[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]. / Lebensqualität und Arbeitsfähigkeit nach unfallchirurgischer Rehabilitation ­ Ergebnisse der icfPROreha-Studie.

BACKGROUND: Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries. METHODS: Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted. RESULT: Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation. CONCLUSION: Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

[Trauma rehabilitation : Implementation and challenges]. / Traumarehabilitation : Implementation und Herausforderungen.

The current state of posttraumatic rehabilitation in Germany is on the one hand shaped by the efforts of the primary care providers in the acute setting to transfer patients as soon as possible to rehabilitation in accordance with the requirement for a continuous chain of rehabilitation. On the other hand, there are still important treatment gaps due to a lack of options, specialized structures and financing. This has the consequence that severely injured patients sometimes experience substantial difficulties, setbacks and delays on their way back to social participation. This article presents the various phases of rehabilitation and the existing challenges in order to guarantee the universally acknowledged demand for a continuous rehabilitation chain. Reference is made to the missing structures and simultaneously to the necessary continuity of the processes, the quality assurance and the financial prerequisites for new forms of care. This is exemplified by how the continuum of posttraumatic rehabilitation of the German statutory accident insurance with the successful reintegration of trauma victims in work and social life could be a model for insured persons of the statutory health insurance and the German pension fund. The scientific societies of trauma surgery and rehabilitation medicine also promote the model of a differentiated trauma rehabilitation and sustain the idea of a trauma rehabilitation network to increase the chances of the severely injured for the best possible quality of life and social participation.

ICF-based prediction of return to work after trauma rehabilitation: Results of the icfPROreha study in patients with severe musculoskeletal injuries.

Background: Physical aspects such as the type and severity of an injury are not the only factors contributing to whether or not a person can return to work (RTW) after a serious injury. A more comprehensive, biopsychosocial approach is needed to understand the complexity of RTW fully. The study aims to identify predictors of RTW 78 weeks after discharge from initial inpatient trauma rehabilitation in patients with severe musculoskeletal injuries using a biopsychosocial perspective. Methods: This is a prospective multicenter longitudinal study with a follow-up of up to 78 weeks after discharge from trauma rehabilitation. Data on potential predictors were collected at admission to rehabilitation using a comprehensive assessment tool. The status of RTW (yes vs. no) was assessed 78 weeks after discharge from rehabilitation. The data were randomly divided into a training and a validation data set in a ratio of 9:1. On the training data, we performed bivariate and multiple logistic regression analyses on the association of RTW and potential predictors. The final logit model was selected via stepwise variable selection based on the Akaike information criterion. The final model was validated for the training and the validation data. Results: Data from 761 patients (n = 561 male, 73.7%; mean age: 47.5 years, SD 12.3), primarily suffering from severe injuries to large joints and complex fractures of the large tubular bones, could be considered for analyses. At 78 weeks after discharge, 618 patients (81.2%) had returned to work. Eleven predictors remained in the final logit model: general health, current state of health, sensation of pain, limitations and restrictions in activities and participation (disability), professional sector, ongoing legal disputes, financial concerns (assets), personality traits, life satisfaction preaccident, attitude to life, and demand for pension claim. A predicted probability for RTW based on the multiple logistic regression model of 76.3% was revealed as the optimal cut-off score based on the ROC curve. Conclusion: A holistic biopsychosocial approach is needed to address RTW and strengthen person-centered treatment and rehabilitation. Patients at risk for no RTW in the long term can already be identified at the onset of rehabilitation.

[Rehabilitation after multiple traumata]. / Rehabilitation nach Mehrfachverletzung.

BACKGROUND: The reintegration into the social and professional environment and the achievement of the best possible quality of life after multiple injuries can often only be achieved after a lengthy rehabilitation process and belongs in the hands of experienced doctors, therapists, and rehabilitation managers. REHABILITATION PHASES: Rehabilitation after serious accidents must be differentiated from "normal" orthopedic rehabilitation after elective surgery. The challenges of trauma rehabilitation require coordinated rehabilitation phases. This is the only way to avoid the so-called "rehab hole" between discharge from the acute clinic and the start of post-acute rehabilitation. A 6-phase model is described. After acute treatment (phase A) and any necessary early rehabilitation (phase B), phase C of post-acute rehabilitation places special demands on the rehabilitation facility. Phase D of the follow-up rehabilitation is established. The further rehabilitation (phase E) provides measures specifically tailored to the consequences of the accident, such as pain rehabilitation or activity-oriented procedures. Long-term follow-up care for previously severely injured patients is necessary (phase F). PROSPECTS: An integration of trauma rehabilitation centers into the existing trauma network remains the goal to improve the outcome after polytrauma.

[Requirements for trauma rehabilitation centers : Post-acute rehabilitation (phase C) after severe trauma injury]. / Anforderungen an Traumarehabilitationszentren : Postakute Rehabilitation (Phase C) nach schwerer Unfallverletzung.

Severely injured patients need a qualified and seamless rehabilitation after the end of the acute treatment. This post-acute rehabilitation (phase C) places high demands on the rehabilitation facility in terms of personnel, material, organizational and spatial requirements.The working group on trauma rehabilitation of the German Society for Orthopedics and Traumatology e. V. (DGOU) and other experts have agreed on requirements for post-acute phase C rehabilitation for seriously injured people. These concern both the personnel and material requirements for a highly specialized orthopedic trauma surgery trauma rehabilitation as well as the demands on processes, organization and quality assurance.A seamless transition to the follow-up and further treatment of seriously injured people in the TraumaNetzwerk DGU® is ensured through a high level of qualification and the corresponding infrastructure of supraregional trauma rehabilitation centers. This also places new demands on the TraumaZentren DGU®. Only if these are met can the treatment and rehabilitation of seriously injured people be optimized.

[Trauma reha score : How can we define the rehabilitation needs of the severely injured?] / Trauma-Reha-Score : Wie können wir den Rehabedarf Schwerverletzter definieren?

A seamless rehabilitation of polytrauma patients starting as early as possible is the primary goal in order to ensure long-term participation and quality of life. In reality, however, there is often still a large time gap between acute care and inpatient rehabilitation, the "rehab hole".The aim of the phase model of trauma rehabilitation is to ensure a complete rehabilitation chain. After acute patient care (phase A) and a potentially required early patient rehabilitation (phase B), trauma rehabilitation should seamlessly continue on to phase C.In order to identify those patients who require specialized phase C trauma rehabilitation before discharge from acute treatment, the DGOU trauma rehabilitation working group suggests a simple assessment. The trauma rehabilitation score (TRS) is based on two parts, a prescreening and a main screening. It supports the trauma surgeon at the end of the acute treatment with the needs-based indications for further rehabilitation and serves as an argumentation aid to the payers of the rehabilitation.In addition to the early rehabilitation Barthel index (FRB) for assessing the need for care and mobility, other relevant characteristics are recorded. From a rehabilitation point of view, a special effort arises from an increased diagnostic and therapeutic needs, through specialist care and treatment in nonorthopedic areas, extensive wound management, pain therapy measures, the provision of aids and special psychological care for the seriously injured.

[Prediction of Return to Work following Multiple Trauma in Patients with ISS of at least 25]. / Prädiktion des Return to Work nach Polytrauma bei Patienten mit einem ISS von 25 und höher.

PURPOSE: Survival rates after severe multiple trauma have continually increased in the last decades. Return to work (RTW) of persons affected by severe multiple trauma is important to assure their quality of life and social participation. Therefore, knowledge about aspects associated with RTW is essential for acute and rehabilitative care and treatment. Aim of the study is to analyze RTW in patients with multiple trauma and to identify predictors for RTW. METHODS: To identify aspects that predict RTW, 84 patients in working age and with ISS ≥ 25 were included in a mono-center study. Data were collected by using routine data of the German TraumaRegister DGU® and POLO chart, a standardized patient-reported outcome assessed during follow-up. Bivariate analyses (Chi-Quadrat-test, Wilcoxon Mann-Whitney-test, t-test) were used to test for associations with RTW. Selected variables were included in a logistic regression model to predict RTW. RESULTS: In total, 58% of patients returned to work during follow-up. Age, duration of treatment in ICU and time between admission and follow-up were selected as predictors for RTW. Self-reported general health was also crucial for RTW in patients, whereas pre-existing comorbidities or other stressful events do not contribute to the prediction of RTW. CONCLUSION: RTW of patients with severe multiple trauma is determined by several factors. Older patients with low general health have problems to return to previous work.

Variability in trunk and pelvic movement of transfemoral amputees using a C-leg system compared to healthy controls.

OBJECTIVE: Gait variability is a measure of gait disturbance, and therefore constitutes a useful parameter for gait assessment as well as planning of therapeutic and medical interventions. To date, variability during walking has not been adequately analyzed in amputees. The aim of this examination was to evaluate trunk and pelvic movement variability in transfemoral amputees. The effect of different types of walking surfaces on variability in trunk and pelvic movement was also studied. METHOD: This prospective clinical examination compares 20 transfemoral amputees (17 ♂, 42 ±â€¯16 years; 3 ♀, 48 ±â€¯3 years) with a group of 20 age and mass matched healthy controls regarding the extent of variability in trunk and pelvic movement. Kinematic data of trunk and pelvic movement during walking on level, uneven ground and slope was captured by eight infrared cameras (Vicon Nexus ™, Oxford, UK). Variability in trunk and pelvic movement was analyzed. Univariate ANCOVA and ANOVA with repeated measures and post hoc tests were used for statistical comparison. Fall history was retrospectively collected from medical history to assess the association between falls and variability in trunk and pelvic movement. RESULTS: Trunk and pelvic movement variability in amputees was significantly higher during walking on uneven ground and slope compared to healthy controls (p ≤ 0.05). Variability in trunk and pelvic movement was increased during walking on uneven ground and slope compared to even ground for both groups (p ≤ 0.05). CONCLUSION: Amputees showed increased trunk and pelvic movement variability during walking on uneven ground and slope, indicating an affected gait pattern in comparison to healthy controls. Therefore, trunk and pelvic movement variability could be a potential marker for gait quality with diagnostic implications.

[Pain Rehabilitation in CRPS]. / Schmerzrehabilitation beim CRPS.

Chronic pain can be distinguished into malignant and non-malignant pain, that is, in pain with no prospect of healing, e. g. Tumor pain, and pain, where there is a chance of recovery and a good quality of life. While tumor pain is primarily about adequate and rapid pain reduction, the therapeutic treatment concept of non-malignant chronic pain is based on the bio-psycho-social model of the International Classification of Functioning, Disability and Health (ICF).The restoration of everyday functions and participation are in particular focus, which is why it is appropriate to speak of "pain rehabilitation". The concept of pain rehabilitation under the direction of rehabilitation physicians, in collaboration with pain therapists and psychologists, ensures optimal seamless rehabilitation from a single source with the overall rehabilitation goal, in addition to the best possible quality of life, to restore participation, in particular to reach a successful reintegration into everyday life and working life.Using the example of the CRPS, the therapeutic and medicinal options of pain rehabilitation are presented. Focal points are the phase-appropriate physiotherapy and occupational therapy, supported by physical measures. Especially with the CRPS, an early diagnosis is crucial for the prognosis. Orthopedic surgeons are particularly required here, as are all other doctors who treat patients after injuries. The treatment of the CRPS remains challenging despite new therapeutic approaches and should be reserved for specialized outpatient departments and clinics in more complex and severe cases.

Relation between the amount of daily activity and gait quality in transfemoral amputees.

Gait variability is often associated with reduced coordination and increased instability during walking. Especially for patients with musculoskeletal conditions, variability in gait might be associated with the level of daily activity. Therefore, this study examines kinematic variability during walking and the association with daily activity in patients with transfemoral amputation. Therefore, 15 transfemoral amputees, using the C-leg prosthesis of Otto Bock, between 18 and 65 years were recruited during their hospital stay. All patients were able to walk without crutches in everyday life and were familiar with walking using the C-leg system. Gait parameters and data of variability were captured during walking in a gait laboratory by eight infrared cameras (Vicon). Daily activity was assessed using a three-dimensional acceleration sensor of VitaMove. Patients showed variability from 0.84° up to 1.96° in frontal pelvis motion and from 0.9° up to 4.02° in trunk obliquity. The results show a significant correlation between activity and variability in trunk (r = -0.58; P ≤ 0.05) and pelvis (r = -0.63; P ≤ 0.01) as well as gait velocity (r = 0.6; P ≤ 0.05). However, kinematic variability and gait velocity are not related to each other. In conclusion, the results show that kinematic gait variability is associated with the extent of activity and therefore presents an important parameter for assessing amputees' gait quality and daily activity.

[Rehabilitation after Traumatic Fracture of Thoracic and Lumbar Spine]. / Rehabilitation nach traumatischen Frakturen der Brust- und Lendenwirbelsäule.

On the basis of the S2-k guideline "Rehabilitation after traumatic fractures of the thoracic und lumbar spine without neurologic disorder", this article gives an overview of target-oriented rehabilitation of patients with minor fractures or those with column stability and unstable spinal fractures which are stabilised by surgery. To obtain early social and job related reintegration, outpatient or inpatient rehabilitation has to start immediately after treatment in hospital. Rehabilitation must be orientated towards the biopsychosocial model of ICF and has to be adapted for the patient. The overall goal of rehabilitation is functional restoration of patient health to enable participation in society, life and job. Individual goals may change during rehabilitation, because of differential progress in therapy. Pain management must be orientated towards individual requirements and mental health has to be tested early, especially in polytrauma patients. Disorders have to be treated by psychotherapy, because psychic stress supports chronification of pain. Generally early exercise and physiotherapy are recommended in the guideline, with patient education for health-seeking behavior. Otherwise an orthesis device is not really necessary for treatment of a stable fracture. To improve the outcome of rehabilitation aftercare, treatment has to be arranged during rehabilitation, especially for employed patients.

[Rehabilitation after Multiple Trauma]. / Rehabilitation nach Polytrauma.

Many polytrauma patients report significant long-term impairments to their physical and mental health, resulting in a reduction of their quality of life. In addition to the obvious physical accident sequences, psychological influences and the individual context factors pose special challenges to the rehabilitation team and the infrastructure of the facility. Professional reintegration and chronic pain are particularly common problems in the trauma rehabilitation. The central task of rehabilitation after accidents is the restoration or substantial improvement of the functional health and thus the reintegration into the social and professional environment. The overall rehabilitation goal is based on the biopsychosocial ICF model: the patient should achieve the best possible quality of life despite his functional impairments, and the workability and functional capability are to be restored as well as possible. This goal can only be reached after a lengthy process, in the course of which differentiated measures must be coordinated. This is the task of experienced doctors, therapists and rehabilitation managers, who accompany the patient permanently. The rehabilitation after serious accidents is to be distinguished from the "normal" orthopedic rehabilitation after elective interventions. The challenges of traumatic rehabilitation require special processes, infrastructures, as well as interrelated and coordinated rehabilitation phases. The three-phase model described in the "Weißbuch Schwerverletztenversorgung der DGU" has to be differentiated. Between the discharge from the acute care clinic and the beginning of the post-acute rehabilitation, a "rehabilitation hole" frequently occurs. The early rehabilitation, by definition, a part of the acute treatment, cannot adequately close this hole. A 6-phase model is proposed. Phase C of post-acute rehabilitation places particular demands on the rehabilitation facility. The further rehabilitation (phase E) provides specific measures, such as pain rehabilitation or activity-oriented procedures. A long-term follow-up of formerly seriously injured patients is necessary (phase F). An integration of trauma rehabilitation centers into the existing trauma network remains the long-term goal to improve the outcome after polytrauma.

[A phase model of trauma rehabilitation : How can we avoid the "rehab-hole"?] / Phasenmodell der Traumarehabilitation : Wie können wir das "Rehaloch" vermeiden?

Advances in the rescue chain and first aid of polytrauma patients, which have consequently increased their chance of survival, have led to an increase in demands for rehabilitation. However, there is still a large hole in the continuity of rehabilitation between acute patient care and in-patient rehabilitation, the so-called "rehab-hole". The consequences are untapped rehabilitation potential, loss of strength, endurance and motivation as well as impairment of function of the patient.Based on the phase model of neurological/neurosurgical rehabilitation, we propose a step model for the rehabilitation of polytrauma patients that ensures an uninterrupted chain of rehabilitation. After acute patient care (phase a) and a potentially required early patient rehabilitation (phase b), trauma rehabilitation should seamlessly continue on to phase c. The implementation of phase c after acute patient rehabilitation requires changes in the structure of "orthopaedic" rehabilitation clinics and financial support due the large consumption of resources by more complexly injured patients in this phase. The subsequent rehabilitation in phase d is well established and complies with current rehabilitation measures (AHB, BGSW). Further rehabilitation measures may be essential for social and occupational reintegration of the patient (phase e), depending on the complexity of their injuries after the accident. For patients with long-lasting results after an accident, it is crucial to implement continuous follow-ups (phase f) to ensure a better long-term outcome.In order to implement this phase model it is necessary to establish specialized facilities that meet the particular requirements needed for phase c. This tri-phased treatment model in trauma centres can therefore be used in trauma rehabilitation. In addition to the already established local and regional rehabilitation centres, nationwide trauma rehabilitation centres have adopted phase c rehabilitation.