Acute Hip Fracture

Rehabilitation

Michelle Fitzgerald BSc, MSc, MISCP

Senior Physiotherapist, Tallaght Hospital, Dublin

4th 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)

Hip Fractures

10%

Die within a month

33%

Die within a year

50%

Unable to walk

unaided

25%

Long Term Care

Stretch Health System

(British Orthopaedic Association 2007, Cummings and Melton., 2002,

Department of Health 2013, Hall et al., 2000, Keen, 2003, McGowan et al., 2013)

The “Hip Attack”

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

(Boonen et al., 2004, Dubljanin-Raspopovic et al., 2013, Hirose et al., 2010)

Post-Op Long-Term

Mobility

Survival

+

Function

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

Direct Communication

International Guidelines

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

(ANZHFR 2014, NICE 2011, Waddell 2011, SIGN 2009, BOA 2007)

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 Fitzgerald1, Blake, C2. Askin, D3. Coughlan, T3.

Quinlan, J3. Cunningham, C2.

1 Physiotherapy Department & Bone and Joint Unit2, Tallaght Hospital

3 School Of Public Health, Physiotherapy & Population Science, UCD

What should we do?

Rehabilitation Planning

Influencing factors

Optimise early

mobility

(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

Day 1

• Patient Demographics

• Fracture-Specific Characteristics

Day 7

• Mobility Outcome MeasuresCumulated Ambulatory Score (CAS) Timed up and Go (TUG)

Discharge• Discharge Details

Data Collection Time-Points

Demographics

Age

Premorbid place of

residence

New Mobility Score

Fall location

Sex

Fracture-Specific

ASA

Fracture Type

Operation Time to Surgery

Ability to stand day

one

Day 1

• Patient Demographics

• Fracture-Specific Characteristics

Day 7

• Mobility Outcome MeasuresCumulated Ambulatory Score (CAS) Timed up and Go (TUG)

Discharge• Discharge Details

Data Collection Time-Points

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 OutdoorIndoorp value

0.180 (0.58-0.557)Reference

p=0.003

3.848 (1.053 – 14.061)Reference

p=0.042

ASA ≤ 2≥ 3p value

3.014 (1.060 – 8.569)Reference

p=0.039

Time to Surgery <36hours≥36hours

p value

8.625 (1.827 – 40.707)Reference

p=0.006

5.472 (1.073-27.907)Reference

p=0.041

NMS 0-67-9

p value

Reference0.304 (0.111-0.833)

p=0.021

Reference 3.366 (1.042 – 10.879)

p=0.043

Predictor variable Univariate analysis OR (CI)

Multivariate analysis OR (CI)

Fall Location OutdoorIndoorp value

0.180 (0.58-0.557)Reference

p=0.003

3.848 (1.053 – 14.061)Reference

p=0.042

ASA ≤ 2≥ 3p value

3.014 (1.060 – 8.569)Reference

p=0.039

Time to Surgery <36hours≥36hours

p value

8.625 (1.827 – 40.707)Reference

p=0.006

5.472 (1.073-27.907)Reference

p=0.041

NMS 0-67-9

p value

Reference0.304 (0.111-0.833)

p=0.021

Reference 3.366 (1.042 – 10.879)

p=0.043

Predictor variable Univariate analysis OR (CI)

Multivariate analysis OR (CI)

Fall Location OutdoorIndoorp value

0.180 (0.58-0.557)Reference

p=0.003

3.848 (1.053 – 14.061)Reference

p=0.042

ASA ≤ 2≥ 3p value

3.014 (1.060 – 8.569)Reference

p=0.039

Time to Surgery <36hours≥36hours

p value

8.625 (1.827 – 40.707)Reference

p=0.006

5.472 (1.073-27.907)Reference

p=0.041

NMS 0-67-9

p value

Reference0.304 (0.111-0.833)

p=0.021

Reference 3.366 (1.042 – 10.879)

p=0.043

Predictor variable Univariate analysis OR (CI)

Multivariate analysis OR (CI)

Fall Location OutdoorIndoorp value

0.180 (0.58-0.557)Reference

p=0.003

3.848 (1.053 – 14.061)Reference

p=0.042

ASA ≤ 2≥ 3p value

3.014 (1.060 – 8.569)Reference

p=0.039

Time to Surgery <36hours≥36hours

p value

8.625 (1.827 – 40.707)Reference

p=0.006

5.472 (1.073-27.907)Reference

p=0.041

NMS 0-67-9

p value

Reference0.304 (0.111-0.833)

p=0.021

Reference 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)

Clinical Implications

3 Predictors

Mobility Measures

Modifiable variables

Pre-fracture function

CAS & NMS

Feasible clinical indicators

for early rehabilitation planning

IHFD Rehabilitation Data-fields 2016

First postoperative

day

DischargeLonger term

Baseline function

Baseline

• New Mobility Score (0-9 + individual sections)

1st 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

Service provision

No extra work

Ideal outcome measures

Leading hip

fracture care

Irish data

Guideline adherence

Service provision

No extra work

Ideal outcome measures

Leading hip

fracture care

Irish data

Exciting Times Ahead !!

Advocate

Encourage

Site visits

AHP reps

Future data-fields

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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