Gamification in rehabilitation of metacarpal fracture using cost-effective end-user device: A randomized controlled trial.

STUDY DESIGN: This is a two-group randomized controlled trial. INTRODUCTION: Finger stiffness after treatment for metacarpal fractures often occurs due to poor compliance to the conventional rehabilitation programs. Gamification has shown success in improving adherence to and effectiveness of various therapies. PURPOSE OF THE STUDY: The purpose of this study was to evaluate whether gamification, using cost-effective devices was comparable with conventional physiotherapy in improving hand functions and adherence to rehabilitation in metacarpal fractures. METHODS: A 2-group randomized controlled trial involving 19 patients was conducted. Participants were randomized to a control (conventional physiotherapy, n = 10) or interventional group (gamification, n = 9). The grips strength and composite finger range of motion were measured at the baseline and each follow-up together with Patient-Rated Wrist and Hand Evaluation scores and compliance. RESULTS: There were no significant differences on improvements of grip strength (means difference 24.38 vs 20.44, P = .289) and composite finger range of motion (means difference 50.50 vs 51.11, P = .886). However, the gamification group showed better results in Patient-Rated Wrist and Hand Evaluation (mean 0.44 vs 8.45, P = .038) and compliance (P < .05). No adverse events were reported. DISCUSSION: Our results suggest that gamification using a cost-effective device demonstrated similar effectiveness as conventional physiotherapy in post-metacarpal fracture rehabilitation. CONCLUSIONS: Gamification using a mobile device is an inexpensive and safe alternative to conventional physiotherapy for hand rehabilitation after metacarpal fractures. It effectively serves as a guide for future development of cost-effective technology-enhanced therapy.

Cost-Effectiveness of the Transmural Trauma Care Model (TTCM) for the Rehabilitation of Trauma Patients.

OBJECTIVES: To assess the societal cost-effectiveness of the Transmural Trauma Care Model (TTCM), a multidisciplinary transmural rehabilitation model for trauma patients, compared with regular care. METHODS: The economic evaluation was performed alongside a before-and-after study, with a convenience control group measured only afterward, and a 9-month follow-up. Control group patients received regular care and were measured before implementation of the TTCM. Intervention group patients received the TTCM and were measured after its implementation. The primary outcome was generic health-related quality of life (HR-QOL). Secondary outcomes included disease-specific HR-QOL, pain, functional status, and perceived recovery. RESULTS: Eighty-three trauma patients were included in the intervention group and fifty-seven in the control group. Total societal costs were lower in the intervention group than in the control group, but not statistically significantly so (EUR-267; 95 percent confidence interval [CI], EUR-4,175-3011). At 9 months, there was no statistically significant between-group differences in generic HR-QOL (0.05;95 percent CI, -0.02-0.12) and perceived recovery (0.09;95 percent CI, -0.09-0.28). However, mean between-group differences were statistically significantly in favor of the intervention group for disease-specific HR-QOL (-8.2;95 percent CI, -15.0--1.4), pain (-0.84;95CI, -1.42--0.26), and functional status (-20.1;95 percent CI, -29.6--10.7). Cost-effectiveness acceptability curves indicated that if decision makers are not willing to pay anything per unit of effect gained, the TTCM has a 0.54-0.58 probability of being cost-effective compared with regular care. For all outcomes, this probability increased with increasing values of willingness-to-pay. CONCLUSIONS: The TTCM may be cost-effective compared with regular care, depending on the decision-makers willingness to pay and the probability of cost-effectiveness that they perceive as acceptable.

Rehabilitation Utilization for Falls Among Community-Dwelling Older Adults in the United States in the National Health and Aging Trends Study.

OBJECTIVE: To determine the characteristics of community-dwelling older adults receiving fall-related rehabilitation. DESIGN: Cross-sectional analysis of the fifth round (2015) of the National Health and Aging Trends Study (NHATS). Fall-related rehabilitation utilization was analyzed using weighted multinomial logistic regression with SEs adjusted for the sample design. SETTING: In-person interviews of a nationally representative sample of community-dwelling older adults. PARTICIPANTS: Medicare beneficiaries from NHATS (N=7062). INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Rehabilitation utilization categorized into fall-related rehabilitation, other rehabilitation, or no rehabilitation. RESULTS: Fall status (single fall: odds ratio [OR]=2.96; 95% confidence interval [CI], 1.52-5.77; recurrent falls: OR=14.21; 95% CI, 7.45-27.10), fear of falling (OR=3.11; 95% CI, 1.90-5.08), poor Short Physical Performance Battery scores (score 0: OR=6.62; 95% CI, 3.31-13.24; score 1-4: OR=4.65; 95% CI, 2.23-9.68), and hip fracture (OR=3.24; 95% CI, 1.46-7.20) were all associated with receiving fall-related rehabilitation. Lower education level (less than high school diploma compared with 4-y college degree: OR=.21; 95% CI, .11-.40) and Hispanic ethnicity (OR=.37; 95% CI, .15-.87) were associated with not receiving fall-related rehabilitation. CONCLUSIONS: Hispanic older adults and older adults who are less educated are less likely to receive fall-related rehabilitation. Recurrent fallers followed by those who fell once in the past year were more likely to receive fall-related rehabilitation than are older adults who have not had a fall in the past year.

Nurse Practitioner Fracture Liaison Role: A Concept Analysis.

BACKGROUND: With the worldwide growing aging population, the high prevalence of osteoporosis-related fractures is associated with high morbidity and mortality. Healthcare costs for treating fractures and subsequent complications will increase to $25 billion by 2025. PURPOSE: This article articulates a comprehensive concept analysis of the nurse practitioner fracture liaison (NPFL) role to provide new insights into the role of nurse practitioner in osteoporosis care coordination. METHODS: Walker and Avant's concept analysis framework was used to identify the attributes, antecedents, consequences, and empirical referents of the NPFL role. Model cases illustrated real-life examples of the NPFL role. CONCLUSION: The impact of NPFL role is rather novel in promoting healthy bone living at local, national, and international communities. Linking the refined outcome of the concept analysis of the NPFL role to osteoporosis care helps close osteoporosis care gaps, improve healthcare outcomes, and alleviate financial burden by reducing secondary fracture and complications.

Paediatric fracture clinic re-design: Incorporating a virtual fracture clinic.

INTRODUCTION: The use of virtual fracture clinics (VFCs) and home management protocols is increasing. The main aim of this research is to determine whether a paediatric home management programme and VFC can be used safely to manage a range of suitable fractures in children. MATERIALS AND METHODS: Protocols for the home management of stable paediatric fractures were designed by two consultant paediatric orthopaedic surgeons. These were for children between the ages of 18 months and 15 years 364 days. A new tariff was negotiated with the clinical commissioning groups (CCGs) for a VFC new patient review. A prospective analysis was performed for the first 2 months of the programme. Further review periods were undertaken 6 months later and 12 months after that. RESULTS: Sixty-five patients were reviewed in the first 10 VFCs (mean 6.5 cases per week). After 6 months, 164 patients were reviewed in a 3-month period in the VFC, a mean of 11 cases per week. A year later the number of patients reviewed in the VFC had continued to increase with a total of 253 patients in 3 months, mean 21 cases per week. This gave a saving to the CCG of £45,000 per year and to the hospital of £106,000 per year. There were no serious adverse consequences to any patients from the use of the pathway. DISCUSSION AND CONCLUSION: We have reported on the introduction of a paediatric VFC and a home management programme for stable paediatric fractures. We are not aware of any reports in the orthopaedic literature that have described such a comprehensive and innovative re-organisation of paediatric fracture services. We estimate that the NHS could save approximately £10.1 million if all hospitals in England introduced this.

Hospital-at-home Integrated Care Program for Older Patients With Orthopedic Processes: An Efficient Alternative to Usual Hospital-Based Care.

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.

The impact of non weight bearing: A prospective cohort study.

BACKGROUND: Patients with lower limb injuries are commonly advised to non weight bear (NWB) on their injured limb as part of treatment. Occasionally, patients complain that offloading one limb, associated with the use of crutches or other mobility aids, may lead to pain on one of the other supporting limbs. This has led to compensation claims (1) but has never been the subject of formal research. METHODS: A prospective cohort trial was undertaken to address this question. Patients were recruited from two Metropolitan Hospital Orthopaedic Fracture Clinics and Orthopaedic Wards. A survey was administered at two time points; the first at the point of definitive orthopaedic treatment and commencement of the NWB phase. The second after the NWB phase was completed. The surveys included a pain Visual Analogue Scale (VAS), Short Form (SF)12, a pain body chart and a health questionnaire. RESULTS: A total of 55 patients were enrolled in the study. Seven patients developed new joint pain after a period NWB. These patients scored significantly lower on the follow up SF12 when compared to those who did not develop new pain (p=0.045). Follow up phone calls at least 6 months following completion of the second survey revealed that all initial and new pain areas in these participants had resolved. The main limitation of this study was the limited numbers. CONCLUSION: This study supports the idea that crutches, prescribed in the short term to allow a limb to be NWB, achieve this aim with minimal impact. Their use may be associated with new other joint pain however it can be anticipated this will resolve after cessation of crutch use.

Evaluation of Ambulatory Geriatric Rehabilitation (EAGER): study protocol of a matched cohort study based on claims data.

BACKGROUND: Ambulatory geriatric rehabilitation (AGR) is a community based outpatient intervention which aims to improve physical function, maintain independent living of geriatric patients, avoiding hospitalisation and institutionalisation. It should therefore reduce health care costs. The objective of our study is to evaluate the effectiveness of AGR for frail elderly patients insured by the statutory health insurance AOK Nordost compared to care as usual. Outcome variables are progression to higher nursing care levels, admission to nursing home, incident fractures, hospital admission, ambulatory care sensitive hospital admissions, days spent in hospital, and health care costs. METHODS: This matched cohort study aims to estimate average treatment effects of AGR. For this purpose we will compare patients receiving AGR with matched patients receiving care as usual. Patients in the intervention group were treated between the years 2009 and 2013 from three centres in Mecklenburg-Vorpommern, Germany. Matching will be conducted using propensity score techniques. Claims data will be provided by the statutory health insurance AOK Nordost. The primary outcomes are the progression of nursing care levels, incident fractures, and admission to nursing home. Secondary outcomes are total and ambulatory care sensitive hospital admissions, and health care costs from the statutory health insurance perspective. Data will be analysed using appropriate regression models. DISCUSSION: This study aims to quantify the effectiveness of AGR. Results will be important for providers of AGR, policy makers and stakeholders to make informed decisions on whether to continue, modify or extend AGR. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) S00008926 , registered 29.07.2015.

Social Support and Actual Versus Expected Length of Stay in Inpatient Rehabilitation Facilities.

OBJECTIVES: To describe impairment-specific patterns in shorter- and longer-than-expected lengths of stay in inpatient rehabilitation, and examine the independent effects of social support on deviations from expected lengths of stay. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries (N=119,437) who were discharged from inpatient rehabilitation facilities in 2012 after stroke, lower extremity fracture, or lower extremity joint replacement. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Relative length of stay (actual minus expected). The Centers for Medicare & Medicaid Services posts annual expected lengths of stay based on patients' clinical profiles at admission. We created a 3-category outcome variable: short, expected, long. Our primary independent variable (social support) also included 3 categories: family/friends, paid/other, none. RESULTS: Mean ± SD actual lengths of stay for joint replacement, fracture, and stroke were 9.8±3.6, 13.8±4.5, and 15.8±7.3 days, respectively; relative lengths of stay were -1.2±3.1, -1.6±3.7, and -1.7±5.2 days. Nearly half of patients (47%-48%) were discharged more than 1 day earlier than expected in all 3 groups, whereas 14% of joint replacement, 15% of fracture, and 20% of stroke patients were discharged more than 1 day later than expected. In multinomial regression analysis, using family/friends as the reference group, paid/other support was associated (P<.05) with higher odds of long stays in joint replacement. No social support was associated with lower odds of short stays in all 3 impairment groups and higher odds of long stays in fracture and joint replacement. CONCLUSIONS: Inpatient rehabilitation experiences and outcomes can be substantially affected by a patient's level of social support. More research is needed to better understand these relationships and possible unintended consequences in terms of patient access issues and provider-level quality measures.

The economic burden of outpatient appointments following paediatric fractures.

INTRODUCTION: Paediatric fractures are common and frequently followed-up. The aim of this study is to quantify the private costs for the affected families, as well as the costs for society due to paediatric fracture clinic follow-up appointments. PATIENTS AND METHODS: 295 paired parent and surgeon questionnaire regarding the cost related to a scheduled follow-up appointment for an upper limb fracture in children aged 6-13 years were collected prospectively over 7 months. In addition, the medical appropriateness of the appointment and whether or not the control changed the management of the fracture was investigated. RESULTS: The direct cost of attending a paediatric upper limb fracture clinic was estimated to €48.5 while the cost for society due to productivity loss was €78.4 per consultation. In 89.2% of the cases the surgeons found the appointment necessary, it was deemed unnecessary or inconclusive in 10.6%. The treatment plan was altered in 6.8%, and an extra follow up was scheduled in 5.8%. Fractures of the clavicle were most often regarded as unnecessary to follow up clinically or radiologically by the surgeons. DISCUSSION: The direct cost for the affected families and the costs for society due to productivity loss of paediatric fracture follow-up appointments are noticeable. Although most patients and surgeons deem these controls as valuable, they lead to a change in treatment plan in only 12.6% of the cases. A stringent management protocol can safely reduce the number of clinical and radiographical follow-ups.

Clinical assessment tools identify functional deficits in fragility fracture patients.

PURPOSE: To identify inexpensive, noninvasive, portable, clinical assessment tools that can be used to assess functional performance measures that may put older patients at risk for falls such as balance, handgrip strength, and lumbopelvic control. PATIENTS AND METHODS: Twenty fragility fracture patients and 21 healthy control subjects were evaluated using clinical assessment tools (Nintendo Wii Balance Board [WBB], a handheld dynamometer, and an application for the Apple iPod Touch, the Level Belt) that measure functional performance during activity of daily living tasks. The main outcome measurements were balance (WBB), handgrip strength (handheld dynamometer), and lumbopelvic control (iPod Touch Level Belt), which were compared between fragility fracture patients and healthy controls. RESULTS: Fragility fracture patients had lower scores on the vertical component of the WBB Torso Twist task (P=0.042) and greater medial-lateral lumbopelvic sway during a 40 m walk (P=0.026) when compared to healthy controls. Unexpectedly, the fracture patients had significantly higher scores on the left leg (P=0.020) and total components (P=0.010) of the WBB Single Leg Stand task as well as less faults during the left Single Leg Stand task (P=0.003). CONCLUSION: The clinical assessment tools utilized in this study are relatively inexpensive and portable tools of performance measures capable of detecting differences in postural sway between fragility fracture patients and controls.

Comparing Comorbidity Indices to Predict Post-Acute Rehabilitation Outcomes in Older Adults.

OBJECTIVE: Compare 5 comorbidity indices to predict community discharge and functional status following post-acute rehabilitation. DESIGN: This was a retrospective study of Medicare beneficiaries with stroke, lower-extremity fracture, and joint replacement discharged from inpatient rehabilitation in 2011 (N = 105,275). Community discharge and self-care, mobility, and cognitive function were compared using the Charlson, Elixhauser, Tier, Functional Comorbidity, and Hierarchical Condition Category comorbidity indices. RESULTS: Of the patients, 64.4% were female, and 84.6% were non-Hispanic white. Mean age was 79.3 (SD, 7.5) years. Base regression models including sociodemographic and clinical variables explained 56.6%, 42.2%, and 23.0% of the variance (R) for discharge self-care; 47.4%, 30.9%, and 18.6% for mobility; and 62.0%, 55.3%, and 37.3% for cognition across the 3 impairment groups. R values for self-care, mobility, and cognition increased by 0.2% to 3.3% when the comorbidity indices were added to the models. The base model C statistics for community discharge were 0.58 (stroke), 0.61 (fracture), and 0.62 (joint replacement). The C statistics increased more than 25% with the addition of discharge functional status to the base model. Adding the comorbidity indices individually to the base model resulted in C-statistic increases of 1% to 2%. CONCLUSION: Comorbidity indices were poor predictors of community discharge and functional status in Medicare beneficiaries receiving inpatient rehabilitation.

[Orthopaedic and trauma surgical care until 2050. Analysis of the utilization behavior for relevant diseases and derivation of the number of medical service providers]. / Orthopädisch-unfallchirurgische Versorgung bis 2050. Analyse des Inanspruchnahmeverhaltens bei relevanten Erkrankungen und Ableitung der Häufigkeit ärztlicher Leistungserbringer.

BACKGROUND: Due to current and prospective demographic developments, the provision of high-quality medical care is not guaranteed in Germany. OBJECTIVES: The aim of this study is to analyze the utilization of medical service providers for diseases related to orthopedic/trauma surgery and deduce the corresponding number of medical service providers until 2050. MATERIALS AND METHODS: Data provided by the Statistical Offices of the Federal Republic and the Federal States and the Scientific Institute of the AOK (2008-2012) were used to analyze the utilization behavior of four pre-determined orthopedic/trauma surgery disease groups (osteoarthritis, back pain, osteoporosis, trauma). Routine data of the current (2012) health care provision delivered by the compulsory health insurances (GKV) are the basis of the prognosis. Using population projections from the Federal Statistical Office, the health care demand until 2050 was predicted and using statistics from the German Medical Association, the number of required health care providers was determined. RESULTS: An increase in physician consultations until 2040 is expected for osteoarthritis (+ 21 %), osteoporosis (26 %), and trauma (+ 13 %). From 2040-2050 the health care utilization behavior of all examined diseases is expected to decrease. The increasing health care usage behavior until 2040 is associated with an increase in health care providers. CONCLUSIONS: Until 2030 a significant increase in the burden of orthopedic/trauma surgery diseases is expected. In 2050 the level of health care needs will be equivalent to that in 2030. Comprehensive needs assessment and planning are needed in order to create health care provision structures and processes that address potential changes in utilization behavior.

Examining the Association Between Comorbidity Indexes and Functional Status in Hospitalized Medicare Fee-for-Service Beneficiaries.

BACKGROUND: Medicare data from acute hospitals do not contain information on functional status. This lack of information limits the ability to conduct rehabilitation-related health services research. OBJECTIVE: The purpose of this study was to examine the associations between 5 comorbidity indexes derived from acute care claims data and functional status assessed at admission to an inpatient rehabilitation facility (IRF). Comorbidity indexes included tier comorbidity, Functional Comorbidity Index (FCI), Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Hierarchical Condition Category (HCC). DESIGN: This was a retrospective cohort study. METHODS: Medicare beneficiaries with stroke, lower extremity joint replacement, and lower extremity fracture discharged to an IRF in 2011 were studied (N=105,441). Data from the beneficiary summary file, Medicare Provider Analysis and Review (MedPAR) file, and Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) file were linked. Inpatient rehabilitation facility admission functional status was used as a proxy for acute hospital discharge functional status. Separate linear regression models for each impairment group were developed to assess the relationships between the comorbidity indexes and functional status. Base models included age, sex, race/ethnicity, disability, dual eligibility, and length of stay. Subsequent models included individual comorbidity indexes. Values of variance explained (R(2)) with each comorbidity index were compared. RESULTS: Base models explained 7.7% of the variance in motor function ratings for stroke, 3.8% for joint replacement, and 7.3% for fracture. The R(2) increased marginally when comorbidity indexes were added to base models for stroke, joint replacement, and fracture: Charlson Comorbidity Index (0.4%, 0.5%, 0.3%), tier comorbidity (0.2%, 0.6%, 0.5%), FCI (0.4%, 1.2%, 1.6%), Elixhauser Comorbidity Index (1.2%, 1.9%, 3.5%), and HCC (2.2%, 2.1%, 2.8%). LIMITATION: Patients from 3 impairment categories were included in the sample. CONCLUSIONS: The 5 comorbidity indexes contributed little to predicting functional status. The indexes examined were not useful as proxies for functional status in the acute settings studied.

Reproducibility of the six-minute walk test and Glittre ADL-test in patients hospitalized for acute and exacerbated chronic lung disease

Background: The 6-minute walk test (6MWT) and the Glittre ADL-test (GT) are used to assess functional capacity and exercise tolerance; however, the reproducibility of these tests needs further study in patients with acute lung diseases. Objectives: The aim of this study was to investigate the reproducibility of the 6MWT and GT performed in patients hospitalized for acute and exacerbated chronic lung diseases. Method: 48 h after hospitalization, 81 patients (50 males, age: 52±18 years, FEV1: 58±20% of the predicted value) performed two 6MWTs and two GTs in random order on different days. Results: There was no difference between the first and second 6MWT (median 349 m [284-419] and 363 m [288-432], respectively) (ICC: 0.97; P<0.0001). A difference between the first and second tests was found in GT (median 286 s [220-378] and 244 s [197-323] respectively; P<0.001) (ICC: 0.91; P<0.0001). Conclusion: Although both the 6MWT and GT were reproducible, the best results occurred in the second test, demonstrating a learning effect. These results indicate that at least two tests are necessary to obtain reliable assessments. .

[Return to Work after Fractures of the Pelvis and the Acetabulum]. / Berufliche Wiedereingliederung nach Becken- und Azetabulumfrakturen.

BACKGROUND AND INTRODUCTION: Pelvic and acetabular fractures are severe injuries with serious consequences that mainly happen to young people. Therefore it is highly interesting to find out to what extent affected patients succeed in returning to work, which is an important factor concerning quality of live. Thus, the objective of this study was to estimate the "return to work" in a two-year follow-up after rehabilitative treatment of patients with pelvic and acetabular fractures and to identify influencing factors. METHODS: A retrospective cohort study was conducted using population-based administrative data of the Baden-Württemberg statutory pension fund. All patients (age 18 to 63 years) who had participated in a rehabilitation programme between 2004 and 2009 due to a pelvic or acetabular fracture were included. Return to work was modelled using multivariate logistic regression analysis. Rehabilitants were classified as "returned" if they have paid at least one monthly contribution due to employment during 13 to 24 months after rehabilitation. Age, gender, diagnostic group, type of rehabilitation programme, fractures of the spine, nerve injuries of the lumbosacral area and/or the lower limb and employment status before the fractures were considered as prognostic covariates. RESULTS: Two-thirds of the 249 researched patients returned to work. This corresponds to a reduction of employment amounting to 16.6 % for patients with a pelvic fracture and 20.8 % for patients with an acetabular fracture. Main predictor for a return to work was the employment status before the fracture. Younger patients had a better chance to return to work than older ones. Patients with fractures of the spine or nerve injuries of the lumbosacral area and/or the lower limb had a 73 % or, respectively, 78 % higher risk of not returning to work. CONCLUSION: Fractures of the pelvis and the acetabulum currently lead in one of five patients to loss of employment. Thereby the trauma threatens the social security of the young patients. Follow-up care should be intensified to increase recovery rates and reduce the burden of long-term work disability.

The association between physical medicine and rehabilitation service utilization and disability duration following work-related fracture.

BACKGROUND: Rural residents with work-related fractures utilize healthcare differently and return to work (RTW) sooner than their similarly-injured urban peers. OBJECTIVE: To elucidate the relationship between physical medicine and rehabilitation (PM&R) service usage and work-disability duration following work-related injury. DESIGN: Retrospective cohort study, employing a two-phase sequential analysis. The project involved a longitudinal analysis of PM&R utilization and work-disability duration of 2,216 people across the U.S. who fractured a bone, received PM&R services, and had at least seven days off work. In the first phase of the analysis each individual was assigned a PM&R utilization score based on how similar his or her usage was to that typical of rural residents. The second phase tested the relationship between assigned PM&R utilization scores and work-disability duration. RESULTS: Differences in urban versus rural PM&R utilization included less total PM&R services and fewer passive services in the first 8 weeks for rural claimants. Among those off work for more than a month, rural residents used more active services just prior to RTW, with a gradual decreasing of services leading up to RTW. Controlling for covariates, aggregate PM&R utilization scores were found to relate to time to first RTW (Hazard Ratio=1.66, p<0.005). CONCLUSIONS: Findings suggest that using services in a way that is more consistent with rural patterns is associated with decreased work-disability durations. Consistent with previous studies, results suggest that passive services, prolonged episodes of care, and failure to focus on transitioning to self-management are related to longer work-disability durations.

Gait and function as tools for the assessment of fracture repair - the role of movement analysis for the assessment of fracture healing.

Assessment of gait and function might be as sensitive tool to monitor the progress of fracture healing. Currently available assessment tools for function use instrumented three dimensional gait analysis or pedobarography. The analysis is focused on gait or movement parameters and seeks to identify abnormalities or asymmetries between legs or arms. The additional inclusion of muscle function by electromyography can further elucidate functional performance and its temporal development. Alternative approaches abstain from directly assessing function in the laboratory but rather determine the amount of activities of daily living or the mere ability to perform defined tasks such as walking, stair climbing or running. Some of these methods have been applied to determine recovery after orthopaedic interventions including fracture repair. The combination of lab-based functional measurements and assessment of physical activities in daily live may offer a valuable level of information about the gait quality and quantity of individual patients which sheds light on functional limitations or rehabilitation of gait and mobility after a disease or injury and the respective conservative, medical or surgical treatment.

Transitions of care and rehabilitation after fragility fractures.

Transitions in care are a vulnerable time period for patients during which unintended errors may occur. This article discusses potential risks that could occur during care transitions, suggested improvements, and the transition from hospital to skilled nursing facilities for patients needing rehabilitation after their discharge from the hospital. Different rehabilitation settings and their reimbursement are reviewed. Common potential medical conditions arising in patients undergoing rehabilitation, rehabilitation goals, and secondary prevention also are discussed.