Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties

PURPOSE

Ankle fractures are commonly occurring fractures, especially in the aging population, where they often present as fragility fractures. The disease burden and economic costs to the patient and society are considerable. Choosing accurate outcome measures for the evaluation of the management of ankle fractures in clinical trials facilitates better decision-making. This systematic review assesses the evidence for the measurement properties of patient-reported outcome measures (PROMs) used in the evaluation of adult patients with ankle fractures.

METHODS

Searches were performed in CINAHL, EMBASE, Medline and Google Scholar from the date of inception to July 2021. Studies that assessed the measurement properties of a PROM in an adult ankle fracture population were included. The included studies were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of PROMs.

RESULTS

In total, 13 different PROMs were identified in the 23 included articles. Only the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM) presented some evidence on content validity. The Olerud-Molander Ankle Score (OMAS) and Self-reported Foot and Ankle Score (SEFAS) displayed good evidence of construct validity and internal consistency. The measurement properties of the OMAS, LEFS and SEFAS were most studied.

CONCLUSION

The absence of validation studies covering all measurement properties of PROMs used in the adult ankle fracture population precludes the recommendation of a specific PROM to be used in the evaluation of this population. Further research should focus on validation of the content validity of the instruments used in patients with ankle fractures.

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BACKGROUND

The incidence of ankle fractures is increasing and the clinical outcome is highly variable.

QUESTION

What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?

DATA SOURCES

Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.

STUDY SELECTION

Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.

RESULTS

Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.

CONCLUSION

There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020184830.

Validity and reliability of the Australian Therapy Outcome Measures - Physiotherapy, for podiatry (AusTOMs-PT for use in podiatry)

Background

Valid and reliable outcome measure enable measurement of health care service impact. There are limited valid and reliable outcome measures for use in podiatry practice to measure the impact of treatment. This research aimed to test the face validity of the AusTOMs for Physiotherapy (AusTOMs-PT), it’s adaptability to podiatry clinical practice and the reliability of its use with podiatrists.

Methods

Stage 1 used a nominal group technique with podiatrists who worked in public and/or private settings. All podiatrists underwent self-directed training in the AusTOMs framework and measures prior to interviews or focus group discussion. Discussion was centred about transferability of the core scales of the AusTOMs-PT and an adjunct measure, AusTOMs for Occupational Therapy (AusTOMs-OT) to podiatry practice.

Stage 2 used 10 case studies representative of people who had foot or ankle concerns. Podiatrists were recruited and trained in the use of the relevant AusTOMs-PT scales. Podiatrists individually scored the cases at two timepoints (1 month apart) using the six scales from the AusTOMs-PT deemed by stage 1 as relevant to podiatry. Intra and inter-rater reliability of scales were determined using intraclass correlation coefficients (ICCs).

Results

Thirteen podiatrists participated in individual or focus group interviews in Stage 1. Consensus was gained on six of the nine core scales adopted from the AusTOMs-PT. These were 1. Balance and Postural Control, 3. Musculoskeletal Movement Related Functions, 4. Neurological Movement Related Functions, 5. Pain, 7. Sensory Functions, 8. Skin Functions. Each core scale rated the functional domains of Impairment, Activity Limitation, Participation Restriction and Wellbeing/Distress relating to that presentation of goals of the person in the case study.

There were 22 podiatrists complete training and scored two rounds of case studies using the six scales in Stage 2. There were 91%(n = 20) participants with an intra-rater ICC > 0.5 (moderate or greater). Each domain had an inter-rater reliability of > 0.9 (excellent) during the first round.

Conclusions

The AusTOMs-PT for use in podiatry may be implemented to record change in impairment, function, participation and wellbeing of people receiving podiatry treatment. Podiatry specific training and mentoring, together with repeated use could be expected to improve intra-reliability.

A systematic review of the measurement properties of patient reported outcome measures used for adults with an ankle fracture

BACKGROUND

Ankle fractures are painful and debilitating injuries that pose a significant burden to society and healthcare systems. Patient reported outcome measures (PROMs) are commonly used outcome measures in clinical trials of interventions for ankle fracture but there is little evidence on their validity and reliability. This systematic review aims to identify and appraise evidence for the measurement properties of ankle specific PROMs used in adults with an ankle fracture using Consensus Based Standards for the Selection of Health Measurement Instrument (COSMIN) methodology.

METHODS

We searched MEDLINE, Embase and CINAHL online databases for evidence of measurement properties of ankle specific PROMs. Articles were included if they assessed or described the development of the PROM in adults with ankle fracture. Articles were ineligible if they used the PROM to assess the measurement properties of another instrument. Abstracts without full articles and conference proceedings were ineligible, as were articles that adapted the PROM under evaluation without any formal justification of the changes as part of a cross-cultural validation or translation process. Two reviewers completed the screening. To assess methodological quality we used COSMIN risk of bias checklist and summarised evidence using COSMIN quality criteria and a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Two reviewers assessed the methodological quality and extracted the data for a sample of articles.

RESULTS

The searches returned a total of 377 articles. From these, six articles were included after application of eligibility criteria. These articles evaluated three PROMs: A-FORM, OMAS and AAOS. The A-FORM had evidence of a robust development process within the patient population, however lacks post-formulation testing. The OMAS showed sufficient levels of reliability, internal consistency and construct validity. The AAOS showed low quality evidence of sufficient construct validity.

CONCLUSIONS

There is insufficient evidence to support the recommendation of a particular PROM for use in adult ankle fracture research based on COSMIN methodology. Further validation of these outcome measures is required in order to ensure PROMs used in this area are sufficiently valid and reliable to assess treatment effects. This would enable high quality, evidenced-based management of adults with ankle fracture.

Primary outcome measures used in interventional trials for ankle fractures: a systematic review

Background

Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture.

Methods

We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type.

Results

The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s.

Conclusion

This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.

Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems

Recovery after ankle fractures places a considerable burden on patients both short and long term. Numerous tools called patient-reported outcome measures (PROMs) have been developed to measure the outcome of ankle fractures. They can assist clinicians to measure the effect, guide intervention, and assess the rate of recovery. We identified and evaluated the psychometric properties of PROMs used in the assessment of ankle fractures. In a systematic search, we examined 4 databases from inception to December 4, 2016. Search terms included ankle fracture, ankle pain, disability, gait, questionnaire, and PROMs. Reference lists were also examined. The inclusion criteria were English studies and adult populations. The psychometric properties of the identified PROMs were examined, including internal consistency, test-retest reliability, validity, floor-ceiling effects, and minimally important clinical differences. We identified 22 PROMs relating to ankle pain and disability. Only 5 were specifically used for ankle fractures. The 36-item short-form health survey and short musculoskeletal functional assessment reported floor-ceiling effects, and the lower extremity functional scale reported good responsiveness and content validity, although these are not tools specifically related to ankle fractures. The ankle-fracture outcome of rehabilitation measure (A-FORM) and the Olerud and Molander questionnaire were ankle fracture specific and assessed for internal consistency and validity. Clinicians should use the most appropriate PROM to evaluate patients' recovery from ankle fractures. The A-FORM currently has the most appropriate evidence supporting its use as a PROM for ankle fracture management and rehabilitation.

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial

Background

Following surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks’ immobilisation in a below-knee cast.

Method/design

We have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included.

Discussion

The EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines.

Trial registration

ISRCTN, ID: ISRCTN11212729. Registered retrospectively on 20 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2691-7) contains supplementary material, which is available to authorized users.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN

Case series.

BACKGROUND

Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures.

CASE DESCRIPTION

Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline.

OUTCOMES

Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

DISCUSSION

Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

LEVEL OF EVIDENCE

Therapy, level 4.

Radiographic imaging for traumatic ankle injuries: a demand profile and investigation of radiological reporting timeframes from an Australian tertiary facility

BACKGROUND

Radiographic examinations of the ankle are important in the clinical management of ankle injuries in hospital emergency departments. National (Australian) Emergency Access Targets (NEAT) stipulate that 90 percent of presentations should leave the emergency department within 4 hours. For a radiological report to have clinical usefulness and relevance to clinical teams treating patients with ankle injuries in emergency departments, the report would need to be prepared and available to the clinical team within the NEAT 4 hour timeframe; before the patient has left the emergency department. However, little is known about the demand profile of ankle injuries requiring radiographic examination or time until radiological reports are available for this clinical group in Australian public hospital emergency settings.

METHODS

This study utilised a prospective cohort of consecutive cases of ankle examinations from patients (n = 437) with suspected traumatic ankle injuries presenting to the emergency department of a tertiary hospital facility. Time stamps from the hospital Picture Archiving and Communication System were used to record the timing of three processing milestones for each patient's radiographic examination; the time of image acquisition, time of a provisional radiological report being made available for viewing by referring clinical teams, and time of final verification of radiological report.

RESULTS

Radiological reports and all three time stamps were available for 431 (98.6%) cases and were included in analysis. The total time between image acquisition and final radiological report verification exceeded 4 hours for 404 (92.5%) cases. The peak demand for radiographic examination of ankles was on weekend days, and in the afternoon and evening. The majority of examinations were provisionally reported and verified during weekday daytime shift hours.

CONCLUSIONS

Provisional or final radiological reports were frequently not available within 4 hours of image acquisition among this sample. Effective and cost-efficient strategies to improve the support provided to referring clinical teams from medical imaging departments may enhance emergency care interventions for people presenting to emergency departments with ankle injuries; particularly those with imaging findings that may be challenging for junior clinical staff to interpret without a definitive radiological report.