Accelerated rehabilitation after proximal femoral fracture: a randomized controlled trial

Influence of patient's dressing on spontaneous physical activity and length of hospital stay in surgical patients

Wearing hospital gown (HG) as opposed to plain-clothes (PC) may contribute to the general state of inactivity of hospitalised patients. We designed a randomized study to determine the influence of clothing on the level of spontaneous physical activity (SPA) and to assess the length of hospital stay. Using triaxial accelerometry we measured the SPA in two groups of surgical patients, before and after an elective operation. Twenty eight patients received instructions to wear plain-clothes (group PC) during their stay in the hospital as soon as possible from a surgical point of view. Twenty-nine patients, serving as a control group, did not receive any specific instructions and as a result, were mostly wearing hospital gowns (group HG). Following the admission to the hospital, both groups showed a 50% decrease in SPA when compared to the recordings obtained during the last 24 hours spent at home. During the postoperative period, the SPA increased progressively in both groups. Although patients in group PC tended to be more active than those in the control group, the SPA was not significantly different (P = 0.4). Similarly, patients in group PC left the hospital 10 hours earlier than patients in group HG (P = 0.4). The power of our study was nevertheless low and a sample size of 700 patients might show statistically significant results. We conclude that wearing plain-clothes when hospitalized for elective surgery is not associated with complications and could be included in postoperative rehabilitation program.

Treatment strength in rehabilitation

OBJECTIVE

To propose treatment strength as central to an understanding of rehabilitation treatment, to delineate its features, to examine related research, and to suggest ways to improve the specification and conceptualization of treatment.

DATA SOURCES

Published literature.

STUDY SELECTION

Definitions were proposed for treatment strength components: purity, specificity, dose, intensity, duration, timing, and treater characteristics and organization. Three measures of treatment exposure were selected as having the most research: length of inpatient stay, treatment intensity, and treatment specificity (using as example the stroke rehabilitation unit). Length of stay information was selected primarily from studies using multifacility data systems. All studies identified as using greater treatment intensity or augmented treatment were selected. Because of the large literature on stroke units, selected studies were chosen that used randomized controlled trials or community-based data.

RESULTS

Greater treatment exposure, as measured by length of stay, generally results in greater benefit, although there are wide variations for a given condition over time and across countries. Research on treatment intensity uses various definitions for intensity with mixed results. Specialization, in the form of the stroke rehabilitation unit, generally produces superior outcomes than other types of care, although there is little investigation of the reasons for benefit.

CONCLUSIONS

Understanding of rehabilitation treatment would be improved by (1) routinely reporting hours of service by discipline, (2) using treatment strength concepts, (3) analyzing the relation of naturally occurring variations of treatment strength to outcomes, and (4) developing a taxonomy of treatment types.

Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial

OBJECTIVE

To determine the effect of a home exercise program on strength, postural control, and mobility following hip fracture.

DESIGN

Randomized controlled trial of 1 month's duration.

SETTING

Daily exercise carried out within the subjects' home environments.

PARTICIPANTS

Forty-two people 64 to 94 years of age, 35 of whom were living independently in the community and 7 of whom were residing in institutional care. Subjects were recruited on average 7 months after a fall-related hip fracture and randomly allocated to either the intervention or the control group (n = 21 each). The groups were well matched in terms of medical conditions, medication use, disability, and activity levels.

INTERVENTION

A "home-based" program of weight-bearing exercise established at a visit by a physiotherapist.

MAIN OUTCOME MEASURES

Quadriceps strength, postural sway, functional reach, weight-bearing ability, walking velocity, and self-rated fall risk. The subjects undertook these assessments at the beginning and end of the trial.

RESULTS

At pretest, exercisers and controls performed similarly in all tests. At the end of the trial, the intervention group showed significantly greater quadriceps strength in the affected (hip-fractured) leg and increased walking velocity. The intervention subjects also improved their weight-bearing ability and reported reduced subjective falls risk. In contrast, there were no significant improvements in any of the test measures in the controls. Within the intervention group, improvements in quadriceps strength were significantly associated with improved performances in the weight-bearing test measures and with increased walking velocity.

CONCLUSIONS

This exercise program improved strength and mobility following hip fracture. Further research is needed to ascertain whether the extent of this improvement in these fall risk factors is sufficient to prevent falls.

Cohort study of risk of institutionalisation after hip fracture

The purpose of this study was to describe the rate of permanent placement in aged care institutions (nursing homes and hostels) after hip fracture and to assess whether or not hip fracture is an independent risk factor for institutionalisation. It was a cohort study with median follow-up time of 14 months. Subjects were 291 people living in the community in western Sydney: 13] with hip fractures and 160 controls. Permanent admission to an aged care institution and/or death during follow-up was assessed by telephone interview with study subjects of carers. Data on potential confounders were collected with an interviewer-administered questionnaire at the time of recruitment into the study. During follow-up, 27 per cent of hip fracture cases and 5 per cent of controls were admitted to an aged care institution. The age- and sex-adjusted hazard ratio for hip fracture and institutionalisation was 5.1 (95 per cent confidence interval (CI) 2.2 to 11.9). Adjusting for multiple health-related factors reduced the strength of association but the hazard ratio remained high at 4.0 (CI 1.7 to 9.5). The risk of institutionalisation after hip fracture is high; this is only partly explained by the poor pre-fracture health status of many people who fracture their hips.

Preoperative assessment and postoperative management of the elderly surgical patient

The population undergoing surgery is aging and this trend will continue for many decades to come. Better anaesthetic and surgical techniques are lowering the risk-benefit ratio for surgery, making it an increasingly attractive treatment option. Good preoperative assessment and postoperative management form an integral part of strategies to minimise morbidity and mortality while maximising hospital efficiency.

Orthopaedic and trauma surgery

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Critical path analysis for the management of fractured neck of femur

The aim of this study was to determine the effect of a critical path analysis, used as a management tool, on the efficiency of clinical service delivery for patients with a fractured neck of femur. It is a before-and-after study of the medical records of all patients admitted between October 1992 and October 1993 with a primary diagnosis of fractured neck of femur, but excluding patients under 50 years old and those with multiple fractures or metastatic disease. Patients fell into two groups: those admitted in the six months before the introduction of a clinical management program based on a critical path analysis, and those admitted after the introduction of the program in April 1993 (88 program cases and 90 nonprogram cases). A medical records administrator blinded to the program category of the patients independently coded diagnostic data, while other data were abstracted from the clinical notes. The length of stay for a fractured neck of femur declined from a mean of 19.3 days to a mean of 11.0 days (P < 0.0001). The outcome measures were: the distance walked just before discharge from hospital, the discharge destination, and unplanned readmission. These did not change significantly, and the wound infection rate declined during the period of the intervention. The implementation of a clinical management pathway based on a critical path analysis dramatically reduced the length of stay for patients admitted with a fractured neck of femur while maintaining quality of outcomes. Critical path analysis is a useful management tool to improve the efficiency of certain clinical services.

Cost effectiveness of accelerated rehabilitation after proximal femoral fracture

A randomised controlled trial comparing an accelerated rehabilitation program after proximal femoral fracture with conventional care and rehabilitation was conducted with 252 elderly patients treated at an Australian general hospital in 1989/1990. This paper presents a cost-effectiveness analysis of the accelerated rehabilitation program. The measure of cost was all direct costs of treatment and subsequent care (medical and non-medical) incurred during the 4 months after fracture. Effectiveness was defined as whether the patient returned to semi-independent living; or if moderately or severely disabled prior to the fracture to the premorbid level of physical independence. The cost for treatment up to 4 months after fracture was estimated at A$ 10,600 per accelerated rehabilitation patient and A$ 12,800 per conventional care patient (1990 Australian dollars, A$). Thus, accelerated rehabilitation releases resources equivalent to approximately 17% of costs for treatment per patient. When cost effectiveness is considered, the potential cost savings rise to 38% per recovered patient.

External hip protectors: likely non-compliance among high risk elderly people living in the community

The factors that may influence compliance with wearing of external hip protectors by potential users living in the community were investigated. Elderly women (median age 83 years) who were hospitalised after fracture, joint replacement or falls and were expected to return to community living participated. Five focus groups were conducted. Most participants said they would not use the hip protector demonstrated. The main objections were a perceived lack of comfort in wearing the appliance, particularly in bed, coupled with the belief that they were not at high risk. Other lesser issues were the extra effort needed to wear the device, appearance, accuracy of fit, cost and unfamiliarity with the protectors. These findings suggest that, in general, high risk elderly women living in the community will be unlikely to use external hip protectors unless there is considerable encouragement from family members and/or health professionals. Educational programmes could reduce some misconceptions about hip fracture, and reinforce the benefits of wearing a protective appliance. They may also increase awareness of personal risk. An introductory period of supervised wearing of the hip protectors, while in hospital or respite care, may enhance compliance.

Carer burden after proximal femoral fracture

This carer study forms part of a wider study which compares accelerated rehabilitation after proximal femoral fracture with conventional care. Two measures of burden on family caregivers were used; social worker's assessment of overall burden and an index of disruption to carers' lives. Participants were carers of 200 patients interviewed at five periods up to 12 months after fracture. Carer burden prior to the fracture was the strongest predictor of subsequent burden, with carers of patients in nursing homes and patients with a cognitive or physical disability being more burdened. Carer burden may increase or decrease after the patient's injury, irrespective of randomization group. There is no simple relationship between burden and randomized group. Accelerated rehabilitation does not impact greatly on carer burden, but already severely burdened carers may benefit from additional counselling/information. Specific ways in which carers; lives were disrupted are reported.