Self Care - Hip Fracture Surgical Repair

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Outpatient Therapy

Cho-Hee Im, SPT

Harris Hip Score
Purpose: Assess the ability of an individual with the hip joint disorder to care for him/herself.
Acronym: HHS
Description: maximum 100 points (best possible function)
- Covering Pain ( 1 item, 44 points possible)
- Function and activities (7 items, 47 points possible): Gait (33 points possible),Limp,Support distance walked, Distance walked, Stairs, Shoes and socks, Sitting, Enter public transportation
- ROM and absence of deformity (3 items, 9 points possible)
ICF domain: activity 
Length of test: 5 minutes or less
Time to administer: 10 minutes or less (including self-report and ROM measurement by therapist) 
Number of items: 8 items
Domain: ADL; function, pain, motion and deformity
Assessment type: Pain, ROM, performance measure
Equipment Required: goniometer, ruler
Training required: None necessary
Cost: free
Actual Cost: Free
Diagnosis: Hip osteoarthritis, total hip arthroplasty, hip fracture
Populations tested: Geriatric populations 

Normative data1
- Fitek cementless cup implant (Marchetti et al, 2005, n=100; mean age of surgery= 61 (17-80); mean follow- up time = 9 years and 7 months (9-11 years); surgery performed by 2 surgeons (P.G.M and R.B); clinical outcome evaluation at 5 and 10 years by HHS and radiograph.; causes of disease=arthritis, dysplastic arthritis, osteonecrosis, posttraumatic arthritis)
• HHS score (0-100)

poor fair good excellent
< 70 70-79 80-89 90-100

Interrater reliability2
- Lower-Extremity Dysfunction (Oberg et al, 1994, n=105; mean age= 69 (46-91) years; pre-operatively tested= 105 patients for total joint replacement surgery (causes= OA of hip and knee); a sub group of 42 patients were examined for inter-rater reliability.)
• Reliability is statistically measured by the Goodman-Kruskal Gamma coefficients and most of variables showed .99 to 1.00.
• According to the study, the HHS showed very high Intertester-reliability in hip OA patients. Since aging is one of the major factors of both OA and hip fracture, the interrater reliability is related to the hip fracture post-surgical populations. 

Content validity 2
- Lower-Extremity Dysfunction (Oberg et al, 1994, n=105; mean age= 69 (46-91) years; pre-operatively tested= 105 patients for total joint replacement surgery (causes= OA of hip and knee); a sub group of 42 patients were examined for inter-rester reliability.)
• The article assessed the content validity 20 different lower extremity assessment tools by dividing into 5 subgroups; hip impairment, knee impairment, physical disability, social disability (handicap), and pain.
• Validity tested by means of factor analysis
• The subgrouping (5 variables) were compared with the subgrouping obtained by the statistical factor analysis; determined by the criterion “eigenvalue>1.0. 
• Most of the factors were grouped according to the preliminary subgrouping.
• The study chose the HHS as one of tools shows lower extremity dysfunction and limitation in ADL. The HHS was included in physical limitation related to hip joint OA. The factor analysis showed very similar grouping to author’s subgrouping. This result showed that the HHS has good content validity. 
• Even though, the study was not assess the validity of the HHS with hip fracture post-surgical populations, OA is one of the main aging related-diseases and hip fracture occurs mostly in elderly populations so the validity of the HHS in hip OA patients can be considered in hip fracture post-surgical population patients. 

Ceiling effects3
- Acetabular fracture ( Ovre et al, 2005; n= 450; mean age= 44 (12-92) years; 10 year cohort study; outcome instruments at 6,12 month and 2,5,7,8, and 10 years after fracture)
• Mean HHS was 90 (32-100) with SD 13( the mean pain score of the HHS=40 (10-44); the mean mobility/ ROM score=4.9 (2-5), SD .39; the mean functional score 50 (11-56), SD 8.6
• The 25th and 50th percentiles showed the values of 86 and 96 points, respectively, while the 75th gave the ceiling value of 100 points.

- Osteoarthritis: (Hoeksma et al, 2003; n=75; mean age= 72 (6) years; selected among 109 OA patients to analyze responsiveness of the HHS; most of patients have moderate to severe OA; patients were treated in a hospital setting twice a week for 5 weeks)
• Responsiveness of the HHS was compared to walking speed, pain during walking, and the SF-36 by assessing the external criterion (experienced (self-reported) recovery after treatment). 
• Responsiveness ratio of the HHS= 1.75 (higher than other tools) 
• Areas under the (ROC) curve and optimal cut off points of the HHS
ROC=.92; 95% CI= .85-1.00; 
Close to 1.0 means that a tool can discriminate between improved and stable patients 100%.  
• The HHS shows not great responsiveness than other tools in OA patients. It also can detect the difference between improved and stable of the treatment outcome. In hip fracture post surgical population, the HHS will be a good tool to outpatient physical therapists to examine the exercise intervention outcome. 

*The validity and reliability of the HHS has not been established only within hip fracture post surgical populations. 
*Some of the HHS data are from studies in hip osteoarthritis or total hip replacement populations. 
*The HHS was originally developed to evaluate orthopedic hip surgery outcome. Even though most of studies have been used and assessed the HHS in hip OA or total hip replacement populations, not hip fracture post-surgical populations, the HHS were used to assess functional level of subjects to predict their ADLs. Therefore, these data would be appropriate to use to hip fracture post-surgical populations in outpatient as a rehabilitation outcome measurement. 

1. Marchetti P, Binazzi R, Vaccari V, et al. Long-term results with cementless fitek (or fitmore) cups. J Arthroplasty. 2005;20(6):730-737. doi: 10.1016/j.arth.2004.11.019.

2. Oberg U, Oberg B, Oberg T. Validity and reliability of a new assessment of lower-extremity dysfunction. Phys Ther. 1994;74(9):861-871.

3. Ovre S, Sandvik L, Madsen JE, Roise O. Comparison of distribution, agreement and correlation between the original and modified merle d'aubigne-postel score and the harris hip score after acetabular fracture treatment: Moderate agreement, high ceiling effect and excellent correlation in 450 patients. Acta Orthop. 2005;76(6):796-802. doi: 10.1080/17453670510045390.

4. Hoeksma HL, Van Den Ende CH, Ronday HK, Heering A, Breedveld FC. Comparison of the responsiveness of the harris hip score with generic measures for hip function in osteoarthritis of the hip. Ann Rheum Dis. 2003;62(10):935-938.

The Lower Extremity Functional Scale for Outpatient Setting

Staci Kovelman, SPT

The Lower Extremity Functional Scale is an appropriate tool for the outpatient environment to look at self- care for a patient with a surgical repair after a hip fracture. This scale is a self-report questionnaire. Patients answer the question "Today, do you or would you have any difficulty at all with:" in regards to twenty different activities. Each activity can be scored from 0-4 by the patient depending on the level of difficulty they have with each task. The total score is aggregated at the end and a score of 80 indicates a very high functioning patient. The scale takes 2 minutes to administer. While the PTNow website describes this tool as being relevant in the acute care setting with patients whom have received a total hip arthroplasty, an article in the Physical Therapy Journal shows its reliability and validity to be used in the outpatient environment for patients with a variety of lower extremity musculoskeletal disorders including surgical repair after hip fracture.1 It can also be used to show progress of patients throughout outpatient physical therapy and has a minimal detectable change score of 9.1 The scale measures lower extremity function through asking about ease of activities of daily living and higher levels of function such as running, going up and down 10 stairs, and standing for an hour. By including more vigorous activities, this scale relates well to the outpatient environment patient setting since most patients will already be weight bearing and will hopefully be discharged independent in most ADLS’s.

The Lower Extremity Functional Scale can be accessed at:

1. Binkley J, Stratford P, Lott S, et al. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Physical Therapy. 1999;79(4):371‐383.

Assisted Living Facility

Heather Miller, SPT

The LEFS requires no training on the part of the physical therapist and is free to use. The LEFS provides an SEM of 5.3 points, a MCID of 9.0 points, and an excellent test-retest reliability (R = 0.86-0.94). In addition to this, the LEFS is a 20-item assessment that captures common ADLs of a patient with a hip fracture that other assessment tools such as the Barthel Index does not:

  • Rolling over in bed
  • Getting in and out of a car
  • Getting in and out of the bath
  • Squatting
  • Lifting an object from the floor

The LEFS aspects of self care are addressed in greater detail and is very applicable to a hip fracture patient:

  • 0 = extreme difficulty or unable to perform
  • 1 = quite a bit of difficulty
  • 2 = moderate difficulty
  • 3 = a little bit of difficulty
  • 4 = no difficulty

This scenario gives the patient a better picture of the task he or she must perform simply by the wording of the question. It is a very specific task and is highly applicable to a hip fracture patient as bending to do such an activity could potentially be very difficult to do. It is for these reasons that the tool best suited to show functional gains in the hip fracture population is the Lower Extremity Functional Scale.

Title of Assessment Lower Extremity Functional Scale (LEFS)
Link to Instrument
Purpose To assess difficulty with functional activities that may affect basic ADL and IADL ability
Description Contains a 20-item assessment of activities of daily living specifically dealing with lower limb function including: bed mobility, stair climbing, ambulation, dressing, getting in and out of a car, getting in and out of the bath, and sitting or standing for an extended period of time. Patients rate each activity on an ordinal scale from 0-4 based on the amount of difficulty perceived with each task: 0 - extreme difficulty or unable to perform, 1 - quite a bit of difficulty, 2 - moderate difficulty, 3 - a little bit of difficulty, and 4 - no difficulty. Higher scores are associated with better lower extremity function with a maximum score possible of 80. The score earned is used to calculate the percentage of maximal function through the formula: % of maximal function = LEFS score/80*100
ICF Domain Activity; participation
Time to Administer 2-5 minutes
Number of Items 20-item assessment
Equipment Required None necessary
Training Required Non necessary
Cost Free
Population Hip fracture
Standard Error of Measurement (SEM) SEM = 5.3 points
Minimally Clinically Important Difference (MCID) MCID = 9.0 points
Cut-Off Scores not identified
Test-Retest Reliability Excellent test-retest reliability (R = 0.86-0.94)
Criterion Validity (Predictive/Concurrent) not identified
Construct Validity (Convergent/Discriminant) not identified
Floor/Ceiling Effects not identified


Mangione KK, Palombaro KM. Exercise prescription for a patient 3 months after hip fracture. Physical Therapy. July 2005;85(7):676-687.

Binkley JM, Stratford PW, Lott SA, Riddle DL, The North American Orthopaedic Rehabilitation Research Network. The lower extremity functional scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy. April 1999;79(4):371-383.

Home Care Setting

Jenny Place, SPT

The Continuous Scale Physical Functional Performance Test (CS-PFP 10)

The CS-PFP 10 includes complex functional tasks typically required for independent living. It consists of 10 household tasks in 5 domains. The 5 domains are lower body strength, upper body strength, upper body flexibility, balance, and coordination. Time, weight, or distance are recorded for each task and scored from 0-100. A score of 0 indicates poor function and a score of 100 indicates excellent function. A total score is determined by averaging the scores of all 5 domains. The test takes approximately 30 minutes to administer. Training is available for this outcome measurement tool, but not required for test administration.

This test contains many self-care items that an older adult would eventually need to do to function independently at home. It can be used by the Physical Therapist for assessment, progress, and eventually discharge from in-home care. In patients, it also fosters confidence in performing functional in-home tasks as they relate to self-care. Several items relate directly to self-care such as loading and unloading a washing machine or donning and doffing a jacket. Other items might not seem directly related to self-care, but they encompass components of self-care tasks. If a person can climb stairs and reach overhead to a shelf, they could also step up into their shower and reach for body wash on a higher shelf.
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