Workforce competencies required to provide
community rehabilitation for aged clients after
orthopaedic surgery - a literature review.
Prepared by
Emmah Doig
&
Delena Amsters
For the Community Rehabilitation Workforce Project
16/12/05
1
Executive Summary
This literature review explored the nature of rehabilitation and support needs of aged
clients after orthopaedic surgery. This was undertaken in order to establish the types
of workforce competencies required to meet these needs in community rehabilitation
(CR) settings. For the purpose of this review CR was defined as delivery of
rehabilitation in home and community settings.
Characteristics of the various client groups, as well as short and long term outcomes
documented in the literature, were examined in order to inform the community
rehabilitation and support needs. In turn, workforce competencies have been
extrapolated from the rehabilitation and support needs.
The nature of CR will differ for joint replacements as compared with hip fracture
given the unplanned nature of hip fracture. There is an opportunity for provision of
pre-admission assessment and education for elective surgery participants so
competencies must reflect the ability to provide consistent and meaningful
informational support throughout the continuum. The review highlighted the need for
high quality CR services to support early discharge programmes as these are
commonly utilised in cases of elective orthopaedic surgery.
There was a strong bias in the literature towards the need for expertise in physical and
functional management and environmental compensation. However, the literature
clearly highlights the need for skills to assist clients to manage changing social and
emotional needs and provide a focus on societal participation, both in the short and
long term. Pain management skills were seen as an imperative for effective CR due to
the high frequency of persistent pain amongst this client population.
Competence in assessing care support needs and carer burden, and knowledge of
available community support services are a critical part of CR. Skills to assist clients
and caregivers to manage cognitive deficit was emphasised for hip fracture clients.
The ability to implement risk management strategies to prevent future falls and allay
client fears of future falls is also an essential competency.
Despite the presence of a prescriptive element to provision of CR to this client group,
the need for workers to be competent at individualising assessment, planning and
intervention was strongly emphasised.
2
Table of Contents
Executive Summary ..................................................................................................... 2
Table of Contents ........................................................................................................... 3
List of Tables ................................................................................................................ 4
1.
Context of the Literature Review ................................................................... 5
1.
Context of the Literature Review ................................................................... 5
2.
What are the rehabilitation and support needs of people aged 65 and over
following discharge from hospital after hip fracture?.............................................. 5
Characteristics of the hip fracture population ............................................................ 5
Functional status post hip fracture rehabilitation ....................................................... 6
Rehabilitation outcomes after hip fracture for patients with cognitive deficits,
dementia and delirium................................................................................................ 7
The particular needs of patients with dementia who experience hip fracture............ 7
3.
What are the rehabilitation and support needs of people aged 65 and over
following discharge from hospital after THR? ......................................................... 9
Characteristics of the hip replacement population ..................................................... 9
Outcomes post THR ................................................................................................... 9
Long term outcomes following THR ....................................................................... 10
Carer Burden ............................................................................................................ 10
Information needs .................................................................................................... 11
4.
What are the rehabilitation and support needs of people aged 65 and over
following discharge from hospital after TKR? ....................................................... 12
Characteristics of the TKR population .................................................................... 12
TKR outcomes ......................................................................................................... 13
Long term outcomes post TKR ................................................................................ 13
5.
What competencies do CR workers require in order to meet these
rehabilitation and support needs? ............................................................................ 15
6.
Conclusion ...................................................................................................... 16
7.
References ....................................................................................................... 18
Appendix 1: Search Strategy .................................................................................... 22
3
List of Tables
Table 1: Rehabilitation and support needs after hip fracture ................................ 8
Table 2: Rehabilitation and support needs following THR .................................. 11
Table 3: Rehabilitation and support needs following TKR .................................. 14
Table 4: CR competencies for workers providing services post hip fracture ..... 15
Table 5: CR competencies for workers providing services post THR and TKR . 16
4
1.
Context of the Literature Review
This review has been undertaken as part of the Community Rehabilitation Workforce
(CRW) Project, funded through the Commonwealth Pathways Home Programme.
The aim of the CRW Project is to optimise the capability of the current and future
workforce to develop, implement and evaluate community rehabilitation (CR)
programmes to meet the current and emerging health needs of the Queensland
community.
This review will assist the CRW Project to determine the CR workforce competencies
required to meet the health needs of aged clients after orthopaedic surgery.
The specific questions that will be addressed by this review, in relation to these aims
are:
1. What are the rehabilitation and support needs of people aged 65 and over
following discharge from hospital aftera) hip fracture
b) total hip replacement (THR)
c) knee joint replacement (TKR)?
2. What competencies do CR workers require in order to provide these
rehabilitation and support needs to people aged 65 and over following discharge
from hospital aftera) hip fracture
b) hip joint replacement
c) knee joint replacement?
The scope of the review has been limited to hip fracture, knee replacement and hip
replacement as these are the major orthopaedic diagnostic groups for patients over 65
who are hospitalised in Queensland. The full literature search strategy is outlined in
Appendix 1.
2.
What are the rehabilitation and support needs of people aged
65 and over following discharge from hospital after hip
fracture?
The characteristics of the hip fracture population as well as short and long term
outcomes after hip fracture, indicate probable rehabilitation and support needs for this
client group. A summary of these probable key needs and a description of the
supporting literature have been provided in Table 1.
Characteristics of the hip fracture population
Arinzon (1) reports the incidence of osteoporotic fractures as increasing and refers to
this as an epidemic. Consequently, there is an expected need for increased resources
to treat people with fractured neck of femur due to an ageing population (2, 3) which
suggests that measures to facilitate early discharge will be imperative. A
5
comprehensive ortho-geriatric approach to rehabilitation following hip fracture, rather
than an orthopaedic approach alone is advocated given the diversity and constellation
of potential problems in older people due to the complications arising from age
related concomitant medical conditions (4).
Increasing age has been associated with poorer functional recovery from hip fracture
and older patients (85 years and over) have been found to be more functionally
dependent pre-fracture, have higher co-morbidities and are likely to live alone (1, 5).
Co-morbidities including osteoarthritis, pulmonary disease, diabetes, stroke, previous
fracture, depression and cognitive deficit have been found to be more prevalent in oldold patients (85 years and over) compared to young elderly (65-74 years) (1). Hip
fracture is more than twice as frequent in patients with dementia compared to the
general population (6). Lieberman et al (7) reported the incidence of hearing or visual
impairment in a large group of 896 patients hospitalised for rehabilitation with hip
fracture to be approximately 25%. Visual impairment was found to have a significant
and negative impact on efficacy of rehabilitation and the authors concluded that
attention needs to be paid to optimising a patient’s visual acuity in rehabilitation (7).
Functional status post hip fracture rehabilitation
The majority of patients fail to regain their pre-fracture ambulatory and functional
status (5, 8, 9) which provides the impetus for studies investigating rehabilitation
programs that extend beyond the initial post operative period (ie. six and 12 months
post fracture). Several factors have been associated with functional recovery
following hip fracture. Older age, poorer pre-fracture physical function and cognitive
deficit have been associated with poorer prognosis and functional recovery after hip
fracture (1, 5, 8). Co-morbid status, gender, type of fracture and operative delay have
also been associated with functional outcome (1). Increasing age and the presence of
co-morbidities has been associated with increased use of home health care after
rehabilitation (10).
There is a high prevalence of persistent hip pain at three months after surgical repair
of a hip fracture. Those with moderate to severe hip pain report greater difficulty with
activities of daily living (ADL) performance and worse self perceptions of quality of
life which in turn is associated with more symptoms of depression (11). The
implications of these results are that patient education about the prevalence of pain
and strategies for management, as well as monitoring and treatment of depression are
essential for optimising outcomes. Hip fracture is one of the most serious
consequences of a fall. Mckee et al (12) found that perceived risk of further falls was
associated with high functional limitations post fall and worry over further falls was
associated with falling again after discharge. Further investigation was recommended
into the worry over further falls in the recovery from hip fracture and the potential for
intervention (12). An Australian study by Whitehead et al (13) showed that in a group
of patients who had returned to live in the community post hip fracture, 20% had
fallen at four months post hip fracture and this group had less confidence in their
ability to carry out activities without falling (falls efficacy) than the non-fallers, and
higher levels of handicap. Those assessed as having a low gait speed also
demonstrated lower falls efficacy and higher levels of handicap than those with a
normal gait speed. However ADL as measured by the Modified Bartel Index (MBI),
which is a common rehabilitation outcome measure, was not significantly different
6
between these groups. This suggests a range of outcome measures needs to be taken
to ensure a comprehensive assessment.
Rehabilitation outcomes after hip fracture for patients with cognitive deficits,
dementia and delirium
Patients with cognitive deficit have been shown to demonstrate similar functional
gains (compared to baseline functioning) after inpatient rehabilitation post hip fracture
to those without cognitive deficit (4, 14, 15) indicating that they should not be
excluded as candidates for rehabilitation. Beloosesky et al (16) found pre-fracture
mobility status to be predictive of mobility gains after hip fracture rehabilitation rather
than cognitive status. Generally, length of stay in inpatient rehabilitation has been
found to be significantly longer for those with cognitive impairment (4), with the
exception of Beloosesky et al (16) who found there to be no differences in length of
stay based on cognitive function.
Patients with dementia tend to have a reduced length of acute hospital stay following
hip fracture compared to patients without dementia as they are often able to return to a
residential care facility (2). Van Dortmont et al (17) concluded that patients with
dementia who undergo hemi arthroplasty for displaced fractured neck of femur have
higher mortality rates and significantly worse outcomes in terms of return to prefracture mobility status when compared to those without dementia. Those patients
with more severe Alzheimer’s disease have been found to be more likely to remain
immobile after hip fracture and this factor was found to be a major influence in
precluding return to the same residential care facility (18). Post-operative delirium
has been associated with the development of dementia.
One study (19) investigated patients admitted with hip fracture with no evidence of
pre-fracture dementia and assessed them for postoperative disorientation and
confusion with subsequent follow-up five years after discharge. The results indicated
that those who experienced post-operative delirium were more likely to develop
dementia and had a higher mortality rate (19). The authors indicated that those
experiencing pre or post operative delirium should be assessed for aetiology and
underlying organic brain disorder (19).
The particular needs of patients with dementia who experience hip fracture
The unique needs of patients with dementia who experience hip fracture are
demonstrated in a study by Hedman et al (20). This study explored the perspectives of
the next of kin of patients with dementia who underwent rehabilitation following a hip
fracture. The study identified that relatives felt that competence is diminished in
terms of hearing, vision, health, cognition, memory and communication and the
person needs specific rehabilitation support. In light of this they identified the need
for support in rehabilitation in terms of: strategies to attract patients into performing
rehabilitation activities to prevent the person becoming bedridden; help with
practising tasks; reminding the person what to do; supervision and positive
encouragement. Relatives also identified the impact of the environment on the person
with dementia, including the staff’s knowledge of dementia and the patient’s abilities,
and emphasised the benefit of a familiar environment for the patient.
7
Table 1: Rehabilitation and support needs after hip fracture
Need
Strengthening,
Transfers training,
ADL retraining,
Environmental
compensation
Individualised
rehabilitation plans
and support
arrangements
Home health care
Involvement of
patient and family in
decision making
Fatigue management,
Pain management
Falls prevention
Adaptive Equipment
Description
the descriptive Tinetti study suggests the main CR needs are
in the areas of upper and lower extremity conditioning,
transfers training, complex ADLs such as dressing and
bathing and more environmental compensation for
instrumental ADLs such as shopping and laundry.
Due to the likelihood of the presence of complicating factors
such as co-morbidities and cognitive deficits, the context,
content and duration of rehabilitation programs and the
amount and duration of support is most appropriately
assessed on a case-by-case basis.
Patients that are clinically more complex with co-morbidities
and are older are likely to require home health care after
rehabilitation.
Patients and their families need to be involved in
communication and decision making, especially during
hospital to home transition.
Interventions are needed to assist in dealing with fatigue and
persistent hip pain including energy conservation techniques,
planning rest periods, pain management strategies which
may in turn reduce depression, improve quality of life and
increase independence with ADLs.
Interventions such as group sessions are needed to reduce
fear of falling and reduce feelings of loss of control may
improve function and reduce the number of subsequent falls.
Prescription of adaptive equipment to promote function as
this has been identified as a factor in successful transition
from hospital to home.
8
Reference
(21)
(1, 5, 8, 10)
(10)
(22)
(11, 23)
(12, 13, 23)
(23)
3. What are the rehabilitation and support needs of people aged 65
and over following discharge from hospital after THR?
The characteristics of the population undergoing THR as well as short and long term
outcomes after THR indicate probable rehabilitation and support needs for this client
group. A summary of these probable key needs and a description of the supporting
literature, has been provided in Table 2.
Characteristics of the hip replacement population
Most people undergo hip joint replacement due to the presence of advanced primary
or secondary osteoarthritis of the hip (24, 25) and do so to relieve hip pain and
improve functional status (26). Therefore admission to hospital for hip joint
replacement is a planned event and mostly involves a standardised protocol of
preadmission assessment, pre and post surgical education and planned discharge
within a predetermined timeframe. It is assumed that patients admitted to hospital to
undergo elective hip joint replacement are medically fit to undergo surgery,
potentially reducing the likelihood of complications due to concomitant medical
problems. Consequently the timing and nature of CR for people with hip joint
replacement will differ from CR for people following hip fracture, given the
unplanned nature of the hospital admission and the concomitant age-related medical
problems associated with hip fracture. Factors found to be associated with the
likelihood of extended hospital stay following THR, however, include older age,
presence of co-morbidities and lower pre-operative MBI scores (27).
Outcomes post THR
The appropriate timing of discharge and ability to predict discharge date from hospital
to home is important in order to effectively plan post discharge support and
rehabilitation services.
A Western Australian study concluded that based on a MBI score of 90/100 as an
indicator of safe functional level of discharge, 58% of a sample of 65 patients were fit
for discharge by day eight post THR. The group that required an extended stay of 10
days or more were older, had more co-morbidities, had pre-operative impairment in
hip strength and lower pre-operative MBI scores (27). The authors concluded that
some patients may be discharged earlier with lower MBI scores if they have a high
level of family support on returning home (27). Predicting discharge destination is
important in planning discharge and in identifying those people at risk of not
returning to live at home, in order to target them for special intervention or services
(28). Physical readiness and safety for discharge is the focus of planning discharge of
patients after THR. Patients report prior to discharge that they are ready for discharge
when they feel ‘psychologically’ safe as well as ‘physically’ safe. A perception of
psychological and physical safety was found to be achieved by those who felt
confident and had support at home (29). Given the reducing lengths of hospital stay,
health professionals are required to address these factors within a relatively short time
period. This may be achieved by giving consistent and accurate information about
discharge and post-hospital period, arrangement of personal alarm systems for
9
patients who live alone, and discussion and arrangement of supports after discharge
(29)
The Risk Assessment and Prediction Tool (RAPT), which was developed based on an
Australian sample, has been shown to be a predictor of discharge destination after
THR or TKR with 75.2% accuracy. It includes age, gender, preoperative walking
distance and walking aid, community supports and presence of a caregiver on return
home as factors relating to discharge destination (30). An American study found
cognition and basic motor function associated with ADLs, length of stay and marital
status were important predictors of discharge destination after hospital discharge from
THR or TKR (28). A further study found that being unable to walk at discharge,
older age, obesity and living alone were factors associated with likelihood to be
discharged to a rehabilitation facility post THR rather than discharged directly home
(31).
A study describing the outcomes post THR (265 patients) and TKR (135 patients)
discharged at day 4-5 (short-stay) or day 8-10 (long-stay) concluded there were no
differences in outcomes between short and long stay patients at 3 and 12 months post
discharge (32). A study of outcomes for 353 patients following THR with an average
LOS of 9.5 days indicated that LOS in itself is not an important determinant of
outcome after THR however concluded that reduction in LOS may be accompanied
by increase in demands for primary and community care services (33).
Long term outcomes following THR
Impairments in hip strength were reported in a sample of 53 participants who were at
least 1.5 years post THR when compared to age-matched healthy controls (34).
Impairments in postural stability of the involved hip were reported as significantly
reduced in a sample of 14 participants who were 12 months post THR when compared
to the uninvolved hip (35). At three years post THR 10% of a sample of 922
participants reported at least moderate difficulty with all functional activities (25).
Hip strength and knee extensor strength has been shown to be a predictor of walking
speed and functional performance in patients with THR (35-37). This has been the
impetus for a number of studies investigating long-term and late phase rehabilitation
programs focussing on weight bearing and postural stability.
The presence of preoperative impairments (33) as well as pain, poor mental health,
more than one common geriatric problem such as history of a fall or decreased
balance, vision or hearing problems, the presence of obesity and less than a college
education (25) have been associated with poorer long-term functional recovery
following THR.
Carer Burden
Carer burden is an important consideration given the potential for poorer functional
status post-surgery under early discharge from hospital schemes. A survey of care
services three months post THR or TKR indicated that patients who visited their GP
in the early post discharge period did so primarily due to problems with pain and 97%
reported no concerns with their ability to manage at home following discharge (32).
However, at three months post discharge the majority relied on informal carers for
10
assistance with shopping and housework, less for cooking and personal hygiene with
31% of patients reporting that their carer found it difficult to cope with this in the
early post-discharge period (32). A survey of 34 informal caregivers, who were
mostly female, and care receivers prior to and 3 months following total hip
replacement indicated there was no significant reduction in carer’s stress level after
the THR and 52.2% of the carers, indicated feeling quite stressed from caring for their
relative at three months post THR (38). The feasibility of rehabilitation at home may
also be strongly influenced by the availability of support at home (30) and there is a
lack of research examining the impact of early discharge and home based
rehabilitation upon significant others.
Information needs
A study exploring patients’ perceived needs before and four months after THR across
two hospitals in the UK indicated that the standardised provision of information,
equipment and therapy post THR helped with their preparation for surgery and
recovery however this was found to be less effective for the patients who had multiple
impairments prior to surgery and who developed problems after surgery (39). The
standardised approach post hip replacement (as outlined by Harris and Candando (40)
is described as provision of information regarding precautions, activity limitations,
physical exercise, equipment and home environmental modifications and ambulation
guidelines. For patients undergoing THR with multiple pre-surgery impairments and
complications post surgery, rehabilitation and advice needs to be more individualised
(39). Patients who have undergone total hip or knee replacement and their spouses
reported the need to be prepared for potential transitional and role changes (ie.
changes in social activity, roles at home) post surgery (41), which is not typically
included in the standardised post-THR treatment regime. Patients and their spouses
also indicated that during their hospital stay, information provision and teaching of
skills occurs over a short period of time and isn’t always applicable to the home
environment (41). A survey of patients before and 2 weeks after THR indicated that
while patients learning needs were a little greater in hospital than at home, the type of
information needed remained the same across settings: information about
complications and avoidance of complications; knowledge of medication; physical
exercise and ADLs to do and avoid(42).
Table 2: Rehabilitation and support needs following THR
Need
Long term rehabilitation,
Postural stability,
Lower limb strengthening,
Monitoring
Support and assistance with ADLs
Description
Long-term, late phase (from four months up
to two years) CR in the form of a monitored
home program focussing on weight bearing
and postural stability for patients, appears
to be warranted due to the presence of
deficits in lower limb strength years post
hip replacement surgery and the association
this has with everyday functioning.
Potential need for support and assistance
with functional activities and ADLs due to
functional and mobility deficits that may be
ongoing or at least a need for assistance in
11
Reference
(25, 35-37)
(25, 34, 35, 43)
Support for caregivers,
Skills for caregivers,
Assessment for necessary
aids/adaptations/services
Exercise groups,
Written information,
Individualised protocols
Provision of information
To feel ‘psychologically’ safe for
discharge
the early post discharge period.
For relatives who are experiencing care
giver stress, they require support and
recognition, skills to assist their relative in
ADLs and skills to manage stress. Patients
could also benefit from assessment for
necessary aids, adaptations or services
required to maximise independence.
For the majority of patients standardised
regimes of therapy and advice (ie. exercise
groups, standard written information RE:
recovery and ADL performance) may be
sufficient however for patients with
multiple impairments or post-operative
complications, rehabilitation and advice
provided needs to be individualised.
Provision of information regarding
complications, avoidance of complications,
and physical activity and ADL restrictions.
To feel ‘psychologically safe’ as well as
‘physically safe’ on discharge by being
provided with accurate and consistent
information about discharge home and
having support after discharge (29).
(38)
(39)
(42)
(29)
4. What are the rehabilitation and support needs of people aged 65
and over following discharge from hospital after TKR?
The characteristics of the population undergoing TKR as well as short and long term
outcomes has been used to indicate probable rehabilitation and support needs for this
group. A summary of these probable key needs and a description of the supporting
literature, has been provided in Table 3.
Characteristics of the TKR population
Total knee replacement surgery is successful in the treatment of joints compromised
by osteoarthritis and other disorders of the knee, and pain relief is one of the most
important post operative aims (44). Therefore, like admission to hospital for THR,
TKR is a planned event and mostly involves a standardised protocol of preadmission
assessment, pre and post surgical education and planned discharge within a
predetermined timeframe. However, one comparative study reported a 30%
complication rate in a group of 37 patients allocated to early discharge and hospital at
home post TKR, which prevented planned early discharge (45). A standardised
protocol with pre-determined timing for hospital discharge to CR following TKR may
not be possible for every patient. Older age (27, 30, 46), presence of co-morbidities
and lower pre-operative MBI scores (27), female gender, absence of a carer,
housebound prior to admission (30) and presence of diabetes mellitus (46) are factors
that have been found to be associated with longer hospital stay and discharge to
inpatient rehabilitation following TKR.
12
TKR outcomes
A particular yardstick for discharge after TKR is knee flexion range of motion. Ritter
and Campbell (47) reported that the amount of post operative knee flexion had
statistically significant effect on walking and stair climbing ability. Ninety degrees of
knee flexion has been shown to be adequate for most ADLs (48).
Studies indicate a loss of knee flexion at 12 months (49) and in patients with
osteoarthritis of the knee (50). This has been found to be related to pre-operative knee
contracture (51).
Oldmeadow et al (30) described outcomes of 105 patients across three Melbourne
hospitals with a mean length of acute stay of 6.5 days, and reported that on discharge
from acute care 56% of participants had achieved independent functional mobility
adequate for discharge home. Of those participants that achieved independent
functional mobility, about two thirds were discharged home and the remainder were
discharged to institutional rehabilitation. The authors reported the most common
reason for discharge to rehabilitation in these cases appeared to be non-clinical
factors, including the availability of a rehabilitation bed and pressure to reduce length
of stay. Other reasons for discharge to rehabilitation included:, the need to progress
from a walking frame to crutches; having a knee range of motion less than 55 degrees:
and needing ongoing wound care, all of which the authors report could be managed
by community services. This finding highlights the benefits of predicting timely
discharge to appropriate levels of services, including the identification of ways to
discharge patients directly home. Oldmeadow et al (30) suggest that identification of
pre-operative factors may be useful in the early post operative period and cite their
findings of association between increasing age, female gender, housebound before
admission and absence of a carer with more frequent discharge to institutional
rehabilitation following total knee arthroplasty (30). Forrest et al (46) identified age
and the presence of diabetes mellitus to be associated with need for admission to
inpatient rehabilitation after knee arthroplasty. Bindelglass et al (52) describe a rating
tool based on pre-operative factors however this was found to be accurate 73% of the
time in determining the need for discharge to a rehabilitation facility.
Long term outcomes post TKR
Fuchs et al (53) compared patients with TKR with a group of age-matched controls
without TKR and found that participants with TKR (who were an average 21.5
months post TKR) had poorer functional capabilities, more pain, lower quality of life
scores, poorer gait pattern and muscle activity. Brander et al (44) described a group
of 116 patients following TKR and found that one in eight patients report significant
pain at six and 12 months post surgery, with preoperative depression and anxiety
associated with higher levels of pain and use of more postoperative health services.
Identification and treatment of depression and anxiety before surgery may therefore
be important for improving outcome after TKR (44). Heightened preoperative pain
was also associated with heightened postoperative pain and therefore preoperative
pain management, physical therapy and education may reduce poor outcomes (44). A
study of quality of life (QOL) one to four months following TKR revealed that
participants reported social factors such as caregiver burden, decreased social activity
13
and shrinking social networks to be factors that they felt prevented improvements in
their QOL after TKR (54).
Table 3: Rehabilitation and support needs following TKR
Need
Knee ROM
Pain management,
Treatment of anxiety
and depression
Support and
assistance for ADLs
Resumption of social
roles
Description
Long term management to prevent loss of knee range of
motion especially for those with osteoarthritis and preoperative knee contracture.
Pain management early post discharge and potentially
6-12 months post TKR and inclusion of treatment of
anxiety and depression in patients where this may
contribute to their experience of pain.
Potentially need for support and assistance with
functional activities and ADLs due to functional deficits
that may be ongoing or at least a need for assistance in
the early post discharge period.
Assistance to resume social roles despite reduced knee
function in order to optimise quality of life.
14
Reference
(50, 51)
(44)
(53)
(54)
5. What competencies do CR workers require in order to meet
these rehabilitation and support needs?
Findings of research pertaining to outcomes early and several years post discharge
from hospital after hip fracture, TKR or THR, as well as the outcomes of intervention
studies, indicate the competencies required by health workers providing CR.
Summaries of these suggested competencies have been provided in Tables 4 and 5.
Table 4: CR competencies for workers providing services post hip fracture
Competency
Individualised assessment skills
to inform an individualised
intervention
Understanding impact of
cognitive deficit on
rehabilitation
Care and support needs
assessment skills
Understanding of unique needs
of patients with dementia
Awareness of indicators of
visual acuity problems and how
to optimise
Pain Management,
Fatigue Management
Falls Prevention
Exercise based conditioning,
Transfers training,
ADL retraining,
Environmental compensation
Description
Tinetti et al suggest an ability to implement a
systematic, individualised assessment to
inform an individualised intervention given
the multiplicity of factors such as comorbidities, cognitive impairment, age, premorbid functional level on outcomes.
Skills in assessment of cognitive status and
implementation of rehabilitation with an
understanding of the impact of cognitive
deficits on rehabilitation.
Accurate assessment of care needs and social
support.
Skills in management and understanding of
needs of patients with dementia given the
frequency of hip fracture in patients with
dementia. This may involved upskilling
rehabilitation providers in nursing homes.
Awareness of the prevalence of visual acuity
problems and need to optimise patient’s
vision in order to optimise rehabilitation
outcomes.
Holistic skills in the management of pain and
fatigue.
Skills in falls prevention and addressing
worry over falls to increase confidence with
participation in ADLs.
Skills in exercise based conditioning,
transfers training, ADL retraining and
environmental compensation.
15
Reference
(8)
(14-16)
(55)
(6)
(7)
(15, 23)
(12)
(21)
Table 5: CR competencies for workers providing services post THR and TKR
Competency
Care and support needs assessment
skills
Knowledge of potential range of
impairments and impact on function
Knowledge of pre-arthroplasty
protocols and information provision
Knowledge of impact impairments
on QOL,
Rehabilitation focus that maximises
QOL by targeting
activity/participation .
Rehabilitation skills:
Exercise-based activity,
Improving mobility ,
Improving physical function,
ADL retraining,
Environmental compensation
Pain management skills
Skills in prevention and
identification of carer burden,
Knowledge of available support
services,
Skills in running carers’ groups.
Description
Accurate assessment of care needs and social
support including instrumental and social
support for which there are valid and reliable
orthogeriatric assessment tools including the
Groningen orthopaedic social support scale.
Recognition of the importance of preparing
patients and their families for best case-worst
case scenarios in terms of recovery and
resumption of previous roles.
Understanding of pre-arthroplasty protocols
and information given in hospital in order to
be able to repeat the information and check
the skills given in hospital to ensure
knowledge and skills has been transferred to
the home environment.
Broader perspective beyond physical
functioning to QOL. Attention to impact of
reduced participation in social activity/roles
and enabling access to/participation in social
activity despite deficits in physical function
(ie. community access, transport issues).
Skills in exercise based rehabilitation to
maximise knee ROM, mobility and physical
function, ADL retraining and environmental
compensation.
Reference
(55)
Expertise in pain management, education and
ability to know when there is a need for
specialised pain management services.
Awareness of the potential for burden on
informal carers and knowledge of services
such as respite and paid care to ease burden on
family. Skills in recognising and supporting
carers who are experiencing stress associated
with caring and skills in running carer’s
groups.
(44)
(41)
(41)
(54)
(34, 43, 49, 51,
56)
(32)
6. Conclusion
Rehabilitation needs exist in terms of functional status, mobility, lower limb
strengthening, postural stability, pain management, falls prevention and interventions
to improve quality of life years post hip fracture, THR and TKR. The timing and
nature of CR will differ for joint replacements as compared with hip fracture given the
unplanned nature of hip fracture and the concomitant age-related medical problems
associated with hip fracture. Where a prescriptive, standardised protocol of preadmission assessment and education and early discharge to CR may be appropriate for
the majority of planned elective hip and knee joint replacements, this is unlikely to be
appropriate for most patients following hip fracture.
16
Competencies common in provision of CR for people post hip fracture, THR and
TKR in the community include individualised assessment skills to guide
individualised intervention programs; skills in assessing care support needs and carer
burden; knowledge of available community support services; skills in pain assessment
and management of pain and fatigue; skills in exercise based training to improve
physical function and mobility, transfers and ADL and environmental compensation.
Competencies specific for clients post hip fracture in the community include
understanding of the impact of cognitive deficit on rehabilitation and skills in
managing people with cognitive deficits, dementia specific skills for clients with
dementia and hip fracture as well as skills in prevention of falls. Competencies
specific to management post TKR and THR include knowledge of pre-arthroplasty
protocols to enable carry over of education and management to the home/community
environment, knowledge of the functional implications of impairments and a quality
of life (QOL) and a participation focus.
17
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21
Appendix 1: Search Strategy
1. Identified published literature in research journals by searching electronic
databases using the following broad key search terms (number of hits):
Hip arthroplasty rehabilitation (277)
Knee arthroplasty rehabilitation (257)
Hip replacement rehabilitation (290)
Knee replacement rehabilitation (344)
Proximal femoral fracture rehabilitation (32)
Proximal femoral fracture (269)
Fractured Femur (577)
Fractured neck of femur (443)
CR and fracture (23)
Searches were carried out between 10/08/2005 and 18/08/2005 on the following
electronic databases:
 Silverplatter Medline
 Rehabilitation and Physical Medicine
 Cochrane Database register of controlled trials
 Cochrane Database SR
 Allied Health and Complementary Medicine
 CINAHL and Pre CINAHL
 Psychlit
2. Titles and abstracts of the articles retrieved were reviewed. Those not meeting the
inclusion criteria were excluded. A full report was retrieved for those meeting the
inclusion criteria.
3. Reference lists of included articles were reviewed. A full report was obtained for
relevant articles after analysis of the title and if the article met the inclusion criteria on
further review.
Inclusion/Exclusion criteria:
 All levels of evidence were reviewed
 Studies reviewed only included participants who were 65 years of age and
over and have undergone orthopaedic surgery post proximal femoral fracture
or have had a total knee replacement or total hip replacement.
 Studies reviewed involved post surgical/hip fracture rehabilitation
interventions carried out in hospitals, day centres and the participant’s home
setting, studies reporting outcomes post hospital discharge following hip
fracture, THR and TKR
 English language full text published literature from 1990 to 2005.
22