Holiday rehabilitation improves daily living function for the most vulnerable hip fracture patients

Hip fractures are common in older adults, and their consequences extend well beyond the fracture itself. Surgery stabilizes the bone, but many patients experience a lasting decline in their ability to perform basic daily activities - dressing, bathing, transferring from a bed to a chair, walking to the toilet. Postoperative rehabilitation drives recovery of those functions, and there is evidence that rehabilitation delivered outside standard weekday hours, including on weekends and public holidays, can improve outcomes. The question that has been poorly addressed is which patients benefit most from that extended schedule.

A research group at Osaka Metropolitan University Graduate School of Medicine examined that question using data from 77,947 patients aged 60 or older who underwent surgery after a hip fracture. The analysis was led by graduate student Tsubasa Bito, Specially Appointed Assistant Professor Ryota Kawai, and Professor Ayumi Shintani from the Department of Medical Statistics, with contributions from the Department of Orthopedic Surgery. The findings were published in Annals of Physical and Rehabilitation Medicine.

Measuring independence: the Barthel Index

The study used the Barthel Index, a standardized tool that assesses a patient ability to perform 10 activities of daily living - feeding, bathing, grooming, dressing, bladder control, bowel control, toilet use, transfers, mobility, and stair climbing. Scores range from 0 (complete dependence) to 100 (complete independence). The researchers analyzed changes in Barthel Index scores from admission to discharge, comparing patients who received rehabilitation on holidays within 7 days of surgery against those who did not, stratified by age and initial Barthel score.

Who benefits from holiday rehabilitation

The findings showed a clear stratification by baseline function and age. Patients over 80 years old who received rehabilitation on holidays had higher Barthel Index scores at discharge than comparable patients who did not. Similarly, patients with initial Barthel scores of 0 to 10 - those with near-complete dependence on admission - showed significant improvements in discharge scores when holiday rehabilitation was provided.

In contrast, patients admitted with higher Barthel Index scores did not show significant improvement in discharge scores from additional holiday rehabilitation. For patients who were already relatively independent at admission, extending rehabilitation into holidays did not produce measurable added benefit.

This stratification has direct practical implications. Many hospitals face staffing constraints that make it difficult to provide physiotherapy to all hip fracture patients on weekends and public holidays. If limited rehabilitation resources must be rationed on those days, the data suggest that prioritizing the oldest patients and those with the lowest functional independence at admission would produce the greatest improvement in population-level outcomes.

"The results of this study provide large-scale data supporting the practice of prioritizing interventions for elderly patients and those with difficulty performing activities independently, which had previously been based on empirical experience," stated Bito.

Professor Shintani added: "We believe the research findings will provide useful information for prescribing effective rehabilitation with limited human resources."

Context and limitations

The study drew on a large administrative database with nearly 78,000 cases, giving it substantial statistical power to detect differences across subgroups. However, administrative database studies are limited by the quality and completeness of the recorded data. The Barthel Index was measured at admission and at discharge, but the study does not provide information about rehabilitation at the specific details of holiday therapy - its duration, intensity, or specific components - which could vary across institutions and staff.

The analysis also does not account for differences in institutional resources, staffing ratios, or the quality of weekday rehabilitation across the hospitals contributing data. A hospital that provides high-quality weekday rehabilitation might see different marginal returns from holiday sessions than a hospital with limited weekday care. Long-term functional outcomes - whether holiday rehabilitation during hospitalization translates into better independence at 3, 6, or 12 months after discharge - were not examined in this study.

The study population was Japanese, and norms for rehabilitation intensity, hospital length of stay, and post-discharge care pathways differ internationally. Whether the findings translate directly to healthcare systems in Europe, North America, or other settings requires validation in those contexts.