Lara Kimmel - Academia.edu (original) (raw)

Papers by Lara Kimmel

Journal of trauma nursing, Mar 1, 2023

Physical therapy, Oct 12, 2022

Objective Hip fractures are common and significantly impact mobility and physical function. Measu... more Objective Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting. Methods Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist. Results Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed “Up & Go” Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63–2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] >0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%–60% of patients). The TUG, CAS, and BI all had good clinical utility. Conclusion Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting. Impact This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

The New Zealand journal of physiotherapy, May 10, 2023

The objective of this study was to quantify physical activity undertaken by patients in the acute... more The objective of this study was to quantify physical activity undertaken by patients in the acute setting following elective lower limb joint replacement and determine the relationship between physical activity and hospital outcomes (length of stay [LOS] and discharge destination). This prospective observational study included 74 adults with osteoarthritis who underwent lower limb arthroplasty (total hip replacement n = 38, total knee replacement n = 36). Participants were fitted with an accelerometer and inclinometer-based device (activPAL3TM) post-operatively prior to first mobilisation for the duration of the acute hospital admission. Physical activity data collected were steps, sit-to-stand transitions and upright time (standing and stepping). The relationship between each physical activity variable and hospital outcomes was calculated using logistic regression (for discharge destination) and linear regression (for LOS). Potential confounding factors considered in multivariable models included age, sex, body mass index, Risk Assessment Prediction Tool, American Society of Anesthesiologists Score and surgical procedure. Analyses for the relationship with these outcomes used physical activity data from day two as these comprised the largest dataset for a single day. Participants’ mean (SD) age was 67 (10) years and 53% were female. Participants performed a median (IQR) of 136 (50–294) steps, 17 (11–75) transitions and 52 (32–94) upright minutes per day. All physical activity variables were significantly negatively associated with LOS (steps p = 0.016, transition p = 0.025, upright time p = 0.024). There was a significant association between discharge to inpatient rehabilitation for steps (p = 0.010) and transitions (p = 0.005).

Prosthetics and Orthotics International, Mar 25, 2022

BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering inj... more BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

The New Zealand journal of physiotherapy, May 10, 2023

This study presents findings from a benchmarking survey describing reported practice in Australia... more This study presents findings from a benchmarking survey describing reported practice in Australia and New Zealand for pre-and post-operative total joint arthroplasty management. The aim of this study was to identify differences in service delivery between both public and private healthcare sectors and geographical regions. Surveys were sent to senior physiotherapists and undertaken online. Responses were received from 125 institutions. Predicted length of stay (LOS) varied across regions with most therapists reporting an agreed LOS of ≥ 3 days (83% total hip arthroplasty; 89% total knee arthroplasty). Significantly longer LOS was reported in the private healthcare sector (p = 0.001). Patients in New Zealand and Western Australia were reported as more likely to be discharged directly home following total hip arthroplasty (p = 0.001) and total knee arthroplasty (p < 0.001) compared with other regions. The majority of physiotherapists suggested they would mobilise patients on post-operative day 0 (total hip arthroplasty 53%; total knee arthroplasty 55%), with both hospital and patient factors cited as barriers to early mobility. Heterogeneity of care across both healthcare sector and region is prevalent following elective total joint arthroplasty in Australia and New Zealand. Research opportunities regarding optimal management remain, particularly in regard to discharge destination, length of stay, and timing of first mobility.

Trauma is a major cause of hospitalisation and mortality in working aged adults. In Victoria, a c... more Trauma is a major cause of hospitalisation and mortality in working aged adults. In Victoria, a coordinated state trauma system was established in 1999 and resulted in a reduction in the risk of in-hospital mortality. This system was predominantly focused on the pre-hospital and hospital care of the injured patient, whereas the post discharge patient management was not specifically addressed in the design of the system. Rehabilitation is an accepted part of the continuum of care of the trauma patient and inpatient rehabilitation has been shown to benefit the spinal cord injured and the traumatic brain injured population. However, an equivalent level of evidence for the benefit of inpatient rehabilitation following orthopaedic trauma is lacking. Further, the decision-making regarding discharge destination following orthopaedic trauma is complex and strongly linked to socio-economic and financial factors. The aim of this thesis was to identify the predictors of discharge to inpatient rehabilitation, the role of inpatient rehabilitation following orthopaedic trauma in working aged adults, and its impact on patient outcomes. Data for this thesis were collected between 2007 and 2014. The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was used and the clinicians involved in the qualitative study worked in one of the four VOTOR hospitals or the rehabilitation centres that receive patients cared for acutely in these hospitals. The research findings show that it is possible to successfully predict those patients who are discharged to inpatient rehabilitation following isolated lower limb fracture using a simple bedside tool. This tool will assist the acute hospital clinicians plan early for discharge, with the aim of reducing confusion, limiting unnecessary inpatient rehabilitation referrals, and facilitating early and appropriate discharge. The importance of assisted discharge planning is underscored by the results of two qualitative studies, which showed marked variability between clinicians (both within the acute hospital and rehabilitation) in decision-making processes, and poor engagement of patients in their discharge planning. Patients also reported inadequate information about their injuries and their follow-up care. Outcomes for those discharged to inpatient rehabilitation were compared to home discharge. Using a propensity score analysis, patients discharged to inpatient rehabilitation were found to have worse return to work and functional outcomes at 12-months post-injury. However, the groups remain mismatched for some of the potential confounders and a randomised controlled trial is needed to definitively determine which discharge option results in superior long term outcomes. Based on the new knowledge presented in this thesis, a range of recommendations have been made to facilitate improved management of the orthopaedic trauma patient following their acute hospital stay. Involvement of the key stakeholders at all stages of the acute care, discharge planning and post-discharge stages of recovery, including patients, medical and allied health staff, administrators, funding bodies and policy makers will be vital to ensure best practice and care of the trauma patient throughout the continuum of care from time of injury to the ultimate aim of a return to community living.

Australian Journal of Advanced Nursing, Mar 1, 2003

The aim of this study was to compare the health related quality of life (HRQoL), satisfaction and... more The aim of this study was to compare the health related quality of life (HRQoL), satisfaction and functional outcomes of patients with fractured neck of femur treated with standard care to those treated with a clinical pathway at a major Melbourne university teaching hospital. A 12-month prospective cohort study was conducted comprising 57 patients admitted via the emergency department with a primary diagnosis of fractured neck of femur. Of these, 28 were treated with standard care and 29 using a coordinated multidisciplinary clinical pathway for fractured neck of femur. Outcome measures included; Medical Outcomes Study Short Form (SF-36), Modified Barthels Index (MBI), Timed Up and Go (TU&G), Patient Satisfaction and Perception Form (PSPF) and clinical indicators including; length of stay, time to mobilise, and, complication rates. Results indicated that there was no significant difference between the groups on clinical and functional outcome, quality of life and satisfaction. Pathway patients had a 3.3 day shorter length of stay and less complications than standard care patients. We conclude that patients cared for under a clinical pathway for fractured neck of femur in this study did not experience decreased health related quality of life or satisfaction with care.

Injury-international Journal of The Care of The Injured, Feb 1, 2018

Background: Acute Kidney Injury (AKI) complicates the management of at least 25% of patients with... more Background: Acute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with% TBSA ! 10, as well as the relationship with hospital metrics such as length of stay (LOS). Methods: Retrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression. Results: Between 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median%TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with%TBSA 10-19. Factors associated with AKI included increasing age and%TBSA (OR 1.05 p < 0.001) as well as increased surgeries (p < 0.041) and a cardiac comorbidity (p < 0.01). All patients with renal comorbidity developed AKI. In the%TBSA 10-19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P < 0.001). Conclusion: This is the first study to show an association between patients with%TBSA 10-19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.

Prosthetics & Orthotics International

BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering inj... more BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

Journal of Heart and Lung Transplantation, Apr 1, 2017

Conclusion: The ERO form has been designed to ensure that information deemed relevant by UK impla... more Conclusion: The ERO form has been designed to ensure that information deemed relevant by UK implanting centres is provided by the donor centre. It is hoped that this will prevent miscommunication and better cooperation among the teams.

Australasian Journal on Ageing, Jul 23, 2020

The aim of this study was to describe the demographics of patients from residential aged care fac... more The aim of this study was to describe the demographics of patients from residential aged care facilities (RACFs) who underwent fixation of hip fracture and to compare 12-month functional and mortality outcomes for those returning to their RACF with those admitted to a subacute facility (SAF) following their acute hospital stay. Methods: A retrospective review was undertaken of all patients from a RACF with high-level care needs admitted to Alfred Hospital, Melbourne, for fixation of hip fracture in 2014-2015. Data including demographic and hospital event details, length of stay (LOS), discharge destination and 12-month functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), were collected. Factors related to discharge destination and outcomes were analysed. Results: Ninety patients from a RACF were included in this study, with 68 patients (76%) returning to their RACF and 22 (24%) admitted to a SAF after acute hospital stay. Those discharged to a SAF had an average LOS at this facility of 20.79 days (SD 8.02). The SAF group also had a longer acute LOS (7 days IQR 5-10, compared to 6 days IQR 4-7.5) but there was no difference between groups at 12 months in terms of mortality or function, with 50% of all patients deceased at this time point (n = 40) and the remaining 40 patients (50%) reporting a poor functional outcome. Conclusions: Mobility status during acute and subacute stay, and 12-month functional and mortality outcomes were similar in both groups irrespective of discharge destination, with the influence of cognition and concomitant medical issues currently unknown. Further research is required to evaluate the efficacy of current hip fracture models of care, the factors that influence clinician discharge planning decision-making and to interrogate new models of care that support rehabilitation and complex medical management in RACFs. K E Y W O R D S femoral neck fractures, health services for older people, nursing homes, patient discharge, physical therapy speciality 2 |

Journal of Science and Medicine in Sport, Nov 1, 2018

International journal of therapy and rehabilitation, Mar 1, 2014

Background Water displacement is considered to be the gold standard for measuring foot volume; ho... more Background Water displacement is considered to be the gold standard for measuring foot volume; however, it is time-consuming and infrequently used in clinical practice. The objectives of this study were to determine whether a home-made water displacement device is a reliable and time-efficient method for determining foot volume. Methods Thirty participants with no foot pathologies were enrolled and had their foot volume measured in two home-made water volumetry devices (Preski and PreskiLite). The participants' foot volumes were measured on two occasions on each of two different days. Results All measurements were achieved in less than 90 seconds. Within-day reliability was high (intraclass correlation [ICC]=0.997–0.999) with the minimal detectable change (MDC) at the 90% confidence level (MDC90) of less than 25 ml for both devices. Mean differences in volume displaced between days were small (range 0.6– -5.4 mls). For between-day measures on the same leg, the mean coefficient of variation ranged from 0.65–1 with associated ICCs of 0.989–0.997. The MDC90 for between-day measures was 46 ml for the PreskiLite and 23 ml for the Preski. The difference in volume displaced between right and left legs was less than the MDC90 for both devices. Conclusions A novel, home-made water volumetry device provides reliable measures of foot volume both within and between days. Measurements taken on the contralateral leg provide an adequate control. These portable devices provide rapid measurements and only one measurement is needed per day.

The journal of trauma and acute care surgery, Mar 7, 2023

Disability and Rehabilitation, Dec 21, 2022

Clinical Rehabilitation, Jun 17, 2022

Objective The aim of this study was to assess changes in patient activities and interactions obse... more Objective The aim of this study was to assess changes in patient activities and interactions observed in response to a new trauma ward at a level 1 trauma centre, and subsequently, a new allied health staffing model. Design Explorative case study using behavioural mapping. Setting Level 1 trauma centre in Melbourne, Australia. Participants Hospitalised trauma patients. Main measures Behavioural mapping of patients’ activities and interactions was conducted by two observers over three 4-day observation phases: (i) at baseline, (ii) on the new ward and (iii) with the new staffing model. Changes in activities and interactions were assessed via negative binomial regression models and reported as incident rate ratios. Results In total, 1264 patient observations were recorded over an 18-month period. After moving to the new ward, patients were observed performing activities of daily living at a 2.1-fold higher rate than at baseline (95% confidence interval: 1.18, 3.81) but walking/standing/climbing stairs 54% less (95% confidence interval: 0.22, 0.94). Subsequent to the new staffing model, patients were observed in the gym at a 4.1-fold higher rate (95% confidence interval: 1.60, 10.32) and interacting with allied health professionals at a 9.1-fold higher rate (95% confidence interval: 4.88, 16.98), than at baseline. After COVID-19 restrictions were introduced, patients were observed lying down 22% more (95% confidence interval: 1.04, 1.43), with 73% fewer visitor interactions (95% confidence interval: 0.17, 0.43). Conclusions Greater engagement in physical and social activities was observed following the implementation of the new allied health staffing model at a level 1 trauma centre. Whether these changes translate to improved trauma outcomes is important to investigate.

Disability and Rehabilitation, May 29, 2020

Purpose: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine i... more Purpose: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine its impact on hospital outcomes, and explore staff perceptions of caring for patients with obesity. Methods: A retrospective audit of inpatients admitted to a sub-acute rehabilitation hospital over 12 months. Hospital outcomes included length of stay (LOS), Functional Independence measure (FIM), and discharge destination. Linear regression models were used to determine whether obesity was associated with hospital outcomes. Staff working on rehabilitation wards were invited to complete a survey exploring their perceptions on caring for those who are obese. Results: Of 1280 episodes of care, 359 (28%) patients were classified as obese with a body mass index 30 kg/m À2. Obesity was not associated with LOS or functional improvement after controlling for age, gender, and admission FIM. One hundred and twelve hospital staff (response rate 71%) completed the survey. Most rated their bariatric care knowledge as average (45%) or good (36%). The majority (60%) perceived that patients with obesity have longer LOS than those who are non-obese. Conclusion: One-third of patients admitted to inpatient subacute rehabilitation were classified as obese. Whilst obesity was not associated with poorer hospital outcomes, staff perceived that obesity negatively impacts on care requirements and LOS. ä IMPLICATIONS FOR REHABILITATION A third of patients admitted to a public, inpatient rehabilitation setting may be classified as obese based on their body mass index. Although staff perceived that obesity negatively impacts on length of stay and functional gains, there was no evidence that obesity was associated with poorer hospital outcomes. Patients who are classified as obese were able to achieve comparable hospital outcomes including length of stay in the rehabilitation setting to those who are not obese.

The New Zealand journal of physiotherapy, Nov 1, 2016

Traumatic injury places a great burden on individuals and society. As mortality plateaus in matur... more Traumatic injury places a great burden on individuals and society. As mortality plateaus in mature trauma systems, there is an increasing shift towards understanding patients' morbidity and functional outcomes. Physiotherapy plays a key role in recovery after traumatic injury, but little is currently known about its role in the acute hospital setting for trauma patients. This study aimed to document physiotherapy service structure and practice in adult major trauma services (MTS) across Australia and New Zealand. A survey was distributed electronically to physiotherapists working within designated MTS (n=25), achieving a 92% response rate (n=23). Physiotherapy service delivery, expertise and availability varied greatly. Only seven sites (30%) had a dedicated trauma physiotherapist with this showing a trend towards an association with major trauma admissions (provided by the Australian Trauma Registry; p=0.07). Only eight (35%) had blanket referral systems for physiotherapy review, which was significantly associated with having a dedicated specialised physiotherapist (p =0.015). Most ran a five day/week service for all patients with priority cover over the weekends (78% n=18). Future research should explore the benefits of specialised trauma physiotherapy roles in optimising patient outcomes in order to standardise this across all trauma centres in Australia and New Zealand.

Emergency Radiology, Aug 19, 2021

Purpose Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long ... more Purpose Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. Methods Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. Results Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17–69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring − 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. Conclusion CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Physical therapy, Jul 29, 2021

Objective. The longer-term impact of injury is increasingly recognized, but the early phases of r... more Objective. The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury. Methods. In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early vs late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function. Results. Participants had a median age of 52 years (interquartile range = 33-68 years), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds-1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18%-33% of participants). All had strong known-groups validity (early vs late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79-0.94). Conclusion. All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge. Impact. This study is an important step toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury.

Journal of trauma nursing, Mar 1, 2023

Physical therapy, Oct 12, 2022

Objective Hip fractures are common and significantly impact mobility and physical function. Measu... more Objective Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting. Methods Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist. Results Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed “Up &amp; Go” Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63–2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] &gt;0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%–60% of patients). The TUG, CAS, and BI all had good clinical utility. Conclusion Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting. Impact This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

The New Zealand journal of physiotherapy, May 10, 2023

The objective of this study was to quantify physical activity undertaken by patients in the acute... more The objective of this study was to quantify physical activity undertaken by patients in the acute setting following elective lower limb joint replacement and determine the relationship between physical activity and hospital outcomes (length of stay [LOS] and discharge destination). This prospective observational study included 74 adults with osteoarthritis who underwent lower limb arthroplasty (total hip replacement n = 38, total knee replacement n = 36). Participants were fitted with an accelerometer and inclinometer-based device (activPAL3TM) post-operatively prior to first mobilisation for the duration of the acute hospital admission. Physical activity data collected were steps, sit-to-stand transitions and upright time (standing and stepping). The relationship between each physical activity variable and hospital outcomes was calculated using logistic regression (for discharge destination) and linear regression (for LOS). Potential confounding factors considered in multivariable models included age, sex, body mass index, Risk Assessment Prediction Tool, American Society of Anesthesiologists Score and surgical procedure. Analyses for the relationship with these outcomes used physical activity data from day two as these comprised the largest dataset for a single day. Participants’ mean (SD) age was 67 (10) years and 53% were female. Participants performed a median (IQR) of 136 (50–294) steps, 17 (11–75) transitions and 52 (32–94) upright minutes per day. All physical activity variables were significantly negatively associated with LOS (steps p = 0.016, transition p = 0.025, upright time p = 0.024). There was a significant association between discharge to inpatient rehabilitation for steps (p = 0.010) and transitions (p = 0.005).

Prosthetics and Orthotics International, Mar 25, 2022

BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering inj... more BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

The New Zealand journal of physiotherapy, May 10, 2023

This study presents findings from a benchmarking survey describing reported practice in Australia... more This study presents findings from a benchmarking survey describing reported practice in Australia and New Zealand for pre-and post-operative total joint arthroplasty management. The aim of this study was to identify differences in service delivery between both public and private healthcare sectors and geographical regions. Surveys were sent to senior physiotherapists and undertaken online. Responses were received from 125 institutions. Predicted length of stay (LOS) varied across regions with most therapists reporting an agreed LOS of ≥ 3 days (83% total hip arthroplasty; 89% total knee arthroplasty). Significantly longer LOS was reported in the private healthcare sector (p = 0.001). Patients in New Zealand and Western Australia were reported as more likely to be discharged directly home following total hip arthroplasty (p = 0.001) and total knee arthroplasty (p < 0.001) compared with other regions. The majority of physiotherapists suggested they would mobilise patients on post-operative day 0 (total hip arthroplasty 53%; total knee arthroplasty 55%), with both hospital and patient factors cited as barriers to early mobility. Heterogeneity of care across both healthcare sector and region is prevalent following elective total joint arthroplasty in Australia and New Zealand. Research opportunities regarding optimal management remain, particularly in regard to discharge destination, length of stay, and timing of first mobility.

Trauma is a major cause of hospitalisation and mortality in working aged adults. In Victoria, a c... more Trauma is a major cause of hospitalisation and mortality in working aged adults. In Victoria, a coordinated state trauma system was established in 1999 and resulted in a reduction in the risk of in-hospital mortality. This system was predominantly focused on the pre-hospital and hospital care of the injured patient, whereas the post discharge patient management was not specifically addressed in the design of the system. Rehabilitation is an accepted part of the continuum of care of the trauma patient and inpatient rehabilitation has been shown to benefit the spinal cord injured and the traumatic brain injured population. However, an equivalent level of evidence for the benefit of inpatient rehabilitation following orthopaedic trauma is lacking. Further, the decision-making regarding discharge destination following orthopaedic trauma is complex and strongly linked to socio-economic and financial factors. The aim of this thesis was to identify the predictors of discharge to inpatient rehabilitation, the role of inpatient rehabilitation following orthopaedic trauma in working aged adults, and its impact on patient outcomes. Data for this thesis were collected between 2007 and 2014. The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was used and the clinicians involved in the qualitative study worked in one of the four VOTOR hospitals or the rehabilitation centres that receive patients cared for acutely in these hospitals. The research findings show that it is possible to successfully predict those patients who are discharged to inpatient rehabilitation following isolated lower limb fracture using a simple bedside tool. This tool will assist the acute hospital clinicians plan early for discharge, with the aim of reducing confusion, limiting unnecessary inpatient rehabilitation referrals, and facilitating early and appropriate discharge. The importance of assisted discharge planning is underscored by the results of two qualitative studies, which showed marked variability between clinicians (both within the acute hospital and rehabilitation) in decision-making processes, and poor engagement of patients in their discharge planning. Patients also reported inadequate information about their injuries and their follow-up care. Outcomes for those discharged to inpatient rehabilitation were compared to home discharge. Using a propensity score analysis, patients discharged to inpatient rehabilitation were found to have worse return to work and functional outcomes at 12-months post-injury. However, the groups remain mismatched for some of the potential confounders and a randomised controlled trial is needed to definitively determine which discharge option results in superior long term outcomes. Based on the new knowledge presented in this thesis, a range of recommendations have been made to facilitate improved management of the orthopaedic trauma patient following their acute hospital stay. Involvement of the key stakeholders at all stages of the acute care, discharge planning and post-discharge stages of recovery, including patients, medical and allied health staff, administrators, funding bodies and policy makers will be vital to ensure best practice and care of the trauma patient throughout the continuum of care from time of injury to the ultimate aim of a return to community living.

Australian Journal of Advanced Nursing, Mar 1, 2003

The aim of this study was to compare the health related quality of life (HRQoL), satisfaction and... more The aim of this study was to compare the health related quality of life (HRQoL), satisfaction and functional outcomes of patients with fractured neck of femur treated with standard care to those treated with a clinical pathway at a major Melbourne university teaching hospital. A 12-month prospective cohort study was conducted comprising 57 patients admitted via the emergency department with a primary diagnosis of fractured neck of femur. Of these, 28 were treated with standard care and 29 using a coordinated multidisciplinary clinical pathway for fractured neck of femur. Outcome measures included; Medical Outcomes Study Short Form (SF-36), Modified Barthels Index (MBI), Timed Up and Go (TU&G), Patient Satisfaction and Perception Form (PSPF) and clinical indicators including; length of stay, time to mobilise, and, complication rates. Results indicated that there was no significant difference between the groups on clinical and functional outcome, quality of life and satisfaction. Pathway patients had a 3.3 day shorter length of stay and less complications than standard care patients. We conclude that patients cared for under a clinical pathway for fractured neck of femur in this study did not experience decreased health related quality of life or satisfaction with care.

Injury-international Journal of The Care of The Injured, Feb 1, 2018

Background: Acute Kidney Injury (AKI) complicates the management of at least 25% of patients with... more Background: Acute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with% TBSA ! 10, as well as the relationship with hospital metrics such as length of stay (LOS). Methods: Retrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression. Results: Between 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median%TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with%TBSA 10-19. Factors associated with AKI included increasing age and%TBSA (OR 1.05 p < 0.001) as well as increased surgeries (p < 0.041) and a cardiac comorbidity (p < 0.01). All patients with renal comorbidity developed AKI. In the%TBSA 10-19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P < 0.001). Conclusion: This is the first study to show an association between patients with%TBSA 10-19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.

Prosthetics & Orthotics International

BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering inj... more BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.

Journal of Heart and Lung Transplantation, Apr 1, 2017

Conclusion: The ERO form has been designed to ensure that information deemed relevant by UK impla... more Conclusion: The ERO form has been designed to ensure that information deemed relevant by UK implanting centres is provided by the donor centre. It is hoped that this will prevent miscommunication and better cooperation among the teams.

Australasian Journal on Ageing, Jul 23, 2020

The aim of this study was to describe the demographics of patients from residential aged care fac... more The aim of this study was to describe the demographics of patients from residential aged care facilities (RACFs) who underwent fixation of hip fracture and to compare 12-month functional and mortality outcomes for those returning to their RACF with those admitted to a subacute facility (SAF) following their acute hospital stay. Methods: A retrospective review was undertaken of all patients from a RACF with high-level care needs admitted to Alfred Hospital, Melbourne, for fixation of hip fracture in 2014-2015. Data including demographic and hospital event details, length of stay (LOS), discharge destination and 12-month functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), were collected. Factors related to discharge destination and outcomes were analysed. Results: Ninety patients from a RACF were included in this study, with 68 patients (76%) returning to their RACF and 22 (24%) admitted to a SAF after acute hospital stay. Those discharged to a SAF had an average LOS at this facility of 20.79 days (SD 8.02). The SAF group also had a longer acute LOS (7 days IQR 5-10, compared to 6 days IQR 4-7.5) but there was no difference between groups at 12 months in terms of mortality or function, with 50% of all patients deceased at this time point (n = 40) and the remaining 40 patients (50%) reporting a poor functional outcome. Conclusions: Mobility status during acute and subacute stay, and 12-month functional and mortality outcomes were similar in both groups irrespective of discharge destination, with the influence of cognition and concomitant medical issues currently unknown. Further research is required to evaluate the efficacy of current hip fracture models of care, the factors that influence clinician discharge planning decision-making and to interrogate new models of care that support rehabilitation and complex medical management in RACFs. K E Y W O R D S femoral neck fractures, health services for older people, nursing homes, patient discharge, physical therapy speciality 2 |

Journal of Science and Medicine in Sport, Nov 1, 2018

International journal of therapy and rehabilitation, Mar 1, 2014

Background Water displacement is considered to be the gold standard for measuring foot volume; ho... more Background Water displacement is considered to be the gold standard for measuring foot volume; however, it is time-consuming and infrequently used in clinical practice. The objectives of this study were to determine whether a home-made water displacement device is a reliable and time-efficient method for determining foot volume. Methods Thirty participants with no foot pathologies were enrolled and had their foot volume measured in two home-made water volumetry devices (Preski and PreskiLite). The participants' foot volumes were measured on two occasions on each of two different days. Results All measurements were achieved in less than 90 seconds. Within-day reliability was high (intraclass correlation [ICC]=0.997–0.999) with the minimal detectable change (MDC) at the 90% confidence level (MDC90) of less than 25 ml for both devices. Mean differences in volume displaced between days were small (range 0.6– -5.4 mls). For between-day measures on the same leg, the mean coefficient of variation ranged from 0.65–1 with associated ICCs of 0.989–0.997. The MDC90 for between-day measures was 46 ml for the PreskiLite and 23 ml for the Preski. The difference in volume displaced between right and left legs was less than the MDC90 for both devices. Conclusions A novel, home-made water volumetry device provides reliable measures of foot volume both within and between days. Measurements taken on the contralateral leg provide an adequate control. These portable devices provide rapid measurements and only one measurement is needed per day.

The journal of trauma and acute care surgery, Mar 7, 2023

Disability and Rehabilitation, Dec 21, 2022

Clinical Rehabilitation, Jun 17, 2022

Objective The aim of this study was to assess changes in patient activities and interactions obse... more Objective The aim of this study was to assess changes in patient activities and interactions observed in response to a new trauma ward at a level 1 trauma centre, and subsequently, a new allied health staffing model. Design Explorative case study using behavioural mapping. Setting Level 1 trauma centre in Melbourne, Australia. Participants Hospitalised trauma patients. Main measures Behavioural mapping of patients’ activities and interactions was conducted by two observers over three 4-day observation phases: (i) at baseline, (ii) on the new ward and (iii) with the new staffing model. Changes in activities and interactions were assessed via negative binomial regression models and reported as incident rate ratios. Results In total, 1264 patient observations were recorded over an 18-month period. After moving to the new ward, patients were observed performing activities of daily living at a 2.1-fold higher rate than at baseline (95% confidence interval: 1.18, 3.81) but walking/standing/climbing stairs 54% less (95% confidence interval: 0.22, 0.94). Subsequent to the new staffing model, patients were observed in the gym at a 4.1-fold higher rate (95% confidence interval: 1.60, 10.32) and interacting with allied health professionals at a 9.1-fold higher rate (95% confidence interval: 4.88, 16.98), than at baseline. After COVID-19 restrictions were introduced, patients were observed lying down 22% more (95% confidence interval: 1.04, 1.43), with 73% fewer visitor interactions (95% confidence interval: 0.17, 0.43). Conclusions Greater engagement in physical and social activities was observed following the implementation of the new allied health staffing model at a level 1 trauma centre. Whether these changes translate to improved trauma outcomes is important to investigate.

Disability and Rehabilitation, May 29, 2020

Purpose: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine i... more Purpose: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine its impact on hospital outcomes, and explore staff perceptions of caring for patients with obesity. Methods: A retrospective audit of inpatients admitted to a sub-acute rehabilitation hospital over 12 months. Hospital outcomes included length of stay (LOS), Functional Independence measure (FIM), and discharge destination. Linear regression models were used to determine whether obesity was associated with hospital outcomes. Staff working on rehabilitation wards were invited to complete a survey exploring their perceptions on caring for those who are obese. Results: Of 1280 episodes of care, 359 (28%) patients were classified as obese with a body mass index 30 kg/m À2. Obesity was not associated with LOS or functional improvement after controlling for age, gender, and admission FIM. One hundred and twelve hospital staff (response rate 71%) completed the survey. Most rated their bariatric care knowledge as average (45%) or good (36%). The majority (60%) perceived that patients with obesity have longer LOS than those who are non-obese. Conclusion: One-third of patients admitted to inpatient subacute rehabilitation were classified as obese. Whilst obesity was not associated with poorer hospital outcomes, staff perceived that obesity negatively impacts on care requirements and LOS. ä IMPLICATIONS FOR REHABILITATION A third of patients admitted to a public, inpatient rehabilitation setting may be classified as obese based on their body mass index. Although staff perceived that obesity negatively impacts on length of stay and functional gains, there was no evidence that obesity was associated with poorer hospital outcomes. Patients who are classified as obese were able to achieve comparable hospital outcomes including length of stay in the rehabilitation setting to those who are not obese.

The New Zealand journal of physiotherapy, Nov 1, 2016

Traumatic injury places a great burden on individuals and society. As mortality plateaus in matur... more Traumatic injury places a great burden on individuals and society. As mortality plateaus in mature trauma systems, there is an increasing shift towards understanding patients' morbidity and functional outcomes. Physiotherapy plays a key role in recovery after traumatic injury, but little is currently known about its role in the acute hospital setting for trauma patients. This study aimed to document physiotherapy service structure and practice in adult major trauma services (MTS) across Australia and New Zealand. A survey was distributed electronically to physiotherapists working within designated MTS (n=25), achieving a 92% response rate (n=23). Physiotherapy service delivery, expertise and availability varied greatly. Only seven sites (30%) had a dedicated trauma physiotherapist with this showing a trend towards an association with major trauma admissions (provided by the Australian Trauma Registry; p=0.07). Only eight (35%) had blanket referral systems for physiotherapy review, which was significantly associated with having a dedicated specialised physiotherapist (p =0.015). Most ran a five day/week service for all patients with priority cover over the weekends (78% n=18). Future research should explore the benefits of specialised trauma physiotherapy roles in optimising patient outcomes in order to standardise this across all trauma centres in Australia and New Zealand.

Emergency Radiology, Aug 19, 2021

Purpose Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long ... more Purpose Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. Methods Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. Results Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17–69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring − 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. Conclusion CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Physical therapy, Jul 29, 2021

Objective. The longer-term impact of injury is increasingly recognized, but the early phases of r... more Objective. The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury. Methods. In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early vs late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function. Results. Participants had a median age of 52 years (interquartile range = 33-68 years), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds-1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18%-33% of participants). All had strong known-groups validity (early vs late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79-0.94). Conclusion. All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge. Impact. This study is an important step toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury.