Hip fractures occur in more than 300 000 individuals each year in the USA and to at least 2 million individuals worldwide, resulting in considerable long-term morbidity, increased mortality and total treatment costs estimated at more than US$S6 billion annually (Cooper et al., 1992;US Congress Office of Technology Assessment, 1994;Graves and Owings, 1998). With the aging of the population in the USA and worldwide, the annual number of hip fractures is projected to double by the year 2040 (Zuckerman, 1996).
Hip fractures also often lead to sustained functional disability, reflected in a loss of ability to ambulate, climb stairs or conduct personal care activities of daily living (ADL). Prospective studies of hip fracture patients have found that up to 76% do not recover to their pre-fracture ambulatory status or ADL levels within one year (Jette et al., 1987;Cummings et al., 1988;Magaziner et al., 1990;Egol et al., 1997;Kramer et al., 1997;Hannan et al., 2001). Recent evidence revealed that considerable residual disability persists in numerous ADL up to two years after fracture (Magaziner et al., 2000). Commonly identified risk factors for poorer functional recovery include nursing home residence at time of fracture, advanced age, greater pre-fracture disability, presence of dementia or delirium and fewer social supports (Cummings et al., 1988;Magaziner et al., 1990;Young et al., 1996;Egol et al., 1997;Nanna et al., 1997).
Among the potentially important but understudied factors that may influence functional recovery after hip fracture are psychological factors. Nearly 20 years ago, Nickens (1983) called attention to ‘psychosocial issues’ that might affect functional recovery and other outcomes after hip fracture. He posed a series of unanswered research questions based on a literature review to date, including whether depression in hip fracture patients may hinder recovery and whether there are ‘certain character structures’ that yield better or worse outcomes after hip fracture (Nickens, 1983). Since that time, despite the voluminous literature on hip fracture outcomes and their predictors, virtually no research has been conducted on psychological factors. In the only known published research on this topic in a prospective cohort study, Mossey et al. (1989) found that hip fracture patients with more post-surgery depressive symptoms experienced poorer functional recovery 12 months after the fracture.
There is reason to believe that other psychological factors might affect functional recovery. An important candidate variable is self-efficacy, which refers to the confidence a person has in their ability to perform a specific behavior (Bandura, 1977). In the context of health beliefs and behaviors, self-efficacy refers to the belief that one can assume personal control over health problems by learning about or participating in key aspects of care (Lorig et al., 1989;Bandura, 1991;Holman and Lorig, 1992). Measures of self-efficacy have been devised for people with musculoskeletal disorders, encompassing domains such as pain control, diet and exercise (Lorig et al., 1989;Horan et al., 1998). Self-efficacy measures have been correlated with performing self-care behaviors and with reductions in depressive symptoms, in chronic arthritis patients (Lorig et al., 1989, 1993;Holman and Lorig, 1992;Horan et al., 1998) and in stroke patients (Robinson-Smith et al., 2000).
Rehabilitation therapy, primarily physical and occupational therapy, is the clinical mechanism employed most commonly to address functional recovery after hip fracture. Anecdotal evidence from rehabilitation therapists and nurses suggests that hip fracture patients with more confidence in their ability to perform rehabilitation protocols (rehabilitation therapy self-efficacy) experience better functional outcomes. This clinical evidence implies that if rehabilitation therapy self-efficacy is enhanced in hip fracture patients, then they may improve their chances of recovery to pre-fracture levels of physical functioning. To our knowledge, however, there is no published scientific evidence establishing a link between rehabilitation self-efficacy and functional recovery after hip fracture.
Therefore, the primary objective of this study was to test the hypothesis that hospitalized hip fracture patients with greater reported self-efficacy for conducting rehabilitation therapy would have a greater likelihood of recovering to pre-fracture levels of physical function six months after the fracture. This hypothesis was tested controlling for pre-fracture function and depressive symptoms. To achieve this objective, a new measure of rehabilitation therapy self-efficacy was developed and tested; measurement results are also reported in this paper.
Sample and data collection procedures
The prospective cohort study on which this report is based enrolled 55 community-dwelling older adults admitted to two hospitals in the state of Connecticut, USA, for hip fracture repair over a 12-month period in 1999 and 2000. Patients were recruited consecutively on the Orthopedic Units of both hospitals according to a standard protocol. Sample eligibility criteria included living in the community and being ambulatory at the time of the index hip fracture, being English-speaking and having a fracture due to reasons other than multiple traumatic accident (for example, automobile accident) or metastatic cancer. Patients in the study cohort, who provided written consent, were interviewed by a trained research assistant to determine the patient's level of pre-fracture function (during the four weeks immediately prior to the hip fracture), current level of self-efficacy for performing rehabilitation therapy, current level of depressive symptoms and other measures of physical and mental health. Proxy respondents were approached for study participation when eligible patients were unable to complete the consent process. Consenting proxy respondents supplied data on the patient's sociodemographic characteristics and level of pre-fracture function but were not asked about the patient's psychological status. Hospital records were reviewed and abstracted to determine the type and severity of hip fracture, type of surgical procedure, medical comorbidities and amount of rehabilitation therapy received during the acute care stay. Upon hospital discharge, patients were followed into post-acute rehabilitation settings, where their records were abstracted to document the total amount of physical and occupational therapy they received. Six months after the fracture, a telephone interview was conducted with study patients or proxies to determine patients' current level of functioning. The study protocol was approved by the institutional review boards at both sites.
Rehabilitation therapy self-efficacy
This series of questions was developed to determine how confident people are that they will be able to perform mobility-related activities of daily living and exercises instructed by physical or occupational therapists after a hip fracture. The questions were designed for administration in a face-to-face interview format, as part of an in-hospital interview conducted with hip-fracture patients. The self-efficacy questions were developed by three of the authors (Fortinsky, Bohannon and Litt) and pilot tested with six consenting patients at one of the sites before the final version was adopted for use in the study.
The stem of the question is ‘How confident are you that, over the NEXT FOUR WEEKS, you will be able to …’ and the eight statements are
- perform exercises as instructed by the physical therapist or occupational therapist;
- do exercises as instructed by the therapist even if they are difficult for you;
- transfer independently to and from your bed as instructed by the therapist;
- transfer independently to and from a chair as instructed by the therapist;
- keep your fractured hip in the position recommended by the therapist during transfers and walking;
- limit the amount of weight you put on your fractured hip as recommended by the therapist;
- walk independently with help from a walker or cane, as instructed by a therapist;
- do exercises as instructed by the therapist even if they make you tired.
The four-week time frame was used because typical stays in acute and post-acute rehabilitation settings after hip fracture in the study area during the study period average three to four weeks (less than one week in hospital and two to three weeks in post-acute rehabilitation facilities).
All eight questions have the same response categories and corresponding values: (1) not at all confident I will be able to do this; (2) a little confident; (3) somewhat confident; (4) mostly confident; and (5) completely confident. Scores could range from 8 to 40, with lower scores representing less rehabilitation therapy self-efficacy.
The 11-item Iowa form of the Center for Epidemiological Studies–Depression (CES-D) scale was used in this study to capture depressive symptoms (Kohout et al., 1993). This shorter form of the CES-D was used to alleviate respondent burden; response categories refer to the number of days in the previous week that each item or symptom was experienced. The internal consistency reliability of this 11-item measure in the study sample was adequate (Cronbach's alpha = 0.74).
The physical domain of the functional independence measure (FIM) was used to ascertain pre-fracture level of physical functioning and to determine current level of functioning six months after fracture. The FIM is a standard physical disability measurement system in rehabilitation medicine (Hamilton et al., 1987). Personal care ADL evaluated by the FIM include bathing, dressing upper body, dressing lower body, toileting, bladder control, bowel control, transfer from bed to chair, transfer from bed to toilet, transfer into tub or shower, ambulation and climbing stairs. Each FIM item response ranges on a seven-point scale from ‘complete independence’ (7) to ‘total assistance’ (1). In this study, to determine pre-fracture functioning, patients or proxies were asked during the in-hospital interview about how well patients were functioning ‘during the four weeks immediately prior’ to the hip fracture.
After reviewing numerous published approaches to determining functional recovery, we chose to focus on two lower body FIM items, walking and climbing stairs, as our dependent variable. Following a recent article by Hannan et al. (2001), we summed these two items to form a locomotion score (Pearson correlation coefficient between these two items in this study sample = 0.64). Therefore, pre-fracture and six-month post-fracture locomotion scores could range from 2 to 14, with a higher score reflecting greater independence. Patients were categorized as either ‘recovered’ or ‘not recovered’ by comparing six-month post-fracture locomotion scores to pre-fracture locomotion scores. This dichotomous measurement approach is supported by the clinical literature, in which the successful return to pre-fracture level of locomotion is viewed as an important treatment goal (Egol et al., 1997).
Descriptive statistics were used to inspect the distribution of responses to the eight rehabilitation therapy self-efficacy items, followed by an exploratory principal components analysis to determine how the items clustered. These analyses were conducted with the goal of establishing preliminary support for a measurement approach to help understand the effect of self-efficacy on functional recovery. Logistic regression analysis was performed to determine whether the likelihood of locomotion recovery was associated with rehabilitation therapy self-efficacy, controlling for pre-fracture level of locomotion. Because depressive symptoms have been shown to influence functional recovery after hip fracture (Mossey et al., 1989), we then evaluated the independent effect of rehabilitation self-efficacy on locomotion recovery after adding the level of depressive symptoms as a covariate. These analyses were repeated with ordinary least-squares regression models, using post-fracture locomotion level as the dependent variable. Results were very similar; therefore, results using locomotion recovery as the dependent variable are presented in this paper.
A total of 41 patients and 14 proxies consented to participate; proxies provided sociodemographic and pre-fracture function information but not self-efficacy or other psychological data about patients. Of the 41 patients capable of providing self-efficacy responses, 34 provided complete, unbiased self-efficacy data (six patients were in the pilot test phase of instrument development and one additional patient did not complete the in-hospital interview). These 34 study patients are included in results showing the measurement properties of the rehabilitation therapy self-efficacy items. Of these 34 patients, complete six-month follow-up data were obtained for 24 patients; these 24 patients are included in logistic regression analyses in which functional recovery is regressed on self-efficacy scores and covariates.
For the total study sample of 55 patients, 82% were women and the mean age was 82 years (SD = 6 years). All patients except one were Caucasian by self-definition or proxy definition. A third of the sample had less than a high-school education, a third completed high school only and the remaining third completed at least some college. Most patients were nearly or completely independent in locomotion before the fracture, with 75% scoring either 13 or 14 on the locomotion scale (maximum score = 14). Patients with complete data for logistic regression analyses (n = 24) were younger than the remaining 31 study patients (mean = 79 years compared with 84 years;P = 0.007 by t-test) and more independent in pre-fracture FIM locomotion score (mean = 13.0 compared with 11.4;P = 0.04 by t-test); no differences were found for sex or education level.
Descriptive results of the rehabilitation therapy self-efficacy measure
Table 1 shows distributional statistics for each of the eight rehabilitation therapy self-efficacy items among the 34 study patients with self-efficacy data. In the second column of this table, the sample mean score for each item could range from 1 (all responded ‘not at all confident’) to 5 (all responded ‘completely confident’). The third column shows the percentage of the sample responding ‘completely confident’ for each item. Item mean scores were grouped between 3.8 and 4.0, SDs ranged from 1.1 to 1.2 and the percentage responding ‘completely confident’ about rehabilitation items ranged from 32% to 41%.
Principal components analysis indicated that all eight items clustered into a single component with an eigenvalue of 6.57; 82% of the variance in all items was explained by this single component. Internal consistency reliability was very high (Cronbach's alpha = 0.97). Given these results, item scores were summed to create a rehabilitation self-efficacy score ranging from 8 to 40. The mean for the summed score was 31.6 (SD = 8.4).
Locomotion recovery and association with self-efficacy
Among the 24 study patients included in regression analyses, eight patients (33%) recovered to or exceeded pre-fracture level of locomotion by six months after fracture; the remaining 16 patients did not fully recover to pre-fracture level.
As Table 2 shows, logistic regression analysis results revealed that hip fracture patients with higher self-efficacy scores had a greater likelihood of locomotion recovery, controlling for pre-fracture locomotion function level (adjusted odds ratio (AOR) = 1.21; 95% confidence interval (CI) = 1.00–1.45;P = 0.05). This positive association between rehabilitation therapy self-efficacy and likelihood of locomotion recovery persisted after adding depressive symptoms (CES-D score) to this logistic regression model (AOR for self-efficacy = 1.18; 95% CI = 0.99–1.42;P = 0.07). In contrast to the finding by Mossey et al. (1989), depressive symptoms were not found to be associated with likelihood of functional recovery in this study sample.
The major objective of this paper was to test the hypothesis that rehabilitation therapy self-efficacy would have a positive effect on locomotion recovery after hip fracture. To achieve these objectives, an original approach to measure rehabilitation therapy self-efficacy was employed and evaluated. Three major findings are emphasized. First, in a small sample of hip fracture patients capable of participating in a hospital interview after the fracture, reported self-efficacy for conducting rehabilitation therapy in the following four weeks was generally quite high, although variation was seen in all self-efficacy items. Second, higher reported rehabilitation therapy self-efficacy scores in the hospital interview were associated significantly with a greater likelihood of recovering locomotion function six months later, controlling for pre-fracture locomotion level. Third, this positive association persisted even after controlling for depressive symptoms, although at a higher significance level.
To our knowledge, this is the first study to provide empirical evidence supporting the measurement and predictive potential of rehabilitation therapy self-efficacy in hip fracture patients. Study findings support the potential value of maximizing rehabilitation therapy self-efficacy in hip fracture patients soon after hospitalization for surgical repair as a strategy for helping them achieve locomotion recovery.
The major methodological constraint of this study is the small sample size, which limited the ability to evaluate the measurement properties of the self-efficacy measure. The small sample size also prevented analyses that could shed light on important clinical variables that may independently affect reported rehabilitation therapy self-efficacy in the hospital setting, including medical comorbidities and physical symptoms such as pain and weakness.
Nevertheless, the positive relationship between rehabilitation therapy self-efficacy level and likelihood of locomotion recovery six months later is a promising finding in a patient population that is known to experience considerable residual disability long after conventional episodes of surgical repair and rehabilitation. Future research and interventions with larger samples of hip fracture patients should incorporate the important psychological factor of rehabilitation therapy self-efficacy by refining its measurement properties and determining whether changes in self-efficacy can be accomplished and lead to improved functional outcomes. Bandura (1977) referred to four sources of self-efficacy including enactive mastery and verbal persuasion. Rehabilitation therapists may be able to promote enactive mastery in hip fracture patients and use verbal persuasion techniques to enhance patients' rehabilitation therapy self-efficacy. Such a self-efficacy enhancement intervention may hold promise for yielding improved functional outcomes after surgery for hip fracture.
The study in which this paper is based was supported in part by a grant from the National Institute on Aging (Pb0AG13631) to the Claude D. Pepper Ceder Americans Independence Center at the University of Connecticut Health Center. We gratefully acknowledge the efforts made by Anne Horbatuck and Patricia Kaehrle, Clinical Coordinators on the orthopedic units where study patients were recruited.
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