- Email: [email protected]
A national review of two orthopaedic rehabilitation pathways: hip fracture and total knee replacement (TKR)
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
score on FMA) and 8.8% (+5.8 score on FMA) respectively in upper limb impairments at post-intervention from baseline. Changes were maintained for the sub-acute group but decreased by 4.2% for the chronic group at follow-up. All participants felt that the robot therapy was a positive experience but some participants felt tDCS was uncomfortable. After the trial, the participants felt major improvements in their upper limb impairments however they were still experiencing difficulties when picking up objects with their affected hand. Conclusion(s): Our results suggest that the intervention was feasible and that robot therapy for the arm is of benefit in the sub-acute and chronic phase however, adding tDCS did not result in an additional effect on upper limb impairment. Future research should include larger trials exploring different types and modes of non-invasive brain stimulation with intensive upper limb rehabilitation programmes. Implications: A significant larger improvement in upper limb impairment was found in people with sub-acute stroke indicating that the potential effectiveness of integrating intensive robot therapy within standard rehabilitation programmes in early stages of stroke needs to be explored. Keywords: Upper limb impairments; Stroke; Rehabilitation Funding acknowledgements: We thank Wessex Medical Trust, Strategic Educational Pathways Scholarships, University of Southampton and the participants for their time and contribution. Ethics approval: NRES Committee South Central – Southampton B (11/SC/0345). http://dx.doi.org/10.1016/j.physio.2015.03.1475 Special Interest Report Platform Presentation Number: SI-PL-2475 Monday 4 May 2015 14:18 Rooms 328–329 A NATIONAL REVIEW OF TWO ORTHOPAEDIC REHABILITATION PATHWAYS: HIP FRACTURE AND TOTAL KNEE REPLACEMENT (TKR) R. ten Hove Chartered Society of Physiotherapy, Practice and Development, London, United Kingdom Background: A national review of two orthopaedic rehabilitation pathways, focused on TKR and hip fracture, was undertaken in response to an invitation from the British Orthopaedic Association (BOA) to contribute to its national review of the state of orthopaedics in England (entitled ‘Getting It Right First Time’, or ‘GIRFT’). Due to the increasing age of the population, in the UK and throughout the world, the incidence of hip fracture is a major health concern. In the UK 76,000 people year suffer a hip
eS1497
fracture; the incidence is projected to rise. Hip fracture carries with it a high risk of mortality. Only 30% of people fully recover, the rest are left with long-term disability. Also significant costs to health and social care, £2billion in England in 2013. TKR rehabilitation is an area of high activity for UK physiotherapists. Over 100,000 were performed in the UK in 2013. The existence of a large number of post-operative protocols highlights the likelihood of wide variation in practice. Purpose: The review objectives were to identify best practice; highlight challenges within each patient pathway; and recommend improvements to reduce variation and optimise the quality of patient outcomes and experience. Methods: • Stage 1 involved secure online data collection, sought from all orthopaedic physiotherapy services leads in NHS trusts in England, in both acute and community settings. • Stage 2, involved visits to 15 NHS trusts at which interviews were undertaken with orthopaedic physiotherapists, representing the whole patient pathway. Visits were organised to ensure a breadth of geographical location and representation from Trusts with above and below average length of stay for hip fracture patients. • A review of the evidence base for rehabilitation was undertaken, while expert contributions from related specialist physiotherapy networks were secured to inform the survey and its evaluation. Results: Both survey and interviews identified some excellent examples of rehabilitation along both pathways. Broadly, the general the findings were as follows: • Variation in rehabilitation practice • Under-resourced services for the delivery of seven-day services and rehabilitation at • Lack of emphasis on rehabilitation at an adequate intensity and frequency to optimise patient progression and outcomes • A lack of integrated commissioning and provision of rehabilitation services, resulting in many hip fracture patients not being able to access the level of rehabilitation that would enable them to meet their individual goals. Conclusion(s): The review showed that well-designed and appropriately funded physiotherapy services provide excellent rehabilitation for patients recovering from a hip fracture or TKR. These services provide early, intensive rehabilitation focused on regaining function and well-being. For hip fracture patients, it is important that this is continued after discharge to allow them to get back to daily activities. However, these services are not universally available across the country, with variation in provision highlighted. Implications: The review provides the strong scope to lobby commissioners to adopt its recommendations to improve patient care and cost-effectiveness. It also
eS1498
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
highlighted the value of developing best practice guidance to reduce variations in practice for these pathways. Keywords: Semi-structured interviews; Hip fracture; Total knee replacement Funding acknowledgements: The visits were funded by the CSP. Ethics approval: Ethics approval was not required. http://dx.doi.org/10.1016/j.physio.2015.03.1476 Research Report Platform Presentation Number: RR-PL-1240 Saturday 2 May 2015 11:07 Rooms 328–329 ANTERIOR CRUCIATE LIGAMENT INJURY ABOUT 20 YEARS POST-TREATMENT: A KINEMATIC ANALYSIS OF ONE-LEG VERTICAL JUMP E. Tengman, H. Grip, J. Markström, C. Häger Umeå University, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå, Sweden Background: Injury of the anterior cruciate ligament (ACL) may lead to reduced knee function. The impact of the injury in the long term is debatable, due partly to the scarcity of physical tests that evaluate jump performance and movement pattern long after injury. Purpose: The aim was to examine jump height and knee kinematics during single-legged Vertical Jump (VJ) on average 23 ± 2 years after unilateral ACL injury in persons treated with surgery in combination with physiotherapy, or physiotherapy only. These were compared to non-injured controls. Methods: 3D kinematics (Oqus, Qualisys® , 240 Hz) during three VJs were explored in 70 persons after unilateral ACL injury (KACL-study); 33 (46 ± 5 yrs, 21 men) had been treated with physiotherapy and ACL reconstruction (ACLR ) and 37 (48 ± 6 yrs, 23 men) with physiotherapy alone (ACLPT ). We also tested 33 age-and-gender matched controls (47 ± 5 yrs, 21 men). We analysed means of the three jumps for: 1) jump height and 2) maximal knee joint angles (flexion, abduction/adduction, and internal/external rotation) during Take-Off and Landing phases. ANOVAs were used for comparison of data between groups (injured knee compared to control’s dominant knee) and paired t-tests for comparison between injured and non-injured leg. Results: Both ACLR (p = 0.006) and ACLPT (p < 0.001) had a lower mean jump height using the injured leg compared to the non-injured leg, while controls had no leg difference in jump height (p = 0.062). Nevertheless, ACLR had similar mean jump height as controls both for the injured and noninjured leg, while ACLPT had a lower jump height using the injured leg (p = 0.031) compared to controls. Regarding knee joint kinematics, ACL-injured displayed leg asymmetries
while controls did not. ACLR had less internal knee rotation of the injured compared to the non-injured knee at Landing (p = 0.032). ACLPT had less knee internal rotation at Take-off (p = 0.011) and less knee flexion and internal rotation at Landing (p = 0.012 and p = 0.001, respectively) compared to the non-injured knee. As for group comparisons, ACLR showed similar movement patterns to controls, while the injured leg of ACLPT displayed less knee flexion and less internal rotation at Take-off (p = 0.003 and p = 0.017 respectively) and at Landing (p < 0.001 and p = 0.031 respectively) compared to controls. No group differences were seen for the non-injured knee. Conclusion(s): Persons with an ACL injury have a decreased jump capacity and altered knee joint kinematics during VJ on their injured leg more than 20 years post injury. The kinematic alterations during VJ seem more evident for those who have been treated with physiotherapy alone, while those who have undergone surgery have movement patterns similar to controls. ACLR also have similar hop height to controls. There is a growing evidence of consequences on knee function in the very long-term after ACL injury, including changes in movement patterns, which may be important in relation to developing knee osteoarthritis. Such analyses are under way. Implications: Increased testing of physical capacity and movement patterns in the short and long term after ACL injury may be warranted. Keywords: Biomechanics; Movement pattern; Jump performance Funding acknowledgements: Swedish Scientific Research Council (Häger); Umeå University, Umeå School of Sport Science, Västerbotten county council; Swedish Association for Rheumatology. Ethics approval: The project was approved by the Regional Ethical Review Board in Umeå, Sweden. http://dx.doi.org/10.1016/j.physio.2015.03.1477 Research Report Platform Presentation Number: RR-PL-1530 Monday 4 May 2015 13:56 Rooms 300–301 ANTERIOR CRUCIATE LIGAMENT INJURY ABOUT 20 YEARS POST-TREATMENT: A KINEMATIC ANALYSIS OF ONE-LEG SIDE HOPS F. Bergman, E. Tengman, H. Grip, C. Häger Umeå University, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå, Sweden Background: Rupture of the anterior cruciate ligament (ACL) is a common injury to the knee joint and often occurs during landing after a jump, when changing motion direction, during decelerations or side-cutting manoeuvres. Hop
score on FMA) and 8.8% (+5.8 score on FMA) respectively in upper limb impairments at post-intervention from baseline. Changes were maintained for the sub-acute group but decreased by 4.2% for the chronic group at follow-up. All participants felt that the robot therapy was a positive experience but some participants felt tDCS was uncomfortable. After the trial, the participants felt major improvements in their upper limb impairments however they were still experiencing difficulties when picking up objects with their affected hand. Conclusion(s): Our results suggest that the intervention was feasible and that robot therapy for the arm is of benefit in the sub-acute and chronic phase however, adding tDCS did not result in an additional effect on upper limb impairment. Future research should include larger trials exploring different types and modes of non-invasive brain stimulation with intensive upper limb rehabilitation programmes. Implications: A significant larger improvement in upper limb impairment was found in people with sub-acute stroke indicating that the potential effectiveness of integrating intensive robot therapy within standard rehabilitation programmes in early stages of stroke needs to be explored. Keywords: Upper limb impairments; Stroke; Rehabilitation Funding acknowledgements: We thank Wessex Medical Trust, Strategic Educational Pathways Scholarships, University of Southampton and the participants for their time and contribution. Ethics approval: NRES Committee South Central – Southampton B (11/SC/0345). http://dx.doi.org/10.1016/j.physio.2015.03.1475 Special Interest Report Platform Presentation Number: SI-PL-2475 Monday 4 May 2015 14:18 Rooms 328–329 A NATIONAL REVIEW OF TWO ORTHOPAEDIC REHABILITATION PATHWAYS: HIP FRACTURE AND TOTAL KNEE REPLACEMENT (TKR) R. ten Hove Chartered Society of Physiotherapy, Practice and Development, London, United Kingdom Background: A national review of two orthopaedic rehabilitation pathways, focused on TKR and hip fracture, was undertaken in response to an invitation from the British Orthopaedic Association (BOA) to contribute to its national review of the state of orthopaedics in England (entitled ‘Getting It Right First Time’, or ‘GIRFT’). Due to the increasing age of the population, in the UK and throughout the world, the incidence of hip fracture is a major health concern. In the UK 76,000 people year suffer a hip
eS1497
fracture; the incidence is projected to rise. Hip fracture carries with it a high risk of mortality. Only 30% of people fully recover, the rest are left with long-term disability. Also significant costs to health and social care, £2billion in England in 2013. TKR rehabilitation is an area of high activity for UK physiotherapists. Over 100,000 were performed in the UK in 2013. The existence of a large number of post-operative protocols highlights the likelihood of wide variation in practice. Purpose: The review objectives were to identify best practice; highlight challenges within each patient pathway; and recommend improvements to reduce variation and optimise the quality of patient outcomes and experience. Methods: • Stage 1 involved secure online data collection, sought from all orthopaedic physiotherapy services leads in NHS trusts in England, in both acute and community settings. • Stage 2, involved visits to 15 NHS trusts at which interviews were undertaken with orthopaedic physiotherapists, representing the whole patient pathway. Visits were organised to ensure a breadth of geographical location and representation from Trusts with above and below average length of stay for hip fracture patients. • A review of the evidence base for rehabilitation was undertaken, while expert contributions from related specialist physiotherapy networks were secured to inform the survey and its evaluation. Results: Both survey and interviews identified some excellent examples of rehabilitation along both pathways. Broadly, the general the findings were as follows: • Variation in rehabilitation practice • Under-resourced services for the delivery of seven-day services and rehabilitation at • Lack of emphasis on rehabilitation at an adequate intensity and frequency to optimise patient progression and outcomes • A lack of integrated commissioning and provision of rehabilitation services, resulting in many hip fracture patients not being able to access the level of rehabilitation that would enable them to meet their individual goals. Conclusion(s): The review showed that well-designed and appropriately funded physiotherapy services provide excellent rehabilitation for patients recovering from a hip fracture or TKR. These services provide early, intensive rehabilitation focused on regaining function and well-being. For hip fracture patients, it is important that this is continued after discharge to allow them to get back to daily activities. However, these services are not universally available across the country, with variation in provision highlighted. Implications: The review provides the strong scope to lobby commissioners to adopt its recommendations to improve patient care and cost-effectiveness. It also
eS1498
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
highlighted the value of developing best practice guidance to reduce variations in practice for these pathways. Keywords: Semi-structured interviews; Hip fracture; Total knee replacement Funding acknowledgements: The visits were funded by the CSP. Ethics approval: Ethics approval was not required. http://dx.doi.org/10.1016/j.physio.2015.03.1476 Research Report Platform Presentation Number: RR-PL-1240 Saturday 2 May 2015 11:07 Rooms 328–329 ANTERIOR CRUCIATE LIGAMENT INJURY ABOUT 20 YEARS POST-TREATMENT: A KINEMATIC ANALYSIS OF ONE-LEG VERTICAL JUMP E. Tengman, H. Grip, J. Markström, C. Häger Umeå University, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå, Sweden Background: Injury of the anterior cruciate ligament (ACL) may lead to reduced knee function. The impact of the injury in the long term is debatable, due partly to the scarcity of physical tests that evaluate jump performance and movement pattern long after injury. Purpose: The aim was to examine jump height and knee kinematics during single-legged Vertical Jump (VJ) on average 23 ± 2 years after unilateral ACL injury in persons treated with surgery in combination with physiotherapy, or physiotherapy only. These were compared to non-injured controls. Methods: 3D kinematics (Oqus, Qualisys® , 240 Hz) during three VJs were explored in 70 persons after unilateral ACL injury (KACL-study); 33 (46 ± 5 yrs, 21 men) had been treated with physiotherapy and ACL reconstruction (ACLR ) and 37 (48 ± 6 yrs, 23 men) with physiotherapy alone (ACLPT ). We also tested 33 age-and-gender matched controls (47 ± 5 yrs, 21 men). We analysed means of the three jumps for: 1) jump height and 2) maximal knee joint angles (flexion, abduction/adduction, and internal/external rotation) during Take-Off and Landing phases. ANOVAs were used for comparison of data between groups (injured knee compared to control’s dominant knee) and paired t-tests for comparison between injured and non-injured leg. Results: Both ACLR (p = 0.006) and ACLPT (p < 0.001) had a lower mean jump height using the injured leg compared to the non-injured leg, while controls had no leg difference in jump height (p = 0.062). Nevertheless, ACLR had similar mean jump height as controls both for the injured and noninjured leg, while ACLPT had a lower jump height using the injured leg (p = 0.031) compared to controls. Regarding knee joint kinematics, ACL-injured displayed leg asymmetries
while controls did not. ACLR had less internal knee rotation of the injured compared to the non-injured knee at Landing (p = 0.032). ACLPT had less knee internal rotation at Take-off (p = 0.011) and less knee flexion and internal rotation at Landing (p = 0.012 and p = 0.001, respectively) compared to the non-injured knee. As for group comparisons, ACLR showed similar movement patterns to controls, while the injured leg of ACLPT displayed less knee flexion and less internal rotation at Take-off (p = 0.003 and p = 0.017 respectively) and at Landing (p < 0.001 and p = 0.031 respectively) compared to controls. No group differences were seen for the non-injured knee. Conclusion(s): Persons with an ACL injury have a decreased jump capacity and altered knee joint kinematics during VJ on their injured leg more than 20 years post injury. The kinematic alterations during VJ seem more evident for those who have been treated with physiotherapy alone, while those who have undergone surgery have movement patterns similar to controls. ACLR also have similar hop height to controls. There is a growing evidence of consequences on knee function in the very long-term after ACL injury, including changes in movement patterns, which may be important in relation to developing knee osteoarthritis. Such analyses are under way. Implications: Increased testing of physical capacity and movement patterns in the short and long term after ACL injury may be warranted. Keywords: Biomechanics; Movement pattern; Jump performance Funding acknowledgements: Swedish Scientific Research Council (Häger); Umeå University, Umeå School of Sport Science, Västerbotten county council; Swedish Association for Rheumatology. Ethics approval: The project was approved by the Regional Ethical Review Board in Umeå, Sweden. http://dx.doi.org/10.1016/j.physio.2015.03.1477 Research Report Platform Presentation Number: RR-PL-1530 Monday 4 May 2015 13:56 Rooms 300–301 ANTERIOR CRUCIATE LIGAMENT INJURY ABOUT 20 YEARS POST-TREATMENT: A KINEMATIC ANALYSIS OF ONE-LEG SIDE HOPS F. Bergman, E. Tengman, H. Grip, C. Häger Umeå University, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå, Sweden Background: Rupture of the anterior cruciate ligament (ACL) is a common injury to the knee joint and often occurs during landing after a jump, when changing motion direction, during decelerations or side-cutting manoeuvres. Hop