Implementation of supplemental physiotherapy following hip fracture surgery: a protocol for the process evaluation of a randomised controlled trial.

BACKGROUND: Patient outcomes following low-trauma hip fracture are suboptimal resulting in increased healthcare costs and poor functional outcomes at 1 year. Providing early and intensive in-hospital physiotherapy could help improve patient outcomes and reduce costs following hip fracture surgery. The HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER) trial will compare usual care physiotherapy to intensive in-hospital physiotherapy for patients following hip fracture surgery. The complex environments in which the intervention is implemented present unique contextual challenges that may impact intervention effectiveness. This study aims to complete a process evaluation to identify barriers and facilitators to implementation and explore the patient, carer and clinician experience of intensive therapy following hip fracture surgery. METHODS AND ANALYSIS: The process evaluation is embedded within a two-arm randomised, controlled, assessor-blinded trial recruiting 620 participants from eight Australian hospitals who have had surgery for a hip fracture sustained via a low-trauma injury. A theory-based mixed method process evaluation will be completed in tandem with the HIPSTER trial. Patient and carer semi-structured interviews will be completed at 6 weeks following hip fracture surgery. The clinician experience will be explored through online surveys completed pre- and post-implementation of intensive therapy and mapped to domains of the Theoretical Domains Framework (TDF). Translation and behaviour change success will be assessed using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework and a combination of qualitative and quantitative data collection methods. These data will assist with the development of an Implementation Toolkit aiding future translation into practice. DISCUSSION: The embedded process evaluation will help understand the interplay between the implementation context and the intensive therapy intervention following surgery for low-trauma hip fracture. Understanding these mechanisms, if effective, will assist with transferability into other contexts and wider translation into practice. TRIAL REGISTRATION: ACTRN 12622001442796.

The influence of hospital and home environments on physical activity and sedentary behaviour: Perceptions of people recovering from fractures.

BACKGROUND: A lack of evidence exists contrasting the factors that influence physical activity and sedentary behaviour in both hospital and home settings before and after discharge from acute hospitalisation for fractures. OBJECTIVE: To describe and compare perceptions of environmental influences on physical activity in hospital and home settings in people recovering from fractures. METHOD: Semi-structured interviews were conducted with patients hospitalised following fractures (hip fracture or multi-trauma), exploring the barriers and enablers to physical activity within hospital and home settings. Interviews were conducted within two weeks of hospital discharge, audio recorded and transcribed prior to thematic analysis via a framework approach. RESULTS: Between December 2022 and May 2023, 12 semi-structured interviews were undertaken with an equal number of participants who sustained an isolated hip fracture or multi-trauma. The median (IQR) age of participants was 60 (52-68) years, with half being male, and the majority sustaining their injuries via transport crashes. Three main themes that influenced physical activity behaviours in hospital and home settings were: having the opportunity, having a reason, and having support and assistance to be active. CONCLUSION: During the period of reduced physical capability following fracture, patients need to be provided with opportunities and motivation to be active, particularly within the hospital setting. Findings from this study will assist clinicians to better support people recovering from fractures via greater engagement in physical activity within hospital and home settings.

HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER): a protocol for a randomised controlled trial.

INTRODUCTION: Hip fractures result in substantial health impacts for patients and costs to health systems. Many patients require prolonged hospital stays and up to 60% do not regain their prefracture level of mobility within 1 year. Physical rehabilitation plays a key role in regaining physical function and independence; however, there are no recommendations regarding the optimal intensity. This study aims to compare the clinical efficacy and cost-effectiveness of early intensive in-hospital physiotherapy compared with usual care in patients who have had surgery following a hip fracture. METHODS AND ANALYSIS: This two-arm randomised, controlled, assessor-blinded trial will recruit 620 participants who have had surgery following a hip fracture from eight hospitals. Participants will be randomised 1:1 to receive usual care (physiotherapy according to usual practice at the site) or intensive physiotherapy in the hospital over the first 7 days following surgery (two additional sessions per day, one delivered by a physiotherapist and the other by an allied health assistant). The primary outcome is the total hospital length of stay, measured from the date of hospital admission to the date of hospital discharge, including both acute and subacute hospital days. Secondary outcomes are functional mobility, health-related quality of life, concerns about falling, discharge destination, proportion of patients remaining in hospital at 30 days, return to preadmission mobility and residence at 120 days and adverse events. Twelve months of follow-up will capture data on healthcare utilisation. A cost-effectiveness evaluation will be undertaken, and a process evaluation will document barriers and facilitators to implementation. ETHICS AND DISSEMINATION: The Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients and carers. TRIAL REGISTRATION NUMBER: ACTRN12622001442796.

Perspectives of telehealth access and implementation in people recovering from serious transport injury, health care providers and compensation system staff during the COVID-19 pandemic in Australia.

INTRODUCTION: Before the COVID-19 pandemic, few injury compensation schemes supported access to service-delivery via telehealth. The aim of this qualitative study was to explore the perspectives of people recovering from serious transport injury, health care providers, and senior staff of a transport injury compensation scheme, in relation to the uptake and implementation of telehealth during the COVID-19 pandemic, and its ongoing use. METHODS: Semi-structured interviews were undertaken with 35 participants, including 15 seriously injured patients, 16 health care providers and 4 compensation scheme staff. A thematic analysis was performed using a framework approach. RESULTS: Themes identified included the need to provide continuity of care via telehealth during the pandemic for patients recovering from injury, and the associated organisational and technical support needs. It was noted that some types of services worked well via telehealth, including psychology, while others did not, including physical assessments. The convenience of telehealth was highlighted, in relation to reduced travel. However, there were often safety fears relating to falls, and communication issues with injured people. CONCLUSIONS: This research found that the majority of injured patients and health care providers had benefitted from the introduction of service delivery via telehealth during the pandemic for some types of services. Participants saw opportunities for continued benefit post-pandemic, particularly for improving equity of access to health care for people with barriers to mobility and travel.

The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management.

OBJECTIVES: To report on the long-term outcomes of the management of translated proximal humerus fractures. DESIGN: A prospective cohort study was conducted from January 2010 to December 2018. SETTING: Academic Level 1 trauma center. PARTICIPANTS/PATIENTS: A total of 108 patients with a proximal humerus fracture with ≥100% translation, defined as no cortical bony contact between the shaft and humeral head fragments, were included. INTERVENTION: Patients were managed nonoperatively with sling immobilization or with operative management as determined by the treating surgeon. MAIN OUTCOME MEASURES: Outcome measures were the Oxford Shoulder Score, EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, nonunion/malunion, and avascular necrosis. RESULTS: Of the 108 patients, 76 underwent operative intervention and 32 were managed nonoperatively. The mean (SD) age in the operative group was 54.3 (±20.2) years and in the nonoperative group was 73.3 (±15.3) years ( P < 0.001). There was no association between Oxford Shoulder Score and management options (mean 38.5 [±9.5] operative versus mean 41.3 [±8.5] nonoperative, P = 0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference was 0.16 (95% CI, 0.04-0.27; P = 0.008); EQ-5D VAS adjusted mean difference was 19.2 (95% CI, 5.2-33.2; P = 0.008). Operative management was associated with a lower odds of nonunion (adjusted OR 0.30; 95% CI, 0.09-0.97; P = 0.04), malunion (adjusted OR 0.14; 95% CI, 0.04-0.51; P = 0.003), and complications (adjusted OR 0.07; 95% CI, 0.02-0.32; P = 0.001). CONCLUSION: Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes after surgical fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness of a purpose-built ward environment and new allied health model of care for major trauma.

BACKGROUND: Targeted rehabilitation within the acute inpatient setting could have a substantial impact on improving outcomes for major trauma patients. The aim of this study was to investigate the cost-effectiveness of the introduction of a purpose-built ward environment, and a new allied health model of care (AHMOC) delivered in the acute inpatient setting, in a major trauma population. METHODS: The statewide trauma registry, the trauma center's data warehouse, and electronic medical record data were used for this observational study. There were three phases: baseline, new ward, and new AHMOC. Cost-effectiveness was measured as cost per quality-adjusted life year using preinjury, hospital discharge, 1-month and 6-month 5-level, EQ-5D utility scores. Total costs included initial acute and inpatient rehabilitation care, as well as outpatient, readmission and ED presentations to 6-months. RESULTS: Four hundred eleven patients were included. Case-mix was stable between phases. The median (IQR) number of allied health services received by patients was 8 (5-17) at baseline, 10 (5-19) in the new ward phase, and 17 (9-23) in the AHMOC phase. The proportion discharged to rehabilitation was 37% at baseline, 45% with the new ward and 28% with the new AHMOC. Mean (SD) total Australian dollar costs were $69,335 ($141,175) at baseline, $55,943 ($82,706) with the new ward and $37,833 ($49,004) with the AHMOC. The probability of the AHMOC being cost-effective at a willingness-to-pay threshold of $50,000 per quality-adjusted life year was 99.4% compared with baseline and 98% compared with the new ward. CONCLUSION: The new allied health model of care was found to be a cost-effective intervention. Uptake of this model of allied health care at other trauma centers has the potential to reduce the cost and burden of major trauma. LEVEL OF EVIDENCE: Economic and Value-based Evaluations; Level III.

Perceptions of an Interactive Trauma Recovery Information Booklet.

BACKGROUND: Previous research has shown that people with traumatic injuries have unmet information needs with respect to their injuries, management, and recovery. An interactive trauma recovery information booklet was developed and implemented to address these information needs at a major trauma center in Victoria, Australia. OBJECTIVE: The aim of this quality improvement project was to explore patient and clinician perceptions of a recovery information booklet introduced into a trauma ward. METHODS: Semistructured interviews with trauma patients, family members, and health professionals were undertaken and thematically analyzed using a framework approach. In total, 34 patients, 10 family members, and 26 health professionals were interviewed. RESULTS: Overall, the booklet was well accepted by most participants and was perceived to contain useful information. The design, content, pictures, and readability were all positively appraised. Many participants used the booklet to record personalized information and to ask health professionals questions about their injuries and management. CONCLUSION: Our findings highlight the usefulness and acceptability of a low-cost interactive booklet intervention to facilitate the provision of quality of information and patient-health professional interactions on a trauma ward.

Validity of the activPAL and ActiGraph for measuring sitting time and steps in hospitalised orthopaedic patients with altered weight bearing.

PURPOSE: To determine the criterion validity of the activPAL and ActiGraph for measuring steps and sitting/sedentary time, compared to observation, in people hospitalised following orthopaedic lower limb injury who were weight bearing (WB) (i.e., walking) or non-weight bearing (NWB) (i.e., hopping). MATERIALS AND METHODS: Participants wore an activPAL and ActiGraph on the hip/thigh/unaffected (UA)/affected ankle (AA) while completing bouts of walking and sitting. Lin's concordance correlation coefficient, Bland-Altman methods, and ratio of agreement were used to compare device-measured to observed (videoed) step count, sitting/sedentary time. RESULTS: In 42 participants, the ActiGraph demonstrated excellent concordance with the observed step count when worn on the ankle (LCC 0.91-0.92) compared to the hip (LCC 0.56) in participants that were WB. The ActiGraph AA achieved the highest concordance (LCC 0.71) with observed steps in participants NWB. The activPAL had poor concordance with observed steps, particularly at slow gait speeds, in participants that were WB (LCC 0.38-0.46), however was less influenced by gait speed and had good concordance in NWB participants (LCC 0.52-0.69). The activPAL (LCC 0.79-0.88) and ActiGraph UA (LCC 0.94) showed excellent concordance with observed sitting and sedentary time, respectively. CONCLUSIONS: The ActiGraph worn at the ankle provided the most valid measure of steps in people who are WB and NWB following orthopaedic injury, while the activPAL was best for measuring sitting time.Implications for rehabilitationTo accurately measure both steps and sitting time in people with lower limb orthopaedic injuries, a combination of activity monitors should be used (i.e., ActiGraph for steps, activPAL for sitting time).The ActiGraph device when worn on the ankle demonstrated the strongest agreement with observed step count in people who were weight bearing and non-weight bearing.Caution is needed when using thigh- or hip-worn devices in people who walk slowly.

Measurement of Mobility and Physical Function in Patients Hospitalized With Hip Fracture: A Systematic Review of Instruments and Their Measurement Properties.

OBJECTIVE: Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting. METHODS: Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist. RESULTS: Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed "Up & Go" Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63-2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] >0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%-60% of patients). The TUG, CAS, and BI all had good clinical utility. CONCLUSION: Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting. IMPACT: This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

Can a new ward environment and intensive allied health staffing model enhance therapeutic opportunities in trauma care? A behavioural mapping study of patients' activities and interactions.

OBJECTIVE: The aim of this study was to assess changes in patient activities and interactions observed in response to a new trauma ward at a level 1 trauma centre, and subsequently, a new allied health staffing model. DESIGN: Explorative case study using behavioural mapping. SETTING: Level 1 trauma centre in Melbourne, Australia. PARTICIPANTS: Hospitalised trauma patients. MAIN MEASURES: Behavioural mapping of patients' activities and interactions was conducted by two observers over three 4-day observation phases: (i) at baseline, (ii) on the new ward and (iii) with the new staffing model. Changes in activities and interactions were assessed via negative binomial regression models and reported as incident rate ratios. RESULTS: In total, 1264 patient observations were recorded over an 18-month period. After moving to the new ward, patients were observed performing activities of daily living at a 2.1-fold higher rate than at baseline (95% confidence interval: 1.18, 3.81) but walking/standing/climbing stairs 54% less (95% confidence interval: 0.22, 0.94). Subsequent to the new staffing model, patients were observed in the gym at a 4.1-fold higher rate (95% confidence interval: 1.60, 10.32) and interacting with allied health professionals at a 9.1-fold higher rate (95% confidence interval: 4.88, 16.98), than at baseline. After COVID-19 restrictions were introduced, patients were observed lying down 22% more (95% confidence interval: 1.04, 1.43), with 73% fewer visitor interactions (95% confidence interval: 0.17, 0.43). CONCLUSIONS: Greater engagement in physical and social activities was observed following the implementation of the new allied health staffing model at a level 1 trauma centre. Whether these changes translate to improved trauma outcomes is important to investigate.

Outcomes after application of halothoracic orthosis for cervical spine trauma.

BACKGROUND: Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS: Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS: Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION: Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

The impact of obesity in rehabilitation: a mismatch between staff perception and hospital outcomes.

PURPOSE: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine its impact on hospital outcomes, and explore staff perceptions of caring for patients with obesity. METHODS: A retrospective audit of inpatients admitted to a sub-acute rehabilitation hospital over 12 months. Hospital outcomes included length of stay (LOS), Functional Independence measure (FIM), and discharge destination. Linear regression models were used to determine whether obesity was associated with hospital outcomes. Staff working on rehabilitation wards were invited to complete a survey exploring their perceptions on caring for those who are obese. RESULTS: Of 1280 episodes of care, 359 (28%) patients were classified as obese with a body mass index ≥30 kg/m2. Obesity was not associated with LOS or functional improvement after controlling for age, gender, and admission FIM. One hundred and twelve hospital staff (response rate 71%) completed the survey. Most rated their bariatric care knowledge as average (45%) or good (36%). The majority (60%) perceived that patients with obesity have longer LOS than those who are non-obese. CONCLUSION: One-third of patients admitted to inpatient subacute rehabilitation were classified as obese. Whilst obesity was not associated with poorer hospital outcomes, staff perceived that obesity negatively impacts on care requirements and LOS.Implications for rehabilitationA third of patients admitted to a public, inpatient rehabilitation setting may be classified as obese based on their body mass index.Although staff perceived that obesity negatively impacts on length of stay and functional gains, there was no evidence that obesity was associated with poorer hospital outcomes.Patients who are classified as obese were able to achieve comparable hospital outcomes including length of stay in the rehabilitation setting to those who are not obese.

Radiological features of pulmonary fat embolism in trauma patients: a case series.

PURPOSE: Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. METHODS: Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. RESULTS: Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17-69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring - 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. CONCLUSION: CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients.

Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032). Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record. What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record. What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement. What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.

The AWESCORE, a patient-reported outcome measure: development, feasibility, reliability, validity and responsiveness for adults with cystic fibrosis.

BACKGROUND: Quality of life has improved dramatically over the past two decades in people with cystic fibrosis (CF). Quantification has been enabled by patient-reported outcome measures (PROMs); however, many are lengthy and can be challenging to use in routine clinical practice. We propose a short-form PROM that correlates well with established quality-of-life measures. METHODS: We evaluated the utility of a 10-item score (AWESCORE) by measuring reliability, validity and responsiveness in adults with CF. The questions were developed by thematic analysis of survey questions to patients in a single adult CF centre. Each question was scored using a numerical rating scale 0 to 10. Total scores ranged from 0 to 100. Test-retest reliability was assessed over 24 h. To determine validity, comparisons were sought between stable subjects and those in pulmonary exacerbation, and between AWESCORE and Cystic Fibrosis Questionnaire - Revised (CFQ-R). Responsiveness to pulmonary exacerbation in individual subjects was evaluated. RESULTS: Five domains, each with two questions, were identified for respiratory, physical, nutritional, psychological and general health. A total of 246 consecutive adults attending the outpatient clinic completed the AWESCORE. Scores were higher during clinical stability compared to pulmonary exacerbation (mean± sd): 73±11 versus 48±11 (p<0.001). Each domain scored worse during an acute exacerbation (p<0.001). No differences in reliability were observed in scores on retesting using Bland-Altman comparison. The CFQ-R scores (mean±sd: 813±125) and AWESCORE (81±13) were moderately correlated (Pearson's r=0.649; p=0.002). CONCLUSIONS: The AWESCORE is valid, reliable and responsive to altered health status in CF.

Rocktape provides no benefit over sham taping in people with knee osteoarthritis who are completing an exercise program: a randomised trial.

OBJECTIVES: To investigate if Rocktape combined with exercise is more effective than exercise and sham taping in patients with knee osteoarthritis. DESIGN: Single institution, prospective, participant and assessor blinded, randomised study. SETTING: Outpatient physiotherapy department of a tertiary hospital. PARTICIPANTS: Thirty-six patients with knee osteoarthritis. INTERVENTION: Participants were randomised to either; 1) Rocktape plus exercise or 2) sham taping plus exercise. MAIN OUTCOME MEASURES: A linear mixed-effect model was used to assess differences between groups over time for the primary outcome measure (VAS at rest and movement) as well as the secondary outcome measures. Secondary measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS), 30second sit to stand, 40m walk and stair climb tests. Exercise adherence and analgesia use were recorded via a diary. Outcomes were assessed at baseline, immediately prior to the first tape application and immediately following first taping (both at one week after baseline), then two and five weeks after first tape application. RESULTS: There were no between group differences over time in pain at rest [median Rocktape group 0.035 (IQR -0.1 to 3.0) vs median sham 0 (IQR 0 to 1.6) mean adj diff (0.053, 95% CI -0.17 to 0.27)] or with movement [median tape group 2.45 (IQR -0.5 to 4.8) vs median sham 2.0 (IQR 0.8 to 4.1) mean adj diff 0.072, 95% CI -0.20 to 0.35]. There were no significant differences between groups in any of the KOOS subscales or performance-based tests administered over time. Pain on movement significantly improved over time in both groups, whilst pain at rest only improved at the final time point. CONCLUSION: There was no additional benefit of Rocktape over sham tape in patients with knee osteoarthritis who were completing a home exercise program over five weeks. TRIAL REGISTRATION: Clinical Trials Registry (#NCT02049216).

Reliability, Validity, Clinical Utility, and Responsiveness of Measures for Assessing Mobility and Physical Function in Patients With Traumatic Injury in the Acute Care Hospital Setting: A Prospective Study.

OBJECTIVE: The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury. METHODS: In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early vs late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function. RESULTS: Participants had a median age of 52 years (interquartile range = 33-68 years), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds-1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18%-33% of participants). All had strong known-groups validity (early vs late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79-0.94). CONCLUSION: All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge. IMPACT: This study is an important step toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7.

AIMS: Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). METHODS: Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. RESULTS: In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. CONCLUSION: A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769-774.

Incidence of lower limb amputation in Central Australia.

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA. Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis. Results In the period 2012-17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100000 for females and 104.6 per 100000 for males in this region. In total, 84% (n=140) of those requiring amputation surgery identified as Aboriginal Australians (P<0.001), 54% (n=75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P<0.001) and require renal dialysis (P<0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n=103) lived very remotely (>100km from the central town's centre), compared with 23% of non-Aboriginal Australians (P<0.001). In addition, 46% (n=64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P=0.014) and had a higher mortality rate following amputation (P=0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%). Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts. What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known. What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis. What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.