Filling the care gap: exercise prescriptions for older adults after fractures

An integrated knowledge translation project used input from consumers—those living with osteoporosis—clinicians, researchers and healthcare policy-makers to identify what health practitioners most need to know to fill the post-fracture care gap.

Dr. Susan R. Harris

  • Professor Emerita, Department of Physical Therapy, University of British Columbia

Associates and partners

  • Ms. Dorothy McNaughton, Consumer Collaborator
  • Ms. Ethel Cook, Consumer Collaborator
  • Dr. Lynne Feehan, Physical Therapy, University of British Columbia
  • Disabilities Health Research Network

Co-Applicants

  • Dr. Dawn Burnett, Canadian Physiotherapy Association
  • Ms. Alison Hoens, Physiotherapy, St. Paul’s Hospital/Providence Health Care
  • Dr. Linda Li, Harold Robinson/Arthritis Society Chair in Arthritic Diseases, Physical Therapy, University of British Columbia
  • Ms. Jessie McGowan, Health Sciences Librarian, University of Ottawa
  • Dr. William Miller, Occupational Science & Occupational Therapy, University of British Columbia
  • Dr. Donna MacIntyre, Physical Therapy, University of British Columbia
  • Ms. Margaret Mousseau, Policy & Practice, Canadian Physiotherapy Association
  • Dr. Darlene Reid, Physical Therapy, University of British Columbia
  • Dr. Meena Sran, Osteoporosis Program, B.C. Women’s Health Centre
  • Dr. Peter Tugwell, Institute of Population Health, University of Ottawa
  • Ms. Marie Westby, PhD Candidate in Rehabilitation Sciences, University of British Columbia

Issue

Prevention of osteoporotic fractures through exercise is well documented, but little is known about the role of exercise in the rehabilitation process for osteoporotic patients who have suffered a fracture.

Fractures among Canada’s aging population have a major impact on health care costs, quality of life and ability to earn income. Forty percent of women, and thirteen percent of men in Canada have a lifetime risk fracture related to osteoporosis. The cost of treating osteoporotic fractures in Canada is $1.9 billion annually. Fifteen to twenty-five per cent of hip fractures require admission to a nursing home. And spine and hip fractures are associated with an increased risk of death in the first year after occurrence.

Research

As a physiotherapist, Dr. Susan Harris was well acquainted with the impacts of osteoporotic fractures in older patients. 

“We know a lot about the role of exercise in the prevention of fractures in patients with osteoporosis. But it was frustrating to realize that clinicians had little scientific information on which to base rehabilitation treatment plans for older adults who had already had a fracture. We wanted to determine what research had been done—worldwide—on the most effective exercise prescriptions for rehabilitation. And we wanted to make that information available to practitioners and healthcare policy-makers.”

Using a Canadian Institutes of Health Research (CIHR) Knowledge Synthesis grant, Dr. Harris gathered a research team to review the literature on exercise prescription after osteoporosis-related fractures. Their scoping study systematically mapped the key concepts, theories, sources of evidence and gaps in the research. Adopting an integrated knowledge translation approach, Dr. Harris worked closely with people from across the treatment spectrum: consumers—people living with osteoporosis—collaborated throughout the project. She consulted with physiotherapists who work daily with persons with osteoporosis, with researchers who study the disease and with healthcare policy makers. These consultations shaped the research design, refined her search parameters, and ultimately informed the results.

It wasn’t an easy task. Employing CIHR guidelines for an integrated knowledge translation approach meant learning new ways to collaborate and consult. “I applaud CIHR for making it challenging. I learned so much just from writing the proposal. And the research process benefited greatly from the inclusion of so many perspectives.” 

The range of evidence was not limited to English language studies. Dr. Harris and her team translated articles published in Chinese, Danish, French and German. Over the year-long project, they screened over 9000 titles and abstracts, and did in-depth reviews on nearly 300 full-length articles. Of these, 154 met all the scoping criteria and provided the data for the final report.

Results

How did the project help fill the knowledge gap? Dr. Harris and her team shared the global research findings on post-fracture care through workshops and plain language fact sheets prepared for Osteoporosis Canada and other consumer groups.

In 2011, Osteoporosis International published two articles, by Dr. Harris and her team: the results of the scoping review, and a discussion of the effects of therapeutic exercise for persons with osteoporotic vertebral fractures.

A year later, the second paper was cited in an article about vertebral fractures in the New England Journal of Medicine, which stated, “Although there are uncertainties about the effect of therapeutic exercise, we would recommend a target PT program that incorporates postural retraining and exercises to improve the strength of the back extensor musculature and mobility.”

"It’s exciting when your published research is read and contributes to better care,” says Dr. Harris. “Our results have been shared at major international meetings, and in Canadian conversations with the care community. But I believe there is still much work to be done in Canada and abroad to place this information into the hands of practitioners.”