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
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
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.
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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.
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
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 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.
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.
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
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
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
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