Title: Developing a multidisciplinary rehabilitation package following hip fracture. Acronym: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)
Funder: Division for Social Care and Health Research (Wales)

Abstract: DESIGN: MRC Framework Phase I-systematic review of published evidence survey of current services focus groups design of rehabilitation programme. Phase II-cohort randomised feasibility study focus groups.SETTING: Secondary care orthopaedic in-patient facility community hospital community and primary care following hospital discharge.STRATEGY FOR REVIEWING LITERATURE: The principles of realist synthesis will be used to explain the mechanism of multidisciplinary rehabilitation and to establish which component of the intervention works for whom and in what circumstances. We will search databases and track citations to identify studies. Type of study: randomised and non-randomised controlled trials observational studies economic evaluations qualitative studies. Type of participant: elderly adults with hip fractures. Type of intervention: multi-disciplinary rehabilitation including interventions targetting physical and psychosocial function also risk factors for poor prognosis. Type of outcome: mortality pain functional status quality of life health utility health service use costs patients’ experience. Two reviewers will independently screen papers for inclusion and assess study quality using appropriate scoring systems for each type of study. Data will be extracted by one reviewer and checked for accuracy by a second. Data will be synthesised and themed using the principle of ‘what works for whom how and in what circumstances for rehabilitation in this group of patients. Meta-analyses will be performed where appropriate. SURVEY STRATEGY: We will sample the centres in the National Hip Fracture Database (n=176). We will ask about the provision and content of their rehabilitation programmes staffing levels and budgets for current service provision. TARGET POPULATION: Elderly adults with proximal femoral fracture who were previously living independently and who have recently received surgical treatment including those with cognitive impairment.HEALTH TECHNOLOGIES BEING ASSESSED: The theoretical framework will be the International Classification of Functioning Disability and Health. In this model impairments of muscle strength balance and self-efficacy result in activity limitation (disability) leading to participant restriction (handicap). Successful rehabilitation will improve strength balance and self-efficacy enhancing physical activity and promoting social participation. Management of hip fracture patients is guided by recent draft guidelines and involves the joint care by geriatricians and orthopaedic surgeons often in a formal hip fracture programme. The core components of multidisciplinary rehabilitation in the hospital and the community include medicine nursing physiotherapy occupational therapy and social care but may also include dieticians pharmacists and psychologists. We plan to improve co-ordination between primary and secondary care using multidisciplinary team meetings and a case management approach. In order to improve patients’ self-reliance and coping we will incorporate additional components into a multilevel community based rehabilitation. These will include: an exercise programme featuring progressive resistance training taught by community physiotherapists which has already been developed and tested following elective hip surgery to improve strength physical function balance and co-ordination; provision of aids appliances adaptations and a home safety assessment from occupational therapists; a psychological intervention using a workbook approach employing a cognitive-behavioural approach to address factors such as fear of falling (shown to be a risk factor for negative outcomes and present in 50% of patients) and low mood; signposting access to local social interventions to promote social inclusion. The content mode of delivery and the professional responsibility for each component of the programme will be informed by findings from three focus groups with multidisciplinary teams


Research activity codes: 6.7 PHYSICAL
Health categories: INJURIES AND ACCIDENTS