Coordinated multidisciplinary rehabilitation after hip fracture

PURPOSE: To review the topic of coordinated multidisciplinary rehabilitation after hip fracture from a research perspective and to provide information to guide the provision of rehabilitation services for patients with hip fracture. METHODS: Literature review including searches of Medline, Embase, Cochrane Collaboration and evidence based clinical guidelines, checking of references of publications and consultation with researchers. RESULTS: The research evidence is heterogeneous and remains inclusive. Programs that assist patients with hip fracture to regain function and return home as soon as feasible are likely to be effective as they appear to increase the percentage of patients who return home and remain there after hip fracture. Rehabilitation programs that achieve this are likely to be cost effective. These programs involve health professionals from multiple disciplines (nurses, allied health professionals and medical practitioners) who work collaboratively, may operate in several settings, and routinely provide specific treatments that are supported by strong evidence of effectiveness. CONCLUSIONS: Patients with hip fracture should be offered a coordinated a multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements.     

Coordinated multidisciplinary rehabilitation after hip fracture

Purpose: To review the topic of coordinated multidisciplinary rehabilitation after hip fracture from a research perspective and to provide information to guide the provision of rehabilitation services for patients with hip fracture.

Methods: Literature review including searches of Medline, Embase, Cochrane Collaboration and evidence based clinical guidelines, checking of references of publications and consultation with researchers.

Results: The research evidence is heterogeneous and remains inclusive. Programs that assist patients with hip fracture to regain function and return home as soon as feasible are likely to be effective as they appear to increase the percentage of patients who return home and remain there after hip fracture. Rehabilitation programs that achieve this are likely to be cost effective. These programs involve health professionals from multiple disciplines (nurses, allied health professionals and medical practitioners) who work collaboratively, may operate in several settings, and routinely provide specific treatments that are supported by strong evidence of effectiveness.

Conclusions: Patients with hip fracture should be offered a coordinated a multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements.     

Costs and consequences of hip fracture occurrence in old age: An economic perspective

Purpose: To summarize the reported short- and long-term costs associated with hip fracture occurrence in old age, based on a systematic literature review of published studies. A further aim is to provide a clinician-oriented discussion of the different types of economic evaluations, with an emphasis on studies that examined potential determinants of the costs of care after hip fracture.

Method: Literature review.

Main results: Even after the initial hospitalization, hip fractures continue to generate significant costs throughout the one-year period after discharge, but particularly during the first three months. Cost estimates based on data obtained prospectively from hip-fracture patients and matched controls showed that the costs associated with the treatment of hip-fracture patients are about three times greater than those resulting from the treatment of age and residence-matched controls without a fracture. Two-fifths of these excess costs are incurred during the first three months following hospital discharge. Increasing age at the time of injury and living in an institution before the fracture are among the most important determinants of an increased cost of care after hospital discharge. Programs that focus on continuity of care, adopt a multidisciplinary approach, and accelerate rehabilitation have shown to be able to reduce the cost of care after hip fracture.

Conclusions: This review emphasizes the importance of current and future interventions to decrease the incidence of hip fracture. While the current review cannot provide definite answers to the questions of cost containment, our review provides critically important evidence about the need to base health policy decisions on empirical observations. Comprehensive economic analyses of financial costs and health outcomes are needed to develop cost-effective strategies.     

Predicting the success of rehabilitation following hip fractures

Purpose: To review what predictors are of positive or negative value in the rehabilitation procedure following hip fractures.

Method: Reviewing a doctorial thesis on prognosis and rehabilitation of elderly with a hip fracture from 1980 and then review the literature on this subject for the following quarter of a century.

Results: In the Western world the short-term prognosis for early return home after sustaining a hip fracture depends on the success of the operation allowing independent walking and basic activities of daily life, no debilitating disease and having someone at home. The one-year prognosis for having returned and remained at home requires a reasonable good health irrespective of living alone and a somewhat deteriorated hip function.

Conclusions: It is difficult to make comparisons with studies of other populations and other time periods. Different predictors of the rehabilitation are used and the definitions of these are not always the same. They are of varying weight, can change with time and may be interdependent of each other. For example, general medical condition and age are strongly interrelated predictors but age alone is less important than concomitant disease for the success of the rehabilitation. Nevertheless, already on admission of a patient with a fresh hip fracture a reliable prognosis can be done. However, such a prediction must be guided by ethical, social and scientific concerns.     

The impact of psychological factors in recovery following surgery for hip fracture

Purpose. To increase awareness of psychological factors in recovery from hip fracture and to describe strategies that can be used to help patients in the process of recovery.

Method and results. Psychological theory, case examples and clinical observation are used to propose three frameworks for understanding the psychological factors which can impede recovery. Indication of key strategies for assessment and intervention which can be used in rehabilitation services is provided.

Conclusions. An understanding of the psychological factors which can impede recovery in hip fracture is important for all professionals involved in rehabilitation. Psychologists can provide consultation and support for staff working in physical rehabilitation and can work directly with cases where there is complexity. There is still relatively little known about this important area and further research is needed to provide a clear evidence base.     

Clinical pathway after hip fracture

Purpose: Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

Method: The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

Results: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

Conclusion: This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.     

Audit, guidelines and standards: Clinical governance for hip fracture care in Scotland

Purpose: To report on experience of national-level audit, guidelines and standards for hip fracture care in Scotland.

Methods: Scottish Hip Fracture Audit (from 1993) documents case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care are available (1997, updated 2002). Hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004.

Results: Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A&E care, pre-operative delay, multidisciplinary care and audit participation are met

Conclusion: Three national-level initiatives on hip fracture care have delivered: Reliable and large-scale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance, with casemix-adjusted outcome assessment for hip fracture care as a next step.     

Scoring systems to evaluate elderly patients with hip fractures

Purpose: To report about different scales and scoring systems used to evaluate elderly patient with hip fracture during the acute post-fracture phase and during post-operative rehabilitation.

Methods and results: Report of the different scales from a literature review.

Conclusions: Standard validated scales are one of the tools to perform such an evaluation process as objectively as possible and to evaluate surgical, medical and rehabilitative management in these elderly patients. These scales are only a complementary tool, and they cannot replace physical examination. However, these validated tools are probably more accurate than just clinical impression. The appropriate combination of clinical experience and these scales may well contribute to a better care of elderly patients with hip fractures.     

Cemented versus uncemented hip replacement for fracture of the hip

Purpose: Review cemented versus uncemented hemi-arthroplasty hip replacement regarding morbidity and long term results.

Methods: A literature review searching PubMed and Medline was done. Publications applicable to hip fractures treated by hip replacement or hemi-arthroplasty replacement were reviewed.

Results: Several articles compared cemented femoral stems to fracture fixation. There were few articles comparing cemented and uncemented stems. Some noted increased problems with uncemented stems but did consider design factors. Unreamed tapered stems may have may have fewer problems

Conclusions: Prospective studies comparing cemented and uncemented femoral stems are needed to determine the best form of fixation for patients having hip surgery following hip fracture. Tapered uncemented stems may offer as good a result as cemented stems, with less morbidity.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose. To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method. One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results. The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions. Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

Late multidisciplinary rehabilitation in young people after stroke

Purpose: Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population.

Method: Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge.

Results: All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-item Short Form with four domains returning to levels seen in the general population.

Conclusions: This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.     

Predictors for successful vocational rehabilitation for clients with back pain problems

Purpose. The aim of this study was to identify predicting factors for successful vocational rehabilitation for people with back pain problems.

Method. The study was based on data from 347 long-term sick-listed clients collected at the onset of vocational rehabilitation. The outcome was measured 6 months after the conclusion of rehabilitation.

Results. In a first bi-variate analysis, a considerable number of variables were associated with the rehabilitation outcome. In a second multivariate analysis, only four associations remained. These were age, general health, vitality and internal locus of control. Young vital clients in good general health, with a high internal locus of control were more likely than others to return to work.

Conclusion. The findings regarding age, general health and vitality are well in line with previous studies. The findings regarding internal locus of control are more unique.     

Rehabilitation following hip fracture surgery: a comparative study of females and males

Purpose: To compare patient, fracture and rehabilitation variables between male and female patients during the rehabilitation period immediately following surgical repair of hip fracture (HF).

Methods: A prospective cohort study was conducted in a rehabilitation geriatric ward in a tertiary university hospital in southern Israel. The study group consisted of 808 elderly patients, 65 years of age or older, selected for hospitalized rehabilitation following surgery for HF. The measurements included functional studies by the Functional Independence Measure (FIM™) scale, mental status by Folstein Minimental Test and Clock Drawing Test, Geriatric Depression Screening Scale (GDS), demographic and social parameters, laboratory tests, length of rehabilitation, complications and mortality during rehabilitation.

Results: Six hundred and fourteen patients (76%) were women and 194 (24%) were men. The mean age ( ± SD) of the women was 78.4 ± 7.1 years and of the men was 77.8 ± 7.5 (NS). There were no significant differences between women and men in terms of the anatomic site of the fracture or the type of surgery, the complication rate or mortality during rehabilitation, the length of time needed for rehabilitation, the framework to which the patient was discharged, FIM values before the HF, on admission and at the end of rehabilitation, or the difference between FIM scores at these last two points in time.

Conclusions: In selected elderly patients with HF gender does not affect variables associated with hip fracture, the rehabilitation process immediately following the fracture, or the results of rehabilitation.     

Disability prevention and communication among workers, physicians, employers, and insurers--current models and opportunities for improvement

Purpose: To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

Method: Review of selected articles.

Results: Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

Conclusion: Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.     

Developing world rehabilitation strategy II: Flex the muscles, train the brain, and adapt to the impairment

Purpose. To understand some reasons behind the lack of medical rehabilitation resources in developing regions and to propose some actions that can change this problem.

Methods. Focused Medline literature review on AIDS disability in Africa. Editorial observation.

Results. Disability, rather than death or cost of treatment, is likely the greatest burden from AIDS. However only 0.05% of published research on AIDS in Africa relates to disability, so we cannot know this with certainty. This is a direct result of funding priorities, and a consequence of both traditional epidemiological methods and old-line 'cure or die' medical education. The disproportionate lack of medical rehabilitation specialists and facilities is a consequence of the same forces. Similar patterns are seen in rural and developing regions around the world.

Conclusions. Rehabilitation professionals must change healthcare service by using rehabilitation techniques: flexing muscle by insisting that governments, agencies, and philanthropists look at the cost of disability, not just disease; training the brains of young professionals who will practice, research and advocate locally; adapting intervention strategies to the impairments imposed by poverty and distance.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Reliability and construct validity of the client-centred rehabilitation questionnaire

Purpose. A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes.

Method. Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1568 patients discharged from two large inpatient rehabilitation facilities.

Results. The seven conceptually derived subscales all have strong internal (0.72 - 0.87) and test-retest reliability (0.74 - 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities.

Conclusions. The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.     

Reading to stroke unit patients: perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.     

Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: a systematic review

Purpose. A systematic review was conducted to evaluate the effectiveness of workplace rehabilitation interventions for injured workers with low back pain (LBP).

Method. MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and AMED (Allied and Complementary Medicine) were searched from 1982 to 2005 for peer-reviewed studies of rehabilitation interventions that were provided at the workplace to workers with musculoskeletal work-related LBP. Methodological quality appraisal and data extraction were conducted by five reviewers.

Results. Of a total of 1,224 articles that were identified by the search, 15 articles, consisting of 10 studies, were of sufficient quality to be included in the review. The best evidence was that clinical interventions with occupational interventions as well as early return to work/modified work interventions were effective in returning workers to work faster, reducing pain and disability, and decreasing the rate of back injuries. Ergonomic interventions also were found to be effective workplace interventions.

Conclusion. The need for further research in this area is necessary to reduce the burden of back pain on employees and their families, employers, and the health care system.