Feasibility and efficacy of real-time teleresistance exercise programs for physical function in elderly patients after hip fracture surgery: a randomized controlled trial

Abstract

Background

Hip fractures substantially impair quality of life and functional outcomes in elderly individuals. With incidence rates rising globally and in Thailand, effective rehabilitation strategies are crucial. This study evaluated the feasibility and efficacy of teleresistance exercise programs compared with traditional exercise booklets in elderly patients following hip fracture surgery.

Methods

A single-blind, two-arm, parallel-group randomized controlled trial was conducted. Elderly patients aged 60 to 90 years who had undergone hip fracture surgery were randomized into two groups. The intervention group received a 12-week teleresistance exercise program, whereas the control group followed an exercise booklet. The primary outcome was the short physical performance battery (SPPB). The secondary outcomes were the two-minute walk test (2MWT) score, knee extension strength, and anxiety level.

Results

Thirty-three participants with a mean age of 76.8 years (SD 8.6) were enrolled. At 12 weeks, the intervention group presented significant improvements in SPPB scores compared with those of the control group (P = 0.040). There were no significant differences in 2MWT, knee extension strength or anxiety scores between the groups. The improvements in SPPB and 2MWT scores for the intervention group surpassed the minimal clinically important difference.

Conclusions

Compared with traditional exercise booklets, teleresistance exercise programs significantly enhance physical function in elderly patients following hip fracture surgery. This method offers a feasible and effective alternative to standard rehabilitation approaches. Future research should explore long-term effects and refine exercise protocols for telerehabilitation.

Introduction

Hip fractures are major public health issues that significantly affect patients’ quality of life, functional ability [1], and overall health. They also impose substantial costs on healthcare systems [2]. The incidence of hip fractures varies widely worldwide. Between 2005 and 2018, rates ranged from 95.1 per 100 000 in Brazil to 315.9 per 100 000 in Denmark. As the population ages, the number of hip fractures is expected to double by 2050, impacting both men and women. The incidence sharply increases with age [3]. In Thailand, osteoporotic hip fractures are a growing concern. Crude incidence rates rose from 112.7 per 100 000 in 2013 to 146.9 per 100 000 in 2022. During the same period, annual hospitalization costs surged from 17.3 million USD to 42.8 million USD [4].

The median one-year mortality rate after hip fracture is 22.8%[3]. Survivors often experience marked declines in mobility, independence, and health-related quality of life [5]. Between 33% and 69% struggle to return to prefracture daily activities, and 20–66% cannot regain their previous mobility within 6 months [6, 7]. Rehabilitation is essential for restoring independence [8], with evidence supporting the effectiveness of multidisciplinary inpatient rehabilitation [9]. Both outpatient and home-based rehabilitation have proven beneficial [10]. Systematic reviews indicate that home-based approaches can match inpatient options for appropriate patients [11, 12]. Notably, progressive resistance exercises can significantly improve mobility, daily activities, balance, and strength [7, 9, 13].

In Thailand, barriers to accessing rehabilitation include limited healthcare resources, socioeconomic challenges, travel difficulties, and the impact of the COVID-19 pandemic. These factors have hindered continuous rehabilitation efforts. Telerehabilitation has emerged as a promising solution to these challenges. Previous studies have indicated that telerehabilitation is feasible, safe, and effective for home-based rehabilitation in older adults following hip fractures [14]. However, most existing research has focused on asynchronous telerehabilitation methods [15], which lack real-time coaching and feedback. Given the aging population and rising incidence of hip fractures in Thailand, this study aimed to evaluate the feasibility and effectiveness of real-time telerehabilitation resistance exercise programs compared with traditional rehabilitation methods in terms of physical function.

Methods

Study Design

This single-blind, two-arm, parallel-group randomized controlled trial was conducted from March 2022 to March 2023 at the Department of Orthopedic and Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. The study protocol was approved by the Siriraj Institutional Review Board (COA no.Si-835/2021) and registered with the Thai Clinical Trials Registry (https://www.thaiclinicaltrials.org/show/TCTR20220123001). The study adhered to the principles of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants prior to study initiation. The trial adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for randomized trials.

Participants

Eligible participants were elderly patients aged 60 to 90 years with diagnosed fragility hip fractures who underwent surgery within 48 h of admission. The inclusion criteria required participants to:

• Communicate in Thai.

• Possess capable cognitive function, defined as a Thai Mental State Examination score greater than 20 [16].

• Be able to walk independently or with a gait aid for at least 5 m before the fracture.

• Be permitted to ambulate with weight-bearing as tolerated post-surgery.

• Have a caregiver available to support exercise activities.

The exclusion criteria were pathologic fractures, postoperative complications impairing exercise ability, severe cardiovascular or respiratory diseases, dementia, musculoskeletal problems, hemiparesis, psychiatric disorders, and the presence of a cardiac pacemaker.

A physiatrist (P.D.) screened and enrolled participants. Eligible participants and their caregivers were informed about the study’s objectives, procedures, and privacy measures. After the baseline assessments, the participants were randomly assigned to either the intervention or the control group.

Randomization and blinding

Randomization was achieved via computer-generated blocks of four, with preprepared random numbers concealed in sequentially numbered opaque envelopes. A physiatrist (J.K.), blinded to the baseline results, opened these envelopes to assign interventions. Figure 1 illustrates the participant recruitment and retention flowchart. Thirty-three participants completed the trial and were included in the intention-to-treat analysis.

Fig. 1.

Study flow diagram

Outcome measures

Research assistants collected baseline demographic data before hospital discharge. The items were age, sex, body mass index (BMI), comorbidities, nutritional status via the Mini Nutritional Assessment–Short Form [17], premorbid walking function (use or not use gaitaid), type of femoral fracture, and surgical procedures. were collected by research assistants before hospital discharge.

Clinical assessments were conducted at baseline and at 6 and 12 weeks post discharge by a physiotherapist blinded to the group allocations. The primary outcome measure was the short physical performance battery (SPPB), which has good to excellent test-retest reliability (intraclass correlation coefficient 0.72–0.92) [18].

The secondary outcome measures were as follows:

• Two-minute walk test (2MWT). This test assesses walking endurance; the intraclass correlation coefficient is 0.95 [19].

• Knee extension strength. This strength was measured via a hand-held dynamometer.

• Anxiety level. This was evaluated via the Thai Hospital Anxiety and Depression Scale [20].

• Fall incidence. This was tracked through patient and caregiver interviews.

No trial outcome changes occurred during the study.

Intervention group

The participants in the intervention group received a telerehabilitation program within 1 week after discharge and engaged in a 12-week teleresistance exercise regimen. Each session comprised a warm-up, resistance exercises, and a cool-down. A range of motion and stretching exercises were used for the warm-up and cool-down. The resistance component focused on progressive strengthening of the upper and lower extremities, with weights increasing by 0.5 to 1 kg, as tolerated. The upper extremity exercises targeted the muscles around the shoulders and elbows, whereas the lower extremity exercises focused on the muscles around the hips, knees, and ankles.

During the first 6 weeks, the participants completed real-time videoconference exercises with a physiotherapist via the LINE application three times per week, with each session lasting approximately 45 min. In weeks 7 to 12, the number of sessions decreased to twice weekly, with an additional self-directed exercise session once weekly. The participants also received an exercise booklet containing textual instructions, pictures, and video clips.

Control group

The participants in the control group received usual care, which included an exercise booklet with textual instructions and pictures. The exercises comprised range-of-motion and resistance exercises for the hip, knee, and ankle muscles. The exercises were to be performed as 8 to 10 repetitions per set, with three sets per day at least 3 days per week.

Adjunct therapies

Both groups received daily oral nutritional supplements 400 Kcal/day, 1000 mg calcium carbonate, and 40 000 IU ergocalciferol during hospitalization and for 3 months postdischarge. Standard in-hospital physical therapy was provided, along with fall prevention education and occupational therapy for home modifications. The participants were instructed on appropriate self-care on the basis of their type of surgery. Before discharge, the participants and caregivers were trained on a home-based exercise program and were advised to engage in walking exercises (10 min per session, three times a day, at least 3 days per week) for 12 weeks. Compliance logs were maintained, and participants were advised to avoid other therapy programs during the study period.

Sample size calculation

The sample size estimation was based on SPPB data from Ninlerd et al. [21] The nQuery Advisor program was used for two-group t tests with equal means. The estimation used a control group mean SPPB score of 6.7, a standard deviation of 1.5, a minimal clinically important difference of 1.34, a power of 80%, and a significance level (α) of 0.05. The required sample size was 21 participants per group.

Statistical analysis

Statistical analyses were conducted using SPSS version 29 [22]. The Shapiro-Wilk test was employed to assess the normality of data distribution. Continuous variables that exhibited a normal distribution—specifically age, body mass index (BMI), Short Physical Performance Battery (SPPB) scores total and subcomponent scores (balance, gait speed, chair stand), two-minute walk test (2MWT) results, knee extension strength, and anxiety scores—are reported as means with standard deviations. Conversely, non-normally distributed outcomes, such as the Mini Nutritional Assessment scores, are presented as medians along with interquartile ranges. Categorical variables are expressed as frequencies and percentages.

Differences in baseline characteristics between the control and intervention groups were analyzed using independent samples t-tests for continuous outcomes and chi-square tests for categorical outcomes. Furthermore, the differences in outcomes measured at baseline compared to 6 weeks and baseline compared to 12 weeks between the two groups were evaluated using one-sample t-tests. All data analyses were performed using an intention-to-treat approach, with the last observation carried forward where applicable. A p-value of less than 0.05 was deemed statistically significant.

Results

Participant flow and baseline characteristics

Between March 2022 and March 2023, 174 patients with fragility hip fractures were assessed for eligibility. Among these, 141 were excluded for various reasons: 31 due to age limitations, 69 due to medical conditions that precluded participation in tele-resistance exercises, 30 lacked caregivers to support tele-exercise, and 11 declined to participate (Fig. 1). Consequently, 33 patients were enrolled in the study, with an average age of 76.8 ± 8.62 years; 27 participants (81.8%) were women.

The mean BMI was 23.9 ± 3.95 kg/m². Common comorbidities were hypertension, dyslipidemia, and diabetes mellitus. Most participants were at risk of malnutrition. All individuals were able to walk independently in the community prior to their fracture, had a history of indoor falls between 6 AM and 6 PM, and primarily had femoral neck fractures treated with arthroplasty.

After the baseline assessments, the participants were randomly allocated to the control and intervention groups. The demographic and clinical characteristics of each group were not significantly different (Table 1). However, participants in the control group were older, had a higher BMI, and used gait aids more often than those in the intervention group.

Table 1.

Demographic and clinical characteristics of the participants

	Control group (n = 17)	Intervention group (n = 16)	P-value
Sex [n (%)]			0.398
Female	15 (88.2)	12 (75.0)
Male	2 (11.8)	4 (25.0)
Age (years)*	78.3 ± 7.66	75.1 ± 9.51	0.299
BMI (kg/m2)*	25.1 ± 4.49	22.7 ± 2.95	0.083
Comorbidities [n (%)]
Hypertension	12 (85.7)	9 (69.2)	0.385
Diabetes mellitus	4 (28.6)	6 (46.2)	0.440
Dyslipidemia	9 (64.3)	8 (61.5)	1.000
Osteoarthritis	4 (28.6)	4 (30.8)	1.000
Cardiovascular disease	2 (14.3)	0 (0.0)	0.481
Pulmonary disease	1 (7.1)	0 (0.0)	1.000
Stroke	1 (7.1)	0 (0.0)	1.000
Mini nutritional assessment	9 (8,12)	10.5 (9.25,11.75)	0.326
Premorbid walking function
Use gait aid	5 (29.4)	2 (12.5)	0.175
Type of fracture [n (%)]			0.305
Fracture neck of femur	14 (82.3)	11 (68.7)
Trochanteric fracture	3 (17.7)	5 (31.0)
Surgery [n (%)]			0.702
Arthroplasty	13 (76.5)	10 (62.5)
Internal fixation	4 (23.5)	6 (37.5)

IQR Interquartile range

*mean + SD, **median (IQR)

 ^a significant at p value<0.05

Primary outcome: improvements in SPPB scores

The Short Physical Performance Battery (SPPB) scores at baseline, 6 weeks and 12 weeks for both the control and intervention are presented (Fig. 2A). Both groups demonstrated significant within-group improvements in SPPB scores at 6 and 12 weeks post-baseline (Table 2). At 12 weeks, the intervention group showed a significantly greater increase in SPPB scores compared to the control group (p = 0.040), despite no significant between-group differences at earlier time points.

Fig. 2.

Outcome measures at different time points

Table 2.

Changes in outcomes from baseline to 6 weeks and baseline to 12 weeks

Outcomes	Baseline	Change in 6weeks (95% CI)	Change in 12 weeks (95% CI)	P-value6wks	P-value12wks
SPPB
Control	3.29 ± 1.99	1.00 (0.02,1.98)	1.76 (0.57,2.96)	0.046*	0.007*
Intervention	3.69 ± 1.78	1.63 (0.22,3.03)	3.63 (2.21,5.04)	0.026*	< 0.001*
P-value	0.555	0.438	0.040*
2 MWT (meters)
Control	9.36 ± 4.44	11.05 (4.60,17.50)	25.57 (13.48,37.67)	0.002*	< 0.001*
Intervention	13.61 ± 8.37	25.04 (13.16,36.92)	45.21 (26.26,64.16)	< 0.001*	< 0.001*
P- value	0.076	0.032*	0.074
KE strength: fractured side (Kg)
Control	49.95 ± 17.37	7.71 (−0.16,15.58)	12.12 (4.58,19.66)	0.054	0.004*
Intervention	56.59 ± 18.15	14.19 (4.29,24.09)	17.43 (6.06,28.79)	0.008*	0.005*
P-value	0.292	0.282	0.409
KE strength: sound side (Kg)
Control	60.18 ± 15.38	10.29 (1.60,18.98)	14.05 (2.87,25.23)	0.023*	0.017*
Intervention	74.48 ± 22.65	8.33 (−1.80,18.47)	8.78 (−5.14,22.70)	0.100	0.199
P-value	0.041*	0.757	0.532
Anxiety score
Control	5.53 ± 2.79	2.06 (0.42,3.70)	2.12 (0.48,3.75)	0.017*	0.014*
Intervention	4.56 ± 2.94	1.19 (−0.04,2.77)	2.56 (0.99,4.13)	0.131	0.003*
p-value	0.340	0.424	0.680

*significant at p value < 0.05, 95%CI 95% confidence interval

SPPB Short Physical Performance Battery, 2MWT 2 min walk test, KE Knee extension

Analysis of SPPB components revealed further distinctions. For balance, both groups improved significantly at 12 weeks, but between-group differences were not statistically significant. Gait speed improved significantly in both groups at 12 weeks, with the intervention group exhibiting a significantly greater improvement than the control group (p = 0.006). In the chair stand component, both groups improved significantly over time. While between-group differences were not statistically significant, the intervention group consistently outperformed the control group at both 6 and 12 weeks (Table 3).

Table 3.

Changed scores of SPPB components from baseline to 6 weeks and baseline to 12 weeks

SPPB components	Baseline	Change in 6weeks (95% CI)	Change in 12 weeks (95% CI)	P-value6wks	P-value12wks
Balance
Control	2.06 ± 1.6	0.53(−2.44,1.30)	0.76(0.00,1.53)	0.17	0.049*
Intervention	2.50 ± 1.5	0.31(−0.67,1.29)	0.87(0.76,1.67)	0.51	0.03*
P-value	0.43	0.71	0.83
Gait speed
Control	0.94 ± 0.24	0.00 (0.00,0.00)	0.24(0.01,0.46)	NA	0.04*
Intervention	0.94 ± 0.25	0.31(−0.11,0.73)	1.12(0.55,1.70)	0.14	0.001*
P- value	0.97	0.14	0.006*
Chair stand
Control	0.29 ± 0.47	0.50(0.11,0.89)	0.81(0.22,1.40)	0.015*	0.001*
Intervention	0.25 ± 0.45	1.0(0.48,1.51)	(1.63(0.13,2.32)	0.001*	< 0.001*
P-value	0.78	0.109	0.068

95%CI 95% confidence interval, SPPB Short Physical Performance Battery

*significant at p value < 0.05

Secondary outcomes

2-Minute Walk Test (2MWT)

The distances achieved in the 2MWT at baseline, 6 weeks, and 12 weeks for both groups are illustrated (Fig. 2B). There were no significant differences between the control and intervention groups at baseline. Both groups demonstrated significant improvements from baseline at 6 weeks (control group: P = 0.002; intervention group: P < 0.001) and at 12 weeks (both groups: P < 0.001). At the 6-week mark, the intervention group exhibited significantly greater changes in 2MWT distance compared to the control group (P = 0.032), although no significant difference was observed at 12 weeks (Table 2).

Knee extension strength

Knee extension strength, measured on both sides at baseline, 6 weeks, and 12 weeks, is presented (Fig. 2C and D). At baseline, there was no significant difference in knee strength of the fractured side between the groups. The change in knee extension strength within the control group from baseline to 6 weeks was not statistically significant; however, a significant change was observed from baseline to 12 weeks (P = 0.004). Conversely, the intervention group demonstrated significant changes in knee extension strength from baseline to both 6 weeks (P = 0.008) and 12 weeks (P = 0.005). Between-group comparisons revealed no significant differences in changes in knee extension strength from baseline to 6 weeks or from baseline to 12 weeks (Table 2).

Regarding the sound side, the baseline knee strength in the intervention group was significantly greater than that of the control group (P = 0.041). The control group exhibited significant changes in knee extension strength from baseline to both 6 weeks (P = 0.023) and 12 weeks (P = 0.017). In contrast, the intervention group showed no significant changes from baseline to either 6 weeks or 12 weeks. Additionally, there were no significant differences between groups at both time points (Table 2).

Anxiety scores

Anxiety scores at baseline, 6 weeks, and 12 weeks for both groups are depicted (Fig. 2E). At baseline, there were no significant differences in anxiety scores between the control and intervention groups. The changes in anxiety scores from baseline to 6 weeks (P = 0.017) and from baseline to 12 weeks (P = 0.014) were significant within the control group. In the intervention group, no significant difference was observed in anxiety scores from baseline to 6 weeks, while a significant difference was noted from baseline to 12 weeks (P = 0.003). Between-group comparisons indicated no significant differences at both 6 weeks and 12 weeks (Table 2).

Exercise adherence and falls

The overall exercise adherence rate in the intervention group was 70%. The primary reasons for missed sessions were caregiver unavailability and conflicts with hospital appointments.

Regarding, the adverse events, within the intervention group, one participant (6.7%) experienced a fall within 6 weeks of discharge, which was deemed unrelated to the tele-resistance exercise program. No serious complications were reported.

Discussion

Impact of telerehabilitation on physical function

Immobilization after major surgery and during hospitalization can substantially decrease muscle strength and function. Physical training has been shown to improve strength and functional performance in patients recovering from hip fractures [23]. This study demonstrated that telerehabilitation programs, specifically tele-resistance exercises, can significantly enhance physical function in elderly patients following hip fracture surgery. At 12 weeks postintervention, the improvements were particularly notable compared with those achieved with traditional exercise booklets. This is the first study to implement such a program for fragility hip fractures in Thailand, contributing important evidence from a low-resource context.

Advantages of real-time video conferencing

The intervention employed real-time video conferencing through the LINE application to deliver exercises and provide immediate feedback from physiotherapists. This method differs from other telerehabilitation approaches, which typically use prerecorded videos or less interactive platforms [15]. The ability to offer real-time feedback allowed for personalized adjustments, likely contributing to the observed improvements in physical function. Additionally, participants could use smartphones or tablets with a standard application, making this telerehabilitation approach more accessible and cost-effective than systems relying on complex technology.

Challenges with traditional rehabilitation

Rehabilitation after surgery primarily aims to restore mobility. In the standard approach, older adults with hip fractures and their caregivers typically receive training on home exercise programs upon discharge, supplemented by an exercise booklet. However, clinical observations have shown that some patients struggle to follow and progress with these exercises, leading to delayed mobility recovery. Furthermore, mobility issues often prevent patients from receiving outpatient therapy, as they rely on caregiver assistance and face transportation challenges. These barriers can exacerbate inequities in healthcare access, particularly for those in remote or underserved areas. The trial addressed these limitations by introducing a more structured and accessible alternative the 12-week tele-resistance exercise program which allowed patients to receive rehabilitation remotely. This approach not only enhances accessibility but also potentially reduces inequities in healthcare access, aligning with the sustainable development goals [24].

Safety considerations in telerehabilitation

Safety is paramount in remote exercise programs. Therefore, 100 patients who were considered unsafe for telerehabilitation were excluded from the study. There were 31 participants with extreme ages and 69 conditions that could prohibit active exercise were excluded from the study. A meta-analysis reported that physiotherapist-led, exercise-based telerehabilitation is noninferior to face-to-face rehabilitation and superior to no intervention for older adults with musculoskeletal conditions [25]. Systematic reviews have also indicated that progressive resistance exercises following hip fracture surgery improve mobility, activities of daily living, balance, lower-limb strength, and performance in various tasks [26, 27]. Therefore, tele-resistance exercise was selected as the intervention. Tele-resistance exercise showed an adherence rate of 70%, demonstrating its superior effectiveness compared to using exercise booklets demonstrating its effectiveness compared to exercise booklets.

Primary outcome: improvements in SPPB scores

The Short Physical Performance Battery (SPPB) served as the primary outcome measure, evaluating balance, gait speed, and lower limb strength. At 12 weeks, the intervention group demonstrated a median improvement of 3.5 points—exceeding the threshold for substantial clinical relevance in older adults [15, 28]. This result aligns with previous meta-analyses supporting the efficacy of home-based digital interventions in enhancing physical function among elderly populations [15].

The use of real-time telerehabilitation, which provided personalized instruction and immediate feedback, likely contributed to these superior outcomes. Unlike conventional home programs that rely on static materials, the interactive nature of this approach allowed for progressive, individualized resistance training. This supports existing evidence indicating that supervised exercise produces greater functional gains than unsupervised programs in older adults [29].

Analysis of individual SPPB components revealed significant improvements across all domains within the intervention group. Notably, the chair stand test, which reflects lower limb strength, showed marked improvement as early as six weeks—a finding consistent with Vikberg et al., who reported similar early responses to resistance training. [30] Gait speed improved progressively in both groups, but significantly more in the intervention group by week 12. This is consistent with literature suggesting that resistance, multimodal, and coordination-focused training effectively enhance gait performance in older individuals [31, 32]. The early gains observed may have encouraged greater voluntary activity, thereby reinforcing ongoing improvements.

In contrast, while balance scores increased gradually over time, there was no significant between-group difference. Given that postural control involves multiple physiological systems, a multicomponent approach incorporating proprioceptive, aerobic, and neuromuscular training may be necessary to elicit more pronounced improvements in this domain [33].

Overall, the findings indicate that real-time tele-resistance exercise was effective in improving overall physical performance, particularly in total SPPB scores and gait speed, when compared to traditional unsupervised home rehabilitation.

Secondary outcomes

2-Minute walk test (2MWT)

The 2MWT revealed that both groups improved significantly from baseline at 6 and 12 weeks. Notably, the intervention group showed greater improvement at 6 weeks, though this difference did not remain statistically significant at 12 weeks. Despite this, the absolute gain in walking distance remained higher in the intervention group at both follow-up points. The mean increase of 21.4 m surpassed the minimal detectable change in older adults, suggesting clinically meaningful improvement in ambulatory capacity [19].

This finding aligns with evidence linking 2MWT performance to aerobic capacity during rehabilitation after hip fracture. [34] However, variability in the 12-week results may reflect natural recovery trajectories or increasing physical activity in the control group. Some studies have also suggested that endurance gains in this context may stem primarily from increased muscle strength [35, 36].

Knee extension strength

Contrary to expectations, no significant between-group differences were observed in knee extension strength on the fractured side. This contrasts with prior research showing strength improvements with resistance training. The limited impact may be due to the low intensity and volume of resistance used (0.5–1 kg), which may be insufficient for inducing measurable hypertrophy or strength gains, particularly in frail or sarcopenic populations [37].

Additionally, the control group had lower baseline strength, which may have motivated more self-directed exercise. Once participants regained mobility, reduced adherence may have further attenuated strength gains. While adherence to tele-resistance training was approximately 70%, no data were available for adherence to unsupervised exercises. The reduction in supervised sessions from twice weekly to once weekly after week 6 may have also affected training consistency and outcomes [38].

Anxiety scores and sociocultural factors

Improvements in anxiety were observed in both groups, though no significant between-group differences emerged. This contrasts with findings from Wu et al., who reported reduced anxiety with telerehabilitation [39]. Nevertheless, our findings are consistent with studies showing that physical activity can positively influence anxiety in older adults [40].

In the Thai context, strong familial caregiving support may have contributed to generally low baseline anxiety and steady improvements over time. Cultural values emphasizing elder care may mitigate psychological distress associated with physical decline, especially when combined with functional recovery. Additionally, greater mobility limitations and comorbidities in the control group may have been associated with higher fear of falling, which can influence anxiety scores [41, 42].

Safety and adverse events

Importantly, our study did not report any adverse effects or deaths related to the tele-resistance exercise program. One fall occurred in the intervention group; however, it was unrelated to the exercise program and did not result in serious complications. This study underscores the effectiveness of home-based digital health interventions involving communication, feedback, education, and telerehabilitation, which enhance functional outcomes among older patients recovering from hip fractures postsurgery [15].

Limitations

Several limitations must be acknowledged in this study. First, a significant number of patients were excluded due to safety concerns about remote exercise. Since this study was conducted in a tertiary, university-based medical school, the participants may have had more severe health conditions and a higher prevalence of comorbidities compared to those in community-based hospitals. Consequently, the findings may not be applicable to patients in such settings. Second, the relatively small sample size limits the generalizability of the results. This small sample size was partly due to recruitment challenges toward the end of 2022. During this period, many caregivers who were proficient in using smart devices and the LINE video call application had to resume on-site work, reducing their availability to support patients in the telerehabilitation program. Then some of the participants were institutionalized during this time, further limiting the pool of eligible participants. Increasing the sample size in future research could enhance the robustness of the findings. Additionally, the current study employed a conventional approach that included an exercise booklet and a home exercise program provided prior to discharge. This approach resulted in reduced therapist interaction for the control group, which may have negatively influenced their physical outcomes. Moreover, the participants in the control group were older and utilized gait aids more frequently compared to those in the intervention group. Previous research has established that older age and reduced walking abilities were associated with diminished functional recovery following hip fractures [6, 43]. Therefore, it is possible that the control group experienced poorer recovery outcomes than the intervention group. Finally, investigating the long-term effects of telerehabilitation is crucial for evaluating the sustainability of the observed benefits.

Conclusions

This study demonstrates that a 12-week, real-time tele-resistance exercise program significantly improves physical function in older adults following hip fracture surgery, particularly in SPPB scores and gait speed, compared to traditional home-based rehabilitation. Delivered via a widely accessible platform, the intervention proved both safe and feasible, with high adherence and no serious adverse events reported.

Although improvements in balance and knee strength were limited, the program showed early functional gains and meaningful enhancements in mobility. The findings highlight the value of supervised, interactive telerehabilitation in promoting recovery, especially in low-resource settings where access to conventional therapy is limited. Future research with larger, more diverse populations is needed to confirm long-term outcomes and broader applicability.

Abbreviations

SPPB

Short physical performance battery

2MWT

2-minute walk test

KE

knee extension 

BMI

Body mass index

Authors’ contributions

PD and JK conceived the study, designed the protocol, analyzed the data, and prepared the manuscript. RY, PC, KK, and TC designed the protocol and assisted with the data collection. AU, EV, VS, and US participated in the study design, and commented on the manuscript. All authors read and approved the final version of the manuscript.

Funding

This research project is supported by Siriraj Research Development Fund (Managed by Routine to Research: R2R) Grant Number IO-R01635015 Faculty of Medicine Siriraj Hospital, Mahidol University.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. In addition, supplementary materials are available upon request.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Siriraj Institutional Review Board (COA no.Si-835/2021). Written informed consent was obtained from all participants prior to study initiation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.