Harnessing psychological resilience in hip fracture recovery: The overlooked role of sense of coherence

Abstract

Hip fracture recovery hinges on more than fixation and early mobilization; patients’ capacity to interpret the event, regulate emotions, and re-engage with valued roles is equally decisive. Sense of coherence (SOC) - comprising comprehensibility, manageability, and meaningfulness - offers a concise resilience lens that connects perioperative education, symptom self-management, and values-based rehabilitation. Converging evidence links stronger SOC with lower anxiety/depression and greater post-traumatic growth, suggesting an underused lever for improving both psychological and functional trajectories. This article synthesizes conceptual and clinical signals around SOC in orthogeriatric care and outlines a practical pathway to integrate it without adding burden: (1) Plain-language mapping of the care timeline to strengthen comprehensibility; (2) Brief goal-setting, graded activity, and pain-coping skills to enhance manageability; and (3) Narrative reframing plus small prosocial actions to cultivate meaningfulness. Routine tracking with the 13-item Sense of Coherence Scale, the Hospital Anxiety and Depression Scale, and the Post-Traumatic Growth Inventory can be paired with pragmatic endpoints - time-to-mobilization, length of stay, and 90-day events - to evaluate feasibility and impact. Positioning SOC as a modifiable resilience target may help bridge psychology and rehabilitation in standard hip-fracture pathways and yield measurable gains in emotional recovery and participation.

Key Words: Adaptation psychological; Anxiety; Depression; Geriatrics; Hip fractures; Orthopedic procedures; Patient-reported outcome measures; Perioperative care; Rehabilitation; Sense of coherence

Core Tip: Sense of coherence provides an actionable resilience framework for hip fracture recovery: Making care comprehensible (simple timelines and expectations), manageable (brief goals, graded activity, pain-coping), and meaningful (values-based reframing and micro-acts) can be embedded into routine ortho-geriatric workflows. Tracking 13-item Sense of Coherence Scale, Hospital Anxiety and Depression Scale, Post-Traumatic Growth Inventory alongside mobilization time, length of stay, and short-term readmissions enables low-burden evaluation and supports iterative improvement in both psychological and functional outcomes.

INTRODUCTION

Hip fracture is often followed by substantial psychological distress - most notably anxiety, depression, and fear of falling - that is clinically consequential rather than incidental. Such factors are repeatedly linked to restricted activity, delayed mobilization, and slower functional gains after surgery, with fear of falling in particular predicting poorer gait, balance, and overall recovery[1,2]. Depression is also common in this population, reinforcing the rationale for routine screening and timely management during rehabilitation[3]. Beyond single symptoms, contemporary syntheses emphasize that addressing psychosocial distress within rehabilitation can improve outcomes and participation after hip fracture[4]. Against this backdrop, findings from Wu et al[1] in intertrochanteric fracture patients - showing inverse links between affective symptoms and post-traumatic growth (PTG), and placing psychological health at the center of recovery - add discipline-specific momentum to this shift in focus.

This study has three goals tailored to hip-fracture orthogeriatric care: (1) To argue, from domain evidence, that the sense of coherence (SOC) is a clinically relevant lever influencing adherence, mobilization, and recovery; (2) To translate SOC into ward-ready workflows aligned with routine touchpoints [admission, postoperative days (POD) 1 and 2, early rehab, discharge]; and (3) To make the pathway evaluable through a minimal cadence - 13-item Sense of Coherence Scale (SOC-13), Hospital Anxiety and Depression Scale (HADS), and Post-Traumatic Growth Inventory-Short Form (PTGI-SF) administered at admission, discharge, and 6-12 weeks - plus pragmatic endpoints. This addresses a field-specific gap: Mainstream orthogeriatric resources and trials improve transitions and rehabilitation yet seldom articulate a resilience target or an SOC-based “minimal dose” within the pathway. We therefore anchor our blueprint to orthopedic and geriatric studies - qualitative syntheses and trials of hip-fracture transitions, physiotherapy management guidance, and scalable digital rehab after hip fracture (Active Hip+) - and position SOC as the missing psychological throughline that connects education, activity prescriptions, and meaning-centered work in everyday care.

INTERRELATION BETWEEN SOC AND PTG

SOC - the core of the salutogenic model - integrates comprehensibility, manageability, and meaningfulness into a pragmatic lens for adaptation under stress, offering a structure to translate resilience science into practice[5,6]. Foundational and synthesis work consistently position SOC as a health-promoting orientation rather than a disease-focused trait[7].

In older adults, prospective evidence shows SOC buffers the impact of adversity on health and well-being: Pre-disaster SOC mitigated the effects of housing damage on multiple outcomes in survivors of the 2011 Japan earthquake and tsunami. Systematic reviews likewise link higher SOC to better mental health and lower distress, including in community-dwelling elders. These converging data support SOC’s relevance for late-life recovery after serious injury[8].

Within orthopedic contexts, Wu et al[1] report that SOC correlates positively with PTG in intertrochanteric fracture patients, complementing inverse associations between affective symptoms (HADS-A/HADS-D) and PTG - placing psychological coherence on the same axis as recovery-oriented outcomes. External literature echoes this pattern in trauma-exposed populations: Among firefighters and other professionals, higher SOC aligns with greater PTG, and meta-analytic evidence shows SOC is associated with lower post-traumatic symptom burden. Together, these findings situate SOC as a plausible upstream determinant of growth rather than merely a correlate of low distress[9].

Mechanistically, SOC’s three facets map onto adaptive emotion regulation - especially cognitive reappraisal - which predicts more positive affect and aligns with the “manageability” and “meaningfulness” components central to SOC. This appraisal-to-growth pathway provides a biologically and psychologically credible route by which higher SOC could facilitate PTG in the aftermath of hip fracture[10].

OBSERVATIONAL EVIDENCE SUPPORTING SOC AS A PROTECTIVE FACTOR

Across hip-fracture cohorts and related older-adult samples, SOC consistently behaves as a protective marker. In intertrochanteric patients, SOC correlates positively with PTG while anxiety and depression relate inversely, situating psychological coherence on the same axis as recovery-oriented outcomes[1]. Beyond PTG, lower SOC is linked to greater frailty in community-dwelling elders, aligning SOC with broader vulnerability processes that undermine resilience[11]. In hip-fracture survivors undertaking progressive resistance training, higher SOC predicted better adherence and larger gains in strength, mobility, and balance - evidence that SOC tracks day-to-day rehabilitation behavior and response[12]. Earlier prospective work in hip-fracture inpatients found that weaker SOC forecast longer stays and poorer subsequent function and quality of life, underscoring prognostic value for clinical pathways. Finally, these SOC patterns align with companion risks such as fear of falling, which is common post-fracture and consistently associated with worse functional recovery, reinforcing the need for early psychosocial assessment and support (Table 1)[1,2,4,8,11,12].

Table 1 Observational evidence linking sense of coherence to recovery-relevant outcomes in hip-fracture and older-adult cohorts.

Ref.	Population and setting	Design and SOC measure	Outcome(s)	Key finding (direction)	Notes
Wu et al[1], 2025	Intertrochanteric femoral fracture; postoperative inpatients	Cross-sectional; SOC (instrument per paper)	PTG; Hospital Anxiety and Depression Scale-A/D	Conversion between higher SOC and higher PTG; anxiety/depression inversely related to PTG	Positions psychological coherence on the recovery axis
Chen et al[11], 2022	Community-dwelling older adults (China)	Cross-sectional; 13-item SOC	Frailty (multidimensional)	Conversion between lower SOC and higher frailty	Signals broader vulnerability processes
Portegijs et al[12], 2014	Older adults with hip-fracture history undergoing progressive resistance training	Prospective training cohort; SOC (baseline)	Adherence; gains in strength, mobility, balance	Higher SOC transform into better adherence and larger functional gains	Behavioral relevance for day-to-day rehab
Gadhvi et al[2], 2023	Hip-fracture survivors (systematic review)	Systematic review	Fear of falling and related constructs	Fear of falling common; associated with worse function	Companion risk aligned with low coherence patterns
Hikichi et al[8], 2023	Older disaster survivors (Japan)	Prospective outcome-wide study; SOC baseline	Multiple health and well-being outcomes	Higher pre-event SOC buffered adverse impacts	External validity for resilience role of SOC
Taylor et al[4], 2024	Hip fracture (qualitative synthesis)	Systematic review of qualitative studies	Psychosocial impacts	Psychological distress affects participation and recovery	Context for early psychosocial assessment

PTG: Post-traumatic growth; SOC: Sense of coherence.

INTERVENTION STRATEGIES TO ENHANCE SOC IN OLDER ADULTS

Short-term changeability and time course

Although the SOC in older adults exhibits a relatively stable trait-like quality, it is not immutable. Emerging evidence indicates that SOC can be enhanced through structured, salutogenesis-oriented nonpharmacological interventions. The most pronounced improvement typically occurs within approximately three months after the intervention, with gradual attenuation during extended follow-up - a pattern that supports the incorporation of “booster” or consolidation sessions in clinical practice. Several integrative reviews further demonstrate that multicomponent programs emphasizing resource activation, meaning-making, and coping-skills training tend to improve SOC, quality of life, and self-efficacy simultaneously[13,14].

Strategy mapping to SOC dimensions

From an intervention standpoint, clinically applicable strategies tend to integrate the three core dimensions of SOC - comprehensibility, manageability, and meaningfulness - into a cohesive framework[15,16]. A commonly adopted approach is the use of simplified health education and transparent care pathways to enhance comprehensibility. For instance, clearly presenting key recovery milestones such as surgery, pain control, early mobilization, and discharge through concise educational materials and teach-back methods has demonstrated feasibility in both community-based elder care programs and randomized trial settings. To cultivate a sense of meaningfulness, narrative-oriented and meaning-oriented components - such as guided cognitive reappraisal and values clarification - are often employed, with early-stage trials showing upward trends in SOC following such interventions. Manageability is frequently addressed by embedding graded goals and brief coping strategies, such as breathing exercises and pain reframing, into daily activity prescriptions. This not only strengthens perceived control but also aligns with existing evidence linking physical activity interventions to improvements in SOC, particularly among individuals with lower baseline coherence. Furthermore, group-based programs emphasizing personal strengths and resource activation - typically delivered over 8-12 weeks and supplemented by home visits or resource booklets - have shown both practical feasibility and positive effects on SOC in pilot randomized controlled trials (RCTs) targeting older adults. Finally, salutogenesis-based self-care curricula have demonstrated dual benefits in randomized controlled studies by enhancing both SOC and psychological aspects of quality of life, suggesting strong potential for adaptation across varied care contexts[14,17,18].

Embedding micro-intervention bundles at routine touchpoints

Mapping the above evidence onto geriatric orthopedic assessment and perioperative care, a practical approach involves embedding compact yet comprehensive “micro-intervention bundles” at routine clinical touchpoints. During key stages - admission education, POD 1 and 2, early rehabilitation, and discharge planning - one-page care timelines and frequently asked questions can be provided to enhance comprehensibility[19-21]. To support manageability, Specific, measurable, achievable, relevant, and time-bound (framework for goal setting) (SMART) goal-setting, tiered walking or resistance plans, and brief coping techniques (such as breathing exercises or pain reappraisal) can be integrated into daily recovery routines. Meanwhile, exercises in guided value-based reflection and simple prosocial “micro-actions” (e.g., small gestures of kindness or self-affirmation tasks) can help nurture a sense of meaningfulness. Recognizing that the effects of SOC-enhancing interventions may diminish over time, low-burden follow-up strategies - such as nurse-led phone check-ins or remote sessions with physical therapists - should be scheduled within the first three months post-discharge to consolidate and sustain psychological gains[13,22,23].

Measurement and evaluation framework

For assessment and individualized support, it is recommended to adopt the SOC-13 as the core instrument, complemented by the HADS and the short form of the PTGI-SF to enable ongoing monitoring and stratified intervention. Psychometric studies have noted localized item dependencies within the SOC-13, which can affect its dimensional assumptions. However, when items are grouped into three test lets - corresponding to the dimensions of comprehensibility, manageability, and meaningfulness - and analyzed using Rasch modeling, the total score demonstrates improved fit to a unidimensional structure. Therefore, in clinical practice, the total SOC-13 should be prioritized, while subdimension scores should be interpreted cautiously and, if reported, clearly labeled as exploratory. This scoring strategy also facilitates pragmatic quality improvement initiatives and pre-post evaluations at the department or ward level[24].

SOC-13 (psychometric profile and interpretability in older/orthopedic contexts): SOC-13 is not a diagnostic screen but a summative indicator of coherence; thus, accuracy metrics (sensitivity/specificity) are not applicable. Psychometric investigations using Rasch modeling consistently report local item dependencies and recommend treating the SOC-13 total as essentially unidimensional - often improved by three testlets mapped to comprehensibility, manageability, and meaningfulness - while interpreting subscales with caution. Reliability is acceptable to good in adults and older people (e.g., α = 0.76-0.85; test-retest reliability reported in clinical samples), and measurement invariance across gender/age has been documented. Accordingly, we will prioritize the SOC-13 total forward-level QI and pre-post evaluation[25].

HADS (screening accuracy and interpreting change): For the HADS - a validated screening tool for anxiety and depression in somatic and hospital populations - large-scale syntheses consistently demonstrate robust diagnostic accuracy. Classical meta-analyses and diagnostic reviews support subscale cut-offs of ≥ 8 (possible) and ≥ 11 (probable), whereas an individual participant data meta-analysis indicates that HADS-D ≥ 7 yields the optimal balance of sensitivity (0.82) and specificity (0.78) across diverse reference standards. Accordingly, we employ HADS-A and HADS-D as screening and change-tracking endpoints, rather than for diagnostic adjudication.

Regarding interpretability of change, published minimal clinically important difference (MCID) estimates vary by condition. Distribution-based studies typically report = 2.0-2.5 points for HADS-A and 1.9-2.3 points for HADS-D, while disease-specific, anchor-based analyses suggest subscale MCIDs of approximately 3 points and 4 points (corresponding to a total-score change of 5 points and 6 points) in musculoskeletal populations. Based on this evidence, we conservatively define a ≥ 2-point change on either subscale as the threshold for minimal meaningful improvement or deterioration, and we report effect sizes with 95%CI within the present study context[26].

PTGI-SF (reliability, validity, and use in tracking growth): For the PTGI-SF, 10 items, the total score demonstrates high internal consistency (commonly Cronbach’s α = 0.86-0.90) and good test-retest reliability (e.g., r = 0.71). The original short-form development and subsequent multilingual validations have confirmed its construct validity and cross-population applicability. More recent studies across diverse languages and cultural contexts - including older adult and community samples - likewise report robust reliability, validity, and, in several analyses, measurement invariance. Accordingly, we use the PTGI-SF total score to track trajectories of growth-related change and interpret it alongside functional outcomes. Given that the PTGI-SF is not a diagnostic instrument and lacks a universal MCID, we report standardized effect sizes and distribution-based reference thresholds to ensure comparability and reproducibility across studies[27].

Summary for practice

In conclusion, several key evidence-based insights support the integration of SOC into geriatric orthopedic care. First, SOC can be meaningfully improved in the short term through multicomponent, salutogenesis-informed interventions. Embedding elements such as patient education, meaning-centered reflection, graded physical activity, and brief coping strategies into routine care pathways has demonstrated both feasibility and clinical relevance. To mitigate the natural decline in SOC effects over time, low-intensity reinforcement - such as brief follow-up calls or remote check-ins - should be incorporated into post-discharge planning. For evaluation, the SOC-13 total score should be prioritized as the primary outcome measure, with complementary use of the HADS and the short-form PTGI-SF to support individualized care and program-level quality improvement. Taken together, these strategies and their positive evidence base provide a clear, actionable framework for systematically embedding SOC-based interventions into the continuum of geriatric orthopedic rehabilitation[13].

CLINICAL IMPLEMENTATION EXAMPLES AND WORKFLOWS

Clinical rationale and evidence base

Translating the SOC from theory into executable practice within orthogeriatric care pathways is supported by multiple layers of evidence. Among patients with hip fractures, higher SOC scores predict better rehabilitation adherence and greater gains in muscle strength, gait, and balance, indicating that SOC functions not merely as a psychological trait but is tightly coupled with daily rehabilitation behaviors[12]. Moreover, salutogenesis-based interventions incorporating multicomponent elements - such as health education, goal setting, and coping skills training - can significantly enhance SOC and concurrently improve psychological outcomes within approximately three months in older and chronically ill populations[13]. The high prevalence of fear of falling and depressive symptoms after hip fracture, both of which are associated with poor functional recovery, further underscores the necessity of perioperative SOC assessment and targeted intervention[2,3].

Touchpoint-anchored bedside workflows

In integrated orthogeriatric care pathways, we propose anchoring four routine contact points - admission, POD 1 and 2, early rehabilitation, and discharge education - as key opportunities to gradually embed the three dimensions of the SOC framework - comprehensibility, manageability, and meaningfulness - with minimal additional workload. At admission, nurses can enhance comprehensibility by using a concise one-page care timeline combined with the teach-back method to reinforce understanding. Evidence from the Your Care Needs You cluster RCT shows that fostering patient engagement during hospitalization improves discharge coordination and overall care experience[19]. During early postoperative rehabilitation, physical therapists can promote manageability through SMART goal-setting, graded walking and resistance training, and brief sessions of breathing exercises or pain re-evaluation. Physical activity interventions in frail older adults have been shown to strengthen SOC, with the greatest gains observed among those with initially low SOC levels[16]. Subsequently, psychologists or social workers can nurture meaningfulness through values clarification and brief narrative reframing. The SHAPE pilot RCT offers a feasible paradigm combining group sessions, home visits, and resource manuals to enhance patients’ perceived health resources and coping capacity[14]. In parallel, teach-back-based discharge communication and structured educational materials can further reduce information loss, improve adherence, and facilitate safer transitions of care.

Maintenance, evaluation, and scale-up

To sustain early gains, low-burden “light-touch” follow-ups - such as nurse-led phone calls or tele-rehabilitation contacts - should be scheduled within 6-12 weeks after discharge. The evaluation framework ought to remain “light yet rigorous”, prioritizing psychological proximal outcomes measured by the SOC-13 total score, complemented by the HADS and the short form of the PTGI-SF. In parallel, essential patient-centered endpoints - including time to first independent ambulation, length of hospital stay, and 90-day readmission or complication rates - should be continuously monitored. To ensure scalability and reproducibility, process indicators should be routinely collected within an implementation-science framework, covering acceptability, adoption, feasibility, fidelity, reach, staff time, and incremental cost. These data can be displayed using run charts to enable rapid-cycle learning and continuous improvement. As the pathway progresses toward large-scale implementation, adopting a cluster-randomized or stepped-wedge trial design will help strengthen causal inference and support evidence-based integration into standard care[28].

CLINICAL INTEGRATION AND FUTURE RESEARCH PRIORITIES

Integrated model and role delineation

A coherent way to integrate SOC principles into orthogeriatric care is to embed a small, scripted bundle across routine touchpoints - admission, POD 1 and 2, early physiotherapy, and discharge education - so that comprehensibility, manageability, and meaningfulness are addressed repeatedly and consistently. In practice, a nurse can lead one-page timelines and teach-back to strengthen comprehensibility; a physiotherapist can guide SMART goal-setting, graded activity, and brief pain-coping strategies to reinforce manageability; and a psychologist or social worker can facilitate values-based reframing and brief narrative work to cultivate meaningfulness[29,30]. Short scripts and checklists placed in the electronic health record (EHR) improve reliability and handoffs, while predefined escalation triggers (for example, clinically significant rises in HADS scores or delirium alerts) favor timely referral over passive “watchful waiting” (Table 2)[31,32]. This orthogeriatric-specific positioning - linking SOC explicitly to existing transition-of-care and physiotherapy guidance - clarifies what this article does, why it matters, and how it can be used, thus addressing a prevailing lacuna and marking our distinct contribution to routine hip-fracture pathways.

Table 2 Sense of coherence-informed micro-bundle embedded across orthogeriatric touchpoints.

Touchpoint	Primary aim [comprehensibility-manageability-meaningfulness (the three components of the Sense of Coherence framework)]	Responsible role(s)	Core actions/scripts	Escalation triggers	electronic health record documentation
Admission	Comprehensibility	Nurse	One-page care timeline; teach-back of expectations	High Hospital Anxiety and Depression Scale scores; delirium risk flags	Checklist completion; patient understanding recorded
Postoperative days 1 and 2	Manageability	Physiotherapist; nurse	Specific, measurable, achievable, relevant, and time-bound (framework for goal setting) goals; graded mobilization; brief pain-coping (breathing, reappraisal)	Uncontrolled pain; non-progress in mobilization	Daily goal tracking; barriers noted
Early physiotherapy	Manageability + meaningfulness	Physiotherapist; psych/social work	Progressive activity plan; values-based reframing; micro-acts	Low engagement; mood deterioration	Session notes with goal attainment scaling
Discharge education	Comprehensibility + meaningfulness	Nurse; psych/social work	Frequently asked questions sheet; warning signs; community resources; narrative “next steps”	Incomplete self-management plan	Discharge checklist; referrals logged

Psych/social work: Psychology or social work (clinical liaison roles within orthogeriatric care).

Operational integration

Operational integration (roles, time, and workflow). We specify a ward-level deployment that minimizes disruption to routine care. For a typical 20-bed orthogeriatric unit, we designate two role champions (one nurse, one physiotherapist) and a consult-liaison psychologist/social worker who is activated by predefined escalation triggers. The incremental time per patient is modest and embedded within existing encounters: (1) Admission orientation led by nursing (10 minutes) to strengthen comprehensibility; (2) POD 1 and 2 manageability micro-bundle during physical and occupational therapy (PT-OT) (12-15 minutes/day) covering SMART goals, graded mobilization, and a brief coping drill; (3) Early-rehab reinforcements appended to routine therapy (10-15 minutes, 3-5 times/week); and (4) A discharge consolidation jointly delivered by nurse + psychology or social work (clinical liaison roles within orthogeriatric care) (15 minutes) focusing on values, two micro-actions, and a 2-week home plan. Scripts and checklists are stored as EHR smart phrases/order-set notes to support reliability and handoffs, consistent with our earlier recommendation to place short scripts and escalation triggers in the record. Weekend/after-hours coverage relies on the nurse champion (teach-back + checklist), with deferred psych/social input at the next business day if escalation criteria are met. This operational plan concretizes the who/what/when already outlined and aligns with the touchpoint-role mapping in Table 2.

Evaluation framework and outcomes

Evaluation should remain light but disciplined. A core set comprising the SOC-13 total score, HADS, and a brief PTGI administered at admission, discharge, and 6-12 weeks can map proximal psychological change, while pragmatic clinical endpoints - time to first mobilization, length of stay (LOS), and 90-day readmissions or complications - anchor the program to patient-important outcomes. Ward-level run charts and simple before-after cycles support rapid learning; for stronger causal inference during scale-up, cluster or stepped-wedge roll-outs are preferable. Because multimorbidity, socioeconomic context, and habitual physical activity can confound both psychological and functional recovery, teams should stratify analyses or adjust accordingly and use these factors to tailor intervention intensity[33,34].

Temporal cadence and minimal dose

We specify a pragmatic schedule to enhance temporal clarity and reproducibility: (1) Day 0 (admission): One 10-minute SOC-oriented orientation by nursing staff using a one-page timeline and teach-back to strengthen comprehensibility; (2) POD 1 and 2: A 12-15-minute daily “manageability micro-bundle” embedded within routine PT/OT (SMART goals, graded ambulation or resistance, brief breathing/pain-reappraisal); (3) Days 3-7: 10-15-minute reinforcements appended to usual therapy 3-5 times/week; and (4) Discharge day: A 15-minute consolidation (values clarification + two prosocial “micro-actions” + a 2-week home plan with red-flag education and teach-back) to cultivate meaningfulness. Post-discharge, schedule light-touch contacts at weeks 2, 6, and 12 (5-7 minutes each; nurse-led phone/tele-rehab), with optional PT tele-check if gait goals are unmet. Outcome cadence: (1) Administer SOC-13 (total score), HADS, and PTGI-SF at admission (baseline), discharge, and 6-12 weeks; and (2) Record functional endpoints (time to first independent ambulation, LOS, 90-day readmission/complications) and summarize weekly on ward-level run charts. Escalation triggers include HADS subscale ≥ 11 or a ≥ 5-point drop in SOC-13 relative to baseline, prompting psychologist referral and an additional contact within 72 hours. This cadence aligns with our low-burden ethos while making the model temporally explicit and auditable.

Future research priorities

Near-term research should clarify mechanisms and optimize the package rather than merely reproducing aggregate effects. Mediation analyses can test whether early SOC gains drive subsequent improvements in mood and mobilization. Moderation work should examine effects in key subgroups - patients with multiple chronic conditions, low income, low baseline activity, or mild cognitive or sensory impairment - to inform equity-focused tailoring[35]. Component evaluation using factorial or SMART designs can compare “comprehensibility-only”, “manageability-only”, and full-bundle variants, identifying the smallest effective set that is feasible on busy wards. Durability studies need to calibrate the cadence and format of booster contacts (for example, brief nurse or physiotherapy tele-touches) to sustain SOC after discharge without overburdening staff or patients (Table 3)[36,37].

Table 3 Near-term research priorities and suggested study designs.

Question	Hypothesized mechanism/effect	Design archetype	Sample/setting	Primary outcome(s)	Notes
Mediation: Do early SOC gains drive later mood/mobilization	SOC (increase) transform into HADS (reduce) transform into earlier mobilization	Longitudinal cohort + mediation models	Orthogeriatric wards; n ≥ 300	Indirect effect (SOC transform into HADS transform into time to mobilization)	Adjust for multimorbidity/SES/activity
Moderation: Who benefits most	Effect sizes larger in low-SES, multimorbidity, low activity	Pre-specified subgroup analyses	Routine care registry or stepped-wedge cluster randomized trial	Interaction terms	Equity-focused tailoring
Component efficiency	Full bundle not always needed	Factorial or specific, measurable, achievable, relevant, and time-bound (framework for goal setting) trial	Busy wards; pragmatic recruitment	SOC-13 change; length of Stay	Identify minimal effective package
Durability and maintenance	Structured boosters sustain SOC gains	Adaptive follow-up schedule trial	Post-discharge tele-contacts	SOC-13 at 12-24 weeks	Balance burden vs benefit
Implementation and cost	Feasible at scale with fidelity	Hybrid effectiveness-implementation	Multi-site rollout	Reach, adoption, fidelity, time-motion costs	Inform scale-up decisions

HADS: Hospital Anxiety and Depression Scale; SES: Socioeconomic status; SOC: Sense of coherence; SOC-13: 13-item Sense of Coherence Scale.

Implementation outcomes and safety safeguards

Implementation outcomes deserve equal attention. Prospective capture of reach, adoption, fidelity, staff time, and incremental costs will determine whether the approach is scalable beyond early adopters. Safety safeguards should be explicit: Routine screening for major depression and delirium, coordination with falls-prevention protocols, and analgesia optimization reduce the risk that increased activity compromises safety or adherence[38-40].

Synthesis and call to action

Taken together, a multidimensional rehabilitation framework that operationalizes comprehensibility, manageability, and meaningfulness offer a practical bridge between surgical healing and psychological resilience. The observational signal for SOC, coupled with clear contextual modifiers, argues for orthogeriatric teams to pilot this integrated approach now - measuring what matters, learning iteratively, and building the evidence base for durable, scalable implementation.

Resource allocation, training, and scalability

Resource allocation, training, and scalability. We propose a minimal allocation that most wards can absorb: (1) Nurse champion approximately 0.10 full-time equivalent (FTE); (2) PT/OT champion approximately 0.10 FTE (combined); and (3) Psych/social liaison approximately 0.05 FTE, primarily for escalations. Materials are limited to a one-page timeline/frequently asked questions and a two-page quick-reference (embedded in the EHR). Training consists of a 60-minute in-service plus three observed sessions per role, after which 10% of encounters are audited weekly for fidelity (checklist completion, teach-back documented, goal attainment recorded), with feedback loops via ward run charts. To track feasibility and cost, we capture staff time and incremental costs alongside reach, adoption, and fidelity, as already recommended for implementation outcomes; a brief time-motion log integrated in the EHR note satisfies this requirement. For sites with limited psychology coverage, a nurse-led “tight variant” (education + goals + brief coping + discharge teach-back) is the default, with tele-psych consults for flagged cases. As adoption grows, rollout proceeds via plan-do-study-act cycles and, during scale-up, cluster or stepped-wedge designs to strengthen causal inference and inform resource decisions[41,42].

Statistical signal in orthogeriatric populations

Across orthogeriatric samples, low SOC is statistically associated with longer LOS and worse cognitive/functional indices soon after hip fracture (Swedish cohort; prospective 4-month follow-up)[43]. In secondary analyses of a 12-week randomized trial of progressive resistance training after hip fracture, SOC moderated rehabilitation response: Group-by-SOC interaction was significant for timed up-and-go (P = 0.005) and Berg Balance Scale (P = 0.040), and weaker SOC predicted poorer training adherence (P = 0.009) independent of adherence level[12]. Extending to major orthopedic procedures, low baseline SOC predicted impaired early quality-of-recovery after total hip/knee arthroplasty, supporting its value as a preoperative risk indicator and triage cue for targeted support[44]. Notably, intensive strength-power training did not change SOC over 12 weeks in a hip-fracture RCT, implying that SOC-oriented psycho-behavioral components (education, coping skills, values work) may be necessary alongside physical training to shift coherence itself[45]. Collectively, these statistics clarify where SOC sits in the recovery pathway (adherence and complex mobility) and why perioperative assessment plus brief, targeted interventions are warranted.

Analysis plan for ward-level evaluations

Forward-level evaluations, we recommend pre-post and cohort comparisons using multivariable models that adjust for key confounders (age, sex, pre-fracture function, comorbidity, baseline HADS, delirium risk). Primary proximal endpoint is SOC-13 total, with HADS and PTGI-SF as secondary proximal outcomes; patient-important endpoints include time to first independent ambulation, LOS, and 90-day readmission/complications. To clarify mechanisms, mediation analyses can test whether early adherence (e.g., therapy minutes attended, goal attainment) mediates SOC’s effect on mobilization/LOS (consistent with the adherence signal above); moderation by baseline SOC strata can be examined to identify high-yield subgroups. Implementation outcomes (acceptability, adoption, feasibility, fidelity, reach, staff time, incremental cost) should be routinely captured and displayed as run charts to enable rapid-cycle learning; for scale-up, cluster-randomized or stepped-wedge designs will strengthen causal inference. This plan is statistically modest yet decision-oriented and fits the low-burden ethos of orthogeriatric services[46].

CONCLUSION

Hip fracture recovery demands more than surgical fixation and early mobilization - it also requires restoring psychological coherence. Evidence synthesized herein underscores that a stronger SOC not only mitigates anxiety, depression, and fear of falling but also promotes adherence, mobilization, and PTG. Embedding the triad of comprehensibility, manageability, and meaningfulness within standard orthogeriatric workflows - through brief education, graded goals, and values-based reflection - offers a low-burden, scalable means to bridge psychological and physical rehabilitation. The proposed micro-intervention bundles and light-touch evaluation framework make SOC enhancement both feasible and auditable within real-world wards. Moving forward, integrating SOC-informed practices into perioperative care pathways represents a pragmatic step toward holistic recovery - one that measures what matters, empowers resilience, and reconnects patients to life beyond fracture.