Summary of the main findings from Phase I

The three components of the first phase of the study aimed to systematically develop an enhanced rehabilitation intervention by collating the available evidence and developing theories on what current rehabilitation programmes consist of, how effective they are and how patients and health-care professionals view them.

From the realist review (see Chapter 2) an overarching theory was developed that, in our target population of patients who have varied pre-fracture functions and comorbidities, a tailored intervention incorporating increased quality and amount of practice of exercise and ADL could improve confidence, mood, self-efficacy, function and mobility, and reduce the fear of falling.

A survey of UK health-care professionals involved in the rehabilitation of hip fracture patients (see Chapter 4) identified the ability to tailor rehabilitation to individual needs and the role of multidisciplinary rehabilitation teams as important factors in patient recovery, but reported that communication between the different providers (e.g. acute and community services) required improvement in some areas. Survey respondents also reported variability in the provision of services, the availability of resources, the assessment of patient progress and the assessment of psychological mediators of recovery.

Focus groups with rehabilitation health-care professionals and hip fracture patients and their carers conducted across North Wales also identified variability as a pertinent theme that underpinned the delivery of rehabilitation programmes and how they were received by patients (see Chapter 5). This led to uncertainty for patients and carers in what to expect during recovery, and patients and carers identified a need for better communication and information from health-care professionals to help manage expectations and support patient recovery. Patient engagement in rehabilitation and confidence in seeking out and accessing services were also identified as potential barriers to recovery. The traumatic experience of falling and fracturing also had an important psychosocial impact in terms of anxiety, fear of falling and loss of independence.

Designing the enhanced rehabilitation intervention

Based on the findings described in the previous section, we identified four main criteria that our intervention should fulfil:

1. allow for tailoring to account for pre-fracture function and comorbidities
2. increase the amount and quality of exercise, and improve engagement and self-efficacy
3. address the psychological impact of hip fracture and patients’ need for information
4. improve the co-ordination of services.

With this in mind, we developed a programme comprising both physical and psychological components. The physical component consisted of the provision of six additional rehabilitation sessions made available to patients on discharge to their permanent place of residence. Physiotherapists and dual-trained technical instructors conducted these sessions and tailored the content of the sessions to individual needs. The psychological component consisted of a patient-held information workbook and goal-setting diary to be used in conjunction with the extra sessions and the support of the therapists. The physiotherapists used the initial extra session to assess each patient’s function and any existing comorbidities, and to discuss his or her individual aims for recovery. The physiotherapist then guided patients to set achievable goals, which were worked on with the technical instructors in the remaining five sessions.

A previously developed stroke rehabilitation workbook³⁰⁰ guided the topic areas of the workbook and the specific content was informed by the findings from the Phase I focus groups. The workbook contained information on:

• the physiological aspects of hip fracture and surgery and how these could impact on recovery
• what to expect during recovery from a hip fracture, including answers to common questions, details of other people’s experiences and the role of the health-care team
• the variability in progress between individuals and the importance of physical exercise for progressing
• fear of falling and fall prevention services
• other services that may be useful, including charities.

The goal-setting diary included information on how to use the diary and emphasised the importance of making goals specific, measurable and achievable. The diary was designed to be introduced to patients prior to or during their first intervention session by a qualified physiotherapist, who could support them in the setting of their initial goals, making sure that they were appropriate for their individual capabilities. The format of the diary was set up to facilitate this and it encouraged patients and carers to review progress over a time period that they could set themselves and comment on (Figure 7). Both the goal-setting diary and the information workbook encouraged patients to ask their therapists and health-care professionals for guidance in their recovery, as well as providing signposting to other relevant services.

FIGURE 7

Example page of the goal-setting diary.

The aim of the physical component of the intervention was to increase the intensity and/or frequency of physical exercise and ADL, with supervision from physiotherapists and occupational therapists. By providing additional therapy sessions and, thus, increasing the opportunity for practice and professional support, we aimed to improve overall mobility, independence and functional outcomes by:

• improving muscle strength
• improving mood and self-efficacy
• increasing confidence and reducing fear of falling.

The psychological components aimed to improve patient engagement in the rehabilitation programme by giving patients a sense of ownership of their own recovery, with patient-led goals and patient-held documents. This was achieved by:

• enhancing self-efficacy through goal-setting to increase motivation and promote participation in their rehabilitation
• self-monitoring and feedback on goals
• verbal encouragement and support from professionals
• providing information on what to expect from recovery
• increasing confidence through reassurance and encouraging patients to seek advice.

Although the psychological components were mediated through the workbook and goal-setting diary, the additional sessions were also an opportunity for patients to obtain reassurance and guidance from a qualified health-care professional. Similarly, the psychological components aimed to increase confidence and self-efficacy, which would affect patients’ ability and willingness to perform exercises, thus improving their physical outcomes. The complex nature of the intervention activities and their proposed outcomes were described in a logic model (Figure 8). This linked programme theory from the realist review with the relevant component of the intervention, the short- and long-term goals of the intervention and functional outcomes in terms of the International Classification of Functioning, Disability and Health. We also mapped the intervention components to the NICE recommendations for multidisciplinary rehabilitation of hip fracture⁷ (Figure 9).

FIGURE 8

Logic model of intervention activities and proposed goals. ICF, International Classification of Functioning, Disability and Health.

FIGURE 9

Mapping the intervention to NICE guidance on hip fracture.

Patient and public involvement

A patient and public involvement representative commented on all aspects of the intervention, including the content of the information workbook and the goal-setting diary.