The baseline results of our randomized controlled trial emphasize that there is an urgent need to develop long-term rehabilitation strategies for mobility recovery and prevention of mobility disability after hip fracture. According to the patients' own report, only half of them received a home exercise program and followed up the instructions given by the health care personnel on a daily basis. Home exercise programs were not updated and programs did not include any external resistance, walking or balance exercises. Less than 15% of the participants were referred to physiotherapy, while the rest did not get any further instructions or follow-up for recovery of mobility and functional capacity.
Previous studies have shown poor mobility recovery after hip fracture and some of the studies suggest that this phenomenon may turn out to be permanent [1, 10, 45]. Poor lower limb muscle strength, postural balance and hip pain are associated with poor mobility recovery after hip fracture [10, 45]. Muscle strength deficit on the fractured side is associated with greater pain on the fractured compared to the non-fractured side  and large muscle strength deficit is associated with mobility limitation and balance impairment . Some recovery is expected to occur during the first six months after hip fracture. However, our earlier study showed that community-dwelling older men and women who had suffered a hip fracture on average four years earlier were significantly weaker, had a significant side-to-side difference in lower limb muscle strength [11, 15] and had significantly impaired postural balance and balance confidence  compared to the age and sex matched controls with no major lower limb injuries. The presence of multiple impairments, pain and poor balance confidence (fear of falling) strongly suggest increased and cumulative risk for loss of mobility in the near future if targeted rehabilitation with follow-up for mobility recovery is not available.
The standard care, in this study, did not include the follow-up for mobility recovery. It included home exercise programs with five to seven exercises mostly for the fractured limb. Programs were not updated to a more challenging one and no additional resistance was used. None of the participants were followed-up for the home exercise program. Variation in the rehabilitation activities and lack of guidelines for mobility limitation and disability prevention after hip fracture has been recognized worldwide [47, 48]. It has been suggested that better functional outcomes could be achieved with more intensive rehabilitation and promotion of physical activity after hip fracture [47, 48].
The aim of the ProMo -intervention is to restore mobility after hip fracture and it was firmly grounded to existing research literature. As we wanted to include all hip fracture patients who could potentially benefit from the rehabilitation, also the weakest and the oldest ones, the program was designed to take place at the participants' home. The ProMo is a 1-year progressive physical exercise and physical activity counseling program reinforced by advise, support and encouragement for safe walking as well as discussions on fall prevention and pain management strategies. Pain assessment and fear of falling management was regarded as an essential part of the program as older people who had had a hip fracture suffer from residual pain [12, 49] and fear of falling . Both pain [12, 50, 51] and fear of falling [52–54] have been independently associated with mobility limitation, activity restriction, low physical functioning and falls among older populations. To our knowledge and based on a recently updated Cochrane review  there is no previously published effectiveness RCT among community-dwelling hip fracture participants including a home-based intervention specifically targeting on mobility recovery and which has mobility limitation and disability as the main outcome. Encouraging evidence on effects of interventions with similar components on the level of physical activity , functional capacity  and health related quality of life  have, however, been reported.
The recruitment process of this study included eligibility screening in multiple phases and there was close collaboration with clinicians at the local hospital and health care centers. In total, 296 patients who fulfilled the inclusion criteria were identified and informed about the study at the hospital. From those approximately half (n = 161) were interested in and further informed about the study. From those who expressed initial interest 84% (n = 136) signed informed consent and were enrolled in the study. This was regarded as a sufficient number of participants, allowing a 35% attrition rate, ending with 44 in each study group. Because our participants were recruited at the clinic (health care centre) prior to discharge to home, we set our safety margin in the attrition rate higher than 20% which was recommended by Ferrucci et al in their consensus report . We expected some changes in health status, living conditions and willingness to participate to occur already before the baseline measurements. Accordingly, 26% were further excluded due to poor health, alcoholism and living conditions and 15% declined participation mostly due to poor self-rated health and tiredness (Figure 1). Finally, 81 men and women were assessed at baseline and randomly assigned into ProMo -intervention and control groups. Despite of careful planning of the study and target of the recruitment period from 24 to 33 months, we did not completely reach the estimated number needed for this study. However, as the intervention is home-based and individually targeted and the main outcomes can be assessed at the participants' home, we trust that the additional drop-out will be small. The demographics of our study participants is comparable to earlier studies involving community-dwelling older people recovering from hip fracture; the majority of them are women and the mean age is close to 80 .
In conclusion, this report summarized the rationale, procedures and intervention of a 1-year RCT with 1-year follow-up on the effectiveness of home-based rehabilitation program aiming to restore mobility after hip fracture among community-dwelling over 60-year-old men and women. The special feature of the current study is that we reinforce the home exercise program by advice, support and encouragement for safe walking and discussions on fall prevention and pain management strategies. In addition, promotion of using existing exercise and rehabilitation services available for older people in their own community was performed by physical activity counseling. These facilities will be available for the participants also after finishing the project. This intervention study will provide knowledge of the rehabilitation for mobility recovery among community-living older people after hip fracture. However, the effectiveness of the program can only be assessed after the end of the study.