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February 28, 2007

Road to Recovery

There has been a shift towards shorter inpatient stays in the field of orthopaedics over the last decade. This has led to significant changes in rehabilitation practice and the role of the therapist, writes Grahame Pope.

By Grahame Pope

Orthopaedic surgery and rehabilitation have undergone major changes in the last ten years. Patients are spending less time in hospital after surgery, and as a result, their rehabilitation is starting earlier and is much more intensive.

Part of the change in rehabilitation practices is due to the recognition that early mobilisation, in most instances, produces better outcomes. In almost any area of orthopaedic surgery, from joint replacement to tendon repair to fracture management, the earlier someone gets moving again – in a very managed and controlled way – the better the outcome.

When I trained 20 years ago, physiotherapists and occupational therapists would often assess a patient before surgery. This practice then seemed to fall out of favour, probably because of major changes in the UK’s NHS at the time. Now, however, the practice is in vogue again. Today, the rise of multi-professional pre-surgery clinics means that a patient’s situation can be fully assessed, enabling rehabilitation to be implemented much earlier.

MULTI-SKILLED

Therapists are now working in different ways and from a more clinically advanced position. The current trend is towards extended-scope practitioners who take on tasks and roles that 15 years ago would have come under the domain of the medic. There has also been an increase in number consultant therapists who are able to make major clinical decisions.

Recently, therapists have begun acquiring abilities to supplement their care skills. These new skills range from ordering additional tests, such as blood tests, X-rays or ultrasound scans, to interpreting the results from tests and making decisions about management plans and referrals. And therapists are proving to be well suited to these new roles.

In the UK, studies show that about 70% of patients who see an orthopaedic surgeon do not require surgery. However, they may need to access some sort of management, whether it is a physiotherapist to set up an exercise programme or an occupational therapist to arrange aids for daily living. This is where the benefits of a multi-skilled therapy team become apparent. The team is able to provide services and produce results that make a considerable difference to a patient’s life – and all without the expense of a consultant.

CHANGING PRACTICES

One major challenge currently facing rehabilitation practitioners – and surgeons – is in the field of joint replacement. As people live longer and are encouraged to live more active lives, the durability of joint replacements is being tested. In the past, a joint replacement would be expected to last for a patient’s full lifespan.

However, lengthening lifespans and greater activity levels mean that there is increasing demand for revisions and replacements. Such procedures are difficult, not least because the existing joint replacement has to be removed in an operation that is far more complex than the original surgery.

As prosthetics improve, there has been a shift in rehabilitation practice. It is now much more concerned with preparing individuals properly for surgery to ensure good outcomes, as well as with dealing with the outcome of the surgery.

One further change in rehabilitation practice is that, as hospital stays are now much shorter, there is a greater focus on providing rehabilitation after patients have left hospital to help them make as full a recovery as possible. We are seeing services being provided in health centres, leisure centres, community centres and other settings close to patients’ homes, and not just in outpatient clinics.

SURGICAL APPROACH

Surgical techniques are now being employed at an early stage to try and prevent damage to joints that could lead to the need for them to be replaced. Such techniques include joint resurfacing and cartilage culturing for transplantation into joints. These innovative techniques will hopefully reduce the need for major surgery.

However, interventions such as joint resurfacing create some additional rehabilitation needs. Resurfacing has to be followed by a lengthy period when there must only be controlled movement of the joint, to prevent further damage. At the same time, it is extremely important that the management plan maintains the anatomical area’s function and strength as much as possible.

BACK PAIN

There has been a significant shift in thinking on the treatment of back pain. It is an enormous problem and one of the greatest burdens on the healthcare system. It is also one of the major causes of days off work.

“Little time is spent on educating healthcare professionals on psychological aspects of patient care.”

Over the last few years, the management of back pain and back problems has moved away from interventionist procedures, such as surgery or treatments – physiotherapy or acupuncture – towards a cognitive, behavioural approach, whereby patients are encouraged to come to terms with their problems and are given tools to help them manage them and, in some cases, overcome them.

Again, the focus is on multi-skilled healthcare professionals rather than medics. Although the patient may be referred into the system and assessed, at some point, by a medic, most management and interventions are provided by therapists and psychologists. It is not so much about doing things to the patient as about encouraging them to take more responsibility for their problems.

NEW THINKING

In the past, we have possibly been so focused on diagnosing what is wrong with an individual that we have forgotten that we are dealing with an individual. Today, a much more holistic approach to care is taken. This is not a new idea, but it is only recently that it has been taken up and developed in realistic applications that have provided a real alternative for patients.

We know that the relationship a patient has with their carer or treatment provider has a substantial impact on their welfare, yet little time is spent on educating healthcare professionals on psychological aspects of patient care – and this is the case across most of the healthcare professions. The group that probably spends most time in psychological aspects of patient care is occupational therapists, partly because this group often works in mental healthcare.

However, therapists and other healthcare professionals need to develop new skills centred on managing behavioural problems and counselling, skills that are highly effective in producing desired aims and outcomes. This is something that therapists can be very good at, because they spend comparatively large periods of time with their patients. Overall we must make sure that a rehabilitation programme takes advantage of increasing skill levels in the heathcare professions.

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