Acute Hip Fracture Rehabilitation

Acute Hip Fracture Rehabilitation Michelle Fitzgerald BSc, MSc, MISCP Senior Physiotherapist, Tallaght Hospital, Dublin 4 th National Irish Hip Fracture Conference RCSI 18th November 2015

Mobilise with physio

Overview 1. Why mobility is important 2. The evidence base 3. Research study 4. The plan for 2016

Background Senior Physiotherapist, Tallaght Hospital MSc Neuromusculoskeletal Physiotherapy UCD Hip fracture research, audit & quality improvement National hip fracture steering group member Irish National Orthopaedic Register Global Fragility Fracture Network Clinical interest group orthopaedics (CPO, IPONG)

The Hip Attack 10% Die within a month Stretch Health System Hip Fractures 33% Die within a year 25% Long Term Care 50% Unable to walk unaided (British Orthopaedic Association 2007, Cummings and Melton., 2002, Department of Health 2013, Hall et al., 2000, Keen, 2003, McGowan et al., 2013)

What predicts mortality?

What predicts hip fracture mortality? Age Gender Medical fitness Comorbidities Cognition Etc Etc

Anything else?

What else predicts mortality? Early mobility

Early Mobility is Important Post-Op Long-Term Mobility Survival + Function (Boonen et al., 2004, Dubljanin-Raspopovic et al., 2013, Hirose et al., 2010)

Active Acute Rehabilitation Maximises recovery Successful discharge home Decreases length of stay Reduce overall cost (Laflamme et al 2012, Kristenson et al 2007, NICE 2010, Beaupre et al 2013, BOA 2010)

Rehabilitation of hip fractures is the central challenge for trauma services (British Orthopaedic Association 2007)

Review of Rehabilitation Amount of rehab varies widely in acute hospitals Confidence in rehabilitation progression More intense post-operative physio Barriers identified No data in Ireland Time for change (British Orthopaedic Association 2015, Health Service Executive, 2012, National Institute for Health and Clinical Excellence, 2011, Ranhoff et al., 2010, Svensson et al., 1996, Thomas et al., 2007)

Time for Change in Ireland In order to get better we need to measure what we are currently doing. First step in effecting change: Add function specific data-fields to the IHFD Functional progress Rehabilitation service provision Effect of hospital approaches

Irish Hip Fracture Physio Working Group Irish Physiotherapy Hip Fracture Working Group Edel Callanan (Orthopaedic QCCD therapy lead) Dr C Blake & Dr C Cunningham (UCD) Michelle Fitzgerald (Senior Physiotherapist) ADPATE framework for guideline adaptation

Databases International Guidelines Direct Communication

(ANZHFR 2014, NICE 2011, Waddell 2011, SIGN 2009, BOA 2007) Care Standard Guideline Synopsis Physio assessment First postoperative day Frequency of mobilisation Daily (7days) Rehabilitation Early, MDT Discharge planning Early, MDT, individualised Type of physiotherapy Multidimensional

Standardised Outcome Measures Hip fracture mobility measures vary widely Feasible in clinical practice Valid and reliable Hip fracture population Predict outcome Comparison and research (Foss et al., 2006, Farag et al., 2012, Hollman et al., 2008, Laflamme et al., 2012, Kristensen et al., 2009b, Kristensen et al., 2007)

New Mobility Score NMS Category Score Functional ability 0 Not at all 1 Assistance of one person 2 With an aid 3 No difficulty/no aid Indoor walking, outdoor walking, shopping

New Mobility Score NMS Category Score Functional ability 0 Not at all 1 Assistance of one person 2 With an aid 3 No difficulty/no aid Overall Score: 0-9

Cumulated Ambulatory Score (CAS) CAS Category Score Functional Ability 0 Not at all 1 Assistance 1-2 people 2 Independent Bed mobility, STS, mobilisation

Cumulated Ambulatory Score (CAS) CAS Category Score Functional Ability 0 Not at all 1 Assistance 1-2 people 2 Independent Overall Score: 0-6

Predictors of Mobility Outcome at One Week Post Hip Fracture Surgery Michelle Fitzgerald 1, Blake, C 2. Askin, D 3. Coughlan, T 3. Quinlan, J 3. Cunningham, C 2. 1 Physiotherapy Department & Bone and Joint Unit 2, Tallaght Hospital 3 School Of Public Health, Physiotherapy & Population Science, UCD

What should we do? Optimise early mobility Influencing factors Rehabilitation Planning (Health Service Executive, 2012, National Institute for Health and Clinical Excellence, 2011, Ranhoff et al., 2010, Svensson et al., 1996, Thomas et al., 2007)

Study Aim Identify independent predictors of mobility at one week post hip fracture surgery

Methods 6 month study period Prospective observational cohort study 77 patients included (age 77.4±10.2 years) Low trauma hip fractures Routine physiotherapy Chi-square, fischer exact, regression analysis

Data Collection Time-Points Day 1 Patient Demographics Fracture-Specific Characteristics Day 7 Mobility Outcome Measures Cumulated Ambulatory Score (CAS) Timed up and Go (TUG) Discharge Discharge Details

Age Sex Premorbid place of residence Demographics Fall location New Mobility Score

ASA Ability to stand day one Fracture- Specific Fracture Type Time to Surgery Operation

Data Collection Time-Points Day 1 Patient Demographics Fracture-Specific Characteristics Day 7 Mobility Outcome Measures Cumulated Ambulatory Score (CAS) Timed up and Go (TUG) Discharge Discharge Details

Results: One Week Postoperatively Mobility Outcome Result Median CAS score 3 Independent mobility 31% (n=24) Mean (SD) TUG 61.7 (±21.1) secs

Rehabilitation Needs Low functional ability Rehabilitation to achieve pre-morbid function Early stratification for rehabilitation pathways (Laflamme et al 2012, Kristenson et al 2007, NICE 2010, Beaupre et al 2013, BOA 2010)

Predictor variable Univariate analysis OR (CI) Multivariate analysis OR (CI) Fall Location Outdoor Indoor p value 0.180 (0.58-0.557) p=0.003 3.848 (1.053 14.061) p=0.042 ASA 2 3 p value 3.014 (1.060 8.569) p=0.039 Time to Surgery <36hours 36hours p value 8.625 (1.827 40.707) p=0.006 5.472 (1.073-27.907) p=0.041 NMS 0-6 7-9 p value 0.304 (0.111-0.833) p=0.021 3.366 (1.042 10.879) p=0.043

Total CAS Score at Day 7 Ability to stand day 1 (p=0.018) Age (p=0.018) Fall location (p=0.005) Premorbid place of residence (p=0.014) ASA (p=0.005) Time to surgery (p=0.002) NMS (p=0.002)

3 Predictors Prefracture function Clinical Implications Mobility Measures Modifiable variables

CAS & NMS Feasible clinical indicators for early rehabilitation planning

IHFD Rehabilitation Data-fields 2016 Baseline function First postoperative day Longer term Discharge

Baseline New Mobility Score (0-9 + individual sections) 1 st post-op Day Physio assessment (Yes/No) Mobilisation (Yes physio/yes other/no) Cumulated Ambulatory Score (0-6) Discharge Cumulated Ambulatory Score (0-6) 30day & 120 day New Mobility Score (0-9 + individual sections)

Guideline adherence Irish data Service provision Leading hip fracture care No extra work Ideal outcome measures

Exciting Times Ahead!! Advocate Site visits Future data-fields Encourage AHP reps

Acknowledgements National hip fracture steering group Physiotherapy hip fracture working group Integrated care pathway work to date by physios/ots

Thank You!

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