Rehabilitation after orthopaedic major trauma

Jacqueline Claydon February 2014Clinical Research Associate awarded by CLRN 2013

Orthopaedic Trauma Rehab Clinic

To use the rehabilitation prescription to improve patient care

Pilot: May – November 2013◦ n=143, mean 5.0 months

Physiotherapy-led consultation◦ Subjective and clinical assessment of all injuries◦ Reassess Rehabilitation Prescription◦ Set Rehabilitation Goals

Refer to clinical and rehabilitation services

Qualitative Research◦ Patient perception of recovery and rehabilitation after orthopaedic major trauma, n=15

Harry’s story

Background

Male, 63, working Fall from a height Major Trauma bypass

0

10

20

30

40

16 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 +

9 1010

18 20

11 1110

11 9 1117 17

13 13 10Perc

enta

ge, %

Age, years

Non-ortho Ortho

28

18

55RetiredNot work preWorking

Work Status % (Ortho)

Age distribution, %

Want to go back to work, I’ve

worked all my life

Mechanism

Motorbikes: 14%

Fall from height: 22%

Slips, trips and falls: 30% Sports: 6%

Road accident: 15%

Bike: 4%

Assault: 1%

Industrial: 1%

Pedestrian: 8%

Harry’s injuries

Clinical database, n=692

Orthopaedic: ◦ Pilon fracture ankle

Spanning ex-fix; ORIF Non weight-bearing 3 months

◦ T12 wedge fracture: conservative

ISS 13 ◦ Level 1 All 42% (Ortho 26%)◦ Level 2 All 34% (Ortho 11%)

Ortho48%Neuro

26%

Spines17%

Rehabilitation PrescriptionsOrtho

General

Burns

Neuro

Other

Max Fax

Plastics

Resp

SCI

Spines

ISS does not reflect functional limitations

Inpatient Rehabilitation Needs

n=143

Initial

Mobility 97%

IADL 79%

Wound management 73%

Pain 95%

Environment 50%

Vocation/Education 21%

Urinary incontinence 14%

Nutrition 7%

Ventilator / Pulm rehab 2%

Mood 4%

Other

Upper limb function 6%

Falls/balance 1%

Sports / hobbies 1%

◦ Physiotherapy◦ OT◦ Nurse◦ Orthopaedics◦ Pain team

Rehabilitation Prescription

They were so good

everybody, right through, the

doctors as well

Discharge home with equipment and carer support ◦ 7 days after injury

Minimal mobility◦ Non weightbearing, zimmer frame

Fracture clinic follow up◦ Physio referral when weightbearing status changes

Trauma Rehab clinic

Discharge planning

Rehabilitation Reality

Environmental issues◦ Not able to manage in own home

Partner’s bungalow◦ Stuck in the house

Wheelchair from the red cross

Fracture complications◦ Osteopenia:

Referred for urgent physio to commence weightbearing

Accessing physiotherapy Geographic issues

Not accept referral from MTC Different health authority than usual

residence (although he pays his Council Tax there)

No capacity for urgent referrals

we rang the Red Cross, and uh, they said yes, and that’s the best, it was twenty pound to hire it, and that’s the best twenty pound I

ever, ever spent

If you hadn’t rung that day and stepped in, I still mightn’t be

getting physio

“…. It got us really down, you know. Got us really down. I know I need physio, why can’t I have it?

…..and I felt is it because I’ve got a Hospital C consultant and Hospital O won’t look after us ….”

I just thought, why

can’t everybody

get together

South Tyneside: 4%

Sunderland: 5%

Cumbria: 5%

Gateshead: 5%

Northumberland: 19%

NUTH: 47%

County Durham and Darlington: 11%

Geographic distribution

Increase at review Rehabilitation needs change with time

Initial Review

Mobility 97% 60%

IADL 79% 30%

Wound management 73% 6%

Pain 95% 27%

Environment 50% 4%

Vocation/Education 21% 26%

Urinary incontinence 14% 2%

Nutrition 7% 3%

Ventilator / Pulm rehab 2% 8%

Mood 4% 22%

Other

Upper limb function 6% 16%

Falls/ balance 1% 6%

Driving 0 21%

Financial difficulties 0 5%

Sports / hobbies 1% 4%

Rehabilitation prescription review

Outpatient and community teams◦Orthopaedics◦Physiotherapy◦ Access to

Pain team Health psychology OT

Trauma Rehab clinic

Identified unmet rehabilitation needs

None23%

Not yet6%

Unmet 49%

Current22%

Referrals made ◦ Physiotherapy 36◦ Health psychology 18◦ Orthopaedics 8◦ Other 21

Falls, exercise prescription, pulmonary rehab, pain management

Trauma Rehab Clinic

Rehabilitation needs change with time

Rehabilitation needs change with time ◦ Trauma rehab clinic effectively identifies

current multidisciplinary needs

Improved co-ordination and communication between existing services◦ Virtual team

Raised awareness: inequalities of rehabilitation provision

I felt like I was being treated as a person

No-one had set any goals, think it will help me move forward

I was surprised I’d not been

seen

Newcastle Clinical AHP group◦ Improving co-ordination and communication between local teams

Regional AHP clinical conference◦ Clinical skills◦ Start to build regional network

Research: patient perceptions of recovery and rehabilitation after orthopaedic major trauma◦ Data analysis completion May 2014

What’s next…

I’ve got to be honest. I didn’t think it

would take as long. You think you’re like, I’ll be back in work in

four or five weeks. It’s hard to grasp

“Changed me outlook on life. Live for tomorrow, ‘cause you never know what’s going to happen” Harry, 2013

Major Trauma Rehabilitation

Rehabilitation Prescription