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

Intervenciones para mejorar la movilidad después de la cirugía por fractura de cadera en adultos

Declaraciones de intereses de los autores

Versión publicada: 07 septiembre 2022 Historial de versiones

https://doi.org/10.1002/14651858.CD001704.pub5

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Resumen

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Antecedentes

Mejorar los desenlaces de movilidad tras una fractura de cadera es clave para la recuperación. Las posibles estrategias incluyen el entrenamiento de la marcha, el ejercicio y la estimulación muscular. Esta es una actualización de una revisión Cochrane publicada por última vez en 2011.

Objetivos

Evaluar los efectos (beneficiosos y perjudiciales) de las intervenciones destinadas a mejorar la movilidad y la funcionalidad física después de la cirugía por fractura de cadera en adultos.

Métodos de búsqueda

Se realizaron búsquedas en el Registro especializado del Grupo Cochrane de Lesiones óseas, articulares y musculares (Cochrane Bone, Joint and Muscle Trauma Group), el Registro Cochrane central de ensayos controlados (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE, Embase, CINAHL, registros de ensayos y listas de referencias, hasta marzo de 2021.

Criterios de selección

Todos los ensayos aleatorizados o cuasialeatorizados que evaluaran estrategias de movilidad después de la cirugía por fractura de cadera. Las estrategias elegibles tenían como objetivo mejorar la movilidad e incluían programas de atención, ejercicio (entrenamiento de la marcha, del equilibrio y funcional, entrenamiento de resistencia/fuerza, resistencia, flexibilidad, ejercicio tridimensional [3D] y actividad física general) o estimulación muscular. La intervención se comparó con la atención habitual (en el hospital) o con la atención habitual, ninguna intervención, ejercicio simulado o visita social (después del hospital).

Obtención y análisis de los datos

Los miembros del equipo de autores de la revisión seleccionaron de forma independiente los ensayos para inclusión, evaluaron el riesgo de sesgo y extrajeron los datos. Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane. Se utilizó el punto temporal de evaluación más cercano a los cuatro meses para los estudios intrahospitalarios, y el punto temporal más cercano al final de la intervención para los estudios poshospitalarios. Los desenlaces fundamentales fueron la movilidad, la velocidad de marcha, la funcionalidad, la calidad de vida relacionada con la salud, la mortalidad, los efectos adversos y la vuelta a vivir en la residencia anterior a la fractura.

Resultados principales

Se incluyeron 40 ensayos controlados aleatorizados (ECA) con 4059 participantes de 17 países. La edad promedio de los participantes fue 80 años y el 80% eran mujeres. La mediana del número de participantes en el estudio fue de 81 y todos los ensayos tenían un riesgo de sesgo incierto o alto en uno o más dominios. La mayoría de los ensayos excluyó a las personas con deterioro cognitivo (70%), inmovilidad y enfermedades médicas que afectaran a la movilidad (72%).

Ámbito hospitalario, estrategia de movilidad versus control

Dieciocho ensayos (1433 participantes) compararon las estrategias de movilidad con el control (atención habitual) en hospitales. En general, dichas estrategias podrían dar lugar a un aumento moderado y clínicamente importante de la movilidad (diferencia de medias estandarizada [DME] 0,53; intervalo de confianza [IC] del 95%: 0,10 a 0,96; siete estudios, 507 participantes; evidencia de certeza baja) y a una mejoría pequeña y clínicamente importante de la velocidad de marcha (el IC cruza el cero, por lo que no se descarta la falta de efecto, DME 0,16; IC del 95%: ‐0,05 a 0,37; seis estudios, 360 participantes; evidencia de certeza moderada). Las estrategias de movilidad podrían dar lugar a una diferencia escasa o nula en la mortalidad a corto plazo (razón de riesgos [RR] 1,06; IC del 95%: 0,48 a 2,30; seis estudios, 489 participantes; evidencia de certeza baja) o a largo plazo (RR 1,22; IC del 95%: 0,48 a 3.12; dos estudios, 133 participantes; evidencia de certeza baja), los eventos adversos medidos por el reingreso en el hospital (RR 0,70; IC del 95%: 0,44 a 1,11; cuatro estudios, 322 participantes; evidencia de certeza baja) o el retorno a la residencia anterior a la fractura (RR 1,07, IC del 95%: 0,73 a 1,56; dos estudios, 240 participantes; evidencia de certeza baja). No se sabe si las estrategias de movilidad mejoran la funcionalidad o la calidad de vida relacionada con la salud, ya que la certeza de la evidencia fue muy baja.

El entrenamiento de la marcha, el equilibrio y funcional probablemente causa una mejoría moderada de la movilidad (DME 0,57; IC del 95%: 0,07 a 1,06; seis estudios, 463 participantes; evidencia de certeza moderada). Los efectos sobre la movilidad del entrenamiento de resistencia fueron escasos o nulos. Ningún estudio de otros tipos de ejercicios o estimulación eléctrica informó sobre desenlaces de movilidad.

Ámbito poshospitalario, estrategia de movilidad versus control

Veintidós ensayos (2626 participantes) compararon estrategias de movilidad con el control (atención habitual, ninguna intervención, ejercicio simulado o visita social) en un ámbito poshospitalario. Las estrategias de movilidad conducen a un aumento pequeño y clínicamente importante de la movilidad (DME 0,32; IC del 95%: 0,11 a 0,54; siete estudios, 761 participantes; evidencia de certeza alta) y a una mejoría pequeña y clínicamente importante de la velocidad de marcha en comparación con el control (DME 0,16; IC del 95%: 0,04 a 0,29; 14 estudios, 1067 participantes; evidencia de certeza alta). Las estrategias de movilidad dan lugar a un pequeño aumento clínicamente no importante en la funcionalidad (DME 0,23; IC del 95%: 0,10 a 0,36; nueve estudios, 936 participantes; evidencia de certeza alta) y probablemente conducen a un ligero aumento en la calidad de vida que podría no ser clínicamente importante (DME 0,14; IC del 95%: ‐0,00 a 0,29; diez estudios, 785 participantes; evidencia de certeza moderada). Las estrategias de movilidad probablemente dan lugar a una diferencia pequeña o a ninguna diferencia en la mortalidad a corto plazo (RR 1,01; IC del 95%: 0,49 a 2,06; ocho estudios, 737 participantes; evidencia de certeza moderada). Las estrategias de movilidad podrían dar lugar a una diferencia escasa o nula en la mortalidad a largo plazo (RR 0,73; IC del 95%: 0,39 a 1,37; cuatro estudios, 588 participantes; evidencia de certeza baja) o en los eventos adversos medidos por el reingreso hospitalario (el IC del 95% incluye una gran reducción y un gran aumento, RR 0,86; IC del 95%: 0,52 a 1,42; dos estudios, 206 participantes; evidencia de certeza baja).

El entrenamiento que incluye la marcha, el equilibrio y el ejercicio funcional da lugar a un aumento pequeño y clínicamente importante de la movilidad (DME 0,20; IC del 95%: 0,05 a 0,36; cinco estudios, 621 participantes; evidencia de certeza alta), mientras que el entrenamiento clasificado como ejercicio principalmente de resistencia o fuerza podría dar lugar a un aumento clínicamente importante de la movilidad medido mediante la distancia caminada en seis minutos (diferencia de medias [DM] 55,65; IC del 95%: 28,58 a 82,72; tres estudios, 198 participantes; evidencia de certeza baja). El entrenamiento que incluye múltiples componentes de intervención probablemente da lugar a un aumento considerable y clínicamente importante de la movilidad (DME 0,94; IC del 95%: 0,53 a 1,34; dos estudios, 104 participantes; evidencia de certeza moderada). No está claro el efecto del entrenamiento aeróbico sobre la movilidad (evidencia de certeza muy baja). Ningún estudio de otros tipos de ejercicios o estimulación eléctrica informó sobre desenlaces de movilidad.

Conclusiones de los autores

Las intervenciones dirigidas a la mejoría de la movilidad después de una fractura de cadera podrían dar lugar a una mejoría clínicamente importante de la movilidad y la velocidad de marcha en el ámbito hospitalario y poshospitalario, en comparación con la atención convencional. Las intervenciones que incluyen el entrenamiento de la marcha, el equilibrio y las tareas funcionales son especialmente efectivas. Había poca o ninguna diferencia entre los grupos en el número de eventos adversos informados. Los ensayos futuros deberían incluir un seguimiento a largo plazo y desenlaces económicos, determinar el impacto relativo de los diferentes tipos de ejercicios y establecer la efectividad en las economías emergentes.

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Resumen en términos sencillos

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¿Las estrategias de movilidad mejoran y restablecen la movilidad después de la cirugía por fractura de cadera en adultos?

Mensajes clave

La movilidad es la capacidad de moverse, incluida la de ponerse de pie y caminar. Las estrategias de movilidad son tratamientos cuyo objetivo es ayudar a las personas a moverse mejor.

El tratamiento de movilidad realizado en el hospital podría mejorar de forma moderada la movilidad de las personas a los cuatro meses después de la fractura de cadera. El efecto del tratamiento de movilidad sobre otros desenlaces principales no estuvo claro. El tratamiento de movilidad realizado tras el alta hospitalaria por una fractura de cadera mejora la movilidad, probablemente aumenta la velocidad de marcha, mejora ligeramente la funcionalidad y reduce las caídas.

Los estudios futuros se deberían centrar en qué tipos de tratamientos funcionan mejor y si los tratamientos funcionan en los países más pobres.

¿Qué se puede hacer para mejorar la movilidad tras una fractura de cadera?

Uno de los principales objetivos de los cuidados tras una cirugía por fractura de cadera es conseguir que las personas vuelvan a ponerse en pie de forma segura, moviéndose y caminando de nuevo. Inicialmente, se puede pedir a las personas que guarden reposo en cama y que limiten el levantamiento de peso. Después, se utilizan diversas estrategias para mejorar la movilidad, como el reentrenamiento de la marcha, los programas de ejercicio y la estimulación eléctrica durante la estancia hospitalaria y, a menudo, tras el alta hospitalaria.

¿Qué se quería averiguar?

Se deseaba determinar lo siguiente:

‐ si los tratamientos de movilidad administrados en el hospital o tras el alta hospitalaria ayudan a las personas a moverse mejor;

‐ qué tipo de tratamientos ayudan a las personas a moverse mejor después de una fractura de cadera.

También se quería saber si los tratamientos de movilidad pueden causar efectos no deseados.

¿Qué se hizo?

Primero se buscaron estudios que compararan:

‐ el entrenamiento de la movilidad frente a ningún entrenamiento de la movilidad; o

‐ diferentes métodos y tiempos de tratamientos de movilidad.

Se compararon y resumieron los resultados, y se evaluó la confianza en la evidencia según factores como la metodología y el tamaño de los estudios.

¿Qué se encontró?

Se encontraron 40 estudios en los que participaron 4059 personas con fractura de cadera, la mayoría de las cuales tenían más de 65 años, con un promedio de edad de 80 años. En el estudio más pequeño participaron 26 personas y en el más grande 336. Los estudios se realizaron en 17 países. Muchos de los estudios utilizaron métodos deficientes. Veintisiete estudios recibieron financiación, en su mayoría de organizaciones gubernamentales y de organizaciones de financiación de la investigación.

Resultados principales

Dieciocho estudios evaluaron estrategias de movilidad que se iniciaron en el hospital dentro de la semana posterior a la cirugía por fractura de cadera. El tratamiento de movilidad realizado en el hospital podría aumentar de forma moderada la movilidad de las personas a los cuatro meses después de la fractura y probablemente aumenta la velocidad de marcha en un grado pequeño, pero importante. El tratamiento de la movilidad probablemente no influye en el reingreso en el hospital, la vuelta a la vida en el hogar ni la muerte. No está claro si el tratamiento de la movilidad afecta la funcionalidad física (la capacidad de moverse y desenvolverse en el entorno) o el bienestar.

Veintidós ensayos evaluaron estrategias de movilidad de más larga duración que se iniciaron tras el alta hospitalaria y se llevaron a cabo en el domicilio, en complejos residenciales para jubilados y en clínicas ambulatorias. En estos ámbitos, el tratamiento de la movilidad aumenta la movilidad en un grado pequeño pero importante, aumenta considerablemente la velocidad de marcha y conduce a un aumento pequeño pero no importante de la funcionalidad. En comparación con ningún tratamiento, las visitas sociales o la atención habitual, el tratamiento de movilidad probablemente mejora ligeramente el bienestar de las personas, pero no hasta un nivel importante. El tratamiento de la movilidad probablemente no influye en el reingreso en el hospital ni en la muerte.

Los tipos de tratamiento que parecen efectivos para mejorar la movilidad de las personas son los ejercicios adicionales a la fisioterapia estándar. Tanto en el hospital como después del alta hospitalaria, los ejercicios útiles se centran en el equilibrio, la marcha y las tareas funcionales. Tras el alta hospitalaria, el entrenamiento de fuerza o de resistencia adicional también podría mejorar la movilidad. El efecto de la estimulación eléctrica no estuvo claro.

En general, la revisión encontró que tanto en el hospital como después del alta, hay suficiente evidencia para afirmar que el tratamiento dirigido a la movilidad es probablemente mejor que ningún tratamiento adicional para ayudar a las personas a volver a ponerse de pie de forma segura, moverse y caminar de nuevo después de la cirugía por fractura de cadera.

¿Cuáles son las limitaciones de la evidencia?

Se tiene una confianza baja a moderada en los resultados de los estudios en los hospitales. La confianza se redujo porque: algunos de los estudios no informaron sobre todos sus resultados; utilizaron diferentes formas de administrar los tratamientos; y muchos de los estudios eran pequeños.

Se tiene más confianza en los resultados de los estudios realizados tras el alta hospitalaria, incluida el hallazgo de que el entrenamiento de la movilidad mejora el movimiento y la marcha. Existe menos confianza en los resultados de los efectos graves no deseados, debido al escaso número de efectos no deseados informados.

¿Cuál es el grado de actualización de esta evidencia?

Esta revisión actualiza una revisión anterior. La evidencia está actualizada hasta marzo de 2021.

Authors' conclusions

Implications for practice

In the in‐hospital setting, interventions targeting improvement in mobility after hip fracture surgery in adults may improve mobility (low‐certainty evidence), and probably improve walking (moderate‐certainty evidence) compared with conventional care, respectively (summary of findings Table 1). The effects of mobility strategies are less certain for other main outcomes, mainly reflecting the low number of studies and participants. There is low‐certainty evidence that mobility strategies may make little or no difference to mortality, re‐admission and return to living at the pre‐fracture residence. We are uncertain whether mobility strategies improve functioning or health‐related quality of life as the certainty of the evidence is very low.

In the post‐hospital setting, the evidence for the use of additional mobility strategies to improve outcomes after discharge following hip fracture surgery has greater certainty than for the in‐hospital setting. There is high‐certainty evidence that mobility strategies lead to a meaningful increase in mobility compared to control (usual care, no intervention, sham exercise or social visit). Mobility strategies also lead to a small improvement in functioning, which is not meaningful (high‐certainty evidence), and mobility strategies probably cause meaningful improvement in walking speed (moderate‐certainty evidence). The effects of mobility strategies are less clear for other main outcomes, mainly reflecting under‐reporting of these outcomes in the included trials. Mobilisation strategies probably make no difference to short‐term mortality, may make little or no difference to adverse outcomes of long‐term mortality or re‐admission, and probably lead to a slight, non‐meaningful increase in health‐related quality of life.

Pooled data examining the effect of the intervention versus control do not capture the details of the certainty of evidence for all the plausible individual comparisons. We attempted to address this by exploring the effects of different intervention types. In the included in‐hospital and post‐hospital trials, interventions that included gait, balance and functional tasks had moderate‐ and high‐certainty evidence for effectiveness at increasing mobility. In the post‐hospital setting, mobility may also be increased by resistance or endurance training in addition to gait, balance and functional training. Readers may wish to examine further details of the intervention and control arms of individual trials presented in Table 1 and the Description of studies.

Implications for research

The presence of ongoing trials points to the importance of maintaining this review, but further primary research in the form of sufficiently‐powered, preferably multicentre, high‐quality randomised controlled trials is also required to inform practice. Such research should focus on interventions that are likely to have a beneficial overall, long‐term impact; thus, trials should have long‐term (one year or more) and comprehensive follow‐up, including the collection of validated and patient‐orientated outcome measures, and economic outcomes. Given the investment required for such trials, priority questions and areas need to be identified. We consider that this endeavour should be open to general debate, but some clues can be gained from this review and the following considerations.

This review already gives some indication of the variety of questions that clinicians consider important and have, we assume, successfully justified to ethics committees and, often, to funders. With some exceptions, such as Graham 1968, the control arm of which is not relevant to current practice, the questions evaluated incompletely by these trials remain pertinent. Some can be considered as pilot studies and after appropriate adjustments, such as to the study design, power and perhaps to the interventions, a potentially more informative trial will emerge.

Further research is needed to determine the relative impact of different types of exercise programmes. These studies must be very large to be adequately powered to detect differences in effects between interventions.

Further work is required to establish the effectiveness of rehabilitation after hip fracture in emerging economies, and in Asia where hip fractures are increasing most rapidly (Gullberg 1997).

It is debatable whether future research priorities should be on the evaluation of multi‐faceted or multi‐component interventions (excluded from this review when not solely aimed at mobilisation) with mobilisation components, rather than mobilisation interventions or programmes by themselves. This is particularly relevant to rehabilitation after discharge from hospital, which is an increasingly important area. Lessons from the literature on fall prevention (Cameron 2018; Sherrington 2019) and strength training (Liu 2009) in older people may be applicable here as well as generally to rehabilitation after hip fracture surgery. We consider, however, that it is still useful to investigate mobilisation strategies in themselves, particularly as these will form a substantive part of any rehabilitation intervention for this patient group.

Some consideration of these trials' results must be given to the differences in the physical and mental capacities of people with hip fracture. Different interventions may be suitable for different subgroups of hip fracture patients: for instance, the more frail versus more physically able. Thus, trials could also investigate whether differing responses to interventions occur among different subgroups of hip fracture patients. Of course such investigations should take into account methodological concerns about excessive subgroup analyses in clinical trials and prespecify subgroups and use appropriate statistical techniques (Sun 2010).

Validated patient‐orientated outcome measures are needed, to measure what is important for individual patients. Development of a standard portfolio of validated and patient‐orientated outcome measures for trials would facilitate meta‐analysis of the results of future trials.

Summary of findings

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
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
	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.
^aMobility strategies may include exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. ^bA control intervention may be: usual orthopaedic, medical care or allied health care. ^cThe all‐studies population risk was based on the number of events and the number of participants in the control groups of studies included in this review reporting this outcome. ^dMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs).^eDowngraded by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results, with the confidence intervals (CIs) crossing zero). Downgraded one level for imprecision, with wide CI. Not downgraded for inconsistency; the substantial heterogeneity (I² = 84%) is explained by inclusion of Monticone 2018 and the large between‐group difference in the volume and intensity of functional exercise undertaken, compared with other studies. Removing Monticone 2018 reduced I² to 44%, and it changed the effect size from SMD 0.53 (95% CI 0.10 to 0.96) to SMD 0.29 (95% CI 0.03 to 0.55). ^fCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^gWalking speed, measured using distance/time. ^hNot downgraded due to risk of bias (as removing studies with high risk of bias in one or more items had no impact on results, with similar point estimate and CIs). Downgraded due to imprecision, with CI crossing zero. ⁱFunctioning, using functioning scales. ^jDowngraded by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results), downgraded one level due to substantial heterogeneity (I² = 81%), and downgraded one level due to imprecision (n = 315). ^kDowngraded by one level due to risk of bias (removing the studies with high risk of bias in one or more items had a marked impact on results), one level for imprecision (small number of trials and participants, wide CI) and one level due to substantial heterogeneity (I² = 71%). ^lOur illustrative risks for dichotomous outcomes were based on the proportion calculated from the number of people who experienced the event divided by the number of people in the group, for the control group in those trials included in the analysis for that outcome. ^mWe downgraded both the short‐term and long‐term analyses by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results) and one level for imprecision (few events and wide CI). ⁿDowngraded one level for imprecision (few events and wide CI) and one level because a large number of studies included in the review did not contribute to this adverse event outcome. ^oDowngraded one level for imprecision (few events and wide CI) and one level because a large number of studies included in the review did not contribute to the outcome.

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

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
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
		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.
^aA control intervention may be: usual orthopaedic, medical care or allied health care. ^bMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). A higher score indicates better mobility. ^cMobility strategies involve postoperative care programmes such as immediate or delayed weight bearing after surgery, and any other mobilisation strategies, such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. We categorised the exercise and physical training strategies using the Prevention of Falls Network Europe (ProFaNE) guidelines, see Appendix 1. These categories are gait, balance and functional training; strength/resistance training; flexibility; 3D (Tai Chi, dance); general physical activity; endurance; multiple types of exercise; other. Electrical stimulation is an additional intervention type. ^dDowngraded one level for inconsistency (unexplained heterogeneity, I² = 84%). ^eCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^fMean was estimated from median for the single study. ^gDowngraded one level for risk of bias and one level for imprecision. ^hDowngraded one level for risk of bias and one level for imprecision.

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Mobility strategies compared with control (e.g. usual care) after hip fracture surgery in the post‐hospital setting
Patient or population: adults following hip fracture surgery Settings: post‐hospital Intervention: mobility strategies^a Comparison: non‐provision control^b
	Assumed risk	Corresponding risk
	Control^c	Intervention
Mobility^d ‐ overall analysis Using different mobility scales: mPPT (range 0 to 36), POMA (range 0 to 30), SPPB (range 0 to 12), PPME (range 0 to 12). A higher score indicates better mobility. Follow‐up: range 2 months to 12 months	In the control group, the mean scores for the outcomes were: mPPT (23.3), POMA (20.7), SPPB (range 6 to 7.72), PPME (10.1)	SMD 0.32 higher (0.11 higher to 0.54 higher)	SMD 0.32 (0.11 to 0.54)	761 (7)	⊕⊕⊕⊕ High^e	Overall, there is a small (based on Cohen's effect sizes^f) increase in mobility compared with control (SMD 0.32). Re‐expressing the results using the 12‐point SPPB, the intervention group scored 0.89 points higher (95% CI 0.30 to 1.50). Small meaningful change for SPPB: 0.27 to 0.55 points; substantial meaningful change: 0.99 to 1.34 points (Perera 2006). Types of intervention in included trials: gait, balance and functional exercise: 5 studies; multiple types: 2 studies.
Walkingspeed^g ‐ overall analysis Measured using metres/second (m/s) and metres/minute (m/min). A higher score indicates faster walking. Follow‐up: range 1 month to 12 months	The mean walking speed score in the control group ranged from 0.44 m/s to 0.97 m/s, and 20 m/min to 59.4 m/min.	SMD 0.16 higher (0.04 higher to 0.29 higher)	SMD 0.16 (0.04 to 0.29)	1067 (14)	⊕⊕⊕⊕ High^h	There is a small increase in walking speed compared with control (SMD 0.16). Re‐expressing the results using gait speed (m/sec), there was an increase in gait speed of 0.05 m/s in the intervention group (MD 0.05, 95% CI 0.01 to 0.09). Small meaningful change for walking speed is 0.04 to 0.06 m/s (Perera 2006). Types of intervention in included trials: gait, balance and functional exercise: 7 studies; resistance exercise: 3 studies; endurance exercise: 1 study; multiple types: 3 studies.
Functioningⁱ ‐ overall analysis Using different functioning scales: FSQ (range 0 to 36), BI (range 0 to 100), AM‐PAC daily activity (range 9 to 101), COPM (range 0 to 20), LEFS (range 0 to 80), NEADL (range 0 to 66). A higher score indicates better functioning. Follow‐up: range 3 months to 12 months	In the control group, the mean scores for the outcomes were: FSQ (24.8), BI (94.5), AM‐PAC (58.6), COPM (6.54), LEFS (28.8), NEADL (range 14.2 to 43.2).	SMD 0.23 higher (0.10 higher to 0.36 higher)	SMD 0.23 (0.10 to 0.36)	936 (9)	⊕⊕⊕⊕ High^j	Overall, there is a small increase in functioning compared with control (SMD 0.23). Re‐expressing the results using the BI, the intervention group scored 1.4 points higher (95% CI 0.6 to 2.1). MID for the BI (post‐hip surgery) is typically 9.8 (Unnanuntana 2018). Types of intervention in included trials: gait, balance and functional exercise: 4 studies; resistance exercise: 2 studies; multiple types: 2 studies; other: 1 study
HRQoL using EQ‐ 5D (range 0 to 1), SF‐36 (range 0 to 100), SF‐12 (range 0 to 100), and WHOQOL‐BREF (range 0 to 130). A higher score indicates better quality of life. Follow‐up: range 3 months to 6 months	In the control group, the mean scores for the outcomes were: EQ‐5D (range 0.6 to 0.75), SF‐36 (range 48 to 63), SF‐12 (45.5), WHOQOL‐BREF (13.2).	SMD 0.14 higher (0.00 lower to 0.29 higher)	SMD 0.14 (0.00 to 0.29)	785 (10)	⊕⊕⊕⊝ Moderate^k	SMD was calculated for 5 trials with EQ‐5D, 3 trials with SF‐36, 1 trial with SF‐12, 1 trial with WHOQOL‐BREF. Re‐expressing the results using the EQ‐5D (0 to 1 scale), there was an increase in quality of life of 0.01 in the intervention group (95% CI ‐0.007 to 0.08). MID for the EQ‐5D is typically 0.074 (Walters 2005). Re‐expressing the results using the SF‐36 (0 to 100 scale), there was an increase in quality of life of 3 points in the intervention group (95% CI ‐0.6 to 5.7). MID for SF‐36 typically 3 to 5 (Walters 2003). Mobility strategies probably make little important difference to patient‐reported health‐related quality of life compared with control. Types of intervention in included trials: gait, balance and functional exercise: 4 studies; resistance exercise: 3 studies; endurance exercise: 1 study; multiple types: 1 study; other: 1 study
Mortality Follow‐up: range 3 months to 12 months	Short term: 35 per 1000^l	Short term: 35 per 1000 (14 to 72)	Short term: RR 1.01 (0.49 to 2.06)	Short term: 737 (8)	⊕⊕⊕⊝ Moderate^m	Overall, there is moderate‐certainty evidence that mobility strategies probably make little or no difference to mortality compared to control in the short term. It is unclear whether mobility strategies reduce mortality in the long term as the certainty of evidence is low and the 95% CI includes both a reduction in the risk of mortality and an increase in the risk of mortality. Types of intervention in included trials: gait, balance and functional exercise: 3 studies; resistance exercise: 3 studies; multiple types: 5 studies.
Mortality Follow‐up: range 3 months to 12 months	Long term: 71 per 1000^l	Long term: 52 per 1000 (28 to 97)	Long term: RR 0.73 (0.39 to 1.37)	Long term: 588 (4)	⊕⊕⊝⊝ Lowⁿ
Adverse event: number of people who were re‐admitted Follow‐up: range 1 month to 12 months	231 per 1000^l	199 (120 to 328)	RR 0.86 (0.52 to 1.42)	206 (2)	⊕⊕⊝⊝ Low^o	The evidence is of low certainty: the intervention may decrease the number of re‐admissions by 14%; however, the 95% CI includes the possibility of both a 48% reduction and a 42% increase. Types of intervention in included trials: multiple types: 1 study; other: 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). AM‐PAC: Activity Measure for Post Acute Care; BI: Barthel Index; CI: confidence interval; COPM: Canadian Occupational Performance Measure; EQ5D: EuroQoL‐5Dl; FSQ: Functional StaRR: risk ratio; HRQoL: Health‐Related Quality of Life; LEFS: Lower Extremity Functional Scale; MID: minimal important difference; MD: mean difference; mPPT: modified Physical Performance Test; tus Questionnaire; NEADL: Nottingham Extended Activities of Daily Living; PME: Physical Performance and Mobility Examination; POMA: Performance Oriented Mobility Assessment; PWHOQOL BREF: World Health Organization Quality of LIfe short version; SMD: standardised mean difference; SF12: Short Form‐12 SF36: Short Form‐36; SPPB: Short Physical Performance Battery.
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.
^a Postoperative care programmes such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. ^bA non‐provision control is defined as no intervention, usual care, sham exercise (the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit. ^cThe all‐studies population risk was based on the number of events and the number of participants in the control group. ^dMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). ^eNot downgraded for risk of bias, as point estimate increased from 0.32 to 0.38 and CI remained close to zero (95% CI from (0.11 to 0.54) to (‐0.04 to 0.79)) upon removal of the trials at a high risk of bias in one or more items. ^fCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^gWalking speed, measured using distance/time. ^hNot downgraded for risk of bias, as point estimate reduced from 0.16 to 0.14 and CI remained close to zero (95% CI from (0.04 to 0.29) to (‐0.08 to 0.36) upon removal of the trials at a high risk of bias in one or more items. ⁱFunctioning, using functioning scales. ^jNot downgraded for risk of bias, as point estimate increased and CI remained above zero upon removal of the trials at a high risk of bias in one or more domains. ^kDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had a marked impact on results). ^lOur illustrative risks for dichotomous outcomes were based on the proportion calculated from the number of people who experienced the event divided by the number of people in the group, for the control group in those trials included in the analysis for that outcome. ^mNot downgraded for risk of bias, as results were essentially unchanged with removal of the trials at a high risk of bias in one or more domains. Downgraded by one level due to imprecision (few events and wide CI). ⁿDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had an important impact on results) and one level for imprecision (few events and wide CI). ^oWe downgraded one level for risk of bias, as both trials were at a high risk of bias in one or more domains. Downgraded one level for imprecision (few events and wide CI).

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

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
Different types of mobility strategies compared with control after hip fracture surgery, on mobility, in the post‐hospital setting
Patient or population: adults following hip fracture surgery Settings: post‐hospital Comparison: non‐provision control^a Outcome: mobility^b
		Assumed risk	Corresponding risk
		Control	Intervention
Gait, balance and functional training Follow‐up: range 2 months to 12 months	Mobility scales, using different scales: SPPB (range 0 to 12), PPME (range 0 to 12). A higher score indicates better mobility.	In the control group, the mean scores for the outcomes were: SPPB (range 6 to 7.72), PPME (10.1).	SMD 0.20 higher (0.05 higher to 0.36 higher)	SMD 0.20 (95% CI 0.05 to 0.36)	621 (5)	⊕⊕⊕⊕ High^d	Interventions classified as gait, balance and functional training cause a small^e increase in mobility compared with control. Re‐expressing the results using the 12‐point SPPB, the intervention group scored 0.55 points higher (95% CI 0.14 to 1.0). Small meaningful change for SPPB: 0.27 to 0.55 points; substantial meaningful change: 0.99 to 1.34 points (Perera 2006).
	TUG (lower score = faster)	The mean TUG time in the control group was 30.22 seconds.	MD 7.57 seconds faster (19.25 seconds faster to 4.11 seconds slower)	MD ‐7.57 (‐19.25 to 4.11)	128 (1)	⊕⊝⊝⊝ Very low^f	Gait, balance and functional training may increase TUG speed by 7.57 seconds; however, the 95% confidence interval includes both a reduction and increase in TUG.
	6 Minute Walk Test				0
Resistance/strength training Follow‐up: range 10 weeks to 3 months	Mobility scales				0
	TUG	The mean TUG time in the control group was 20 seconds.	MD 6 seconds faster (12.95 seconds faster to 0.95 seconds slower)	MD ‐6.00 (‐12.95, 0.95)	96 (1)	⊕⊕⊝⊝ Low^g	Resistance/strength training may increase TUG speed by 6 seconds; however, the 95% confidence interval includes both a reduction and increase in TUG.
	6MWT	The mean 6MWT distance in the control group was 243 m.	MD 56 metres further (29 metres further to 83 metres further)	MD 55.65 (28.58 to 82.72)	198 (3)	⊕⊕⊝⊝ Low^h	Resistance/strength training may increase 6MWT by 53 metres. MID for the 6MWT (adults with pathology) is typically 14.0 to 30.5m (Bohannon 2017).
Flexibility	All				0		0 studies contained a mobility strategy categorised as primarily being flexibility.
3D (Tai Chi, dance)	All				0		0 studies contained a mobility strategy categorised as primarily being 3D.
General physical activity	All				0		0 studies contained a mobility strategy categorised as primarily being general physical activity.
Endurance Follow‐up: 3 months	Mobility scales				0
	TUG				0
	6MWT	The mean 6MWT distance in the control group was 266 m.	MD 12.7 metres further (72 metres less to 97 metres further).	MD 12.70 (‐72.12, 97.52)	21 (1)	⊕⊝⊝⊝ Very lowⁱ	We are uncertain whether endurance training improves mobility as the certainty of the evidence is very low.
Multiple primary types of exercise Follow‐up: range 2 months to 6 months	Mobility scales, using different mobility scales: mPPT (range 0 to 36), POMA (range 0 to 30).	In the control group, the mean scores for the outcomes were: mPPT (23.3), POMA (range 20.7).	SMD 0.94 higher (0.53 higher to 1.34 higher)	SMD 0.94 (0.53 to 1.34)	104 (2)	⊕⊕⊕⊝ Moderate^j	Interventions that contain multiple types of exercise probably leads to a moderate increase in mobility. Re‐expressing the results using the 12‐point SPPB, the intervention group scored 2.6 points higher (95% CI 1.47 to 3.71). Substantial meaningful change for SPPB: 0.99 to 1.34 points (Perera 2006).
	TUG				0
	6MWT	The mean 6MWT distance in the control group was 233.1 m.	MD 9 metres further (15 metres less to 33 metres further)	9.30 (‐14.62 to 33.22)	187 (1)	⊕⊕⊝⊝ Low^k	Interventions containing strength training and endurance training may increase 6MWT by 9 metres. MID for the 6MWT (adults with pathology) is typically 14.0 to 30.5m (Bohannon 2017).
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). 6MWT: 6‐Minute Walk Test; CI: confidence interval; MID: minimal important difference; mPPT: modified Physical Performance Test; POMA: Performance Oriented Mobility Assessment; PPME: Physical Performance and Mobility Examination; SMD: standardised mean difference; SPPB: Short Physical Performance Battery; 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.
^aA non‐provision control is defined as no intervention, usual care, sham exercise (the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit. ^bMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). A higher score indicates better mobility. ^cMobility strategies involve postoperative care programmes such as immediate or delayed weight bearing after surgery, and any other mobilisation strategies, such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. We categorised the exercise and physical training strategies using the Prevention of Falls Network Europe (ProFaNE) guidelines, see Appendix 1. These categories are gait, balance and functional training; strength/resistance training; flexibility; 3D (Tai Chi, dance); general physical activity; endurance; multiple types of exercise; other. Electrical stimulation is an additional intervention type. ^dNot downgraded for risk of bias (removing studies with high risk of bias in one or more domains had no important impact on results). ^eCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^fDowngraded one level for risk of bias and two levels for imprecision. ^gDowngraded two levels for imprecision. ^hDowngraded one level for risk of bias (all studies had high risk of bias for at least one item) and one level for imprecision. ⁱDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had an important impact on results) and two levels for imprecision). ^jDowngraded for imprecision. ^kDowngraded one level for risk of bias and one level for imprecision.

Background

Description of the condition

Hip fractures, which are fractures of the proximal femur, can be subdivided into intracapsular fractures (those occurring proximal to the attachment of the hip joint capsule to the femur) and extracapsular (those occurring distal to the hip joint capsule). The majority of hip fractures occur in older people with an average age of around 80 years. Females predominate over males by about four to one and the injury is usually the result of a simple fall. This reflects the loss of skeletal strength from osteoporosis. As well as osteoporosis, people experiencing a hip fracture frequently have other medical and physical problems associated with ageing, including impaired mobility and frailty.

Currently, in high‐income nations the majority of hip fractures are treated surgically, which enables earlier mobilisation of the patient and avoids some of the complications of prolonged recumbency and immobilisation. Surgery entails either internal fixation, where the fracture is fixed using various implants and thereby retaining the femoral head, or by replacing the femoral head with a prosthesis.

Although surgery is generally successful, few people recover fully from their hip fracture (Dyer 2016).

Between 5% and 10% of people die within one month of their hip fracture. About one‐third of people will have died by one year after fracture, compared with an expected annual mortality of about 10% in this age group (Roche 2005). Most survivors fail to regain their former levels of mobility and activity, many become more dependent, and 10% to 60% of survivors are unable to return to their previous residence (Magaziner 2000; Royal College of Physicians 2019).

Description of the intervention

A variety of postoperative care programmes following surgery for hip fracture have been employed. In the early stages, these include bed rest and restricted weight bearing. Mobilisation is a major component of postoperative care and rehabilitation. Various mobilisation strategies are in use. These aim to get people out of bed, back on their feet, weight bearing, moving and walking. Other strategies for mobilisation relate to the nature of the physiotherapy or exercise regimens used. These include mobilisation interventions, such as exercise and electrical stimulation of muscles, which aim to minimise impairments (such as reduced strength) and improve the physical performance of walking. Exercise programmes may include one or more types of exercise. The Prevention of Falls Network Europe (ProFaNE) developed a taxonomy that classifies exercise type as: i) balance, gait and functional (task) training; ii) strength/resistance training (including power); iii) flexibility; iv) three‐dimensional (3D) exercise (e.g. Tai Chi, dance, Qigong); v) general physical activity; vi) endurance; and vii) other kinds of exercises (Lamb 2011; Appendix 1). This taxonomy captures how multiple types of exercise can be delivered within an exercise programme.

This review, an update of Handoll 2011, focuses on mobilisation strategies. Thus, this review does not include trials testing interventions, including multi‐component interventions, that aim to enhance outcomes other than mobility. Separate Cochrane Reviews consider other aspects of rehabilitation after hip fracture, including single therapy programmes specifically designed to improve physical and psychosocial functioning (Crotty 2010), multidisciplinary care programmes (Handoll 2009), nutritional supplementation (Avenell 2016), fall prevention (Cameron 2018; Sherrington 2019), and models of care including enhanced rehabilitation strategies designed specifically for people with dementia (Smith 2020).

How the intervention might work

The timing and extent of weight bearing form part of any mobilisation strategy after hip fracture surgery. Other components of mobilisation strategies generally involve various forms of exercise regimens; again, the extent and timing of these will vary. Their aim is to improve people's walking ability and associated functioning. The possibility of a refracture and other complications usually affects the decisions as to when to allow restricted or full weight bearing on the injured hip and the subsequent pace and stages of physical rehabilitation. In particular, following internal fixation of a hip fracture, individuals are at risk of several complications of fracture healing. For example, the implant may fail to hold the fracture or 'cut‐out' of the bone (penetration of the implant from the proximal femur either into the hip joint or external to the femur), causing pain and impaired mobility. This may require revision surgery to re‐fix the fracture, or replace the femoral head with an arthroplasty. Other complications of fracture healing that may occur are non‐union of the fracture (that is, failure of the fracture to heal) and avascular necrosis of the femoral head (also termed segmental collapse or aseptic necrosis).

Different considerations feature in the later stages of rehabilitation, which occur after discharge from hospital and in a community or residential care setting. Mobilisation strategies across the continuum aim to improve the individual's walking ability and associated functioning. However, compared with the in‐hospital setting, there may be a greater emphasis on independent and confident ambulation post‐hospital, with the correct use of ambulatory aids, as well as specific interventions such as muscle strengthening (voluntary and via electrical stimulation) and balance training exercises, that aim to minimise or correct impairments; for example, various impairments may manifest as a limp during walking.

Why it is important to do this review

In 2018, a group of leading professional medical organisations published a global call to action to improve the care of people with fragility fractures (Dreinhofer 2018). This broad‐based and international collaboration identified an urgent need to improve acute and post‐acute care following fragility fracture, plus secondary prevention to prevent further fractures (Dreinhofer 2018). Worldwide, an estimated 1.26 million hip fractures occurred in adults in 1990, with predictions of numbers rising to 6.26 million by the year 2050 (Curtis 2017). The age‐standardised rates of hip fracture are advancing differently among countries (some countries report decreased rates, some increased and some stable (Veronese 2018)). However, given the increasing number of older people worldwide, the total numbers of hip fracture cases and their economic consequences are likely to rise substantially (Sànchez‐Riera 2017). These developments, together with the generally unfavourable outcome in survivors (many of whom become more dependent and move into residential care), mean that the burden on society from hip fractures is immense and increasing.

Mobility is the ability for a person to move within environments, from their home, to their community and beyond (Webber 2010). Improving mobility outcomes is key to relieving the burden on individuals, their carers and society. The previous version of this review noted the insufficiency of the evidence to inform practice, but it also identified ongoing trials that potentially could help address this gap (Handoll 2011). This update continues the systematic review of the evidence on mobilisation strategies for these fractures.

Objectives

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

Methods

Criteria for considering studies for this review

Types of studies

We included all randomised controlled trials (including cluster‐randomised controlled trials) comparing different postoperative mobilisation strategies or programmes after surgery to repair an acute hip fracture. We considered for inclusion quasi‐randomised trials (for example, allocation by alternation or date of birth) and trials in which the treatment allocation was inadequately concealed. We included published and unpublished reports; however, we included trials reported only in conference abstracts only if sufficient data were available from correspondence with study authors or from the final report of the trial.

Types of participants

We included trials involving skeletally mature individuals treated for a hip fracture. We included studies in which interventions were commenced for most participants within one year of fracture.

We included trials involving adults who had undergone hip fracture surgery, irrespective of the type of fracture of the proximal femur (e.g. intracapsular or extracapsular), or type of surgery (e.g. internal fixation, hemiarthroplasty, total hip replacement). We did not define specific age limits, but we anticipated that most participants would be aged 65 years and over. Although it may not be specified in all trials, we anticipated the majority of participants would have had a fragility fracture; that is, a low‐energy trauma fracture, such as a fall from a standing height. We included mixed population trials, specifically those also including participants who had elective hip replacement or other lower‐limb fractures, provided the majority were hip fracture patients.

Types of interventions

We included trials of postoperative care programmes, such as immediate or delayed weight bearing after surgery, and any other mobilisation strategies, such as exercises, physical training and electrical stimulation, used at various stages in rehabilitation, which aim to improve walking ability and minimise functional impairments. We excluded trials testing interventions that did not aim specifically to improve mobility, and those testing care programmes, management strategies and other multi‐component interventions that were not solely aimed at mobilisation. All trials testing mobilisation strategies with nutrition as a co‐intervention have been included in updates since 2011 (Handoll 2011).

From 2019, we categorised exercise and physical training strategies using the Prevention of Falls Network Europe (ProFaNE) guidelines (see Appendix 1). These categories are gait, balance and functional training; strength/resistance training; flexibility; 3D (Tai Chi, dance); general physical activity; endurance; other kinds of exercises. We categorised strategies as 'multiple types of exercise' when two or more of the ProFaNE categories were major components of the intervention.

We grouped trials according to the basic stage in the rehabilitation process when the trial intervention(s) commenced: either in‐hospital (where preoperative, operative and postoperative acute and subacute care is undertaken) or post‐hospital (following discharge from in‐hospital care after hip fracture surgery: outpatients, residential care units, nursing homes and community health care centres, as well as an individual’s own home, where rehabilitation is undertaken).

Comparisons

We included trials where the intervention was compared with a control group that received no intervention, usual care, sham exercise (the exercise appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit. We acknowledge that usual care differs greatly between locations and has changed over time. We also included trials comparing two or more interventions if a) the difference between the intervention and control groups was a mobilisation strategy, or b) if two types of intervention programmes were compared, including the comparison of increased intensity versus standard intensity of intervention, within the same setting and same type of intervention.

In the in‐hospital setting, we considered the following main comparisons for people after surgery for a hip fracture.

Provision of any specific mobilisation strategy or programme and non‐provision, where the non‐provision control is defined as usual orthopaedic, medical care or allied health care.
Different mobilisation strategies or programmes such as:
- early (e.g. day of or day following surgery) versus late mobilisation, within the same setting and type of exercise;
- programmes of different intensity, within the same setting and type of exercise;
- programmes with different components; for example, different types of exercise (weight‐bearing versus non‐weight‐bearing exercises).

In studies conducted entirely in the post‐hospital (outpatient and community) setting, we considered the following main comparisons for people after surgery for a hip fracture who had been discharged from in‐hospital care.

Provision of any specific mobilisation strategy or programme and non‐provision, where the non‐provision control is defined as no intervention, usual care, sham exercise (where the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit.
Different mobilisation strategies or programmes for people such as:
- programmes of different intensity, within the same setting and type of exercise;
- programmes with different components; for example, different types of exercise (aerobic versus resistance).

Types of outcome measures

While the outcomes we sought remained largely unchanged from the previous version (see Handoll 2011), we restructured the types of outcome measures into three categories, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system guidance: a) the seven 'critical' or main outcomes for presentation, where appropriate, in summary of findings tables; b) other 'important' outcomes; and c) economic and resource outcomes. We made these changes to align with updates to related Cochrane Reviews in hip fracture (we elaborate on the changes in Differences between protocol and review). The outcomes also align with the core outcome set for hip fracture trials (Haywood 2014; Smith 2019).

As noted above, the main focus of the interventions tested in this review is to safely restore or, better still, enhance mobility and physical functioning. Such interventions and outcome assessment can apply to the whole rehabilitation period. We describe the outcomes in more detail in Appendix 2.

The main outcomes include one time point from each study. For in‐hospital studies with outcomes measured at multiple time points, we focused on an interim outcome at approximately four months. It has been established that quality of life and poor outcome (defined as death or deterioration in residential status) are likely to be consistent at four months and 12 months (Griffin 2015). Where an outcome was not measured at four months, we used the nearest outcome to four months. For post‐hospital studies, we used the time point closest to the end of the intervention period.

Main or 'critical' outcomes

We selected the following main or 'critical' outcomes for presentation in summary of findings tables and other summary sections of the review.

For each outcome, we planned pooled analysis of one outcome measure per study. For studies with outcomes measured at multiple time points, we used the outcome measured at the time point closest to four months (in‐hospital studies) or the time point closest to the end of the intervention period (outpatient and community studies), unless specified below. We did not include outcomes collected at different time points for a single trial.

Mobility. The order of priority was broad mobility measures (i.e. scales seeking to measure a number of aspects of mobility, such as the Short Physical Performance Battery, Timed Up and Go test, Elderly Mobility Scale, Parker Mobility Score), followed by endurance walking measures over a longer distance (e.g. 6‐Minute Walk Test). We prioritised continuous outcomes over dichotomous ones, and objective measures over self‐reported measures.
Walking speed. Using observed gait measures, the order of priority was 10‐Metre Walk Test then 6‐Metre Walk Test. We gave preference to fast walk and used usual speed walk if no fast walk was reported.
Functioning. We used measures of functioning, prioritising continuous outcomes over dichotomous ones, and objective measures over self‐reported measures.
Health‐related quality of life measures (e.g. 36‐item Short Form Health Survey (SF‐36), EQ‐5D). We prioritised the more commonly measured SF‐36 and EQ‐5D. We prioritised the time point closest to four months; however, we considered how mortality was reported and the availability of death‐adjusted estimates (Parsons 2018).
Mortality (all cause): short term (around four months, but we also accepted at‐discharge data) and long term (around 12 months).
Adverse effects. We prioritised the number of events; however, if these data were unavailable, we reported the number of people experiencing one or more of the following, at final follow‐up:
- re‐admission
- re‐operation (unplanned return to operating theatre)
- surgical complications of fixation within the follow‐up period of the study
- avascular necrosis
- non‐union of the fracture (the definition of non‐union is that used within each individual study, and this outcome includes early re‐displacement of the fracture)
- other complications (e.g. thromboembolic complications (deep vein thrombosis or pulmonary embolism))
- falls (rate of falls or number of people who fell).
- pain (persistent hip or lower‐limb pain at the final follow‐up assessment): verbal rating or visual analogue score (VAS).
Return to living at pre‐fracture residence (home), for in‐hospital studies. Timing between four and 12 months.

Other important outcomes

The following list summarises other important outcomes presented in this review. These outcomes include individual categories of the mobility measures (walking (aid and subjective measures), balance, sit to stand).

Mobility: walking
- use of walking aids / need for assistance
- self‐reported measures (e.g. difficulty walking 400 metres)
Mobility: balance while standing, reaching and stepping
- observed balance measures (e.g. functional reach, step test, timed tandem stance)
- self‐reported balance measures
Mobility: sit to stand
- observed sit to stand measures (e.g. timed sit to stand)
Muscle strength (of the affected leg; priority for quadriceps strength)
Activities of daily living (e.g. Barthel Index, Functional Independence Measure)
Patient‐reported measures of lower‐limb or hip function (e.g. Hip Rating Questionnaire, Harris Hip Score, Oxford Hip Score, Merle D’Aubigne Hip Score)
Participant satisfaction
- acceptability of interventions
- adherence

Economic and resource outcomes

We summarised any economic analyses reported by the included trials. We reviewed each trial report for costs and resource data that would enable economic evaluation. The resources considered depended on the context and stage of rehabilitation; these included:

length of hospital stay (in days);
number of physiotherapy sessions;
number of outpatient attendances; and
need for special care.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10 March 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (10 March 2021, Issue 3), MEDLINE (Ovid MEDLINE 1946 to 9 March 2021), Embase (Ovid 1974 to 10 March 2021 Week 09), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO 1982 to 10 March 2021) and the Physiotherapy Evidence Database (PEDro) (2010 to 10 March 2021). For this update, we limited the search results for MEDLINE, Embase and CINAHL from 2010 onwards. No language or publication restrictions were applied.

In MEDLINE, we combined the subject‐specific terms with the sensitivity‐maximising version of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials (Lefebvre 2019) (Appendix 3). Search strategies for CENTRAL, EMBASE, and CINAHL can also be found in Appendix 3.

We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal (ICTRP) (10 March 2021) and ClinicalTrials.gov (10 March 2021) to identify ongoing and recently completed trials (Appendix 3).

Searching other resources

We checked reference lists of articles and contacted study authors.

Data collection and analysis

Selection of studies

For this update, SD, NF or WK conducted initial scrutiny of electronic database downloads. SD, NF, JD and WK independently performed study selection from lists of potentially eligible trials provided by the Trials Search Co‐ordinator of the Cochrane Bone, Joint and Muscle Trauma Group; and subsequently from full reports where doubts remained. Trial selection was by consensus and discussion with CS as necessary.

Data extraction and management

At least two review authors independently extracted trial information and data, using a pre‐piloted data extraction form. We resolved differences through discussion. Review authors were not blinded to study authors and sources. Review authors did not assess their own trials.

We recorded the following items using a standardised data extraction form.

General information: study author’s name and year; study ID; citation of paper; trial registration, period of study (dates) and specified primary outcomes.
Trial details: trial design; sample size; location; setting.
- Setting was described as:
  - In‐patient settings where preoperative, operative and postoperative acute and subacute care is undertaken.
  - Post‐hospital settings, including residential care units, nursing homes and community health care centres, hospital outpatient clinics, as well as an individual’s own home, where rehabilitation is undertaken.
Inclusion and exclusion criteria (noting whether there was exclusion for cognitive impairment, dementia or delirium); comparability of groups; length of follow‐up; stratification; and funding source.
Risk of bias assessment and justification for judgements: sequence generation; allocation concealment; blinding (participants, personnel), blinding (outcome assessors); incomplete outcome data; and selective outcome reporting.
Characteristics of participants: age; gender; pre‐fracture mobility (prior use of walking aids versus not); other conditions/illnesses; type of fracture (intracapsular versus extracapsular fractures); mental status, treatment received; the number randomised, analysed and lost to follow‐up; and dropouts in each arm (with reasons).
Interventions: experimental and control interventions; details of intervention programme (stage of rehabilitation, content, duration, frequency, intensity and individual‐ or group‐based delivery, level of supervision, instructor:participant ratio); timing of intervention; uptake of intervention (acceptance of intervention), whether studies assessed adherence (compliance) with interventions and associated data (e.g. number of sessions attended); and additional co‐interventions (such as motivational strategies, additional information or support given to participants); expertise of personnel delivering intervention (expert health provider (e.g. therapist) versus personnel not specified as an expert, their role, timing).
Details of review outcomes (Types of outcome measures) to include time of measurement and type of measurement tool (including direction of scales where appropriate).
We assessed five aspects of trial design and reporting that would help us judge the applicability of the trial findings. The five aspects were: definition of the study population; description of the interventions; description of outcome measures; length of follow‐up; and assessment of compliance/adherence with interventions.

Assessment of risk of bias in included studies

At least two review authors independently assessed risk of bias in newly included studies, without masking of the source and authorship. At least one review author assessed risk of bias for trials that had been assessed in previous versions of the review. We piloted the assessment form on two trials. We resolved all differences through discussion. We used the tool outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). This tool incorporates the following domains:

sequence generation (selection bias);
allocation concealment (selection bias);
blinding of participants and personnel (performance bias);
blinding of outcome assessors (detection bias);
incomplete outcome data (attrition bias);
selective reporting (reporting bias);
other risks of bias.

During assessment of detection bias and attrition bias, we considered three different types of outcomes separately: i) observer‐reported outcomes involving some judgement (mobility, walking speed, functional outcomes, activities of daily living and strength); ii) observer‐reported outcomes not involving judgement (death, re‐admission, re‐operation, surgical complications, return to living at home); iii) participant/proxy‐reported outcomes (health‐related quality of life, pain, falls, patient‐reported questionnaires, satisfaction).

When considering blinding (detection bias) for staff‐reported (in‐hospital studies) and self‐reported (in‐hospital and post‐hospital studies) outcomes of health‐related quality of life, pain, falls, patient‐reported questionnaires and satisfaction, we recognised that some risk of bias is inherent. However, it can be minimised by blinding of research staff and statisticians involved in data collection and analysis, and we made an assessment on the basis of these factors. If data collection and analysis were not performed by blinded research staff, we considered the risk of bias to be high. If data collection and analysis were performed by blinded research staff, we considered the risk of bias to be unclear.

For 'other bias', we assessed four additional sources of bias: bias resulting from imbalances in key baseline characteristics (e.g. pre‐injury mobility, mental test score, type of surgery); performance bias such as that resulting from lack of comparability in the experience of care providers; bias relating to the recall of falls due to unreliable methods of ascertainment; and bias relating to cluster‐randomised trials. For trials using cluster‐randomisation, we considered additional risk of bias relating to recruitment, baseline imbalance, loss of clusters, incorrect analysis and comparability with individually‐randomised trials, as described in Chapter 23 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021b).

Measures of treatment effect

We calculated risk ratios or rate ratios (for falls) and 95% confidence intervals (CI) for dichotomous outcomes; standardised mean differences (SMD) and 95% confidence intervals for continuous outcomes where different scales were pooled; and mean differences and 95% confidence intervals for continuous outcomes where a single scale was pooled. We present final values rather than change scores for continuous outcomes.

To facilitate interpretation of the mobility and functioning outcomes, where investigators measured outcomes using different instruments, we expressed SMD in the units of one of the measurement instruments used by the included studies. Using the approach suggested by Schünemann 2022, we calculated the absolute difference in means by multiplying the SMD by an estimate of the standard deviation (SD) associated with the most familiar instrument. We obtained this SD by calculating a weighted pre‐intervention average across all intervention groups of all studies that used the selected instrument. We compared the summary effect, re‐expressed in the original units of that particular instrument, with the minimal important difference, when this was available. During analysis of mobility outcome according to the different types of exercise interventions, we re‐expressed SMD in the units of one of the measurement instruments only when the between‐group difference was statistically significant.

Unit of analysis issues

We included one cluster‐randomised trial (Pol 2019). The study authors adjusted for clustering in the analysis. No trials reported the inclusion of people with bilateral hip fractures.

All participants in Sylliaas 2012 were previously in the intervention arm of an earlier study included in this review (Sylliaas 2011). As a result, we did not include data from Sylliaas 2012 in the analyses of intervention effect.

Dealing with missing data

We contacted trial authors to request missing data. Where possible, we performed intention‐to‐treat analyses to include all people randomised. However, we used actual denominators of participants contributing data to the relevant outcome assessments where dropouts were identified. We were alert to the potential mislabelling or non‐identification of standard errors and standard deviations. Unless we could derive missing standard deviations from confidence intervals or standard errors, we did not assume values in order to present these in the analyses.

Assessment of heterogeneity

Where study interventions were considered sufficiently similar to be combined in meta‐analyses, we assessed heterogeneity of treatment effects by visual inspection of forest plots along with consideration of the Chi² test (with a significance level at P < 0.10) and the I² statistic for statistical heterogeneity, in conjunction with likely causes of clinical heterogeneity. We based our interpretation of the I² results on that suggested by Higgins 2011: 0% to 40% might not be important; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent substantial heterogeneity; and 75% to 100% may represent considerable heterogeneity.

Assessment of reporting biases

There were insufficient trials and data for the assessment of reporting biases. Our search of clinical trial registers has the potential to reduce the impact of publication bias, especially in the future. For individual trials, we checked all publications and trial registration details where available to assess completeness and consistency in outcome reporting. For outcomes that included more than 10 data points, we constructed and visually inspected funnel plots.

Data synthesis

During pooling, we initially pooled the results of comparable groups of trials using a fixed‐effect model and 95% confidence intervals. Where there was substantial heterogeneity between the results of individual trials, and/or when considered appropriate, we viewed and presented the results of pooling studies using a random‐effects model instead of those from the fixed‐effect model. Where scales within a meta‐analysis were contrary (i.e. a higher score indicating better performance versus a higher score indicating worse performance), we multiplied by ‐1 to invert scales for consistency with other trial outcomes (Sambunkak 2017).

Included studies measured the mobility outcome using a range of instruments, not all of which could be combined in meta‐analysis. We undertook separate meta‐analyses for the mobility scales (continuous outcome), the Timed Up and Go test (measured in seconds), and the 6‐Minute Walk Test (measured in metres).

Some studies reported data for the same outcome using more than one measurement tool. To avoid a unit of analysis error, we used data from only one tool. However, because we were concerned that we would lose information, we also presented analyses for the mobility outcome with the results separated according to the types of measurement tool; this allowed a study to contribute to multiple outcome measures.

In the summary of findings tables, we presented adverse events in terms of hospital re‐admissions. Pooling of the different types of adverse events was not appropriate as some outcomes were subsets of others, some were too dissimilar and the denominators of reported results were often unclear.

Our interpretations of continuous outcomes were based upon guiding rules for interpreting SMDs (‘Cohen’s effect sizes’ (Cohen 1998)), or expressed in the units of a specific measurement instrument where appropriate.

Subgroup analysis and investigation of heterogeneity

Where appropriate and depending on whether sufficient studies were available, we planned the following subgroup analyses.

Trials excluding participants with cognitive impairment, dementia or delirium versus trials not excluding participants based upon cognition
Secondary and social care, with intervention delivered in home and community, versus intervention delivered in outpatient clinics, for post‐hospital interventions
Expertise (expert health provider (e.g. therapist) versus personnel not specified as an expert), for post‐hospital interventions
In‐hospital ward versus rehabilitation ward
Mean age ≤ 80 years versus mean age > 80 years.

We undertook subgroup analyses for each outcome, where there were ten or more studies in the analysis.

We investigated whether the results of subgroups were significantly different by inspecting the overlap of CIs and performing the test for subgroup differences available in Review Manager 5.4 (Review Manager 2020).

We performed subgroup analysis of secondary and social care (interventions delivered in the home and community) versus outpatient care (interventions delivered in the outpatient setting) in the post‐hospital setting.

Our prespecified subgroup analysis by expert versus non‐expert delivery of intervention was not possible. We assumed all interventions were delivered by experts in the in‐hospital setting. The three post‐hospital studies that did not have experts deliver the intervention did not contribute to the main outcomes, so these subgroup analyses could not be conducted.

Sensitivity analysis

We conducted our prespecified sensitivity analyses for the mobility outcome, measured using mobility scales. The sensitivity analyses included assessing the effect of excluding trials at high or unclear risk of bias associated with a lack of allocation concealment; trials at high risk of bias on any domain; trials reported only in conference abstracts; trials that included mixed populations; trials that did not clearly focus on or predominantly include the target population of people with a fragility fracture resulting from low‐energy trauma; and in‐hospital trials that measured outcomes at the end of the in‐hospital phase (the usual time point used in analyses was that closest to four months). We undertook post hoc sensitivity analysis to examine the impact on the results of the use of fixed‐effect rather than random‐effects models for data pooling for the mobility outcome.

Summary of findings and assessment of the certainty of the evidence

We used the GRADE approach to assess the certainty of evidence related to all critical outcomes listed in the Types of outcome measures (Schünemann 2017). We assessed the certainty of the evidence as ‘high’, ‘moderate’, ‘low’ or ‘very low’ depending on the presence and extent of five factors: risk of bias; inconsistency of effect; indirectness; imprecision; and publication bias.

Risk of bias. We downgraded by one level due to risk of bias when either all studies had high risk of bias in one or more domains or removing studies with high risk of bias in one or more domains had a marked impact on results. We did not downgrade for risk of bias where removing studies with high risk of bias in one or more domains changed the point estimate to a stronger effect with or without narrower confidence intervals (CI). We did not consider risk of bias domains that were not related to the outcome of interest (e.g. domains related to falls when evaluating GRADE for mortality).
Inconsistency. We downgraded for inconsistency where there was significant heterogeneity (I² exceeded 60%) that could not be explained.
Indirectness. We downgraded for indirectness where trials examined a limited version of the main review question with regard to population, intervention, comparison or outcomes.
Imprecision. We downgraded for imprecision when there were fewer than 400 participants for continuous outcomes, fewer than 300 events for dichotomous outcomes, the CI was wide or the CI crossed zero and estimates of clinically important effect.
Publication bias. For outcomes that included more than 10 data points, we constructed and visually inspected funnel plots.

We prepared summary of finding tables featuring the 'critical' outcomes for the intervention versus control comparison, for the in‐hospital setting and post‐hospital setting. For adverse events, we reported re‐admission to hospital. We also prepared summary of finding tables featuring the mobility outcome for the intervention versus control comparison, for different types of exercise and electrical stimulation, for the in‐hospital setting and post‐hospital setting. We used standardised qualitative statements to describe the different combinations of effect size and the certainty of evidence (Cochrane Norway 2017). Our illustrative risks for dichotomous outcomes were based on the proportion calculated from the number of people who experienced the event divided by the number of people in the group, for those trials included in the analysis for that outcome.

In addition, we also applied GRADE to the mobility outcome when analysed according to the different types of exercise interventions, and we prepared bespoke summary of findings tables to summarise the effect sizes and describe the certainty of this evidence. We applied GRADE to other important outcomes in all comparison groups when the between‐group difference in treatment effect was statistically significant.

Results

Description of studies

Results of the search

For this update (January 2010 to March 2021), we screened a total of 3424 records from the following databases: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10); CENTRAL (561), MEDLINE (401), Embase (1190), CINAHL (252), PEDro (125), the WHO International Clinical Trials Registry Platform (361) and ClinicalTrials.gov (524). We also found 35 potentially eligible studies from other sources.

We identified a total of 62 new studies (127 reports) potentially eligible for inclusion, and obtained full reports of these, where possible. After full‐text review, we included 21 new studies (see Characteristics of included studies), excluded 18 (Excluded studies), and classified 21 as ongoing studies (Ongoing studies). Two studies await classification (Studies awaiting classification). A flow diagram summarising the study selection process is shown in Figure 1.

Figure 1

Study flow diagram

Overall, there are now 40 included studies, 18 excluded studies, two studies awaiting classification and 21 ongoing trials.

The results from the previous searches (up to April 2010) are shown in Appendix 4. Three ongoing studies from Handoll 2011 have been included in this update (Kronborg 2017, previously Kristensen 2009, NCT00848913; Latham 2014, previously Jette 2008, NCT00592813; Salpakoski 2015, previously Sipila 2011, ISRCTN53680197). The 22 excluded studies in Handoll 2011 are not reported in the update.

Included studies

This review now includes 40 trials with 4059 participants. Details are provided in the Characteristics of included studies and are summarised briefly below. Due to the size of the review, we have not inserted links to all study references in the following description, but full details can be viewed in Appendix 5. We have summarised characteristics of the included studies in Table 1 and Table 2.

Open in table viewer

Table 1. Key characteristics of participants and intervention approach

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

NR: not reported; NWB: non‐weight bearing; WB: weight bearing
^aParticipants with severe cognitive dysfunction (obey command ≤ 1 step ) were excluded. At baseline, 21/38 participants had cognitive dysfunction, defined using Mini‐Mental State Examination score adjusted with age and education level.

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

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%

^aIntervention delivered in hospital and after discharge. Majority of intervention delivered in inpatient setting
^bIntervention started as inpatient. Majority of intervention delivered in post‐hospital setting
^cThree study arms
^dCluster‐randomised trial

Thirty‐nine included trials were published as full reports in journals; one trial was published as an abstract with additional information provided by study authors (Ohoka 2015). The publication dates range from 1968 (Graham 1968) to 2020 (Oh 2020; Sherrington 2020). Two studies did not contribute any outcomes to this review: Suwanpasu 2014 included no outcomes of interest, while participants in Sylliaas 2012 were a subset of those in Sylliaas 2011.

We included 21 new trials, with a total of 2470 participants, in this update. Six were in‐hospital trials (Kimmel 2016; Kronborg 2017; Monticone 2018; Oh 2020; Ohoka 2015; Van Ooijen 2016), 14 were community rehabilitation trials (Bischoff‐Ferrari 2010; Langford 2015; Latham 2014; Magaziner 2019; Mangione 2010; Orwig 2011; Pol 2019; Salpakoski 2015; Sherrington 2020; Stasi 2019; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019; Williams 2016), and one trial did not explicitly report how the intervention was delivered (Suwanpasu 2014).

Twenty‐seven of the included studies received funding, primarily from governmental, university and professional research funding bodies. The Van Ooijen 2016 trial was funded by the company, affiliated with two authors, that manufactured and patented the treadmills used in the intervention.

Design

Thirty‐eight trials were randomised controlled trials, although two of these provided no details of their method of randomisation (Graham 1968; Tsauo 2005), and thus the use of quasi‐randomised methods for sequence generation cannot be ruled out. Baker 1991 was a quasi‐randomised trial using alternation for treatment allocation. Bischoff‐Ferrari 2010 was a 2x2 factorial design but we included only two trial arms in this review. Pol 2019 was a three‐arm, stepped‐wedge cluster‐randomised trial. Thirty‐three trials had two comparison groups; four trials had three comparison groups (Mangione 2005; Sherrington 2004; Pol 2019; Van Ooijen 2016); and two trials had four comparison groups (Miller 2006; Resnick 2007). Of the latter two studies, we included only three groups from each study in the review.

In Table 3, we show our assessment of five aspects of trial design and reporting, to facilitate judgement of the applicability of the trial findings. The majority of studies (37/40) defined the study population; most studies (33/40) described the interventions (seven studies did not adequately describe the intervention dosage or usual care); and most (36/40) described outcome measures. Length of follow‐up exceeded six months in 16/40 trials, with trials in the in‐hospital setting generally having shorter follow‐up than those conducted after discharge. Compliance or adherence to interventions was reported in less than half (16/40) of included trails.

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

	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

Sample sizes

The 40 included trials involved a total of 4059 participants. The median number of participants randomised per trial was 81 (interquartile range (IQR) 49 to 147). Study size ranged from 26 participants (Braid 2008; Mangione 2010) to 336 participants (Sherrington 2020).

Setting

The trials were conducted in 17 different countries: Australia (9 trials); Canada (1); Denmark (2); Finland (2); Germany (1); Greece (1); Italy (1); Japan (1); the Netherlands (2); Norway (3); Russia (1); South Korea (1); Switzerland (1); Taiwan (1); Thailand (1); UK (5); and USA (7). See Appendix 5.

Eighteen trials examined primarily in‐hospital rehabilitation; that is, settings where preoperative, operative and postoperative acute and subacute care is undertaken. Of these trials, 16 were single‐centre and two were multi‐centre trials; seven trials were in orthopaedic wards, 10 in rehabilitation wards and one ward type was unclear.

Nineteen trials were classified in the review as post‐hospital studies. Rehabilitation was undertaken predominantly in individuals' own homes; some trials had options for intervention in community health care centres; one trial had a rehabilitation component in skilled nursing facilities before discharge home (Pol 2019); and no studies were conducted in a social care setting. Three trials, also classified as post‐hospital studies, were in the outpatient setting with an additional home‐based component (Binder 2004; Sylliaas 2011; Sylliaas 2012).

Details of the timing of trial recruitment provided for included trials show Graham 1968 had the earliest start date (1961) and Pol 2019 the most recent start date (2016).

Participants

Overall, 80% of included participants were women, with the majority of participants in each trial being women (63% to 100% of trial population). Seven trials only included women (Baker 1991; Hauer 2002; Lamb 2002; Lauridsen 2002; Ohoka 2015; Orwig 2011; Resnick 2007). The average participant age in the included trials was 80 years. The mean ages of trial participants ranged from 71 years (Gorodetskyi 2007) to 90 years (Ohoka 2015), and was 80 or above in 24 trials. Thirty‐four trials set lower age limits, ranging from 50 years (Karumo 1977) to 90 years (Ohoka 2015). Twenty‐eight trials, including 19 of the 22 post‐hospital trials and nine of the 18 in‐hospital trials, specifically excluded people with various extents of cognitive impairment, judged according to various criteria and assessment instruments. Explicit exclusion criteria relating to previous and/or current immobility and/or medical conditions affecting mobility were stated in all trials except Bischoff‐Ferrari 2010, Gorodetskyi 2007, Langford 2015, Mangione 2010, Monticone 2018, Ohoka 2015, Pol 2019, Suwanpasu 2014, Sylliaas 2012, Tsauo 2005 and Williams 2016. The majority of included trials did not select on type of hip fracture, except for Gorodetskyi 2007, which specified trochanteric fractures, Graham 1968 (displaced intracapsular fractures), Karumo 1977 (femoral neck fractures), Kimmel 2016 (isolated subcapital or intertrochanteric hip fractures), Monticone 2018 (extracapsular hip fractures), Salpakoski 2015 (femoral neck or pertrochanteric fractures), Stasi 2019 (femoral neck fractures), Suwanpasu 2014 (femoral neck, intertrochanteric or subtrochanteric fractures), Sylliaas 2011 and Sylliaas 2012 (femoral neck or trochanteric fractures) and Taraldsen 2019 (intracapsular or extracapsular fractures). While not stated explicitly in some trials, it is very likely that all trial participants had surgery for a hip fracture except for three participants in Hauer 2002 who had elective hip surgery, and 12 participants in Miller 2006 who were treated for another lower limb fracture. For Sherrington 2020, data were obtained for 194 participants treated for hip fracture, exclusive of the 142 participants with pelvic or other lower limb fractures.

Interventions

Differences in duration, type and composition of the intervention are shown in Table 1 and Appendix 5.

In‐hospital rehabilitation

In the in‐hospital setting, 16 trials with 1100 participants compared the effect of different types of mobility training with a control intervention such as usual care, very gentle exercise or 'sham exercise'. Two trials (333 participants) compared the effect of different timing of mobility training (Graham 1968; Oldmeadow 2006).

The intervention was delivered by an expert health professional in all in‐hospital studies.

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

Gait, balance and functional exercises

Two‐week programme of weight‐bearing exercise versus non‐weight‐bearing exercise: Sherrington 2003 (80 participants, Australia)
Weight‐bearing exercise twice daily for 60 minutes per day for 16 weeks versus usual care (mainly non‐weight‐bearing exercise for 30 minutes per day): Moseley 2009 (160 participants, Australia)
Treadmill gait retraining programme versus conventional gait retraining: Baker 1991 (40 participants, Australia)
Body‐weight supported treadmill training (10 minutes, four times per week) plus standard physiotherapy (40 minutes per day, six times per week) versus standard physiotherapy (40 minutes per day, six times per week): Ohoka 2015 (27 participants, Japan)
Body‐weight supported treadmill training (20 minutes/day for 10 consecutive work days) plus standard physiotherapy (30 minutes per day for 10 consecutive work days) versus standard physiotherapy (30 minutes per day for 10 consecutive work days): Oh 2020 (45 participants, Korea)
Six weeks C‐Mill gait adaptability treadmill training or conventional treadmill training (two study arms pooled for analysis) versus usual physiotherapy: Van Ooijen 2016 (70 participants, the Netherlands)
Two additional physiotherapy sessions/day, seven days/week versus usual care of one session/day. Additional sessions focused on function and gait: Kimmel 2016 (92 participants, Australia)
Three‐week programme of 90 minutes of balance task‐specific exercise in standing, transfers, gait and stairs training versus control (90 minutes open kinetic chain exercises in the supine position): Monticone 2018 (52 participants, Italy)
Twice daily physiotherapy versus standard regimen of once daily physiotherapy: Karumo 1977 (100 participants, Finland)
Intensive physiotherapy comprising six hours of physiotherapy per week versus standard physiotherapy of 15 to 30 minutes each weekday: Lauridsen 2002 (88 participants, Denmark)

Resistance exercises

Quadriceps muscle strengthening regimen for six weeks versus conventional physiotherapy alone: Mitchell 2001 (80 participants, UK)
Twelve‐week programme of resistance training versus resistance training for 12 weeks plus nutritional supplementation for six weeks versus attention control starting seven days post injury: Miller 2006 (75 participants; 63 with hip fracture, Australia)
Additional daily progressive knee‐extension strength training with three sets of 10 repetitions at 10 repetition maximum (RM), versus routine physiotherapy only (12 lower limb exercises and basic mobility): Kronborg 2017 (90 participants, Denmark)

Electrical stimulation of the quadriceps

Six‐week programme of electrical stimulation of the quadriceps muscle (18‐minute sessions) versus no electrical stimulation: Braid 2008 (26 participants, UK)
Six‐week programme of electrical stimulation of the quadriceps for three hours daily versus placebo stimulation: Lamb 2002 (27 participants, UK)
Ten‐day programme of electrical stimulation for 20 to 30 minutes at three sites close to surgical incision versus placebo stimulation: Gorodetskyi 2007 (60 participants, Russia)

In‐hospital rehabilitation: comparing different timing of intervention

Early assisted ambulation (within 48 hours) versus delayed assisted ambulation after surgery (fixation or hemiarthroplasty): Oldmeadow 2006 (60 participants, Australia)
Weight bearing at two weeks versus 12 weeks after internal fixation of a displaced intracapsular fracture: Graham 1968 (273 participants, UK)

Post‐hospital rehabilitation

In the post‐hospital setting, all 22 trials compared the effect of mobility training with no intervention, usual care, sham exercise or a social visit. Four of these trials each had two intervention groups and one control group, resulting in a total of 26 intervention arms (Mangione 2005; Pol 2019; Resnick 2007; Sherrington 2004). The two intervention arms in Mangione 2005 and Sherrington 2004 were sufficiently different to compare the different types of exercise programmes; for these two studies we compared each intervention arm with the control arm, and also compared the two different types of exercise programmes. The two intervention arms in Pol 2019 and Resnick 2007 were similar and therefore were combined for the analysis of intervention arm versus control arm.

The interventions tested by the 22 trials in the post‐hospital category all started after hospital discharge, except for three trials that commenced in the in‐hospital setting but delivered the majority of the intervention in the community (Bischoff‐Ferrari 2010; Langford 2015; Stasi 2019). The stage of rehabilitation at planned commencement varied: namely, recent discharge from in‐hospital treatment or rehabilitation (Hauer 2002; Orwig 2011; Pol 2019; Salpakoski 2015; Suwanpasu 2014; Tsauo 2005; Williams 2016); at completion of standard physical therapy (Binder 2004; Latham 2014; Magaziner 2019; Mangione 2005; Mangione 2010; Resnick 2007; Sherrington 2020); and later home‐based exercises (Sherrington 1997; Sherrington 2004; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019).

The intervention was delivered by an expert health professional in 19 of the 22 post‐hospital studies, by a non‐expert (trained assistant) in one (Lamb 2002), and in two trials, it was unclear (Graham 1968; Hauer 2002).

We grouped the intervention arms by their primary exercise modality into six categories (Appendix 6) using the ProFaNE taxonomy (Appendix 1).

Most intervention arms (n = 9; 35%) included gait, balance and functional exercises as the primary intervention (ProFaNE taxonomy gait/balance/co‐ordination/functional task training).
Strength/resistance training was the primary component of six (23%) intervention arms.
Endurance training alone was the primary component of one (5%) intervention arm.
Multiple categories of the ProFaNE taxonomy were the primary intervention in five (19%) intervention arms (resistance training plus endurance training in three intervention arms; balance and functional exercise plus resistance training in two arms)
No studies included flexibility exercise, 3D exercise or general physical activity training as a primary intervention component.

We categorised the mobility strategy interventions in four trials as 'other': coaching based on cognitive behavioural therapy (two arms in Pol 2019); additional post‐discharge physiotherapy telephone support and coaching (Langford 2015); specific group of muscle contractions in the supine position (one intervention arm of Sherrington 2004); and a physical activity enhancing program, based on Resnick's self‐efficacy model (outlined in Resnick 2009) (Suwanpasu 2014).

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

Gait, balance and functional exercises

Additional 30 minutes of physiotherapy during acute care (total 60 minutes) plus additional 30 minutes per day unsupervised home programme for 12 months versus standard physiotherapy (30 minutes per day during acute care with no home programme): Bischoff‐Ferrari 2010 (173 participants, Switzerland)
Six months of training with monthly telephone calls using cognitive behavioural strategies, functional tasks using a Thera‐band programme based on INVEST (Bean 2004) and Sherrington 1997 programmes, versus attention control (nutrition education): Latham 2014 (232 participants, USA)
Home‐based, year‐long programme including progressive home exercise programme (strength training plus stretching three times per week, balance and walking exercises two to three times per week) and physical activity counselling, versus control (standard care, including written home exercise programme), after discharge from hospital: Salpakoski 2015 (81 participants, Finland)
One month of home‐based, weight‐bearing exercises started seven months after hip fracture versus usual care (no specific instructions): Sherrington 1997 (44 participants, Australia)
Four months of home‐based, weight‐bearing exercises or home‐based, non‐weight‐bearing exercises (performed in the supine position) versus no specific instructions started 22 weeks after hip fracture: Sherrington 2004 (120 participants, Australia)
Ten home visits plus phone calls over 12 months to deliver an individualised physiotherapist‐prescribed home programme of weight‐bearing balance and strength exercises plus fall prevention advice, versus usual care: Sherrington 2020 (194 participants with hip fracture, Australia)
Ten weeks of two exercise sessions per week with physiotherapists at home, targeting balance and gait with individually‐tailored, weight‐bearing exercises, all entailing change in base of support, versus usual care: Taraldsen 2019 (143 participants, Norway)
Three months, delivered in eight visits, of home‐based individualised physical therapy versus unsupervised home exercise on discharge from an acute ward: Tsauo 2005 (54 participants, Taiwan)
Six home‐based physiotherapy sessions over three months, delivered by a physiotherapist or technical instructor in home or outpatient clinic, plus novel information workbook and goal‐setting diary, in addition to usual rehabilitation services, versus usual care (usual rehabilitation services, of variable content): Williams 2016 (61 participants, Wales)

Resistance exercises

Twelve weeks of supervised, home‐based moderate‐ to high‐intensity resistance training versus education control group after completion of usual physical therapy: Mangione 2005 (41 participants, USA)
Ten weeks of progressive resistance leg strengthening exercises versus control (TENS causing no muscle contraction): Mangione 2010 (26 participants, USA)
Twelve‐week hip abductor strength training programme, three times per week with physiotherapist, from week 3 after discharge. Home‐based sessions, 40 to 55 minutes, progressing to three sets of 15 repetitions, with resistance added, versus control group receiving lesser intensity of hip abductor strengthening (approximately 10 minutes less per session, strengthening commenced two weeks later, resistance added later): Stasi 2019 (100 participants, Greece)
Three months of progressive resistance training twice weekly in outpatient setting as well as once a week at home, plus treadmill warm‐up and walking versus usual care (no specific instructions): Sylliaas 2011 (150 participants, Norway)
Six months of prolonged resistance training (three months of Sylliaas 2011 plus additional three months) plus treadmill warm‐up and walking versus usual care (no specific instructions): Sylliaas 2012 (95 participants, Norway)

Endurance exercise

Twelve weeks of supervised aerobic exercise training versus education control group after completion of usual physical therapy: Mangione 2005 (41 participants, USA)

Multiple categories

Six months of supervised intensive outpatient physical therapy and exercise training versus low‐intensity home exercise after completion of standard therapy: Binder 2004 (90 participants, USA)
Twelve weeks of intensive physical training versus placebo motor activity starting about four to five weeks after surgery upon discharge from in‐hospital rehabilitation: Hauer 2002 (28 participants; three had elective hip surgery, Germany)
Sixteen weeks of two to three times per week physiotherapist home visits to implement and progress: i) lower limb strength training programme using portable progressive resistance device, ii) endurance training (outdoor ambulation, indoor walking or other upright activity) aiming for 20 minutes at 50% of heart rate reserve. Compared with active control of seated active range‐of‐motion exercises and sensory‐level TENS: Magaziner 2019 (210 participants, USA)
Twelve months of home‐based exercise with a self‐efficacy based motivational component including aerobic exercise using Stairstep and stretching versus usual care: Orwig 2011 (180 participants, USA)
Twelve‐month programme of trainer‐led exercise sessions with or without motivational interventions (two arms pooled for this analysis) versus usual care (no intervention) after completion of standard rehabilitation: Resnick 2007 (155 participants, USA)

Other

Twelve months of additional telephone support and coaching: up to five post‐discharge telephone calls from physiotherapist: Langford 2015 (30 participants, Canada)
Four weeks of weekly coaching based on cognitive behavioural therapy, with a focus on increasing daily activity and practising exercises where indicated, plus a second intervention arm also wearing a physical activity monitor, versus usual care (physiotherapy and occupational therapy) in skilled nursing facilities for short‐term rehabilitation: Pol 2019 (240 participants, the Netherlands)
Face‐to‐face contact and five telephone calls for seven weeks post‐surgery, to implement a physical activity‐enhancing programme, based on Resnick's self‐efficacy model (Resnick 2009), versus standard care control (physical activity for hip fracture booklet): Suwanpasu 2014 (46 participants, Thailand)

Post‐hospital rehabilitation: comparing two different types of intervention

Twelve weeks of supervised, home‐based moderate‐ to high‐intensity resistance training versus aerobic exercise training after completion of usual physical therapy: Mangione 2005 (41 participants, USA)
Four months of home‐based, weight‐bearing exercises versus home‐based, non‐weight‐bearing exercises (performed in the supine position) started 22 weeks after hip fracture: Sherrington 2004 (120 participants, Australia)

Excluded studies

We excluded 18 studies during this update. We give brief details and reasons for exclusion of these studies in Characteristics of excluded studies. The primary reasons for exclusion related to study design (three trials), study participants (three trials) and study intervention (12 trials). For studies excluded in the previous version of this review, see Handoll 2011.

Ongoing studies

Details of the 21 ongoing trials are provided in the Characteristics of ongoing studies. Almost all studies are set in the in‐hospital rehabilitation or community settings, with exercise being the dominant intervention and robotic‐assisted balance training being evaluated in three trials.

Studies awaiting classification

Two trials await classification.

Che 2020 randomised 78 participants with 'old' femoral neck fractures. The intervention group received early rehabilitation training and the control group underwent routine rehabilitation. A conference abstract has been published. We have requested by email further details on the time post fracture, intervention, outcome measures and results.

Wu XY 2019 randomised 100 participants undergoing cementless total hip arthroplasty for femoral neck fracture. Weight‐bearing exercise was commenced early in the intervention group, versus at three weeks in the control group. We await translation of this study to English.

Risk of bias in included studies

We summarise our risk of bias judgements for 13 domains for the individual trials in Figure 2 and Figure 3. Details are described in the risk of bias tables in Characteristics of included studies. Blank spaces in the risk of bias summary figure indicate that we made no judgement for the domain because it was not applicable to the individual study (for example, because the study did not measure these outcomes).

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias domain for each included study

Note: a 'Yes' (+) judgement means that review authors considered there was a low risk of bias associated with the item, whereas a 'No' (‐) means that there was a high risk of bias. Assessments that resulted in an 'Unclear' (?) verdict often reflected a lack of information upon which to judge the domain. However, lack of information on blinding for mobility outcomes was always taken to imply that there was no blinding and rated as a 'No'; similarly for unblinded staff/self‐reported outcomes (health‐related quality of life, pain, falls, patient‐reported questionnaires and satisfaction), lack of information on blinding of researchers was rated as 'No', data collated by blinded researchers was rated 'Unclear'. An empty square (no judgement) indicates the domain was not applicable to that study.

Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

Allocation

We judged 21 trials (51%) to be at low risk of selection bias resulting from adequate sequence generation and allocation concealment; three additional trials took adequate measures to safeguard allocation concealment only. Conversely, Sherrington 1997, by using an open list, failed to conceal allocation and we judged this study to be at high risk of selection bias. Baker 1991, a quasi‐randomised trial using alternation, was at high risk of selection bias.

Blinding

Performance bias

The majority of studies (38 studies, 95%) did not blind participants or therapists (which in many cases is not feasible for these interventions), leading us to rate their risk of performance bias as unclear. A low risk of performance bias was judged likely for Lamb 2002, which used placebo stimulation. We considered one study to be at high risk of bias: the treating physiotherapist referred participants for outcome assessment once they considered the study objectives had been obtained (Lauridsen 2002).

Detection bias

Twenty‐seven trials had a low risk of detection bias for observer‐reported outcomes involving some judgement (mobility, walking speed, functional outcomes, activities of daily living and strength) due to assessor blinding of these measurable outcomes. Magaziner 2019 reported blinding, yet assessors were unblinded for three participants; the majority of trials did not report instances of unblinding. No blinding was reported in 12 trials, resulting in high risk of bias.

We judged 17 trials to be at a low risk of detection bias for observer‐reported outcomes not involving judgement (death, re‐admission, re‐operation, surgical complications, return to living at home), as they clearly described the methods for measurement of the outcome. We considered 16 trials to have an unclear risk of bias due to lack of blinding of assessors, inadequate description of how outcomes were measured, or both. Risk of bias was high in one trial where there was no blinding for discharge arrangements (return to living at home) (Oldmeadow 2006), an outcome which is potentially susceptible to bias.

We judged none of the trials to be at low risk of detection bias for participant/proxy‐reported outcomes (health‐related quality of life, pain, falls, patient‐reported questionnaires, satisfaction). We assessed 16 trials to be at unclear risk of bias, and four trials at high risk, for these outcomes. We assessed risk of detection bias for fall outcomes as unclear in the two trials that did not specify whether there was blinding (Bischoff‐Ferrari 2010; Ohoka 2015), and in the five trials that specified that assessors recording and entering fall data were blinded, yet participants reporting falls were not blinded (Langford 2015; Moseley 2009; Orwig 2011; Sherrington 2020; Van Ooijen 2016). The risk of bias was high in Taraldsen 2019, with falls reported in retrospect by participants and staff who were aware of group allocation.

Incomplete outcome data

We judged 13 trials to be at low risk of bias from the incompleteness of data on observer‐reported outcomes involving some judgement (mobility, walking speed, functional outcomes, activities of daily living and strength). We assessed 16 trials to be at high risk of bias for various reasons, including large losses to follow‐up, imbalances in loss to follow‐up between groups, incomplete data and post‐randomisation exclusions. For 11 trials, the impact of post‐randomisation exclusions and differential loss to follow‐up led to an unclear risk of bias rating. For observer‐reported outcomes not involving judgement (death, re‐admission, re‐operation, surgical complications, return to living at home), we considered 16 trials to be at low risk of bias, 11 at high risk of bias and 10 as unclear. For participant/proxy‐reported outcomes (health‐related quality of life, pain, falls, patient‐reported questionnaires, satisfaction), we considered six trials to be at low risk of bias, 10 at high risk of bias and five as unclear.

Selective reporting

The lack of prospective trial registration and protocols hindered the appraisal of the risk of bias from selective reporting. We considered six trials (Baker 1991; Graham 1968; Karumo 1977; Kronborg 2017; Oldmeadow 2006; Orwig 2011), which also featured incomplete reporting of trial results, to be at high risk of selective reporting bias. We considered 13 trials to be at low risk of bias and 21 as unclear.

Other potential sources of bias

Baseline characteristics

We judged five trials to be at high risk of bias in the estimate of the intervention effect due to major imbalances in baseline characteristics. This judgement resulted primarily from a lack of information on baseline characteristics in Graham 1968 and Karumo 1977; and from baseline imbalances in Mangione 2005 (the control group was more depressed and started the study seven weeks earlier than the two intervention groups), Kimmel 2016 (there were disproportionately more females and fewer carers in the home in the intervention group), and Sherrington 1997 (disproportionately more males in the intervention group).

Care programmes

We judged the risk of performance bias from important differences between intervention and control groups in care programmes other than the trial interventions or differences in the experience of care providers as low in 22 trials and unclear in eight trials (usually based on inadequate information). We assessed the risk of performance bias from between‐group differences in care programmes as high in 10 trials: Graham 1968 provided no information on care programmes; the extreme variation (28 to 200 days) in the timing of the first intervention visit from the trainer to the participants in Resnick 2007 may have affected trial findings; additional treadmill training was not the only difference between groups in Ohoka 2015, as the time in standard therapy was greater in the intervention group. In multiple post‐hospital trials, the lack of control for the effect of social interaction in the intervention group may have impacted upon the intervention effect (Bischoff‐Ferrari 2010; Orwig 2011; Sherrington 2020; Suwanpasu 2014; Sylliaas 2011; Sylliaas 2012; Taraldsen 2019).

Ascertainment bias for measurement of falls

Four of the eight trials that measured falls had low risk of bias for the method of ascertaining falls, while the risk of bias was unclear in four trials (Moseley 2009; Ohoka 2015; Orwig 2011; Taraldsen 2019).

Cluster‐randomised controlled trials

We judged the only cluster‐randomised trial, Pol 2019, to be at low risk of bias due to clustering. 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.

Effects of interventions

See: 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

In this section, we report outcomes separately for in‐hospital studies and post‐hospital studies. For in‐hospital studies, we distinguish two comparisons: studies which compared a mobilisation strategy with usual care (labelled as Comparison 1); and studies that compared different timings of an intervention in‐hospital (labelled as Comparison 2). For post‐hospital studies, we also distinguish two comparisons: studies which compared a mobilisation strategy with usual care (labelled as Comparison 3); and studies that compared one type of intervention with another type in the post‐hospital setting (labelled as Comparison 4).

For each outcome described below, we report the overall pooled effects of all mobilisation strategies. We summarise the findings and illustrate the absolute impact of interventions for critical outcomes in two summary of findings tables for the overall 'mobilisation strategy versus usual care' comparison in the in‐hospital setting (summary of findings Table 1), and the overall 'mobilisation strategy versus control' comparison in the post‐hospital setting (summary of findings Table 3).

We also report the effects on mobility according to each exercise category of the ProFaNE taxonomy (Appendix 1; Appendix 6), as well as the results of exercise interventions that included multiple categories or electrical stimulation. We summarise the findings for the mobility outcome and illustrate the absolute impact of each type of exercise category versus usual care in the in‐hospital setting, and versus control in the post‐hospital setting, in bespoke summary of findings tables (summary of findings Table 2; summary of findings Table 4).

We did not present summary of findings tables for the studies that compared different timings of an intervention in‐hospital or the studies that compared one type of intervention with another type in the post‐hospital setting.

Two post‐hospital studies did not contribute any outcomes to the review (Suwanpasu 2014; Sylliaas 2012).

Comparison 1. In‐hospital rehabilitation studies: mobilisation strategy versus usual care: critical outcomes

Note the mobilisation strategy interventions are compared with non‐provision of any specific mobilisation strategy, where the non‐provision control is defined as usual orthopaedic, medical care or allied health care.

Effect of mobilisation strategy versus usual care on mobility

Pooled analysis showed mobility strategies may improve mobility (measured using mobility scales) at the time point closest to four months (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; P = 0.02, I² = 81%; 7 studies, 507 participants; low‐certainty evidence, downgraded due to risk of bias and imprecision; Analysis 1.1). The substantial heterogeneity in this analysis is explained by inclusion of Monticone 2018 and the large between‐group difference in the volume and intensity of functional exercise undertaken, compared with other studies. Removing Monticone 2018 reduced I² to 44%, and it changed the effect size from SMD 0.53 (95% CI 0.10 to 0.96) to SMD 0.29 (95% CI 0.03 to 0.55).

Re‐expressing the results using the 12‐point Physical Performance and Mobility Examination (PPME), the intervention group scored 1.46 points higher (95% CI 0.28 to 2.64). The minimal important difference (MID) for the PPME is typically 1.13 to 2.15 (de Morton 2008).

Pooled analyses of dichotomous outcomes showed low‐certainty evidence that the intervention group may have less failure to regain pre‐fracture mobility, compared with controls (RR 0.48, 95% CI 0.27 to 0.85; P = 0.01, I² = 0%; 2 studies, 64 participants; low certainty evidence, downgraded for risk of bias and imprecision; Analysis 1.2). There may be a beneficial effect of mobility strategies on self‐reported mobility as measured using the Western Ontario and McMaster Universities Osteoarthritis Index, physical function subscale (range 0 to 100, with lower score showing better function) (MD 25.40, 95% CI 28.72 to 22.08; 1 study, 52 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 1.3).

Types of intervention

Gait, balance or functional training

Trials where exercise interventions were classified as primarily gait, balance or functional task training using the ProFaNE taxonomy probably lead to a moderate improvement in mobility (measured using mobility scales) (SMD 0.57, 95% CI 0.07 to 1.06; P = 0.02, I² = 84%; 6 studies, 463 participants; moderate‐certainty evidence; Analysis 1.4). Re‐expressing the results using the 12‐point PPME, the intervention group scored 1.56 points higher (95% CI 0.02 to 2.92). The MID for the PPME is typically 1.13 to 2.15 (de Morton 2008).

Resistance/strength training

Exercises classified as primarily resistance/strength training may make little or no difference to mobility as the certainty of evidence is low and the 95% CI included both a reduction and an increase in mobility (measured using mobility scales) (mean difference (MD) 1.0, 95% CI ‐0.81 to 2.81; P = 0.28; 1 study, 44 participants; low‐certainty evidence; Analysis 1.5). Similarly, resistance/strength training interventions may make little or no difference to mobility as measured by the Timed Up and Go test (TUG), as the certainty of evidence is low and the 95% CI includes both a reduction and an increase in score (MD ‐1.5, 95% CI ‐6.4 to 3.4; 1 study, 74 participants; low‐certainty evidence; Analysis 1.6).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity, endurance, multiple intervention types or electrical stimulation.

We reported the outcomes separately for each of eight different mobility measurement tools in Analysis 1.7.

Effect of mobilisation strategy versus usual care on walking speed

Pooled analysis provided moderate‐certainty evidence that mobilisation strategies probably improve walking speed compared to control; however, the 95% confidence interval includes the possibility of both increased and reduced walking speed (SMD 0.16, 95% CI ‐0.05 to 0.37; P = 0.13, I² = 0%; 6 studies, 360 participants; moderate‐certainty evidence, downgraded for imprecision; Analysis 1.8). Re‐expressing the results using gait speed (metres/second, or m/s), showed an increase of 0.04 m/s in the intervention group (MD 0.04, 95% CI ‐0.01 to 0.08), which is considered a small meaningful change for gait speed (Perera 2006); however, the CI included both an increase and reduction in gait speed.

Types of intervention

Gait, balance or functional training

Trials where exercise interventions were classified as primarily gait, balance or functional task training using the ProFaNE taxonomy probably lead to a small improvement in walking speed; however, the 95% CI included both increased and decreased walking speed (SMD 0.15, 95% CI ‐0.07 to 0.36; P = 0.19, I² = 0%; 5 studies, 336 participants; Analysis 1.9).

Electrical stimulation

Electrical stimulation increased walking speed in one small study; however, the 95% CI included both increased and decreased walking speed (MD 0.11, 95% CI ‐0.12 to 0.34; P = 0.35; 1 study, 24 participants; Analysis 1.10).

No studies contained interventions classified as primarily resistance/strength, flexibility, 3D, general physical activity, endurance training or multiple intervention types.

Effect of mobilisation strategy versus usual care on functioning

We are uncertain whether mobility strategies improve functioning compared with control as the certainty of the evidence was very low (SMD 0.75, 95% CI 0.24 to 1.26; P = 0.04, I² = 79%; 7 studies, 379 participants; very low‐certainty evidence, downgraded due to risk of bias, substantial heterogeneity and imprecision; Analysis 1.11). Re‐expressing the results using the Barthel Index, the intervention group scored 4.4 points higher (95% CI 1.4 to 7.38). The MID for the Barthel Index (post hip surgery) is typically 9.8 (Unnanuntana 2018).

Types of intervention

Gait, balance or functional training

The effect of exercise interventions classified as primarily gait, balance or functional task training on functioning is unclear as the certainty of the evidence is very low (SMD 0.56, 95% CI ‐0.00 to 1.13; I² = 79%; 5 studies, 312 participants; very low‐certainty evidence, downgraded for risk of bias, imprecision and inconsistency; Analysis 1.12).

Resistance/strength training

It is unclear whether exercise interventions classified as primarily resistance/strength training increase functioning, as the certainty of evidence was very low (MD 1.00, 95% CI 0.56 to 1.44; 1 study, 44 participants; very low‐certainty evidence, downgraded for risk of bias and two levels for imprecision; Analysis 1.13).

Electrical stimulation

A single study showed electrical stimulation may increase functioning (MD 3.0, 95% CI 1.0 to 5.00; 1 study, 23 participants; low‐certainty evidence, downgraded two levels for imprecision; Analysis 1.14).

No studies contained interventions classified as primarily flexibility, 3D, general physical activity or endurance.

Effect of mobilisation strategy versus usual care on health‐related quality of life

We were able to pool data from four of the five trials that assessed health‐related quality of life in‐hospital. Based on pooled SMD results from the four trials, we are uncertain whether mobility strategies improve health‐related quality of life as the certainty of the evidence was very low (SMD 0.39, 95% CI ‐0.07 to 0.85; P = 0.01, I² = 71%; 4 studies, 314 participants; very low‐certainty evidence downgraded due to risk of bias, imprecision and heterogeneity; Analysis 1.15). The trial that could not be included in the meta‐analysis reported no significant difference between groups (Miller 2006; outcomes were reported as median and the denominator was not confirmed).

Transformation of this result to the EQ‐5D score (0 to 1 scale), showed the mean difference (0.03, 95% CI ‐0.02 to 0.22) was smaller than the MID for the EQ‐5D, which is typically 0.074 (Walters 2005).

The time point for measurement ranged from 10 weeks (Kimmel 2016) to six months (Van Ooijen 2016).

Effect of mobilisation strategy versus usual care on mortality

Death was reported in eight trials with separate data for the intervention and control groups; six trials reported deaths in the short term and two in the long term (12 months). No deaths were clearly associated with trial participation.

Short‐term mortality (around 4 months or at discharge)

In the short term, mobility strategies may make little or no difference to the number of people who die compared with usual care; the certainty of the evidence is low and the 95% CI includes the possibility of both reduced and increased death with mobility strategy intervention (RR 1.06, 95% CI 0.48 to 2.30; P = 0.89, I² = 0%; 6 studies, 489 participants; low‐certainty evidence, downgraded two levels due to risk of bias (removing studies with high risk of bias in one or more domains had a marked impact on results) and imprecision (few events and wide CI); Analysis 1.16).

Types of intervention

Gait, balance or functional training

There was no clear evidence of an effect of exercise interventions classified as primarily gait, balance or functional task training using the ProFaNE taxonomy (RR 1.43, 95% CI 0.44 to 4.66; I² = 0%; 3 studies, 293 participants; Analysis 1.17).

Resistance/strength training

There was no clear evidence of an effect of exercise interventions classified as resistance/strength training (RR 0.83, 95% CI 0.26 to 2.62; I² = 6%; 2 studies, 170 participants; Analysis 1.18).

Electrical stimulation

There was no clear evidence of an effect of exercise interventions classified as electrical stimulation (RR 0.73, 95% CI 0.05 to 10.49; 1 study, 26 participants; Analysis 1.19).

No studies contained interventions classified as primarily flexibility, 3D, general physical activity or endurance.

Long‐term mortality (around 12 months)

In the long term, mobility strategies may make little or no difference to the number of people who die compared with usual care (RR 1.22, 95% CI 0.48 to 3.12; P = 0.67, I² = 0%; 2 studies, 133 participants; low‐certainty evidence, downgraded two levels due to risk of bias and imprecision; Analysis 1.20).

Types of intervention

Gait, balance or functional training

There was no evidence of an effect on long‐term mortality of exercise interventions classified as primarily gait, balance or functional task training using the ProFaNE taxonomy (RR 1.47, 95% CI 0.16 to 13.35; 1 study, 70 participants; Analysis 1.21).

Resistance/strength training

There was no evidence of an effect of exercise interventions classified as primarily resistance/strength training (RR 1.16, 95% CI 0.41 to 3.26; 1 study, 63 participants; Analysis 1.22).

No studies contained interventions classified as primarily flexibility, 3D, general physical activity, endurance or electrical stimulation.

Effect of mobilisation strategy versus usual care on adverse events

Mobility strategies may make little or no difference to re‐admission compared with usual care: there is low‐certainty evidence and the CI includes both a reduction and an increase in re‐admission (RR 0.70, 95% CI 0.44 to 1.11; P = 0.13, I² = 33%; 4 studies, 322 participants; low‐certainty evidence, downgraded for imprecision and risk of bias; Analysis 1.23).

Mobility strategies may make little or no difference to re‐operation (RR 0.32, 95% CI 0.01 to 7.57; P = 0.48; 1 study, 80 participants; Analysis 1.23), number of people who reported pain versus no pain (RR 1.12, 95% CI 0.80 to 1.57; P = 0.53, I² = 0%; 3 studies, 245 participants; Analysis 1.23), number of people who experienced one or more falls (RR 0.67, 95% CI 0.32 to 1.38; P = 0.28; 1 study, 50 participants; Analysis 1.23), rate of falls (rate ratio 0.85, 95% CI 0.64 to 1.12; P = 0.25; 3 studies, 214 participants; Analysis 1.24) or other orthopaedic complications (RR 1.50, 95% CI 0.45 to 4.95; 1 study, 88 participants; Analysis 1.23). The effect of mobility strategies on surgical complications could not be estimated, with a single small study reporting no complications (Analysis 1.23). The effect of mobility strategies on pain as measured by continuous measures was markedly different in the two studies that measured it, with less pain in the intervention group in Monticone 2018 but little to no difference in Lamb 2002. We did not combine these studies as I² = 98% (Analysis 1.25).

Effect of mobilisation strategy versus usual care on number of people who returned to living at pre‐fracture residence

Mobility strategies may make little or no difference to the proportion of people who return to living at their pre‐fracture residence compared with usual care in the two studies that could be combined (RR 1.07, 95% CI 0.73 to 1.56; I² = 19%; 2 studies, 240 participants; low‐certainty evidence, downgraded due to imprecision and indirectness; Analysis 1.26), or in a third study (RR 0.57, 95% CI 0.23 to 1.41; 1 study, 86 participants; Analysis 1.27).

Types of intervention

Gait, balance or functional training

There was no evidence of an effect of exercise interventions classified primarily as gait, balance or functional task training using the ProFaNE taxonomy (RR 1.23, 95% CI 0.79 to 1.91; 1 study, 150 participants; Analysis 1.28).

Resistance/strength training

There was no evidence of an effect of exercise interventions classified primarily as resistance/strength training (RR 0.75, 95% CI 0.35 to 1.60; 1 study, 90 participants; Analysis 1.29).

Comparison 1. In‐hospital rehabilitation studies: mobilisation strategy versus usual care: other important outcomes

Effect of mobilisation strategy versus usual care on mobility: walking (aids and self‐reported outcomes)

Two studies evaluated the effect of mobility strategies on ability to walk unaided or with walking aids; pooled results showed no strong evidence of effect (RR 0.91, 95% CI 0.74 to 1.11; I² = 0%; 2 studies, 230 participants; Analysis 2.1).

No studies measured self‐reported walking outcomes.

Effect of mobilisation strategy versus usual care on mobility: balance

Pooled analysis of two studies that reported measures of balance (reach) indicated that mobility strategies may improve balance (reach) compared with control (SMD 0.37, 95% CI 0.01 to 0.73; P = 0.05, I² = 0%; 2 studies, 121 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 2.2) and may improve score on the Berg Balance Scale (MD 9.37, 95% CI 2.70 to 16.04; P = 0.006; 1 study, 41 participants; low‐certainty evidence, downgraded two points for imprecision; Analysis 2.3). There was no evidence of a treatment effect in studies measuring the ability to tandem stand (RR 0.80, 95% CI 0.28 to 2.27; 1 study, 24 participants; Analysis 2.4), take repeated steps (MD 1.40, 95% CI ‐0.23 to 3.03; 1 study, 150 participants; Analysis 2.5) or in the pooling of two studies using subjective measures of balance (RR 0.96, 95% CI 0.71 to 1.29; I² = 64%; 2 studies, 226 participants; random effects; Analysis 2.6).

Effect of mobilisation strategy versus usual care on mobility: sit to stand

Pooled analysis of two studies indicated that mobilisation strategies probably improve sit to stand ability compared with control (MD 0.04, 95% CI 0.01 to 0.07; P = 0.005, I² = 0%; 2 studies, 227 participants; moderate‐certainty evidence; Analysis 2.7).

Effect of mobilisation strategy versus usual care on muscle strength

Mobility strategies may make little or no difference to lower‐limb strength compared with control, as the 95% confidence interval includes the possibility of both increased and reduced strength (SMD 0.11, 95% CI ‐0.07 to 0.28; P = 0.24, I² = 38%; 8 studies, 498 participants; low‐certainty evidence; Analysis 2.8).

Effect of mobilisation strategy versus usual care on activities of daily living

We are uncertain whether mobility strategies improve activities of daily living compared with control as the certainty of the evidence was very low (SMD 0.87, 95% CI 0.35 to 1.38; P = 0.001, I² = 66%; 5 studies, 306 participants; very low‐certainty evidence; Analysis 2.9). We downgraded this result due to risk of bias, substantial heterogeneity and imprecision.

Effect of mobilisation strategy versus usual care on self‐reported measures of lower‐limb or hip function

No in‐hospital studies reported patient‐reported measures of lower‐limb or hip function.

Effect of mobilisation strategy versus usual care on participant satisfaction

Acceptability of interventions

No in‐hospital trials measured satisfaction.

Adherence

Six of the 18 in‐hospital studies measured and reported adherence (Appendix 7). Measures used to quantify adherence were varied; the majority of studies summarised the number of intervention sessions completed (n = 2), proportion of prescribed sessions attended (n = 1), proportion of participants who completed all sessions (n = 1) or quantified the amount of exercise performed (n = 2).

Resource outcomes

Available data on resource use is reported in Appendix 8. Length of hospital stay (in days) was reported in intervention and control groups in nine in‐hospital trials. Mean length of stay ranged from 17 days in the intervention versus 11 days in the control group (Oldmeadow 2006) to 92 days intervention versus 98 days in the control group (Ohoka 2015). Four trials reported data appropriate for pooling; pooled analysis provided no clear evidence that mobility strategies reduce the length of hospital stay compared with control, with the 95% confidence interval including the possibility of both increased and reduced length of stay (MD ‐0.83, 95% CI ‐3.94 to 2.28; I² = 45%; 4 studies, 335 participants; Analysis 2.10). The number of physiotherapy sessions was reported in four in‐hospital trials (range of mean of 6 sessions to mean of 17 sessions). Moseley 2009 reported less community service use in the intervention group (RR 0.75, 95% CI 0.56 to 1.03; P = 0.09; 1 study, 98 participants; Analysis 2.11).

Comparison 2. In‐hospital studies: comparing different timings of mobility intervention: critical and other important outcomes

Two trials compared the effect of different timings of mobility training (Oldmeadow 2006; Graham 1968). There are no data for the following critical outcomes: mobility, gait speed, functioning or health‐related quality of life. The two studies were insufficiently similar to be combined in meta‐analysis.

Effect of early versus delayed rehabilitation on mortality

There may be little or no impact on mortality when weight bearing commences at two weeks compared with 12 weeks post‐surgery (RR 0.74, 95% CI 0.43 to 1.29; 1 study, 273 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 3.1).

We are uncertain of the impact of commencing ambulation less than 48 hours compared with more than 48 hours postoperatively, as the certainty of evidence is very low (RR 3.20, 95% CI 0.14 to 75.55; 1 study, 60 participants; very low‐certainty evidence, downgraded for risk of bias and two levels for imprecision; Analysis 3.2).

Effect of early versus delayed rehabilitation on adverse events

No studies evaluated the effect of different timings of intervention on hospital re‐admission.

We are uncertain of the impact of commencing weight bearing at two weeks compared with 12 weeks post‐surgery for the adverse events of avascular necrosis (RR 0.69, 95% CI 0.33 to 1.42; 1 study, 112 participants), infection (RR 0.65, 95% CI 0.11 to 3.81; 1 study, 270 participants) or non‐union (RR 1.06, 95% CI 0.56 to 2.03; 1 study, 212 participants), as there is very low‐certainty evidence, downgraded one level for risk of bias and two levels for imprecision (see Analysis 3.3).

Effect of early versus delayed rehabilitation on number of people who returned to living at pre‐fracture residence

There may be little or no impact of commencing ambulation less than 48 hours compared with more than 48 hours postoperatively on the outcome of return to living at home (RR 0.86, 95% CI 0.72 to 1.02; P = 0.09; 1 study, 60 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 3.4).

Effect of early versus delayed rehabilitation on mobility: need for assistance with transfers

There may be little or no impact of commencing ambulation less than 48 hours compared with more than 48 hours postoperatively on the need for assistance with transfers at one week follow‐up (RR 0.51, 95% CI 0.29 to 0.89; P = 0.02; 1 study, 60 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 3.5).

In‐hospital studies: sensitivity analyses

For the mobility outcome (mobility scales) we carried out six sensitivity analyses to explore the stability of the results. For each of these analyses, the impact on the pooled mobility strategy versus control mobility outcome is summarised in Appendix 9.

Sensitivity analyses revealed little difference in the results when we excluded trials at high or unclear risk of bias associated with a lack of allocation concealment, removed trials with high risk of bias on any domains, removed trials that were reported only in conference abstracts, removed in‐hospital trials that measured outcomes at the end of the in‐hospital phase (the usual time point was that closest to four months), or using fixed‐effect (rather than random‐effects) meta‐analysis for the mobility outcome. There were no trials that focused on a population different from our target population (i.e. people with a fragility fracture resulting from low‐energy trauma), and no trials with mixed populations.

Funnel plots

We did not construct any funnel plots as all outcomes had fewer than 10 data points.

Comparison 3. Post‐hospital rehabilitation studies: mobilisation strategy versus usual care: critical outcomes

In these studies, the provision of any specific mobilisation strategy or programme was compared with non‐provision, where the non‐provision control was defined as no intervention, usual care, sham exercise (where the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit.

Effect of mobilisation strategy versus usual care on mobility

Pooled analysis provided evidence that mobilisation strategies increase mobility, measured using mobility scales, compared with control (SMD 0.32, 95% CI 0.11 to 0.54; P = 0.003, I² = 48%; 7 studies, 761 participants; high‐certainty evidence; Analysis 4.1). Re‐expressing the results using the 12‐point Short Physical Performance Battery (SPPB), the intervention group scored 0.89 points higher (95% CI 0.30 to 1.50), which exceeds small meaningful change for SPPB (0.27 to 0.55 points) and is smaller than substantial meaningful change (0.99 to 1.34 points) (Perera 2006).

Mobility strategies may make little or no difference to mobility as measured by TUG, as the certainty of evidence is low and the 95% CI includes both a reduction and an increase in score (MD ‐1.98, 95% CI ‐5.59 to 1.63; I² = 15%; 4 studies, 375 participants; low‐certainty evidence; Analysis 4.2). Mobility training probably increases mobility, measured by the 6‐Minute Walk Test (6MWT), compared with control (MD 28.66, 95% CI 10.88 to 46.44; I² = 37%; 5 studies, 396 participants; moderate‐certainty evidence; Analysis 4.3).

Types of intervention

Gait, balance or functional training

Trials where exercise interventions were classified as primarily gait, balance or functional task training using the ProFaNE taxonomy lead to a moderate improvement in mobility (measured using mobility scales) (SMD 0.20, 95% CI 0.05 to 0.36; I² = 0%; 5 studies, 621 participants; high‐certainty evidence; Analysis 4.4). Re‐expressing the results using the 12‐point SPPB, the intervention group scored 0.55 points higher (95% CI 0.14 to 1.0), which is a small meaningful change on this outcome measure (Perera 2006). The effect on mobility measured using TUG is not clear as the certainty of evidence is very low (MD ‐7.57, 95% CI ‐19.25 to 4.11; 1 study, 128 participants; very low‐certainty evidence; Analysis 4.5).

No studies of gait, balance or functional task training measured mobility using the 6MWT.

Resistance/strength training

Trials where exercise interventions were classified as primarily resistance/strength training may make little or no difference to mobility (measured using TUG) as the certainty of evidence is low and the 95% CI included both a reduction and an increase in mobility (MD ‐6.00, 95% CI ‐12.95 to 0.95; 1 study, 96 participants; low‐certainty evidence; Analysis 4.6). Resistance/strength training may increase mobility as measured using the 6MWT (MD 55.65, 95% CI 28.58 to 82.72; I² = 0%; 3 studies, 198 participants; low‐certainty evidence; Analysis 4.7). The minimal important difference (MID) for the 6MWT (adults with pathology) is typically 14.0 m to 30.5 m (Bohannon 2017).

No studies of resistance/strength training measured mobility using mobility scales.

Endurance training

The effect of exercises classified as being primarily endurance training on mobility measured using the 6MWT is not clear as the certainty of evidence is very low (MD 12.70, 95% CI ‐72.12 to 97.52; 1 study, 21 participants; very low‐certainty evidence; Analysis 4.8).

Multiple types of exercise

Interventions containing multiple primary types of exercise probably lead to a moderate increase in mobility (mobility scales) (SMD 0.94, 95% CI 0.53 to 1.34; I² = 6%; 2 studies, 104 participants; moderate‐certainty evidence; Analysis 4.9). Both studies included gait, balance or functional training plus resistance/strength training ProFaNE categories (Binder 2004; Hauer 2002). Re‐expressing the results using the 12‐point SPPB, the intervention group scored 2.6 points higher (95% CI 1.47 to 3.71), with substantial meaningful change for SPPB being 0.99 to 1.34 points (Perera 2006). A study including multiple types of interventions, classified in ProFaNE as strength training and endurance training, may have little or no effect on mobility (6MWT) (MD 9.30, 95% CI ‐14.62 to 33.22; 1 study, 187 participants; low‐certainty evidence; Analysis 4.10). The mean 6MWT distance in the intervention group was 9 m further (95% CI 15 m less to 33 m further) than in the control group, with a MID of 14.0 m to 30.5 m (Bohannon 2017).

No studies containing multiple primary types of exercise measured mobility using TUG.

Other

Two interventions were classified as 'other', according to the ProFaNE taxonomy. Non‐weight‐bearing exercise had no clear effect on mobility (mobility scales) compared with control (MD 0.40, 95% CI ‐0.37 to 1.17; 1 study, 72 participants; Analysis 4.11); nor did cognitive behavioural therapy with or without a sensor to monitor physical activity (MD 0.58, 95% CI ‐3.96 to 5.11; 1 study, 151 participants; Analysis 4.12).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity or electrical stimulation.

We reported the outcomes separately for each of eight different mobility measurement tools in Analysis 4.13.

Three studies reported self‐reported mobility outcomes. There was no strong evidence of an intervention effect on the continuously scored Activity Measure for Post Acute Care (range 9 to 101, higher score indicates better function) (MD 1.46, 95% CI ‐0.62 to 3.53; I² = 0%; 2 studies, 355 participants; Analysis 4.14). The intervention group may be more likely to be able to climb a flight of stairs compared with the control group (RR 0.45, 95% CI 0.29 to 0.72; I² = 0%; 2 studies, 148 participants; low‐certainty evidence; Analysis 4.15).

Effect of mobilisation strategy versus usual care on walking speed

Pooled analysis provided high‐certainty evidence that mobilisation strategies improve walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; I² = 1%; 14 studies, 1067 participants; high‐certainty evidence; Analysis 4.16). Re‐expressing the results using gait speed (m/sec), there was an increase in gait speed of 0.05 m/sec in the intervention group (MD 0.05, 95% CI 0.01 to 0.09). A small meaningful change for gait speed is 0.04 to 0.06 m/sec (Perera 2006).

Types of intervention

Gait, balance or functional training

Trials where exercise interventions were classified as primarily gait, balance or functional task training using the ProFaNE taxonomy have no clear effect on gait speed; the 95% CI includes both a reduction and increase in gait speed (SMD 0.08, 95% CI ‐0.09 to 0.25; I² = 0%; 7 studies, 511 participants; Analysis 4.17).

Resistance/strength training

The impact of trials classified primarily as resistance/strength training on gait speed is unclear; the 95% CI includes both a reduction and increase in gait speed (SMD 0.29, 95% CI ‐0.01 to 0.58; I² = 0%; 3 studies, 197 participants; Analysis 4.18).

Endurance

In the single study with an intervention arm classified primarily as endurance training, the 95% CI included both a reduction and increase in gait speed (MD 0.14, 95% CI ‐0.06 to 0.34; 1 study, 22 participants; Analysis 4.19).

Multiple types of intervention

It is unclear whether training involving multiple ProFaNE categories increases walking speed as the certainty of evidence is very low (SMD 0.53, 95% CI ‐0.13 to 1.18; I² = 81%; 3 studies, 285 participants; very low‐certainty evidence, downgraded for risk of bias, inconsistency and imprecision; Analysis 4.20).

Other

Two Interventions were classified as 'other' according to the ProFaNE taxonomy. Post‐discharge telephone support and coaching had no clear effect on walking speed compared with control (MD 0.00, 95% CI ‐0.20 to 0.20; 1 study, 26 participants; Analysis 4.21), nor did non‐weightbearing exercise (MD 0.06, 95% CI ‐0.19 to 0.31; 1 study; 72 participants; Analysis 4.22).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity or electrical stimulation.

Subgroup analyses

Subgroup analysis by trials excluding participants with cognitive impairment at baseline found no evidence of a difference in the effect of mobility strategies on walking speed outcome between trials where participants were specifically excluded if they had impaired cognition (SMD 0.19, 95% CI 0.04 to 0.34; 12 studies, 762 participants) and with trials that did not have impaired cognition as an exclusion criterion (SMD 0.07, 95% CI ‐0.16 to 0.29; 2 studies, 304 participants. Test for subgroup differences: Chi² = 0.79, degrees of freedom (df) = 1, P = 0.37, I² = 0%; Analysis 4.23).

Subgroup analysis found no evidence of a difference in the effect of mobility strategies on walking speed outcome between trials where interventions were delivered in the outpatient setting (SMD 0.35, 95% CI 0.08 to 0.62; I² = 24%; 2 studies, 229 participants) and trials where interventions were delivered in the secondary and social care setting (SMD 0.11, 95% CI ‐0.02 to 0.25; I² = 0%; 14 studies, 838 participants. Test for subgroup differences: Chi² = 2.34, df = 1, P = 0.13, I² = 57.3%; Analysis 4.24). Note that no trials were conducted in a social care setting.

Subgroup analysis by age found no evidence of a difference in the effect of mobility strategies on walking speed outcome between trials where mean age was 80 years or less (SMD 0.12, 95% CI ‐0.05 to 0.30; I² = 0%; 10 studies, 536 participants) and trials where mean age was above 80 years (SMD 0.18, 95% CI 0.01 to 0.36; I² = 48%; 6 studies, 530 participants. Test for subgroup differences: Chi² = 0.23, df = 1, P = 0.63, I² = 0%; Analysis 4.25).

Effect of mobilisation strategy versus usual care on functioning

Whilst there is high‐certainty evidence indicating mobility strategies increase function, this improvement is unlikely to be clinically important (SMD 0.23, 95% CI 0.10 to 0.36; I² = 0%; 9 studies, 936 participants; high‐certainty evidence; Analysis 4.26). Re‐expressing the results using the Barthel Index, the intervention group scored 1.4 points higher (95% CI 0.6 to 2.1). The MID for the Barthel Index (post‐hip surgery) is typically 9.8 (Unnanuntana 2018).

Intervention types

Gait, balance or functional training

The impact of gait, balance or functional task training on functioning is unclear as the 95% CI includes both increased and reduced functioning (SMD 0.17, 95% CI ‐0.02 to 0.36; I² = 0%; 4 studies, 432 participants; Analysis 4.27).

Resistance/strength training

Exercises classified as primarily resistance or strength training may increase functioning (SMD 0.29, 95% CI 0.03 to 0.55; I² = 0%; 2 studies, 246 participants; low‐certainty evidence; Analysis 4.28)

Multiple types of intervention

The impact of training involving multiple ProFaNE components is unclear for the functioning outcome (SMD 0.34, 95% CI ‐0.04 to 0.72; I² = 0%; 2 studies, 107 participants; Analysis 4.29).

Other

In a trial comparing cognitive behavioural therapy with or without physical activity monitor with control, the effect of intervention on functioning is unclear as the 95% CI includes both increased and reduced functioning (MD 0.34, 95% CI ‐0.13 to 0.81, I² = 0%; 2 studies, 151 participants; Analysis 4.30).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity or electrical stimulation.

Effect of mobilisation strategy versus usual care on health‐related quality of life

Mobility strategies probably lead to a slight increase in health‐related quality of life that may not be clinically meaningful (SMD 0.14, 95% CI ‐0.00 to 0.29; I² = 29%; 10 studies, 785 participants; moderate‐certainty evidence; Analysis 4.31). Re‐expressing the results using the EQ‐5D (0 to 1 scale), there was an increase in quality of life of 0.01 in the intervention group (95% CI ‐0.007 to 0.08). The MID for the EQ‐5D is typically 0.074 (Walters 2005). Re‐expressing the results using the SF‐36 (0 to 100 scale), there was an increase in quality of life of 3 points in the intervention group (95% CI ‐0.6 to 5.7). The MID for SF‐36 is typically 3 to 5 (Walters 2003). Thus, the respective means were smaller than the MIDs for both scales, although the 95% CI for the SF‐36 included the MID.

Intervention types

Gait, balance or functional training

The impact of gait, balance or functional task training on functioning is unclear as the 95% CI includes both increased and reduced functioning (SMD 0.08, 95% CI ‐0.37 to 0.53; I² = 0%; 4 studies, 316 participants; Analysis 4.32).

Resistance/strength training

Exercises classified as primarily resistance or strength training may make little or no difference to functioning as the 95% CI includes both increased and reduced functioning (SMD 0.15, 95% CI ‐0.14 to 0.45; I² = 0%; 3 studies, 197 participants; low‐certainty evidence; Analysis 4.33)

Endurance training

The impact of exercises classified as primarily endurance training is unclear (MD 9.50, 95% CI ‐8.56 to 27.56; I² = 0%; 1 study, 22 participants; Analysis 4.34).

Multiple types of intervention

Training involving multiple ProFaNE components may improve health‐related quality of life, as measured using the SF‐36 Physical Function subscale (MD 11.00, 95% CI 0.42 to 21.58; 1 study, 83 participants; Analysis 4.35).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity or electrical stimulation.

Subgroup analyses

Subgroup analysis by trials excluding participants with cognitive impairment at baseline found no evidence of a difference in the effect of mobility strategies on health‐related quality of life outcome between trials where participants were specifically excluded if they had impaired cognition (SMD 0.17, 95% CI 0.01 to 0.33; I² = 33%; 11 studies, 665 participants) compared with trials that did not have impaired cognition as an exclusion criterion (SMD 0.00, 95% CI ‐0.36 to 0.36; I² = 0%; 1 study, 120 participants. Test for subgroup differences: Chi² = 0.73, df = 1 (P = 0.39), I² = 0; Analysis 4.36).

Subgroup analysis found no evidence of a difference in the effect of mobility strategies on health‐related quality of life outcome between trials where interventions were delivered in the outpatient setting (SMD 0.18, 95% CI ‐0.09 to 0.45; I² = 56%; 2 studies, 233 participants) and trials where interventions were delivered in the secondary and social care setting (SMD 0.13, 95% CI ‐0.04 to 0.30; I² = 32%; 10 studies, 552 participants), where strength was increased in both settings. (Test for subgroup differences: Chi² = 0.09, df = 1 (P = 0.76), I² = 0%; Analysis 4.37).

Subgroup analysis by age found no evidence of a difference in the effect of mobility strategies on health‐related quality of life outcome between trials where mean age was 80 years or less (SMD 0.25, 95% CI ‐0.05 to 0.55; I² = 66%; 5 studies, 184 participants) and trials where mean age was above 80 years (SMD 0.11, 95% CI ‐0.05 to 0.27; I² = 0%; 7 studies, 601 participants. Test for subgroup differences: Chi² = 0.64, df = 1 (P = 0.43), I² = 0%, Analysis 4.38).

Effect of mobilisation strategy versus usual care on mortality

Death was reported in 12 studies with separate data for the intervention and control groups; eight studies reported short‐term mortality and four reported long‐term (12 months) mortality.

Short‐term mortality (around 4 months or at discharge)

In the short term, mobility strategies probably have no impact on the number of people who die compared with usual care; the certainty of the evidence is moderate and the 95% CI includes the possibility of both reduced and increased death with a mobility strategy intervention (RR 1.01, 95% CI 0.49 to 2.06; P = 0.99, I² = 0%; 7 studies, 737 participants; moderate‐certainty evidence, downgraded due to imprecision (few events and wide CI); Analysis 4.39).

Types of intervention

Gait, balance or functional training

There was no clear evidence of an effect of exercise interventions classified as primarily gait, balance or functional task training using the ProFaNE taxonomy (RR 1.12, 95% CI 0.46 to 2.72; I² = 0%; 3 studies, 264 participants; Analysis 4.40).

Resistance/strength training

There was no clear evidence of an effect of exercise interventions classified as primarily resistance/strength training (RR 1.40, 95% CI 0.19 to 10.03; I² = 0%; 2 studies, 123 participants; Analysis 4.41).

Multiple types of intervention

The impact of training involving multiple ProFaNE components is unclear as the 95% CI includes both reduced and increased mortality (RR 0.61, 95% CI 0.08 to 4.55; I² = 0%; 2 studies, 290 participants; Analysis 4.42).

Other

In a trial comparing non‐weight bearing exercise with control, the effect of intervention on mortality is unclear as the 95% CI includes both increased and reduced mortality (RR 0.50, 95% CI 0.03 to 7.59; 1 study, 60 participants; Analysis 4.43).

No studies contained interventions classified primarily as flexibility, 3D, general physical activity, endurance or electrical stimulation.

Long‐term mortality (around 12 months)

In the long term, it is unclear whether mobility strategies impact the number of people who die compared with usual care (RR 0.73, 95% CI 0.39 to 1.37; P = 0.33, I² = 0%; 4 studies, 588 participants; low‐certainty evidence, downgraded two levels due to risk of bias (removing studies with high risk of bias in one or more domains had a marked impact on results) and imprecision (few events and wide CI); Analysis 4.44).

Types of intervention

Gait, balance or functional training

There was no clear evidence of an effect of exercise interventions classified as primarily gait, balance or functional task training using the ProFaNE taxonomy on long‐term mortality (RR 0.75, 95% CI 0.34 to 1.67; I² = 0%; 2 studies, 254 participants; Analysis 4.45).

Multiple types of intervention

The impact of training involving multiple ProFaNE components is unclear as the 95% CI includes both reduced and increased mortality (RR 0.70, 95% CI 0.25 to 1.96; I² = 0%; 2 studies, 334 participants; Analysis 4.46).

Effect of mobilisation strategy versus usual care on adverse events

We prespecified re‐admission to hospital as the critical adverse event to be reported in the summary of findings table (summary of findings Table 3). There is no clear evidence of the effect of mobility strategies on re‐admissions: mobilisation strategies may decrease the number of re‐admissions; however, the 95% confidence interval includes the possibility of both a large reduction and large increase. We downgraded the evidence by one level for risk of bias, as both trials were at a high risk of bias in one or more domains, and one level for imprecision due to very few events and wide CIs (RR 0.86, 95% CI 0.52 to 1.42; I² = 0%; 2 studies, 206 participants; low‐certainty evidence; Analysis 4.47). A single study that reported re‐admission rate and could not be pooled had a similar result (RR 1.00, 95% CI 0.62 to 1.60; 1 study, 173 participants; Analysis 4.48).

There was no strong evidence of an effect of mobility strategies on the adverse outcomes of re‐operation (RR 0.46, 95% CI 0.20 to 1.08; 1 study, 173 participants; Analysis 4.47), or surgical complications (RR 0.92, 95% CI 0.06 to 13.18; 1 study, 25 participants; Analysis 4.47).

Pooled analysis provided evidence that mobilisation strategies probably reduce the number of falls by 21% compared with control (rate ratio 0.79, 95% CI 0.63 to 0.99; I² = 0%; 3 studies, 397 participants; moderate‐certainty evidence, downgraded one level for risk of bias; Analysis 4.49). Exercise interventions classified as primarily gait, balance or functional task training using the ProFaNE taxonomy reduced falls (rate ratio 0.78, 95% CI 0.62 to 0.99; I² = 0%; 2 studies, 367 participants; Analysis 4.50); however, there was no evidence of an effect of additional phone support and coaching (rate ratio 1.00, 95% CI 0.14 to 7.10; 1 study, 26 participants; Analysis 4.51).

There was no strong evidence of an effect of mobility strategies on the number of people experiencing one or more falls (risk ratio 1.03, 95% CI 0.85 to 1.25; 4 studies, 527 participants; Analysis 4.52).

There was no evidence of an effect of mobility strategies on pain in the three studies that used a continuous pain score (SMD ‐0.04, 95% CI ‐0.29 to 0.22; I² = 0%; 3 studies, 242 participants; Analysis 4.53), or one study using a dichotomous score to determine the impact on pain of weight‐bearing (OR 1.40, 95% CI 0.48 to 4.10; 71 participants) and non‐weight‐bearing exercise (OR 0.82, 95% CI 0.26 to 2.55; 73 participants) compared with control (Sherrington 2004).

Comparison 3. Post‐hospital rehabilitation studies: mobilisation strategy versus usual care: other important outcomes

Effect of mobilisation strategy versus usual care on mobility: walking (aids and self‐reported outcomes)

Pooled analysis provided no evidence that mobilisation strategies affect walking‐aid use compared with control (RR 0.46, 95% CI 0.16 to 1.31; I² = 94%; 4 studies, 314 participants; low‐certainty evidence; Analysis 5.1).

Pooled analysis of two studies provided no evidence that mobilisation strategies improved subjective walking measures (number of people who said they had difficulty or inability to walk specified distances) compared to control (RR 0.55, 95% CI 0.28 to 1.06; I² = 0%; 2 studies, 182 participants; Analysis 5.2).

Effect of mobilisation strategy versus usual care on mobility: balance

Pooled analysis provided no clear evidence that mobility training improves balance compared with control when balance is measured using reach (MD 1.30, 95% CI ‐1.70 to 4.31; I² = 34%; 2 studies, 144 participants; Analysis 5.3), timed standing in various positions (SMD 0.24, 95% CI ‐0.37 to 0.86; I² = 79%; 2 studies, 234 participants; Analysis 5.4) or balance scales (SMD 0.28, 95% CI ‐0.52 to 1.08; I² = 71%; 2 studies, 212 participants; Analysis 5.5). For self‐reported measures of balance, pooled analysis provided contradictory evidence for the effect of mobility training on balance compared with control, although the level of evidence was low to very low. For continuous outcomes, the intervention group reported more unsteadiness (MD ‐0.66, 95% CI ‐1.19 to ‐0.13; I² = 0%; 1 study, 24 participants; very low‐certainty evidence; Analysis 5.6), and for dichotomous outcomes, the intervention group may report less unsteadiness (RR 0.82, 95% CI 0.69, 0.98; I² = 0%; 2 studies, 148 participants; low‐certainty evidence; Analysis 5.7).

Effect of mobilisation strategy versus usual care on mobility: sit to stand

Pooled analysis provided evidence that mobilisation strategies may improve sit to stand mobility compared with control (MD ‐6.49, 95% CI ‐12.23 to ‐0.75; I² = 91%; 5 studies, 457 participants; low‐certainty evidence, downgraded one level as all studies had high risk of bias in at least one domain and one level for inconsistency; Analysis 5.8)

Effect of mobilisation strategy versus usual care on muscle strength

Pooled analysis found that mobilisation strategies increase lower‐limb strength compared with control (SMD 0.30, 95% CI 0.18 to 0.42; I² = 34%; 14 studies, 1121 participants; high‐certainty evidence; Analysis 5.9).

Subgroup analyses

Subgroup analysis by trials excluding participants with cognitive impairment at baseline found evidence of a significantly greater effect of mobility strategies on strength outcome in trials where participants were specifically excluded if they had impaired cognition (SMD 0.37, 95% CI 0.23 to 0.50; I² = 23%; 14 studies, 891 participants) compared with trials that did not have impaired cognition as an exclusion criterion (SMD 0.07, 95% CI ‐0.19 to 0.33; I² = 51%; 2 studies, 230 participants. Test for subgroup differences: Chi² = 3.86, df = 1, P = 0.05, I² = 74.1%; Analysis 5.10).

Subgroup analysis found no evidence of a difference in the effect of mobility strategies on strength outcome between trials where interventions were delivered in the outpatient setting (SMD 0.67, 95% CI 0.39 to 0.95; I² = 0%; 2 studies, 227 participants) and trials where interventions were delivered in the secondary and social care setting (SMD 0.39, 95% CI 0.25 to 0.52; I² = 15%; 12 studies, 890 participants); however, both stages of rehabilitation resulted in increased strength. (Test for subgroup differences: Chi² = 3.15, df = 1, P = 0.08, I² = 68.2%; Analysis 5.11.)

Subgroup analysis by age found no evidence of a difference in the effect of mobility strategies on strength outcome between trials where mean age was 80 years or less (SMD 0.35, 95% CI 0.16 to 0.54; I² = 48%; 8 studies, 464 participants) and trials where mean age was above 80 years (SMD 0.27, 95% CI 0.11 to 0.43; I² = 70%; 6 studies, 657 participants); however, both stages of rehabilitation resulted in increased strength. (Test for subgroup differences: Chi² = 0.39, df = 1, P = 0.53, I² = 0%; Analysis 5.12).

Effect of mobilisation strategy versus usual care on activities of daily living

There is no evidence that mobility strategies improve activities of daily living (SMD ‐0.01, 95% CI ‐0.26 to 0.23; I² = 55%; 6 studies, 683 participants; Analysis 5.13).

Effect of mobilisation strategy versus usual care on self‐reported measures of lower‐limb or hip function

It is unclear whether mobility strategies improve lower‐limb or hip function (SMD 0.78, 95% CI ‐20 to 1.77; I² = 74%; 2 studies, 106 participants; Analysis 5.14). This was measured using the Hip Rating Questionnaire (Binder 2004) and Harris Hip Score (Tsauo 2005).

Effect of mobilisation strategy versus usual care on participant satisfaction

Acceptability of interventions

No trials in the post‐hospital setting measured acceptability of interventions.

Adherence

Of the 22 post‐hospital studies, 14 measured and reported adherence (Appendix 7). Measures used to quantify adherence were varied; the majority of studies summarised the number of intervention sessions completed (n = 5), proportion of prescribed sessions attended (n = 1), proportion of participants who completed a specified number of sessions/week (n = 3), proportion of participants who completed all sessions (n = 1) or quantified the amount of exercise performed (n =4).

Resource outcomes

Resources use is reported in Appendix 8. The number of physiotherapy sessions was reported in six post‐hospital trials (range = mean of 2 sessions to mean of 36 sessions). No studies reported the number of outpatient attendances or need for special care. Langford 2015 reported the total telephone intervention time delivered for the intervention group, over 5 calls, was 151 minutes (range 42 to 286 minutes).

Comparison 4. Post‐hospital studies: comparing different mobility strategy interventions: critical and other important outcomes

Endurance training versus resistance training

One study compared endurance training versus resistance training (Mangione 2005).

Effect of endurance training versus resistance training on mobility

There was no evidence of a difference in effect on mobility measured using the 6‐Minute Walk Test (MD ‐42.20, 95% CI ‐131.07 to 46.67; 1 study, 23 participants; Analysis 6.1).

Effect of endurance training versus resistance training on walking speed

There was no evidence of a difference in effect on walking speed (MD ‐0.08, 95% CI ‐0.30 to 0.14; 1 study, 23 participants; Analysis 6.2).

Effect of endurance training versus resistance training on health‐related quality of life

There was no evidence of a difference in effect on health‐related quality of life (MD 0.20, 95% CI ‐18.36 to 18.76; 1 study, 23 participants; Analysis 6.3).

Effect of endurance training versus resistance training on strength

There was no evidence of a difference in effect on strength (MD ‐7.50, 95% CI ‐24.08 to 9.08; 1 study, 23 participants; Analysis 6.4).

Weight‐bearing versus non‐weight‐bearing exercise

One study compared weight‐bearing exercise (classified as primarily gait, balance, co‐ordination or functional task training using the ProFaNE taxonomy) and non‐weight‐bearing exercise (classified as other) (Sherrington 2004).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on mobility

There was no evidence of a difference in effect on mobility measured using a mobility scale (MD ‐0.20, 95% CI ‐1.13 to 0.73; 1 study, 69 participants; Analysis 6.5).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on walking speed

There was no evidence of a difference in effect on walking speed (MD ‐0.70, 95% CI ‐5.40 to 4.00; 1 study, 69 participants; Analysis 6.6).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on mortality

There was no evidence of a difference in effect on short‐term mortality (RR 3.00, 95% CI 0.33 to 27.63; 1 study, 80 participants; Analysis 6.7).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on adverse events

There was no evidence of a difference in effect on pain from fracture (RR 1.51, 95% CI 0.65 to 3.53; 1 study, 72 participants; Analysis 6.8), pain during exercise (RR 2.11, 95% CI 0.80 to 5.57; 1 study, 72 participants; Analysis 6.8) or number of people who fell (RR 1.06, 95% CI 0.53 to 2.12; 1 study, 72 participants; Analysis 6.9).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on balance

The weight‐bearing group may have better objective balance at four months compared with the control group (MD 4.90, 95% CI 0.87 to 8.93; 1 study, 68 participants; low‐certainty evidence, downgraded for risk of bias and imprecision; Analysis 6.10); however, there was no between‐group difference for self‐reported balance (RR 1.02, 95% CI 0.77 to 1.34; 1 study, 72 participants; Analysis 6.11).

Effect of weight‐bearing exercise versus non‐weight‐bearing exercise on strength

There was no evidence of a difference in effect on strength (MD 27.30, 95% CI ‐3.41 to 58.01; 1 study, 66 participants; Analysis 6.12).

Post‐hospital studies: sensitivity analyses

For the mobility outcome (broad mobility measures), we carried out five sensitivity analyses to explore the stability of the results. For each of these analyses, the impact on the pooled mobility strategy versus control mobility outcome is summarised in Appendix 9.

Sensitivity analyses revealed little difference in the results when we excluded trials at high or unclear risk of bias associated with a lack of allocation concealment, removed trials with high risk of bias on any domains, removed trials that did not clearly focus on people with a fragility fracture resulting from low‐energy trauma, removed trials with mixed populations, or used fixed‐effect (rather than random‐effects) meta‐analysis for the mobility outcome. There were no trials reported only in conference abstracts.

Funnel plots

The funnel plots in Figure 4, Figure 5 and Figure 6 do show some asymmetry. However, we did not consider the asymmetry sufficient to downgrade the level of evidence.

Figure 4

Funnel plot of comparison 4: post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes. Outcome 4.16: walking speed: combined data for all strategy types

Figure 5

Funnel plot of comparison 4: post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes. Outcome 4.31: health‐related quality of life (measured using HRQoL scales): combined data for all strategy types

Figure 6

Funnel plot of comparison 5: post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes. Outcome: 5.9 strength

Economic outcomes

Of the 40 included studies, we identified two that had reported economic data (Appendix 10). Taraldsen 2019 reported costs of intervention and health services from the broad healthcare perspective, plus cost‐effectiveness analysis results. The probability that a home‐based exercise programme delivered for four months was cost‐effective was below 39% for any incremental cost‐effectiveness ratio (ICER) ceiling ratio below EUR 150,000 per quality‐adjusted life‐year (QALY) gained. Williams 2016 reported costs from a public sector perspective, considering the cost of health services, social services and medications. Cost‐effectiveness analysis was not conducted as there was no between‐group difference in QALYs.

Adherence

Across both in‐hospital and post‐hospital settings, 20 studies measured and reported adherence (Appendix 7). Measures used to quantify adherence were varied. The majority of studies summarised the number of intervention sessions completed (n = 7). Other studies: measured the proportion of prescribed sessions attended (n = 3); measured the proportion of participants who completed a specified number of sessions/week (n = 4); measured the proportion of participants who completed all sessions (n = 2); or quantified the amount of exercise performed (n = 4). The median proportion of intervention group participants that met the study's prespecified definition of adherence was 83% (IQR 70 to 93) (10 studies).

Discussion

Summary of main results

Our review covers mobilisation strategies implemented during rehabilitation after hip fracture surgery. The evidence from randomised and quasi‐randomised trials now comprises that from 40 trials. In some trials, methodological flaws undermined the validity of their findings. The trials involved a total of 4059 participants, most of whom were female and aged over 65 years. Of these, 18 trials (1433 participants) contributed to the evidence for the ‘mobility strategy versus control comparison’ for at least one of the main outcomes in the in‐hospital setting. Twenty trials (2485 participants) contributed evidence for the ‘mobility strategy versus control comparison’ for at least one of the main outcomes in the post‐hospital setting. Two trials (141 participants) in the post‐hospital setting did not contribute to the main outcomes.

Our interpretations of continuous outcomes, presented in summary of findings Table 1, summary of findings Table 2, summary of findings Table 3 and summary of findings Table 4 are based upon guiding rules for interpreting SMDs (‘Cohen’s effect sizes’) and expressed in the units of a specific measurement instrument where appropriate. Our illustrative risks for dichotomous outcomes presented in summary of findings Table 1 and summary of findings Table 3 are based on proportions calculated from the number of people who experienced the event divided by the number of people in the group, for those trials included in the analysis for that outcome.

We classified the exercise interventions using the ProFaNE classification system. As described in Appendix 6, of the 46 comparisons conducted in 40 studies, 23 compared interventions classified as primarily gait, balance and functional training, with usual care. Resistance training was evaluated in eight studies, endurance training in one study, multiple categories in seven studies (usually gait, balance and functional training combined with resistance training), and three comparisons were categorised as 'other'. In addition, three studies primarily involved electrical stimulation.

In‐hospital setting, mobility strategy versus control

Mobility strategy versus control

Mobility strategies may cause a moderate, meaningful improvement in mobility; however, we assessed the certainty of the evidence as low. Overall, there is moderate‐certainty evidence of a small, meaningful improvement in walking speed compared with control; however, the confidence interval includes both slower walking and faster walking. Any difference in the effect of in‐hospital mobility strategies on mobility and walking may be due to mobility measures being more sensitive to smaller changes in mobility than walking outcomes (particularly the use of an aid or assistance).

Mobility strategies may make little or no difference to short‐term or long‐term mortality (low‐certainty evidence), re‐admission (low‐certainty evidence) or return to living at the pre‐fracture residence (low‐certainty evidence). We are uncertain whether mobility strategies improve functioning or health‐related quality of life as we assessed the certainty of the evidence as very low. Mobility strategies may make little or no difference to the adverse events of re‐operation, pain or falls.

Regarding non‐critical outcomes, mobility strategies may make little or no difference to the ability to walk unaided or with walking aids. Mobility strategies may increase balance (measured using reach and balance scales, low‐certainty evidence) and probably improve sit to stand ability (moderate‐certainty evidence). There is also low‐certainty evidence that mobility strategies may increase strength; however, the 95% confidence interval includes the possibility of both increased and reduced strength.

Resource use was reported to varying degrees in 18 studies. It was most often reported in terms of length of hospital stay and number of physiotherapy sessions. Four studies with 335 participants were available for pooling of data, with the mobility strategies making little or no difference to length of hospital stay.

Types of interventions

When we explored the effect of different types of mobility strategies on the mobility outcome, interventions that include training of gait, balance and functional tasks were effective in increasing mobility. The effects of resistance training were unclear. No studies evaluated the effect of other forms of exercise or electrical stimulation on the critical outcome of mobility. Electrical stimulation may improve function in the in‐hospital setting.

Other comparisons

One study found early assisted ambulation commencing within 48 hours postoperatively may reduce the need for assistance with transfers at one week follow‐up, compared with assisted ambulation starting after 48 hours post‐surgery (low‐certainty evidence). The impact of early versus delayed rehabilitation on mortality and adverse events is unclear as the certainty of evidence is very low, and there may be little or no impact on return to living at home (low certainty evidence).

Subgroup analyses

There were insufficient studies to conduct subgroup analyses.

Post‐hospital setting, mobility strategy versus control

Mobility strategy versus control

There is high‐certainty evidence that mobility strategies lead to a small, clinically‐meaningful increase in mobility compared with control (usual care, no intervention, sham exercise or social visit) in the post‐hospital setting. Mobility strategies make small, clinically meaningful improvements in walking speed compared to control (high‐certainty evidence), lead to a small, non‐clinically meaningful improvement in functioning (high‐certainty evidence) and probably lead to a slight increase in health‐related quality of life that may not be meaningful (moderate‐certainty evidence).

Mobility strategies probably make little or no difference to short‐term mortality compared with control (moderate‐certainty evidence). Mobility strategies may make little or no difference to the adverse outcomes of long‐term mortality or re‐admission (low‐certainty evidence). It is unclear whether mobilisation strategies affect re‐operation, pain or the number of people who fall, due to low‐ and very low‐certainty of evidence. There is moderate‐certainty evidence, however, that number of falls were probably reduced by 21% compared with control.

Regarding non‐critical outcomes, mobility strategies may improve sit to stand ability (low‐certainty evidence), and increase muscle strength (high‐certainty evidence). There may be little or no effect on the need for a walking aid or objective measures of balance.

Resource use was difficult to establish. The number of physiotherapy sessions conducted varied greatly between studies and there was little reporting of other resource use.

Types of interventions

Interventions that include training comprising gait, balance and functional tasks were effective in increasing mobility in the post‐hospital setting (high‐certainty evidence).

There was low‐certainty evidence that resistance training may also increase mobility (measured in distance) and functioning in the post‐hospital setting.

Interventions containing multiple categories of exercise from the ProFaNE taxonomy (resistance or endurance training in addition to gait, balance and functional training), probably improve mobility post‐hospital (moderate‐certainty evidence).

The effect of endurance training interventions is unclear as we assessed the certainty of evidence as very low for many of the outcomes.

No studies evaluated the effect of other forms of exercise or electrical stimulation on the critical outcome of mobility.

Subgroup analyses

There were sufficient studies to conduct subgroup analyses for three outcomes: walking speed, health‐related quality of life and strength. There was probably little or no difference in the effect of mobility strategies on gait speed, health‐related quality of life and strength in trials where the intervention was delivered in an outpatient setting versus secondary and social care setting or delivered in trials with a mean participant age of 80 years or less versus more than 80 years. Subgroup analysis found a larger effect of mobility strategies on strength outcomes in trials where participants were excluded if they had impaired cognition compared with trials where participants were not excluded; however, this subgroup effect was not evident for gait speed and health‐related quality of life outcomes.

Economic data

Only two of the 40 studies in this review reported economic data, with the single cost‐effectiveness analysis of home exercise targeting gait and balance finding no evidence of the intervention being cost‐effective from the comparison of incremental costs and QALYs eight months after randomisation (Taraldsen 2019).

Overall completeness and applicability of evidence

Trial design and participants

We have provided additional details on the study populations and interventions in Table 1, Table 2, Appendix 5 and Appendix 6.

The participants were post‐hip fracture, primarily women (80%) and of a range of ages. Participant characteristics varied markedly due to the methods of recruitment and inclusion and exclusion criteria.

The majority of trials excluded older people who were cognitively impaired (70%) or had a history of immobility, medical conditions affecting mobility or both (72%). The results of this review may therefore not be applicable to these high‐risk groups. The majority of trials were relatively small (median = 81 participants), with a mean age of 80 (ranging from a mean age of 71 to a maximum mean age of 90 years).

In the 18 in‐hospital trials, six reported follow‐up at discharge, 12 reported follow‐up beyond discharge, including two that reported outcomes at 12 months. In the 22 post‐hospital trials, nine reported follow‐up at one to three months, six reported follow‐up at four to six months, one at nine months and six reported 12‐month follow‐up. Trials were undertaken over a period of 58 years from 1961 to 2019.

Setting

We included a further 21 RCTs of interventions for improving mobility after hip fracture surgery in this review update compared with Handoll 2011. The trials were conducted in 17 countries using a variety of healthcare models: differences in healthcare provision and policies, including the type of surgery and the extent of support post‐hospital discharge, may impact the effectiveness of some interventions. There is a lack of trials undertaken in low‐income countries, residential aged care settings and social care settings.

Interventions

We classified the exercise interventions using the ProFaNE classification system. While this classification system is well described (Lamb 2011, Appendix 1), there is a degree of subjectivity when classifying the interventions in the presence of brief descriptions in trial reports. The duration of the intervention in the in‐hospital trials ranged from two to 16 weeks. In the post‐hospital studies, the duration of the intervention ranged from one month to one year, with 50% of trials delivering their intervention for three to four months, and 27% of trials delivering the intervention for 12 months.

The pooling of many studies into such categories does not readily inform decisions about which interventions to choose in practice. We suggest that practitioners examine the details of the intervention and comparator in individual trials that are effective, taking into account any risk of bias, to help inform which particular interventions within an effective category may be applicable in their setting.

It would be useful if we were able to provide more information on individual aspects of intervention programmes, including their intensity. Unfortunately, this is not possible given variation in reporting and the likely variability of these factors within trials. Future trials could explore optional intensity of therapies, as both under‐ and over‐treatment could involve risks for those with complex chronic conditions.

Comparisons

Some difficultly may arise in interpreting results from these analyses as outcomes are pooled as comparisons against conventional care (for in‐hospital studies) or against conventional care, sham or no exercise (in post‐hospital studies). As the studies have been conducted in many different nations, over an extended period of time (1961 to 2020), conventional care will vary considerably over time, and therefore applicability to a particular, current, local context may be difficult to determine. In some trials, which interventions make up the control group (particularly where it is conventional care) is not clearly reported.

We suggest that readers examine the details of trials as described in Table 1, Table 2, Appendix 5 and Appendix 6 to determine which trials in particular are the most applicable to their local context, in terms of setting and conventional care approaches.

Outcomes

We sought data for the critical outcomes using mobility measures (analysed as mobility scales, outcomes measured in seconds and outcomes measured in distance), walking speed, functioning, health‐related quality of life, mortality, number of people who experienced five specified adverse events (with re‐admission shown on the summary of findings table), and return to living at the pre‐fracture residence (in‐hospital studies). However, few studies provided health‐related quality of life, adverse event or return to residence data.

We sought minimal clinically important differences for the critical outcomes. We re‐expressed mobility, measured using mobility scales, using the 12‐point Physical Performance and Mobility Examination (PPME) in the in‐hospital setting. The mean point estimate of effect (1.46 points) exceeded the minimal important difference for PPME, which is typically 1.13 to 2.15 (de Morton 2008). Likewise in the post‐hospital setting, where we re‐expressed the mobility result using the 12‐point Short Physical Performance Battery, the mean point estimate of the effect of the intervention (0.89 points) exceeded the small meaningful change (0.27 to 0.55 points) but was less than the substantial meaningful change of 0.99 to 1.34 points reported by Perera 2006.

Mobility training interventions increased walking speed in excess of the minimal important difference in both the in‐hospital (0.05 metres/second (m/s)) and post‐hospital (0.05 m/s) settings, with small meaningful change for gait speed being 0.04 to 0.06 m/s (Perera 2006). The minimal important difference for functioning was not reached in the in‐hospital or post‐hospital analyses, when the results were re‐expressed using the Barthel Index. Minimal important difference (post‐hip surgery) is typically 9.8 points (Unnanuntana 2018).

The mean minimal important difference for quality of life has been reported as 0.074 on the EQ‐5D (Walters 2005), or as 3 to 5 on the SF‐36 (Walters 2003). Mobility interventions delivered post‐hospital had a mean point estimate of effect below these values, when converted to these quality of life scales (reported converted values in‐hospital EQ‐5D = 0.03; post‐hospital EQ‐5D = 0.01; SF‐36 = 3).

We prespecified that, in addition to the main outcomes, we would also report mobility in terms of walking aids, subjective mobility, balance and sit to stand. We also reported muscle strength, activities of daily living, lower‐limb or hip function and participant satisfaction outcomes.

For in‐hospital trials in this review, we selected the outcome closest to four months post‐intervention for analysis. In some cases, this decision excluded data at different time points, and for other trials, the data included are actually for a shorter or longer intervention time. This may reduce the applicability of the 4‐month time point to practice and does mean that information from some trials on shorter and longer time periods has not been used within this review. For post‐hospital trials, we selected the outcome at the end of the intervention period.

Other considerations relating to applicability

Table 3 shows our assessments for each trial of five aspects of relevance to ascertaining external validity: definition of the study population, description of the interventions, definition of primary outcome measures, length of follow‐up, assessment of compliance.

In some studies there were incomplete descriptions of study inclusion (three trials), interventions (eight trials) or outcomes (five trials), limiting the ability to determine the applicability or details of results of these trials. We considered the timing of outcome measurement as suboptimal in 31 trials, and especially in those where participants were followed up to either hospital discharge or only until the end of the intervention. Some assessment of compliance with allocated interventions or control interventions was reported in sixteen trials, but ten other trials which reported compliance only did so for the active intervention group(s).

Certainty of the evidence

This review provides very low‐ to high‐certainty evidence of the effectiveness of interventions for improving mobility after hip fracture surgery in adults.

We have summarised the GRADE certainty of evidence in four summary of findings tables:

summary of findings Table 1 (mobility strategy versus control in the in‐hospital setting);
summary of findings Table 2 (different types of interventions on mobility outcome, in hospital);
summary of findings Table 3 (mobility strategy versus control in the post‐hospital setting);
summary of findings Table 4 (different types of interventions on mobility outcome, post‐hospital).

The certainty of the evidence for different outcomes across settings ranged from very low to high. We downgraded the level of evidence by one level for risk of bias if the results changed upon removal of the trials with a high risk of bias on one or more domains. We did not downgrade for risk of bias where removing studies with high risk of bias in one or more domains changed the point estimate to a stronger effect with narrower confidence intervals, or to a similar effect with wider confidence intervals. We downgraded one level for inconsistency if heterogeneity exceeded 60%, but not where this was explained by subgroup or sensitivity analyses. We downgraded by one or two levels for imprecision in the presence of wide confidence intervals, or where there were too few participants or events. We downgraded the level of evidence one level for return to pre‐fracture residence as a large number of trials did not contribute to the outcome.The funnel plots in Figure 4, Figure 5 and Figure 6 do show some asymmetry; however, we did not consider the asymmetry sufficient to downgrade the level of evidence.

Sensitivity analyses indicate the results for the mobility outcome are stable to risks of bias associated with allocation concealment and participant selection. In several instances, exclusion of studies at high risk of bias increased the effect estimates, providing stronger support for conclusions of effectiveness. During the GRADE assessment, we downgraded the certainty of evidence based on sensitivity analysis for risk of bias (removal of trials with one or more domains at high risk of bias) for three outcomes in both the in‐hospital and post‐hospital analyses (mobility, functioning and health‐related quality of life).

This review’s analyses of critical outcomes display minimal to substantial heterogeneity with P < 0.05 for the Chi² test and I² values up to 81%. We believe this likely represents between‐study differences in the nature of programmes (e.g. adherence, dose, intensity) and target populations, which was not explained by our subgroup analyses and necessitates further investigation. Considering the stability of results, we do not believe this undermines the meta‐analyses we have undertaken.

One consideration in interpreting the certainty of the evidence is that the evaluation of rehabilitation interventions is difficult to do well. These are generally complex interventions with considerable variation in practice, including the often adaptive nature of rehabilitation, where treatment is varied according to the perceived needs and progress of individual patients. Some aspects of trial methodology, notably concealment of allocation, are possible but others, such as blinding, are more of a challenge for these trials. In particular, blinding of participants is not possible in trials of many physical interventions such as exercise. Blinding of outcome assessors is possible for tests of mobility but not for self‐reported outcomes where the participant is effectively the outcome assessor. Thus, we have based judgements on whether risk was minimised in the different types of outcomes.

Potential biases in the review process

We designed this review to minimise the risk of potential biases. We used multiple databases to conduct a comprehensive search of the published literature and searched clinical trial registries for completed studies not previously identified. Two review authors independently undertook screening, data extraction and risk of bias assessments in duplicate. We acknowledge some relevant trials may have been missed despite this thorough search strategy, especially if they were published only in conference proceedings or in languages other than English.

While we consider that we have included and excluded trials appropriately, the variety and complexity of trial interventions encountered in the eligible trials made it difficult to apply our criteria in some instances. Indeed, we sometimes progressed to the point of data extraction with trials that we subsequently realised were not suitable. These have required us to reconsider and clarify our inclusion criteria, such as setting a limit on the time for starting the intervention at one year post‐fracture. We have also excluded trials that tested multifactorial interventions or primarily focused on elective hip surgery. The reason for excluding the first category is that it is not possible to separate out the effects of the mobilisation component of multifactorial interventions. Although the aim of these trials is to restore or augment function, we have kept our focus on mobilisation and mobility. These latter outcomes remain key objectives for people after hip fracture surgery. The exclusion of trials focusing on elective hip replacement surgery reflects that these populations are likely to differ in important ways to the generally older and frailer populations sustaining a hip fracture.

The previous version of this review deemed meta‐analysis inappropriate because of the differences in the included trials in terms of trial participants, settings, interventions or a combination of these (Handoll 2011). With the addition of 21 trials in the current update, the categorisation into two established intervention stages (in‐hospital and post‐hospital), and modification of the outcome measures (in response to a commissioning brief generated in relation to the Cochrane Programme Grant on the management of hip fracture), we judged it appropriate to pool data in meta‐analyses in this update. As the presentation of different interventions separately is useful for clinicians, we have also presented the effects of different interventions separately in addition to the overall results.

The variation in the broad mobility and function outcome measures used by different trials necessitated the use of standardised mean differences to meta‐analyse these outcomes, which can be difficult to interpret. We consider that the pooling of data for different measures of mobility and functioning is of value from the more general perspective of informing health funders and managers on the likely effectiveness of the interventions. The consistently‐measured walking outcomes did, however, enable comparison, with accepted cutoffs for clinically meaningful changes in gait speed.

Lastly, one of the authors (Catherine Sherrington) was the lead investigator of four trials included in the review (Sherrington 1997; Sherrington 2003; Sherrington 2004; Sherrington 2020), and a co‐investigator on Moseley 2009. Processing of these trials was carried out by other review authors to avoid conflict of interest.

Agreements and disagreements with other studies or reviews

Our review of the importance of interventions for improving mobility after hip fracture surgery in adults extends the findings of Handoll 2011 by pooling results from multiple studies and by categorising exercise intervention programmes to determine the primary exercise component for each included trial (Appendix 1).

Multiple systematic reviews have assessed the effect of interventions on mobility outcomes following hip fracture. These reviews identified the same trials included in this review, in addition to a number of non‐randomised controlled trials. McDonough 2021 provided a comprehensive overview of relevant systematic reviews in their recently published clinical practice guidelines, 'Physical therapy management of older adults with hip fracture' (McDonough 2021).

A 2016 meta‐analysis of 13 trials evaluating the effect of structured exercise on mobility after hip fracture found small improvements in mobility after hip fracture (Diong 2016).

Beckmann 2020 conducted a systematic review and meta‐analysis including nine RCTs of exercise interventions started within the first three months after hip fracture. Findings were generally consistent with this review; the authors found high‐ to moderate‐certainty evidence that the intervention improved physical function, despite high heterogeneity (I² = 92%). Eight of the included trials were also included in this review (Binder 2004; Hauer 2002; Kimmel 2016; Kronborg 2017; Monticone 2018; Moseley 2009; Sherrington 2003; Van Ooijen 2016); one of the trials (Mendelsohn 2008) was excluded from this review as it was an upper‐body exercise programme focused on cardiovascular fitness rather than being a mobilisation strategy. Two of the included trials were categorised as post‐hospital interventions in this review (Binder 2004; Hauer 2002).

Kuijlaars 2019 and Chen 2019 conducted systematic reviews and meta‐analyses of home‐based exercise interventions following hip fracture. Kuijlaars 2019 included six trials conducted in older people, all of which were included in this review as post‐hospital interventions (Latham 2014; Mangione 2005; Mangione 2010; Orwig 2011; Salpakoski 2015; Sherrington 1997), and found limited evidence for improvements in performance‐based activities of daily living, and over the long term for fast gait speed. Chen 2019 included eleven trials; seven were included in this review (Binder 2004; Latham 2014; Mangione 2005; Mangione 2010; Sherrington 1997; Sherrington 2004; Tsauo 2005), four were excluded (one due to hip fracture on average three years prior to the trial (Edgren 2012), one as it was a trial of early discharge (Crotty 2002) and two had multi‐component interventions (Tinetti 1999; Zidén 2008). They found that the effect on physical function was not significant, although there was a significant improvement in leg strength and the 6‐Minute Walk Test.

Lee and colleagues conducted two systematic reviews and meta‐analyses of randomised controlled trials of the effects of exercise interventions in improving outcomes following hip fracture surgery (Lee 2017; Lee 2019). Lee 2017 examined the effects of lower‐limb progressive resistance exercise and included eight RCTs. The authors reported a significant improvement in mobility, activities of daily living, balance and lower‐limb strength or power with the intervention. Four included trials were also included in this review (Mangione 2005; Mangione 2010; Sylliaas 2011; Sylliaas 2012). We excluded Sylliaas 2012 from our meta‐analysis as it included a subgroup of participants from an earlier trial (Sylliaas 2011). Four other trials were excluded from this review: two as the participants sustained their hip fracture on average more than one year prior to the trial (Edgren 2012: mean of 3 years; Portegijs 2008: mean of 4.4 years), and two trials as they examined multifactorial interventions in which the effects of the mobilisation strategy could not be distinguished from the other intervention components (Peterson 2004a; Singh 2012).

Lee 2019 included eight RCTs of balance training and concluded that the intervention significantly improves overall physical functioning, balance, gait, lower‐limb strength, activities of daily living and health‐related quality of life. Seven of these trials were also included in this review (Binder 2004; Hauer 2002; Latham 2014; Moseley 2009; Monticone 2018; Sherrington 1997; Sherrington 2004). We excluded Peterson 2004a from this review as it examined a multifactorial intervention; this trial was included in both the progressive resistance and balance meta‐analysis by Lee and colleagues. Wu J 2019 included nine RCTs of balance training with similar results.

The fall‐prevention impact of mobility strategies in the post‐hospital population is consistent with the results of a previous Cochrane Review in community‐dwelling older people (Sherrington 2019).

Figure 1

Study flow diagram

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias domain for each included study

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 4

Funnel plot of comparison 4: post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes. Outcome 4.16: walking speed: combined data for all strategy types

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Figure 5

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Figure 6

Funnel plot of comparison 5: post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes. Outcome: 5.9 strength

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Analysis 1.1

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 1: Mobility (measured using mobility scales): combined data for all strategy types

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Analysis 1.2

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 2: Mobility (failure to regain pre‐facture mobility): combined data for all strategy types

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Analysis 1.3

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 3: Mobility (measured using self‐reported outcomes): combined data for all strategy types

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Analysis 1.4

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 4: Mobility (measured using mobility scales): gait, balance and function

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Analysis 1.5

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 5: Mobility (measured using mobility scales): resistance/strength training

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Analysis 1.6

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 6: Mobility (measured in seconds using TUG): resistance/strength training

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Analysis 1.7

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 7: Mobility (measured using mobility scales) reporting individual outcome measures

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Analysis 1.8

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 8: Walking speed (measured as metres/time): combined data for all strategy types

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Analysis 1.9

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 9: Walking speed (measured as metres/time): gait, balance and function

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Analysis 1.10

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 10: Walking speed (measured as metres/time): electrical stimulation

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Analysis 1.11

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 11: Functioning (measured using functioning scales): combined data for all strategy types

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Analysis 1.12

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 12: Functioning (measured using functioning scales): gait, balance and function

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Analysis 1.13

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 13: Functioning (measured using functioning scales): resistance/strength training

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Analysis 1.14

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 14: Functioning (measured using functioning scales): electrical stimulation

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Analysis 1.15

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 15: Health‐related quality of life (measured using HRQoL scales): gait, balance and function

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Analysis 1.16

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 16: Mortality, short term: combined data for all strategy types

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Analysis 1.17

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 17: Mortality, short term: gait, balance and function

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Analysis 1.18

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 18: Mortality, short term: resistance/strength training

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Analysis 1.19

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 19: Mortality, short term: electrical stimulation

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Analysis 1.20

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 20: Mortality, long term: combined data for all strategy types

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Analysis 1.21

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 21: Mortality, long term: gait, balance and function

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Analysis 1.22

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 22: Mortality, long term: resistance/strength training

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Analysis 1.23

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 23: Adverse events (measured using dichotomous outcomes): combined data for all strategy types

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Analysis 1.24

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 24: Adverse events (measured using rate of falls): all studies were gait, balance and function

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Analysis 1.25

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 25: Adverse events (measured using continuous measures of pain): combined data for all strategy types

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$Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 26: Return to living at pre‐fracture residence: combined data for all strategy types$

Analysis 1.26

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 26: Return to living at pre‐fracture residence: combined data for all strategy types

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$Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 27: Return to living at pre‐fracture residence: additional study not included in main analysis$

Analysis 1.27

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 27: Return to living at pre‐fracture residence: additional study not included in main analysis

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$Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 28: Return to living at pre‐fracture residence: gait, balance and function$

Analysis 1.28

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 28: Return to living at pre‐fracture residence: gait, balance and function

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$Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 29: Return to living at pre‐fracture residence: resistance/strength training$

Analysis 1.29

Comparison 1: In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes, Outcome 29: Return to living at pre‐fracture residence: resistance/strength training

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Analysis 2.1

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 1: Walking, use of walking aid/need for assistance

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Analysis 2.2

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 2: Balance (measured using functional reach test, cm)

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Analysis 2.3

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 3: Balance (measured using balance scale)

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Analysis 2.4

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 4: Balance (measured using ability to tandem stand)

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Analysis 2.5

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 5: Balance (measured using step test; number of steps)

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Analysis 2.6

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 6: Balance (measured using self‐reported outcomes)

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Analysis 2.7

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 7: Sit to stand (measured as number of stand ups/second)

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Analysis 2.8

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 8: Strength

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Analysis 2.9

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 9: Activities of daily living (measured using ADL scales)

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Analysis 2.10

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 10: Resource use (measured by length of hospital stay)

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Analysis 2.11

Comparison 2: In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes, Outcome 11: Resource use (measured by use of community services)

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Analysis 3.1

Comparison 3: In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 1: Weight‐bearing at 2 wks v weight‐bearing at 12 weeks (mortality)

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Analysis 3.2

Comparison 3: In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 2: Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (mortality)

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Analysis 3.3

Comparison 3: In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 3: Weight‐bearing at 2 wks v weight‐bearing at 12 weeks (adverse events)

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Analysis 3.4

Comparison 3: In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 4: Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (return to living at home)

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Analysis 3.5

Comparison 3: In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 5: Early assisted ambulation (< 48 hrs) v delayed assisted ambulation (walking aid/assistance)

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Analysis 4.1

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 1: Mobility (measured using mobility scales): combined data for all strategy types

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Analysis 4.2

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 2: Mobility (measured using Timed Up and Go, seconds): combined data for all strategy types

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Analysis 4.3

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 3: Mobility (measured using 6‐Minute Walk Test, metres): combined data for all strategy types

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Analysis 4.4

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 4: Mobility (measured using mobility scales): gait, balance and function

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Analysis 4.5

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 5: Mobility (measured using Timed Up and Go, seconds): gait, balance and function

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Analysis 4.6

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 6: Mobility (measured using Timed Up and Go, seconds): resistance/strength training

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Analysis 4.7

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 7: Mobility (measured using 6‐Minute Walk Test, metres): resistance/strength training

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Analysis 4.8

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 8: Mobility (measured using 6‐Minute Walk Test, metres): endurance training

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Analysis 4.9

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 9: Mobility (measured using mobility scales): multiple component

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Analysis 4.10

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 10: Mobility (measured using 6‐Minute Walk Test, metres): multiple component

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Analysis 4.11

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 11: Mobility (measured using mobility scales): other type of exercise (non‐weight bearing exercise)

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Analysis 4.12

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 12: Mobility (measured using Timed Up and Go, seconds): other type of exercise OT +/‐ sensor)

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Analysis 4.13

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 13: Mobility (measured using mobility scales) reporting individual outcome measures

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Analysis 4.14

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 14: Mobility (measured using self‐report, continuous scales): combined data for all strategy types

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Analysis 4.15

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 15: Mobility (measured using self‐reported, dichotomous outcome): combined data for all strategy types

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Analysis 4.16

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 16: Walking speed: combined data for all strategy types

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Analysis 4.17

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 17: Walking speed: gait, balance and function

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Analysis 4.18

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 18: Walking speed: resistance/strength training

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Analysis 4.19

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 19: Walking speed: endurance

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Analysis 4.20

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 20: Walking speed: multiple component

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Analysis 4.21

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 21: Walking speed: other (post‐discharge physio telephone support and coaching)

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Analysis 4.22

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 22: Walking speed: other (non‐weight bearing)

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Analysis 4.23

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 23: Walking speed subgrouped by studies with cognitive impairment included v studies with cognitive impairment not included, combined data for all strategy types

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Analysis 4.24

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 24: Walking speed: subgrouped by outpatient v secondary and social care setting

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Analysis 4.25

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 25: Walking speed subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategies

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Analysis 4.26

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 26: Functioning (measured using functioning scales): combined data for all strategy types

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Analysis 4.27

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 27: Functioning (measured using functioning scales): gait, balance and function

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Analysis 4.28

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 28: Functioning (measured using functioning scales): resistance/strength training

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Analysis 4.29

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 29: Functioning (measured using functioning scales): multiple components

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Analysis 4.30

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 30: Functioning (measured using functioning scales): other: OT +/‐ sensor

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Analysis 4.31

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 31: Health‐related quality of life (measured using HRQoL scales): combined data for all strategy types

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Analysis 4.32

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 32: Health‐related quality of life (measured using HRQoL scales): gait, balance and function

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Analysis 4.33

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 33: Health‐related quality of life (measured using HRQoL scales): resistance/strength training

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Analysis 4.34

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 34: Health‐related quality of life (measured using HRQoL scales): endurance

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Analysis 4.35

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 35: Health‐related quality of life (measured using HRQoL scales): multiple components

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Analysis 4.36

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 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

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Analysis 4.37

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 37: Health‐related quality of life subgrouped by outpatient v secondary and social care setting

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Analysis 4.38

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 38: Health‐related quality of life subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategy

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Analysis 4.39

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 39: Mortality, short term: combined data for all strategy types

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Analysis 4.40

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 40: Mortality, short term: gait, balance and function

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Analysis 4.41

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 41: Mortality, short term: resistance/strength training

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Analysis 4.42

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 42: Mortality, short term: multiple components

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Analysis 4.43

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 43: Mortality, short term: other: non‐weight bearing

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Analysis 4.44

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 44: Mortality, long term: combined data for all strategy types

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Analysis 4.45

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 45: Mortality, long term: gait, balance and function

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Analysis 4.46

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 46: Mortality, long term: multiple components

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Analysis 4.47

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 47: Adverse events (measured using dichotomous outcomes): combined data for all strategy types

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Analysis 4.48

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 48: Adverse events (measured using re‐admission rate: combined for all strategy types

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Analysis 4.49

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 49: Adverse events (measured using rate of falls): combined for all strategy types

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Analysis 4.50

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 50: Adverse events (measured using rate of falls): gait, balance and function

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Analysis 4.51

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 51: Adverse events (measured using rate of falls): other (additional phone support and coaching)

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Analysis 4.52

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 52: Adverse events (measured as number of people who experienced 1 or more falls)

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Analysis 4.53

Comparison 4: Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes, Outcome 53: Adverse events (measured using continuous measure of pain)

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Analysis 5.1

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 1: Walking (measured as use of walking aid/need for assistance)

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Analysis 5.2

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 2: Walking (measured using self‐reported outcomes)

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Analysis 5.3

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 3: Balance (measured using functional reach test, cm)

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Analysis 5.4

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 4: Balance (measured using timed standing in various positions)

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Analysis 5.5

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 5: Balance (measured using balance scale)

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Analysis 5.6

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 6: Balance (measured using continuous self‐reported meaure)

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Analysis 5.7

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 7: Balance (measured using dichotomous self‐reported measure)

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Analysis 5.8

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 8: Sit to stand (measured as number of stand ups/second)

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Analysis 5.9

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 9: Strength

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Analysis 5.10

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 10: Strength subgrouped by studies with cognitive impairment included v studies with cognitive impairment not included, combined data for all strategy types

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Analysis 5.11

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 11: Strength subgrouped by stage of rehabilitation

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Analysis 5.12

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 12: Strength subgrouped by mean age ≤ 80 years v > 80 years, combined data for all strategies

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Analysis 5.13

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 13: Activities of daily living (measured using ADL scales)

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Analysis 5.14

Comparison 5: Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes, Outcome 14: Self‐reported measures of lower limb/hip function

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Analysis 6.1

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 1: Resistance/strength training v endurance training (mobility measured using 6‐Minute Walk Test

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Analysis 6.2

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 2: Resistance/strength training v endurance training (walking speed)

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Analysis 6.3

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 3: Resistance/strength training v endurance training (health‐related quality of life)

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Analysis 6.4

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 4: Resistance/strength training v endurance training (strength)

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Analysis 6.5

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 5: Gait, balance and function v other (muscle contraction in supine) (mobility measured using mobility scale)

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Analysis 6.6

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 6: Gait, balance and function v other (muscle contraction in supine) (walking speed)

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Analysis 6.7

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 7: Gait, balance and function v other (muscle contraction in supine) (mortality)

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Analysis 6.8

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 8: Gait, balance and function v other (muscle contraction in supine) (Adverse events: pain)

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Analysis 6.9

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 9: Gait, balance and function v other (muscle contraction in supine) (Adverse events: number of people who fell)

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Analysis 6.10

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 10: Gait, balance and function v other (muscle contraction in supine) (Balance, observed)

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Analysis 6.11

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 11: Gait, balance and function v other (muscle contraction in supine) (Balance, self‐reported)

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Analysis 6.12

Comparison 6: Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes, Outcome 12: Gait, balance and function v other (muscle contraction in supine) (strength)

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
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
	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.
^aMobility strategies may include exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. ^bA control intervention may be: usual orthopaedic, medical care or allied health care. ^cThe all‐studies population risk was based on the number of events and the number of participants in the control groups of studies included in this review reporting this outcome. ^dMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs).^eDowngraded by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results, with the confidence intervals (CIs) crossing zero). Downgraded one level for imprecision, with wide CI. Not downgraded for inconsistency; the substantial heterogeneity (I² = 84%) is explained by inclusion of Monticone 2018 and the large between‐group difference in the volume and intensity of functional exercise undertaken, compared with other studies. Removing Monticone 2018 reduced I² to 44%, and it changed the effect size from SMD 0.53 (95% CI 0.10 to 0.96) to SMD 0.29 (95% CI 0.03 to 0.55). ^fCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^gWalking speed, measured using distance/time. ^hNot downgraded due to risk of bias (as removing studies with high risk of bias in one or more items had no impact on results, with similar point estimate and CIs). Downgraded due to imprecision, with CI crossing zero. ⁱFunctioning, using functioning scales. ^jDowngraded by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results), downgraded one level due to substantial heterogeneity (I² = 81%), and downgraded one level due to imprecision (n = 315). ^kDowngraded by one level due to risk of bias (removing the studies with high risk of bias in one or more items had a marked impact on results), one level for imprecision (small number of trials and participants, wide CI) and one level due to substantial heterogeneity (I² = 71%). ^lOur illustrative risks for dichotomous outcomes were based on the proportion calculated from the number of people who experienced the event divided by the number of people in the group, for the control group in those trials included in the analysis for that outcome. ^mWe downgraded both the short‐term and long‐term analyses by one level due to risk of bias (removing studies with high risk of bias in one or more items had a marked impact on results) and one level for imprecision (few events and wide CI). ⁿDowngraded one level for imprecision (few events and wide CI) and one level because a large number of studies included in the review did not contribute to this adverse event outcome. ^oDowngraded one level for imprecision (few events and wide CI) and one level because a large number of studies included in the review did not contribute to the outcome.

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

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

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
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
		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.
^aA control intervention may be: usual orthopaedic, medical care or allied health care. ^bMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). A higher score indicates better mobility. ^cMobility strategies involve postoperative care programmes such as immediate or delayed weight bearing after surgery, and any other mobilisation strategies, such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. We categorised the exercise and physical training strategies using the Prevention of Falls Network Europe (ProFaNE) guidelines, see Appendix 1. These categories are gait, balance and functional training; strength/resistance training; flexibility; 3D (Tai Chi, dance); general physical activity; endurance; multiple types of exercise; other. Electrical stimulation is an additional intervention type. ^dDowngraded one level for inconsistency (unexplained heterogeneity, I² = 84%). ^eCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^fMean was estimated from median for the single study. ^gDowngraded one level for risk of bias and one level for imprecision. ^hDowngraded one level for risk of bias and one level for imprecision.

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

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Mobility strategies compared with control (e.g. usual care) after hip fracture surgery in the post‐hospital setting
Patient or population: adults following hip fracture surgery Settings: post‐hospital Intervention: mobility strategies^a Comparison: non‐provision control^b
	Assumed risk	Corresponding risk
	Control^c	Intervention
Mobility^d ‐ overall analysis Using different mobility scales: mPPT (range 0 to 36), POMA (range 0 to 30), SPPB (range 0 to 12), PPME (range 0 to 12). A higher score indicates better mobility. Follow‐up: range 2 months to 12 months	In the control group, the mean scores for the outcomes were: mPPT (23.3), POMA (20.7), SPPB (range 6 to 7.72), PPME (10.1)	SMD 0.32 higher (0.11 higher to 0.54 higher)	SMD 0.32 (0.11 to 0.54)	761 (7)	⊕⊕⊕⊕ High^e	Overall, there is a small (based on Cohen's effect sizes^f) increase in mobility compared with control (SMD 0.32). Re‐expressing the results using the 12‐point SPPB, the intervention group scored 0.89 points higher (95% CI 0.30 to 1.50). Small meaningful change for SPPB: 0.27 to 0.55 points; substantial meaningful change: 0.99 to 1.34 points (Perera 2006). Types of intervention in included trials: gait, balance and functional exercise: 5 studies; multiple types: 2 studies.
Walkingspeed^g ‐ overall analysis Measured using metres/second (m/s) and metres/minute (m/min). A higher score indicates faster walking. Follow‐up: range 1 month to 12 months	The mean walking speed score in the control group ranged from 0.44 m/s to 0.97 m/s, and 20 m/min to 59.4 m/min.	SMD 0.16 higher (0.04 higher to 0.29 higher)	SMD 0.16 (0.04 to 0.29)	1067 (14)	⊕⊕⊕⊕ High^h	There is a small increase in walking speed compared with control (SMD 0.16). Re‐expressing the results using gait speed (m/sec), there was an increase in gait speed of 0.05 m/s in the intervention group (MD 0.05, 95% CI 0.01 to 0.09). Small meaningful change for walking speed is 0.04 to 0.06 m/s (Perera 2006). Types of intervention in included trials: gait, balance and functional exercise: 7 studies; resistance exercise: 3 studies; endurance exercise: 1 study; multiple types: 3 studies.
Functioningⁱ ‐ overall analysis Using different functioning scales: FSQ (range 0 to 36), BI (range 0 to 100), AM‐PAC daily activity (range 9 to 101), COPM (range 0 to 20), LEFS (range 0 to 80), NEADL (range 0 to 66). A higher score indicates better functioning. Follow‐up: range 3 months to 12 months	In the control group, the mean scores for the outcomes were: FSQ (24.8), BI (94.5), AM‐PAC (58.6), COPM (6.54), LEFS (28.8), NEADL (range 14.2 to 43.2).	SMD 0.23 higher (0.10 higher to 0.36 higher)	SMD 0.23 (0.10 to 0.36)	936 (9)	⊕⊕⊕⊕ High^j	Overall, there is a small increase in functioning compared with control (SMD 0.23). Re‐expressing the results using the BI, the intervention group scored 1.4 points higher (95% CI 0.6 to 2.1). MID for the BI (post‐hip surgery) is typically 9.8 (Unnanuntana 2018). Types of intervention in included trials: gait, balance and functional exercise: 4 studies; resistance exercise: 2 studies; multiple types: 2 studies; other: 1 study
HRQoL using EQ‐ 5D (range 0 to 1), SF‐36 (range 0 to 100), SF‐12 (range 0 to 100), and WHOQOL‐BREF (range 0 to 130). A higher score indicates better quality of life. Follow‐up: range 3 months to 6 months	In the control group, the mean scores for the outcomes were: EQ‐5D (range 0.6 to 0.75), SF‐36 (range 48 to 63), SF‐12 (45.5), WHOQOL‐BREF (13.2).	SMD 0.14 higher (0.00 lower to 0.29 higher)	SMD 0.14 (0.00 to 0.29)	785 (10)	⊕⊕⊕⊝ Moderate^k	SMD was calculated for 5 trials with EQ‐5D, 3 trials with SF‐36, 1 trial with SF‐12, 1 trial with WHOQOL‐BREF. Re‐expressing the results using the EQ‐5D (0 to 1 scale), there was an increase in quality of life of 0.01 in the intervention group (95% CI ‐0.007 to 0.08). MID for the EQ‐5D is typically 0.074 (Walters 2005). Re‐expressing the results using the SF‐36 (0 to 100 scale), there was an increase in quality of life of 3 points in the intervention group (95% CI ‐0.6 to 5.7). MID for SF‐36 typically 3 to 5 (Walters 2003). Mobility strategies probably make little important difference to patient‐reported health‐related quality of life compared with control. Types of intervention in included trials: gait, balance and functional exercise: 4 studies; resistance exercise: 3 studies; endurance exercise: 1 study; multiple types: 1 study; other: 1 study
Mortality Follow‐up: range 3 months to 12 months	Short term: 35 per 1000^l	Short term: 35 per 1000 (14 to 72)	Short term: RR 1.01 (0.49 to 2.06)	Short term: 737 (8)	⊕⊕⊕⊝ Moderate^m	Overall, there is moderate‐certainty evidence that mobility strategies probably make little or no difference to mortality compared to control in the short term. It is unclear whether mobility strategies reduce mortality in the long term as the certainty of evidence is low and the 95% CI includes both a reduction in the risk of mortality and an increase in the risk of mortality. Types of intervention in included trials: gait, balance and functional exercise: 3 studies; resistance exercise: 3 studies; multiple types: 5 studies.
Mortality Follow‐up: range 3 months to 12 months	Long term: 71 per 1000^l	Long term: 52 per 1000 (28 to 97)	Long term: RR 0.73 (0.39 to 1.37)	Long term: 588 (4)	⊕⊕⊝⊝ Lowⁿ
Adverse event: number of people who were re‐admitted Follow‐up: range 1 month to 12 months	231 per 1000^l	199 (120 to 328)	RR 0.86 (0.52 to 1.42)	206 (2)	⊕⊕⊝⊝ Low^o	The evidence is of low certainty: the intervention may decrease the number of re‐admissions by 14%; however, the 95% CI includes the possibility of both a 48% reduction and a 42% increase. Types of intervention in included trials: multiple types: 1 study; other: 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). AM‐PAC: Activity Measure for Post Acute Care; BI: Barthel Index; CI: confidence interval; COPM: Canadian Occupational Performance Measure; EQ5D: EuroQoL‐5Dl; FSQ: Functional StaRR: risk ratio; HRQoL: Health‐Related Quality of Life; LEFS: Lower Extremity Functional Scale; MID: minimal important difference; MD: mean difference; mPPT: modified Physical Performance Test; tus Questionnaire; NEADL: Nottingham Extended Activities of Daily Living; PME: Physical Performance and Mobility Examination; POMA: Performance Oriented Mobility Assessment; PWHOQOL BREF: World Health Organization Quality of LIfe short version; SMD: standardised mean difference; SF12: Short Form‐12 SF36: Short Form‐36; SPPB: Short Physical Performance Battery.
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.
^a Postoperative care programmes such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. ^bA non‐provision control is defined as no intervention, usual care, sham exercise (the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit. ^cThe all‐studies population risk was based on the number of events and the number of participants in the control group. ^dMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). ^eNot downgraded for risk of bias, as point estimate increased from 0.32 to 0.38 and CI remained close to zero (95% CI from (0.11 to 0.54) to (‐0.04 to 0.79)) upon removal of the trials at a high risk of bias in one or more items. ^fCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^gWalking speed, measured using distance/time. ^hNot downgraded for risk of bias, as point estimate reduced from 0.16 to 0.14 and CI remained close to zero (95% CI from (0.04 to 0.29) to (‐0.08 to 0.36) upon removal of the trials at a high risk of bias in one or more items. ⁱFunctioning, using functioning scales. ^jNot downgraded for risk of bias, as point estimate increased and CI remained above zero upon removal of the trials at a high risk of bias in one or more domains. ^kDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had a marked impact on results). ^lOur illustrative risks for dichotomous outcomes were based on the proportion calculated from the number of people who experienced the event divided by the number of people in the group, for the control group in those trials included in the analysis for that outcome. ^mNot downgraded for risk of bias, as results were essentially unchanged with removal of the trials at a high risk of bias in one or more domains. Downgraded by one level due to imprecision (few events and wide CI). ⁿDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had an important impact on results) and one level for imprecision (few events and wide CI). ^oWe downgraded one level for risk of bias, as both trials were at a high risk of bias in one or more domains. Downgraded one level for imprecision (few events and wide CI).

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

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

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
Different types of mobility strategies compared with control after hip fracture surgery, on mobility, in the post‐hospital setting
Patient or population: adults following hip fracture surgery Settings: post‐hospital Comparison: non‐provision control^a Outcome: mobility^b
		Assumed risk	Corresponding risk
		Control	Intervention
Gait, balance and functional training Follow‐up: range 2 months to 12 months	Mobility scales, using different scales: SPPB (range 0 to 12), PPME (range 0 to 12). A higher score indicates better mobility.	In the control group, the mean scores for the outcomes were: SPPB (range 6 to 7.72), PPME (10.1).	SMD 0.20 higher (0.05 higher to 0.36 higher)	SMD 0.20 (95% CI 0.05 to 0.36)	621 (5)	⊕⊕⊕⊕ High^d	Interventions classified as gait, balance and functional training cause a small^e increase in mobility compared with control. Re‐expressing the results using the 12‐point SPPB, the intervention group scored 0.55 points higher (95% CI 0.14 to 1.0). Small meaningful change for SPPB: 0.27 to 0.55 points; substantial meaningful change: 0.99 to 1.34 points (Perera 2006).
	TUG (lower score = faster)	The mean TUG time in the control group was 30.22 seconds.	MD 7.57 seconds faster (19.25 seconds faster to 4.11 seconds slower)	MD ‐7.57 (‐19.25 to 4.11)	128 (1)	⊕⊝⊝⊝ Very low^f	Gait, balance and functional training may increase TUG speed by 7.57 seconds; however, the 95% confidence interval includes both a reduction and increase in TUG.
	6 Minute Walk Test				0
Resistance/strength training Follow‐up: range 10 weeks to 3 months	Mobility scales				0
	TUG	The mean TUG time in the control group was 20 seconds.	MD 6 seconds faster (12.95 seconds faster to 0.95 seconds slower)	MD ‐6.00 (‐12.95, 0.95)	96 (1)	⊕⊕⊝⊝ Low^g	Resistance/strength training may increase TUG speed by 6 seconds; however, the 95% confidence interval includes both a reduction and increase in TUG.
	6MWT	The mean 6MWT distance in the control group was 243 m.	MD 56 metres further (29 metres further to 83 metres further)	MD 55.65 (28.58 to 82.72)	198 (3)	⊕⊕⊝⊝ Low^h	Resistance/strength training may increase 6MWT by 53 metres. MID for the 6MWT (adults with pathology) is typically 14.0 to 30.5m (Bohannon 2017).
Flexibility	All				0		0 studies contained a mobility strategy categorised as primarily being flexibility.
3D (Tai Chi, dance)	All				0		0 studies contained a mobility strategy categorised as primarily being 3D.
General physical activity	All				0		0 studies contained a mobility strategy categorised as primarily being general physical activity.
Endurance Follow‐up: 3 months	Mobility scales				0
	TUG				0
	6MWT	The mean 6MWT distance in the control group was 266 m.	MD 12.7 metres further (72 metres less to 97 metres further).	MD 12.70 (‐72.12, 97.52)	21 (1)	⊕⊝⊝⊝ Very lowⁱ	We are uncertain whether endurance training improves mobility as the certainty of the evidence is very low.
Multiple primary types of exercise Follow‐up: range 2 months to 6 months	Mobility scales, using different mobility scales: mPPT (range 0 to 36), POMA (range 0 to 30).	In the control group, the mean scores for the outcomes were: mPPT (23.3), POMA (range 20.7).	SMD 0.94 higher (0.53 higher to 1.34 higher)	SMD 0.94 (0.53 to 1.34)	104 (2)	⊕⊕⊕⊝ Moderate^j	Interventions that contain multiple types of exercise probably leads to a moderate increase in mobility. Re‐expressing the results using the 12‐point SPPB, the intervention group scored 2.6 points higher (95% CI 1.47 to 3.71). Substantial meaningful change for SPPB: 0.99 to 1.34 points (Perera 2006).
	TUG				0
	6MWT	The mean 6MWT distance in the control group was 233.1 m.	MD 9 metres further (15 metres less to 33 metres further)	9.30 (‐14.62 to 33.22)	187 (1)	⊕⊕⊝⊝ Low^k	Interventions containing strength training and endurance training may increase 6MWT by 9 metres. MID for the 6MWT (adults with pathology) is typically 14.0 to 30.5m (Bohannon 2017).
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). 6MWT: 6‐Minute Walk Test; CI: confidence interval; MID: minimal important difference; mPPT: modified Physical Performance Test; POMA: Performance Oriented Mobility Assessment; PPME: Physical Performance and Mobility Examination; SMD: standardised mean difference; SPPB: Short Physical Performance Battery; 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.
^aA non‐provision control is defined as no intervention, usual care, sham exercise (the exercise was intended to be a control, or appeared to be of insufficient intensity and progression to have beneficial effects on mobility) or a social visit. ^bMobility, measuring the ability of a person to move. Scales may measure a number of aspects of mobility (e.g. sit to stand, walking, turning, stairs). A higher score indicates better mobility. ^cMobility strategies involve postoperative care programmes such as immediate or delayed weight bearing after surgery, and any other mobilisation strategies, such as exercises, physical training and muscle stimulation, used at various stages in rehabilitation, which aim to improve walking and minimise functional impairments. We categorised the exercise and physical training strategies using the Prevention of Falls Network Europe (ProFaNE) guidelines, see Appendix 1. These categories are gait, balance and functional training; strength/resistance training; flexibility; 3D (Tai Chi, dance); general physical activity; endurance; multiple types of exercise; other. Electrical stimulation is an additional intervention type. ^dNot downgraded for risk of bias (removing studies with high risk of bias in one or more domains had no important impact on results). ^eCohen's effect size 0.2 is described as small, 0.5 as medium/moderate effect, 0.8 as large effect (Sawilowsky 2009). ^fDowngraded one level for risk of bias and two levels for imprecision. ^gDowngraded two levels for imprecision. ^hDowngraded one level for risk of bias (all studies had high risk of bias for at least one item) and one level for imprecision. ⁱDowngraded one level for risk of bias (removing studies with high risk of bias in one or more domains had an important impact on results) and two levels for imprecision). ^jDowngraded for imprecision. ^kDowngraded one level for risk of bias and one level for imprecision.

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Table 1. Key characteristics of participants and intervention approach

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
NR: not reported; NWB: non‐weight bearing; WB: weight bearing ^aParticipants with severe cognitive dysfunction (obey command ≤ 1 step ) were excluded. At baseline, 21/38 participants had cognitive dysfunction, defined using Mini‐Mental State Examination score adjusted with age and education level.

Table 1. Key characteristics of participants and intervention approach

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

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%
^aIntervention delivered in hospital and after discharge. Majority of intervention delivered in inpatient setting ^bIntervention started as inpatient. Majority of intervention delivered in post‐hospital setting ^cThree study arms ^dCluster‐randomised trial

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

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

	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

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

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Comparison 1. In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes

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 Show forest plot	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 Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.4 Mobility (measured using mobility scales): gait, balance and function Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.6 Mobility (measured in seconds using TUG): resistance/strength training Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.7 Mobility (measured using mobility scales) reporting individual outcome measures Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.11 Functioning (measured using functioning scales): combined data for all strategy types Show forest plot	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 Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.14 Functioning (measured using functioning scales): electrical stimulation Show forest plot	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 Show forest plot	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 Show forest plot	6	489	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.48, 2.30]

1.17 Mortality, short term: gait, balance and function Show forest plot	3	293	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [0.44, 4.66]

1.18 Mortality, short term: resistance/strength training Show forest plot	2	170	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.26, 2.62]

1.19 Mortality, short term: electrical stimulation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.20 Mortality, long term: combined data for all strategy types Show forest plot	2	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.48, 3.12]

1.21 Mortality, long term: gait, balance and function Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.22 Mortality, long term: resistance/strength training Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	2	240	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.73, 1.56]

1.27 Return to living at pre‐fracture residence: additional study not included in main analysis Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.28 Return to living at pre‐fracture residence: gait, balance and function Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.29 Return to living at pre‐fracture residence: resistance/strength training Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 1. In‐hospital rehabilitation: mobilisation strategy versus usual care, critical outcomes

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Comparison 2. In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Walking, use of walking aid/need for assistance Show forest plot	2	230	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.74, 1.11]

2.2 Balance (measured using functional reach test, cm) Show forest plot	2	121	Std. Mean Difference (IV, Fixed, 95% CI)	0.37 [0.01, 0.73]

2.3 Balance (measured using balance scale) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.4 Balance (measured using ability to tandem stand) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.5 Balance (measured using step test; number of steps) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.6 Balance (measured using self‐reported outcomes) Show forest plot	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) Show forest plot	2	227	Mean Difference (IV, Fixed, 95% CI)	0.04 [0.01, 0.07]

2.8 Strength Show forest plot	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) Show forest plot	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) Show forest plot	4	335	Mean Difference (IV, Fixed, 95% CI)	‐0.83 [‐3.94, 2.28]

2.11 Resource use (measured by use of community services) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 2. In‐hospital rehabilitation: mobilisation strategy versus usual care, other important outcomes

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Comparison 3. In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes

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) Show forest plot	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) Show forest plot	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) Show forest plot	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) Show forest plot	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) Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.29, 0.89]

Comparison 3. In‐hospital rehabilitation: comparing different intervention strategies, critical outcomes

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Comparison 4. Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes

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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.6 Mobility (measured using Timed Up and Go, seconds): resistance/strength training Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.7 Mobility (measured using 6‐Minute Walk Test, metres): resistance/strength training Show forest plot	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 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.9 Mobility (measured using mobility scales): multiple component Show forest plot	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 Show forest plot	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) Show forest plot	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) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.13 Mobility (measured using mobility scales) reporting individual outcome measures Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	14	1067	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [0.04, 0.29]

4.17 Walking speed: gait, balance and function Show forest plot	7	511	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.09, 0.25]

4.18 Walking speed: resistance/strength training Show forest plot	3	197	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.01, 0.58]

4.19 Walking speed: endurance Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.20 Walking speed: multiple component Show forest plot	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) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.22 Walking speed: other (non‐weight bearing) Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	2	246	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [0.03, 0.55]

4.29 Functioning (measured using functioning scales): multiple components Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	7	737	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.49, 2.06]

4.40 Mortality, short term: gait, balance and function Show forest plot	3	264	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.46, 2.72]

4.41 Mortality, short term: resistance/strength training Show forest plot	2	123	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.19, 10.03]

4.42 Mortality, short term: multiple components Show forest plot	2	290	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.08, 4.55]

4.43 Mortality, short term: other: non‐weight bearing Show forest plot	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 Show forest plot	4	588	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.39, 1.37]

4.45 Mortality, long term: gait, balance and function Show forest plot	2	254	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.34, 1.67]

4.46 Mortality, long term: multiple components Show forest plot	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 Show forest plot	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 Show forest plot	1		Rate Ratio (IV, Fixed, 95% CI)	Totals not selected

4.49 Adverse events (measured using rate of falls): combined for all strategy types Show forest plot	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 Show forest plot	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) Show forest plot	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) Show forest plot	4		Risk Ratio (IV, Fixed, 95% CI)	1.03 [0.85, 1.25]

4.53 Adverse events (measured using continuous measure of pain) Show forest plot	3	242	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.29, 0.22]

Comparison 4. Post‐hospital rehabilitation: mobilisation strategy versus control, critical outcomes

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Comparison 5. Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes

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) Show forest plot	4	314	Risk Ratio (M‐H, Random, 95% CI)	0.46 [0.16, 1.31]

5.2 Walking (measured using self‐reported outcomes) Show forest plot	2	182	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.28, 1.06]

5.3 Balance (measured using functional reach test, cm) Show forest plot	2	144	Mean Difference (IV, Fixed, 95% CI)	1.30 [‐1.70, 4.31]

5.4 Balance (measured using timed standing in various positions) Show forest plot	2	234	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.37, 0.86]

5.5 Balance (measured using balance scale) Show forest plot	2	212	Std. Mean Difference (IV, Random, 95% CI)	0.28 [‐0.52, 1.08]

5.6 Balance (measured using continuous self‐reported meaure) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.7 Balance (measured using dichotomous self‐reported measure) Show forest plot	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) Show forest plot	5	457	Mean Difference (IV, Random, 95% CI)	‐6.49 [‐12.23, ‐0.75]

5.9 Strength Show forest plot	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 Show forest plot	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 Show forest plot	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 Show forest plot	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) Show forest plot	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 Show forest plot	2	106	Std. Mean Difference (IV, Random, 95% CI)	0.78 [‐0.20, 1.77]

Comparison 5. Post‐hospital rehabilitation: mobilisation strategy versus control, other important outcomes

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Comparison 6. Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Resistance/strength training v endurance training (mobility measured using 6‐Minute Walk Test Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.2 Resistance/strength training v endurance training (walking speed) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.3 Resistance/strength training v endurance training (health‐related quality of life) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.4 Resistance/strength training v endurance training (strength) Show forest plot	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) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.6 Gait, balance and function v other (muscle contraction in supine) (walking speed) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.7 Gait, balance and function v other (muscle contraction in supine) (mortality) Show forest plot	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) Show forest plot	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) Show forest plot	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) Show forest plot	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) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.12 Gait, balance and function v other (muscle contraction in supine) (strength) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 6. Post‐hospital rehabilitation: comparing different intervention strategies, critical outcomes

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Resumen

Antecedentes

Objetivos

Métodos de búsqueda

Criterios de selección

Obtención y análisis de los datos

Resultados principales

Conclusiones de los autores

PICO

PICO

Population

Intervention

Comparison

Outcome

Resumen en términos sencillos

¿Las estrategias de movilidad mejoran y restablecen la movilidad después de la cirugía por fractura de cadera en adultos?

Resumen visual

Authors' conclusions

Implications for practice

Implications for research

Summary of findings

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

Included studies

Design

Sample sizes

Setting

Participants

Interventions

In‐hospital rehabilitation

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

In‐hospital rehabilitation: comparing different timing of intervention

Post‐hospital rehabilitation

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

Post‐hospital rehabilitation: comparing two different types of intervention

Excluded studies

Ongoing studies

Studies awaiting classification

Risk of bias in included studies

Allocation

Blinding

Performance bias

Detection bias

Incomplete outcome data

Selective reporting