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Regaining Equal Leg Strength After Hip Fracture

Posted on: 09/11/2008
A hip fracture later in life can be very disabling. Many older adults don't survive the injury. Death from complications within six months' time occurs in up to half of all cases. Those who do live often never regain their prefracture strength or function. Studies show that a loss of muscle strength and power on the fractured side limit movement and balance.

In this study, researchers explore the effects of an intensive, progressive exercise training program designed to improve strength and power on the weak side. Restoring symmetry of strength (equal on both sides) may help improve balance and mobility.

The study included adults ages 60 to 85 years old with a history of hip fracture. Some participants had a recent (six months ago) fracture. Others were up to seven years post-fracture. Everyone could walk unassisted. The patients were divided into two groups: the training group and the control group.

Strength measurements were taken before the study began. Handgrip (general) strength was measured using a handheld dynamometer (device used to measure strength). Leg strength was measured using an adjustable dynamometer chair. Leg (knee) extension (both sides) was the main measure taken.

Other measures included time to walk 10 meters (32 feet) at a usual pace. Everyone was allowed to report their usual mobility ability indoors and outdoors. Standing balance was also tested using a computer force platform system. Height and weight were recorded along with self-reported level of physical activity.

The training group was given an exercise program to improve the strength on the weaker side and reduce the power difference between the two legs. They met twice a week for 12 weeks at a senior gym. They were supervised by a physical therapist. After warm-up exercises, strength and power exercises were performed (first by the weaker leg, then by the stronger leg).

The therapist started each patient in the training group out with low loads. Low resistance was used with this older population for safety reasons. The exercises consisted of leg presses and ankle plantarflexion (rising up on toes while wearing a weighted vest). Proper technique and posture was emphasized. Training intensity increased according to each person's tolerance.

The control group did not do any special exercises. They were told to just follow their usual activities. The therapist rechecked everyone's strength at the end of seven weeks and adjusted the program for the exercise group as needed. Ninety per cent of the exercise group was cooperative and completed the program.

After the 12-week trial was over, measurements were retaken and the data was analyzed. The authors found that in the exercise group, the weaker leg did get stronger. The difference in strength between the two sides evened out. Power in the stronger leg didn't change. Walking speed and balance weren't affected by the training. The training group did report improved ability to walk outdoors after training.

The authors suggested several reasons why only one measure (uneven strength from side to side) changed significantly in the training group. First, there may have been a cross-training effect from one side to the other.

Second, in order to see an effect on balance or mobility, increased training loads for the stronger versus weaker leg may be needed. It's possible that since the leg strengthening was done in the seated position, balance wasn't directly affected (or improved). It may be necessary to do specific balance or functional exercises in order to see changes in balance or mobility.

Third, the differences in balance, strength, and mobility might be greater in a group of patients who were in poor health before starting the training program. In this study, everyone was in fairly good health as shown by their ability to walk independently.

And finally, from a statistical standpoint, there weren't enough patients in the final study. This may explain the lack of changes in walking and balance. The authors suggest a larger sample size studied over a longer period of time in order to show training effects more clearly.

This study showed that it is safe for patients with a previous history of a hip fracture to perform resistance training in the sitting position. For those who have balance problems, this may be preferred to start. Other muscles (such as the hip abductors and adductors) may have been strengthened with this study, but they were not tested so the effect was unobserved.

Erja Portegijs, MSc, et al. Effects of Resistance Training on Lower-Extremity Impairments in Older People With Hip Fracture. In Archives of Physical Medicine and Rehabilitation. September 2008. Vol. 89. No. 9. Pp. 1667-1674.

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