London South Bank University, London, UK; Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
The aim of this chapter is to provide an evidence-based discussion of rehabilitation of the orthopaedic and trauma patient. There are many who require and will benefit from rehabilitation and some specific examples will be provided within this chapter and within other condition-specific chapters. Where robust evidence exists there will be a critical application of research to approaches to rehabilitation. However, to date there is limited high level evidence to support many aspects of patient rehabilitation within trauma and orthopaedics. There are two relevant Cochrane systematic reviews relating to rehabilitation; Cameron et al.’s (2009) review included nine studies comparing coordinated multidisciplinary approaches to rehabilitation of older patients with proximal femoral fractures to usual orthopaedic care (this review is discussed in more detail within the team approaches to rehabilitation section) and Mason et al.’s (2012) review which included two trials related to rehabilitation following hamstring injuries. In addition, a search revealed seven studies comparing rehabilitation settings (which are critically discussed within the rehabilitation settings section). The information within this chapter is, therefore, in the main based upon evidence from the following sources: formal education, symposia, conference presentations, non-research publications, expert opinion and reflections on clinical experience (of the author and other clinical experts).
History and context of rehabilitation
Rehabilitation is a process which aims to optimise a patient’s full recovery potential following an episode of illness, trauma or surgery. Mauk (2012) offers the following definition:
(Rehabilitation is a process of adaptation or recovery through which an individual suffering from a disabling or functionally limiting condition, whether temporary or irreversible, participates to regain maximal function, independence and restoration.) (p2).
There are two key misconceptions about rehabilitation to be cognisant of. Firstly, rehabilitation is not a place; it is a process. Hence, to state “the patient is waiting to go to rehabilitation” is a misnomer and furthermore is detrimental to the patient as the rehabilitation process should begin as soon as the patient is medically stable. Secondly, there is frequently a misconception that rehabilitation is about restoring the individual to their pre-injury/surgery status. This is not always possible and a significant aspect of rehabilitation is to support the patient and their family to adapt to a change in their functional ability. Rehabilitation has a number of key goals including:
- restoration of optimum function (physical, social and psychological)
- promote and sustain maximum independence and provide assistance where care deficits exist
- facilitation of adaptation when return to former health status or function is not possible
- psychological support for the patient and their family who have experienced trauma, change or loss (in the context of loss of the former self)
- prevention and early detection of complications
- supporting the patient to meet their short-, medium- and long-term goals
- creating enabling environments to facilitate independence and social integration
- education of the patient and informal carers to understand their condition and ongoing treatment and management strategies
- promote self-management and patient empowerment
- optimising health and quality of life (including pain management).
The concept of rehabilitation in healthcare is not a new phenomenon. The importance of restoring function following trauma in particular has been evident over many centuries, particularly during war and conflict. Florence Nightingale pioneered rehabilitation as a nursing concept during the Crimean War. Many developments in prosthetics, assistive devices, mobility aids, new treatments and therapies have been as a direct result of the need to support those wounded in conflict either as service men and women or civilian causalities and to facilitate, when possible, military personnel’s return to active duty. Sadly, in contemporary society, the world continues to be plagued by conflict, war and terrorism and the need for evidence-based rehabilitation has never been greater.
Models of care
Many of those requiring rehabilitation will have either a permanent or temporary disability. In recent years there has been a realisation and acknowledgement that disabled people are not the problem, the problem is the way that society is organised to discriminate against those individuals with a disability (Jester 2007). In the UK (and reflected in the law in other parts of the world), the Disability Discrimination Act of 1995 has supported the view that it is a societal responsibility to prohibit less favourable treatment of people with a disability. The Act gave new rights in relation to access to goods, services and facilities, employment and buying or renting land or property and has supported the social model of disability where the onus is on society to make adjustments and support those with a disability. Crosby and Jackson (2000) summarised what disabled people have identified as their fundamental needs in order to be able to live independently:
- information about choices
- peer support and counselling
- appropriate housing, which you can get into, move about in, live in and is in the right place
- equipment to support you to do the things you want to do
- personal assistance to facilitate independence
- accessible transport
- access to the built environment.
Healthcare practitioners have a key responsibility to provide information about enabling environments, patient’s rights under the Disability Discrimination Act and to signpost patients and their families to further information and services to optimise their independence. Apart from the social model of disability, practitioners need to have an applied working knowledge of frameworks and models that embrace maximising patient independence, promote a focus on health and wellbeing and support patients and families to cope with change and make adaptations. Neuman’s Systems Model (Neuman 1982) focuses on the impact of illness and disability on both the patient and the informal caregiver and is based upon their identification of inherent stressors and personal strengths which can be recruited to aid coping and adaptation. Roy’s Adaptation Model (Roy 1984) focuses on modes of adaptation, which include physiological role function, self-concept and interdependence modes. Both of these models lend themselves well to orthopaedic and trauma care generally, but are particularly pertinent in the rehabilitation phase.
There has been a realisation that it is both undesirable and unfeasible to promote paternalistic models of healthcare support for individuals with chronic disease and/or disability. A self-management (SM) model is preferable where individuals with chronic disease and/or disability embrace an internal locus of control for their own health and wellbeing. Self-management requires education and preparation of the individual and Redman (2004) suggests SM programmes must use problem-based learning approaches and include skill development in problem solving, development of clinical judgement, self-efficacy building and belief modification and symptom reinterpretation.
The rehabilitation process
Rehabilitation should begin as soon as the patient is medically stable enough to engage with it. It is important to emphasise that the patient and their family (if appropriate) are viewed as equal partners with practitioners within the rehabilitation process and not as passive recipients. Rehabilitation is best viewed as a cyclical process beginning with comprehensive assessment, agreeing short-, medium- and long-term goals, development of a collaborative plan to work toward the goals and evaluation of progress. As the patient achieves goals either partially or fully then the cycle begins again with re-assessment.
Comprehensive assessment is the first stage of the rehabilitation process. It is essential to gather data to form a baseline to measure progress against and ascertain the patient’s support systems and home situation. The patient may be entering the rehabilitative phase within the same unit as their acute episode of treatment. In that case the team will already have assessed the patient and have relevant information about the health status and social situation. If the patient is, however, transferred from acute services to rehabilitation in another setting, a more comprehensive rehabilitation-focused assessment will be needed. A comprehensive discussion of assessment in trauma and orthopaedics is provided in Chapter 7, but an assessment within the context of rehabilitation needs to have a stronger psycho/social focus than the typical medical model. Hoeman (2008) suggests that assessment within the rehabilitation phase should have a specific focus on functional skills, psychosocial status, environment and financial status. There are a number of models that lend themselves to rehabilitation including Roy’s adaptation model (Roy 1984) and Orem’s (Orem 2001) self-care deficit model.
Goal setting is not generally used in the acute care setting where the nursing process tends to focus on the identification of actual or potential patient problems. Goals have the following characteristics:
- Goals are positive statements of intent with associated time frames.
- Goals should be realistic and achievable, but at the same time provide appropriate challenge to the patient to give them something to strive and work toward.
- Goals should be discussed and agreed with the patient and family/significant others if appropriate and progress toward goals regularly reviewed and documented.
It is good practice for the goals to be a combination of short-, medium- and long-term as achievement of short-term goals can help to motivate the patient to push toward the medium- and long-term goals. For example, the patient with a traumatic amputation of a lower limb may have a short-term goal of being able to stand for a short period with their new/temporary prosthesis, a medium-term goal of walking up and down stairs with their prosthetic limb and a long-term goal of returning to a sport such as horse riding using their prosthesis.
Developing an implementation plan and evaluation
Once goals have been mutually agreed between the patient and multidisciplinary team (MDT) a plan to support the achievement of the goals needs to be developed and reviewed on a daily basis. The plan should make explicit the roles and required actions of the patient/family and each member of the MDT to achieve the goals. It must be agreed which member/s of the team has the best skills and expertise to support the patient with each particular goal (Jester 2007). Often nurses will have an important continuing function with all of the goals due to their 24-hour presence with the patient. Realistic time scales should also be agreed between the MDT and the patient and then documented. It is important that the plan minimises the use of jargon and is understandable to the lay person. Treatment and therapies planned should be evidence-based and advantages, potential disadvantages and associated risk should be discussed with the patient in order for their consent to participate to be considered informed.