Chapter 6
Rehabilitation and the orthopaedic and musculoskeletal trauma patient
Rebecca Jester
London South Bank University, London, UK; Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
Introduction
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.
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
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.
Progress toward achievement of the agreed goals needs to be reviewed on a regular basis. The process of evaluation should be shared between the MDT, patient and family where appropriate. Evaluation involves both the gathering of objective and subjective measurements to make an informed decision regarding change in the patient’s function and status. Subjective data include seeking the patient’s own perceptions, typically through self-reported generic Health Related Quality of Life (HRQoL) and disease-specific measures (which are discussed later within this chapter and are defined in Chapter 7) along with pain assessment. Objective data include clinician-measured function, movement and physiological parameters; examples of these are provided later within this chapter. Once evaluation has been completed new goals can be set or adjustments made to existing goals.
Team approaches to rehabilitation
Effective team working is one of the most important factors in successful rehabilitation, but it is important to understand what is meant by team working and the different approaches such as multidisciplinary, interdisciplinary and transdisciplinary and their cognate advantages and disadvantages (see Box 6.1). A description and comparison of these approaches is provided in Table 6.1. There is a move away from multidisciplinary working. As more care and rehabilitation is provided in the community setting there is a growing realisation that team members need to share skills and knowledge to have a wider repertoire of skills than the traditional professional-specific model. Multi-skilling between nurses and therapists is becoming common, particularly in ‘Hospital at Home’ schemes as it is not cost-effective or desirable for the patient for discreet professions to make multiple visits. The team involved in rehabilitation of the trauma/orthopaedic patient typically involves nurses, healthcare and therapy assistants, physiotherapists, occupational therapists, social workers, medical practitioners and orthotists. Other professionals such as the dietician and psychologist may be included if the patient’s goals require their input. It is essential that practitioners fully embrace the patient and if appropriate family or informal carers as legitimate members of the team.
Box 6.1 Evidence digest: Multidisciplinary approaches for inpatient rehabilitation
Table 6.1 Description and summary of key differences between MDT, IDT and TDT approaches to team working
| MDT (Multidisciplinary team) | IDT (Interdisciplinary team) | TDT (Transdisciplinary team) |
| Independent profession-specific assessments of the patient | Shared assessment documentation and sharing of assessment data to avoid repetition. | The primary clinician will lead the assessment but draw on expertise of other team members as appropriate |
| Clearly demarcated role boundaries | Blurring of professional boundaries and more multi-skilling between professional groups | Members of team cross-train and develop a portfolio of skills that transcend traditional professional role descriptors |
| Communication is more vertical than lateral and team conferences do not usually take place. | Regular communication in the form of goal review and case conferences | The primary clinician acts as the communication coordinator, but communication is open and non-hierarchal |
| Each member of the team usually works independently to achieve discipline specific goals | Goals are patient-centred and shared with all members to work toward | Goals are patient-centred and team members are often cross-trained to work toward the goals |
| Each member of the team retains their own records for individual patients | Use of integrated care pathways and shared documentation | Records tend to be patient held and updated in partnership with patient and family |
| Team leader tends to nearly always be a medical doctor | Team leader not profession-specific, but based on the leader having the most appropriate experience, skills and leadership and co-ordination abilities | One team member designated as the primary clinician for the patient, but is guided by other professionals as required |
The role of the nurse
Nurses make a unique contribution to the rehabilitation process and yet continue to struggle to articulate what their contribution and role are. Conversely the contribution of therapists, social workers, physicians and psychologists is well defined within the literature (Jester 1997). Waters (1996) considered the role of nurses to be secondary to other members of the MDT and comprising three main components:
- general maintenance – including overall ward management and maintenance of patients’ physical wellbeing in terms of nutrition, hygiene and skin care
- Expertise in areas such as tissue viability, continence and pain management
- Carry-on role – nurses maintain the progress made by therapists over the 24 hour period e.g. mobility and dressing practice.
The description of the nurse’s role offered by Waters (1996) underestimates the essential nature of these fundamental aspects of the rehabilitation process. Specifically, the patient who has unmanaged pain or develops sepsis from pressure ulcers is not going to be able to fully commit to working toward their rehabilitation goals. Nurses also have a fundamental role in assessing and managing the risk of complications such as infection, pressure ulcers and venous thromboembolism which pose a serious threat to the patient’s wellbeing and ability to progress with their rehabilitation.
Nurses are still predominantly the only professional group to have a 24-hour presence and work over the 7-day week. This allows them to develop a strong therapeutic relationship with the patient and be sensitive and observant to small, but potentially significant changes in the patient’s condition. Nurses are likely to be the only profession available to speak to and update families during visiting times about progress in the rehabilitation process. This unique 24-hour presence also enables the nurse to see how the patient functions over the 24-hour period. This can provide a valuable insight into the patient’s readiness for discharge. For example, the patient who is safe and independent during the day may become disorientated and have a propensity to fall during the night.
Traditionally nurses working with patients in the acute phase of their care will provide assistance with the activities of daily living that the patient is too unwell to do for themselves. Within the restorative phase, however, the nurse needs to optimise independence and to encourage the patient to do as much for themselves as possible. The transition from direct caring to a more supportive ‘hands-off’ approach can be difficult for both patients and nurses to come to terms with. A study by Ellul et al. (1993) reported that when nurses incorporated the skills patients were learning in therapy sessions into everyday aspects of the patient’s care, it resulted in a 55% increase in the time that patients spent engaged in meaningful therapeutic activity contributing toward achievement of their goals.
To date the nursing role in rehabilitation remains underdeveloped, partly through a relatively low emphasis on rehabilitation within the pre-qualifying nursing curriculum and few opportunities at postgraduate/post registration level. This may also be due to nursing being unable to clearly articulate the value of its role in rehabilitation compared to other professionals such as therapists. However, rehabilitation as a specialism is gaining momentum. The potential role of nurses in rehabilitation, if they were afforded better support and education to develop the requisite skills, was summarised in the work of Nolan et al. (1997) who suggested the following role contributions:
- assessment of physical condition, delivery of evidence-based care and prevention of complications
- education/counselling
- psychosocial interventions
- support and education of family carers
- coordinating, liaison and facilitating transition.
The RCN (2007) guidance on the role of the rehabilitation nurse outlined eight categories where the nurse can positively influence rehabilitation:
- essential nursing skills
- therapeutic practice
- coordination
- education
- empowerment and advocacy
- clinical governance
- political awareness
- advice and counselling.
Psychological support in rehabilitation
Both the work of Nolan (1997) and the RCN guidelines (2007) have emphasised the importance of the nurse in providing psychological support to patients engaged in rehabilitation. Many trauma and orthopaedic patients who require rehabilitation will have some degree of altered body image. Body image is defined by Schilder (1935) as:
(the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves.) (p17)
Price (1990) identifies dimensions of body image; perception, cognition, social and aesthetic and proposes a 5-dimensional model of body image comprising three body concepts (Box 6.2) and two mitigating personal responses to change or threat to the body concepts which are personal coping strategies and our social support network.
Box 6.2 Body concepts (Price 1990a). Reproduced with permission from Prentice Hall
Price (1990) recommends that for the individual to have an acceptable self-body image, an equilibrium needs to be maintained between the three concepts and two personal responses. The trauma and orthopaedic patient may have severe threats to their body concepts due to temporary or permanent changes to their body such as scoliosis, limb shortening due to hip pathology, amputation, scarring from surgery or trauma, need for an external fixator, casts and use of walking/mobility aids. The impact of alterations of body image should be explored with the patient and appropriate support put in place. This may be to empower the patient to optimise self-help and informal support through support groups and family/social support or referral to counselling and psychotherapy.
Trauma and orthopaedic conditions that may benefit from rehabilitation
The need for rehabilitation will exponentially rise as the demographic profile of the population continues to age. Those requiring trauma and orthopaedic care will range from the very young child to the very elderly and will often have a number of co-morbid conditions. For example, the infant born with congenital orthopaedic conditions such as osteogenesis imperfecta (brittle bone disease) will need lifelong support to optimise function and minimise disability. Broadly, the type of conditions that require rehabilitation to optimise function can be categorised as:
- acute onset – for example fractures, bone tumours, osteomyelitis and soft tissue injury such as ligament ruptures
- gradual onset with relapsing course – for example rheumatoid arthritis and low back pain
- acute onset with constant course – such as spinal cord injury, traumatic amputation and ankylosing spondylitis
- gradual onset and progressive course – such as osteoarthritis, bone and joint tuberculosis and degenerative spondylolisthesis.
Nurses working within trauma and orthopaedics with very young infants through to the very elderly require knowledge, skills and competence in rehabilitation no matter where the care setting might be.
Rehabilitation settings
Traditionally, rehabilitation for trauma and orthopaedic patients was delivered within the in-patient setting either within the same unit as the acute phase of care or following transfer to a specialist rehabilitation facility. The second of these options frequently led to the rehabilitation phase not being instigated until the patient was transferred and had a deleterious impact on patient outcomes and length of stay. There is, however, an increasing shift of rehabilitation into the community setting. This shift has, in part, been due to a systematic reduction in the number of hospital beds available and the realisation that prolonged hospitalisation is not therapeutically beneficial for many ─ specifically children and older adults. Another influencing factor is that community rehabilitation is less costly and is also more realistic in the patient’s own home (Jester 2007). There is a gradual move away from rehabilitation services being medically led with community-based services often being led by specialist nurses and therapists. There is a growing evidence base to support the superiority of home-based rehabilitation compared to in-patient models within trauma and orthopaedics.
There also appears to be a growing body of evidence to support home-based rehabilitation compared to hospital-based alternatives. A summary of the evidence is provided in Box 6.3. However, it is important to remember that home-based interventions often require the patient to have sufficient family/informal carer support to be eligible for ‘Hospital at Home’ (HaH) type schemes. Smith (1999) recommended that decisions about location of rehabilitation services should consider:
- Appropriateness ─ or relevance of the service for the patient. For example home-based rehabilitation may be more realistic for some individuals, but for others their levels of social support may present risk for home-based interventions.
- Equity ─ there should be equal access to rehabilitation, not dependent on locality.
- Accessibility ─ this relates to issues of physical accessibility as discussed earlier within this chapter and issues such as waiting times for specialist rehabilitation services.
- Acceptability ─ the degree to which the rehabilitation service meets the expectations of the patient.
Within contemporary healthcare, commissioners often make decisions about setting up or discontinuation of services based on cost-effectiveness and patient choice and preference may not be always be considered. Jester (2003) urged that decisions regarding rehabilitation setting following joint arthroplasty of the knee and hip should take into consideration patient preference, their locus of control and support systems and that the orthopaedic nurse has a key role in advocating for patient choice regarding location of their rehabilitation.
Summary
This chapter has aimed to demonstrate that most trauma and orthopaedic patients will require some form of rehabilitation and therefore the nurse needs to optimise their role and contribution to the rehabilitation process. Rehabilitation has been defined as a goal-orientated process that should be begin as soon as the patient is medically stable following trauma or elective interventions. A relatively strong evidence base has been presented regarding the choice of rehabilitation settings, with home-based models proving a more cost-effective alternative to inpatient approaches, although the importance of patient choice and consideration of suitability were emphasised. Nurses will need to work across the interface of hospital and community settings to support patients through the rehabilitation journey and should ensure they have the requisite skills and knowledge to facilitate this. Also the benefits of transdisciplinary team working have been explored where nurses and therapists share and expand their collective repertoire of skills and underpinning knowledge.
Recommended further reading
- Hoeman, S. (2008) Rehabilitation Nursing: Prevention, Intervention and Outcomes, 4th edn. Mosby Elsevier, St Louis.
- Jester, R. (2007) Advancing Practice in Rehabilitation Nursing. Wiley Blackwell, Oxford.
- Mauk, K. (2012) Rehabilitation Nursing: A Contemporary Approach to Practice. Jones and Bartlett. Sudbury, MA.
References
- Cameron, I., Handoll, H., Finnegan, T., Madhok, R. and Langhorne, P. (2009) Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures (Review). John Wiley and Sons Ltd. Cochrane Database of Systematic Reviews, Issue 4.
- Crosby, N. and Jackson, R. (2000) The Seven Needs and the Social Model of Disability. Coalition for Inclusive Living, Derbyshire.
- Ellul, J., Watkins, C., Ferguson, N. and Barer, D. (1993) Increasing patient engagement in rehabilitation activities. Clinical Rehabilitation, 7, 297–302.
- Grant, J.A., Mohtadi, N.G., Maitland, M.E. and Zernicke, R.F. (2005) Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. The American Journal of Sports Medicine, 33(9), 1288–1297.
- Hoeman, S. (2008) Rehabilitation Nursing: Prevention, Intervention and Outcomes, 4th edn. Mosby Elsevier, St. Louis.
- Jester, R. (2003) Early discharge to Hospital at Home: Should it be a matter of choice? Journal of Orthopaedic Nursing, b (2), 64–69.
- Jester, R. (2007) Advancing Practice in Rehabilitation Nursing. Wiley Blackwell, Oxford.
- Jester, R. and Hicks, C. (2003) Using cost-effectiveness analysis to compare hospital at home and in-patient interventions. Part 1. Journal of Clinical Nursing, 12, 13–19.
- Jester, R. and Hicks, C. (2003) Using cost-effectiveness and analysis to compare hospital at home and in-patient interventions. Part 2. Journal of Clinical Nursing, 12, 20–27.
- Mahomed, N.N., Davis, A.M., Hawker, G. et al. (2008) Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. The Journal of Bone and Joint Surgery (American), 90(8), 1673–1680.
- Mason, D., Dickens, V. and Vail, A. (2012) Rehabilitation for hamstring injuries. Cochrane Database of Systematic Reviews 12 (Art. No.: CD004575). DOI: 10.1002/14651858.CD004575.pub3.
- Mauk, K. (2012) Rehabilitation Nursing: A Contemporary Approach to Practice. Jones and Bartlett, Sudbury, MA.
- Neuman, B. (1982) The Neuman Systems Model: Application to Nursing Education and Practice. Appleton Century Crofts, Norwalk, CT.
- Nolan, M., Booth, A. and Nolan, J. (1997) New Directions in Rehabilitation: Exploring the Nursing Contribution. Research Report Series No 6. English National Board for Nursing, Midwifery and Health Visiting, London.
- Orem, D.E. (2001) Nursing: Concepts of Practice, 6th edn. Mosby, London.
- Price, B. (1990) Body image. Nursing Concepts and Care. Prentice Hall, London.
- Redman, B.K. (2004) Patient Self Management for People with Chronic Diseases. Jones and Bartlett, Massachusetts.
- Roy, C. (1984) Introduction to Nursing: An Adaptation Model, 2nd edn. Prentice Hall, Englewood Cliffs, NJ.
- Royal College of Nursing (2007) The Role of the Rehabilitation Nurse: RCN Guidance. RCN Publishing, London.
- Schilder, P. (1935) Image and Appearance of the Human Body. Kegan Paul, London.
- Siggeirsdottir, K., Olafsson, O., Jonsson, H. et al. (2005) Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement: randomized study of 50 patients with 6 months of follow-up. Acta Orthopaedica, 76(4), 555–562.
- Smith, M. (1999) Rehabilitation in Adult Nursing Practice. Churchill Livingstone, Edinburgh.
- Waters, K. (1996) Rehabilitation: core themes in gerontological nursing, in A Textbook of Gerontological Nursing: Perspectives on Practice (eds L. Wade and K. Waters), Baillere-Tindall, London.
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The team approach and nursing roles in orthopaedic and musculoskeletal trauma care
Key conditions and principles of orthopaedic management
Soft tissue, peripheral nerveand brachial plexus injury
Key musculoskeletal interventions
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