Comparative effectiveness of community-based rehabilitation programs on functional recovery after hip fracture in older adults: a systematic review and network meta-analysis.

BACKGROUND

Community-based rehabilitation is critical for functional recovery in older adults after hip fracture, yet the optimal strategy remains uncertain. Previous reviews are limited by the pooling of heterogeneous interventions and an incomplete assessment of evidence quality. This network meta-analysis (NMA) aimed to compare the effectiveness of different community-based rehabilitation programs and, critically, to formally assess the certainty of the evidence.

METHODS

We conducted a systematic review and NMA of randomized controlled trials (RCTs) from four electronic databases up to August 1, 2025. We included RCTs comparing community-based rehabilitation programs (Comprehensive Multidisciplinary Care [MDC], Structured Home Exercise [HomeEx], Attention/Active Control [AC]) against each other or Usual Care (UC) in adults aged 60 + after hip fracture surgery. Primary outcomes were Physical Performance and Activities of Daily Living (ADL/IADL). The certainty of evidence was evaluated using the GRADE framework.

RESULTS

Twelve RCTs involving 1,510 participants were included. The NMA revealed substantial and statistically significant inconsistency across the network for both Physical Performance (Q = 48.69, p < 0.0001) and ADL/IADL (Q = 18.75, p = 0.001). While point estimates suggested trends favoring active interventions over UC, no comparison reached statistical significance. Critically, the GRADE assessment rated the certainty of evidence for all primary outcome comparisons as very low, due to serious concerns regarding risk of bias, inconsistency, and imprecision.

CONCLUSION

The principal finding of this NMA is the profound heterogeneity and very low certainty of the evidence base for community-based rehabilitation after hip fracture. This finding challenges the practice of treating broad rehabilitation categories as uniform interventions and precludes definitive conclusions about the superiority of any single strategy. While our analysis identifies promising trends that can inform future research, its most significant contribution is the formal quantification of a critical evidence gap, providing an essential roadmap for designing future, high-quality trials capable of delivering robust answers.