rimariIy lhe resonsibiIily of lhe reader The
researcher can enhance lransferabiIily by delaiIing lhe research melhods conlexls and
assumlions underIying lhe sludy
In lhe lvo quaIilalive sludies incIuded in lhis lhesis ve have considered lhe queslion of
lruslvorlhiness by describing lhe aim and research queslions choice of melhod samIing
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dala coIIeclion anaIysis and by resenling resuIls iIIuslraled by quoles coIIecled from lhe
inlervievs in order lo meel lhe crileria of lransarency The resuIls couId lhus be used by
cIinicians lo recognize simiIar silualions and robIems in lhe rehabiIilalion of alienls vilh
lhis in|ury Iurlhermore aII inlervievs vere anaIyzed by lvo eoIe searaleIy before
discussing and comaring lhe findings
Il is nol ossibIe for us lo excIude lhe ossibiIily lhal lhere may be olher vays of
exeriencing a hi fraclure lhan vere reorled in lhis lhesis NeverlheIess lhe varialion of
concelions vhich emerged from lhe inlervievs crealed an oulcome sace covering
quaIilaliveIy differenl asecls of lhe sludied henomenon The findings may aIso serve as
ground for deveIomenl of nev inslrumenls
Cnmbining qua!itativc and quantitativc mcthnds
AIlhough quaIilalive and quanlilalive research melhods have differenl underIying
lheorelicaI assumlions il seems fruilfuI lo combine quaIilalive and quanlilalive dala lo
iIIuslrale comIemenlary asecls of chosen henomena and lo beller undersland lhe
comIexily of many heaIlh care loics Iurlhermore in order lo undersland lhe
individuaI consequences of a serious in|ury Iike hi fraclure and vhich rehabiIilalion
measures lo offer a broad range of knovIedge and underslanding need lo be broughl
logelher UnforlunaleIy quaIilalive and quanlilalive researchers oflen use differenl
assumlions aboul lhe vorId and vays of Iearning aboul il These assumlions may be
seen conlradiclious and researchers are oflen laughl lo masler onIy one lye of melhod
eilher quaIilalive or quanlilalive Combining quanlilalive and quaIilalive melhods is
comIex as lhese melhods beIong lo lradilionaIIy differenl aradigms vilh fundamenlaIIy
differenl hiIosohicaI framevork Hovever hysiolheray as olher heaIlh care
rofessions is based on a diversily of knovIedge vhich imIies lhe need for research
melhods vhich refIecl lhe comIexily of human resonses lo various heaIlh care silualions
Therefore quaIilalive and quanlilalive melhods rovide differenl bul noncomeling
knovIedge vilh equaI imorlance and veighl In lhis lhesis based on lhe diversily of lhe
research queslions bolh quaIilalive and quanlilalive melhods have been used Il is our
oinion lhal lhis combinalion vas of vaIue and conlribuled vilh rich descrilions of lhe
alienls silualion afler a hi fraclure The knovIedge gained lhrough lhe research is
inlended lo be used in communicalion vilh olher cIinicians and may lhus serve as a means
lo deveIo educalion and cIinicaI raclice

ICF
ICI is a cIassificalion syslem and nol an assessmenl inslrumenl Measure inslrumenls can
be assigned lo ICI by coding of individuaI ilems and formalion of so caIIed core sels
Differenl Iimilalions and robIems vilh ICI have been debaled one being lhe
insufficienlIy deveIoed area ersonaI faclors One queslion vhich has been discussed is if
sychoIogicaI funclions couId be regarded as a arl of body funclion or ralher as ersonaI
faclors According lo lhe resenl modeI mosl sychoIogicaI funclions shouId be coded
under body funclion Iurlhermore il has been discussed lhal il is difficuIl lo dislinguish
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belveen lhe aclivily and arlicialion comonenls and lhal lhey shouId ossibIy be
divided inlo lvo comonenls

The ICI can serve as a connecling framevork belveen inlervenlions and oulcome
measures faciIilaling lhe seIeclion of lhe mosl aroriale oulcome measure for lhe aim of
lhe inlervenlion In lhis vay differenl inlervenlions couId be easier comared vilh
resecl lo lhe inlervenlions adminislered and lhe resuIls oblained In lhis lhesis lhe use of
ICI vas Iimiled lo slruclure of lhe oulcome measures Il couId have been vaIuabIe lo Iink
ilem for ilem lo lhe ICI codes in order lo heI fulure decisions aboul vhal oulcomes
shouId be measured hov lo measure lhem and vhal comonenls rehabiIilalion
rogrammes shouId incIude


What is worth knowing?

According lo Trnebohm researchers shouId lry lo roduce vaIuabIe knovIedge for lhe
raclilioners One essenliaI queslion lo ul according lo Trnebohm is Whal do lhe
aclors in lhe fieId need lo knov in order lo be abIe lo erform beller in lheir rofession
He aIso concIuded lhal cIinicaI orienled research shouId concern vhal couId be done lo
heI a erson in a Iife crisis for examIe being admilled lo acule hosilaI afler an acule
in|ury Trnebohm exemIified lhis vilh lhe suggeslion lhal lhe lheraisl buiIds lvo
aradigms a coherenl syslem of lhoughls and lheories one aboul lhe alienl as lhe
erson he or she vas before as he or she is al resenl and as vhal he is al resenl or vhal
she mighl become afler lhe lrealmenl and one aboul lhe lrealmenl of lhe alienl He aIso
suggesls lhal lhe alienl needs lo buiId a aradigm aboul his or her aclive arlicialion in
lhe lrealmenl and lhal lhe success of lhe lrealmenl deends on lhe quaIilies and Iinkage of
lhese aradigms The resenl sludies couId be seen as an alleml lo exIore lhis fieId
of knovIedge One of lhe aims vilh lhe sludies vas lo gain knovIedge of hov lhe alienls
exerience a serious in|ury Iike a hi fraclure vhich couId be seen as exIoring arl of lhe
alienls Iife aradigm Anolher Ionglerm goaI vas lo resenl nev inleresling and
essenliaI knovIedge vhich couId conlribule lo imrovemenl of lrealmenl and rogrammes
vilhin gerialric rehabiIilalion aIicabIe for aII heaIlh care ersonneI and for
hysiolheraisls in arlicuIar











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Ethical aspects

The inlervievs and dala coIIeclion vere carried oul in lhe arlicianls homes unIess a
differenl venue vas requesled and al a lime lhal besl suiled lhe resondenls This meanl
enlering a rivale shere vhich has lo invoIve cerlain consideralions Iurlhermore some
of lhe loics mighl be regarded by lhe resondenl as rivale and il vas lherefore of rime
imorlance lo observe lhe resondenls inlegrily Hovever ve gol no indicalions lhal lhe
sludy visils shouId have harmfuIIy affecled lhe arlicianls in any vay On lhe conlrary
lhere vere arlicianls vho said lhal lhe foIIovu visils made lhem feeI safe and lhal
lhey arecialed having someone lo ask aboul lheir in|ury and vho lhey shouId lurn if
lhey needed heI

The facl lhal lhe arlicianls in lhe sludy may nol be lhe same as lhose vho may benefil
from lhe resuIls of lhe research couId aIso be seen as a diIemma HoefuIIy lhough lhe
knovIedge gained in lhese sludies viII conlribule lo imrovemenl of lhe rehabiIilalion
and lhus lhe silualion for alienls vilh hi fraclure in generaI

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Conclusions and clinical implications




The higher degree of recovery among lhe arlicianls of lhe HR lhal vas found one monlh
six monlhs and one year afler discharge imIies lhal lhe rogramme had more Ionglerm
imacl on indeendence and funclioning lhan vas execled from revious research vilhin
lhe fieId AIlhough lhis vas mosl aarenl in lhe earIy hase of lhe recovery some of lhe
effecls vere aIso more revaiIing IossibIe reasons vere lhe rogrammes earIy slarl and
ils focus on seIfefficacy and exercising daiIy aclivilies in lhe home environmenl as veII as
a high degree of conlinuily and cooeralion among lhe invoIved heaIlh care rofessionaIs
Anolher conlribuling faclor may be lhe bridging funclion of lhe HR rogramme vhich
resumabIy conlribuled lo a smoolh and secure discharge for lhe alienl as veII as for
lheir reIalives

The resuIls accenluale research reorling lhal lhe negalive consequences of a hi fraclure
are subslanliaI and IongIasling Il can be argued lhal a hi fraclure nol onIy invoIves a
broken bone bul aIso has a rofound sychoIogicaI and sociaI imacl for lhe individuaIs
As a hi fraclures slrikes moslIy eIderIy eoIe vho may have exerienced earIier Iosses
and groving disabiIilies il couId add lo lhe risk of ermanenlIy Iosing imorlanl Iife
vaIues

The resuIls from lhe resenl sludies couId conlribule lo deeen heaIlh care rofessionaIs
underslanding of lhe ersonaI consequences of suslaining a hi fraclure One key
comonenl in hi fraclure rogrammes is lo Iel lhe alienls formuIaled needs Iead lhe care
and rehabiIilalion inslead of lhe olher vay around Iurlhermore considering lhe
remaining IongIasling negalive consequences of lhe in|ury il is our oinion lhal
rogrammes suorling alienls seIfreIiance and hoe of recueralion shouId be given
riorily

A remaining chaIIenge for heaIlh care is aIso lo delermine lhe comosilion and duralion of
hosilaI slay and of rehabiIilalion lhal ensures olimaI funclionaI recovery mosl efficienlIy
in oIder eoIe vho suslain a hi fraclure Arranging heaIlh care and rehabiIilalion chains
in order lo Iink logelher differenl heaIlh care organizalions shouId be given riorily Il is
imorlanl for aII rofessionaIs vho meel lhe alienls lo consider lhe alienls exeriences
and lhe sychoIogicaI dimensions and nol rimariIy focus on lhe hysicaI in|ury and
disabiIily Inlervenlion rogrammes lhal acknovIedge eIderIy eoIes fear of faIIing
vhiIe al lhe same lime encouraging a IifeslyIe lhal incIudes hysicaI exercise sociaI
aclivily and connecledness and a caabIe sense of seIf reIiance couId heI eoIe regain a
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high quaIily of Iife during lhe recovery rocess An inleresling fulure research area for
hysiolheraisls is lo furlher invesligale hov imorlanl lhe alienls lrusl in her or his
ovn recourses and abiIilies is for lhe rehabiIilalion oulcomes Iurlhermore in more cIose
delaiI exIore vhal oulcomes are lhe mosl aroriale in lhe rehabiIilalion of eIderIy
eoIe vilh hi fraclure Taking lhe resuIls from lhis lhesis as a slarlingoinl seIf
assessmenl of seIfefficacy such as faIIs or lask efficacy couId be one vaIuabIe arl in lhe
oulcome evaIualion To use body and movemenl as key comonenls in rehabiIilalion as
hysiolheraisls do is a overfuI vay lo reach lhe alienls reaclions and exeriences The
hysiolheraisl can use lhis lo guide lhe alienls lo overcome fear and insecurily caused
by lhe in|ury and lo feeI lhal lhey are abIe lo move and lhus be abIe lo reaIize aclions of
lheir ovn choice

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English summary





Hi fraclure is one of lhe mosl serious consequences of faIIing and is besides slroke lhe
mosl common reason for acule hosilaI slay and rehabiIilalion among eIderIy eoIe OnIy
a minorily of lhe alienls regain lhe hysicaI and sociaI aclivilies lhey had before lhe
fraclure Many of lhe eIderIy exerience an increased mobiIily vhich makes il more
difficuIl lo gel oul of lheir homes and lhere is an increased risk for deressed mood and
inaclivily Wilhin heaIlh care subslanliaI measures have been made in order lo idenlify
effeclive rehabiIilalion modeIs for lhis grou of alienls One of lhe modeIs lhal have
gained groving inleresl during recenl years is home rehabiIilalion Hovever research on
home rehabiIilalion is inconcIusive Iurlhermore lhere is a Iack of knovIedge of hov lhe
alienls lhemseIves exerience lhe recovery and hov lhe in|ury has affecled Iives of lhe
individuaIs

The overaII aim of lhis lhesis vas lo comare a gerialric a home rehabiIilalion rogramme
vilh convenlionaI care and lo foIIov lhe alienls recovery during one year afler discharge
from hosilaI and lo calure lhe alienls ovn exeriences and concelions of lhe
consequences of lhe in|ury and lhe recovery rocess Therefore aIongside measuring lhe
alienls confidence in erforming daiIy aclivilies vilhoul faIIing lheir degree of
indeendence and frequency of daiIy aclivily lheir abiIily lo erform basic funclionaI
aclivilies and lheir erceived heaIlhreIaled quaIily of Iife degree of recovery and mood
ve have aIso inlervieved some of lhe alienls aboul lheir exeriences of lhe consequences
of lhe in|ury ils imacl on lheir daiIy Iives as veII as lheir concelions of lhe recovery
rocess

In lhe lhesis resuIls from lvo sludies in vhich lhe alienls vere randomized lo
arliciale in eilher a home rehabiIilalion rogramme ersons or lo receive
convenlionaI care ersons are resenled The home rehabiIilalion rogramme vhich
slarled immedialeIy afler admission lo hosilaI vas focused on encouraging lhe
arlicianls confidence in erforming daiIy aclivilies such as laking ouldoor vaIks and
exercising daiIy aclivily soon afler discharge The arlicianls in lhe home rehabiIilalion
rogramme received aroximaleIy five visils from hysiolheraisls and occualionaI
lheraisls and occasionaI visils from a nurse AII arlicianls vere foIIovedu in lheir
ovn homes one monlh six monlhs and one year afler discharge during vhich aII
measuremenls and inlervievs vere erformed On lhese occasions measures vere made
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and lhe arlicianls fiIIed in seIfreorl queslionnaires Iurlhermore lhe arlicianls
erformed lvo simIe funclionaI mobiIily lesls

In lhe inlerviev sludies of lhe arlicianls of lhe home rehabiIilalion sludy vere
inlervieved aboul lheir exerienced consequences of lhe fraclure and lheir concelions
aboul vhal had infIuences recovery afler a hi fraclure

The ma|orily of lhe recovery for aII arlicianls look Iace during lhe firsl six monlhs afler
discharge One monlh afler discharge lhose vho had arlicialed in home rehabiIilalion
reorled higher increase in baIance confidence as veII as higher degree of recovery in
indeendence and frequency of daiIy aclivilies as veII as in basic hysicaI mobiIily lhan
lhose vho had received convenlionaI care

One year afler discharge some of lhe differences belveen lhe lvo grous of alienls vere
diminished bul lhose vho had received home rehabiIilalion sliII had a higher degree of
recovery of indeendence in ersonaI care and vaIking as veII as in baIance confidence
and seIfraled hysicaI erformance comared lo lhe grou vho had received
convenlionaI care Al lhe one year foIIovu onIy of lhe home rehabiIilalion
grou and five of lhe convenlionaI care grou considered lhemseIves fuIIy recovered
comared lo before lhe fraclure

The inlerviev sludies one monlh and one year afler discharge reveaIed lhal lhe in|ury had
meanl ma|or changes in lhe inlervievees Iife bolh in a shorl and Ionglerm erseclive
One dominaling exerience vas lhal lhe fraclure had Iimiled lhe abiIily lo Iive as before
The inlervievees exressed lhal lhey had more difficuIlies lo move and lo manage
indeendenlIy in daiIy Iife vhich had aIso made lhem more isoIaled They aIso reorled
lhal lhey had become more afraid and insecure and for some lhe in|ury had meanl lhal
lhey feIl dealh had come cIoser and lhal lhey did nol dare Ian for lhe fulure The in|ury
had Iimiled lheir daiIy Iives and many of lhe negalive consequences remained or had even
deeened one year afler discharge

Differenl rofessionaIs vilhin sociaI and heaIlh care for eIderIy eoIe have somelhing lo
Iearn from lhe resuIls of lhe sludies An essenliaI arl of care and rehabiIilalion afler a hi
fraclure is lo creale heaIlh care chains incIuding conlinued ossibiIilies for rehabiIilalion in
lhe subacule hase afler discharge and for lhose vho need aIso in a Ionger erseclive Il
is aIso erceivabIe lhal lhe home rehabiIilalion rogramme vhich slarled direclIy afler
admission lo lhe acule cIinic and incIuded aclive arlicialion of alienls and lheir
reIalives in lhe goaI selling and discharge Ianning has had imorlance for hov soon lhe
alienls couId regain daiIy aclivilies in lheir ovn homes afler discharge As a hi fraclure
IileraIIy slrikes your feel lhe alienls need exlensive heI and suorl lo mainlain hoe for
recovery and lo be aclive in lheir ovn rehabiIilalion SubsequenlIy heaIlh care
rofessionaIs logelher vilh olher caregivers shouId vork acliveIy lo invoIve lhe alienls
and lheir reIalives in care and rehabiIilalion and nol mainIy focus on lhe medicaI and
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hysicaI needs KnovIedge of lhe sychoIogicaI reaclions lhal may foIIov a hi fraclure
shouId creale lhe basis for hov lo meel and suorl lhe alienl lhrough her recovery
rocess

Hov lo use heaIlh care resources in lhe mosl olimaI vay and hov lo creale a veII
funclioning and economicaIIy defensibIe rehabiIilalion modeIs remains lo exIore in
forlhcoming sludies Such modeIs shouId incIude cooeralion belveen differenl heaIlh
care roviders and revenl lhe risking alienls faIIing belveen chairs


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Acknowledgements
Min lid som doklorand har varil fanlaslisk med olroIigl myckel arbele men
ocks mlen med underbara mnniskor bde de som deIlagil i mina sludier andra
doklorander och andra ersoner inom universilelsvrIden All dessulom f Iov all gra
den forskning som |ag gll och Inglal efler i mnga r med sld bde ekonomiskl och
rakliskl frn VrdaIinslilulel frn Inslilulionen fr arbelslerai och s|ukgymnaslik ingr
nu i Inslilulionen fr neurovelenska och fysioIogi och SahIgrenska akademin vid
Gleborgs universilel och frn SahIgrenska universilelss|ukhusel har varil ell slorl
riviIegium som |ag r myckel lacksam ver }ag har hafl sld och h|I av mnga
ersoner handIedare VrdaIinslilulels AIdreIallforms medarbelare Irare chefer och
verksamma s|ukgymnasler inom SahIgrenska Universilelss|ukhus arbelsleraeuler och
andra koIIegor kursIedare och kursdeIlagare ersonaI inslilulionen och
akademikansIiel m fI }ag viII drfr framfra mill varmasle och d|uasle lack liII aIIa de
ersoner som oIika sll bidragil liII denna avhandIing SecieIIl viII |ag lacka fI|ande
ersoner

Ill varml lack liII aIIa dc!tagarna i sludierna fr all ha lagil sig lid sIl in mig i sina hem
och deIgivil sina erfarenheler och IivsberlleIser Ulan er hade del definilivl inle bIivil
ngon avhandIing

Min huvudhandIedare Margarcta Krcutcr som s genersl deIal med sig av sin slora
kunska inom forskning och som guidal mig genom den ibIand snriga
forskningsrocessen och som aIIlid lagil sig lid nr |ag behvl h|I oavsell om del var heIg
eIIer vardagTack fr dill aIdrig sviklande sld och aII umunlran inle minsl nr |ag knl
mig nedsIagen och lidsressad

Mina lre bihandIedare Kcrstin Frndin som var den frsla forskande s|ukgymnasl |ag
lrffade nr |ag br|ade arbela inom gerialriken SvaIebo s|ukhem och som invigde mig i
fr mig nya mlmeloder Tack fr all du umunlral mig i aIIa u och nedgngar under
doklorandliden och aIIlid kommil med kIoka synunkler Del har varil oerhrl vikligl all
f din handIedning som ocks liIIfrl erseklivel friska Idre C!acsGran Wcncstam
som redan bIev min handIedare i en inlerv|usludie av Idre kvinnor som brulil hflen
Den enlusiasm och gId|e som du sridil har g|orl all |ag aIIlid knl mig uIyfl Del var
ocks du som inlroducerade fenomenografin fr mig och som Irde mig all inle vara rdd
fr all be gamIa damer rila av sina hflsikar 5ynncvc Dah!inIvannII som bIev min
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75
handIedare en bil in i dokloranderioden som varil min VrdaIhandIedare och som s
enlusiasliskl slIIde u och Iyssnade mina rovinlerv|uer och umunlral mig all la
fram del s|ukgymnasliska i avhandIingen Ni har aIIa fyra ell suvernl sll komIelleral
varandra och givil mig oIika vinkIingar mina forskningsfrgor

Medfrfallare Mariannc Hanssnn 5chcrman som s genersl diskuleral och deIal med sig
av sina erfarenheler inom edagogiken och fenomenografin du har i reaIilelen ocks
fungeral som en bihandIedare i mina kvaIilaliva sludier och lagIigl bidragil liII
arlikIarnas kvaIilel Vi har hafl roIigl ocks i vra diskussioner

Mina arbelskamraler inom s|ukgymnasliken aIIlifrn SvaIebo liII MIndaI som aIIlid
slllal och umunlral och deIlagil i givande diskussioner om hur vi kan arbela med
varandra vrig ersonaI och vra alienler och deras anhriga och fr all liIIsammans
formuIera vad vi egenlIigen gr och vad vi skuIIe viI|a gra Irn SvaIebo Ca|sa Wah!bcrg
min gamIa vn och vaendragare som fIyllal liII den slora sladen andra sidan Sverige
dr du fr vidare Gerlrud RoxendahIs anda liIIsammans har vi mnga gIada minnen De
insirerande samlaI vi hafl hemma hos dig r ovrderIiga fr mig Du r dessulom en
vrdefuII medIem av den secieIIa kIubben VIK Vin Iedagogik och KuIlur men kan
lyvrr inle vara med s ofla vra mlen Mnnica M!!cr dill suverna sll all hanlera
en boII och vcka en gru Idre som kommil ner liII gymnsaliken lrols all de var vIdigl
lrlle imonerade mig Ingrid Magnussnn Karin Magnussnn Mnna H|c!m Guni!!a
Lctt 5n!vcig 5vcnssnn m fI Och s Cristina Wngb!ad som fI|l mig nda frn frsla
dagen s|ukgymnaslulbiIdningen och i diverse krer och som liIIsammans med mig
firar r i kommunens l|nsl i r SecieIIl lack liII Lai!a 5trandbcrg som |ag samarbelal
med sedan br|an av laIel och som bIev min nrmsla arbelsIedare lack fr aII
umunlran srkh|I och Iivserfarenhel du deIal med dig av och svamkunska
Ingc!a Wcstman Kum!in som var min chef och som genersl umunlrade mill skande
efler kunska bI a genom all f Iov all g kurser och magislerulbiIdning med fuII In Mina
chefer Mnnica Hcdbcrg Lcna E!am 5taIIan 5karric och Eva Bcckung som aIIa varil
frulsllningar fr all |ag kunnal forlslla med doklorandsludierna er har |ag all lacka fr
all min rofessioneIIa ulveckIing bIivil rakliskl m|Iig men ni har ocks varil mina
menlorer Mnnica FagcvikOIsen som slllal och givil goda rd AIIa mina arbctskamratcr
p s|ukgymnastikcn som bislll vid inkIudering av sludiedeIlagare och dalainsamIing
h|Il mig vid ulrovning och vaI av mlinslrumenl och inle minsl genomfrl
hemrehabiIileringen under lurbuIenla lider Anna Mc!!bcrg Jcnny Larssnn U!!a
Magnc!! Gi!! Asp!in Barbrn Wikandcr Mnnica Larssnn RnsMaric Pnh|anvunri
Victnria Mnh!in Annika Hc!!zn Ingcmarssnn och aIIa ni andra som h|Il och slllal
mig lack Dessulom mina kra vnner och arbelsleraeulkamraler Mariannc Lundh och
AnnCathrinc Lindskng ni har belyll oerhrl myckel fr all |ag har forlsall med
forskningen


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76
Dessulom mina arbelsleraeulkoIIegor SvaIebo de |ag arbelal nrmasl med Ccci!ia
Gncib som fI|de med mig inle bara var|e vecka u liII orloedavdeIningarna fr all
inlerv|ua resumliva alienler liII SvaIeboro|eklel ulan ven liII Nev York dr vi
sluderade hflfraklurvrden liIIsammans med Iile annal Lntta GustaIssnn som visade
mig vad som kan hnda om man har en unduIal och en morol Annc!i Lcrncst! som deIal
mnga gId|efuIIa r d vi om och om igen slarlal hflfraklurrogram efler diverse
organisaloriska omdaningar inom gerialriken du vel hur myckel du belyll och belyder
fr mig bde rofessioneIIl och ersonIigen Och du har varil med och ringl u ver
alienler i RikshflufI|ningar viIkel givil oss ovrderIiga erfarenheler av
leIefoninlerv|uer och hur man hillar ersoner som frsvunnil Du r |u ocks medIem i
kIubben VIK Liksom Tnrbnrg Arvidssnn ven om du inle liIIhr SvaIebogruen du
har fI|l mig genom oIika krer frn sIulel av laIel genom diskussioner om edagogik
och om Iivel och som ocks r en av mina bsla vnner Tack aIIa ni fr suorl och
Iivssld

5tcn Landah! rofessor och min chef efler AIvar Svanborg under min lid SvaIeboVasa
och som r bilrdande chef VrdaIinslilulel Tack fr aIIl sld under resans gng och fr
all du h|Il mig i mI

Lrare och aII ersonaI inslilulionen Cattc Brnbcrg som har insireral mig med
insirerande och krealiva diskussioner om Iivsaradigm vad s|ukgymnaslik r
rreIseIra begre och lermer inom s|ukgymnaslik |a sg var din kunskasbank sIular
Och s har du genersl b|udil skaffning i din fina koIonisluga Janc Car!ssnn som aIIlid
slIIl u med rd och sld 5usannc Rnsbcrg som |ag har Irl mig s myckel av om den
odeIbara kroen Guni!!a GnsmanHcdstrm som h|Il mig nr |ag var viIsen i
inslrumenllrskel och som umunlral under heIa doklorandliden Carin Wi!!n och
HeIIe Wi|k som log lid av sin Iedighel fr all h|Ia mig med vrdefuIIa rd och h|I med
avhandIingen Eva Andrn och Yvnnnc Daving som log sig lid all slla mig in i IAM U!!a
5nnn som Iedsagade mig bIand aIIa mlinslrumenl i ADLsfren Anita Esping som aIIlid i
osiliv anda Isl aIIa organisaloriska frgor Och AnnChar!nttc Bcngtssnn som h|Il mig
genom den snriga fond och sliendied|ungeIn Och aIIa andra lack fr aIIl |ag Irl mig
av er

AIIa mina doklorandkoIIegor bde inslilulionen akademin och inom VrdaI har belyll
och belyder vIdigl myckel fr mig och som belyder s myckel fr mill s|Ivfrlroende
inom forskningen SecieIIl viII |ag lacka VrdaIdokloranderna Maria Larssnn min
rumskamral som ell suvernl sll guidal mig genom SISS och slalisliska anaIyser nr
del som behandIals slalislikkurserna inle rikligl Iandal vi har verkIigen deIal vll och
lorrl under den hr erioden och h|dunklen bde biIdIigl och konkrel var nog resan liII
WCITkongressen i Vancouver Och Carina 5parud Lundin som har insireral mig med
sin energi och IivsIusl du har varil bllre n ginseng Ingc!a 5tci| 5t!brant som aIIlid Isl
mina lexler och givil mig vrdefuIIa rd och kommenlarer men ocks diskuleral Iiv och
Ieverne Maric CcdcrIc!dt som funnils hr och eal mig nr model sviklal Och mnga
76
77
fIer Eva Hn!mgrcn I O!ssnn som |ag har diskuleral randomisering IIS och andra vikliga
frgor med och som aIIlid hafl kIoka rd all ge

IngaLi!! Rahm Ha!!bcrg rofessor och chef fr VrdaIinslilulel lack fr all du lrodde
min forskningside och fr aIIa vrdefuIIa rd och aIIl sld Dessulom andra medarbelare
inom VrdaIinslilulel genom ren 5!vc E!msth! som var den frsla Iedaren
AIdreIallformen och som guidade mig in RCT AnnaKarin Edbcrg som aIIlid r
engagerad kunnig och slllande Edith Andcrssnn fr aII h|I genom VrdaIliden B|rn
Car!qvist som hIIil reda ryggscksengarna Atusa Arya fr aII h|I med Inlernzonen
och aIIa andra lack

Finna Lnvn nch Janct Vcstcr!und fr frslkIassig srkgranskning Va!tcr 5undh fr
vnIig snabb och kunnig assislans i slalisliska frgor

Tnmas Wa!!n som var kIinikchef inom Gerialriken SahIgrenska nr sludien slarlade och
som frn br|an sldde mig och sg liII all del bIev m|Iigl all komma igng

Ma|vnr Martinssnn som umunlral mig all genomfra mina sludier lrols eriodvis
organisaloriskl molslnd

Vrdenhelschefer de vrdavdeIningar som deIlagil i sludierna inle minsl Anita L|ung
som drivande nr del gIIde all slarla hemrehab

AIIa Ikare som |ag samarbelal med genom ren Dan Mc!!strm som i br|an av laIel
inlroducerade mig i osleoorosens vrId Bcngt Lindh och Car! Zcttcrbcrg som var
deIakliga i SvaIeboro|eklel och som Irde mig myckel om hflfraklurer och orloedi kc
Rundgrcn som |ag har Irl mig myckel om den Idrande mnniskan av Och Grc!
5undbcck som var en av de drivande kraflerna nr hflrogrammel fIyllade liII Vasa och
som deIlog i den muIlirofessioneIIa kvaIilelsulveckIingen och forskningen inom
rogrammel Eva 5ixt som osilivl bidragil liII all avhandIingssludierna gick all
genomfra lrols omorganisalion och fIyll och JanO!nph O!ssnn som varil deIaklig i
hemrehabiIileringsrogrammel Och mnga fIer lack

Tack liII min famiI| Min Iskade man B|rn som aIIlid slIIer u och skler hem och
mal ell suvernl sll och som backar u mig i aIIa Igen och mina Iskade barn
5ara och A!ma ni gr Iivel vrl all Ieva Min aa Lcnnart och hans EiBritt min bror
Hanskc och vrig famiI| och sIkl lack fr all ni finns

Min barndomsvn Birgitta Agncssnn viII |ag ocks skicka ell lack liII du r en vn inle
bara nr Iivel Ieker ulan ocks i nden och har h|Il mig all koIa av forskningen d och
d

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78
Mina andra vnner inle all frgImma |ag kan inle nmna aIIa hr Min lv krer som
frgyIIer friliden och gr all |ag hmlar krafl vnner nra och f|rran Margarcta Mcycr
som ger s kIoka rd och som dessulom Inar ul sin Igenhel nr man behver kinesa i
SlockhoIm AnnMaric och 5vcn Larsnn som h|Ier liII nrheIsl vi behver och b|uder
fanlaslisk mal och sIIska Och aIIa mina andra lrevIiga krkamraler som h|Il mig hIIa
Iivsandarna ue lack

Denna Iisla bIev Ing men kunde ha bIivil myckel Ingre TACK ocks ni som inle nmns
med namn hr men som har varil mig liII slor h|I och sld








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References


1. Rehabilitation. http://www.who.int/topics/rehabilitation/en/ [cited]; Available from WHO
home page.
2. Elffors L. Are osteoporotic fractures due to osteoporosis? Aging (Milano). 1998;10:191-
204.
3. Ensrud KE, Ewing SK, Taylor BC, Fink HA, Stone KL, Cauley JA, et al. Frailty and risk of
falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol
A Biol Sci Med Sci. 2007 Jul;62(7):744-51.
4. Taylor BC, Schreiner PJ, Stone KL, Fink HA, Cummings SR, Nevitt MC, et al. Long-term
prediction of incident hip fracture risk in elderly white women: study of osteoporotic
fractures. J Am Geriatr Soc. 2004 Sep;52(9):1479-86.
5. Robbins J, Aragaki AK, Kooperberg C, Watts N, Wactawski-Wende J, Jackson RD, et al.
Factors associated with 5-year risk of hip fracture in postmenopausal women. JAMA. 2007
Nov 28;298(20):2389-98.
6. Fink HA, Harrison SL, Taylor BC, Cummings SR, Schousboe JT, Kuskowski MA, et al.
Differences in site-specific fracture risk among older women with discordant results for
osteoporosis at hip and spine: study of osteoporotic fractures. J Clin Densitom. 2008 Apr-
Jun;11(2):250-9.
7. Marks R, Allegrante JP, Ronald MacKenzie C, Lane JM. Hip fractures among the elderly:
causes, consequences and control. Ageing Res Rev. 2003 Jan;2(1):57-93.
8. Pluijm SM, Smit JH, Tromp EA, Stel VS, Deeg DJ, Bouter LM, et al. A risk profile for
identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-
year prospective study. Osteoporos Int. 2006;17(3):417-25.
9. Lawrence RH, Tennstedt SL, Kasten LE, Shih J, Howland J, Jette AM. Intensity and
correlates of fear of falling and hurting oneself in the next year: baseline findings from a
Roybal Center fear of falling intervention. J Aging Health. 1998 Aug;10(3):267-86.
10. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in
the community. N Engl J Med. 1988 Dec 29;319(26):1701-7.
11. Stel VS, Pluijm SM, Deeg DJ, Smit JH, Bouter LM, Lips P. Functional limitations and poor
physical performance as independent risk factors for self-reported fractures in older
persons. Osteoporos Int. 2004 Sep;15(9):742-50.
12. Coupland C, Wood D, Cooper C. Physical inactivity is an independent risk factor for hip
fracture in the elderly. J Epidemiol Community Health. 1993 Dec;47(6):441-3.
13. Hoidrup S, Sorensen TI, Stroger U, Lauritzen JB, Schroll M, Gronbaek M. Leisure-time
physical activity levels and changes in relation to risk of hip fracture in men and women.
Am J Epidemiol. 2001 Jul 1;154(1):60-8.
14. Farahmand BY, Persson PG, Michaelsson K, Baron JA, Alberts A, Moradi T, et al. Physical
activity and hip fracture: a population-based case-control study. Swedish Hip Fracture
Study Group. Int J Epidemiol. 2000 Apr;29(2):308-14.
15. Butler M, Norton R, Lee-Joe T, Cheng A, Campbell AJ. The risks of hip fracture in older
people from private homes and institutions. Age Ageing. 1996 Sep;25(5):381-5.
16. Wickham CA, Walsh K, Cooper C, Barker DJ, Margetts BM, Morris J, et al. Dietary
calcium, physical activity, and risk of hip fracture: a prospective study. Bmj. 1989 Oct
7;299(6704):889-92.
17. [database on the Internet]. http://www.iofbonehealth.org/.
18. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated
with osteoporotic fractures. Osteoporos Int. 2006 Dec;17(12):1726-33.
79
80
19. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet.
2002 May 18;359(9319):1761-7.
20. Xu L, Lu A, Zhao X, Chen X, Cummings SR. Very low rates of hip fracture in Beijing,
People's Republic of China the Beijing Osteoporosis Project. Am J Epidemiol. 1996 Nov
1;144(9):901-7.
21. Thorngren K. State of the art - hftfraktur. . Stockholm; 2004 Contract No.: Document
Number|.
22. Slemenda C. Prevention of hip fractures: risk factor modification. Am J Med. 1997 Aug
18;103(2A):65S-71S; discussion S-3S.
23. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction
of mobility in elderly fallers. Age Ageing. 1997 May;26(3):189-93.
24. Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling
in elderly persons living in the community. Am J Public Health. 1994 Apr;84(4):565-70.
25. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related
efficacy in relationship to functioning among community-living elders. J Gerontol. 1994
May;49(3):M140-7.
26. Howland J, Peterson EW, Levin WC, Fried L, Pordon D, Bak S. Fear of falling among the
community-dwelling elderly. J Aging Health. 1993 May;5(2):229-43.
27. Lach HW. Incidence and risk factors for developing fear of falling in older adults. Public
Health Nurs. 2005 Jan-Feb;22(1):45-52.
28. Bruce DG, Devine A, Prince RL. Recreational physical activity levels in healthy older
women: the importance of fear of falling. J Am Geriatr Soc. 2002 Jan;50(1):84-9.
29. Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling
and activity restriction: the survey of activities and fear of falling in the elderly (SAFE). J
Gerontol B Psychol Sci Soc Sci. 1998 Jan;53(1):P43-50.
30. Aoyagi K, Ross PD, Davis JW, Wasnich RD, Hayashi T, Takemoto T. Falls among
community-dwelling elderly in Japan. J Bone Miner Res. 1998 Sep;13(9):1468-74.
31. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among
community-based seniors using home care services. Age Ageing. 2004 May;33(3):273-9.
32. Suzuki M, Ohyama N, Yamada K, Kanamori M. The relationship between fear of falling,
activities of daily living and quality of life among elderly individuals. Nurs Health Sci.
2002 Dec;4(4):155-61.
33. Zijlstra GA, van Haastregt JC, van Eijk JT, van Rossum E, Stalenhoef PA, Kempen GI.
Prevalence and correlates of fear of falling, and associated avoidance of activity in the
general population of community-living older people. Age Ageing. 2007 May;36(3):304-9.
34. Clague JE, Petrie PJ, Horan MA. Hypocapnia and its relation to fear of falling. Arch Phys
Med Rehabil. 2000 Nov;81(11):1485-8.
35. Yardley L, Smith H. A prospective study of the relationship between feared consequences
of falling and avoidance of activity in community-living older people. Gerontologist. 2002
Feb;42(1):17-23.
36. Aminzadeh F, Edwards N. Exploring seniors' views on the use of assistive devices in fall
prevention. . Public Health Nurs. 1998;15:297-304.
37. Tinetti ME, Powell L. Fear of falling and low self-efficacy: a cause of dependence in
elderly persons. J Gerontol. 1993 Sep;48 Spec No:35-8.
38. Li F, Fisher KJ, Harmer P, McAuley E, Wilson NL. Fear of falling in elderly persons:
association with falls, functional ability, and quality of life. J Gerontol B Psychol Sci Soc
Sci. 2003 Sep;58(5):P283-90.
39. Kressig RW, Wolf SL, Sattin RW, O'Grady M, Greenspan A, Curns A, et al. Associations
of demographic, functional, and behavioral characteristics with activity-related fear of
falling among older adults transitioning to frailty. J Am Geriatr Soc. 2001
Nov;49(11):1456-62.
80
81
40. Murphy SL, Williams CS, Gill TM. Characteristics associated with fear of falling and
activity restriction in community-living older persons. J Am Geriatr Soc. 2002
Mar;50(3):516-20.
41. Friedman SM, Munoz B, West SK. Falls and fear of falling: which comes first? A
longitudinal prediction model suggests strategies for primary and secondary prevention. J
Am Geriatr Soc. 2002;50:1329-35.
42. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med. 1997 Aug
18;103(2A):51S-63S; discussion S-4S.
43. Myers AH, Robinson EG, Van Natta ML, Michelson JD, Collins K, Baker SP. Hip fractures
among the elderly: factors associated with in-hospital mortality. Am J Epidemiol. 1991 Nov
15;134(10):1128-37.
44. Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporos Int. 2005 Mar;16
Suppl 2:S3-7.
45. Cooper C. The crippling consequences of fractures and their impact on quality of life. Am J
Med. 1997 Aug 18;103(2A):12S-7S; discussion 7S-9S.
46. Magaziner J, Fredman L, Hawkes W, Hebel JR, Zimmerman S, Orwig DL, et al. Changes
in functional status attributable to hip fracture: a comparison of hip fracture patients to
community-dwelling aged. Am J Epidemiol. 2003 Jun 1;157(11):1023-31.
47. Norton R, Butler M, Robinson E, Lee-Joe T, Campbell AJ. Declines in physical functioning
attributable to hip fracture among older people: a follow-up study of case-control
participants. Disabil Rehabil. 2000 May 20;22(8):345-51.
48. Kirke PN, Sutton M, Burke H, Daly L. Outcome of hip fracture in older Irish women: a 2-
year follow-up of subjects in a case-control study. Injury. 2002 Jun;33(5):387-91.
49. Bruggemann L, Nixon RD, Cavenett T. Predicting acute anxiety and depression following
hip fracture. J Behav Med. 2007 Apr;30(2):97-105.
50. Isberner F, Ritzel D, Sarvela P, Brown K, Hu P, Newbolds D. Falls of elderly rural home
health clients. Home Health Care Serv Q. 1998;17(2):41-51.
51. Muller-Thomsen T, Mittermeier O, Ganzer S. Unrecognised and untreated depression in
geriatric patients with hip fractures. Int J Geriatr Psychiatry. 2002 Jul;17(7):683-4.
52. Kempen GI, Sanderman R, Scaf-Klomp W, Ormel J. The role of depressive symptoms in
recovery from injuries to the extremities in older persons. A prospective study. Int J Geriatr
Psychiatry. 2003 Jan;18(1):14-22.
53. Mossey JM, Knott K, Craik R. The effects of persistent depressive symptoms on hip
fracture recovery. J Gerontol. 1990 Sep;45(5):M163-8.
54. Lenze EJ, Munin MC, Dew MA, Rogers JC, Seligman K, Mulsant BH, et al. Adverse
effects of depression and cognitive impairment on rehabilitation participation and recovery
from hip fracture. Int J Geriatr Psychiatry. 2004 May;19(5):472-8.
55. Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term
rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys
Med Rehabil. 2007 Jul;88(7):916-21.
56. Lenze EJ, Munin MC, Skidmore ER, Dew MA, Rogers JC, Whyte EM, et al. Onset of
depression in elderly persons after hip fracture: implications for prevention and early
intervention of late-life depression. J Am Geriatr Soc. 2007 Jan;55(1):81-6.
57. Fredman L, Hawkes WG, Black S, Bertrand RM, Magaziner J. Elderly patients with hip
fracture with positive affect have better functional recovery over 2 years. J Am Geriatr Soc.
2006 Jul;54(7):1074-81.
58. Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA.
Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int.
2000;11(5):460-6.
81
82
59. van Balen R, Steyerberg EW, Polder JJ, Ribbers TL, Habbema JD, Cools HJ. Hip fracture
in elderly patients: outcomes for function, quality of life, and type of residence. Clin Orthop
Relat Res. 2001 Sep(390):232-43.
60. Tidermark J. Quality of life and femoral neck fractures. Acta Orthop Scand Suppl. 2003
Apr;74(309):1-42.
61. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, et al. Quality of
life related to fear of falling and hip fracture in older women: a time trade off study. Bmj.
2000 Feb 5;320(7231):341-6.
62. Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, Toss G. Health-related
quality of life after osteoporotic fractures. Osteoporos Int. 2004 Oct;15(10):834-41.
63. Archibald G. Patients' experiences of hip fracture. J Adv Nurs. 2003 Nov;44(4):385-92.
64. Olsson LE, Nystrom AE, Karlsson J, Ekman I. Admitted with a hip fracture: patient
perceptions of rehabilitation. J Clin Nurs. 2007 May;16(5):853-9.
65. Furstenberg A-L. Expectations about outcome following hip fracture among older people.
Soc Work Health Care. 1986;11(4):33-47.
66. Borkan JM, Quirk M, Sullivan M. Finding meaning after the fall: injury narratives from
elderly hip fracture patients. Soc Sci Med. 1991;33(8):947-57.
67. LeClerc CM, Wells DL, Craig D, Wilson JL. Falling short of the mark: tales of life after
hospital discharge. Clin Nurs Res. 2002 Aug;11(3):242-63; discussion 64-6.
68. Weaver FM, Perloff L, Waters T. Patients' and caregivers' transition from hospital to home:
needs and recommendations. Home Health Care Serv Q. 1998;17(3):27-48.
69. Frankum J, Bray J, Ell M, Philp I. Predicting post-discharge outcome. Br J Occup Ther.
1995(58):370-2.
70. Soderqvist A, Miedel R, Ponzer S, Tidermark J. The influence of cognitive function on
outcome after a hip fracture. J Bone Joint Surg Am. 2006 Oct;88(10):2115-23.
71. Givens JL, Sanft TB, Marcantonio ER. Functional recovery after hip fracture: the combined
effects of depressive symptoms, cognitive impairment, and delirium. J Am Geriatr Soc.
2008 Jun;56(6):1075-9.
72. Cree M, Carriere KC, Soskolne CL, Suarez-Almazor M. Functional dependence after hip
fracture. Am J Phys Med Rehabil. 2001 Oct;80(10):736-43.
73. Folden S, Tappen R. Factors influencing function and recovery following hip repair
surgery. Orthop Nurs. 2007 Jul-Aug;26(4):234-41.
74. Cummings SR, Phillips SL, Wheat ME, Black D, Goosby E, Wlodarczyk D, et al. Recovery
of function after hip fracture. The role of social supports. J Am Geriatr Soc. 1988
Sep;36(9):801-6.
75. Cornwall R, Gilbert MS, Koval KJ, Strauss E, Siu AL. Functional outcomes and mortality
vary among different types of hip fractures: a function of patient characteristics. Clin
Orthop Relat Res. 2004 Aug(425):64-71.
76. Koval KJ, Skovron ML, Aharonoff GB, Meadows SE, Zuckerman JD. Ambulatory ability
after hip fracture. A prospective study in geriatric patients. Clin Orthop Relat Res. 1995
Jan(310):150-9.
77. Eastwood EA, Magaziner J, Wang J, Silberzweig SB, Hannan EL, Strauss E, et al. Patients
with hip fracture: subgroups and their outcomes. J Am Geriatr Soc. 2002 Jul;50(7):1240-9.
78. Beloosesky Y, Grinblat J, Epelboym B, Weiss A, Grosman B, Hendel D. Functional gain of
hip fracture patients in different cognitive and functional groups. Clin Rehabil. 2002
May;16(3):321-8.
79. Roberto KA, Bartmann J. Factors related to older women's recovery from hip fractures:
physical ability, locus of control, and social support. Health Care Women Int. 1993 Sep-
Oct;14(5):457-68.
80. Ceder L. Predicting the success of rehabilitation following hip fractures. Disabil and
Rehabil. 2005;27(18-19):1073-80.
82
83
81. Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD. Predictors of functional recovery
after hip fracture in the elderly. Clin Orthop Relat Res. 1998 Mar(348):22-8.
82. Fortinsky RH, Bohannon RW, Litt MD, Tennen H, Maljanian R, Fifield J, et al.
Rehabilitation therapy self-efficacy and functional recovery after hip fracture. Int J Rehabil
Res. 2002 Sep;25(3):241-6.
83. Voshaar O, Banerjee S, Horan M, Baldwin R, Pendleton N, Proctor R, et al. Fear of falling
more important than pain and depression for functional recovery after surgery for hip
fracture in older people. Psychol Med. 2006;36(11):1635-45.
84. Whitehead C, Miller M, Crotty M. Falls in community-dwelling older persons followinig
hip fracture: impact on self-efficacy, balance and handicap. Clin Rehabil. 2003
Dec;17(8):899-906.
85. WHO. International Classification of Functioning, Disability and Health; ICF. Geneva:
World Health Organization. ; 2001.
86. Stucki G, Cieza A, Melvin J. The International Classification of Functioning, Disability and
Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy.
J Rehabil Med. 2007 May;39(4):279-85.
87. Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M, et al. Recovery
from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000
Sep;55(9):M498-507.
88. Shyu YI, Chen MC, Liang J, Wu CC, Su JY. Predictors of functional recovery for hip
fractured elders during 12 months following hospital discharge: a prospective study on a
Taiwanese sample. Osteoporos Int. 2004 Jun;15(6):475-82.
89. Tsauo JY, Leu WS, Chen YT, Yang RS. Effects on function and quality of life of
postoperative home-based physical therapy for patients with hip fracture. Arch Phys Med
Rehabil. 2005 Oct;86(10):1953-7.
90. Peterson MG, Allegrante JP, Cornell CN, MacKenzie CR, Robbins L, Horton R, et al.
Measuring recovery after a hip fracture using the SF-36 and Cummings scales. Osteoporos
Int. 2002;13(4):296-302.
91. Bohannon R, Kloter K, Copper J. Outcome of patients with hip fracture treated by physical
therapy in acute care hospital. Top Geriatr Rehabil. 1990;6(2):51-8.
92. Barnes B. Ambulation outcomes after hip fracture. Phys Ther. 1984 Mar;64(3):317-23.
93. Burns A, Park K. Proximal femoral fractures in the female patient, a controlled trial: the
role of the occupational therapist and the physiotherapist. Br J Occup Ther.
1992;55(10):397-400.
94. Penrod JD, Boockvar KS, Litke A, Magaziner J, Hannan EL, Halm EA, et al. Physical
therapy and mobility 2 and 6 months after hip fracture. J Am Geriatr Soc. 2004
Jul;52(7):1114-20.
95. Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the
surgical and rehabilitative care of community-dwelling older persons with acute hip
fracture? Arch Intern Med. 1997 Mar 10;157(5):513-20.
96. Hauer K, Specht N, Schuler M, Bartsch P, Oster P. Intensive physical training in geriatric
patients after severe falls and hip surgery. Age Ageing. 2002 Jan;31(1):49-57.
97. Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing
versus non-weight-bearing exercise for improving physical ability after usual care for hip
fracture. Arch Phys Med Rehabil. 2004 May;85(5):710-6.
98. Stenvall M, Olofsson B, Nyberg L, Lundstrom M, Gustafson Y. Improved performance in
activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in
older people with femoral neck fracture: a randomized controlled trial with 1-year follow-
up. J Rehabil Med. 2007 Apr;39(3):232-8.
83
84
99. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Intensive geriatric
rehabilitation of hip fracture patients: a randomized, controlled trial. Acta Orthop Scand.
2002 Aug;73(4):425-31.
100. Naglie G, Tansey C, Kirkland JL, Ogilvie-Harris DJ, Detsky AS, Etchells E, et al.
Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled
trial. CMAJ. 2002 Jul 9;167(1):25-32.
101. Vidan M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric
intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J
Am Geriatr Soc. 2005 Sep;53(9):1476-82.
102. Halbert J, Crotty M, Whitehead C, Cameron I, Kurrle S, Graham S, et al. Multi-disciplinary
rehabilitation after hip fracture is associated with improved outcome: a systematic review. J
Rehabil Med. 2007;39:507-12.
103. Rehabilitering fr hemmaboende ldre personer (English translatio: Rehabilitation for
community-living elderly people). Stockholm: Swedish National Board of Health and
Welfare; 2007 Contract No.: Document Number|.
104. SBU. Avancerad hemsjukvrd och hemrehabilitering - effekter och kostnader (Advanced
home health care and home rehabilitation - effects and costs) (in Swedish). Stockholm: The
Swedish Council on Technology Assessment in Health Care; 1999 Contract No.: Document
Number|.
105. Widen Holmqvist L, von Koch L, Kostulas V, Holm M, Widsell G, Tegler H, et al. A
randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm.
Stroke. 1998 Mar;29(3):591-7.
106. Weiss Z, Snir D, Klein B, Avraham I, Shani R, Zetler H, et al. Effectiveness of home
rehabilitation after stroke in Israel. Int J Rehabil Res. 2004 Jun;27(2):119-25.
107. Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of
community-based rehabilitation provision following stroke or hip fracture in old age. Clin
Rehabil. 2006 Feb;20(2):123-31.
108. Anderson C, Rugenach S, Mhurchu CN, Clark M, Spencer C, Winsor A. Home or hospital
for stroke rehabilitation? Results of a randomized controlled trial. Health outcomes at 6
months. Stroke. 2000;31(5):1024-31.
109. Andersson A, Levin L, Oberg B, Mnsson L. Health care and social welfare costs in home-
based and hospital-based rehabilitation after stroke. Scand J Caring Sci. 2002;16(4):119-25.
110. Gitlin LN, Winter L, Dennis MP, Corcoran M, Schinfeld S, Hauck WW. A randomized trial
of a multicomponent home intervention to reduce functional difficulties in older adults. J
Am Geriatr Soc. 2006 May;54(5):809-16.
111. Sanford JA, Griffiths PC, Richardson P, Hargraves K, Butterfield T, Hoenig H. The effects
of in-home rehabilitation on task self-efficacy in mobility-impaired adults: a randomized
clinical trial. JAGS. 2006;54:1641-8.
112. Papaioannou A, Adachi JD, Winegard K, Ferko N, Parkinson W, Cook RJ, et al. Efficacy of
home-based exercise for improving quality of life among elderly women with symptomatic
osteoporosis-related vertebral fractures. Osteoporos Int. 2003 Aug;14(8):677-82.
113. Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a
community-based program for reducing the incidence of falls in the elderly: a randomized
trial. J Am Geriatr Soc. 2004 Sep;52(9):1487-94.
114. Ceder L, Thorngren KG, Wallden B. Prognostic indicators and early home rehabilitation in
elderly patients with hip fractures. Clin Orthop Relat Res. 1980 Oct(152):173-84.
115. Jarnlo GB, Ceder L, Thorngren KG. Early rehabilitation at home of elderly patients with hip
fractures and consumption of resources in primary care. Scand J Prim Health Care. 1984
Sep;2(3):105-12.
84
85
116. Crotty M, Whitehead CH, Gray S, Finucane PM. Early discharge and home rehabilitation
after hip fracture achieves functional improvements: a randomized controlled trial. Clin
Rehabil. 2002 Jun;16(4):406-13.
117. Crotty M, Whitehead C, Miller M, Gray S. Patient and caregiver outcomes 12 months after
home-based therapy for hip fracture: a randomized controlled trial. Arch Phys Med Rehabil.
2003 Aug;84(8):1237-9.
118. Kuisma R. A randomized, controlled comparison of home versus institutional rehabilitation
of patients with hip fracture. Clin Rehabil. 2002 Aug;16(5):553-61.
119. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol.
1990 Nov;45(6):P239-43.
120. Tinetti ME, Baker DI, Gottschalk M, Williams CS, Pollack D, Garrett P, et al. Home-based
multicomponent rehabilitation program for older persons after hip fracture: a randomized
trial. Arch Phys Med Rehabil. 1999 Aug;80(8):916-22.
121. Porn I. Health and adaptedness. Theor Med. 1993 Dec;14(4):295-303.
122. Trnebohm H. Livsparadigm och livsvrldar. Gteborg: Theory of science; 1989 Contract
No.: Document Number|.
123. Trnebohm H. What is worth knowing in occupational therapy? Am J Occup Ther.
1990;45(5):451-4.
124. Hardy SE, Gill TM. Factors associated with recovery of independence among newly
disabled older persons. Arch Intern Med. 2005;165:106-12.
125. Gill TM, Robinson JT, Tinetti ME. Predictors of recovery in activities of daily living
(ADLs) among disabled older persons living in the community. J Gen Intern Med.
1997;12:757-62.
126. Bandura A. Self efficacy: The exercise of control. Basingstoke: W.H. Freeman; 1997.
127. Lazarus RS. Psychological stress and the coping process. New York: McGraw-Hill; 1966.
128. Rotter J. Generalized expectancies for internal versus external control of reinforcement.
Psychol Monogr. 1966(80):whole issue.
129. Bandura A, Jourdan F. Self-regulatory mechanisms governing the impact of social
comparison on complex decision-making. J Pers Soc Psychol. 1991;60:941-51.
130. Stretton CM, Latham NK, Carter KN, Lee AC, Anderson CS. Determinants of physical
health in frail older people: the importance of self-efficacy. Clin Rehabil. 2006
Apr;20(4):357-66.
131. Fuzhong L, McAuley E, Fisher KJ, Harmer P, Chaumeton N, Wilson NL. Self-efficacy as a
mediator between fear of falling and functional ability in the elderly. J Aging Health. 2002
Nov;14(4):452-66.
132. Seeman TE, Unger JB, McAvay G, Mendes de Leon CF. Self-efficacy beliefs and perceived
declines in functional ability: MacArthur studies of successful aging. J Gerontol B Psychol
Sci Soc Sci. 1999 Jul;54(4):P214-22.
133. McAuley E, Konopack JF, Morris KS, Motl RW, Hu L, Doerksen SE, et al. Physical
activity and functional limitations in older women: influence of self-efficacy. J Gerontol B
Psychol Sci Soc Sci. 2006 Sep;61(5):P270-7.
134. Sattin RW, Easley KA, Wolf SL, Chen Y, Kutner MH. Reduction in fear of falling through
intense tai chi exercise training in older, transitionally frail adults. J Am Geriatr Soc. 2005
Jul;53(7):1168-78.
135. Arai T, Obuchi S, Inaba Y, Nagasawa H, Shiba Y, Watanabe S, et al. The effects of short-
term exercise intervention on falls self-efficacy and the relationship between changes in
physical function and falls self-efficacy in Japanese older people: a randomized controlled
trial. Am J Phys Med Rehabil. 2007 Feb;86(2):133-41.
136. Cameron ID, Stafford B, Cumming RG, Birks C, Kurrle SE, Lockwood K, et al. Hip
protectors improve falls self-efficacy. Age Ageing. 2000 Jan;29(1):57-62.
85
86
137. Jansson S, Soderlund A. A new treatment programme to improve balance in elderly people-
-an evaluation of an individually tailored home-based exercise programme in five elderly
women with a feeling of unsteadiness. Disabil Rehabil. 2004 Dec 16;26(24):1431-43.
138. Myers AM, Powell LE, Maki BE, Holliday PJ, Brawley LR, Sherk W. Psychological
indicators of balance confidence: relationship to actual and perceived abilities. J Gerontol A
Biol Sci Med Sci. 1996 Jan;51(1):M37-43.
139. Cwikel J, Fried AV. The social epidemiology of falls among community-dwelling elderly:
guidelines for prevention. Disabil Rehabil. 1992 Jul-Sep;14(3):113-21.
140. Peterson E, Howland J, Keilhofner G, Lachman M, Assmann S, Cote J, et al. Falls, self-
efficacy and occupational adaptations among elders. Phys Occup Ther Geriatr.
1999;16(1/2):1-16.
141. Vandervoort AA. Biological and physiological changes. In: Picles A, Compton C, Cott C,
Simpson J, Vandervoort A, editors. Physiotherapy with older persons. London: Saunders;
1995.
142. Walker JE, Howland J. Falls and fear of falling among elderly persons living in the
community: occupational therapy interventions. Am J Occup Ther. 1991 Feb;45(2):119-22.
143. Gagnon N, Flint A. Fear of falling in the elderly. Geriatrics and Aging. 2003;6(7):15-7.
144. McSweeny AJ, Creer TL. Health-related quality-of-life assessment in medical care. Dis
Mon. 1995;41:1-71.
145. Ware JE. Standards for validating health measures: definition and content. J Chron Dis.
1987;40:473-80.
146. Sullivan M. Quality of life assessment in medicine. Nordic J Psychol. 1992;46:79-83.
147. Hays RD, Hahn H, Marshall G. Use of the SF-36 and other health-related quality of life
measures to assess persons with disabilities. Arch Phys Med Rehabil. 2002 Dec;83(12
Suppl 2):S4-9.
148. Lave J, Wenger E. Situated learning. Legitimate peripheral participation. Cambridge:
University of Cambridge Press; 1991.
149. Vygotsky L. Thought and language. Cambridge: MA:MIT Press; 1962.
150. Dewey J. Experience and Education: The 60th Anniversary Edition. Kappa Delta Pi;
1938/1998.
151. Anderson J, Reder L, Simon H. Situated learning and education. Educational Researcher.
1996;25(4):5-11.
152. Ottoson J. After the applause: Exploring multiple influences on application following an
adult education program. Adult Educ Quart. 1997;34(4):5-28.
153. Folstein M, Folstein S, McHugh P. "Mini-mental state". A practical method for grading the
cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-98.
154. Zidn L, Frndin K, Kreuter M. Home rehabilitation after hip fracture. A randomized
controlled study on balance confidence, physical function and everyday activities. Clin
Rehabil. 2008;Manuscript accepted for publication.
155. Askim T, Morkved S, Indredavik B. Does an extended stroke unit service with early
supported discharge have any effect on balance or walking speed? J Rehabil Med. 2006
Nov;38(6):368-74.
156. Fjaertoft H, Indredavik B, Lydersen S. Stroke unit care combined with early supported
discharge: long-term follow-up of a randomized controlled trial. Stroke. 2003(34):2687-91.
157. Hellstrom K, Lindmark B. Fear of falling in patients with stroke: a reliability study. Clin
Rehabil. 1999 Dec;13(6):509-17.
158. Hellstrom K, Lindmark B, Fugl-Meyer A. The Falls-Efficacy Scale, Swedish version: does
it reflect clinically meaningful changes after stroke? Disabil Rehabil. 2002 Jun
15;24(9):471-81.
86
87
159. Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A. A randomized,
controlled trial of a group intervention to reduce fear of falling and associated activity
restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998 Nov;53(6):P384-92.
160. Petrella RJ, Bartha C. Home based exercise therapy for older patients with knee
osteoarthritis: a randomized clinical trial. J Rheumatol. 2000 Sep;27(9):2215-21.
161. Parry SW, Steen N, Galloway SR, Kenny RA, Bond J. Falls and confidence related quality
of life outcome measures in an older British cohort. Postgrad Med J. 2001 Feb;77(904):103-
8.
162. Salbach NM, Mayo NE, Robichaud-Ekstrand S, Hanley JA, Richards CL, Wood-Dauphinee
S. The effect of a task-oriented walking intervention on improving balance self-efficacy
poststroke: a randomized, controlled trial. J Am Geriatr Soc. 2005 Apr;53(4):576-82.
163. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence measure:
a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.
164. Chau N, Daler S, Andre JM, Patris A. Inter-rater agreement of two functional independence
scales: the Functional Independence Measure (FIM) and a subjective uniform continuous
scale. Disabil Rehabil. 1994 Apr-Jun;16(2):63-71.
165. Segal ME, Ditunno JF, Staas WE. Interinstitutional agreement of individual functional
independence measure (FIM) items measured at two sites on one sample of SCI patients.
Paraplegia. 1993 Oct;31(10):622-31.
166. Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional
independence measure: a quantitative review. Arch Phys Med Rehabil. 1996
Dec;77(12):1226-32.
167. Grimby G, Andren E, Holmgren E, Wright B, Linacre JM, Sundh V. Structure of a
combination of Functional Independence Measure and Instrumental Activity Measure items
in community-living persons: a study of individuals with cerebral palsy and spina bifida.
Arch Phys Med Rehabil. 1996 Nov;77(11):1109-14.
168. Grimby G, Andren E, Daving Y, Wright B. Dependence and perceived difficulty in daily
activities in community-living stroke survivors 2 years after stroke: a study of instrumental
structures. Stroke. 1998 Sep;29(9):1843-9.
169. Daving Y, Andrn E, Grimby G. Inter-rater agreement using the Instrumental Activity
Measure. Scand J Occup Ther. 2000(7):33-8.
170. Holbrook M, Skilbeck CE. An activities index for use with stroke patients. Age Ageing.
1983 May;12(2):166-70.
171. Bond MJ, Harris RD, Smith DS, Clark MS. An examination of the factor structure of the
Frenchay Activities Index. Disabil Rehabil. 1992 Jan-Mar;14(1):27-9.
172. Turnbull JC, Kersten P, Habib M, McLellan L, Mullee MA, George S. Validation of the
Frenchay Activities Index in a general population aged 16 years and older. Arch Phys Med
Rehabil. 2000 Aug;81(8):1034-8.
173. Han CW, Yajima Y, Nakajima K, Lee EJ, Meguro M, Kohzuki M. Construct validity of the
Frenchay Activities Index for community-dwelling elderly in Japan. Tohoku J Exp Med.
2006 Oct;210(2):99-107.
174. Schuling J, de Haan R, Limburg M, Groenier KH. The Frenchay Activities Index.
Assessment of functional status in stroke patients. Stroke. 1993 Aug;24(8):1173-7.
175. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for
frail elderly persons. J Am Geriatr Soc. 1991 Feb;39(2):142-8.
176. Ingemarsson AH, Frandin K, Mellstrom D, Moller M. Walking ability and activity level
after hip fracture in the elderly--a follow-up. J Rehabil Med. 2003 Mar;35(2):76-83.
177. Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J
Geriatr Phys Ther. 2006;29:64-8.
178. Kristensen MT, Foss NB, Kehlet H. Timed "Up & Go" test as a predictor of falls within 6
months after hip fracture surgery. Phys Ther. 2007;87(1):24-30.
87
88
179. Okumiya K, Matsubayashi J, Nakamura T, al e. The timed "Up & Go" test is a useful
predictor for falls in community-dwelling older people. J Am Geriatr Soc. 1998;46:928-30.
180. Bohannon RW. Sit-to-stand test for measuring performance of lower extremity muscles.
Percept Mot Skills. 1995 Feb;80(1):163-6.
181. Jette AM, Jette DU, Ng J, Plotkin DJ, Bach MA. Are performance-based measures
sufficiently reliable for use in multicenter trials? Musculoskeletal Impairment (MSI) Study
Group. J Gerontol A Biol Sci Med Sci. 1999 Jan;54(1):M3-6.
182. Ostchega Y, Harris TB, Hirsch R, Parsons VL, Kington R, Katzoff M. Reliability and
prevalence of physical performance examination assessing mobility and balance in older
persons in the US: data from the Third National Health and Nutrition Examination Survey. J
Am Geriatr Soc. 2000 Sep;48(9):1136-41.
183. Schaubert KL, Bohannon RW. Reliability and validity of three strength measures obtained
from community-dwelling elderly persons. J Strength Cond Res. 2005 Aug;19(3):717-20.
184. Radloff LS. The CES-D Scale. A self-report depression scale for research in the general
population. Appl Psychol Measurement. 1977;1:385-401.
185. Gatz M, Johansson B, Pedersen N, Berg S, Reynolds C. A cross-national self-report
measure of depressive symptomatology. Int Psychogeriatr. 1993 Fall;5(2):147-56.
186. Weissman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke BZ. Assessing depressive
symptoms in five psychiatric populations: a validation study. Am J Epidemiol. 1977
Sep;106(3):203-14.
187. Himmelfarb S, Murrell SA. Reliability and validity of five mental health scales in older
persons. J Gerontol. 1983 May;38(3):333-9.
188. Ware J, Snow K, Kosinski M, Gandek B. SF-36. Health survey: manual and interpretation
guide. . Boston, Massachusetts: The Health Institute, New England Medical Center; 1993.
189. Persson LO, Karlsson J, Bengtsson C, Steen B, Sullivan M. The Swedish SF-36 Health
Survey II. Evaluation of clinical validity: results from population studies of elderly and
women in Gothenborg. J Clin Epidemiol. 1998 Nov;51(11):1095-103.
190. Sullivan M, Karlsson J, Ware JE, Jr. The Swedish SF-36 Health Survey--I. Evaluation of
data quality, scaling assumptions, reliability and construct validity across general
populations in Sweden. Soc Sci Med. 1995 Nov;41(10):1349-58.
191. Post MW, de Witte LP, Schrijvers AJ. Quality of life and the ICIDH: towards an integrated
conceptual model for rehabilitation outcomes research. Clin Rehabil. 1999 Feb;13(1):5-15.
192. Marton F. Phenomenography - describing conceptions of the world around us. Instruct Sci.
1981(10):177-200.
193. Wenestam C-G. Phenomenological methodoligies in the service of health. In: Fridlund B,
Hildingh C, editors. Qualitative research methods in the service of health. Lund:
Studentlitteratur; 2000.
194. Karlsson Espmark AK, Hansson Scherman M. Hearing confirms existence and identity--
experiences from persons with presbyacusis. Int J Audiol. 2003 Mar;42(2):106-15.
195. Scherman MH, Dahlgren LO, Lowhagen O. Refusing to be ill: a longitudinal study of
patients' experiences of asthma/allergy. Disabil Rehabil. 2002 Apr 15;24(6):297-307.
196. Willen C, Scherman MH. Group training in a pool causes ripples on the water: experiences
by persons with late effects of polio. J Rehabil Med. 2002 Jul;34(4):191-7.
197. Rydeskog A, Frndin K, Scherman MH. Elderly people's experiences of resistance training.
Adv Physiother. 2005(7):162-9.
198. Marton F, Booth S. Learning and awareness. Mahwah, NJ: Lawrence Erlbaum; 1997.
199. Marton F. Phenomenography. In: Husn T, Postlethwaite T, editors. The International
Encyclopedia of Education. Second ed. Oxford: Pergamon Press; 1994. p. 4424-9.
200. Trigwell K. Phenomenography: An approach to research into geography education. . J
Geogr Higher Educ. 2006;30(2):367-72.
88
89
201. Alexandersson M. Den fenomenografiska ansatsens fokus. In: Starrin B, Svensson P,
editors. Kvalitativ metod och vetenskapsteori. Lund: Studentlitteratur; 1994.
202. Petrella RJ, Payne M, Myers A, Overend T, Chesworth B. Physical function and fear of
falling after hip fracture rehabilitation in the elderly. Am J Phys Med Rehabil. 2000 Mar-
Apr;79(2):154-60.
203. Hellstrom K, Lindmark B, Wahlberg B, Fugl-Meyer AR. Self-efficacy in relation to
impairments and activities of daily living disability in elderly patients with stroke: a
prospective investigation. J Rehabil Med. 2003 Sep;35(5):202-7.
204. Dahlgren L-O, Fallsberg M. Phenomenagraphy as a qualitative approach in social pharmacy
research. J Soc Adm Pharm. 1991;8(4):150-6.
205. Marton F. Phenomenography: Exploring different conceptions of reality. In: Fetterman D,
editor. Qualitative approaches to evaluation in education The silent scientific revolution.
New York: Praeger; 1988.
206. MFR. Riktlinjer fr etisk vrdering av medicinsk humanforskning (Guidelines for ethical
evaluation of medical research involving human subjects). In: Forskningsrdet M, editor.
Stockholm: MFR.
207. Walker C, Hogstel M, Curry L. Hospital discharge of older adults. How nurses can ease the
transition. Am J Nurs. 2007;107(6):60-70.
208. Pearson P, Procter S, Wilcockson J, Allgar V. The process of hospital discharge for medical
patients: a model. J Adv Nurs. 2004 Jun;46(5):496-505.
209. Langhorne P, Holmqvist LW. Early supported discharge after stroke. J Rehabil Med. 2007
Mar;39(2):103-8.
210. Hunt M, Stein C. Living life to the fullest: well elders views of hip fracture. Ageing Int.
2004;29(2):178-98.
211. Kaehrle P, Maljanian R, Bohannon RW, Horowitz S. Factors predicting 12-month outcome
of elderly patients admitted with hip fracture to an acute care hospital. Outcomes Manag
Nurs Pract. 2001 Jul-Sep;5(3):121-6.
212. Carrese J, Mullaney J, Faden R, Finucane T. Planning for death but not serious future
illness: Qualitative study of household elderly patients. Br Med J. 2002;325(7356):125-30.
213. Roder F, Schwab M, Aleker T, Morike K, Thon KP, Klotz U. Proximal femur fracture in
older patients--rehabilitation and clinical outcome. Age Ageing. 2003 Jan;32(1):74-80.
214. Mossey JM, Mutran E, Knott K, Craik R. Determinants of recovery 12 months after hip
fracture: the importance of psychosocial factors. Am J Public Health. 1989 Mar;79(3):279-
86.
215. Mutran EJ, Reitzes DC, Mossey J, Fernandez ME. Social support, depression, and recovery
of walking ability following hip fracture surgery. J Gerontol B Psychol Sci Soc Sci. 1995
Nov;50(6):S354-61.
216. Voshaar RC, Banerjee S, Horan M, Baldwin R, Pendleton N, Proctor R, et al. Predictors of
incident depression after hip fracture surgery. Am J Geriatr Psychiatry. 2007 Sep;15(9):807-
14.
217. Wallston KA, Wallaston B, DeVellio R. Development of multidimensional health locus of
control (MHLC) scales. Health educ monogr. 1978;6:160-70.
218. Calnan M. Control over health and patterns of health-related behaviour. Soc Sci Med.
1989;29(2):131-6.
219. Resnick B, Orwig D, Hawkes W, Shardell M, Golden J, Werner M, et al. The relationship
between psychosocial state and exercise behavior of older women 2 months after hip
fracture. Rehabil Nurs. 2007 Jul-Aug;32(4):139-49.
220. Schwarzer R, Fuchs R. Self efficacy and health behaviours. In: Rutter M, Norman P,
editors. Predicting helath behaviour. Buckingham: Open University Press; 1996.
221. Shaw C. A framework for the study of coping, illness behaviour and outcomes. J Adv Nurs.
1999;29(5):1246-55.
89
90
222. Norman P, Bennett P. Health locus of control. In: Conner M, Norman P, editors. Predicting
health behaviour. Buckingham: Open University Press; 1996.
223. Angus J, Reeve P. Ageism: A threat to "aging well" in the 21st century. J Appl Gerontol.
2006;25(2):137-52.
224. Sherman SR. Changes in age identity; self percetions in middle and late life. J Aging
Studies. 1994;8(4):397-412.
225. Tornstam L. The quo vadis of gerontology: On the scientific paradigm of gerontology. The
Gerontologist. 1992;32:318-26.
226. Furstenberg A-L. Attributions of control by hip fracture patients. Health and Soc Work.
1988;Winter:43-8.
227. Murphy SL, Dubin JA, Gill TM. The development of fear of falling among community-
living older women: predisposing factors and subsequent fall events. J Gerontol A Biol Sci
Med Sci. 2003 Oct;58(10):M943-7.
228. Pearse EO, Redfern DJ, Sinha M, Edge AJ. Outcome following a second hip fracture.
Injury. 2003;34:518-21.
229. Stewart A, Walker LG, Porter RW, al e. Predicting a second hip fracture. J Clin Densitom.
1999;2:363-70.
230. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in
community-dwelling older adults using the Timed "Up & Go" test. Phys Ther.
2000;80:896-903.
231. Thrane G, Joakimsen RM, Thornquist E. The association between timed up and go test and
history of falls: the Tromsoe study. BMC Geriatr.
2007;7(1):http://www.biomedcentral.com/1471-2318/7/1.
232. Judge JO, Schechtman K, Cress E. The relationship bvetween physical performance
measures and independence in instrumental activities of daily living. The FICSIT Group.
Frailty and INjury: Cooperative Studies of Intervention Trials. J Am Geriatr Soc.
1996;44(1):1332-41.
233. MacCulloch PA, Gardner T, Bonner A. Comprehensive fall prevention programs across
settings: a review of the literature. Geriatr Nurs. 2007 Sep-Oct;28(5):306-11.
234. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and
targeted intervention for preventing falls and injuries among older people in community and
emergency care settings: systematic review and meta-analysis. Bmj. 2008 Jan
19;336(7636):130-3.
235. Shumway-Cook A, Silver IF, LeMier M, York S, Cummings P, Koepsell TD. Effectiveless
of a community-based multifactorial intervention on falls and fall risk factors in
community-living older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med
Sci. 2007;62(12):1420-7.
236. McAuley E, Elavsky S, Motl RW, Konopack JF, Hu L, Marquez DX. Physical activity,
self-efficacy, and self-esteem: longitudinal relationships in older adults. J Gerontol B
Psychol Sci Soc Sci. 2005 Sep;60(5):P268-75.
237. McAuley E, Konopack JF, Motl RW, Morris KS, Doerksen SE, Rosengren KR. Physical
activity and quality of life in older adults: influence of health status and self-efficacy. Ann
Behav Med. 2006 Feb;31(1):99-103.
238. Rejeski WJ, King AC, Katula JA, Kritchevsky S, Miller ME, Walkup MP, et al. Physical
activity in prefrail older adults: confidence and satisfaction related to physical function. J
Gerontol B Psychol Sci Soc Sci. 2008 Jan;63(1):P19-26.
239. Deshpande N, Metter EJ, Lauretani F, Bandinelli S, Guralnik J, Ferrucci L. Activity
restriction induced by fear of falling and objective and subjective measures of physical
function: a prospective cohort study. J Am Geriatr Soc. 2008 Apr;56(4):615-20.
240. Kazdin AE. Research design in clinical psychology. Boston: Allyn & Bacon; 2003.
90
91
241. Jorstad EC, Hauer K, Becker C, Lamb SE. Measuring the psychological outcomes of
falling: a systematic review. J Am Geriatr Soc. 2005 Mar;53(3):501-10.
242. Rosen E, Sunnerhagen KS, Kreuter M. Fear of falling, balance, and gait velocity in patients
with stroke. Physiother Theory Pract. 2005 Apr-Jun;21(2):113-20.
243. Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial
validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005
Nov;34(6):614-9.
244. Legters K. Fear of falling. Phys Ther. 2002 Mar;82(3):264-72.
245. Parker SG, Bechinger-English D, Jagger C, Spiers N, Lindesay J. Factors affecting
completion of the SF-36 in older people. Age Ageing. 2006 Jul;35(4):376-81.
246. Seymour DG, Ball AE, Russell EM, Primrose WR, Garratt AM, Crawford JR. Problems in
using health survey questionnaires in older patients with physical disabilities. The reliability
and validity of the SF-36 and the effect of cognitive impairment. J Eval Clin Pract. 2001
Nov;7(4):411-8.
247. Johnson BP. Examining the validity structure of qualitative research. Education.
1997;118(3):282-92.
248. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: Sage; 1985.
249. Smith JK. The problem of criteria for judging interpreteive inquiry. Educational evaluation
and policy analysis. 1984;6:379-91.
250. Barbour R. Mixing qualitative methods: quality assurance or qualitative quagmire? Qual
Health Res. 1998;8:352-61.
251. Meyrick J. What is good qualitative research? A first step towards a comprehensive
approach to judging rigour/quality. J Health Psychol. 2006;11(5):799-808.
252. Malterud K. The art and science of clinical knowledge: evidence beyond measures and
numbers. Lancet. 2001 Aug 4;358(9279):397-400.
253. Casebeer AL, Verhoef MJ. Combining qualitative and quantitative research methods:
considering the possibilities for enhancing the study of chronic diseases.; 1997 Contract
No.: Document Number|.
254. Foss C, Ellefson B. The value of combining qualitative and quantitative approaches in
nursing research by means of methods triangulation. J Adv Nurs. 2002;40(2):242-8.
255. Jette AM. Towards a common language for function, disability, and health. Phys Ther.
2006;86(5):726-34.
256. Jette AM, Haley SM, Kooyoomjian JT. Are the ICF Activity and Participation dimensions
distinct? J Rehabil Med. 2003 May;35(3):145-9.
257. Cieza A, Geyh S, Chatterji S, Kostanjesek N, Ustun B, Stucki G. ICF linking rules: an
update based on lessons learned. J Rehabil Med. 2005;37:212-18.




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Life after hip fracture
Impact of home rehabilitation versus conventional
care and patients experiences of the recovery
process in a short- and long-term perspective
Lena Zidn
Institute of Neuroscience and Physiology
at Sahlgrenska Academy
University of Gothenburg
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ISBN 978-91-628-7604-3
Printed by Intellecta DocuSys AB, V Frlunda