Interventions for improving mobility after hip fracture surgery in adults

Nicola J Fairhall; Suzanne M Dyer; Jenson CS Mak; Joanna Diong; Wing S Kwok; Catherine Sherrington

doi:10.1002/14651858.CD001704.pub5

. 2022 Sep 7;2022(9):CD001704. doi: 10.1002/14651858.CD001704.pub5

Interventions for improving mobility after hip fracture surgery in adults

Nicola J Fairhall ¹, Suzanne M Dyer ², Jenson CS Mak ^3,⁴, Joanna Diong ⁵, Wing S Kwok ⁶, Catherine Sherrington ^6,^✉

Editor: Cochrane Bone, Joint and Muscle Trauma Group

PMCID: PMC9451000 PMID: 36070134

Abstract

Background

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

Objectives

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

Selection criteria

All randomised or quasi‐randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three‐dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in‐hospital) or with usual care, no intervention, sham exercise or social visit (post‐hospital).

Data collection and analysis

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in‐hospital studies, and the time point closest to the end of the intervention for post‐hospital studies. Critical outcomes were mobility, walking speed, functioning, health‐related quality of life, mortality, adverse effects and return to living at pre‐fracture residence.

Main results

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%).

In‐hospital setting, mobility strategy versus control

Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically‐meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low‐certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI ‐0.05 to 0.37; 6 studies, 360 participants; moderate‐certainty evidence). Mobility strategies may make little or no difference to short‐term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low‐certainty evidence) or long‐term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low‐certainty evidence), adverse events measured by hospital re‐admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low‐certainty evidence), or return to pre‐fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low‐certainty evidence). We are uncertain whether mobility strategies improve functioning or health‐related quality of life as the certainty of evidence was very low.

Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate‐certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes.

Post‐hospital setting, mobility strategy versus control

Twenty‐two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post‐hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high‐certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high‐certainty evidence). Mobility strategies lead to a small, non‐clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high‐certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI ‐0.00 to 0.29; 10 studies, 785 participants; moderate‐certainty evidence). Mobility strategies probably make little or no difference to short‐term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate‐certainty evidence). Mobility strategies may make little or no difference to long‐term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low‐certainty evidence) or adverse events measured by hospital re‐admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low‐certainty evidence).

Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high‐certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low‐certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate‐certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low‐certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

Authors' conclusions

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post‐hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between‐group difference in the number of adverse events reported. Future trials should include long‐term follow‐up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Plain language summary

Do mobility strategies improve and restore mobility after hip fracture surgery in adults?

Key messages

Mobility is the ability to move about, including standing up and walking. Mobility strategies are treatments that aim to help people move better.

Mobility treatment undertaken in hospital may moderately improve people's mobility four months after their hip was fractured. The effect of mobility treatment on other main outcomes was unclear. Mobility treatment undertaken after discharge from hospital after a fractured hip improves mobility, probably increases walking speed, improves functioning slightly and reduces falls.

Future studies should focus on which types of treatments work best and whether the treatments work in poorer countries.

What can people do to improve their mobility after a hip fracture?

A key aim of care after surgery for hip fracture is to get people safely back on their feet, moving and walking again. Initially, people may be asked to rest in bed and restrict weight bearing. Then various strategies to improve mobility, including walking retraining, exercise programmes and electrical stimulation, are used during hospital stay and often after discharge from hospital.

What did we want to find out?

We wanted to find out:

‐ whether mobility treatments delivered in the hospital or after discharge from hospital help people move around better;

‐ what type of treatments help people move well after hip fracture.

We also wanted to know if mobility treatments can cause unwanted effects.

What did we do?

We searched for studies that compared:

‐ mobility training against no mobility training; or

‐ different methods and times of mobility treatments.

We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 40 studies that involved 4059 people with hip fracture, most of whom were over 65 years old, with an average age of 80. The smallest study involved 26 people and the largest involved 336 people. The studies were conducted in 17 countries. Many of the studies had weak methods. Twenty‐seven studies received funding, mostly from government and research funding organisations.

Main results

Eighteen studies evaluated mobility strategies that started in the hospital within a week after hip fracture surgery. Mobility treatment undertaken in hospital may moderately increase people's mobility four months after their fracture and probably increases walking speed to a small but meaningful degree. Mobility treatment probably makes little or no difference to re‐admission to hospital, return to living at home, or death. We are not certain if mobility treatment affects physical functioning (the ability to move around and function in one’s environment) or well‐being.

Twenty‐two trials evaluated longer‐duration mobility strategies that started after discharge from hospital and were undertaken in homes, retirement villages and outpatient clinics. In these settings, mobility treatment increases mobility to a small but meaningful degree, meaningfully increases walking speed, and leads to a small but non‐meaningful increase in functioning. Compared to no treatment, social visits or usual care, mobility treatment probably slightly improves people's well‐being but not to a meaningful level. Mobility treatment probably makes little or no difference to re‐admission to hospital or death.

The types of treatment that appear effective in improving people’s mobility are exercises in additional to standard physiotherapy. Both in the hospital and after discharge from hospital, the helpful exercises target balance, walking and functional tasks. After discharge from hospital, extra strength or endurance training may also improve mobility. The effect of electrical stimulation was not clear.

Overall, the review found that both in hospital and after discharge, there is enough evidence to say that treatment targeting mobility is probably better than no extra treatment in helping people get people safely back on their feet, moving and walking again after hip fracture surgery.

What are the limitations of the evidence?

We have low to moderate confidence in the results of the studies in hospitals. Our confidence was lowered because: some of the studies did not report all their results; they used different ways of delivering treatments; and many of the studies were small.

We are more confident in the results of the studies conducted after discharge from hospital, including the finding that mobility training improves movement and walking. We are less confident in the results for unwanted effects, because of the low number of unwanted effects reported.

How up to date is this evidence?

This review updates our previous review. The evidence is up to date to March 2021.

Summary of findings

Summary of findings 1. Summary of findings: in‐hospital studies.

Mobility strategies compared with control (e.g. usual care) after hip fracture surgery in the in‐hospital setting
Patient or population: adults following hip fracture surgery Settings: in‐hospital Intervention: mobility strategies^a Comparison: usual in‐hospital care^b
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control^c	Intervention
Mobility^d ‐ overall analysis Using different mobility scales: MILA (range 0 to 36), EMS (range 0 to 20), BBS (range 0 to 56), PPME (range 0 to 12), Koval (range 1 to 7). Higher values indicate better mobility (except MILA and Koval, where scale was inverted for consistency with other measures). Follow‐up: range 5 days to 4 months	In the control group, the mean scores for the outcomes were: MILA = 19.2; EMS = 16.3 to 17; BBS = 26; PPME = 6.8 to 9.1; Koval = 4.	SMD 0.53 higher (0.10 higher to 0.96 higher)	SMD 0.53 (0.10 to 0.96)	507 (7)	⊕⊕⊝⊝ Low^e	Re‐expressing the results using the 12‐point PPME, the intervention group scored 1.46 points higher (95% CI 0.28 to 2.64). MID for the PPME is typically 1.13 to 2.15 (de Morton 2008). Based on Cohen’s effect sizes^f, mobility strategies may cause a moderate increase in mobility compared with control (SMD 0.53). Types of intervention in included trials: gait, balance and functional exercise: 6 studies; resistance exercise: 1 study
Walking speed^g ‐ overall analysis Measured using metres/second (m/s) and metres/minute (m/min). A higher score indicates faster walking. Follow‐up: range 2 weeks to 4 months	The mean walking speed score in the control group ranged from 0.19 m/s to 0.72 m/s, and was 24.4 m/min.	SMD 0.16 higher (0.05 lower to 0.37 higher)	SMD 0.16 (‐0.05 to 0.37)	360 (6)	⊕⊕⊕⊝ Moderate^h	Overall, there is moderate‐certainty evidence of a small increase in walking (based on Cohen's effect sizes) compared with control (SMD 0.16); however, the confidence interval includes both slower and faster walking. Re‐expressing the results using gait speed (m/s) showed an increase of 0.04 m/s in the intervention group (MD 0.04, 95% CI ‐0.01 to 0.08). Small meaningful change for gait speed is 0.04 m/s to 0.06 m/s (Perera 2006). Types of intervention in included trials: gait, balance and functional exercise: 5 studies; electrical stimulation: 1 study
Functioningⁱ ‐ overall analysis Using different scales: mBI (range 0 to 20), BI (range 0 to 100), FIM (range 18 to 126), NEADL (range 0 to 66). A higher score indicates better functioning. Follow‐up: range 3 weeks to 4 months	In the control group, the mean scores for the outcomes were: mBI: 18; BI: 95; FIM: 69 to 81; NEADL 33.4	SMD 0.75 higher (0.24 higher to 1.26 higher)	SMD 0.75 (0.24 to 1.26)	379 (7)	⊕⊝⊝⊝ Verylow^j	We are uncertain whether mobility strategies improve functioning as the certainty of the evidence is very low. Re‐expressing the results using the BI, the intervention group scored 4.4 points higher (95% CI 1.4 to 7.38). MID for the BI (post‐ hip surgery) is typically 9.8 (Unnanuntana 2018). Types of intervention in included trials: gait, balance and functional exercise: 5 studies; resistance exercise: 1 study.
HRQoL Using EQ‐5D (range 0 to 1) and HOOS (range 0 to 100). A higher score indicates better quality of life. Follow‐up: range 10 weeks to 6 months	In the control group, the mean scores for the outcomes were: EQ‐5D (range 0.54 to 0.62), HOOS 50.37	SMD 0.26 higher (0.07 lower to 0.85 higher)	SMD 0.39 (‐0.07, 0.85)	314 (4)	⊕⊝⊝⊝ Verylow^k	We are uncertain whether mobility strategies improve HRQoL as the certainty of the evidence is very low. We calculated SMD for 3 trials with EQ‐5D and 1 trial with HOOS. Re‐expressing the results using the EQ‐5D (0 to 1 scale), there was an increase in quality of life of 0.03 in the intervention group (95% CI ‐0.02 to 0.22). MID for the EQ‐5D is typically 0.074 (Walters 2005). Types of intervention in included trials: gait, balance and functional exercise: 4 studies.
Mortality Follow‐up: short‐term range 10 days to 6 months; long‐term = 12 months	Short term: 45 per 1000	Short term: 48 per 1000 (22 to 104)	Short term: RR 1.06 (0.48 to 2.30)	Short term: 489 (6)	⊕⊕⊝⊝ Low^m	It is unclear whether mobility strategies reduce mortality as the certainty of evidence is low and the 95% CI includes both a reduction and an increase in the risk of mortality, in both the short term and the long term. Types of intervention in included trials: gait, balance and functional exercise: 4 studies; resistance exercise: 3 studies; electrical stimulation: 1 study.
	Long term: 116 per 1000^l	Long term: 142 per 1000 (56 to 362)	Long term: RR 1.22 (0.48 to 3.12)	Long term: 133 (2)	⊕⊕⊝⊝ Low^m
Adverse event: number of people who were re‐admitted Follow‐up: range 5 days to 4 months	229 per 1000^k	160 (36 to 254)	RR 0.70 (0.44 to 1.11)	322 (4)	⊕⊕⊝⊝ Lowⁿ	It is unclear whether mobility strategies reduce re‐admission compared with usual care, as the CI includes both a reduction and an increase in the risk of re‐admission. Types of intervention in included trials: gait, balance and functional exercise: 3 studies; resistance exercise: 1 study
Number of people who returned to living at pre‐fracture residence Follow‐up: range 10 days to 4 months	705 per 1000^k	754 per 1000 (452 to 1099)	RR 1.07 (0.73 to 1.56)	240 (2)	⊕⊕⊝⊝ Low^o	It is unclear whether mobility strategies increase the odds of returning to living at the pre‐fracture residence: there is low‐certainty evidence and the CI includes both a reduction and an increase in the risk of re‐admission. Types of intervention in included trials: gait, balance and functional exercise: 1 study; resistance exercise: 1 study.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BBS: Berg Balance Scale; BI: Barthel Index; CI: confidence interval; EMS: Elderly Mobility Scale; EQ‐5D: EuroQoL‐5 dimension questionnaire; FIM: Functional Independence Measure; HRQoL: health‐related quality of life; HOOS: Hip Disability and Osteoarthritis Outcome Score; HRQoL: health‐related quality of life; Koval: Koval Walking Ability Score; mBI: modified Barthel Index; MD: mean difference; MID: minimal important difference; MILA: Modified Iowa Level of Assistance; NEADL: Nottingham Extended Activities of Daily Living; PPME: Physical Performance and Mobility Examination; RR: risk ratio; SMD: standardised mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

Different types of mobility strategies compared with control after hip fracture surgery, on mobility, in the in‐hospital setting
Patient or population: adults following hip fracture surgery Settings: in‐hospital Comparison: usual in‐hospital care^a Outcome: mobility, measured using mobility scales, 6‐Minute Walk Test and Timed Up and Go test^b
Intervention type (according to ProFaNE)^c	Mobility outcome	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
		Assumed risk	Corresponding risk
		Control	Intervention
Gait, balance and functional training Follow‐up: range 5 days to 4 months	Mobility scales, using different mobility scales: MILA (range 0 to 36), EMS (range 0 to 20), BBS (range 0 to 56), PPME (range 0 to 12), Koval (range 1 to 7). Higher values indicate better mobility (except MILA and Koval, where scale was inverted for consistency with other outcomes).	In the control group, the mean scores for the outcomes were: MILA = 19.2; EMS = 16.3; BBS = 26; PPME = 6.8 to 9.1; Koval = 4.	SMD 0.57 higher (0.07 higher to 1.06 higher).	SMD 0.57 (0.07 to 1.06)	463 (6)	⊕⊕⊕⊝ Moderate^d	Interventions classified as gait, balance and functional training probably cause a moderate^e increase in mobility compared with control (SMD 0.57). Re‐expressing the results using the 12‐point PPME, the intervention group scored 1.56 points higher (95% CI 0.02 to 2.92). MID for the PPME is typically 1.13 to 2.15 (de Morton 2008).
Resistance/strength training Follow‐up: range 10 days to 4 months	Mobility scales, using EMS (range 0 to 20). Higher values indicate better mobility	The mean^f score on the EMS in the control group was 17.	MD 1 point higher on the EMS (0.81 lower to 2.81 higher).	MD 1.0 (‐0.81 to 2.81)	44 (1)	⊕⊕⊝⊝ Low^g	It is unclear whether resistance/strength training interventions increase mobility as the certainty of evidence is low and the 95% CI includes both a reduction and an increase in mobility.
	TUG (lower score = faster)	The mean TUG time in the control group was 25.4 seconds.	MD 1.5 second faster TUG time (6.4 seconds faster to 3.4 seconds slower)	MD ‐1.5 (‐6.4 to 3.4)	74 (1)	⊕⊕⊝⊝ Low^h	It is unclear whether resistance/strength training interventions improve TUG as the certainty of evidence is low and the 95% CI includes both a reduction and an increase in score.
Flexibility					0		0 studies contained a mobility strategy categorised as primarily being flexibility.
3D (Tai Chi, dance)					0		0 studies contained a mobility strategy categorised as primarily being 3D.
General physical activity					0		0 studies contained a mobility strategy categorised as primarily being general physical activity.
Endurance					0		0 studies contained a mobility strategy categorised as primarily being endurance training.
Multiple types of exercise					0		0 studies contained a mobility strategy categorised as containing multiple types of exercise.
Electrical stimulation					0		0 studies contained a mobility strategy categorised as primarily being electrical stimulation.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BBS: Berg Balance Scale; CI: confidence interval; EMS: Elderly Mobility Scale; Koval: Koval Walking Ability Score; MD: mean difference; MID: minimally important difference; MILA: Modified Iowa Level of Assistance; PPME: Physical Performance and Mobility Examination; SMD: standardised mean difference; TUG: Timed Up and Go test
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

Study ID	Age (mean)	% women	Gait speed in control group at follow‐up (m/s)	Duration of intervention (weeks)	Type of intervention (ProFaNE)	Intervention delivered by expert health provider	Exclusion criterion based on impaired cognition
Baker 1991	84	100%	0.43	Not specified	Balance, gait & functional	Yes	No
Binder 2004	80	74%	0.99	24	Balance, gait & functional; resistance	Yes	Yes
Bischoff‐Ferrari 2010	84	79%	NR	52	Balance, gait & functional	Yes	Yes
Braid 2008	81	92%	NR	6	Electrical stimulation	Yes	Yes
Gorodetskyi 2007	71	67%	NR	1.5	Electrical stimulation	Yes	No
Graham 1968	NR	NR	NR	Early WB v late WB	Balance, gait & functional	Unclear	No
Hauer 2002	81	100%	0.44	12	Balance, gait & functional; resistance	Unclear	Yes
Karumo 1977	73	75%	NR	4.7	Balance, gait & functional	Yes	No
Kimmel 2016	81	64%	NR	1	Balance, gait & functional	Yes	No
Kronborg 2017	80	77%	NR	10 days (or discharge, if discharged prior)	Resistance	Yes	Yes
Lamb 2002	84	100%	0.43	6	Electrical stimulation	No	Yes
Langford 2015	83	63%	0.83	16	Other (telephone support and coaching)	Yes	Yes
Latham 2014	78	69%	NR	24	Balance, gait & functional	Yes	Yes
Lauridsen 2002	80	100%	NR	2	Balance, gait & functional	Yes	No
Magaziner 2019	81	77%	0.74	16	Resistance; endurance	Yes	No
Mangione 2005	79	73%	0.65	12	Resistance; endurance	Yes	Yes
Mangione 2010	81	81%	0.91	10	Resistance	Yes	Yes
Miller 2006	84	77%	0.5	12	Resistance	Yes	Yes
Mitchell 2001	80	84%	0.42	6	Balance, gait & functional; resistance	Unclear	Yes
Monticone 2018	77	71%	NR	3	Balance, gait & functional	Yes	Yes
Moseley 2009	84	81%	0.6	16	Balance, gait & functional	Yes	Yes
Oh 2020	79	68%	NR	2	Balance, gait & functional	Yes	Yes^a
Ohoka 2015	90	100%	0.35	12	Balance, gait & functional	Yes	No
Oldmeadow 2006	79	68%	NR	1	Balance, gait & functional	Yes	No
Orwig 2011	82	100%	NR	52	Resistance; endurance; other (self‐efficacy‐based motivational component)	No	Yes
Pol 2019	80	89%	NR	12	Other (cognitive behavioural therapy (CBT), CBT plus sensory monitoring)	Yes	No
Resnick 2007	81	100%	NR	52	Resistance; endurance; other (motivational interventions)	No	Yes
Salpakoski 2015	80	78%	0.97	52	Balance, gait & functional	Yes	Yes
Sherrington 1997	79	79%	0.5	4	Balance, gait & functional	Yes	Yes
Sherrington 2003	81	68%	0.19	2	Balance, gait & functional	Yes	Yes
Sherrington 2004 (WB group; NWB group)	79	80%	0.55; 0.62	16	Balance, gait & functional; other (specific group of muscle contractions in supine)	Yes	Yes
Sherrington 2020	78	76%	0.83	52	Balance, gait & functional	Yes	Yes
Stasi 2019	78	75%	NR	12	Resistance	Yes	No
Suwanpasu 2014	75	66%	NR	6	Other (physical activity enhancing program, based on Resnick's self‐efficacy model)	No	No
Sylliaas 2011	82	83%	0.51	12	Resistance	Yes	Yes
Sylliaas 2012	82	81%	0.8	12	Resistance	Yes	Yes
Taraldsen 2019	83	77%	0.62	10	Balance, gait & functional	Yes	No
Tsauo 2005	73	80%	0.33	12	Balance, gait & functional	Yes	Yes
Van Ooijen 2016	83	73%	0.72	6	Balance, gait & functional	Yes	Yes
Williams 2016	79	75%	0.8	12	Balance, gait & functional; other (workbook and goal setting diary)	Yes	Yes

Study ID	Setting	Length of follow‐up (months)	No. randomised	No. analysed	% lost to follow‐up
Baker 1991	Inpatient	Until discharge from hospital	40	40	0%
Binder 2004	Post‐hospital	6	90	80	11%
Bischoff‐Ferrari 2010	Post‐hospital	12	173	128	26%
Braid 2008	Inpatient^a	3.5	26	18	31%
Gorodetskyi 2007	Inpatient	10 days	60	60	0%
Graham 1968	Inpatient	12	273	212	22%
Hauer 2002	Post‐hospital	6	28	24	14%
Karumo 1977	Inpatient	3	100	87	13%
Kimmel 2016	Inpatient	6	92	92	0%
Kronborg 2017	Inpatient	10 days	90	74	18%
Lamb 2002	Inpatient^a	3	27	24	11%
Langford 2015	Post‐hospital^b	4 months	30	26	13%
Latham 2014	Post‐hospital	9	232	195	16%
Lauridsen 2002	Inpatient	Until discharge from hospital	88	60	32%
Magaziner 2019	Post‐hospital	4	201	187	7%
Mangione 2005^c	Post‐hospital	3	41	33	20%
Mangione 2010	Post‐hospital	12	26	26	0%
Miller 2006^c	Inpatient^a	3	63	63	0%
Mitchell 2001	Inpatient	4	80	44	45%
Monticone 2018	Inpatient^a	12 (3 weeks used in analysis)	52	52	0%
Moseley 2009	Inpatient^a	4	160	150	6%
Oh 2020	Inpatient	6	45	41	16%
Ohoka 2015	Inpatient	3	27	18	33%
Oldmeadow 2006	Inpatient	0.25	60	60	0%
Orwig 2011	Post‐hospital	12	180	180	0%
Pol 2019^c,d	Post‐hospital	4	240	151	37%
Resnick 2007^c	Post‐hospital	12	155	113	27%
Salpakoski 2015	Post‐hospital	12	81	75	7%
Sherrington 1997	Post‐hospital	1	44	40	9%
Sherrington 2003	Inpatient	0.5	80	77	4%
Sherrington 2004^c	Post‐hospital	4	120	105	13%
Sherrington 2020	Post‐hospital	12	336	159	53%
Stasi 2019	Post‐hospital^b	3	100	96	4%
Suwanpasu 2014	Post‐hospital	1.5	46	46	0%
Sylliaas 2011	Post‐hospital	3	150	150	0%
Sylliaas 2012	Post‐hospital	3	95	90	5%
Taraldsen 2019	Post‐hospital	2	143	123	14%
Tsauo 2005	Post‐hospital	3	54	25	54%
Van Ooijen 2016^c	Inpatient	13 (4 weeks used in analysis)	70	51	27%
Williams 2016	Post‐hospital	3	61	24	61%

	Clearly defined study population?	Interventions sufficiently described?	Main outcomes sufficiently described?	Appropriate timing of outcome measurement? (Yes ≥ 6 months)	Assessment of compliance with interventions
Baker 1991	Yes	Partial: frequency and intensity of gait retraining not described	Yes	No: only followed up until discharge: mean stay in rehabilitation hospital for intervention group was 54 days.	No: although mention of treadmill participants aiming to exceed previous performance on the treadmill
Binder 2004	Yes	Yes	Yes	Partial: although 6 months follow‐up, it was only until the end of the intervention.	Yes: in both groups
Bischoff‐Ferrari 2010	Yes	Yes	Yes	Yes	Yes
Braid 2008	Yes	Partial: usual post‐discharge physiotherapy not described	Yes	Partial: 14 weeks. Intervention ended after 6 weeks.	Partial: compliance and tolerance to electrical stimulation only reported for intervention group
Gorodetskyi 2007	Yes	Yes	Yes (although limited)	No: 10 days marking end of treatment.	Yes: it is stated that intervention was received by all participants
Graham 1968	Partial: inadequate description; excluded post‐randomisation if unsuitable to walk at 2 weeks	Partial: little description of rehabilitation	Partial: no record of mobility outcomes	Yes: 1 year	No
Hauer 2002	Yes	Yes	Partial: however, clarification on some outcome measures was obtained via contact with trial author	Yes: 6 months (3 months after the end of the intervention). Two year follow‐up results reported for whole study population	Yes: in both groups
Karumo 1977	Partial: no mention of exclusion criteria. Though the inclusion criteria were a displaced femoral neck fracture, the implants used for some participants (9 Jewett nails, 1 Rush nail, 1 Kuntscher nail) suggest that some extracapsular fractures were included.	Yes	Partial: incomplete descriptions	No: 9 weeks only for function (3 months for mortality)	No
Kimmel 2016	Yes	Yes	Yes	No: length of follow‐up is Day 5 or discharge if discharged before Day 5	No
Kronborg 2017	Yes	Yes	Yes	No: 10 days or discharge if sooner	Yes: in both groups
Lamb 2002	Yes	Yes	Yes	Partial: 13 weeks from surgery.	Yes: “All of the women used their stimulators for more than 75% of the cumulative time requested”
Langford 2015	Yes	Yes	Yes	Partial	No
Latham 2014	Yes	Yes	Yes	Partial: 9 months	Yes: compliance with interventions assessed: "adherence was 98%”
Lauridsen 2002	Yes	Yes	Yes	No: primary outcome = length of training period; otherwise until discharge	Yes: in terms of the interventions (although not the components)
Magaziner 2019	Yes	Yes	Yes	Partial: 40 weeks	Yes
Mangione 2005	Yes	Yes	Yes	No: 12 weeks for the two intervention groups but 8 weeks only for the control group.	Partial: only compliance of the intervention groups recorded
Mangione 2010	Yes	Yes	Yes	Partial: majority followed up for 16 weeks	Yes
Miller 2006	Yes	Yes	Yes	Partial: 12 weeks only for mobility outcomes. One year follow‐up data for mortality, re‐admissions and admission to higher level of care	Partial: only compliance of the intervention groups recorded
Mitchell 2001	Yes	Yes	Yes	Partial: 16 weeks follow‐up. Intervention ended at 6 weeks	Partial: only compliance with intervention recorded
Monticone 2018	Yes	Partial: dosage about open kinetic chain exercises in the control group not described	Yes	Partial	Yes: “Physiotherapists’ systematic checking of the exercise administration manual revealed excellent compliance rates in both groups".
Moseley 2009	Yes	Yes	Yes	Partial: 16 weeks follow‐up.	Yes: “Participants completed exercise diaries which were analysed to ascertain adherence to the programmes.” Care provider visits also documented
Oh 2020	Yes	Yes	Yes	Partial: 6 months follow‐up (5 months after the end of intervention)	No
Ohoka 2015	Yes	No: standard physical therapy not described. Intensity of treadmill training not described	Yes	Partial: average of approximately 6 months	No
Oldmeadow 2006	Yes	Yes	Yes	No: only until acute hospital discharge. Mobility outcomes at 7 days	Yes: time to first walk recorded in both groups
Orwig 2011	Yes	Yes	Yes	Yes. Outcomes were assessed at 2, 6, and 12 months after hip fracture	Yes. Hours spent exercising quantified
Pol 2019	Yes	Yes	Yes	Partial	Yes
Resnick 2007	Yes	Yes	Yes	No: although follow‐up was 12 months from fracture, this coincided with the end of treatment	Partial: no data for usual care group
Salpakoski 2015	Yes	Partial: control standard care did not have specific dosage for the exercise “5‐7 exercises for the lower limbs”	Yes	Partial	Partial: only compliance in intervention group reported but reported “None of the participants were followed for compliance” in control
Sherrington 1997	Yes	Partial: "Usual care" not described	Yes	No: final assessment at 1 month (27 to 43 days)	Partial: only the intervention group completed diaries and were asked about the specific exercises. However, all participants were asked about general exercise.
Sherrington 2003	Yes	Yes	Yes	No: 2 weeks follow‐up only	Partial: some data available but not regarding weight bearing
Sherrington 2004	Yes	Yes	Yes	Partial: 4 months follow‐up only	Partial: compliance data collected for the two exercise groups but not for the control group.
Sherrington 2020	Yes	Yes	Yes	Yes: 12 months	Partial: compliance data collected for intervention group via diaries
Stasi 2019	Yes	Yes	No	Partial: 6 months	No
Suwanpasu 2014	No	No	Unclear	No: 6 weeks after discharge	No
Sylliaas 2011	Yes	Yes	Yes	No: intervention is only 12 weeks following an observation period of 12 weeks	No: not assessed
Sylliaas 2012	Yes	Yes	Yes	Partial: although is 36 weeks after fracture, trial 1 starts 12 weeks after fracture, final follow‐up is 24 weeks after start of 2011 intervention	No: not assessed
Taraldsen 2019	Yes	Yes	Yes	Yes: T3 = 48 to 56 weeks	Yes
Tsauo 2005	Yes	Yes	Yes	Yes: 6 months' follow‐up.	No. However, 4 participants in the intervention group were excluded because of poor compliance.
Van Ooijen 2016	Yes	Yes	Yes	Partial: 12 months' follow‐up for some but not all outcomes	No, included in protocol bot not reported
Williams 2016	Yes	Yes	Yes	No: 3 months	No

Date	Event	Description
8 May 2021	New citation required and conclusions have changed	1. Authorship of the review has changed. 2. The conclusions of the review were revised to give a more appropriate emphasis to optimal strategies.
8 May 2021	New search has been performed	For this update, the main changes are: 1. Search update to March 2021. 2. Twenty‐one trials, including a total of 2470 participants, were newly included in this update. Six were in‐hospital trials and 15 were post‐hospital rehabilitation trials. 3. Study selection resulted in the exclusion of 18 trials, the placement of 21 trials in ongoing studies and two trials in studies awaiting classification. 4. Restructured list of outcomes. 5. Categorised exercise and physical training interventions using the ProFaNE classification. 6. Assessed four additional sources of bias. 7. Added four new subgroup analyses. 8. Enhanced descriptions of study populations and interventions. 9. Adopted new review format and updated Background, Discussion and Conclusion.

Date	Event	Description
24 July 2008	Amended	Converted to new review format.
31 October 2006	New citation required and conclusions have changed	The main changes for the fourth update of this review, published Issue 1, 2007, were as follows. 1. Date of search for trials was extended to January 2006. 2. Three studies were newly included (Binder 2004; Tsauo 2005; Mangione 2005), one of which was previously waiting assessment (Mangione 2005, formerly Mangione 2001) and one was previously an ongoing study (Binder 2004, formerly Binder 2001). All three trials took place after hospital discharge. 3. A study which was previously ongoing (Crotty 2003) has become Miller 2006 and is awaiting assessment. 4. One study (Braid 2001) previously listed as ongoing is now excluded. 5. Two newly identified studies were excluded (Licciardone 2004; Shyu 2005). 6. Adjustments were made to text and tables to conform to revised methodology and the Cochrane Style Guide. 7. The conclusions of the review were revised to accommodate the new studies. 8. Authorship of the review has changed. For details of previous updates, please see 'Notes'.

Exercise category	ProFaNE description	How we applied the category criteria in this review^a,b
Gait, balance and functional training	Gait training involves specific correction of walking technique (e.g. posture, stride length and cadence) and changes of pace, level and direction. Balance training involves the efficient transfer of bodyweight from one part of the body to another or challenges specific aspects of the balance systems (e.g. vestibular systems). Balance retraining activities range from the re‐education of basic functional movement patterns to a wide variety of dynamic activities that target more sophisticated aspects of balance. Functional training uses functional activities as the training stimulus, and is based on the theoretical concept of task specificity. All gait, balance and functional training should be based on an assessment of the participant’s abilities prior to starting the programme; tailoring of the intervention to the individuals abilities; and progression of the exercise programme as ability improves.	Selected as exercise category if the intervention met the baseline assessment, tailoring and progression criteria. Selected as primary category for interventions where most exercises were conducted standing and where the intervention focus and most time spent was on exercise in this category. We classed programmes that included treadmill walking as this category, if the treadmill training involved specific correction of walking technique.
Strength/resistance (including power)	The term ’resistance training’ covers all types of weight training i.e. contracting the muscles against a resistance to ‘overload’ and bring about a training effect in the muscular system. The resistance is an external force, which can be one’s own body placed in an unusual relationship to gravity (e.g. prone back extension) or an external resistance (e.g. free weight). All strength/resistance training should be based on an assessment of the participant’s abilities prior to starting the programme; tailoring the intervention to the individual’s abilities; and progression of the exercise programme as ability improves.	Selected as exercise category if the intervention met the baseline assessment, tailoring and progression criteria. Selected as primary category for interventions where additional resistance was used or where it was clear that overload was sufficient without external resistance and where the intervention focus and most time spent was on exercise in this category. Electrical stimulation as a single intervention was not included in this category.
Flexibility	Flexibility training is the planned process by which stretching exercises are practised and progressed to restore or maintain the optimal range of movement (ROM) available to a joint or joints. The ranges of motion used by flexibility programmes may vary from restoration/maintenance of the entire physiological range of motion, or alternatively, maintenance of range that is essential to mobility or other functions.	Selected as exercise category if the intervention met the progression of stretching criterion. Selected as primary category for interventions where flexibility training was a stated aim of the intervention and where the intervention focus and most time spent was on exercise in this category.
3D	3D training involves constant movement in a controlled, fluid, repetitive way through all three spatial planes or dimensions (forward and back, side to side, and up and down) . Tai Chi and Qi Gong incorporate specific weight transferences and require upright posture and subtle changes of head position and gaze direction. Dance involves a wide range of dynamic movement qualities, speeds and patterns.	Selected as exercise category if the intervention involved Tai Chi or dance. Selected as primary category for interventions where the intervention focus and most time spent was on exercise in this category.
General physical activity	Physical activity is any bodily movement produced by skeletal muscle contraction resulting in a substantial increase in energy expenditure. Physical activity has both occupational, transportation and recreational components and includes pursuits like golf, tennis and swimming. It also includes other active pastimes such as gardening, cutting wood and carpentry. Physical activity can provide progressive health benefits and is a catalyst for improving health attitudes, health habits and lifestyle. Increasing habitual physical activity should be with specific recommendations as to duration, frequency and intensity if a physical or mental health improvement is indicated.	Selected as exercise category if the intervention included unstructured physical activity. We classed programmes that included un‐structured walking as this category. Selected as primary category for interventions where the intervention focus and most time spent was on exercise in this category.
Endurance	Endurance training is aimed at cardiovascular conditioning and is aerobic in nature and simultaneously increases the heart rate and the return of blood to the heart.	Selected as exercise category if the intervention focused on structured aerobic training. We classed programmes that included treadmill walking as this category if the treadmill training did not involve specific correction of walking technique. Selected as primary category for interventions where the intervention focus and most time spent was on exercise in this category.
Other	Other kinds of exercises not described	Selected as exercise category if the intervention did not meet the other categories listed and where the intervention focus and most time spent was on exercise in this category.

Outcome	Aspects measured	Examples of measurement instruments
GRADE critical outcomes
Mobility	Mobility scales, seeking to measure multiple aspects of mobility, e.g. standing up, walking and stair climbing	Short Physical Performance Battery, Physical Performance and Mobility Examination, Elderly Mobility Scale, Parker Mobility Score
	Timed tasks incorporating multiple aspects of mobility, e.g. standing up, walking and stair climbing, measured in seconds	Timed Up and Go test
	Timed tasks incorporating multiple aspects of mobility, e.g. standing up, walking and stair climbing, endurance, measured in minutes	6‐Minute Walk Test
		Dichotomous outcomes
		Self‐report outcomes
Walking speed	Timed walk	Timed 4‐Metre Walk Test, timed 6‐Metre Walk Test
Functioning	Functioning scales	Canadian Occupational Performance Measure, Nottingham Extended Activities of Daily Living scale
Health‐related quality of life		SF‐36, EQ‐5D
Mortality		Early (< 4 months) and late (> 4 months)
Adverse events	i) Re‐admission
	ii) Re‐operation	Unplanned return to operating theatre
	iii) Surgical complications	Non‐union, avascular necrosis, thromboembolic complications
	iii) Falls	Number of falls, number of people who experienced one or more falls
	ii) Pain	Persistent hip or lower‐limb pain at the final follow‐up assessment. Verbal rating or visual analogue score (VAS)
Return to living at home versus residence in aged care facility (in‐hospital studies only)
GRADE important outcomes
Mobility: walking	Use of walking aid/need for assistance
	Self‐reported outcomes	Self‐reported difficulty walking a specified distance, e.g. 400 m
Mobility: balance while standing, reaching and stepping	Balance while reaching	Functional Reach
	Balance while stepping	Number of steps in specified time
	Balance while standing with different foot positions	Timed tandem stance, timed single leg stand
	Balance scales	Berg Balance Scale
	Balance using self‐report
Mobility: sit to stand	Timed sit to stand	Time to sit to stand 5 times
Muscle strength		One measure of affected leg from each study, with priority for quadriceps
Activities of daily living	Activities of daily living scales	Barthel Index, Functional Independence Measure
Lower‐limb/hip function	Validated patient‐reported measures of lower‐limb or hip function	Hip Rating Questionnaire, Harris Hip Score, Oxford Hip Score, Merle D’Aubigne Hip Score
Patient satisfaction	i) Acceptability of interventions
	ii) Adherence	Porportion of intervention sessions completed, estimate of adherence, proportion of repetitions completed
Resource outcomes
Resources	i) Length of hospital stay	Number of days
	ii) Number of physiotherapy sessions	Number of sessions
	iii) Number of outpatient attendances	Number of attendances
	iv) Need for special care
Economic outcomes
Cost‐effectiveness		Summarise cost‐analyses reported by the included trials

Study description	Links to references
Setting (country)	Australia: Baker 1991; Kimmel 2016; Miller 2006; Moseley 2009; Oldmeadow 2006; Sherrington 1997; Sherrington 2003; Sherrington 2004; Sherrington 2020 Canada: Langford 2015 Denmark: Kronborg 2017; Lauridsen 2002 Finland: Karumo 1977; Salpakoski 2015 Germany: Hauer 2002 Greece: Stasi 2019 Italy: Monticone 2018 Japan: Ohoka 2015 Netherlands: Pol 2019; Van Ooijen 2016 Norway: Sylliaas 2011; Sylliaas 2012; Taraldsen 2019 Russia:Gorodetskyi 2007 South Korea:Oh 2020 Switzerland:Bischoff‐Ferrari 2010 Taiwan:Tsauo 2005 Thailand: Suwanpasu 2014 United Kingdom: Braid 2008; Graham 1968; Lamb 2002; Mitchell 2001; Williams 2016 USA: Binder 2004; Latham 2014; Mangione 2005; Mangione 2010; Orwig 2011; Resnick 2007; Magaziner 2019
Setting	Started study in‐hospital and transitioned to community during study a) Majority of intervention in hospital:Braid 2008; Lamb 2002; Miller 2006; Monticone 2018; Moseley 2009; Stasi 2019 a) Majority of intervention in post‐hospital setting:Bischoff‐Ferrari 2010; Langford 2015; Stasi 2019 In‐hospital(orthopedic ward):Gorodetskyi 2007; Karumo 1977; Kimmel 2016; Kronborg 2017; Lamb 2002; Miller 2006; Oldmeadow 2006 In‐hospital (rehabilitation ward):Baker 1991; Braid 2008; Lauridsen 2002; Mitchell 2001; Monticone 2018; Moseley 2009; Oh 2020; Ohoka 2015; Sherrington 2003; Van Ooijen 2016 In‐hospital (ward unclear):Graham 1968 (started 2 weeks postoperatively) Community:Binder 2004; Bischoff‐Ferrari 2010; Hauer 2002; Langford 2015; Latham 2014; Magaziner 2019; Mangione 2005; Mangione 2010; Orwig 2011; Pol 2019; Resnick 2007; Salpakoski 2015; Sherrington 1997; Sherrington 2004; Sherrington 2020; Stasi 2019; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019; Tsauo 2005; Williams 2016 Unclear:Suwanpasu 2014
Participants
Trials in which all participants were women	Baker 1991; Hauer 2002; Lamb 2002; Lauridsen 2002; Ohoka 2015; Orwig 2011; Resnick 2007
Trials in which mean age was over 80 years	Baker 1991; Binder 2004; Bischoff‐Ferrari 2010; Braid 2008; Hauer 2002; Kimmel 2016; Lamb 2002; Langford 2015; Lauridsen 2002; Magaziner 2019; Mangione 2010; Miller 2006; Mitchell 2001; Moseley 2009; Ohoka 2015; Orwig 2011; Pol 2019; Resnick 2007; Salpakoski 2015; Sherrington 2003; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019; Van Ooijen 2016
Trials excluding participants with cognitive impairment (either defined as an exclusion criterion or implied by the stated requirement to be able to give informed consent, to follow instructions, or both)	Binder 2004; Bischoff‐Ferrari 2010; Braid 2008; Hauer 2002; Kronborg 2017; Lamb 2002; Langford 2015; Latham 2014; Mangione 2005; Mangione 2010; Miller 2006; Mitchell 2001; Monticone 2018; Moseley 2009; Oh 2020; Orwig 2011; Pol 2019; Resnick 2007; Salpakoski 2015; Sherrington 1997; Sherrington 2003; Sherrington 2004; Sherrington 2020; Sylliaas 2011; Sylliaas 2012; Tsauo 2005; Van Ooijen 2016; Williams 2016
Interventions
Comparisons	In‐hospital: Usual physiotherapy: Baker 1991; Graham 1968; Karumo 1977; Kimmel 2016; Kronborg 2017; Lauridsen 2002; Miller 2006; Mitchell 2001; Monticone 2018; Moseley 2009; Oh 2020; Ohoka 2015; Oldmeadow 2006; Sherrington 2003; Suwanpasu 2014; Van Ooijen 2016 Placebo electrical stimulation: Braid 2008; Gorodetskyi 2007; Lamb 2002 Post‐hospital: Exercise programme: Binder 2004; Bischoff‐Ferrari 2010; Hauer 2002; Langford 2015; Latham 2014; Magaziner 2019; Mangione 2005; Orwig 2011; Resnick 2007; Salpakoski 2015; Sherrington 1997; Sherrington 2004; Sherrington 2020; Stasi 2019; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019; Tsauo 2005; Williams 2016 Electrical stimulation: Mangione 2010 Coaching based on cognitive behavioural therapy: Pol 2019
Intervention. Type of exercises according to ProFaNE categorisation, or electrical stimulation	Gait, balance and functional training: Baker 1991; Binder 2004; Bischoff‐Ferrari 2010; Graham 1968; Hauer 2002; Karumo 1977; Kimmel 2016; Latham 2014; Lauridsen 2002; Mitchell 2001; Monticone 2018; Moseley 2009; Oh 2020; Ohoka 2015; Oldmeadow 2006; Salpakoski 2015; Sherrington 1997; Sherrington 2003; Sherrington 2004; Sherrington 2020;Taraldsen 2019; Tsauo 2005; Van Ooijen 2016; Williams 2016 Strength / resistance training: Binder 2004; Hauer 2002; Kronborg 2017; Magaziner 2019; Mangione 2005; Mangione 2010; Miller 2006; Mitchell 2001; Orwig 2011; Resnick 2007; Stasi 2019; Sylliaas 2011; Sylliaas 2012 Flexibility: no studies Three dimensional (3D) exercise: no studies General physical activity: no studies Endurance: Magaziner 2019; Mangione 2005; Orwig 2011; Resnick 2007* Other type of intervention: Langford 2015; Orwig 2011; Pol 2019; Resnick 2007; Sherrington 2004*; Suwanpasu 2014; Williams 2016 Electrical stimulation: Braid 2008; Gorodetskyi 2007; Lamb 2002
Personnel delivering intervention in post‐hospital setting	Expert delivering intervention: Binder 2004; Bischoff‐Ferrari 2010; Langford 2015; Latham 2014; Magaziner 2019; Mangione 2005; Mangione 2010; Pol 2019; Salpakoski 2015; Sherrington 1997; Sherrington 2004; Sherrington 2020; Stasi 2019; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019; Tsauo 2005; Williams 2016 No expert delivering intervention: Orwig 2011; Resnick 2007; Suwanpasu 2014 Unclear: Hauer 2002
* = multi‐group trial appearing in more than one category

Study ID	Gait, balance & functional training	Strength/resistance training	Flexibility	3D (Tai Chi, dance etc.)	General physical activity	Endurance	Other	Electrical stimulation
In‐hospital
Baker 1991	Primary
Braid 2008								Primary
Gorodetskyi 2007								Primary
Graham 1968 early weight bearing (2 weeks)	Primary
Graham 1968 late weight bearing (12 weeks)	Primary
Karumo 1977	Primary
Kimmel 2016	Primary
Kronborg 2017		Primary
Lamb 2002								Primary
Lauridsen 2002	Primary
Miller 2006 resistance training		Primary
Miller 2006 resistance training and nutrition		Primary
Mitchell 2001	Primary^a	Primary
Monticone 2018	Primary
Moseley 2009	Primary
Oh 2020	Primary
Ohoka 2015	Primary
Oldmeadow 2006 early assisted ambulation (< 48 hours)	Primary
Oldmeadow 2006 delayed assisted ambulation (> 48 hours)	Primary
Sherrington 2003	Primary
Van Ooijen 2016	Primary
Post‐hospital
Binder 2004	Primary	Primary	Secondary			Secondary
Bischoff‐Ferrari 2010	Primary
Hauer 2002	Primary	Primary
Langford 2015							Additional post‐discharge physio telephone support and coaching
Latham 2014	Primary	Secondary
Magaziner 2019		Primary				Primary
Mangione 2005 resistance		Primary
Mangione 2005 endurance						Primary
Mangione 2010		Primary
Orwig 2011		Primary				Primary	Self‐efficacy‐based motivational component
Pol 2019							Coaching based on cognitive behavioural therapy
Resnick 2007 exercise group		Primary				Primary
Resnick 2007 exercise plus education/motivation aspect		Primary				Primary	Motivational interventions, including education and goal setting
Salpakoski 2015	Primary
Sherrington 1997	Primary
Sherrington 2004 weight bearing exercise	Primary
Sherrington 2004 non‐weight bearing exercise							Specific group of muscle contractions in supine
Sherrington 2020	Primary
Stasi 2019		Primary
Suwanpasu 2014							Physical activity‐enhancing programme, based on Resnick's self‐efficacy model (Resnick 2009)
Sylliaas 2011		Primary
Sylliaas 2012		Primary
Taraldsen 2019	Primary
Tsauo 2005	Primary	Secondary
Williams 2016	Primary						Workbook and goal‐setting diary

Study ID (source if not primary reference)	Length of stay, intervention/control, mean (SD), n	Number of physiotherapy sessions, intervention/control, mean (SD), n	Number of outpatient attendances, intervention/control, mean (SD), n	Need for special care, intervention/control, mean (SD), n	Community service use, intervention/control, n (%)	Other, intervention/control, mean (SD), n
Binder 2004	‐	Physical therapy group: 2.3 (0.2), n = 44	‐	‐
Bischoff‐Ferrari 2010	‐	No. of physiotherapy sessions during acute care Standard group: 7.6 (95% CI 6.3 to 8.9), n = 86 Extended physiotherapy (PT): 7.2 (95% CI 6.4 to 8.0), n = 87 Total minutes of physiotherapy as an inpatient Standard: 176 (95% CI 144 to 208), n = 86 Extended PT: 292 (95% CI 259 to 326), n = 87 Total duration of physiotherapy post‐hospital = unclear	‐	‐
Karumo 1977	Routine physical therapy group: 35.0 (21.6), n = 49 Intensive physical therapy group: 32.2 (21.7), n = 38	‐	‐	‐
Kimmel 2016	Median (IQR) Control: 35.0 (19.0 to 49.8), n = 46 Intervention: 24.4 (16.4 to 31.6), n = 46	‐	‐	‐
Kronborg 2017	‐	Physiotherapy with strength training: 6.0 (1.9), n = 43 Physiotherapy: 5.6 (1.7), n = 44 Total training time per day (min) Physiotherapy with strength training: 20.6 (5.8), n = 43 Physiotherapy: 23.5 (4.3), n = 44	‐	‐
Langford 2015	‐	‐	‐	‐		Total telephone intervention time over 5 calls: 151 minutes (range 42 to 286 minutes), n = 11
Lauridsen 2002	Median (range) Intervention: 32 (5 to 126), n = 44 Control: 34 (8 to 145), n = 44	Median (range) of training period (days) Intervention: 14 (1 to 42), n = 44 Control: 17 (3 to 58), n = 44 Median (range) total hours spent in training Intervention: Intervention: 6.4 (1.3 to 21.3), n = 44 Control: 4.0 (0.3 to 12.5), n = 44	‐	‐
Mangione 2010	‐	Total no. of sessions planned for all participants Leg strengthening group: 240 (total for 14 participants) Control: 180 (total for 12 participants) Total no. of sessions completed for all participants Leg strengthening group: 237 (total for 14 participants), i.e. mean 17 sessions each Control: 178 (total for 12 participants), i.e. mean 15 sessions each	‐	‐
Miller 2006	Median (95% CI) Exercise group: 23.0 (16.0 to 32.0), n = 25 Nutrition and exercise: 27.5 (13.0 to 31.0), n = 24 Control: 24.0 (17.0 to 30.0), n = 26	‐	‐
Mitchell 2001	Median (IQR) Quadriceps training: 39 (27 to 50), n = 20 Control: 40 (28 to 57), n = 24	‐	‐	‐
Moseley 2009	Days from fracture to rehabilitation admission (days) Median (IQR) High dose weight‐bearing exercise group: 14 (9 to 21), n = 80 Low dose limited weight‐bearing exercise group: 12 (9 to 19), n = 80	Median (IQR) Exercise time with a physiotherapist or assistant (mins) High dose weight‐bearing exercise group: 543 (463), n = 80 Low dose limited weight‐bearing exercise group: 363 (318), n = 80 Median (IQR) no. of sessions during community phase: High dose weight‐bearing exercise group: 8 (4), n = 73 Low dose limited weight‐bearing exercise group: 4 (1), n = 77	‐	‐	User of community services (n (%) High dose weight‐bearing exercise group: 25 (56%) Low dose limited weight‐bearing exercise group: 39 (74%)
Ohoka 2015	Weight bearing group: 92, n = 9 Non‐weight bearing group: 98, n = 9^a	‐	‐	‐
Oldmeadow 2006	Early ambulation group: 16.6 (range 4 to 136), n = 29 Delayed ambulation: 11.4 (range: 5 to 24), n = 31	‐	‐	‐
Orwig 2011	‐	No. of visits to exercise: 36.2, n = 91^a Planned no. of trainers' visits: 56 Actual no. of trainers' visits: 42^a	‐	‐
Pol 2019		Number of sessions delivered, median (IQR): Other therapy (OT) + sensor: 4 (2 to 4) OT: 2 (0 to 4) Duration of sessions at home (min) (median (IQR): OT + sensor: 45 (38.5 to 60) OT: 41 (0 to 60)
Sherrington 2003	Length of stay in the inpatient rehabilitation ward Non‐weight bearing exercise group: 25.2 (12.1), n = 37 Weight bearing exercise group 24.1 (12.4), n = 40 Overall length of stay Non‐weight bearing exercise group: 38.5 (16.3), n = 37 Weight bearing exercise group: 36.2 (13.6), n = 40	‐	‐	‐
Van Ooijen 2016	‐	Planned no. of sessions: 30 Median (minimum to maximum) no. of sessions on the treadmill: Adaptability treadmill: 11 (8 to 15), n = 24 Conventional treadmill: 12 (7 to 14), n = 23 Median (minimum to maximum) no. of physical therapy sessions Adaptability treadmill: 13 (7 to 18), n = 24 Conventional treadmill 12 (7 to 15), n = 23 Usual physical therapy: 27 (16 to 31), n = 23	‐	‐
Williams 2016	Inpatient orthopaedic trauma ward Intervention group: 15.2, n = 25 Control: 10.5, n = 24^a Rehabilitation ward Intervention group: 12.1, n = 25 Control: 18.8, n = 24^a	‐	‐	‐

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Mobility (measured using mobility scales): combined data for all strategy types	7	507	Std. Mean Difference (IV, Random, 95% CI)	0.53 [0.10, 0.96]
1.2 Mobility (failure to regain pre‐facture mobility): combined data for all strategy types	2	64	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.27, 0.85]
1.3 Mobility (measured using self‐reported outcomes): combined data for all strategy types	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4 Mobility (measured using mobility scales): gait, balance and function	6	463	Std. Mean Difference (IV, Random, 95% CI)	0.57 [0.07, 1.06]
1.5 Mobility (measured using mobility scales): resistance/strength training	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6 Mobility (measured in seconds using TUG): resistance/strength training	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.7 Mobility (measured using mobility scales) reporting individual outcome measures	8		Mean Difference (IV, Random, 95% CI)	Subtotals only
1.7.1 Elderly Mobility Scale	2	95	Mean Difference (IV, Random, 95% CI)	0.49 [‐0.81, 1.79]
1.7.2 Physical Performance and Mobility Examination Score	2	227	Mean Difference (IV, Random, 95% CI)	0.34 [‐0.31, 0.99]
1.7.3 Berg Balance Scale	2	93	Mean Difference (IV, Random, 95% CI)	12.39 [8.79, 15.98]
1.7.4 Modified Iowa Level of Assistance	1	92	Mean Difference (IV, Random, 95% CI)	2.70 [‐0.94, 6.34]
1.7.5 Timed Up and Go	3	158	Mean Difference (IV, Random, 95% CI)	4.03 [‐6.17, 14.23]
1.7.6 Performance Oriented Mobility Assessment	1	51	Mean Difference (IV, Random, 95% CI)	0.90 [‐1.14, 2.94]
1.7.7 Koval Walking Ability score	1	41	Mean Difference (IV, Random, 95% CI)	1.53 [0.72, 2.34]
1.7.8 Western Ontario and McMaster Universities OA Index (self‐reported)	1	52	Mean Difference (IV, Random, 95% CI)	‐25.40 [‐28.72, ‐22.08]
1.8 Walking speed (measured as metres/time): combined data for all strategy types	6	360	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [‐0.05, 0.37]
1.9 Walking speed (measured as metres/time): gait, balance and function	5	336	Std. Mean Difference (IV, Fixed, 95% CI)	0.15 [‐0.07, 0.36]
1.10 Walking speed (measured as metres/time): electrical stimulation	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.11 Functioning (measured using functioning scales): combined data for all strategy types	7	379	Std. Mean Difference (IV, Random, 95% CI)	0.75 [0.24, 1.26]
1.12 Functioning (measured using functioning scales): gait, balance and function	5	312	Std. Mean Difference (IV, Random, 95% CI)	0.56 [‐0.00, 1.13]
1.13 Functioning (measured using functioning scales): resistance/strength training	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.14 Functioning (measured using functioning scales): electrical stimulation	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.15 Health‐related quality of life (measured using HRQoL scales): gait, balance and function	4	314	Std. Mean Difference (IV, Random, 95% CI)	0.39 [‐0.07, 0.85]
1.16 Mortality, short term: combined data for all strategy types	6	489	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.48, 2.30]
1.17 Mortality, short term: gait, balance and function	3	293	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [0.44, 4.66]
1.18 Mortality, short term: resistance/strength training	2	170	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.26, 2.62]
1.19 Mortality, short term: electrical stimulation	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.20 Mortality, long term: combined data for all strategy types	2	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.48, 3.12]
1.21 Mortality, long term: gait, balance and function	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.22 Mortality, long term: resistance/strength training	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.23 Adverse events (measured using dichotomous outcomes): combined data for all strategy types	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
1.23.1 Re‐admission	4	322	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.44, 1.11]
1.23.2 Re‐operation	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 7.57]
1.23.3 Surgical complications	1	18	Risk Ratio (M‐H, Fixed, 95% CI)	Not estimable
1.23.4 Pain	3	245	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.80, 1.57]
1.23.5 Falls (number of people who experienced one or more falls)	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.32, 1.38]
1.23.6 Other: orthopaedic complication (as reason for withdrawal from study)	1	88	Risk Ratio (M‐H, Fixed, 95% CI)	1.50 [0.45, 4.95]
1.24 Adverse events (measured using rate of falls): all studies were gait, balance and function	3		Rate Ratio (IV, Fixed, 95% CI)	0.85 [0.64, 1.12]
1.25 Adverse events (measured using continuous measures of pain): combined data for all strategy types	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.26 Return to living at pre‐fracture residence: combined data for all strategy types	2	240	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.73, 1.56]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Walking, use of walking aid/need for assistance	2	230	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.74, 1.11]
2.2 Balance (measured using functional reach test, cm)	2	121	Std. Mean Difference (IV, Fixed, 95% CI)	0.37 [0.01, 0.73]
2.3 Balance (measured using balance scale)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.4 Balance (measured using ability to tandem stand)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.5 Balance (measured using step test; number of steps)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.6 Balance (measured using self‐reported outcomes)	2	226	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.71, 1.29]
2.7 Sit to stand (measured as number of stand ups/second)	2	227	Mean Difference (IV, Fixed, 95% CI)	0.04 [0.01, 0.07]
2.8 Strength	8	498	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.07, 0.28]
2.9 Activities of daily living (measured using ADL scales)	5	206	Std. Mean Difference (IV, Random, 95% CI)	0.87 [0.35, 1.38]
2.10 Resource use (measured by length of hospital stay)	4	335	Mean Difference (IV, Fixed, 95% CI)	‐0.83 [‐3.94, 2.28]
2.11 Resource use (measured by use of community services)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Weight‐bearing at 2 wks v weight‐bearing at 12 weeks (mortality)	1	273	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.43, 1.29]
3.2 Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (mortality)	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	3.20 [0.14, 75.55]
3.3 Weight‐bearing at 2 wks v weight‐bearing at 12 weeks (adverse events)	1	594	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.54, 1.37]
3.3.1 Avascular necrosis	1	112	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.33, 1.42]
3.3.2 Infection	1	270	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.11, 3.81]
3.3.3 Non‐union	1	212	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.56, 2.03]
3.4 Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (return to living at home)	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.72, 1.02]
3.5 Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (walking aid/assistance)	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.29, 0.89]

Study ID	Adherence was measured	Adherence data were reported	Measurement of adherence	Reported adherence results
Baker 1991	No	No	‐	‐
Binder 2004	Yes	Yes	Adherence to exercise programme, measured as the percentage of 72 sessions performed	Intervention group: mean (SD) attendance (/72 sessions) = 87% (24%); mean (SD) number of exercise session per week 2.3 (0.2) Control group: control participants who completed exercise log data (n = 32, 74%). Of these, the percentage of the 72 sessions performed was mean (SD) 131% (62%) (NB: participants in control were advised to perform at least 3 times per week but not prohibited from performing more exercises and the mean compliance reported in control group indicated some participants performed more than 3 times per week)
Bischoff‐Ferrari 2010	Yes	Yes	Adherence to exercise programme	Intervention group: 69% of participants reached 12‐month visit or telephone call and performed the home programme at least once a week
Braid 2008	No	No	‐	‐
Gorodetskyi 2007	No	No	‐	‐
Graham 1968	No	No	‐	‐
Hauer 2002	Yes	Yes	Adherence to exercise programme	Intervention group: mean (SD) [range] adherence to exercise = 93.1% (13.5%) [55% to 100%] Control group: mean (SD) [range] adherence to placebo activities = 96.7 % (6.1%) [83% to 100%]
Karumo 1977	No	No	‐	‐
Kimmel 2016	No	No	‐	‐
Kronborg 2017	Yes	Yes	Adherence to exercise programme	Intervention group: 80% of participants completed all strength training sessions
Lamb 2002	No	No	‐	‐
Langford 2015	Yes	No	‐	‐
Latham 2014	Yes	Yes	Attendance	Intervention group: attendance across 26 weeks = 70%
Lauridsen 2002	Yes	Yes	Adherence to exercise programme	Intervention group: average hours of training = 6.4 hours; average number of days of training = 14 days; average number of hours per day = 0.5 hours. Prescribed physical therapy: 6 hours + non‐supervised training for other 4 days Control group: average hours of training = 4 hours; average number of days of training = 17 days; average number of hours per day = 0.2 hours Prescribed physical therapy: approximately 2 hours (NB: did not clearly state if there is non‐supervised training)
Magaziner 2019	Yes	Yes	Adherence to exercise programme	Intervention group: 72.4% participants completed ≥ 80% expected intervention visits; mean (SD) percentage of expected intervention visits completed per participant = 78.3% (27.6%) Control group: 81% participants completed ≥ 80% expected intervention visits; mean (SD) percentage of expected intervention visits completed per participant = 87.0% (14.3%)
Mangione 2005	Yes	Yes	Attendance	Mean attendance in exercise training = 98%
Mangione 2010	Yes	Yes	Attendance	Intervention group: attendance = 99% (number of sessions completed divided by possible number of sessions = 237/240 sessions). Control group attendance = 99% (178/180 sessions)
Miller 2006	Yes	Yes	Attendance	Adherence to the 12 weeks of resistance training = 86%
Mitchell 2001	Yes	Yes	Adherence to exercise programme	Intervention group: median (range) number of training sessions completed at the six‐week assessment = 11 (10 to 12)
Monticone 2018	Yes	No	‐	‐
Moseley 2009	Yes	Yes	Adherence to exercise programme	Higher dose weight‐bearing exercise group: median (interquartile range (IQR)) total exercise time during the in‐hospital phase = 543 (463) minutes (min); median (IQR) number of times visited by physiotherapist during the community phase = 8 (4); median (IQR) reported walking time: 517 min (1125)). Lower dose weight‐bearing exercise group: median (IQR) total exercise time during the in‐hospital phase = 363 (318) min; median (IQR) number of times visited by physiotherapist during the community phase = 4 (1)
Oh 2020	No	No	‐	‐
Ohoka 2015	No	No	‐	‐
Oldmeadow 2006	No	No	‐	‐
Orwig 2011	Yes	Yes	Adherence to exercise programme	Intervention group: mean number of visits = 36.2
Pol 2019	Yes	Yes	Attendance of the 20 scheduled exercise sessions	Intervention group: 49 of the 70 participants completed the exercise programmes Median number of sessions: 20 Median number of exercises per visits: 5
Resnick 2007	Yes	Yes	Adherence to exercise programme	Combined two exercise groups: mean (SD) exercise time in hours per week at 12 month = 3.22 (3.87) Control group: mean (SD) exercise time in hours per week at 12 month = 0.92 (1.45) NB. Prescribed duration of training was not clear
Salpakoski 2015	Yes	Yes	Adherence to exercise programme	Interevention group: proportion of classes attended (amount of performed exercises over expected number of exercises) during the first 6 months, strengthening = 61%, stretching = 53%, balance = 65%, functional exercises = 69%. All but 1 participant attended the first face‐to‐face physical activity counselling session. Responded to phone contact: first contact = 90%, second contact = 88%, third contact = 83%. Control group: did not follow for compliance with the home exercises
Sherrington 1997	Yes	Yes	Adherence to exercise programme	Mean (SD) [range] number of days of exercise determined from the exercise diaries = 24.7 (3.8) [18 to 30] Prescribed number of days of exercise: 30 days Mean (SD) [range] number of repetitions completed = 737 (664) [154 to 2450]. Median (IQR) number of repetitions = 480 (405 to 692)
Sherrington 2003	No	No	‐	‐
Sherrington 2004	No	No	‐	‐
Sherrington 2020	No	No	‐	‐
Stasi 2019	No	No	‐	‐
Suwanpasu 2014	No	No	‐	‐
Sylliaas 2011	No	No	‐	‐
Sylliaas 2012	No	No	‐	‐
Taraldsen 2019	Yes	Yes	Attendance to occupational therapy sessions	Inpatient period: median (IQR) of in‐hospital number of sessions: 4 (2 to 5) for usual care, 4 (2 to 6) for cognitive behavioural therapy (CBT)‐based occupational therapy, 2.5 (1 to 5) for CBT‐based occupational therapy with sensor monitoring At home: 2 (0 to 4) for CBT‐based occupational therapy and 4 (2 to 4) for CBT‐based occupational therapy with sensor monitoring Duration of session (minutes): 41 (0 to 60) for CBT‐based occupational therapy, 45 (38.5 to 60) for CBT‐based occupational therapy with sensor monitoring
Tsauo 2005	No	No	‐	‐
Van Ooijen 2016	Yes	Yes	Attendance	Adaptability treadmill training group: median (minimum to maximum) number of training sessions on treadmill: 11 (8 to 15); number of sessions of usual therapy = 13 (7 to 18). Conventional treadmill training group: median (minimum to maximum) number of training sessions on treadmill:12 (7 to 14); number of sessions of usual therapy = 12 (7 to 15). Usual physical therapy: median (minimum to maximum) number of sessions = 27 (16 to 31)
Williams 2016	Yes	Yes	Adherence to exercise programme	Number of participants who received 6 sessions = 13; average number of sessions delivered to the intervention participants = 5

Sensitivity analysis	Pooled impact of mobility strategies on mobility outcome (SMD, 95% CI)
In‐hospital trials
Primary analysis, all trials, random‐effects meta‐analysis	SMD 0.53, 95% CI 0.10 to 0.96; participants = 507; studies = 7; I² = 81%
Sensitivity analysis 1, removing trials with unclear or high risk of bias on allocation concealment	SMD 0.58, 95% CI 0.05 to 1.10; participants = 415; studies = 6; I² = 84%
Sensitivity analysis 2, removing trials with high risk of bias on any items	SMD 0.57, 95% CI ‐0.46 to 1.61; participants = 191; studies = 2; I² = 87%
Sensitivity analysis 3, removing trials reported only in conference abstracts	No studies removed
Sensitivity analysis 4, removing trials that did not clearly focus on or predominantly include the target population of people with a fragility fracture resulting from low‐energy trauma	No studies removed
Sensitivity analysis 5, removing trials that included mixed populations	No studies removed
Sensitivity analysis 6, removing in‐hospital trials that measured outcomes at the end of the in‐hospital phase (the usual time point was that closest to four months).	SMD 0.39, 95% CI 0.01 to 0.78; participants = 327; studies = 4; I² = 62%
Sensitivity analysis 7, all trials, fixed‐effects meta‐analysis	SMD 0.38, 95% CI 0.20 to 0.56; participants = 507; studies = 7; I² = 81%
Post‐hospital trials
Primary analysis, all trials, random‐effects meta‐analysis	SMD 0.32, 95% CI 0.11 to 0.54; participants = 761; studies = 7; I² = 48%
Sensitivity analysis 1, removing trials with unclear or high risk of bias on allocation concealment	SMD 0.22, 95% CI ‐0.01 to 0.46; participants = 486; studies = 5; I² = 22%
Sensitivity analysis 2, removing trials with high risk of bias on any items	SMD 0.38, 95% CI ‐0.04 to 0.79; participants = 350; studies = 3; I² = 70%
Sensitivity analysis 3, removing trials reported only in conference abstracts	No studies removed
Sensitivity analysis 4, removing trials that did not clearly focus on or predominantly include the target population of people with a fragility fracture resulting from low‐energy trauma	SMD 0.36, 95% CI 0.10 to 0.62; participants = 602; studies = 6; I² = 53%
Sensitivity analysis 5, removing trials that included mixed populations	SMD 0.36, 95% CI 0.10 to 0.62; participants = 602; studies = 6; I² = 53%
Sensitivity analysis 6, all trials, fixed‐effects meta‐analysis	SMD 0.33, 95% CI 0.17 to 0.50; participants = 602; studies = 6; I² = 53%

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Mobility (measured using mobility scales): combined data for all strategy types	7	761	Std. Mean Difference (IV, Random, 95% CI)	0.32 [0.11, 0.54]
4.2 Mobility (measured using Timed Up and Go, seconds): combined data for all strategy types	3	375	Mean Difference (IV, Fixed, 95% CI)	‐1.98 [‐5.59, 1.63]
4.3 Mobility (measured using 6‐Minute Walk Test, metres): combined data for all strategy types	4	396	Mean Difference (IV, Fixed, 95% CI)	28.66 [10.88, 46.44]
4.4 Mobility (measured using mobility scales): gait, balance and function	5	621	Std. Mean Difference (IV, Fixed, 95% CI)	0.20 [0.05, 0.36]
4.5 Mobility (measured using Timed Up and Go, seconds): gait, balance and function	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.6 Mobility (measured using Timed Up and Go, seconds): resistance/strength training	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.7 Mobility (measured using 6‐Minute Walk Test, metres): resistance/strength training	3	198	Mean Difference (IV, Fixed, 95% CI)	55.65 [28.58, 82.72]
4.8 Mobility (measured using 6‐Minute Walk Test, metres): endurance training	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.9 Mobility (measured using mobility scales): multiple component	2	104	Std. Mean Difference (IV, Fixed, 95% CI)	0.94 [0.53, 1.34]
4.10 Mobility (measured using 6‐Minute Walk Test, metres): multiple component	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.11 Mobility (measured using mobility scales): other type of exercise (non‐weight bearing exercise)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.12 Mobility (measured using Timed Up and Go, seconds): other type of exercise OT +/‐ sensor)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.13 Mobility (measured using mobility scales) reporting individual outcome measures	14		Mean Difference (IV, Random, 95% CI)	Subtotals only
4.13.1 Modified Physical Performance Test	1	80	Mean Difference (IV, Random, 95% CI)	5.70 [2.74, 8.66]
4.13.2 Physical Performance and Mobility Examination Score	1	105	Mean Difference (IV, Random, 95% CI)	0.32 [‐0.42, 1.05]
4.13.3 Short Physical Performance Battery	4	552	Mean Difference (IV, Random, 95% CI)	0.68 [0.15, 1.21]
4.13.4 Performance Oriented Mobility Assessment	1	24	Mean Difference (IV, Random, 95% CI)	4.90 [2.11, 7.69]
4.13.5 Timed Up and Go	3	366	Mean Difference (IV, Random, 95% CI)	1.69 [‐2.74, 6.12]
4.13.6 6 Minute Walk Test	4	396	Mean Difference (IV, Random, 95% CI)	33.98 [7.08, 60.89]
4.14 Mobility (measured using self‐report, continuous scales): combined data for all strategy types	2	355	Mean Difference (IV, Fixed, 95% CI)	1.46 [‐0.62, 3.53]
4.15 Mobility (measured using self‐reported, dichotomous outcome): combined data for all strategy types	1	108	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.29, 0.72]
4.16 Walking speed: combined data for all strategy types	14	1067	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [0.04, 0.29]
4.17 Walking speed: gait, balance and function	7	511	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.09, 0.25]
4.18 Walking speed: resistance/strength training	3	197	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.01, 0.58]
4.19 Walking speed: endurance	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.20 Walking speed: multiple component	3	285	Std. Mean Difference (IV, Random, 95% CI)	0.53 [‐0.13, 1.18]
4.21 Walking speed: other (post‐discharge physio telephone support and coaching)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.22 Walking speed: other (non‐weight bearing)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.23 Walking speed subgrouped by studies with cognitive impairment included v studies with cognitive impairment not included, combined data for all strategy types	14		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.23.1 People with cognitive impairment included	2	304	Std. Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.16, 0.29]
4.23.2 People with cognitive impairment excluded	12	762	Std. Mean Difference (IV, Fixed, 95% CI)	0.19 [0.04, 0.34]
4.24 Walking speed: subgrouped by outpatient v secondary and social care setting	14		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.24.1 Outpatient	2	229	Std. Mean Difference (IV, Fixed, 95% CI)	0.35 [0.08, 0.62]
4.24.2 Secondary and social care	12	838	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.02, 0.25]
4.25 Walking speed subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategies	14		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.25.1 Mean age in study 80 years or less	8	536	Std. Mean Difference (IV, Fixed, 95% CI)	0.12 [‐0.05, 0.30]
4.25.2 Mean age in study > 80 years	6	530	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [0.01, 0.36]
4.26 Functioning (measured using functioning scales): combined data for all strategy types	9	936	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [0.10, 0.36]
4.27 Functioning (measured using functioning scales): gait, balance and function	4	432	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [‐0.02, 0.36]
4.28 Functioning (measured using functioning scales): resistance/strength training	2	246	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [0.03, 0.55]
4.29 Functioning (measured using functioning scales): multiple components	2	107	Std. Mean Difference (IV, Fixed, 95% CI)	0.34 [‐0.04, 0.72]
4.30 Functioning (measured using functioning scales): other: OT +/‐ sensor	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.31 Health‐related quality of life (measured using HRQoL scales): combined data for all strategy types	10	785	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.00, 0.29]
4.32 Health‐related quality of life (measured using HRQoL scales): gait, balance and function	4	316	Std. Mean Difference (IV, Random, 95% CI)	0.08 [‐0.37, 0.53]
4.33 Health‐related quality of life (measured using HRQoL scales): resistance/strength training	3	197	Std. Mean Difference (IV, Fixed, 95% CI)	0.15 [‐0.14, 0.45]
4.34 Health‐related quality of life (measured using HRQoL scales): endurance	1	22	Mean Difference (IV, Random, 95% CI)	9.50 [‐8.56, 27.56]
4.35 Health‐related quality of life (measured using HRQoL scales): multiple components	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.36 Health‐related quality of life subgrouped by studies with cognitive impairment included v studies with cognitive impairment not included, combined data for all strategy types	10		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.36.1 People with cognitive impairment included	1	120	Std. Mean Difference (IV, Fixed, 95% CI)	0.00 [‐0.36, 0.36]
4.36.2 People with cognitive impairment excluded	9	665	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [0.01, 0.33]
4.37 Health‐related quality of life subgrouped by outpatient v secondary and social care setting	10		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.37.1 Outpatient	2	233	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.09, 0.45]
4.37.2 Secondary and social care	8	552	Std. Mean Difference (IV, Fixed, 95% CI)	0.13 [‐0.04, 0.30]
4.38 Health‐related quality of life subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategy	10		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
4.38.1 Mean age in study 80 years or less	4	184	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.05, 0.55]
4.38.2 Mean age in study > 80 years	6	601	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.05, 0.27]
4.39 Mortality, short term: combined data for all strategy types	7	737	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.49, 2.06]
4.40 Mortality, short term: gait, balance and function	3	264	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.46, 2.72]
4.41 Mortality, short term: resistance/strength training	2	123	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.19, 10.03]
4.42 Mortality, short term: multiple components	2	290	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.08, 4.55]
4.43 Mortality, short term: other: non‐weight bearing	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.03, 7.59]
4.44 Mortality, long term: combined data for all strategy types	4	588	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.39, 1.37]
4.45 Mortality, long term: gait, balance and function	2	254	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.34, 1.67]
4.46 Mortality, long term: multiple components	2	334	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.25, 1.96]
4.47 Adverse events (measured using dichotomous outcomes): combined data for all strategy types	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
4.47.1 Re‐admission	2	206	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.52, 1.42]
4.47.2 Re‐operation	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.20, 1.08]
4.47.3 Surgical complications	1	25	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.06, 13.18]
4.48 Adverse events (measured using re‐admission rate: combined for all strategy types	1		Rate Ratio (IV, Fixed, 95% CI)	Totals not selected
4.49 Adverse events (measured using rate of falls): combined for all strategy types	3		Rate Ratio (IV, Fixed, 95% CI)	0.79 [0.63, 0.99]
4.50 Adverse events (measured using rate of falls): gait, balance and function	2		Rate Ratio (IV, Fixed, 95% CI)	0.78 [0.62, 0.99]
4.51 Adverse events (measured using rate of falls): other (additional phone support and coaching)	1		Rate Ratio (IV, Fixed, 95% CI)	Totals not selected
4.52 Adverse events (measured as number of people who experienced 1 or more falls)	4		Risk Ratio (IV, Fixed, 95% CI)	1.03 [0.85, 1.25]
4.53 Adverse events (measured using continuous measure of pain)	3	242	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.29, 0.22]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Walking (measured as use of walking aid/need for assistance)	4	314	Risk Ratio (M‐H, Random, 95% CI)	0.46 [0.16, 1.31]
5.2 Walking (measured using self‐reported outcomes)	2	182	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.28, 1.06]
5.3 Balance (measured using functional reach test, cm)	2	144	Mean Difference (IV, Fixed, 95% CI)	1.30 [‐1.70, 4.31]
5.4 Balance (measured using timed standing in various positions)	2	234	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.37, 0.86]
5.5 Balance (measured using balance scale)	2	212	Std. Mean Difference (IV, Random, 95% CI)	0.28 [‐0.52, 1.08]
5.6 Balance (measured using continuous self‐reported meaure)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.7 Balance (measured using dichotomous self‐reported measure)	2	148	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.69, 0.98]
5.8 Sit to stand (measured as number of stand ups/second)	5	457	Mean Difference (IV, Random, 95% CI)	‐6.49 [‐12.23, ‐0.75]
5.9 Strength	14	1121	Std. Mean Difference (IV, Fixed, 95% CI)	0.30 [0.18, 0.42]
5.10 Strength subgrouped by studies with cognitive impairment included v studies with cognitive impairment not included, combined data for all strategy types	14		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
5.10.1 People with cognitive impairment included	2	230	Std. Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.19, 0.33]
5.10.2 People with cognitive impairment excluded	12	891	Std. Mean Difference (IV, Fixed, 95% CI)	0.37 [0.23, 0.50]
5.11 Strength subgrouped by stage of rehabilitation	12		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
5.11.1 Outpatient	2	227	Std. Mean Difference (IV, Fixed, 95% CI)	0.67 [0.39, 0.95]
5.11.2 Secondary and social care	12	890	Std. Mean Difference (IV, Fixed, 95% CI)	0.39 [0.25, 0.52]
5.12 Strength subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategies	14		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
5.12.1 Mean age in study 80 years or less	8	464	Std. Mean Difference (IV, Fixed, 95% CI)	0.35 [0.16, 0.54]
5.12.2 Mean age in study > 80 years	6	657	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [0.11, 0.43]
5.13 Activities of daily living (measured using ADL scales)	6	683	Std. Mean Difference (IV, Random, 95% CI)	‐0.01 [‐0.26, 0.23]
5.14 Self‐reported measures of lower limb/hip function	2	106	Std. Mean Difference (IV, Random, 95% CI)	0.78 [‐0.20, 1.77]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
6.1 Resistance/strength training v endurance training (mobility measured using 6‐Minute Walk Test	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.2 Resistance/strength training v endurance training (walking speed)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.3 Resistance/strength training v endurance training (health‐related quality of life)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.4 Resistance/strength training v endurance training (strength)	1	Mean Difference (IV, Random, 95% CI)	Totals not selected
6.5 Gait, balance and function v other (muscle contraction in supine) (mobility measured using mobility scale)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.6 Gait, balance and function v other (muscle contraction in supine) (walking speed)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.7 Gait, balance and function v other (muscle contraction in supine) (mortality)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.8 Gait, balance and function v other (muscle contraction in supine) (Adverse events: pain)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.8.1 Pain from fracture	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.8.2 Pain during exercise	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.9 Gait, balance and function v other (muscle contraction in supine) (Adverse events: number of people who fell)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.10 Gait, balance and function v other (muscle contraction in supine) (Balance, observed)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.11 Gait, balance and function v other (muscle contraction in supine) (Balance, self‐reported)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.12 Gait, balance and function v other (muscle contraction in supine) (strength)	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected

*Study characteristics*
Methods	Quasi‐randomised trial: by alternation; participants were allocated "sight unseen"
Participants	Caulfield Hospital, Victoria, Australia Period of study: started 12 May 1985 40 participants Inclusion: women with a hip fracture Exclusion: rheumatoid arthritis, active cardiac disease, neurological condition that would influence gait pattern Age: mean 83.5 years (range 69 to 97 years) % male: none Number lost to follow‐up: probably none, although 1 died.
Interventions	Early postoperative rehabilitation 1. Treadmill gait retraining programme. Use of Repco treadmill with velocity and distance controls. Adjustable side rails for partial weight‐bearing stage. versus 2. Conventional gait retraining involving use of ambulatory aid (walking frame) Both groups had participated in the same muscle strengthening programme beforehand. Other aspects of physical therapy was reported to be similar.
Outcomes	Length of follow‐up: until discharge from rehabilitation hospital Mobility level at discharge (3 levels: house bound; limited outdoor activity; outdoor activity unlimited by symptoms) Walking velocity Knee extensor strength Return to living at home Length of hospital stay Mortality (in hospital)
Notes	A subgroup of 6 'matched pairs' were studied in greater detail for gait analysis, strength and length of stay. These matched pairs are not included in this review. Funding: none declared Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Quasi‐randomised trial involving alternation: "the first patient was allocated to the treadmill group, the second to the control group, and so on".
Allocation concealment (selection bias)	High risk	Predictable sequence even though researcher apparently "allocated patient 'sight unseen'"
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No mention of blinding of therapists conducting the intervention and the participants. Impact of non‐blinding is unclear.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	High risk	There was no mention of blinding.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Not blinded; however, the assessment of the outcome is unlikely to be influenced by knowledge of group allocation
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Measure of mobility assessment was crude. Gait analysis was reported for 6 matched pairs: this decision was not explained fully.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	High risk	The group allocations for the only death and the 5 other participants requiring nursing home or special accommodation were not given.
Selective reporting (reporting bias)	High risk	The reason for reporting gait analysis outcomes for 6 matched pairs was not provided.
Free from baseline imbalance bias?	Unclear risk	Insufficient information
Free from performance bias due to non‐trial interventions?	Low risk	Explicit mention of comparability

*Study characteristics*
Methods	Randomised trial: use of a computer‐generated algorithm and block design, stratified by type of surgery (hemiarthroplasty or internal fixation)
Participants	Community‐dwellers, St Louis, Missouri, USA Period of study: August 1998 to May 2003 90 participants Inclusion: physically frail people (modified Physical Performance Test score of 12 to 28 and ADL difficulty) aged 65 years or over with a surgically‐repaired proximal femoral fracture in the previous 16 weeks who had completed standard physical therapy. Informed consent Exclusion: pathological fracture, contralateral hip fracture, dementia or cognitive impairment, inability to walk 50 feet, visual or hearing impairments interfering with participation, other major medical conditions (cardiopulmonary or neuromuscular disease), taking medication for osteoporosis, on hormone replacement therapy, terminally ill Age: mean 80 years (range not given) % male: 26 Number lost to follow‐up: 5 (2 due to personal reasons, 2 due to medical problems, 1 died)
Interventions	Started after end of standard physical therapy. 1. Six months of supervised exercise carried out 3 times weekly. For the first 3 months, small group (2 to 5 participants) progressive exercise for flexibility, balance, co‐ordination, movement speed, strength and endurance led by a physical therapist. After the first 3 months, progressive resistance training was added (progressed by end of 1 month to 3 sets of 8 to 12 repetitions at 85% to 100% of initial 1 RM voluntary strength. versus 2. Low‐intensity, non‐progressive home exercise programme carried out 3 times weekly after a 1‐hour training session, plus monthly group sessions and weekly 10‐minute telephone calls. Additional interventions for both groups: monitoring and instruction by dietitian if indicated, and vitamin D if indicated at baseline. All received calcium and multi‐vitamin tablets.
Outcomes	Length of follow‐up: 6 months Physical Performance Test score (modified) Functional Status Questionnaire score Instrumental Activities of Daily Living score Basic Activities of Daily Living score Use of assistive gait devices Knee extension strength Fast walking speed Single limb stance time Berg Balance Scale SF‐36 (health, physical function, social subscales) Hip Rating Questionnaire Adherence Adverse events and subsequent fractures Mortality
Notes	Host 2007 reported data only from intervention group participants (31/46 participants) who had completed at least 30 sessions in each of the two 3‐month exercise phases. Measured adherence Funding: National Institute of Aging grant R01 G15795, the Washington University General Clinical Research Center grant 5‐M01 RR00036, the Washington University Clinical Nutrition Research Center grant P30 DK56341, and the Barnes Jewish Hospital Foundation. Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Random assignment ... was performed on completion of the baseline assessments within strata, defined as the types of surgical repair procedure (hemiarthroplasty vs open reduction internal fixation), using a computer generated algorithm and block design."
Allocation concealment (selection bias)	Unclear risk	No clear indication of allocation concealment
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	There was blinding of outcome assessors: "the research staff who conducted the assessments were not involved in exercise training and were blinded to group assignment".
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	Binding relating to attribution of study related/unrelated causes of medical problems or fractures is uncertain.
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	There was blinding of outcome assessors: "the research staff who conducted the assessments were not involved in exercise training and were blinded to group assignment".
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Unclear risk	Five of the 90 participants were lost to follow‐up at 6 months. The last observation for these 5 participants was carried forward and an intention‐to‐treat analysis was conducted with data for the whole trial population.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	Mortality follow‐up adequate
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	Unclear risk	Five of the 90 participants were lost to follow‐up at 6 months. The last observation for these 5 participants was carried forward and an intention‐to‐treat analysis was conducted with data for the whole trial population.
Selective reporting (reporting bias)	Low risk	Pre‐trial completion information shows consistent primary outcome
Free from baseline imbalance bias?	Low risk	Comprehensive breakdown of characteristics without significant differences
Free from performance bias due to non‐trial interventions?	Low risk	Measures taken to counteract differences in social contact in the control group by weekly phone calls

*Study characteristics*
Methods	Randomised trial: 2x2 factorial design
Participants	Triemli City Hospital, Switzerland Period of study: January 2005 to December 2007 173 participants Inclusion: aged 65 years or over with a surgically‐repaired hip fracture, MMSE ≥ 15, able to walk 3 m, German speaking, creatinine clearance of more than 15 mL/min (to convert to millilitres per second, multiply by 0.0167) Exclusion: prior fracture of same hip, metastatic cancer or chemotherapy in the last year, severe visual or hearing impairment, kidney stone in the past 5 years, hypercalcaemia, primary hyperparathyroidism or sarcoidosis Age: mean 84 years (range 65 to 99) % male: 21 Number lost to follow‐up: 22. Analysed as ITT
Interventions	Extended physiotherapy plus high/low dose cholecalciferol 1. Extended physiotherapy plus 800 IU/d cholecalciferol. Supervised 60 min during acute care (additional 30 min home programme instruction each day during acute care) plus unsupervised home programme over 12 months. Advised to maintain usual diet and avoid additional calcium and cholecalciferol supplements. 2. Standard physiotherapy (supervised 30 min/day during acute care plus no home programme) plus 2000 IU/d cholecalciferol 3. Extended physiotherapy plus 2000 IU/d cholecalciferol. 4. Control. Standard physiotherapy (supervised 30 min/day during acute care plus no home program) plus 800 IU/d cholecalciferol. Advised to maintain usual diet and avoid additional calcium and cholecalciferol supplements. Only the comparison of standard versus extended physiotherapy eligible for inclusion in this review.
Outcomes	Length of follow‐up: 24 weeks Mortality Knee extensor Timed Up & Go EQ‐5D‐3L Adverse effects: re‐fracture rate, re‐admission, admission to institution, falls, mild hypercalcaemia, nephrolithiasis Adherence (total days and minutes of physiotherapy)
Notes	Measured adherence Funding: this study was supported by Swiss National Foundations (NFP‐53), Vontobel Foundation, Baugarten Foundation and Swiss National Foundations professorship grant PP00B‐ 114864. Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐based randomisation
Allocation concealment (selection bias)	Unclear risk	Not clearly reported
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	Outcome assessors blinded
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Outcome assessors blinded. All admission records were reviewed by 3 blinded co‐investigators to determine the main cause of re‐admission.
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	Outcome assessors blinded for health‐related quality of life. Blinding of personnel collecting fall data and answering hotline telephones was not specified.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Large degree of loss to follow‐up. Although analysed as ITT, the high degree of attrition incurs a high risk of bias.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	High risk	Large loss to follow‐up
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	High risk	Large loss to follow‐up
Selective reporting (reporting bias)	Unclear risk	Mobility outcomes not clearly stated in study registration
Free from baseline imbalance bias?	Low risk	Groups balanced at baseline
Free from performance bias due to non‐trial interventions?	High risk	Extended physiotherapy had home visits which may have a confounding effect due to the social interaction
Method of ascertaining falls	Low risk	Falls recorded via monthly telephone calls and a patient diary. Also, a telephone hotline to report falls at any time

*Study characteristics*
Methods	Randomised controlled trial
Participants	Two rehabilitation units at two hospitals (Glasgow Royal Infirmary and Hairmyres Hospital), UK Period of study: November 1999 to November 2000 26 participants Inclusion: people aged ≥ 65 years with hip fracture treated surgically (all internal fixation) up to 21 days previously, written informed consent Exclusion: terminal disease, abbreviated mental score < 7/10, previous inability to walk, profoundly deaf, cardiac pacemaker, unstable medical conditions (e.g. pneumonia, heart failure) Age: mean 81 years (range not stated) % male: 8% Number lost to follow‐up: 3 refusals + 2 deaths; also 2 telephone follow‐up only
Interventions	Postoperative rehabilitation 1. Supplementary electrical stimulation (ES) of quadriceps for 6 weeks: 5 days / week for inpatients; twice a week upon discharge. ES consisted of 7 seconds of stimulation of quadriceps followed by 23 seconds of relaxation for 36 repetitions; each session lasted 18 minutes. Delivery by physiotherapist assistant. Usual physiotherapy. versus 2. Usual physiotherapy only. Inpatient physiotherapy consisted of supervised strengthening and range of motion exercises, balance training, work on transfers and progressive gait re‐education. Expert physiotherapist established optimum electrical stimulation post‐baseline measurement but prior to randomisation (tolerance levels not provided for control group participants). Intervention started in hospital, baseline measurements at median 10 to 11 days post‐surgery, and continued at home after hospital discharge.
Outcomes	Length of follow‐up: 14 weeks Elderly Mobility Scale Leg extension power Barthel Index Nottingham Health Profile (gait speed, emotional reactions, energy, pain, physical mobility, sleep, social isolation) Mortality
Notes	Two other outcomes (Timed Up and Go test, isometric quadriceps strength) described in trial registration / abstracts but not in full report Funding: Royal Infirmary Reserch Endowments Fund Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Randomisation was by computer‐generated random numbers"
Allocation concealment (selection bias)	Low risk	"[With] individual patient codes held in opaque sealed envelopes by an administrator independent from the study.”
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	“Measurements were made at baseline, at 6 weeks (the end of intervention) and 14 weeks by a single blinded assessor.”
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Only mortality was reported. “Measurements were made at baseline, at 6 weeks (the end of intervention) and 14 weeks by a single blinded assessor.” Assessment of mortality is not likely to be influenced by knowledge of group allocation.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Unclear risk	Although participant flow data provided, loss to follow‐up was proportionality greater in the intervention group.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	Only mortality reported
Selective reporting (reporting bias)	Unclear risk	Consistent reporting of primary outcomes, but 'Timed Up and Go test' and isometric muscle data indicated in abstract and trial registration form are missing
Free from baseline imbalance bias?	Unclear risk	"There was a non‐significant trend for the control group to have a greater unfractured leg extensor power and higher Barthel scores at study entry." Proportionally fewer intervention group participants had independent mobility at baseline (27% versus 55%).
Free from performance bias due to non‐trial interventions?	Unclear risk	Although participants in both groups received standard physiotherapy while inpatients, it is not clear whether post‐discharge provision was similar.

*Study characteristics*
Methods	Randomised trial: method not stated; stratified by age of participant
Participants	Western Infirmary, Glasgow, UK Period of study: February 1961 to August 1966 273 participants (but possible that 604 participants were randomised) Inclusion: people with a displaced intracapsular proximal femoral fracture (Garden type III or IV) treated by closed reduction and internal fixation with a sliding nail plate. Exclusion (post randomisation): any reason (pulmonary or cardiac complications, deep venous thrombosis, general feebleness, re‐displacement of the fracture) at 2 weeks that the individual was not considered fit enough to walk at this time. Age: not stated (within 56 to 95 for the 175 participants followed up for 3 years) % male: not known Number lost to follow‐up: disregarding post‐randomisation exclusions, 13 with incomplete follow‐up and 43 died at 1 year.
Interventions	Early postoperative rehabilitation. Operative treatment consisted of closed fracture reduction and internal fixation with a sliding nail plate. For the first 2 weeks postop, patients sat out of bed but were not permitted to stand or walk. 1. Early weight bearing at 2 weeks after surgery: unguarded walking versus 2. Delayed weight bearing until 12 weeks after surgery
Outcomes	Length of follow‐up: 1 year for all, 3 years for subgroup Mortality Non‐union of the fracture (failure) Avascular necrosis (segmental collapse) Infection of the hip
Notes	An interim report for 124 trial participants at 3 months was available in 1964 (Abrami 1964), with a second report in 1968 (Graham 1968) which presented results for 273 participants at 1 year and results at 3 years for the 175 participants who had been followed up by then. Data from Abrami 1964 are not presented in the review. Funding: none declared Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	According to earliest report: "After operation, but according to the sequence of their admission to hospital, patients in comparable five‐year age groups were randomly allocated to either the early or the late weight‐bearing groups" (Abrami 1964). But as reported by Graham 1968: "After admission to hospital each patient was allocated, by random selection, to an early or late weight‐bearing group within each decade from fifty‐six to ninety‐five years'. It was emphasised in the report that it was not alternation.
Allocation concealment (selection bias)	Unclear risk	No information
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No mention of blinding. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	High risk	No mention of blinding, nor of measures taken to safeguard knowledge of allocation at follow‐up data collection
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	No mention of blinding; however, assessment of the outcome is unlikely to be influenced by knowledge of group allocation
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Outcomes were not reported. Even so, there was incomplete long‐term follow‐up (only 175 of the 273 included participants ‐ after post‐randomisation exclusions) ‐ see next item.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	High risk	Trial recruitment and randomisation were at hospital admission (604 admitted), but only those 273 patients who were judged as being suitable ‐ in that they could be expected to walk at the 2‐week clinical assessment ‐ were included in the analyses. The number of participants excluded at 2 weeks was not reported. Included participants were analysed in the group they were allocated at randomisation.
Selective reporting (reporting bias)	High risk	No indication of a protocol. Interim results generally reported. Differences between papers in account of trial (e.g. stratification)
Free from baseline imbalance bias?	High risk	Baseline data not given for randomised groups, nor for followed‐up participants, with the exception of gender and age group. All intracapsular fractures treated with same implant
Free from performance bias due to non‐trial interventions?	High risk	No information

PERMALINK

Interventions for improving mobility after hip fracture surgery in adults

Nicola J Fairhall

Suzanne M Dyer

Jenson CS Mak

Joanna Diong

Wing S Kwok

Catherine Sherrington

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings 1. Summary of findings: in‐hospital studies.

Summary of findings 2. Summary of findings: different types of intervention on mobility outcome, in‐hospital.

Summary of findings 3. Summary of findings: post‐hospital studies.

Summary of findings 4. Summary of findings: different types of intervention on mobility outcome, post‐hospital.

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Comparisons

Types of outcome measures

Main or 'critical' outcomes

Other important outcomes

Economic and resource outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

1.

Included studies

1. Key characteristics of participants and intervention approach.

2. Study design, length of follow‐up, setting and trial size.

Design

3. Assessment of items relating to applicability of trial findings.

Sample sizes

Setting

Participants

Interventions

In‐hospital rehabilitation

In‐hospital rehabilitation: comparing intervention to control, grouped by different types of intervention

Gait, balance and functional exercises

Resistance exercises

Electrical stimulation of the quadriceps

In‐hospital rehabilitation: comparing different timing of intervention

Post‐hospital rehabilitation

Post‐hospital rehabilitation: comparing intervention to control, grouped by different types of intervention

Gait, balance and functional exercises

Resistance exercises

Endurance exercise

Multiple categories

Other

*Study characteristics*
Methods	Randomised controlled trial using a protected random number system; stratified by hip‐ or lower‐extremity fracture surgery and non‐hip‐ or lower‐extremity fracture patients (see Notes)
Participants	Heidelberg, Germany Period of study: not stated, but trial may have started around 1997 28 female participants Inclusion: females aged ≥ 75 years (25 with a fall‐related hip fracture and 3 with elective hip surgery) who had experienced a recent injurious fall. Written informed consent and permission from orthopaedic surgeon Exclusion: acute neurological impairment, severe cardiovascular disease, unstable chronic or terminal illness, major depression, severe cognitive impairment, severe musculoskeletal impairment Age: mean 81 years (range not stated) % male: none Number lost to follow‐up: 4 (3 didn't start exercises and 1 dropped out)
Interventions	Started immediately upon hospital discharge. 1. 12‐week regimen of intensive physical training (lower extremity progressive resistance training, progressive functional and balance training). All exercise sessions took place in training groups (4 to 6 participants) supervised by a therapeutic recreation specialist. Each session: 1.5 hours of resistance training (with recovery breaks) and 45 minutes of balance/functional training. Intensity of strength training adjusted to 70% to 90% of individual maximal workload. Basic functions such as walking, stepping or balancing were trained progressively with increasing complexity. versus 2. Placebo motor activity: 1‐hour sessions of activities such as flexibility exercise, callisthenics, ball games and memory tasks while seated. Both regimens, taking place 3 times a week, started on average 4 to 5 weeks after surgery upon discharge from inpatient rehabilitation. Both groups received identical additional physiotherapy (mainly massage, stretching and application of heat or ice) twice weekly for 25 minutes: strength and balance training was excluded from these sessions.
Outcomes	Length of follow‐up: 6 months (12 weeks + 3 months) Walking velocity and cadence Independent weight bearing Performance‐orientated motor assessment Box step Functional Reach Timed Up and Go test Chair and stair rises Activities of daily living; sports and household activities Muscle strength: leg‐press, leg‐extensor, leg flexor, ankle‐plantar flexion, hand grip strength (non‐trained muscle group) Loss of independence Subjective fear of falling Subjective walking steadiness Emotional state: depression, morale and handicap scales Adherence
Notes	Measured adherence This trial was excluded from versions of this review up to Issue 3, 2004 because the intervention began after the early postoperative period covered by this review, which then focused on early postoperative rehabilitation. Trial actually included 57 people who had experienced an injurious fall. One report of the trial gave the results for the subgroup of 28 participants who had hip surgery. Of these, 25 had surgery for a fall‐related hip fracture and 3 had elective hip surgery. The patient characteristics of the latter 3 women were confirmed as being essentially similar to those of the 25 women with hip fracture. A 2‐year follow‐up of the trial is available but only for the whole trial population. Further information, including method of randomisation, received from lead trialist on 05 March 2004 and 24 June 2004 Funding: grant from Ministerium fur Wissenschaft, Forschung und Kunst Baden‐Wuerttemberg and the University of Heidelberg Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Randomization was performed .... using a protected random number system"
Allocation concealment (selection bias)	Low risk	"Randomization was performed by an external person who did not participate in the study using a protected random number system"
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Care providers providing the intervention and the participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	"Main outcome variables were documented by a person blinded to the patients' group assignment."
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	"Main outcome variables were documented by a person blinded to the patients' group assignment."
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Efforts had been made to collect outcome data for the 4 dropouts, 3 of whom did not start the exercises and 1 who discontinued their exercises. However, these data were not available.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Unclear risk	While all participants were accounted for, there were incomplete data on complications (although: 'minor') and long‐term follow‐up.
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	High risk	Efforts had been made to collect outcome data for the 4 dropouts, 3 of whom did not start the exercises and 1 who discontinued their exercises. However, these data were not available.
Selective reporting (reporting bias)	Unclear risk	Unclear. However, the 3 main reports of the trial were consistent in the reported outcomes and the author provided clarification on some of the outcome measures used.
Free from baseline imbalance bias?	Low risk	Baseline characteristics were similar in the 2 groups.
Free from performance bias due to non‐trial interventions?	Low risk	There was no cause for concern.

*Study characteristics*
Methods	Randomised trial: use of random numbers
Participants	University Central Hospital, Helsinki, Finland Period of study: May 1973 to October 1974 100 participants Inclusion: people aged > 50 years with femoral neck fracture treated surgically (internal fixation or prosthesis), capable of independent 'getting about' before fracture Exclusion: none given Age: mean 73 years (range not stated; all over 50 years) % male: 25% Number lost to follow‐up: 13 (excluded from 9‐week follow‐up because of inadequate follow‐up), 4 (excluded from 3‐month mortality data)
Interventions	Early postoperative rehabilitation, started first postoperative day onwards 1. Intensive (performed twice daily) physiotherapy regimen versus 2. Same regimen performed once daily (conventional care) Routine physiotherapy was on average 30 minutes per day. For the intensive group, the physiotherapy time was doubled. Both groups were under supervision of the study physiotherapist. Regimen was continued for 14 days. From first postoperative day, training in walking on crutches; training in sitting in chair; flexion‐extension movements of knee, hip and ankle. Most participants were allowed full weight bearing from the beginning. (For those with internal fixation, crutch use for up to 2 to 3 months.) From second postoperative week, training in walking up and down stairs.
Outcomes	Length of follow‐up: 9 weeks (for strength) Walking ability Ability to move and sit up in bed on first postoperative day Abductor muscle strength at 9 weeks Residence at 9 weeks Mortality "Mechanical" postoperative complications Medical complications, including thromboembolism and postoperative infection Length of hospital stay
Notes	Of the 100 people recruited for the trial, 13 had inadequate follow‐up and the results of these participants are not presented. Most of the results for the trial were presented split according to whether the participant had a prosthesis or internal fixation, rather than by the trial interventions. A thesis (1978, University of Helsinki) was located by Lesley Gillespie (10 June 2004). Requests for a copy met with no success. Funding: none declared Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Using random numbers the patients selected for the study were divided before the operation into two physiotherapy groups."
Allocation concealment (selection bias)	Unclear risk	No report
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No mention of blinding. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	High risk	No mention of blinding
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	No mention of blinding; however, assessment of the outcome is unlikely to be influenced by knowledge of group allocation.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Results for 13 participants with inadequate follow‐up were not presented.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	High risk	Results for 13 participants with inadequate follow‐up were not presented.
Selective reporting (reporting bias)	High risk	Mobility data split by treatment group were not presented.
Free from baseline imbalance bias?	High risk	There was a lack of information on baseline characteristics and comparability; data were not provided for 13 participants with inadequate follow‐up. The report referred to a non‐significantly greater number of participants in the routine physiotherapy group being treated with Jewett nails.
Free from performance bias due to non‐trial interventions?	Low risk	Appears so; the same physiotherapist provided both interventions.

*Study characteristics*
Methods	Randomised controlled trial. Randomly assigned by computer program
Participants	The Alfred Hospital, a level 1 trauma centre, Melbourne, Australia Period of study: March 2014 to January 2015 92 participants Inclusion: at least 65 years old, admitted with an isolated subcapital or intertrochanteric hip fracture, treated by internal fixation or hemiarthroplasty Exclusion: subtrochanteric or pathological fracture; postoperative orders for non‐weight bearing on the operated hip; unable to move independently or needed a gait aid prior to admission; admitted from nursing home Age: mean (SD) = 81.3 (8.2) % male: 36 Number lost to follow‐up: 13 (died = 1, unable to contact via telephone at 6 months = 12)
Interventions	1. Intervention group: usual care* in the morning plus 2 additional daily sessions, 7 days per week. One session (delivered by allied health assistant) practised the achievements of the morning session. One session (delivered by physiotherapist) aimed to improve the functional advances achieved during the earlier physiotherapy session; e.g. increased independence, progression of gait aid (e.g. from frame to crutches) and increasing the distance walked. 2. Control: usual care* in the morning *Usual care: participants in both groups received daily physiotherapy according to usual practice in the trauma centre, 7 days per week. Treatment was individualised and involved bed‐based limb exercises (e.g. strength exercises, such as knee extension, and active hip exercises) and gait re‐training. The goal was early, independent transfer and mobility, with the objective of discharge directly home or to fast stream rehabilitation.
Outcomes	Length of follow‐up: Mobility and Modified Iowa Level of Assistance outcomes = Day 5 postop (or discharge, if discharged before Day 5); QOL 6 months. Modified Iowa Level of Assistance score (hip‐fracture‐specific outcome, with 6 domains, including bed and chair transfer, ambulation, ascending/descending 1 step, and gait aid used, 0 (independent in all activities without a gait aid) to 36 (unable to attempt any of the activities). Day 5 or day of discharge (if earlier) Timed Up and Go test Day 5 or day of discharge (if earlier) Length of stay (acute, inpatient rehabilitation, combined) Inpatient complication Re‐admission SF‐12, EQ‐5D (6 months) Discharge destination Death
Notes	Resource use collected: physiotherapy hours of service, acute / rehab / combined hospital length of stay Funding: Victorian Department of Health (Workforce Innovation and Allied Health) Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Participants were randomly assigned by computer program"
Allocation concealment (selection bias)	Unclear risk	Allocation concealment not specified. Insufficient information to permit judgement
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear. The usual care physiotherapist was blinded to allocated group.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	Blinding specified for Modified Iowa Level of Assistance, Timed Up and Go test.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Blinding not specified, but likely as data were collected from Victorian Orthopaedic Trauma Outcomes Registry, for SF‐12, EQ‐5D and Glasgow Outcome Scale. Blinding not specified for length of stay, inpatient complications, re‐admissions. Outcome measurement is unlikely to be influenced by lack of blinding.
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	Health‐related quality of life data derived from data in the Victorian Orthopaedic Trauma Outcomes Registry. Can assume this was collected by personnel blinded to the study.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Unclear risk	Timed Up and Go test performed only for people who could walk, so only 40/92 (42%) of participants contributed to this measure. All participants contributed to other measures at 5 days postop.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	13/92 (14%) lost to follow‐up at 6 months
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	Low risk	15% lost to follow‐up at 6 months for health‐related quality of life
Selective reporting (reporting bias)	Low risk	All outcomes specified in trial registry and methods section were reported in the results
Free from baseline imbalance bias?	High risk	There were statistically significant between‐group differences in anaesthetic type (general versus spinal), proportion of men, and having a carer at home.
Free from performance bias due to non‐trial interventions?	Low risk	Care and experience of care providers was consistent across groups

*Study characteristics*
Methods	Randomised trial (randomisation was stratified for fracture type (trochanteric/femoral neck))
Participants	Acute orthopaedic ward at a university hospital, Copenhagen, Denmark Period of study: October 2013 to May 2015 90 participants Inclusion: home‐dwelling, primary hip fracture surgery, aged 65 years or older, able to speak and understand the Danish language, independent pre‐fracture indoor walking ability equal to a New Mobility Score ≥ 2 Exclusion: multiple fractures, weight‐bearing restrictions, people unwilling to participate in appropriate rehabilitation or unable to co‐operate in tests, terminal illness, and treatment with total hip arthroplasty or parallel pins Age: mean (SD) 79.6 (7.56) % male: 23 Number lost to follow‐up: 10 (restrictions after X‐ray n = 1, re‐fracture n = 1, discharge without notice n = 2, declined assessment n = 1, death n = 2, transferred n = 2, incomplete follow‐up test of fractured limb n = 1)
Interventions	1. Intervention: routine physiotherapy* plus additional daily individual progressive knee‐extension strength training with 3 sets of 10 repetitions performed with an intensity of 10 repetition maximum (10 RM), defined as ±2 RM of the fractured limb using ankle weight cuffs. 2. Control: routine physiotherapy* *Routine physiotherapy: basic mobility and exercise therapy primarily aimed at lower extremities following a guideline with 12 specific lower limb exercises, progressed individually and conducted daily on weekdays with 1 to 2 contacts per day (weekends included postoperative day 1 to 3 only). Repetitions and intensity were not standardised. Also basic mobility activities, balance and stair climbing aimed at regaining physical function corresponding with levels of pre‐fracture habitual activity, and progression of walking aids.
Outcomes	Change in maximal isometric knee‐extension strength (N·m/kg) in the fractured limb in percentage of non‐fractured limb (Maximal Voluntary Torque per kilo body mass) from inclusion to postoperative day 10 or discharge (follow‐up), using belt‐fixed handheld dynamometer Timed Up and Go test, measured as early as possible after surgery when participant could walk independently with rollator and at follow‐up using a rollator as a standardised walking aid Independent mobility at discharge (scored using Cumulated Ambulation Score) Length of admission (postoperative day of discharge) Discharge destination Pain. Hip‐fracture‐related pain at rest and during outcome assessment, evaluated by Verbal Ranking Scale (score 0 to 4) using the highest pain level reported from each session Death
Notes	The stratification on fracture type was violated in the last 10 included participants due to slow inclusion of participants with a femoral neck fracture, allowing more participants with trochanteric fractures (n = 52) to enter the study compared to femoral neck fractures (n = 38). Measured gait speed and independent mobility, but no data presented. Measured adherence Funding: grants from The IMK Foundation (LK), The Research Foundation of the Capital Region (MTK), The Research Foundation of the Danish Physical Therapy Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"[Randomly] allocated to two different postoperative in‐hospital rehabilitation interventions by a neutral person (blinded to outcomes and patient characteristics) via a computer‐generated list"
Allocation concealment (selection bias)	Low risk	"[Notes] placed in sealed envelopes and marked with participant numbers only"
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	Outcome assessor was blinded to group assignment.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	Method of assessing death was unclear.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Unclear risk	Timed Up and Go test and timed 10 m walk were performed only for people who could walk;unclear what percentage of participants contributed to these measures
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	10/90 (11%) lost to follow‐up
Selective reporting (reporting bias)	High risk	Protocol appended to paper. Thigh and lower leg circumference is an outcome in protocol, but not reported. Protocol states Timed Up and Go test, 10‐Metre Walk Test, New Mobility Score, and isometric strength would be assessed at 16 weeks, but these were not reported in results paper. Data not presented for 10m walk time, but between‐group difference is reported.
Free from baseline imbalance bias?	Low risk	No imbalance noted
Free from performance bias due to non‐trial interventions?	Low risk	Care and experience of care providers appears consistent across groups

*Study characteristics*
Methods	Randomised trial: use of sequentially‐numbered, sealed, opaque envelopes; stratified by pre‐injury mobility
Participants	John Radcliffe Nuffield Orthopaedic Hospital, Oxford, UK Period of study: not stated, earliest report located 1998 27 female participants Inclusion: women aged ≥ 75 years who had surgical fixation (not total hip replacement) of a hip fracture, living in own home or a relative's home or in sheltered housing before their injury. Written informed consent Exclusion: history of stroke or Parkinson's disease, clinical depression or acute mental illness, cognitive impairment: 6 or lower on the Hodkinson Mental Test Score. Other fracture, respiratory or cardiac failure sufficient to prevent walking 50 feet (15.25 m), systolic blood pressure > 200 mmHg or diastolic blood pressure > 100 mmHg, surgical complications, pathological fracture. At medication assessment at day 6: on hypnotics, sedatives, muscle relaxant or medications likely to affect muscular function during postoperative period. Age: mean 84 years (range: not stated) % male: none Number lost to follow‐up: 3 excluded. One had myasthenia gravis (confirmed independently as not related to trial), one a severe chest infection and the third participant withdrew consent after a few days.
Interventions	Early postoperative rehabilitation, started at 7 days after surgery. 1. Patterned neuromuscular (electrical) stimulation of the quadriceps muscle for 3 hours a day for 6 weeks. Stimulus intensity was the minimum required for visible muscle contraction. Each stimulus delivered 0.3 micro coulomb of charge. versus 2. Placebo stimulation for same time period. Interventions started in hospital 1 week after surgery and continued at participants' homes after hospital discharge at 10 to 14 days. A trained assistant, who was independent of the study, showed the participants how to apply the stimulator.
Outcomes	Length of follow‐up: 12 weeks after randomisation (13 weeks after surgery) Recovery of mobility Walking velocity Leg extensor power Compliance Pain (1: no pain to 6: severe pain) Side effects (none)
Notes	Patterned neuromuscular (electrical) stimulation is "a variable frequency stimulus (mean frequency 8.9 Hz) derived from the discharge of a fatiguing motor unit of the quadriceps". The stimulator was designed for home use, being portable and independent of an electric supply. Difficulties found by the participants in changing the batteries meant that weekly visits were required by study personnel. Funding: Research into Ageing and the PPP Healthcare Charitable Trust. Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	“Randomization lists were prepared in advance of the study with a random number table.”
Allocation concealment (selection bias)	Low risk	“Assignments were placed in sealed, numbered, opaque envelopes that were opened in a strict sequence after eligibility had been established and consent obtained.”
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Good attempt made to blind participants with placebo stimulation.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	“The investigator responsible for measuring outcomes and all participants were blind to the treatment assignment."
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Only complications reported, blinding indicated, and assessment of this outcome is unlikely to be influenced by knowledge of group allocation.
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Unclear risk	No data, including group allocation, presented for the 3 people who did not complete the study
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Unclear risk	Only complications reported
Selective reporting (reporting bias)	Unclear risk	Probably, but no trial protocol or trial registration available
Free from baseline imbalance bias?	Unclear risk	Incomplete report of baseline data as those for the 3 post‐randomisation exclusions were not available. No major differences in the available data for those followed up.
Free from performance bias due to non‐trial interventions?	Low risk	No obvious differences. Both arms included similar usual care.

*Study characteristics*
Methods	Randomised trial
Participants	Acute orthopedic unit in metro Vancouver teaching hospital, Vancouver, BC, Canada Period of study: November 2013 to September 2014 30 participants Inclusion: community‐dwelling adults with a recent fall‐related hip fracture ≥ 60 years of age, recruited following surgical repair. English speaking Exclusion: fracture related to metastatic disease or bisphosphonate use, did not return home in the community after hospital discharge, medical contraindications restricting activity and exercise, hearing or speech impairments precluding telephonic communication, or physician‐diagnosed dementia. Age: mean 82.5 years (range 61 to 97) % male: 37% Number lost to follow‐up: 4 (postoperative complications n = 3, moved to residential care n = 1)
Interventions	Additional post‐discharge physiotherapist telephone support and coaching 1. Telephone support and coaching: usual care plus 1‐hour in‐hospital individualised education session using the hip fracture recovery manual and 4 educational videos (FReSH Start), plus up to 5 phone calls in the first 4 months post‐fracture from research physiotherapist (average 151 minutes of phone time). Phone calls focused on goal setting regarding recovery goals, mobility goals, adherence to exercise programme and community reintegration. 2. Usual care: usual care plus 1‐hour in‐hospital individualised education session using the hip fracture recovery manual and 4 educational videos (FReSH Start). Usual care included follow‐up physician and surgeon visits, and usual rehabilitation and home care as appropriate.
Outcomes	Length of follow‐up: 4 months Mobility (observed): 4‐Metre Walk Test Mobility (self‐reported): use of mobility aid Quality of life (EQ‐5D‐5L) Strength: grip Strength Adverse events: falls (risk and number), re‐admissions (30‐day) Pain
Notes	Funding: nil Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Web‐based randomisation service. Stratified randomisation by sex and age group
Allocation concealment (selection bias)	Low risk	An independent statistician from an off‐site consulting firm generated the allocation sequence.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and the participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	High risk	Participants, the research physiotherapist and study co‐ordinator were aware of treatment allocation. Outcome assessment completed by research physiotherapist
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	Participants, the research physiotherapist and study co‐ordinator were aware of treatment allocation. Outcome assessment completed by research physiotherapist. Unclear how this affected objective outcomes
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	High risk	Health‐related quality of life: participants, the research physiotherapist and study co‐ordinator were aware of treatment allocation. Outcome assessment completed by research physiotherapist. Risk of bias for health‐related quality of life = high Falls: ascertained by the same method in both groups, self‐reported by participant. Blinded assessors monitored monthly via telephone. Risk of bias for falls = unclear
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	27% of intervention group participants were lost to follow‐up (3 postop complications, 1 residential care admission). No control group participants were lost to follow‐up. The disproportionate loss in intervention and control groups may affect the outcome and it is possible those lost due to complications had different mobility.
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	High risk	27% of intervention group participants were lost to follow‐up (3 postop complications, 1 residential care admission). No control group participants were lost to follow‐up. The disproportionate loss in intervention and control groups may affect the outcome and it is possible those lost due to complications would have been more likely to be re‐admitted.
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	High risk	27% of intervention group participants were lost to follow‐up (3 postop complications, 1 residential care admission). No control group participants were lost to follow‐up. Those excluded due to complications more likely to have reduced quality of life and greater risk of falls.
Selective reporting (reporting bias)	Low risk	Outcomes not reported in published manuscript were provided by author.
Free from baseline imbalance bias?	Low risk	No significant differences at baseline; additional outcomes provided by author.
Free from performance bias due to non‐trial interventions?	Unclear risk	Incomplete assurance of comparability of other care provided to the 2 groups.
Method of ascertaining falls	Low risk	Monitored falls via prospective self‐reported daily falls diary and monthly telephone calls by a research assistant blinded to group allocation.

*Study characteristics*
Methods	Randomised trial: use of consecutively‐drawn, numbered, sealed, opaque envelopes
Participants	Rehabilitation Unit, Hvidovre Hospital, Copenhagen, Denmark Period of study: not stated 88 participants Inclusion: women aged 60 to 89 years transferred to a rehabilitation unit within 3 weeks after surgical treatment (osteosynthesis or partial hip replacement) of an "uncomplicated" hip fracture, full mobility prior to fracture, full weight bearing allowed, no concomitant disabling disorders, informed consent Exclusion: women who fell ill during the trial with symptoms that hindered training for more than 2 days; women discharged before attaining the planned functional capacity. (These appear to be post‐randomisation exclusion criteria.) Age: median 80 years (range 61 to 89 years) % male: none Number lost to follow‐up: none (37 dropouts still accounted for in analyses)
Interventions	Early postoperative rehabilitation 1. Participants were offered 6 hours per week of intensive physiotherapy, comprising 2 hours on Monday, Wednesday and Friday versus 2. Standard physiotherapy of 15 to 30 minutes per weekday Qualitative content of the 2 programmes were identical: bench exercises, gait, balance, co‐ordination, stair climbing and, in some cases, hydrotherapy. Training was stopped when the planned functional capacity was attained unaided (walk 50 or more metres without resting in 2 minutes or less, using walking stick or quadruped if necessary; climb 1 flight of stairs; manage sit‐to‐stand transfer; move in and out of bed; manage bathing, dressing and lavatory visits) or when participants withdrew from study.
Outcomes	Length of follow‐up: until discharge from hospital Use of walking aids Orthopaedic complication Length of hospital stay Duration of training and length of training period Dropouts from training
Notes	Details of the method of randomisation provided on contact with lead trialist, but no other information gained. The current account of the trial is based on the report in the Danish Medical Bulletin. A colleague, Pernille Jensen, based in Denmark, checked through the paper written in Danish (in Ugeskr Laeger) and confirmed that, with the exception of a few small details, the English paper was a straight translation. Participants in the intervention arm spent significantly more total hours training and significantly more hours per day training than those in the control arm. Measured adherence Funding: none declared Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Patients were randomised"
Allocation concealment (selection bias)	Low risk	Letter from authors to Martyn Parker (06 August 2002): "numbered sealed opaque envelopes drawn consecutively"
Blinding of participants and personnel (performance bias) All outcomes	High risk	"A blinded evaluation was performed by an external observer when the treating physiotherapist considered that the objective [attainment of functional capacity] had been obtained." However, this was after a non‐blinded person had assessed achievement of functional goals.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	High risk	"A blinded evaluation was performed by an external observer when the treating physiotherapist considered that the objective [attainment of functional capacity] had been obtained." However, this was after a non‐blinded person had assessed achievement of functional goals.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Unclear risk	Blinding not specified. Unclear how assessment of adverse effects is influenced by potential knowledge of group allocation
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Low risk	Data provided for all participants for intention‐to‐treat analysis as well as per‐protocol analysis
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	Data provided for all participants for intention‐to‐treat analysis as well as per‐protocol analysis
Selective reporting (reporting bias)	Unclear risk	Possible but no confirmation
Free from baseline imbalance bias?	Low risk	Baseline comparability evident
Free from performance bias due to non‐trial interventions?	Unclear risk	Incomplete assurance of comparability of other care provided to the 2 groups

*Study characteristics*
Methods	Parallel, 2‐group, randomised clinical trial
Participants	Conducted at 3 clinical centres in the USA: Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore Period of study: September 2013 to October 2017 210 participants Inclusion: minimal trauma, closed, non‐pathologic hip fracture with surgical repair; age 60 years and older; community‐dwelling at time of fracture and randomisation; ambulating without human assistance 2 months before the fracture; and walking less than 300 m during the 6‐Minute Walk Test at the time of randomisation Exclusion: medical contraindications for exercise, low potential to benefit from the intervention, and practical impediments to participation Age: mean (SD) 80.75 (8.4) % male: 23 Number lost to follow‐up: 13
Interventions	For both treatment groups, physical therapists provided 60‐minute in‐home intervention visits on non‐consecutive days for 16 weeks. The first 75 participants = 3 visits per week during the first 8 weeks and 2 visits per week during the remaining 8 weeks (40 assigned visits). Participants randomised after the protocol change = 2 visits per week (32 assigned visits). Participants in both groups received 2000 IU of vitamin D3, 600 mg of calcium and a multivitamin daily for 40 weeks. A registered dietician provided nutritional counselling at baseline. Additional dietician consults were provided by telephone if participants lost 2% or more of weight over 4 weeks. 1. Intervention: strength training using portable progressive resistance device, 3 sets of 8 repetitions at 8 RM or body weight, per leg, for 4 muscle groups (leg press, hip abduction, hip extension and heel raises). Intensity reassessed every 2 weeks. Endurance training (outdoor ambulation, indoor walking or other upright activity), aiming for 20 minutes at 50% of heart rate reserve. 2. Active control: "These activities were selected because they are common physical therapy interventions but were not expected to have an effect on walking ability". Seated active range‐of‐motion exercises (neck, trunk, upper and lower limbs), progressed from 3 to 20 repetitions per exercise, target volume > 20 minutes. Sensory‐level TENS unit application to lower extremity muscle groups, frequency = 80 pulses/second, pulse duration = 50 microseconds, and amplitude to produce a minimally detectable tingling sensation to each muscle complex for 7 minutes. Target volume = 21 minutes per session.
Outcomes	16 weeks: 6‐Minute Walk Test Short Physical Performance Battery Balance subscale of Short Physical Performance Battery, and 2 additional single leg stands (eyes open and eyes closed) as used in the National Health and Aging Trends Study (NHATS) Quadriceps Muscle Strength Modified Physical Performance Test Gait speed (fast walking, 50 feet)
Notes	ClinicalTrials.gov Identifier: NCT01783704 Protocol modified during study: reduced target sample size from 300 to 210, expanded eligibility criteria, removed 1 outcome time point (40 weeks), reduced intervention intensity from 3 days/week to 2 days/week Measured adherence Funding: Dr Beamer reported receiving grants from the NIA/NIH and Veterans Affairs. Dr Binder reported receiving grants from Astellas Pharma and an interview stipend from Pfizer. Dr Miller reported being a full‐time employee of Novartis Institutes for Biomedical Research. Ms McBride reported receiving grants from the University of Maryland School of Medicine. Dr Craik reported receiving grants from the NIH and personal fees from the University of Maryland School of Medicine, as well as serving on the external advisory board of the Pepper Center at the University of Maryland School of Medicine. No other disclosures were reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "The random allocation sequence...was implemented using a secure web‐based system. Treatments were assigned according to separate randomization schedules for each clinical site, in randomly ordered blocks of randomly selected sizes of 2, 4, 6, or 8, with equal numbers of participants assigned to each treatment within each block".
Allocation concealment (selection bias)	Low risk	Randomisation "implemented using a secure web‐based system"
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Unclear risk	Quote: "Assessors who measured outcomes were blinded to treatment group; participants were instructed not to discuss group assignments with assessors". 3 cases of unblinding of assessment staff were reported, all in the training group.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Unclear if assessors were blinded for phone calls: quote: "Information on reportable adverse events, including serious or unexpected adverse events or injury that occurred under supervision by study staff, was obtained by telephone interview every 4 weeks". Bias unlikely for mortality
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	Low risk	Less than 20% loss to follow‐up
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Unclear risk	Less than 20% loss to follow‐up
Selective reporting (reporting bias)	Low risk	Authors specify certain outcomes are not reported in this paper, including cost‐effectiveness, quality of life (Short Form‐36 not reported), and activities of daily living (Pepper Assessment Tool for Disability)
Free from baseline imbalance bias?	Low risk	Groups balanced at baseline
Free from performance bias due to non‐trial interventions?	Low risk	For both treatment groups, physical therapists provided 60‐minute in‐home intervention visits on non‐consecutive days for 16 weeks. At study initiation, physical therapists were randomly assigned to treatment groups.

*Study characteristics*
Methods	Randomised trial: use of a list of computer‐generated random numbers
Participants	Community‐dwellers in the vicinity of Arcadia University, USA Period of study: not stated 41 participants Inclusion: people aged 65 years or over living at home after successful hip fracture surgery (partial or total hip replacement or internal fixation) who were willing to go to Arcadia University for assessment, discharged from other physical therapy, informed consent Exclusion: medical contraindications (unstable angina; uncompensated heart failure; on renal dialysis) to resistance or aerobic exercise, stoke with hemiplegia, Parkinson's disease, life expectancy less than 6 months, Mini Mental State Exam score < 20, living in nursing home Age (of 33 completers): mean 79 years (range 64 to 89 years) % male (of 33 completers): 27 Number lost to follow‐up: 8 (1 unable to perform prescribed exercises, 2 withdrew consent, 1 diagnosis of progressive neuromuscular disorder, 4 hospitalisations of whom 2 died)
Interventions	The two intervention groups (1 and 2) received high‐intensity home‐based exercise supervised by a physical therapist in 20 visits over 12 weeks: twice‐weekly for 8 weeks and once‐weekly for 4 weeks. Each session lasted 30 to 40 minutes. 1. Resistance training group did 3 sets of 8 repetitions at 8 RM intensity using a portable resistance exercise machine for hip extensors, hip abductors, knee extensors and plantar flexors versus 2. An aerobic training group did activities that increased the heart rate to 65% to 75% of age‐predicted maximum for 20 continuous minutes (walking, stair climbing or ROM exercises) versus 3. Control group: bi‐weekly mailings on a variety of non‐exercise topics. Participants asked not to begin any new exercise programmes until the study was completed. They were told that they were eligible to receive either of the exercise interventions at the end of the study.
Outcomes	Length of follow‐up: 12 weeks; but only 8 weeks for the control group. 6‐Minute Walk Test distance Maximum voluntary isometric force of the lower extremity Fast gait speed SF‐36 physical function Mortality
Notes	Measured adherence Funding: Foundation for Physical Therapy Research Grant Conflict of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"..assignment to a group was determined by referring to a list of computer‐generated random numbers"
Allocation concealment (selection bias)	Unclear risk	Unclear if allocation concealed
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Therapists conducting the intervention and participants were not blinded to the group assignment. Impact of non‐blinding is unclear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	"The physical therapist examiner was masked to group assignment and performed all testing at baseline and after treatment. Different physical therapists provided the interventions and were masked to outcome testing results." There is no indication on whether the participants were told not to inform the assessor of their group allocation.
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, no judgement	Low risk	Outcomes are clearly reported and unlikely to be affected by lack of blinding.
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	"The physical therapist examiner was masked to group assignment and performed all testing at baseline and after treatment. Different physical therapists provided the interventions and were masked to outcome testing results."
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Participant flow diagram provided but differential loss to follow‐up (6 from the resistance training group of 8 overall)
Incomplete outcome data (attrition bias) Death, re‐admission, re‐operation, surgical complications, return to living at home	Low risk	Participant flow diagram provided
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	Unclear risk	Participant flow diagram provided but differential loss to follow‐up (6 from the resistance training group of 8 overall)
Selective reporting (reporting bias)	Unclear risk	No protocol available. However, the 2 conference abstracts point to consistency in reporting.
Free from baseline imbalance bias?	High risk	Baseline data provided for only 33 of 41 participants. There were some between‐group differences, which may have been clinically significant. In particular, participants in the control group were more depressed and the time from surgery to the start of the study was around 7 weeks more in the 2 exercise groups compared with the control group (19.4 versus 19.7 versus 12.6 weeks).
Free from performance bias due to non‐trial interventions?	Unclear risk	Variation in delivery by the 6 physiotherapists may have occurred.

*Study characteristics*
Methods	Three‐arm stepped‐wedge cluster‐randomised trial
Participants	Skilled nursing facilities, the Netherlands Period of study: 1 April 2016 to 1 December 2017 240 participants Inclusion: people > 65 years old with traumatic hip fracture admitted to a skilled nursing facility with an indication of short‐term rehabilitation, living alone and having an MMSE score of 15 or higher Exclusion: terminally ill, were waiting for permanent placement in a nursing home, or did not give informed consent Age: mean 84 % of male: 20 Number lost to follow‐up: 89
Interventions	1. Usual care: usual discharge planning, usual physiotherapy (focusing on mobility, muscle strength, balance, transfer and walking), usual occupational therapy (focusing on performance of daily functioning and safety at home) 2. Cognitive behavioural therapy (CBT): usual care, plus 4 weeks of weekly coaching based on CBT, including 5 steps: i) Educate on the importance of physical activity and daily exercise; ii) Ascertain the amount of movement and physical activity during the day and give feedback; iii) Define realistic goals for the performance of daily activities; iv) Agree on an activity plan with the patient and, if needed, practice exercises and activities safely; v) Evaluate progress. 3. CBT plus sensory monitoring: usual care, plus 4 weeks of CBT (above), plus 4 weeks of: ‐ wearing of the physical activity monitor (PAM)‐sensor, sensor monitoring, daily instructions how to wear the PAM ‐ weekly coaching based on CBT, including use of the PAM to: i) Ascertain objectively the amount of movement and number of activities during the day and give feedback; ii) Use as a starting point for discussion about the daily patterns and activities that are important to practice; iii) Make new plans for activities; and iv) Evaluate the progress.
Outcomes	Timepont used = after the intervention stopped, at approximately 4 months after the start of rehabilitation Canadian Occupational Performance Measure (performance score) Timed Up and Go test Modified Katz ADL score Fall Efficacy Scale International EuroQol 5D Service use: number of sessions/duration/content
Notes	This intervention was different to others in this review, yet met the inclusion criteria for a mobility strategy. The study authors adjusted for clustering in their analyses. Funding: Dutch grant Fonds Nuts Ohra (1401‐057). MP was supported by the Netherlands Organisation for Scientific Research (NWO) (023.003.059). Conflict of interest: nil
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Generated using STATA software
Allocation concealment (selection bias)	High risk	Quote: "After admission to the nursing home, the nursing home physicians will identify potential patients on the basis of the inclusion criteria.” Physicians likely to be aware of allocation of wards as well as participant characteristics, and admission occurred after allocation of wards. Recruitment period 12 months. If participants admitted after allocation of ward, allocation concealment not possible
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Participants and therapists not blinded to group allocation and the effect of this non‐blinding not clear
Blinding of outcome assessment (detection bias) Observer‐reported outcomes, some judgement	Low risk	Assessors blinded to intervention group (although authors acknowledge potential for unblinding)
Blinding of outcome assessment (detection bias) Participant/proxy‐reported outcomes	Unclear risk	Assessors blinded to intervention group (although authors acknowledge potential for unblinding).
Incomplete outcome data (attrition bias) Observer‐reported outcomes, some judgement	High risk	Large loss to follow‐up (37% at 4 months, 46% at 6 months). (Statistical modelling with imputation performed for 6‐month analysis)
Incomplete outcome data (attrition bias) Participant/proxy‐reported outcomes	High risk	Large loss to follow‐up (37% at 4 months, 46% at 6 months). (Statistical modelling with imputation performed for 6‐month analysis)
Selective reporting (reporting bias)	Unclear risk	Protocol states Canadian Occupational Performance Measure (COPM)‐physical and COPM‐social are both primary outcomes and will be reported combined. The results paper reports COPM‐p as the primary outcome and COPM‐s as the secondary outcome.
Free from baseline imbalance bias?	Low risk	No important baseline imbalance
Free from performance bias due to non‐trial interventions?	Low risk	No important issues
Cluster‐randomised trials	Low risk	Although recruitment did not occur prior to randomisation, baseline characteristics were reported as well‐balanced, adjustment was made for confounders at baseline and for missing values, no clusters were lost, clustering was adjusted for, and the results are comparable with other trials.