Development and evaluation of a rehabilitation programme for people with complex fractures following traumatic injury

Background Complex fractures are life-changing injuries that cause considerable disability and suffering to people with a lasting impact on their overall health and quality of life. The importance of rehabilitation in achieving good outcomes and preventing complications is well recognised.

However, national and regional audits have acknowledged a system-wide gap in NHS rehabilitation provision and inequalities in access for this patient group. At present, it is unclear what the best rehabilitation strategy is for people who sustain complex fractures.

The literature recommends further research is done to optimise outpatient rehabilitation in terms of type, scope and duration with a focus on developing and testing effective interventions that improve function and provide longer-term support. This research topic has been highlighted as a priority for the NHS by the James Lind Alliance.

Research questions Can we define the outpatient rehabilitation programme for adults with complex fractures? Can we deliver this complex fracture intervention?

Aims The aim of this research is to develop and evaluate a rehabilitation programme for adults with complex fractures, following the MRC framework for development of complex interventions. The secondary aims are to understand fidelity and adherence to the programme in an NHS setting. Objectives 1.

To identify key components of a rehabilitation programme for complex fractures based on current evidence (e.g. nature, dosage) 2. To develop a rehabilitation programme for complex fractures and explore barriers and enablers to implementation 3. To define the rehabilitation programme to be implemented 4.

To evaluate whether the rehabilitation programme can be delivered as per protocol (fidelity) and how stakeholders engage (adherence) Methods This is a mixed methods research project involving four work-packages.

Coproduction processes underpin all aspects of the research. 1) A descriptive systematic literature review to identify and list potential rehabilitation components 2) Focus groups to discuss components, barriers and enablers, and develop a rehabilitation programme (4 groups, 6-8 participants in each) 3) A consensus workshop to define the rehabilitation programme to be implemented.

Nominal Group Technique will be used with 12 participants representing all key stakeholders. 4) The rehabilitation programme will be introduced to clinicians and managers at a single site and training provided. The programme will be trialled with 20 patients over a 3-month period and a process evaluation completed.

A fidelity checklist will be used to record if the programme is delivered per protocol.

Individual interviews with participants, clinicians and managers will be completed at the end of the trial to evaluate their adherence with the programme.

Anticipated impact This project will contribute to developing a new model of care to benefit patients with complex fractures and support the development of guidelines to inform clinical practice. The refined protocol, training materials and logic model will inform a future definitive trial.

Dissemination The research outputs will be shared through: Patient and public updates through charity websites, newsletters and social media Patient stories highlighting key messages for managers, commissioners and policymakers Presentations at national conferences Publications in peer-reviewed journals Guideline development with the ATOCP and British Orthopaedic Association