TAC 2013 PLENARY PAPER

An intensive physiotherapy program improves mobility for

trauma patients

Sara Calthorpe, BSc (Hons), Elizabeth A. Barber, BPhysio (Hons), Anne E. Holland, PhD,
Lara Kimmel, BPhysio, Melissa J. Webb, MHSc, Carol Hodgson, PhD,
and Russell L. Gruen, PhD, Melbourne, Victoria, Australia

BACKGROUND: Physiotherapy is integral to modern trauma care. Early physiotherapy and mobility have been shown to improve outcomes in
patients with isolated injuries; however, the optimal intensity of physiotherapy in the multitrauma patient population has not yet
been examined. The primary aim of this study was to determine whether an intensive physiotherapy program resulted in
improved inpatient mobility.
METHODS: We conducted a single-center prospective randomized controlled study of 90 consecutive patients admitted to the Alfred
Hospital (a Level 1 trauma center) in Australia between October 2011 and June 2012 who could participate in ward-based
physiotherapy. Participants were allocated to either usual care (daily physiotherapy treatment, approximately 30 minutes)
or intensive physiotherapy (usual care plus two additional 30-minute treatments each day). The primary outcome measure was
the modified Iowa Level of Assistance (mILOA) score, collected by a blinded assessor at Days 3 and 5 (or earlier if discharged).
Secondary measures included physical readiness for discharge, hospital and rehabilitation length of stay, a patient confidence
and satisfaction scale, and quality of life at 6 months.
RESULTS: Groups were comparable at baseline. Participants in the intensive physiotherapy group achieved significantly improved
mILOA scores on Day 3 (median, 7 points compared with 10 points; p = 0.02) and Day 5 (median, 7.5 points compared with
16 points; p = 0.04) and were more satisfied with their care ( p = 0.01). There was no difference between groups in time to
physical readiness, discharge destination, length of stay, or quality-of-life measures.
CONCLUSION: Intensive physiotherapy resulted in improved mobility in trauma inpatients. Further studies are required to determine if specific
groups benefit more from intensive physiotherapy and if this translates to long-term improvements in outcomes. (J Trauma Acute
Care Surg. 2014;76: 101Y106. Copyright * 2014 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Therapeutic study, level 1.
KEY WORDS: Physiotherapy; trauma; rehabilitation; mobility; physical therapy.

I n most countries, trauma is the leading cause of lost years of

life and productivity in young adults.1 By 2030, trauma is
predicted to be the fifth leading cause of death and the third
leading cause of disability globally.2 Modern trauma systems
aim to reduce mortality and improve functional outcomes,
quality of life, and return to work, school, and family activities.
Numerous studies, including a recent meta-analysis, have con-
firmed a significant reduction in mortality when care is provided
at a Level 1 trauma center.1,3,4 However, evidence exists that
disability persists in the majority of these patients5Y7 and largely
relates to mobility and function.8
Physiotherapy (otherwise known as physical therapy)
is integral to modern trauma care.9 Treatment is primarily
Submitted: July 28, 2013, Revised: September 18, 2013011, Accepted: September
23, 2013.
From the Department of Physiotherapy (S.C., E.A.B., L.K., M.J.W., C.H., A.E.H),
and the Alfred Trauma Service (R.L.G.), The Alfred Hospital; Alfred Health
Clinical School, La Trobe University (A.E.H.); Department of Epidemiology
and Preventive Medicine (L.K.), Australian and New Zealand Intensive Care
Research Centre (C.H.) and Central Clinical School Department of Surgery
(R.L.G.), Monash University; and The National Trauma Research Institute
(R.L.G.), Melbourne, Victoria, Australia.
*S.C. and E.A.B. contributed equally to this study.
This study was presented at the National Trauma Research Institute Trauma Conference,
November 2012, in Melbourne, Australia, and the Trauma Association of Canada
Annual Scientific Meeting, April 11Y13, 2013, in Whistler, British Columbia.
Address for reprints: Sara Calthorpe, Department of Physiotherapy, The Alfred Hos-
pital, PO Box 315, Prahran VIC 3181, Australia; email: s.calthorpe@alfred.org.au.
DOI: 10.1097/TA.0b013e3182ab07c5
J Trauma Acute Care Surg
Volume 76, Number 1
concerned with the remediation of impairments and disabilities
and the promotion of mobility, functional ability, and quality of
life through examination, evaluation, diagnosis, and physical
intervention. Previous research has shown that early physio-
therapy treatments are effective in improving outcomes in
patients with isolated traumatic injuries such as femoral frac-
tures10,11 and ankle fractures.12 Intensive physiotherapy has
been shown to improve mobility and reduce length of stay
(LOS) in patients with medical, cardiothoracic, and neurologic
disorders.13 In two cohort studies,14,15 early or intensive therapy
following war-related trauma was shown to improve motor re-
covery and functional outcomes; however, no randomized
controlled trials into the optimal intensity of treatments have yet
been conducted in multitrauma populations.16
The primary aim of this study was to investigate the
effects of an intensive physiotherapy program on objective
measures of patient mobility. The secondary aims were to as-
sess the effect of intensive physiotherapy on the time taken to
achieve physical independence and readiness for discharge,
hospital LOS, discharge destination, patient confidence and
satisfaction, health-related quality of life, and return to work.
PATIENTS AND METHODS
Design
This was a single-center prospective randomized con-
trolled trial conducted at the Alfred Hospital, a Level 1 trauma
101

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Calthorpe et al.
center in Melbourne, Australia. The Alfred Hospital Trauma
Service treats more than half of the state of Victoria’s trauma
patients, approximately 5,000 per year, with one in five fitting
criteria for major trauma.17
The study was approved by The Alfred Research and
Ethics committee (ACTRN12611001231932).
Subjects
Between October 2011 and June 2012, we screened for
inclusion in the study consecutive patients 18 years and older
who were admitted to the Alfred Hospital Trauma Unit. We
excluded patients who were unable to participate in active
therapy sessions secondary to severe neurologic or cognitive
impairment, were unable to walk owing to fracture pattern (i.e.,
bilaterally nonYweight-bearing lower limbs), required physical
assistance (other than a gait aid) to mobilize before the acci-
dent, were nursing home residents, had spinal cord injuries or
had burns to more than 20% of their body surface area, and
those subsequently found to have no physical injuries, were
deemed safe for discharge on first physiotherapy review, or
were nonYEnglish speaking. Any patient who sustained a
head injury as a result of his or her accident was required
to pass a routine cognitive test (Westmead Post Traumatic
Amnesia Score18) before consent. Patients were eligible for the
study within 24 hours of first active mobilization by a phys-
iotherapist, the minimum level being to sit on the edge of the
bed with two therapists assisting. Written informed consent
was obtained from all participants.
Participants were assigned into one of two groups as
follows: usual care (UC), one daily treatment session of ap-
proximately 30 minutes; or intensive physiotherapy (IP), UC
plus two additional treatments of 30-minute duration each day.
Those assigned to UC acted as the control group. Randomi-
zation was via a computer-generated program, and allocation
was concealed using opaque envelopes.
Interventions
UC is a tailored physiotherapy treatment that aims to
achieve independence in mobility, to allow timely discharge to
an appropriate destination (home or inpatient rehabilitation).
This involved one or more of bed- and chair-based limb ex-
ercises (e.g., strength exercises such as static quadriceps holds),
chest physiotherapy (e.g., airway clearance and lung recruit-
ment exercises), and gait retraining (e.g., gait aid practice,
balance, walking, and endurance exercises). UC was conducted
by physiotherapists who were blinded to trial group allocation.
Each treatment was approximately 30 minutes every morning,
7 days per week.
Participants in the IP group received two additional
treatments per day by an interventional physiotherapist, 7 days
per week. One was a 30-minute ward gym session, undertaking
a supervised exercise program tailored to the individual in-
cluding standing, balance and strength exercises, stretches and
walking as appropriate. The second treatment involved ward
mobility aiming to improve the functional level compared with
the previous physiotherapy treatment (e.g., require less thera-
pist assistance, progress from bed transfers to walking, increase
walking distance). Patients located in the intensive care unit
had the two additional mobility treatments on the ward, rather
102
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J Trauma Acute Care Surg
Volume 76, Number 1
than in the gym. All physiotherapists received the same training
and had a minimum of 1-year experience working in a hospital.
Discharge Criteria
Participants were discharged home once they were
medically stable, deemed physically ready by the blinded UC
physiotherapist and cleared by the multidisciplinary team.
Physical readiness was defined as independence in transfers
from lying to sitting, bed mobility, transfer from bed to chair
and back to bed, walking with or without gait aid as required,
and negotiation of any stairs by which the patient can safely
enter and exit their home.19 If patients were unable to achieve
these criteria before becoming medically stable, they were
transferred to a rehabilitation facility as per usual protocol.
Data Collection
Demographic data were collected including patient char-
acteristics and injury type. The primary outcome was the mod-
ified Iowa Level of Assistance (mILOA) score. The mILOA
consists of four mobility tasks (supine to sitting on the edge of
the bed, sit to stand, walking, and negotiation of one step), which
are graded according to the level of assistance required, use of
gait aid, and the distance that can be walked. The ILOA was
originally described for patients with hip and knee arthroplasty.20
It was then modified for use in patients following fractured neck
of femur.10 Total scores range from 0 to 36, with a score of 0 in-
dicating independence for all items. The ILOA scores were
measured by the blinded UC physiotherapist on Days 3 and 5 of
enrolment in the study (or the day of discharge if earlier). For
those discharged on Days 1 or 2, their scores were analyzed with
Day 3 scores and, likewise, Day 4 discharge scores were ana-
lyzed with Day 5 scores.
Secondary outcomes measures included time from en-
rolment to physical readiness for discharge (minutes), LOS
(acute LOS and combined acute and rehabilitation minutes
when appropriate), discharge destination (home or inpatient
rehabilitation), and a patient confidence and satisfaction scale
(a 4-point scale for confidence with mobility tasks, ability to
manage at home, and satisfaction with the amount of physio-
therapy treatments). Six-month data collected routinely by the
Victorian State Trauma Registry21 and the Victorian Ortho-
paedic Trauma Outcomes Registry5 were also compared be-
tween groups, and all patients were covered by these two
registries. This included the SF12 (a self-reported physical and
mental health questionnaire found to be reliable and valid in
measuring physical and mental outcomes),22 the Glasgow
Outcome ScaleYExtended (GOS-E), (recommended for use by
trauma registries for monitoring functional outcomes),23 and
the EQ-5D score (measuring general health after injury).24
When EQ-5D responses were missing, proxy responses were
substituted where available.25
Sample Size
In this two-treatment parallel-design study, a total of
90 patients were predicted to be needed to detect a treatment
difference with 80% probability at a two-sided 0.05 signifi-
cance level, if the true difference between the treatment and
control groups was 7 points on the mILOA scale, representing
the minimal important clinical difference for this outcome.20
* 2014 Lippincott Williams & Wilkins
J Trauma Acute Care Surg
Volume 76, Number 1 Calthorpe et al.

normally distributed. Differences between groups at baseline

TABLE 1. Patient Demographics
were examined using independent samples t tests for contin-
Patient Characteristic UC (n = 44) IP (n = 43) p uous data and W2 test for categorical data. Data for the outcomes
Sex, male 29 (66) 25 (58) 0.46 of mILOA and LOS were not normally distributed, so these
Age, y 54.4 (20.4) 58.0 (22.2) 0.43 variables were natural log transformed. Differences between
Body mass index, kg/m 26.7 (4.30) 27.4 (5.6) 0.50 groups for outcome variables were compared using univariate
Publicly funded admission 17 (39) 14 (33) 0.55 analysis of variance for continuous variables and W2 test for
Daily alcohol consumption 5 (11) 8 (19) 0.34 categorical variables. The GOS-E data were analyzed using
Current smoker 8 (18) 8 (19) 0.96 ordinal logistic regression.
Home alone 11 (25) 12 (28) 0.76
Employed 28 (64) 16 (37) 0.01 RESULTS
Premorbid ability to walk 91 block 42 (95) 39 (91) 0.38
Mechanism of injury 0.41 Between October 2011 and June 2012, 90 patients were
Motor vehicle or motorcycle collision 23 (52) 20 (47) recruited to the study, with 45 patients randomized into each
Pedestrian/pedal cyclist 3 (7) 7 (16) group. Three patients were withdrawn from the study owing
Fall 12 (27) 14 (33) to evolution of medical issues excluding them from further
Other 6 (14) 2 (5) participation, and one patient withdrew himself or herself.
ISS 14.2 (7.2) 13.2 (5.9) 0.47 Overall, 54 males (62%) were recruited, and half of the
Major trauma (ISS 9 15) 18 (41) 16 (37) 0.79 patients were involved in a motor vehicle collision. Demo-
Upper-limb fracture 9 (20) 14 (33) 0.20 graphic and injury data comparing the two groups are presented
Lower-limb fracture 16 (36) 15 (35) 0.89 in Table 1. There was no difference between the two groups for
Chest injury* 22 (50) 18 (42) 0.45 any factor except for preinjury employment status ( p = 0.01),
Spine injury** 28 (64) 21 (49) 0.16 with the experimental group less likely to be employed.
Pelvic fracture 7 (16) 3 (7) 0.19 Results are presented in Tables 2Y4. Patients in the IP
Required intensive care unit admission 10 (23) 12 (28) 0.58 group received significantly more physiotherapy treatment
Data are presented as n (%) or mean (SD). p value is difference between control and
time ( p G 0.005). The primary outcome measure (mILOA) was
intervention groups. significantly better in the IP group than in UC group at Day 3
*Cardiac contusion, pulmonary contusion, rib fractures, sternal/manubrial fractures, (median, 7 points compared with 10 points; p = 0.02) and Day 5
pneumothorax, hemopneumothorax, pneumomediastinum. (median, 7.5 points compared with 16 points; p = 0.04), with
**Fracture or ligament tear.
the latter exceeding the minimal clinically important difference
(8.5 points).20 Time to physical readiness for discharge and
This was based on the assumption that the SD of the response LOS varied greatly between individuals with no overall dif-
variable was 11.6 units.26 ference between groups. However, post hoc subgroup analysis
showed that for those patients with an Injury Severity Score
Statistical Analysis (ISS) greater than 15, the time to physical readiness for dis-
Analysis was performed using SPSS version 17.0 (IBM, charge was significantly shorter in the intervention group
Chicago, IL). Data are presented as means and SDs or medians (median, 4,053 min [IQR, 1,853Y10,759 minutes] vs. 11,467
and interquartile ranges (IQRs) for data which were not [5,111Y35,915 minutes]; p = 0.049). Similarly, in those who

TABLE 2. Results
Outcome Measures UC (n = 44) IP (n = 43) p
Total physiotherapy treatment time, min 58 (30Y95) 124 (80Y275) 0.005
mILOA e Day 3 10.0 (4Y19) 7 (1Y15) 0.02
mILOA Q Day 5 (n = 46) 16 (4Y24) 7.5 (2Y15) 0.04
Enrolment to physical readiness, min 5,686 (2,613Y13,012) 4,140 (15,68Y11,368) 0.38
Acute hospital LOS, min 8,716 (6,213Y16,089) 11,269 (6,663Y16,726) 0.78
Total LOS all patients, min 12,996 (7,222Y48,100) 16,726 (8,116Y34,861) 0.87
Rehabilitation LOS, min (n = 27) 38,051 (23,349Y66,346) 28,679 (17,956Y40,819) 0.64
Combined acute and rehabilitation LOS, min (n = 27) 53,918 (33,853Y91,502) 39,013 (32,826Y76,278) 0.64
Discharge destination 0.76
Home 27 (61) 28 (65)
Rehabilitation 15 (34) 12 (28)
Other* 2 (5) 3 (7)
Death during admission 0 0 1
Data are presented as median (IQR) or n (%). Data for mILOA and LOS variables were natural log transformed before analysis. p values represent between-group comparison.
*Discharged destination not home or rehabilitation, for example, facility with higher level of care or with family.

* 2014 Lippincott Williams & Wilkins 103

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 J Trauma Acute Care Surg
Calthorpe et al. Volume 76, Number 1

TABLE 3. Satisfaction and Confidence With Treatment

DISCUSSION
Questionnaire This study showed that trauma patients who participate
Question UC (n = 41)* IP (n = 41)* p in an intensive physiotherapy program achieved better func-
Satisfaction with treatment 0.01
tional mobility at Days 3 and 5 of their acute hospital admis-
Not satisfied 0 0
sion. No differences in LOS or discharge destination were
Somewhat satisfied 2 (5) 3 (7)
evident in this relatively small study. This seems to be the first
Satisfied 23 (56) 10 (24)
randomized controlled trial to provide evidence regarding the
Very satisfied 16 (39) 28 (68)
functional outcomes of intensive physiotherapy rehabilitation
Confidence with mobility 0.72
following major trauma.
Not confident 2 (5) 3 (7)
Long-term studies have previously found that mobility
Somewhat confident 8 (20) 8 (20)
and function are the main areas of disability following trauma8
Confident 27 (66) 23 (56)
and remain the patients’ primary concern 1 year on.27 In this
Highly confident 4 (10) 7 (17)
trial, the clinically significant improvement in the mILOA in
Confidence with managing at home 0.13
the IP group reflected a more independent and mobile popu-
Not confident 3 (7) 7 (17)
lation compared with the UC group. We suspect that this im-
Somewhat confident 19 (46) 11 (27)
provement leads to less demand for assistance from other staff
Confident 15 (37) 14 (34)
members.
Highly confident 4 (10) 9 (22)
The length of hospital stay was not different between the
groups in this study. Many factors influence LOS, including
Data are presented as n (%). p values represent between-group comparison. functional independence, discharge destination, and insurance
*Incomplete data.
status.28 The acute hospital LOS in this study did not differ
between groups, although the median of 6.5-day reduction in
rehabilitation LOS and the 10.3-day difference in total LOS for
were not full weight bearing, there was a trend toward de- participants requiring rehabilitation may be clinically and fi-
creased LOS in rehabilitation for the intervention group (me- nancially significant. Given that this study involves a group of
dian, 21,585 minutes [IQR, 15,555Y37,567 minutes] vs. patients who consume large amounts of health care resources,9
53,935 minutes [23,700Y86,962 minutes]; p = 0.075). No other this outcome may be very important to the hospital system. Post
effects of baseline demographic features on time to readiness hoc subgroup analyses suggest that this intervention might be
for discharge or LOS variables were evident. Fifteen partici- particularly beneficial for those with more severe injuries and
pants in the UC group and 12 participants in the IP group who are not able to fully weight bear, although these findings
required rehabilitation hospital admission. There was no sig- should be confirmed in a future study.
nificant difference in discharge destination between groups, While this study was a single-institution study, it in-
and there were no deaths in either group. Participants in the IP cluded a heterogeneous group of patients with multiple inju-
group were more satisfied with the amount of physiotherapy ries, which is likely to reflect diverse patient populations in
received ( p = 0.01). most trauma services in which blunt trauma is the predominant
The EQ-5D scores were completed by proxies for seven mechanism. Furthermore, this study used a robust study design
people in the UC group and four people in the IP group ( p = with randomization and concealed allocation; blinded outcome
0.35). There were no significant differences between groups assessment, which is a critical element of good trial design in
for the GOS-E or any quality-of-life outcome (Table 4). studies of physical interventions; and a high rate of follow-up.

TABLE 4. Quality-of-Life Outcomes

Outcome Measures Control Intervention p
GOS-E n = 39 n = 34
Median (IQR) 6 (5Y6) 6 (3Y7) 0.65
EQ-5D n = 39 n = 34
Mobility problems 20 (51) 14 (41) 0.39
Self-care problems 10 (26) 10 (29) 0.72
Usual activities problems 10 (26) 12 (35) 0.37
Pain or discomfort 23 (59) 17 (50) 0.44
Anxiety or depression 13 (33) 15 (44) 0.35
Visual analogue scale (n = 69), median (IQR) 70 (50Y86) 70 (50 Y75) 0.19
SF-12 n = 32 n = 25
Physical score, median (IQR) 33 (26Y56) 36 (29 Y49) 0.96
Mental score, median (IQR) 55 (50Y58) 54 (37Y58) 0.37
Data are presented as n (%) except where indicated. EQ-5D data are n (%) reporting problems in each domain at 6 months following injury.

104 * 2014 Lippincott Williams & Wilkins

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J Trauma Acute Care Surg
Volume 76, Number 1
However, this study also had some limitations. There is
no validated outcome measure for physical function in the
trauma population. We chose to use the mILOA because this
has been used in a previous study where the main outcome
was patient function following hip surgery.10 Although the
relationship of the mILOA to longer-term outcomes and other
important end points following trauma is not known, it proved
to be a sensitive tool for detecting early changes in function
in this study. This Phase 2 study was not powered to detect
differences in more meaningful end points such as physical
readiness for discharge, LOS, or quality of life; further studies
across multiple sites and with larger numbers will be required
to answer the important question of whether an earlier physi-
cal independence reflects positively on these outcomes. It also
did not include an economic analysis, which would guide
decision makers about the value of investing in more physio-
therapy services.
CONCLUSION
This study showed that intensive inpatient physiother-
apy following traumatic injury resulted in improved physical
function at Days 3 and 5 following hospital admission. Future
studies are needed to identify whether this early improvement
in function results in long-term functional recovery, higher
rates of return to work, and better quality of life in patients
following major trauma.
AUTHORSHIP
S.C., E.A.B., L.K., M.J.W., C.H., A.E.H., and R.L.G. provided the trial design.
S.C., E.A.B., L.K., and M.J.W. performed the literature search. S.C.,
E.A.B., and L.K. performed the data acquisition. S.C., E.A.B., L.K., M.J.W.,
C.H., A.E.H., and R.L.G. performed the data analysis and interpretation.
S.C., E.A.B., L.K., M.J.W., C.H., A.E.H., and R.L.G. reviewed the manuscript.
ACKNOWLEDGMENT
We thank Andrew Corcoran, Jonathon Prescott, Rebecca Robinson and
Jane Elliott. We also thank the Victorian State Trauma Outcome Registry
and Monitoring (VSTORM) group for the provision of VSTR data.
DISCLOSURE
This trial was funded by the Sir Edmund Herring Memorial Scholarship,
Royal Automobile Club of Victoria, received by S.C. and E.A.B. For the
remaining authors, no conflicts were declared.
The Victorian State Trauma Registry (VSTR) is a Department of Health,
State Government of Victoria and Transport Accident CommissionYfunded
project. VOTOR is funded by the TAC via the Institute for Safety, Com-
pensation and Recovery Research.
R.L.G. is supported by a Practitioner Fellowship of the Australian National
Health and Medical Research Council. C.H. is supported by an Early Career
Research Fellowship from the Australian National Health and Medical
Research Council.
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