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Rehabilitation after Hip Surgery

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About Rehabilitation after Hip Surgery

Hip fractures are a major health issue among older adults, and incidence is rising as the population ages. At the same time, the number of individuals undergoing total hip arthroplasty for end-stage osteoarthritis has also increased. 

These two populations—individuals with hip fractures and those undergoing elective hip arthroplasty—represent distinct but overlapping clinical groups. Both are at risk of functional decline, loss of independence, and reduced participation in daily life following surgery.

After hip surgery, periods of reduced mobility and physiological stress may contribute to muscle weakness, balance impairment, worsening of pre-existing comorbidities, and development of new complications. Recovery trajectories vary widely and are influenced by baseline health status, cognitive function, comorbid conditions, surgical factors, and social context.

Post-surgical rehabilitation plays a central role in supporting recovery of function and participation after hip surgery. Outcomes depend not only on surgical success but also on how well rehabilitation addresses the interaction between the individual, their health condition, and their environment.

The World Health Organization defines rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” Consistent with this definition, rehabilitation after hip surgery extends beyond physical recovery alone and should consider activity limitations, participation restrictions, and contextual factors that influence recovery and longer-term outcomes.

About CCG Care Pathways

Purpose

CCG is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Post-Surgical Hip Care Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent
  • Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
  • Key Aspects:
    • Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
    • Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
    • Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
      • Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
      • Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
    • Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic: Age, gender, sex, race/ethnicity.
  • Main concern: Post-surgical status following hip surgery. Document current symptoms and concerns, including pain, mobility limitations, balance issues, fatigue, or functional difficulties, as well as factors that aggravate or relieve symptoms.
  • Surgical history: Indication for surgery (e.g., traumatic hip fracture, fragility fracture, end-stage osteoarthritis), type of surgical procedure (e.g., total hip arthroplasty, hemiarthroplasty, internal fixation), date of surgery, peri-operative complications, weight-bearing status, and post-operative precautions. Document in-patient course and any rehabilitation received prior to current presentation.
  • Medical history and body systems review: Review relevant systems with attention to conditions that may influence recovery, including:
    • Cardiovascular and respiratory conditions
    • Neurologic and cognitive status (including history of dementia, delirium, or stroke)
    • Musculoskeletal conditions (including osteoporosis or prior fractures)
    • Genitourinary and gastrointestinal issues
    • Skin integrity
    • Mental health conditions (e.g., depression, anxiety)
  • Medications and polypharmacy:
    Current medications, including analgesics (opioids and non-opioids), anticoagulants, corticosteroids, psychotropic medications, and supplements. Identify potential medication-related risks affecting rehabilitation (e.g., falls risk, sedation).
  • Health behaviours and functional baseline: Pre-fracture or pre-surgical mobility, use of gait aids, physical activity level, sleep, nutrition, tobacco or alcohol use, and baseline independence in activities of daily living.
  • Cognitive and psychosocial considerations: Assess orientation, memory, attention, and capacity to follow instructions as appropriate. Explore mood, fear of falling, confidence with movement, and expectations for recovery.
  • Social history and supports: Living situation, availability of caregivers, family or social support, caregiving responsibilities, and anticipated discharge destination (e.g., home, assisted living, long-term care).
  • Social determinants of health: Factors such as education, income, housing stability, access to transportation, insurance coverage, and access to rehabilitation services that may influence recovery, length of stay, and outcomes.
  • Previous care and responses: Prior conservative or surgical treatments for hip or lower-extremity conditions and responses to care.
  • Beliefs, goals, and expectations: Patient understanding of their condition and recovery, priorities for function and participation, and individual goals.
  • Flag considerations: Screen for red, yellow, and orange flags for potential referrals or co-management.

​​Outcomes Assessments:

Prioritize outcome measures that align with the individual’s goals, clinical presentation, and post-surgical phase. Selection should be appropriate to the care setting and population (e.g., hip fracture versus elective arthroplasty).

  • Physical performance and mobility:
    Hip range of motion (as relevant), Timed Up and Go (TUG), 10-metre walk test, 6-minute walk test, and balance or step tests, selected based on safety and functional level.
  • Pain:
    Pain intensity using validated scales (e.g. NRS) and body diagrams to document pain location and distribution.
  • Function and participation:
    Patient-reported measures assessing impact on daily activities and participation, such as HOOS, WOMAC,  PSFS, WHODAS,  LEFS, selected based on surgical population and relevance.
  • Recovery: Self-rated recovery scales.
  • Quality of life: Generic health-related quality of life measures (e.g. SF-12).
  • Sleep: Sleep quality where relevant (e.g. PSQI).
  • Falls risk and confidence (as appropriate): History of falls, fear of falling, or confidence with mobility, particularly in hip fracture populations.
  • Work, role, or activity status: Return to usual activities, roles, or work where applicable.
  • Individual goals:
    Establish SMART goals (Specific, Measurable, Achievable, Relevant, Timely) in collaboration with the patient and caregivers as appropriate.
  • Patient experience: Gather and integrate patient-reported experience, preferences, and satisfaction to guide care planning and ongoing monitoring.
4. Red Flags and Differential Diagnosis Requiring Medical Attention

ACTION: Refer immediately to emergency care:

  • Suspected infection or sepsis
    • Fever or chills, increasing pain unresponsive to usual care
    • Redness, warmth, swelling, discharge, foul odor, or red streaking near the surgical site
    • Systemic symptoms in the context of recent surgery or immunosuppression
  • Deep vein thrombosis or pulmonary embolism
    • New or worsening calf, groin, or thigh pain; unilateral swelling, warmth, or redness
    • Sudden shortness of breath, chest pain, dizziness, syncope, or coughing up blood
  • Neurovascular compromise
    • Acute onset of progressive weakness, numbness, loss of distal pulses, or severe pain out of proportion to findings
  • Acute fracture or dislocation
    • Sudden deformity, inability to weight-bear, severe pain following a fall or trauma

ACTION: Refer to appropriate medical provider:

  • Hardware failure or implant-related complications
    • Progressive or worsening pain, mechanical symptoms, limb length discrepancy, or instability
    • Known risk factors such as osteoporosis, prolonged corticosteroid use, advanced age, or history of malignancy
  • Bone or joint pathology
    • Suspected periprosthetic fracture, implant loosening, or migration
    • Suspected spinal fracture in individuals with osteoporosis or trauma history
  • Pressure injuries
    • Non-blanching erythema, discoloration, warmth, swelling, blisters, or open wounds in areas of prolonged pressure
  • Medical or surgical complications
    • Persistent wound drainage, delayed healing, or signs of hematoma
    • New or worsening pain with unclear etiology
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

  • Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
  • Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
  • Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

  • Suicide or self-harm thoughts: thoughts without immediate danger.
  • Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
  • Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

  • Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
  • Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
  • Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
  • Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

  • Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
  • Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
  • Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
  • Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
  • Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
  • Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

  • Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
  • Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
  • Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
  • Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
  • Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.
7. Physical Examination

The physical examination should be targeted, safety-oriented, and informed by surgical history, current precautions, and identified red flags.

  • Observation
    • General appearance, alertness, and ability to engage with assessment.
    • Inspection of the surgical site and surrounding skin for signs of infection, delayed healing, swelling, bruising, or discharge.
    • Posture, sit-to-stand strategy, balance, and gait pattern (with or without assistive devices).
    • Weight-bearing tolerance and adherence to post-operative precautions where applicable.
  • Range of Motion (ROM)
    • Assess active and passive hip ROM (flexion, extension, abduction, adduction, rotation) within post-surgical precautions and patient tolerance.
    • Note pain response, stiffness, asymmetry, or protective movement patterns.
    • Assess adjacent joints (lumbar spine, knee, ankle) as clinically indicated.
  • Strength and Motor Control
    • Screen key lower-limb muscle groups relevant to mobility and transfers, noting asymmetry, inhibition, or difficulty initiating movement.
    • Emphasize functional strength during tasks such as bed mobility, transfers, and ambulation rather than isolated maximal testing early post-surgery.
  • Palpation:
    • Assess peri-articular soft tissues for tenderness, swelling, temperature changes, or hematoma.
    • Avoid deep palpation over the surgical site.
  • Neurological Examination:
    • Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
      • L2: Hip flexors (hip flexion)
      • L3: Quadriceps (knee extension)
      • L4: Tibialis anterior (foot dorsiflexion)
      • L5: Extensor hallucis longus (big toe extension)
      • S1: Gastrocnemius (plantar flexion)
      • S2: Hamstrings (knee flexion)
  • Sensory testing: Assess for sensory deficits in dermatomal distributions:
    • L3: Medial thigh at the knee
    • L4: Medial calf
    • L5: Top of foot and toes
    • S1: Lateral foot and little toe
  • Reflex testing: Assess for asymmetry, diminished/absent reflexes:
    • L4: Patellar reflex
    • L5: Medial hamstring reflex
    • S1: Achilles reflex
  • Functional Assessment
    • Observe bed mobility, transfers, sit-to-stand, turning, and gait as tolerated and safe.
    • Note need for assistance, compensatory strategies, or instability.
  • Special/Orthopedic Tests:
    • Selectively performed only when clinically indicated and safe in the post-surgical context.
    • Avoid provocative testing that may compromise surgical repair or precautions.
  • Imaging Considerations: Imaging is not routinely recommended in the absence of red flags or specific individual factors (e.g. contraindications to treatment).

8. Selection Criteria for Post-Hip-Surgery Rehabilitation

Individuals are eligible for this rehabilitation pathway when the following criteria are met. Clinical judgment should be applied to account for individual needs, care setting, and local resources.

Pre-surgical condition

  • Surgery performed for:
    • Traumatic hip fracture or fragility fracture
    • End-stage hip osteoarthritis
    • Other hip pathology requiring surgical intervention

Surgical intervention

  • Applicable procedures include:
    • Total hip arthroplasty
    • Hemiarthroplasty
    • Hip replacement or prosthesis
    • Hip internal fixation (e.g., screws, plates, intramedullary devices)

Post-surgical status

  • Medically stable following surgery.
  • Cleared for rehabilitation participation according to surgical and medical guidance.
  • Rehabilitation may begin as early as 24 hours post-surgery, depending on clinical status, surgical procedure, and care setting.

Signs and symptoms

  • No unresolved red flags requiring urgent medical management (e.g., acute infection, thromboembolism, hardware failure).
  • Pain, mobility limitations, balance deficits, or functional impairments appropriate for conservative rehabilitation.

Cognitive and psychosocial considerations

  • Able to participate in rehabilitation with or without caregiver support.
  • Cognitive impairment, delirium risk, or psychosocial complexity do not preclude rehabilitation, but may require modified delivery or co-management.

Care context

Applicable across care settings, including acute care, inpatient rehabilitation, outpatient rehabilitation, and home- or community-based care, as appropriate.

9. Treatment Considerations for Post-Hip-Surgery Rehabilitation

Post-surgical hip rehabilitation should be individualized, goal-oriented, and responsive to change over time. A shared decision-making approach that integrates patient goals, clinical judgment, and best available evidence is essential. Rehabilitation should be adapted to surgical type, care setting, medical stability, and functional capacity.

General principles

  • Rehabilitation aims to reduce complications, restore mobility and function, and support return to home and community participation.
  • Care should remain flexible, with progression guided by patient response rather than fixed timelines.
  • Ongoing communication among surgical, medical, and rehabilitation providers is critical, particularly regarding precautions and weight-bearing status.

Education and Self-Management (Colibazzi 2020; Hawke 2019; NICE 2023)

  • Provide tailored, evidence-based information regarding recovery expectations, activity participation, precautions, and self-management. 
  • Education may be delivered using written, verbal, or digital formats and should be adapted to cognitive status and caregiver involvement.
  • No single educational approach has demonstrated superiority; combining education with active rehabilitation is supported.
  • Behavior graded activity, incorporating goal-setting and positive reinforcement, may help increase adherence to activity recommendations and reduce pain.  
  • Assistive devices (e.g., raised toilet seat, mobility aids, dressing aids, long-handle grabbers) may be recommended with appropriate instruction.
  • Address modifiable prognostic factors for recovery (e.g., physical inactivity, fear of movement, unrealistic expectations).

Mobilization (Colibazzi 2020; Min 2021; NICE 2023) 

  • Early mobilization following surgery is recommended once the individual is medically stable.
  • Mobilization frequency and progression should be guided by surgical procedure, precautions, tolerance, and care setting.
  • Regional or soft-tissue–based techniques may be incorporated as appropriate, without compromising surgical integrity.

Supervised Exercise Therapy (AAOS 2023; Colibazzi 2020; Min 2021) 

  • Exercise programs should be individualized and may include:
    • Gait and mobility training
    • Functional task training (e.g., transfers, stair negotiation)
    • Progressive strengthening of hip and lower-limb musculature
    • Balance and postural control activities
  • Programs should align with patient goals, baseline capacity, and psychosocial context.
  • Monitor psychological responses to rehabilitation (e.g., distress, fear, avoidance) and refer for co-management when indicated.
  • Weight-bearing progression should follow surgical guidance, with close interdisciplinary communication.

Unsupervised or Home-Based Exercise (AAOS 2023; Colibazzi 2020) 

  • Home-based or unsupervised programs may be appropriate for some individuals, depending on functional status, safety, and support.
  • Exercise, mobility, and physical activity are important components of recovery regardless of delivery format.
  • Some individuals may benefit from structured longer-term strengthening or task-oriented programs to reduce disability and support participation.
  • Selection of unsupervised programs should consider cognition, adherence, and access to follow-up.
10. Risk Factors and Prognosis Post Hip Surgery

Recovery following hip surgery varies widely and is influenced by individual, surgical, and contextual factors. Identification of risk factors supports realistic goal-setting, appropriate monitoring, and timely co-management.

Risk factors for adverse events or less favourable outcomes (AAOS 2023; NICE 2023)

  • Medical and physiological factors
    • Advanced age
    • Multiple comorbidities
    • Poorly controlled diabetes
    • Osteoporosis
    • Elevated body mass index
    • Frailty and reduced physiological reserve
  • Medication-related factors
    • Polypharmacy
    • Opioid use
    • Anticoagulant or corticosteroid use
  • Functional and cognitive factors
    • Pre-existing mobility limitations
    • Cognitive impairment or delirium
    • History of falls
    • Fear of falling or movement-related anxiety
  • Psychosocial factors
    • Depression, anxiety, fear-avoidance beliefs, catastrophizing
    • Low expectations of recovery
    • Limited caregiver or social support
  • Social determinants of health
    • Low income
    • Limited access to rehabilitation services
    • Housing instability
    • Transportation barriers
    • Insurance coverage constraints
  • Surgical and care-related factors
    • Surgical complications
    • Delayed mobilization
    • Fragmented transitions between care settings

Prognosis

  • Many individuals experience meaningful improvement in mobility, function, and participation following hip surgery when rehabilitation is timely and appropriately matched to needs.
  • Recovery trajectories differ between hip fracture and elective arthroplasty populations, with hip fracture patients generally facing greater risk of prolonged disability and institutionalization.
  • Persistent functional limitations may occur, particularly in the presence of medical complexity, cognitive impairment, or adverse social circumstances.
  • Long-term outcomes are shaped not only by surgical success but by the extent to which rehabilitation addresses modifiable physical, psychological, and contextual factors.
  • Ongoing monitoring and adjustment of care plans are important to optimize recovery and reduce preventable decline.
11. Ongoing Follow-up

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

  • Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
  • Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
  • Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
  • Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
  • Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
  • Referral and co-management: arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
  • Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.
12. Criteria for Discharge

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

  • When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
  • Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
  • When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
  • Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
  • Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
  • Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
  • If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
  • Documentation: record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

References