Impact of telerehabilitation on physical function
Immobilization after major surgery and during hospitalization can substantially decrease muscle strength and function. Physical training has been shown to improve strength and functional performance in patients recovering from hip fractures [23]. This study demonstrated that telerehabilitation programs, specifically tele-resistance exercises, can significantly enhance physical function in elderly patients following hip fracture surgery. At 12 weeks postintervention, the improvements were particularly notable compared with those achieved with traditional exercise booklets. This is the first study to implement such a program for fragility hip fractures in Thailand, contributing important evidence from a low-resource context.
Advantages of real-time video conferencing
The intervention employed real-time video conferencing through the LINE application to deliver exercises and provide immediate feedback from physiotherapists. This method differs from other telerehabilitation approaches, which typically use prerecorded videos or less interactive platforms [15]. The ability to offer real-time feedback allowed for personalized adjustments, likely contributing to the observed improvements in physical function. Additionally, participants could use smartphones or tablets with a standard application, making this telerehabilitation approach more accessible and cost-effective than systems relying on complex technology.
Challenges with traditional rehabilitation
Rehabilitation after surgery primarily aims to restore mobility. In the standard approach, older adults with hip fractures and their caregivers typically receive training on home exercise programs upon discharge, supplemented by an exercise booklet. However, clinical observations have shown that some patients struggle to follow and progress with these exercises, leading to delayed mobility recovery. Furthermore, mobility issues often prevent patients from receiving outpatient therapy, as they rely on caregiver assistance and face transportation challenges. These barriers can exacerbate inequities in healthcare access, particularly for those in remote or underserved areas. The trial addressed these limitations by introducing a more structured and accessible alternative the 12-week tele-resistance exercise program which allowed patients to receive rehabilitation remotely. This approach not only enhances accessibility but also potentially reduces inequities in healthcare access, aligning with the sustainable development goals [24].
Safety considerations in telerehabilitation
Safety is paramount in remote exercise programs. Therefore, 100 patients who were considered unsafe for telerehabilitation were excluded from the study. There were 31 participants with extreme ages and 69 conditions that could prohibit active exercise were excluded from the study. A meta-analysis reported that physiotherapist-led, exercise-based telerehabilitation is noninferior to face-to-face rehabilitation and superior to no intervention for older adults with musculoskeletal conditions [25]. Systematic reviews have also indicated that progressive resistance exercises following hip fracture surgery improve mobility, activities of daily living, balance, lower-limb strength, and performance in various tasks [26, 27]. Therefore, tele-resistance exercise was selected as the intervention. Tele-resistance exercise showed an adherence rate of 70%, demonstrating its superior effectiveness compared to using exercise booklets demonstrating its effectiveness compared to exercise booklets.
Primary outcome: improvements in SPPB scores
The Short Physical Performance Battery (SPPB) served as the primary outcome measure, evaluating balance, gait speed, and lower limb strength. At 12 weeks, the intervention group demonstrated a median improvement of 3.5 points—exceeding the threshold for substantial clinical relevance in older adults [15, 28]. This result aligns with previous meta-analyses supporting the efficacy of home-based digital interventions in enhancing physical function among elderly populations [15].
The use of real-time telerehabilitation, which provided personalized instruction and immediate feedback, likely contributed to these superior outcomes. Unlike conventional home programs that rely on static materials, the interactive nature of this approach allowed for progressive, individualized resistance training. This supports existing evidence indicating that supervised exercise produces greater functional gains than unsupervised programs in older adults [29].
Analysis of individual SPPB components revealed significant improvements across all domains within the intervention group. Notably, the chair stand test, which reflects lower limb strength, showed marked improvement as early as six weeks—a finding consistent with Vikberg et al., who reported similar early responses to resistance training. [30] Gait speed improved progressively in both groups, but significantly more in the intervention group by week 12. This is consistent with literature suggesting that resistance, multimodal, and coordination-focused training effectively enhance gait performance in older individuals [31, 32]. The early gains observed may have encouraged greater voluntary activity, thereby reinforcing ongoing improvements.
In contrast, while balance scores increased gradually over time, there was no significant between-group difference. Given that postural control involves multiple physiological systems, a multicomponent approach incorporating proprioceptive, aerobic, and neuromuscular training may be necessary to elicit more pronounced improvements in this domain [33].
Overall, the findings indicate that real-time tele-resistance exercise was effective in improving overall physical performance, particularly in total SPPB scores and gait speed, when compared to traditional unsupervised home rehabilitation.
Secondary outcomes
2-Minute walk test (2MWT)
The 2MWT revealed that both groups improved significantly from baseline at 6 and 12 weeks. Notably, the intervention group showed greater improvement at 6 weeks, though this difference did not remain statistically significant at 12 weeks. Despite this, the absolute gain in walking distance remained higher in the intervention group at both follow-up points. The mean increase of 21.4 m surpassed the minimal detectable change in older adults, suggesting clinically meaningful improvement in ambulatory capacity [19].
This finding aligns with evidence linking 2MWT performance to aerobic capacity during rehabilitation after hip fracture. [34] However, variability in the 12-week results may reflect natural recovery trajectories or increasing physical activity in the control group. Some studies have also suggested that endurance gains in this context may stem primarily from increased muscle strength [35, 36].
Knee extension strength
Contrary to expectations, no significant between-group differences were observed in knee extension strength on the fractured side. This contrasts with prior research showing strength improvements with resistance training. The limited impact may be due to the low intensity and volume of resistance used (0.5–1 kg), which may be insufficient for inducing measurable hypertrophy or strength gains, particularly in frail or sarcopenic populations [37].
Additionally, the control group had lower baseline strength, which may have motivated more self-directed exercise. Once participants regained mobility, reduced adherence may have further attenuated strength gains. While adherence to tele-resistance training was approximately 70%, no data were available for adherence to unsupervised exercises. The reduction in supervised sessions from twice weekly to once weekly after week 6 may have also affected training consistency and outcomes [38].
Anxiety scores and sociocultural factors
Improvements in anxiety were observed in both groups, though no significant between-group differences emerged. This contrasts with findings from Wu et al., who reported reduced anxiety with telerehabilitation [39]. Nevertheless, our findings are consistent with studies showing that physical activity can positively influence anxiety in older adults [40].
In the Thai context, strong familial caregiving support may have contributed to generally low baseline anxiety and steady improvements over time. Cultural values emphasizing elder care may mitigate psychological distress associated with physical decline, especially when combined with functional recovery. Additionally, greater mobility limitations and comorbidities in the control group may have been associated with higher fear of falling, which can influence anxiety scores [41, 42].
Safety and adverse events
Importantly, our study did not report any adverse effects or deaths related to the tele-resistance exercise program. One fall occurred in the intervention group; however, it was unrelated to the exercise program and did not result in serious complications. This study underscores the effectiveness of home-based digital health interventions involving communication, feedback, education, and telerehabilitation, which enhance functional outcomes among older patients recovering from hip fractures postsurgery [15].
Limitations
Several limitations must be acknowledged in this study. First, a significant number of patients were excluded due to safety concerns about remote exercise. Since this study was conducted in a tertiary, university-based medical school, the participants may have had more severe health conditions and a higher prevalence of comorbidities compared to those in community-based hospitals. Consequently, the findings may not be applicable to patients in such settings. Second, the relatively small sample size limits the generalizability of the results. This small sample size was partly due to recruitment challenges toward the end of 2022. During this period, many caregivers who were proficient in using smart devices and the LINE video call application had to resume on-site work, reducing their availability to support patients in the telerehabilitation program. Then some of the participants were institutionalized during this time, further limiting the pool of eligible participants. Increasing the sample size in future research could enhance the robustness of the findings. Additionally, the current study employed a conventional approach that included an exercise booklet and a home exercise program provided prior to discharge. This approach resulted in reduced therapist interaction for the control group, which may have negatively influenced their physical outcomes. Moreover, the participants in the control group were older and utilized gait aids more frequently compared to those in the intervention group. Previous research has established that older age and reduced walking abilities were associated with diminished functional recovery following hip fractures [6, 43]. Therefore, it is possible that the control group experienced poorer recovery outcomes than the intervention group. Finally, investigating the long-term effects of telerehabilitation is crucial for evaluating the sustainability of the observed benefits.