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• Reect on your practice concerning pain management; which tools do you use?
Do you reassess patients’ pain? And how do you react if the patient is still
in pain?
• Talk with patients and relatives and other health professionals about topics con-
cerning the patient pathway such as preoperative care and pain management.
Reect on what you learn from these discussions, and make suggestions about
how practice might be developed to improve satisfaction and encourage patient
empowerment by involvement of patients and relatives in care.
C. M. Jensen et al.
7.7.2 Further Suggested Reading
• EMBeds (2019) Silver Trauma https://www.embeds.co.uk/2019/10/21/
silver- trauma/
• McSherry W, Rykkje L, Thornton S. (Eds) (2021) Understanding Ageing for
Nurses and Therapists. Springer: Cham. https://link.springer.com/
book/10.1007/978- 3- 030- 40075- 0
• Meehan AJ, Maher AB, Brent L, Copanitsanou P, Cross J, Kimber C, MacDonald
V, Marques A, Peng L, Queirós C, Roigk P, Sheehan KJ, Skúladóttir SS, Hommel
A. (2019) The International Collaboration of Orthopaedic Nursing (ICON): Best
practice nursing care standards for older adults with fragility hip fracture. Int J
Orthop Trauma Nurs. https://doi.org/10.1016/j.ijotn.2018.11.001.
• Palm H. (2021) Hip Fracture: The Choice of Surgery. In: Falaschi, P., Marsh, D. (eds)
Orthogeriatrics. Springer, Cham. https://doi.org/10.1007/978- 3- 030- 48126- 1_9
https://link.springer.com/chapter/10.1007/978- 3- 030- 48126- 1_9
• Pape HC, Kates SL.Hierholzer C.Bischoff-Ferrari HA. (2020) Senior Trauma
Patients. Springer: Cham https://doi.org/10.1007/978- 3- 030- 91483- 7
• Saxon SV etal. (2022) Physical change and aging: a guide for helping profes-
sions, 7.th edition Springer: NewYork
7.8 How toSelf-Assess Learning
To identify learning achieved and the need for further study, the following strategies
may be helpful:
• Examine local documentation of nursing care regarding hip fracture care and
other outcomes, and use this to assess your own knowledge and performance.
Fundamentally, nursing is a team effort, so consider this from your own indi-
vidual perspective as well as that of the team.
• Seek advice and mentorship from other expert clinicians regarding the issues
raised in this chapter, e.g. pain specialists, anaesthetists, orthopaedic surgeons,
geriatricians and physiotherapists. Have ‘learning conversations’ with specialists
and other members of the team to keep up to date on new evidence and dissemi-
nate it to colleagues. These conversations can include any recent new knowledge
or evidence.
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• Review indicators of good practice (e.g. incidence of complications, early mobil-
isation, regular pain assessment and evaluation), and regularly assess patient and
carer views and satisfaction; satisfaction has been recognised as an independent
indicator of nursing care quality.
• Peer review by colleagues can be used to assess individual progress and practice
but should not be too formal. There should be open discussion within the team.
Weekly case conferences can identify nurse-focused issues and enable the
exchange of expertise.
• Collaborate with health professionals from other departments covering the
patient pathway to undertake case evaluation.
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nursing care of the older adult with fragility hip fracture: an international perspective (part 1).
Int J Orthop Trauma Nurs 16(4):177–194
2. Maher AB, Meehan AJ, Hertz K, Hommel A, MacDonald V, O’Sullivan MP etal (2013) Acute
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hospital. Int J Qual Stud Health Well-being 12(1):1307061
7. Karlsson Å, Olofsson B, Stenvall M, Lindelöf N (2022) Older adults' perspectives on rehabilitation and recovery one year after a hip fracture—a qualitative study. BMC Geriatr 22(1):423
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10. Blanco JF, da Casa C, Pablos-Hernández C, González-Ramírez A, Julián-Enríquez JM, DíazÁlvarez A (2021) 30-day mortality after hip fracture surgery: inuence of postoperative factors. PLoS One 16(2):e0246963
11. Palm H (2021) Hip Fracture: The Choice of Surgery. In: Falaschi P, Marsh D (eds)
Orthogeriatrics: the management of older patients with fragility fractures. Springer, Cham
(CH), pp125–141. https://doi.org/10.1007/978- 3- 030- 48126- 1_9
12. Kazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ (2018) Classications in brief: garden classication of femoral neck fractures. Clin Orthop Relat Res 476(2):441–445. https://
doi.org/10.1007/s11999.0000000000000066
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acute care hospital. Wien Med Wochenschr 163(19–20):468–475
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15. Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S etal (2017) ESPEN guideline: clinical nutrition in surgery. Clin Nutr 36(3):623–650
16. Hirsch KR, Wolfe RR, Ferrando AA (2021) Pre- and post-surgical nutrition for preservation of
muscle mass, strength, and functionality following orthopedic surgery. Nutrients 13(5):1675
17. McCann C, Hall A, Leow JM, Harris A, Haz N, Myers K etal (2021) 896 improving intravenous uid therapy to reduce the incidence of acute kidney injury in hip fracture patients. Br
J Surg 108(Supplement_2):znab134.504
18. Hertz K, Santy-Tomlinson J (2014) Fractures in the older person. In: Clarke S, Santy-Tomlinson
J (eds) Orthopaedic and trauma nursing: an evidence-based approach to musculoskeletal care.
Wiley Blackwell, Oxford, pp236–254
19. Chiari P, Forni C, Guberti M, Gazineo D, Ronzoni S, D'Alessandro F (2017) Predictive factors for pressure ulcers in an older adult population hospitalized for hip fractures: a prognostic
cohort study. PLoS One 12(1):e0169909
20. Curtis EM, Moon RJ, Harvey NC, Cooper C (2017) The impact of fragility fracture and
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21. Toney-Butler TJ, Unison-Pace WJ (2022) Nursing admission assessment and examination. In:
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Geriatr Soc 57(8):1331–1346. https://doi.org/10.1111/j.1532- 5415.2009.02376.x
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(2008) Assessment of pain. Br J Anaesth 101(1):17–24
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Lancet 362(9399):1921–1928
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Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study.
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Early Mobilisation andExercise After
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Fragility Fracture
MortenTangeKristensen , DavidJ.Keene ,
andCarmenQueirós
8.1 Introduction
Mobilisation is a critical component of supporting recovery and rehabilitation after
fragility fracture. ‘Mobilisation’ usually refers to moving the injured limb or the act
of mobility practice. Mobility practice includes moving from lying to sitting, sitting
to standing and walking, with or without the aid of others or devices. Mobilisation
and exercise after fragility fracture tend to denote structured activities that are practised and progressed to enable the body to regain movement to enable a return to
function and prevent post-fracture complications.
The aim of this chapter is to promote the role of the nurse and other practitioners
in patients’ early mobilisation and exercise after fragility fractures. The importance
8
M. T. Kristensen (*)
Department of Physical- and Occupational Therapy, Copenhagen University Hospital,
Bispebjerg-Frederiksberg, Copenhagen, NV, Denmark
Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
D. J. Keene
Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
Nufeld Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences,
University of Oxford, Oxford, UK
Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
C. Queirós
Department of Orthophysiatry, Centro Hospitalar Universitário de Santo António,
Porto, Portugal
Escola Superior de Enfermagem do Tâmega e Sousa, Penael, Portugal
Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal
ICBAS– University of Porto, Porto, Portugal
© The Author(s) 2024
K. Hertz, J. Santy-Tomlinson (eds.), Fragility Fracture and Orthogeriatric
Nursing, Perspectives in Nursing Management and Care for Older Adults,
https://doi.org/10.1007/978-3-031-33484-9_8
129
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of early mobilisation and exercise is highlighted, along with practical information
on easily applicable assessments, pain and weight bearing and tips on how to facilitate early mobilisation. There is a focus on early mobilisation after hip fracture as
this is the most common signicant fragility fracture requiring hospitalisation and
surgery. However, many of the issues covered are in common with other types of
fragility fracture.
In many healthcare settings, there may be specialist healthcare professionals in
physical rehabilitation such as physiotherapists, occupational therapists or rehabilitation nurses. While these professionals can provide expertise in assessment and
management of post-fragility fracture mobilisation and exercise, the whole care
team have a role in supporting these activities to enable patients to reach independent mobility in the rst place and their recovery goals in the longer term.
M. T. Kristensen et al.
8.2 Learning Outcomes
At the end of the chapter, the reader will be able to:
• Appreciate the problems of inactivity after fragility fracture.
• Describe the rationale and evidence regarding the importance of early mobilisa-
tion after hip fracture surgery.
• Discuss the trajectory, importance of monitoring and inuence of fracture-related
pain on mobility outcomes.
• Rationalise and question commonly used restrictions after surgery for a fragility
fracture.
• Use easily applicable and valid outcome measures for evaluation of patients with
a fragility fracture.
• Employ strategies to facilitate early mobilisation and exercise after fragility
fracture.
8.3 Immobilisation inFracture Management
The earliest recorded use of immobilisation and rest for injured limbs was by the
ancient Egyptians approximately 3000years B.C. [1]. Ever since, there has been
ongoing renement and use of external splinting and movement restrictions to
manage fractures [2, 3]. A wide range of effects of immobilisation have been
studied in animal and human models (Table8.1). What is evident is that the musculoskeletal system is responsive to mechanical loading, or stress [4] and absence
or diminished mechanical loading below usual levels is detrimental to tissues as
they enter a catabolic state or degradation. Mechanical loading is required for
musculoskeletal tissue homeostasis and, if increased within physiological limits,
is an anabolic, or biosynthesis, stimulus for bone healing [5, 6]. After a fracture,
periods of immobilisation are clinically associated with joint stiffness and muscle
weakness. As a result, there have been efforts to reduce periods of immobilisation
8 Early Mobilisation andExercise After Fragility Fracture
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Table 8.1 Summary of the effects of immobilisation on bones and muscles from basic research
[5, 9–11]
Structure Effect of immobilisation
Bone Increased reabsorption and decreased depositing of bone tissue
Decreased bone stiffness and strength
Muscle Sarcomeres at the myotendinous junction increase in number if immobilised in a
lengthened position and reduce if in a shortened position (starts within 12–24h of
immobilisation)
Atrophy of contractile and non-contractile components
Reduced muscle bre size
Reduced number of collagen bres in tendon
Diminished neural recruitment of motor units
Decrease in motor cortex map area of immobilised muscles
Decreased excitability of corticospinal pathway for immobilised muscles
Decits in muscle strength and endurance
131
and non-weight bearing after fracture as much as possible. For example, there
have been several clinical trials assessing early weight bearing and movement
after ankle fracture surgery [7, 8].
8.4 Early Mobilisation After Fragility Fracture
In the context of fragility fracture management, it is vital to consider the impacts of
immobility on wider body systems, not just the musculoskeletal issues after injury.
After a hip fracture, longer periods of immobility are associated with serious complications, including respiratory infection, delirium, pressure injuries, thromboembolic events, worse recovery of function and increased risk of mortality [12–14].
The importance of early surgical treatment for hip fracture has been shown in a
systematic review [15]. The rationale for early surgery is, in part, to enable early
weight-bearing mobilisation to reduce the detrimental impacts of immobility.
Contemporary surgery for hip fracture using internal xation or arthroplasty should
aim to enable early weight-bearing mobilisation. In fact, early mobilisation is now
increasingly monitored in national hip fracture databases and is core to many clinical guidelines. For example, the United Kingdom’s National Institute for Health and
Care Excellence clinical guidelines for hip fracture recommend ‘mobilisation on the
day after surgery’ [16]. Early mobilisation is also a key recommendation in the
Academy of Orthopaedic Physical Therapy Clinical Practice Guidelines [17].
Studies have used different time cut-offs for dening early mobilisation after hip
fracture surgery, e.g. 24 or 36–48h post-operatively. In practice, this means getting
patients up and mobilising on the day of or day after surgery. In a recent large-scale
observational research in the United Kingdom, early mobilisation after hip fracture
has been found to be associated with increased probability of discharge from hospital [18] and increased survival and ambulatory recovery for patients (with and without dementia) at 30days after surgery [13]. Correspondingly, in Danish and Irish
hip fracture registry studies, early mobilisation has been associated with increased
survival [19, 20]. Focusing on post-surgery ambulatory status as well as the status
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after day one also seem important and are associated with mortality, medical complications and discharge destination for patients admitted from their own home [21].
Two further studies from the Danish hip fracture registry have shown increased
mortality, readmission and risk of infection in patients where the pre-fracture ambulatory status, evaluated with the Cumulated Ambulation Score (CAS) [22], did not
recover at the time of acute hospital discharge [23, 24]. Thus, recovering baseline
mobility as soon as possible has been highlighted as an important rst-step recovery
goal [25].
The CAS is an easily applicable score that was designed for patients with hip
fracture (feasible for all fragility fractures) for the monitoring of basic mobility until
independence has been reached. It evaluates three activities: getting in and out of
bed, ‘sit to stand to sit’ from a chair with armrests and indoor walking with or without an assistive device. A 1-day CAS of 0–6 points is based on a score from 0 to 2
for each activity, where a score of 0=not able to, 1=able to with assistance/guiding
and 2=independent of human assistance [26]. The CAS is currently available in
more than 15 languages and proven feasible in several patient groups, and further
information is available here [27]. Using such a score to monitor mobility following
fragility fracture is not only the domain of the physiotherapist but also a useful way
to evaluate care for nurses and other health professionals.
Although early mobilisation is clearly a critical goal, and something that the
whole care team is responsible for achieving, there are many complex challenges in
achieving this. Common barriers to early mobilisation after hip fracture include
hypotension, pain control issues, agitation or refusal [14], and cardiovascular instability [28]. These barriers are important to assess and actively attempt to prevent and
manage (see Chaps. 7, 12,13 and 14).
M. T. Kristensen et al.
8.5 Fragility Fracture-Related Pain andOther Factors
Influencing Mobilisation
Having a hip fracture is extremely painful for those who experience this injury. The
initial management often involves complete immobilisation until post-surgery.
However, patients with other fragility fractures also experience fracture-related pain
that can compromise their ambulatory status. For example, people who usually use
walking aids can struggle to walk after sustaining a wrist or proximal humerus fracture. Still, patients with a hip fracture are probably the fragility fracture group that
most often experience pain inuencing their ability to mobilise (get up from a chair
and walk) [29].
Effective pain management is crucial following a fragility fracture, enabling
patients to ambulate and participate in the physical training and exercise programmes essential for their recovery (see also Chap. 7). An individualised approach
to pain management is important. People have different experiences of pain and use
of pain medication before their fracture, and varying pain trajectories are seen for
different fracture types. A standard pain management program, where all patients
are given the same pain medication, will be sufcient for some but overtreat some,
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Table 8.2 Overview of common pain assessment scales
Pain score
Visual
Analogue
Scale (VAS)
[30]
Numeric
Rating Scale
(NRS) [31]
Verbal Rating
Scale (VRS)
[32]
Scale
0–10 or
0–100
0–10 Asking patients to report their experienced pain level with a number
0–4 Asking patients that report pain, using categories, if they experience
Assessed by
Asking patients to mark their experienced pain level on a ruler
where no pain is at the far left and 10 is the far right of the ruler
(numbers are on the rear of the ruler and not visible for the patient)
for severity, where 0 is no pain and 10 is worst imaginable pain
pain as follows: 0=no pain, 1=slight pain, 2=moderate pain,
3=severe pain, 4=unbearable pain. Points are not presented for
patients but used for the recording in medical charts
133
and not be sufcient for others. Pain management needs to be guided by ongoing
(several times daily) pain assessments by nurses, physiotherapists and other healthcare professions. A validated pain score is needed. All healthcare professions are
familiar with the Visual Analogue Scale (VAS, 0–10 or 0–100 points) [30] and the
Numeric Rating Scale (NRS, 0–10 points) [31] where patients are asked to, respectively, mark their pain on a ruler or report as a number (Table8.2).
The VAS and NRS pain scores are commonly used for many patient groups.
Following hip fracture, and especially for those with dementia or other cognitive
disorders, the VRS (0–4 points) is valid and superior to the VAS [32, 33]. The VRS
0–4-point scale evaluates pain in categories where:
0=no pain
1=slight pain
2=moderate pain
3=severe pain
4=unbearable pain
Numbers are not presented to the patient; they are only used to record the result
in care records. The VRS manual [34] states: ‘When using the VRS, it is important
to ask about the degree of pain when using the categories and without using numbers’. Many patients nd it difcult to express the degree of pain, so when using the
VRS scale, a dialogue with the patient can be conducted. If the patient indicates
unbearable pain, the practitioner can, for example, ask: ‘Is it as bad as when you just
broke your hip’?
While pain can be assessed at rest, more importantly, it should be assessed during activity such as walking or sit to stand from a chair, to get a ‘true picture’ of how
pain treatment is working. This is referred to as ‘dynamic pain’. Using the VRS for
evaluating whether pain management is sufcient—none to mild pain (VRS 0–1) at
rest and mild to moderate pain (VRS 1–2) during activity—is useful, especially in
the early post-operative stage. At later time points, adjustment of pain management
should be considered for moderate to unbearable pain (VRS 3–4) during activity.
Correspondingly, for patients with acute vertebral fragility fractures, systematic
monitoring of dynamic pain is also recommended, using a scale specically for
patients with dementia who are unable to verbalise their pain [35].
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Fracture-related pain is not the same for different fracture types (Chap. 7).
Patients with an intracapsular femoral fracture (surgical procedure; osteosynthesis
or arthroplasty), for example, can experience less pain than those with extracapsular
inter- and subtrochanteric fractures (surgical procedure; dynamic hip screw or intramedullary hip screw). This is the case both during the rst post-operative days [36]
and on discharge from hospital [37]. Intracapsular femoral fractures are also associated with better ambulatory status [38].
Patients often compare their progress with those around them, leading to disappointment if their recovery progress is not the same. They should be informed that
this can be ‘normal’ and experiencing more pain does not mean that something is
wrong but may simply be due to different fracture types. Other factors that can contribute to a slower recovery for patients with an extracapsular trochanteric fracture
can be the larger blood loss/anaemia [39–41] and the markedly greater quadriceps
strength loss compared to patients with an intracapsular femoral fracture [42]. Hip
fracture-related pain can also inuence the walking distance for the 6-min walking
test [43].
Other factors that inuence the acute care ambulatory status are the age and prefracture functional level of the patient. Pre-fracture functional level evaluated with
the modied [44] New Mobility Score (NMS) [45] is a strong predictor of the basic
mobility CAS level in the acute setting [46–48] and for mortality in the long term
[45, 49]. The NMS, 0–9 points, evaluates three activities: indoor walking, outdoor
walking and walking during shopping. Each activity is scored by asking patients or
relatives/carers how well these activities are managed, with a score of 0=not at all,
1=with help from another person, 2=with a walking aid and 3=no difculty and
no aid (the instrument is available here) [44, 50].
This is important information to give to patients and their relatives worrying
about a slower than expected recovery. Practitioners should also consider these factors in their practice, enabling them to identify when ongoing pain assessment and
management are most needed, as well as the interference of pain (among other
variables) in patient mobility. Close collaboration within the rehab team regarding
pain assessments and management is also important [25]. It is vital to coordinate
periods of more intense mobility and physical training with pain medication doses
and to liaise with the prescribing practitioner if medication seems insufcient during mobility or is a barrier to movement. Fracture-related pain and fatigue are the
most restricting factors for patients with hip fracture being able to ambulate independently and participate in the planned physiotherapy, during the early postoperative period [29].
M. T. Kristensen et al.
8.6 Surgical Procedure andMobilisation After Lower Limb
Fragility Fracture
Different countries have different approaches to movement and weight-bearing
restrictions following fragility fracture surgery. The tendency is that restrictions
have been reduced over the years and are now rare in some parts of the world. Still,
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