Elderly patients with higher self-reported levels of psychological resilience experienced faster walking speed and farther walking distance after hip fracture surgery, researchers report.

The results suggest that addressing psychological resilience in rehabilitation programs could improve walking capacity in older adults after hip fracture, the authors write.

The study was published July 20 in the Journal of the American Geriatrics Society.

Hip fracture in older adults can lead to significant morbidity and mortality, especially if not addressed surgically within 48-72 hours. Lying in bed and not moving can lead to multisystem decompensation within the body. Surgical repair of hip fractures can help patients move around more and reduce their chances of morbidity and mortality.

Yet, even after hip fracture surgery, many older adults do not reach their prefracture level of function. In light of this, researchers at the University of Connecticut were interested in understanding why recovery of walking capacity after hip fractures remains highly variable and what psychological factors in addition to depression might affect walking capacity recovery.

Richard H. Fortinsky, PhD, codirector of the University of Connecticut Older Americans Independence Center, is the corresponding author. To learn more about the role of resilience, he and his colleagues turned to data they collected in the Community Ambulation Project, a multisite, randomized, controlled trial of 210 older adults randomized to two different posthip fracture repair physical therapy protocols.

The Role of Resilience in Recovery

Most study participants were female (77%) and White (96%). Mean age was 80.7 years, with 40% aged 85 years or older. About one-half were widowed, and 47% required an informal caregiver for help. Mean time from hospital admission to randomization was 103.8 (±38.2) days.

In the trial, resilience in patients was measured by the 6-item Brief Resilience Scale. Four months later, timed walking tests were conducted on the same patients.

When Fortinsky and his coauthors analyzed the data, they found that the self-perceived level of psychological resilience in older adults after experiencing a hip fracture was associated with better walking capacity, even after controlling for walking speed and distance at the time resilience was measured.

Mental toughness is an area of recent research in multiple orthopedic studies. As previously reported by Medscape Medical News, patients who have low “grit” may have worse functional outcome following rotator cuff surgery.

In an interview with Medscape Medical News, Fortinsky points out that grit and resilience may be related but should be considered separate attributes.

Grit may be an attribute of how patients can cope with illness or surgery, but “resilience should be viewed in the context of an adverse event and how well individuals believe they can bounce back from adversity.” From his perspective, grit does not presuppose that an adverse event has been added to the equation.

Other orthopedics studies have shown that depression can play a role in how a patient bounces back from surgery, but it may be an independent factor from resilience.

“In our study depression and resilience were only moderately associated with each other, and even after accounting for depression severity resilience had a positive effect on demonstrated walking capacity,” Fortinsky said.

Whether preexisting depression affects psychological resilience after surgery differently than depression coming about from the injury itself is not yet clear. Fortinsky believes it is an “excellent question but we did not have the data to tease these situations apart.”

Recovery Involves More Than Physical Factors

Kevin Freedman, MD, an orthopedic surgeon at the Rothman Institute in Bryn Mawr, Pennsylvania, who was not involved in the study, agrees with Fortinsky that there may be more than just physical factors at play in a patient’s injury recovery.

Dr Kevin Freedman

“As orthopaedists, we need to consider all of the psychological factors that impact our patient outcomes after injury or surgery, including resilience,” Freedman told Medscape Medical News. “In order to use this information to help our patients, we need to measure it, and then study how we can improve it.”

Freedman is the senior author on a recent review titled Resilience in the Orthopaedic Patient, published in the Journal of Bone and Joint Surgery. “Much of resilience is innate to the person, but there is research showing that there is behavioral therapy that can improve resilience,” he said. “Some of this literature in orthopedics is summarized in our recent review article. The goal of further research in this area needs to be on how to improve patient resilience after injury to lead to better outcomes.”

Falls and resulting hip fractures remain important causes of substantial physical disability in the older population. Fortinsky believes that “creative rehabilitation approaches that combine physical with psychological components are needed to increase the proportion of older adults who can achieve an optimal level of walking capacity after hip fracture and maintain an independent lifestyle.” Fortinsky hopes that his research and others become an impetus for these types of integrated protocols to be developed.

Freedman would also like to see measures of resilience more commonly used in evaluating orthopedic patients. “We need to recognize patients with low resilience who may be at greater risk for poor outcomes,” he commented.

“Adding a Brief Resilience Scale to survey patients when seen with these injuries can really help identify those at risk for worse ambulatory ability after surgery,” he said. “We also need to consider cognitive therapy in these patients as well.”

Freedman believes that surgeons often need to be reminded that the mental health of their patients may be one of the biggest factors that correlate with outcomes after surgery. 

“No matter how great a surgery we perform,” he says, “if we are not paying close attention to psychological factors such as resilience in our patients, we may be missing warning signs for poor outcomes or opportunities for improvement.”

J Am Geriatr Soc. Published online July 20, 2022. doi: 10.1111/jgs.17930. Full Text.

Fortinsky and Freedman have no relevant financial relationships to this study.

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