RESUMO
BACKGROUND: A high proportion of patients do not regain outdoor mobility after hip fracture. Rehabilitation explicitly targeting outdoor mobility is needed to enable these older adults to recover activities which they value most. The overarching aim of this study is to determine the feasibility of a randomised controlled trial which aims to assess the clinical- and cost-effectiveness of an intervention designed to enable recovery of outdoor mobility among older adults after hip fracture (the OUTDOOR intervention). METHODS: This is a protocol for a multi-centre pragmatic parallel group (allocation ratio 1:1) randomised controlled assessor-blinded feasibility trial. Adults aged 60 years or more, admitted to hospital from- and planned discharge to- home, with self-reported outdoor mobility in the three-months pre-fracture, surgically treated for hip fracture, and who are able to consent and participate, are eligible. Individuals who require two or more people to support mobility on discharge will be excluded. Screening and consent (or consent to contact) will take place in hospital. Baseline assessment and randomisation will follow discharge from hospital. Participants will then receive usual care (delivered by physiotherapy, occupational therapy, or therapy assistants), or usual care plus the OUTDOOR intervention. The OUTDOOR intervention includes a goal-orientated outdoor mobility programme (supported by up to six in-person visits), therapist-led motivational dialogue (supported by up to four telephone calls), supported by a past-patient led video where recovery experiences are shared, and support to transition to independent ongoing recovery. Therapists delivering the OUTDOOR intervention (distinct from those supporting usual care) will receive training in motivational interviewing and behaviour change techniques. Baseline demographics will be collected. Patient reported outcome measures including health related quality of life, activities of daily living, pain, community mobility, falls related self-efficacy, resource use, readmissions, and mortality will be collected at baseline, 6-weeks, 12-weeks, and 6-months (for those enrolled early in the trial) post-randomisation. Exercise adherence (6- and 12- weeks) and intervention acceptability (12-weeks) will be collected. A subset of 20 participants will also support accelerometery data collection for 10 days at each time point. DISSEMINATION: The trial findings will be disseminated to patients and the public, health professionals and researchers through publications, presentations and social media channels. TRIAL REGISTRATION: The trial has been registered at ISRCTN16147125. PROTOCOL VERSION: 3.0.
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Estudos de Viabilidade , Fraturas do Quadril , Humanos , Fraturas do Quadril/reabilitação , Fraturas do Quadril/cirurgia , Idoso , Feminino , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Atividades Cotidianas , Idoso de 80 Anos ou maisRESUMO
PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.
Assuntos
Fraturas do Quadril , Tempo de Internação , Alta do Paciente , Modalidades de Fisioterapia , Humanos , Feminino , Masculino , Fraturas do Quadril/cirurgia , Fraturas do Quadril/reabilitação , Idoso , Idoso de 80 Anos ou mais , Alta do Paciente/tendências , Modalidades de Fisioterapia/tendências , Estudos de Coortes , Tempo de Internação/tendências , Tempo de Internação/estatística & dados numéricos , Austrália/epidemiologia , Pessoa de Meia-Idade , Nova Zelândia/epidemiologiaRESUMO
OBJECTIVE: To explore the practice of prescribing and implementing early mobilisation and weight-bearing as tolerated after hip fracture surgery in older adults and identify barriers and facilitators to their implementation. METHODS: Semi-structured interviews were conducted with 20 healthcare providers (10 orthopaedic surgeons and 10 physiotherapists) from Saudi Arabian government hospitals. Data were analysed using inductive thematic analysis. RESULTS: While early mobilisation and weight-bearing as tolerated were viewed as important by most participants, they highlighted barriers to the implementation of these practices. Most participants advocated for mobility within 48 h of surgery, aligning with international guidance; however, the implementation of weight-bearing as tolerated was varied. Some participants stressed the type of surgery undertaken as a key factor in weight-bearing prescription. For others, local protocols or clinician preference was seen as most important, the latter partially influenced by where they were trained. Interdisciplinary collaboration between orthopaedic surgeons and physiotherapists was seen as a crucial part of postoperative care and weight-bearing. Patient and family member buy-in was also noted as a key factor, as fear of further injury can impact a patient's adherence to weight-bearing prescriptions. Participants noted a lack of standardised postoperative protocols and the need for routine patient audits to better understand current practices and outcomes. CONCLUSION: This study contributes to national and global discussions on the prescription of early mobilisation and weight-bearing as tolerated. It highlights the necessity for a harmonised approach, incorporating standardised, evidence-based protocols with patient-specific care, robust healthcare governance and routine audits and monitoring for quality assurance and better patient outcomes.
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Deambulação Precoce , Fraturas do Quadril , Humanos , Idoso , Arábia Saudita , Fraturas do Quadril/cirurgia , Pesquisa Qualitativa , Cuidados Pós-OperatóriosRESUMO
OBJECTIVE: To determine the association between the extent of mobilisation within the first postoperative day and 30-day mortality after hip fracture. DESIGN: Cohort study. SETTING: Acute orthopaedic hospital ward. PARTICIPANTS: Consecutive sample of 701 patients, 65 years of age or older, 80% from own home, 49% with a trochanteric fracture, and 61% with an American Society of Anesthesiology grade > 2. INTERVENTION: n/a. MAIN MEASURES: Cumulated ambulation score (CAS) (0-6 points) on the first postoperative day and 30-day postoperative mortality. A CAS = 0 reflects no functional mobility (bedridden), while a CAS = 6 reflects independent out-of-bed-transfer, chair-stand, and indoor walking status. RESULTS: Overall, 86% of patients were mobilised to standing or seated in chair (CAS ≥ 1) on the first postoperative day. A CAS of 0, 1-3, and 4-6 was observed for 97 (14%), 519 (74%), and 85 (12%) patients, respectively. Overall, 61 (8.7%) patients died within 30 days with the highest mortality (23.7%, n = 23) seen for those not mobilised (CAS = 0). Only one patient (1.2%) with a CAS of 4-6 points died. Cox regression analysis adjusted for age, sex, residential status, pre-fracture CAS, fracture type, and American Society of Anesthesiology grade, showed that a one-unit increase in CAS was associated with a 38% lower risk of 30-day mortality (Hazard Ratio = 0.63, 95%Confidence Interval, 0.50-0.78). CONCLUSION: Mobility on the first postoperative day was associated with 30-day postoperative mortality, with a lower risk observed for those completing greater mobility. National registries may consider extending collection of mobility on the first postoperative day from a binary indicator to the CAS which captures the extent of mobility achieved.
Assuntos
Deambulação Precoce , Fraturas do Quadril , Humanos , Fraturas do Quadril/cirurgia , Fraturas do Quadril/reabilitação , Fraturas do Quadril/mortalidade , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Fatores de Tempo , Período Pós-OperatórioRESUMO
PURPOSE: To investigate factors contributing to concerns about falling and activity restriction in the community among older adults who had a hip fracture. METHODS: A mixed method systematic review with a convergent segregated approach. We searched Medline, Embase, PsycInfo, PEDRo, CINAHL and the Cochrane library. Results were synthesised narratively considering physical, psychological, environmental, care, and social factors and presented in tables. Critical appraisal was completed in duplicate. RESULTS: We included 19 studies (9 qualitative, 9 observational, 1 mixed methods) representing 1480 individuals and 23 factors related to concerns about falling and activity restriction. Physical factors included falls history, comorbidities, balance, strength, mobility and functionality. Psychological factors included anxiety and neuroticism scores, perceived confidence in/control over rehabilitation and abilities, and negative/positive affect about the orthopaedic trauma, pre-fracture abilities and future needs. Environmental factors included accessibility in the home, outdoors and with transport. Social and care factors related to the presence or absence of formal and informal networks, which reduced concerns and promoted activity by providing feedback, advice, encouragement, and practical support. CONCLUSION: These findings highlight that to improve concerns about falling and activity restriction after hip fracture, it is important to: improve physical and functional abilities; boost self-confidence; promote positive affect; involve relatives and carers; increase access to clinicians, and; enhance accessibility of the home, outdoors and transport. Most factors were reported on by a small number of studies of varying quality and require replication in future research.
Assuntos
Acidentes por Quedas , Fraturas do Quadril , Humanos , Fraturas do Quadril/psicologia , Idoso , Atividades Cotidianas , Feminino , Idoso de 80 Anos ou mais , Equilíbrio Postural , MasculinoRESUMO
Every year there are 1.3 million hip fractures globally; this is expected to rise to 6 million by 2050. Estimates of global cost is 1.75 million disability adjusted life years, and in established market economies, costs associated with hip fracture represent 1.4% of the total healthcare burden. New models of care will be required to meet this demand. Advance physiotherapy roles in elective arthroplasty across global settings have demonstrated benefit in safely reducing time burden on surgical teams and healthcare costs. The utility of similar roles in the care of hip fracture is unclear. This quality initiative (2020-2023) aimed to implement and evaluate a new model of care substituting a surgical registrar with an advanced physiotherapist in a post-discharge hip fracture clinic. Across many nonlinear, action/reflection cycles, a multi-disciplinary team engaged to operationalize key implementation strategies, mapped to the Expert Recommendations for Implementing Change (ERIC) project. Across the reporting period, 346 patients were seen by an advanced physiotherapist. Eighty-one patients seen by an advanced physiotherapist required informal discussion with the consultant surgeon. Fifteen patients required a formal consultant review. There were no patient complaints, critical incidents or other unintended consequences. The net surgical time realized over the three years was 110 hours.
Assuntos
Fraturas do Quadril , Alta do Paciente , Humanos , Pacientes Ambulatoriais , Assistência ao Convalescente , Fraturas do Quadril/cirurgia , Modalidades de FisioterapiaRESUMO
PURPOSE: to investigate physiotherapists' perspectives of effective community provision following hip fracture. METHODS: qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented. RESULTS: four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented. CONCLUSION: physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.
Assuntos
Fraturas do Quadril , Fisioterapeutas , Humanos , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/terapia , Inglaterra , Londres , Pesquisa QualitativaRESUMO
PURPOSE: To examine the association between physiotherapy access after hip fracture and discharge home, readmission, survival, and mobility recovery. METHODS: A 2017 Physiotherapy Hip Fracture Sprint Audit was linked to hospital records for 5383 patients. Logistic regression was used to estimate the association between physiotherapy access in the first postoperative week and discharge home, 30-day readmission post-discharge, 30-day survival and 120-days mobility recovery post-admission adjusted for age, sex, American Society of Anesthesiology grade, Hospital Frailty Risk Score and prefracture mobility/residence. RESULTS: Overall, 73% were female and 40% had high frailty risk. Patients who received ≥2 hours of physiotherapy (versus less) had 3% (95% Confidence Interval: 0-6%), 4% (2-6%), and 6% (1-11%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 3% (0-6%) lower adjusted probability of readmission. Recipients of exercise (versus mobilisation alone) had 6% (1-12%), 3% (0-7%), and 11% (3-18%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 6% (2-10%) lower adjusted probability of readmission. Recipients of 6-7 days physiotherapy (versus 0-2 days) had 8% (5-11%) higher adjusted probability of survival. For patients with dementia, improved probability of survival, discharge home, readmission and indoor mobility recovery were observed with greater physiotherapy access. CONCLUSION: Greater access to physiotherapy was associated with a higher probability of positive outcomes. For every 100 patients, greater access could equate to an additional eight patients surviving to 30-days and six avoiding 30-day readmission. The findings suggest a potential benefit in terms of home discharge and outdoor mobility recovery. CONTRIBUTION OF THE PAPER.
Assuntos
Fragilidade , Fraturas do Quadril , Humanos , Feminino , Estados Unidos , Masculino , Alta do Paciente , Readmissão do Paciente , Assistência ao Convalescente , Fraturas do Quadril/cirurgia , Modalidades de FisioterapiaRESUMO
BACKGROUND: Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. OBJECTIVES: To assess the effects of case management for integrated care of older people living with frailty compared with usual care. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. DATA COLLECTION AND ANALYSIS: We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. ⢠Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) ⢠Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) ⢠Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) ⢠Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) ⢠Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. ⢠Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) ⢠Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. AUTHORS' CONCLUSIONS: We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.
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Prestação Integrada de Cuidados de Saúde , Fragilidade , Idoso , Humanos , Administração de Caso , Fragilidade/terapia , Pessoal de Saúde , HospitalizaçãoRESUMO
OBJECTIVES: To synthesize evidence for (1) the effectiveness of exercise-based rehabilitation interventions in the community and/or at home after transfemoral and transtibial amputation on pain, physical function, and quality of life and (2) the extent of inequities (unfair, avoidable differences in health) in access to identified interventions. DATA SOURCES: Embase, MEDLINE, PEDro, Cinahl, Global Health, PsycINFO, OpenGrey, and ClinicalTrials.gov were systematically searched from inception to August 12, 2021, for published, unpublished, and registered ongoing randomized controlled trials. STUDY SELECTION: Three review authors completed screening and quality appraisal in Covidence using the Cochrane Risk of Bias Tool. Included were randomized controlled trials of exercise-based rehabilitation interventions based in the community or at home for adults with transfemoral or transtibial amputation that assessed effectiveness on pain, physical function, or quality of life. DATA EXTRACTION: Effectiveness data were extracted to templates defined a priori and the PROGRESS-Plus framework was used for equity factors. DATA SYNTHESIS: Eight completed trials of low to moderate quality, 2 trial protocols, and 3 registered ongoing trials (351 participants across trials) were identified. Interventions included cognitive behavioral therapy, education, and video games, combined with exercise. There was heterogeneity in the mode of exercise as well as outcome measures employed. Intervention effects on pain, physical function, and quality of life were inconsistent. Intervention intensity, time of delivery, and degree of supervision influenced reported effectiveness. Overall, 423 potential participants were inequitably excluded from identified trials (65%), limiting the generalizability of interventions to the underlying population. CONCLUSIONS: Interventions that were tailored, supervised, of higher intensity, and not in the immediate postacute phase showed greater promise for improving specific physical function outcomes. Future trials should explore these effects further and employ more inclusive eligibility to optimize any future implementation.
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Terapia por Exercício , Qualidade de Vida , Adulto , Humanos , Terapia por Exercício/métodos , Dor , Amputação Cirúrgica , Extremidade Inferior/cirurgia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: To develop and validate the stratify-hip algorithm (multivariable prediction models to predict those at low, medium, and high risk across in-hospital death, 30-day death, and residence change after hip fracture). METHODS: Multivariable Fine-Gray and logistic regression of audit data linked to hospital records for older adults surgically treated for hip fracture in England/Wales 2011-14 (development n = 170 411) and 2015-16 (external validation, n = 90 102). Outcomes included time to in-hospital death, death at 30 days, and time to residence change. Predictors included age, sex, pre-fracture mobility, dementia, and pre-fracture residence (not for residence change). Model assumptions, performance, and sensitivity to missingness were assessed. Models were incorporated into the stratify-hip algorithm assigning patients to overall low (low risk across outcomes), medium (low death risk, medium/high risk of residence change), or high (high risk of in-hospital death, high/medium risk of 30-day death) risk. RESULTS: For complete-case analysis, 6 780 of 141 158 patients (4.8%) died in-hospital, 8 693 of 149 258 patients (5.8%) died by 30 days, and 4 461 of 119 420 patients (3.7%) had residence change. Models demonstrated acceptable calibration (observed:expected ratio 0.90, 0.99, and 0.94), and discrimination (area under curve 73.1, 71.1, and 71.5; Brier score 5.7, 5.3, and 5.6) for in-hospital death, 30-day death, and residence change, respectively. Overall, 31%, 28%, and 41% of patients were assigned to overall low, medium, and high risk. External validation and missing data analyses elicited similar findings. The algorithm is available at https://stratifyhip.co.uk. CONCLUSIONS: The current study developed and validated the stratify-hip algorithm as a new tool to risk stratify patients after hip fracture.
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Fraturas do Quadril , Humanos , Idoso , Mortalidade Hospitalar , Fraturas do Quadril/cirurgia , Algoritmos , Inglaterra/epidemiologiaRESUMO
OBJECTIVE: To understand multidisciplinary team healthcare professionals' perceptions of current and optimal provision of acute rehabilitation, perceived facilitators and barriers to implementation, and their implications for patient recovery, using hip fracture as an example. METHODS: A qualitative design was adopted using semi-structured telephone interviews with 20 members of the acute multidisciplinary healthcare team (occupational therapists, physiotherapists, physicians, nurses) working on orthopaedic wards at 15 different hospitals across the UK. Interviews were audio-recorded, transcribed verbatim, anonymised, and then thematically analysed drawing on the Theoretical Domains Framework to enhance our understanding of the findings. RESULTS: We identified four themes: conceptualising a model of rehabilitative practice, which reflected the perceived variability of rehabilitation models, along with facilitators and common patient and organisational barriers for optimal rehabilitation; competing professional and organisational goals, which highlighted the reported incompatibility between organisational goals and person-centred care shaping rehabilitation practices, particularly for more vulnerable patients; engaging teams in collaborative practice, which related to the expressed need to work well with all members of the multidisciplinary team to achieve the same person-centred goals and share rehabilitation practices; and engaging patients and their carers, highlighting the importance of their involvement to achieve a holistic and collaborative approach to rehabilitation in the acute setting. Barriers and facilitators within themes were underpinned by the lack or presence of adequate ways of communicating with patients, carers, and multidisciplinary team members; resources (e.g. equipment, staffing, group classes), and support from people in leadership positions such as management and senior staff. CONCLUSIONS: Cornerstones of optimal acute rehabilitation are effective communication and collaborative practices between the multidisciplinary team, patients and carers. Supportive management and leadership are central to optimise these processes. Organisational constraints are the most commonly perceived barrier to delivering effective rehabilitation in hospital settings, which exacerbate silo working and limited patient engagement.
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Fisioterapeutas , Humanos , Pesquisa Qualitativa , Atenção à Saúde , Equipe de Assistência ao Paciente , Reino UnidoRESUMO
OBJECTIVE: To determine the effectiveness of community-based rehabilitation interventions which incorporate outdoor mobility on physical activity, endurance, outdoor mobility and falls-related self-efficacy in older adults. DESIGN: MEDLINE, Embase, CINAHL, PEDro and OpenGrey were searched systematically from inception to June 2021 for randomised controlled trials (RCTs) of community-based rehabilitation incorporating outdoor mobility on physical activity, endurance, outdoor mobility and/or falls-related self-efficacy in older adults. Duplicate screening, selection, extraction and appraisal were completed. Results were reported descriptively and with random-effects meta-analyses stratified by population (proactive [community-dwelling], reactive [illness/injury]). RESULTS: A total of 29 RCTs with 7,076 participants were identified (66% high bias for at least one domain). The outdoor mobility component was predominantly a walking programme with behaviour change. Rehabilitation for reactive populations increased physical activity (seven RCTs, 587 participants. Hedge's g 1.32, 95% CI: 0.31, 2.32), endurance (four RCTs, 392 participants. Hedges g 0.24; 95% CI: 0.04, 0.44) and outdoor mobility (two RCTs with 663 participants. Go out as much as wanted, likelihood of a journey) at intervention end versus usual care. Where reported, effects were preserved at follow-up. One RCT indicated a benefit of rehabilitation for proactive populations on moderate-to-vigorous activity and outdoor mobility. No effect was noted for falls-related self-efficacy, or other outcomes following rehabilitation for proactive populations. CONCLUSION: Reactive rehabilitation for older adults may include walking programmes with behaviour change techniques. Future research should address the potential benefit of a walking programme for proactive populations and address mobility-related anxiety as a barrier to outdoor mobility for both proactive and reactive populations.
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Exercício Físico , Vida Independente , Idoso , Ansiedade , Humanos , Estado Nutricional , CaminhadaRESUMO
PURPOSE: The purpose of the current review is to synthesize the evidence of patients' perspectives of recovery after hip fracture across the care continuum. METHODS: A systematic search was conducted, focusing on qualitative data from hip fracture patients. Screening, quality appraisal, and a subset of articles for extraction were completed in duplicate. Themes were generated using a thematic synthesis of data from original studies. RESULTS: Fourteen high-quality qualitative studies were included. Four review themes were identified: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support. Patients considered recovery as a return to pre-fracture activities or "normal" enabling independence. Feelings of vulnerability were observed irrespective of the time since hip fracture and only diminished when recovery of function and activities enabled participation in valued activities, e.g., outdoor mobility. Participants expressed a desire to engage in recovery with realistic expectations and the benefits of meaningful feedback reported. While reliance on healthcare professionals decreased towards a later stage of recovery, reliance on social support persisted until recovery was perceived to have been achieved. CONCLUSION: Patient perspectives highlighted hip fracture as a major life event requiring health professional and social support to overcome feelings of vulnerability and enable active engagement in recovery.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals should ensure expectations and goals are set early in the recovery process.Rehabilitation professionals should ensure goals set with patients are tailored to the individual's pre-fracture activities or "normal" promoting independence.Rehabilitation professionals should monitor goals ensuring they are providing support, motivation, and managing expectations across the care continuum.Rehabilitation professionals should address patients' feelings of vulnerability, particularly in the absence of social support, and ensure appropriate ongoing input to maximize recovery.
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Fraturas do Quadril , Humanos , Fraturas do Quadril/reabilitação , Pesquisa Qualitativa , Cuidados Paliativos , Apoio Social , Pessoal de SaúdeRESUMO
BACKGROUND: Early mobilisation leads to a two-fold increase in the adjusted odds of discharge by 30-days compared to late mobilisation. Whether this association varies by patient characteristics identified as reasons for delayed mobilisation is unknown. METHODS: Audit data was linked to hospitalisation records for 133,319 patients 60 years or older surgically treated for hip fracture in England or Wales between 2014 and 2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed between those mobilised early and those mobilised late for subgroups defined by dementia, delirium, hypotension, prefracture ambulation, and prefracture residence, accounting for the competing risk of death. RESULTS: Overall, 34,253 patients presented with dementia, 9818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 1502 had incomplete data for ambulation and 2587 for prefracture residence. 10, 8, 8, 12, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or admitted from residential care mobilised early when compared to those who presented without dementia, delirium, hypotension, with outdoor ambulation prefracture, or admitted from home. The adjusted odds ratios of discharge by 30-days postoperatively among those who mobilised early compared with those who mobilised late were 1.71 (95% CI 1.62-1.81) for those with dementia, 2.06 (95% CI 1.98-2.15) without dementia, 1.56 (95% CI 1.41-1.73) with delirium, 2.00 (95% CI 1.93-2.07) without delirium, 1.83 (95% CI, 1.66-2.02) with hypotension, 1.95 (95% CI, 1.89-2.02) without hypotension, 2.00 (95% CI 1.92-2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70-1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19-2.41) admitted from home, and 1.64 (95% CI 1.51-1.77) admitted from residential care, accounting for the competing risk of death. CONCLUSION: Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of hospital discharge by 30-days postoperatively. However, fewer patients with dementia, delirium, or hypotension, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.
Assuntos
Fraturas do Quadril , Alta do Paciente , Deambulação Precoce , Inglaterra/epidemiologia , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/cirurgia , Humanos , CaminhadaRESUMO
AIMS: The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery. METHODS: Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability. RESULTS: A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia. CONCLUSION: Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article: Bone Joint J 2021;103-B(7):1317-1324.
Assuntos
Demência/complicações , Deambulação Precoce , Fraturas do Quadril/cirurgia , Recuperação de Função Fisiológica , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Humanos , Masculino , Pontuação de Propensão , Taxa de Sobrevida , País de GalesRESUMO
There is limited evidence from 11 randomised controlled trials on the effect of rehabilitation interventions which incorporate outdoor mobility on ambulatory ability and/or self-efficacy after hip fracture. Outdoor mobility should be central (not peripheral) to future intervention studies targeting improvements in ambulatory ability. PURPOSE: Determine the extent to which outdoor mobility is incorporated into rehabilitation interventions after hip fracture. Synthesise the evidence for the effectiveness of these interventions on ambulatory ability and falls-related self-efficacy. METHODS: Systematic search of MEDLINE, Embase, PsychInfo, CINAHL, PEDro and OpenGrey for published and unpublished randomised controlled trials (RCTs) of community-based rehabilitation interventions incorporating outdoor mobility after hip fracture from database inception to January 2021. Exclusion of protocols, pilot/feasibility studies, secondary analyses of RCTs, nonrandomised and non-English language studies. Duplicate screening for eligibility, risk of bias, and data extraction sample. Random effects meta-analysis. Statistical heterogeneity with inconsistency-value (I2). RESULTS: RCTs (n = 11) provided limited detail on target or achieved outdoor mobility intervention components. There was conflicting evidence from 2 RCTs for the effect on outdoor walking ability at 1-3 months (risk difference 0.19; 95% confidence intervals (CI): 0.21, 0.58; I2 = 92%), no effect on walking endurance at intervention end (standardised mean difference 0.05; 95% CI: - 0.26, 0.35; I2 = 36%); and suggestive (CI crosses null) of a small effect on self-efficacy at 1-3 months (standardised mean difference 0.25; 95% CI: - 0.29, 0.78; I2 = 87%) compared with routine care/sham intervention. CONCLUSION: It was not possible to attribute any benefit observed to an outdoor mobility intervention component due to poor reporting of target or achieved outdoor mobility and/or quality of the underlying evidence. Given the low proportion of patients recovering outdoor mobility after hip fracture, future research on interventions with outdoor mobility as a central component is warranted. TRIAL REGISTRATION: PROSPERO registration: CRD42021236541.
Assuntos
Acidentes por Quedas , Fraturas do Quadril , Humanos , Autoeficácia , CaminhadaRESUMO
OBJECTIVE: to explore physiotherapists' perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. METHODS: a qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at seven hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. RESULTS: four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting 'postoperative physiotherapy' as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. CONCLUSION: physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care and allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice, which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles.
Assuntos
Ortopedia , Fisioterapeutas , Humanos , Percepção , Modalidades de Fisioterapia , Pesquisa Qualitativa , Reino UnidoRESUMO
OBJECTIVE: To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30 days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death. METHOD: We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between 1 January 2014 and 31 December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 h of surgery) and those mobilised late, accounting for potential confounders and the competing risk of in-hospital death. RESULTS: A total of 106,722 (79%) of patients first mobilised early. The average rate of discharge was 39.2 (95% CI 38.9-39.5) per 1,000 patient days, varying from 43.1 (95% CI 42.8-43.5) among those who mobilised early to 27.0 (95% CI 26.6-27.5) among those who mobilised late, accounting for the competing risk of death. By 30-day postoperatively, the crude and adjusted odds ratios of discharge were 2.36 (95% CI 2.29-2.43) and 2.08 (95% CI 2.00-2.16), respectively, among those who first mobilised early compared with those who mobilised late, accounting for the competing risk of death. CONCLUSION: Early mobilisation led to a 2-fold increase in the adjusted odds of discharge by 30-day postoperatively. We recommend inclusion of mobilisation within 36 h of surgery as a new UK Best Practice Tariff to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture.