Defining accurate terminology for post-injury weightbearing instructions

Listen to Andrew Duckworth, Alex Trompeter, and Matt Costa discuss the paper 'Defining accurate terminology for post-injury weightbearing instructions' published in the September 2024 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of September. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to start by thanking all of our, all of you for your continued comments and support as well as our big gratitude to our many authors and colleagues who take part in the series that highlights the great work published by our authors in the journal each month.

So today for our monthly podcast, I have the pleasure of being joined by two authors from a paper published in the September edition of the BJJ entitled 'Defining accurate terminology for post-injury weightbearing instructions: a multidisciplinary, nationally approved consensus policy'. So first thing, I'm very pleased to be joined by my editorial board colleague and Professor of Orthopaedics at St. George's University London, Professor Alex Trompeter. Alex, great to have you with us. Thank you. And secondly, we're delighted to welcome back Alex's co-author and our Specialty Editor for Trauma here at the BJJ, Professor Matt Costa. Matt, great to have you back with us always. Thanks Dux.

So Matt, maybe I'll start with yourself for this study, you know, the primary aim of it was to define an agreed set of terminology to be used for post-injury weightbearing instructions in the lower limb in [00:01:00] adults with secondary aim to see if that could maybe be possibly extended, or the consensus could be extended to children, maybe the upper limb in an elective or planned surgery. So Matt, maybe as a background to the study for our listeners, can you give us a brief overview of the state of the current issues with weightbearing instructions, particularly in trauma surgery at the moment and maybe the lack of clarity we currently have in this area.

Yeah, thanks, Dux. So I think we've all been aware of this problem for, for years. I remember it being discussed at various meetings when I was a trainee, which is obviously quite a while back now and, and it continues to be discussed, but there's never been any resolution until Alex really put his back in, into this. I think, I mean, there were several issues about that. We were all aware that we use terms somewhat indiscriminately and occasionally inadvisedly in our postoperative instructions but I think one of the things that really brought this home to me was a few years back, my colleague, Bob Handley, who some of you will know is one of the Senior Trauma surgeons with me in Oxford and a former BOA president.

And he actually sat down in a meeting with the physiotherapists to discuss [00:02:00] this issue amongst other things about mobilization. And what became clear was not just that our instructions were unclear in themselves with lots of acronyms and lots of ill-defined terms. But even when we had got some consensus over what we wanted to happen afterwards, the interpretation of the physios and then the nurses was completely different to what we thought we were telling them.

So this partial weightbearing term ranged from anything from march the patient up and down but with a crutch to keep their weight off it apart from resting their toe on the floor. So, and that's just one example. So it wasn't just that we were inconsistent, it was that what we were saying wasn't translating into anything that the physios and the nurses could actually work with.

And Alex followed this up with a systematic review in the area. And they said it's a previous evidence to confirm what we really already knew that we, we had no consistency. But I think, as I say, the big thing was the really that this, this not just that we were inconsistent, but that actually the communication was really letting down our colleagues, [00:03:00] the nurses and physios, who actually did the hard work of getting the patients back on their feet.

Yeah, no, I totally agree with that. I think it's a really nice precise anecdote that because I think it highlights very truly what, what is the reality and what was the reality of when we gave these instructions and sort of, Alex, that sort of brings me nicely to you in terms of, you know, you've done some work and looked at what was the, the recently published or recently published WiTS study that surveyed over 700 healthcare professionals looking at this. And what did that sort of show?

Yeah, thanks for that. So the, it was kind of a challenge to put a bit of science behind the anecdote that Matt's just said, really. And we'd all been thinking of it and actually WiTS came about a little bit before that. There was another study we published called FFPOM, which was basically just looking at who is and who isn't weightbearing around the country.

Cause I sat in a meeting once and I think there were about 300 people at the BOA in a room and they were asked, you know, who's going to weightbear after this fracture, that fracture and the other. And almost everybody put their hand up and we kind of chuckled to ourselves going we that's probably not [00:04:00] true, so FFPOM was done which demonstrated quite a significant restriction in in post-op weightbearing in lower limb frailty fracture surgery in direct sort of contradiction to the recommendations of the BOASt at the time which had it been extended from hip fractures to all frailty fractures of the lower limb So about two-thirds of patients are restricted in the UK in their mobilization.

And then we started thinking, well, hang on, if we want to challenge that and change it, we need to understand first if the language we're using is fit for purpose. From a scientific point of view, it's going to be really hard to analyze this stuff in any more depth if we're, if we've got this variance in the language that we use.

So the WiTS study came about from that, in that I wanted to understand, or at least show robustly that the language isn't fit for purpose or wasn't fit for purpose. So WiTS was yeah, the 700 odd people responded, which is not a bad response rate for a, for a survey type study. And more importantly, over [00:05:00] half of those respondees were not orthopaedic surgeons.

So we had a huge number of physios, occupational therapists and orthogeriatricians and nurses respond in the allied health professional group. And almost uniformly, there was a lack of consensus in agreement when people were asked to quantify what certain terms meant in terms of percentage weight or what have you.

And uniformly across the board was an agreement amongst all respondees that standardization of terminology would be beneficial. So that kind of gave me a green light, if you like, to go ahead and think about how are we going to move this forward. And what can we do next about this? 

Yeah, no, that's great Alex. I think, like you say, I would encourage our listeners to go and look at that study because I think it, it really, like you said, highlights very clearly with some data that, that anecdote and what we all experienced that Matt describes in very clear numbers and about the just lack of uniformity and understanding really about what we're really saying when we say these terms.

So, like I say, that moves very nicely on them and [00:06:00] gives you the green light, as you say, to go on to this, this work, which you've done, which was a consensus exercise involving all sort of major stakeholders in the patient journey for, for those with musculoskeletal injury. And the consensus exercise primarily aims to seek agreement on a standardized set of terminology for weightbearing instruction.

So Matt, maybe I'll come back to you. This was, this work sort of used a nominal group technique described, so can you maybe just for our listeners describe what that is and how, how the stakeholders were maybe selected?

Yeah so there's various methodologies that are used to, to develop consensus. You're aware of many of these Dux and, and nominal group is, is one such technique. It's just a relatively simple way of creating consensus, usually from a mixed-discipline background group of people in relatively short time period. And it's generally used for quite specific, quite well defined questions.

So if you're doing something really broad, there are other techniques that are probably better for this, but it's a relatively quick way of answering a quite [00:07:00] specific question and in choosing this technique, just rewind a tiny bit. It's important, I think, to recognize that I'm sure all of the listeners will for the BJJ that weightbearing is just one small part of mobilization now, Alex and I would insist that it's a really important part.

Because it gives the foundation for the rest of what the physios and nurses, our colleagues do. But it's one bit and we deliberately focused upon that element because trying to define mobilization for lots of different ligaments and bony injuries in the upper limb and lower limb was going to take a huge amount of time.

And wasn't something that we could do through using a nominal group technique. It was much, much too broad for that. So we quite specifically chose this technique to answer the very refined question of what, which weightbearing terms would we use and which ones we wouldn't, without seeking to address all of the other issues around mobilization for specific injuries.

The alternative that most readers be aware of is a Delphi technique, which is, is [00:08:00] usually used often these days online without any face-to-face meetings. And that's good for getting consensus across lots and lots of people over a series of rounds about a very broad group of issues. The key advantage to me of the nominal group technique over something like a Delphi is that you have a face to face meeting.

So that consensus is reached by discussion rather than through just numbers, weight of numbers in voting. It's actually about people coming together to actually review the issues, check we all understand. The same things and and in my experience of using this over a few times over a few years now, it is really quite an effective way of bringing people together. So you actually get a true consensus rather than just a majority voting in this. And that's why we chose this particular technique. 

Yeah, no, that's that's a great description Matt and I agree with you. I think it's that idea that that discussion develops it doesn't it? And actually, I think the problem with the Delphi, like I say, is online is that you're not really getting the input of other people to make those decisions. No, that's a really great description. And so, Alex, I'll come back to you. You know, obviously, this [00:09:00] was done sort of a pre-meeting, and then there was a consensus meeting. So with pre-meeting information, what was sort of collated, and how was that sort of used?

I think again, I just just wind back ever so slightly and just sort of explain who was involved in this as well, because I think that's really important for the listener. So this was orthopaedic kind of led in the sense that the BOA supported and sponsored this through a sort of process of application for support, which they were very generous with.

But more importantly, we ensured that all of the relevant stakeholders in the patient pathway were included in this process. Bear in mind that probably 90 percent of the patient journey after trauma is in the rehabilitation side of things. So they spend an awful lot longer with other people than they do the orthopaedic surgeon.

So we included representation and we got feedback from the full of sort of buy in, if you like, from the specialist bodies for the Chartered Society of Physios, the Royal College of Occupational Therapists, Royal College of Nursing, the Fragility Fracture Network in the [00:10:00] UK, as well as all the orthopaedic specialist societies of the BOA, and importantly, patient representatives.

So we brought all the key players in the room. And before the meeting, we essentially had a pre-meeting questionnaire that was sent out to everyone. And actually it was kind of a great exercise because it, it, it used a lot of the similar questions that we'd used in WiTS, but to a little bit more depth.

So really asking people you know, would they benefit or would standardizing terms benefit, not just a general benefit, but a benefit patient care, the benefit research, see benefit, you know, clinical practice and then policy development, you know, all the different areas or facets where it could be seen to be useful.

And then you know, really about that after that, we just sort of used it to get a feel for where the discussion may go in the meeting, but we very much have the view that the meeting should be a open forum discussion. But as Matt says, [00:11:00] the remit was to to finesse the wording around weightbearing.

But interestingly, within the meeting, we also then asked what people's views were on discussing mobilization as a whole and and we ended up with consensus that it was too difficult to try and achieve consensus on mobilization because you start bringing in bracing protocols and you know, X, Y and Z after esoteric surgeries, whereas weightbearing is a kind of common theme to virtually all surgery and orthopaedics. You know, loading of the limb essentially is what we're talking about. 

Absolutely. And that's why you see lower limb was the main aim, but there were things you tried to extrapolate too. Yeah, absolutely. And, and so in terms of the maybe for sake of time, I think we'll move on to the results because obviously you had then the pre-meeting results from that and then the, the consensus itself. So Matt, maybe if I come back to you for the findings of the, the sort of pre-meeting exercise, what was, what were the really key take home messages from that?

Yeah, so it's pretty straightforward, really Dux. The there was quite a bit [00:12:00] of disagreement about the clarity or lack of, of individual terms that we put out there. And it was quite surprising that the patient seems to be quite happy with some of the terms in a way that the surgeons and physios weren't, which was, was not something I expected. But one thing that was absolutely clear and there was almost 100 percent agreement was that there needed to be complete clarity about the terms.

That having partial agreements on things was of no use to anyone. So, actually, the, the pre-survey just set the scene beautifully, because everyone got into the room with the mindset, we really need to work out a solution here. And Alex basically locked the door and said no one's getting out until we've achieved that. Not quite, but almost. Everything's open now. Very good. And so, so when you were locked in the consensus meeting, Alex, what were the main main take home messages or take home findings from that?

So I think the primary ones were that firstly, we ironed out whether we were going to try and lock in just weightbearing or mobilization as well. And we agreed weightbearing was really the [00:13:00] focus. We've put in a couple of caveats around mobilization as a whole, but primarily it was weightbearing. The actual first question we asked was, is the term weightbearing fit for purpose? And it was interesting, because some people have said, you know, it's or English? I've had those sort of comments, you know, it should be bearing weight, not weightbearing others, but it's such an ingrained part of our orthopaedic language.

It would be a bit like trying to say we can't use the word fracture anymore. I mean, it just, it wouldn't work, it wouldn't fly. So we kind of had a pretty good consensus there. We were then looking at, as we, as we tried to finesse the language, we also looked at how many terms do we want in terms of the hierarchy?

You know, could we just have, some equivalent to full or where we now sit with unrestricted weightbearing and non- at the other end. And then I think there was pretty good consensus that we needed some sort of middle ground because there will be cohorts of patients where some sort of limitation will be applied.

And then essentially we have that discussion around what those three primary terms are going to [00:14:00] be. And wanted to ensure they were really clear and that there was no risk of sort of messy English or messy acronym creation between them. And so you'll notice that we have unrestricted weightbearing as the sort of equivalent, I guess, to what was full of the real right-hand end of the spectrum, and we have non-weightbearing. But in the middle, instead of using the word restricted, which I guess is the natural counterpart to unrestricted, we've chosen limited. Because limited implies there are limitations that have been put on the patient. Now that may not be weight, that might be a type of activity, and indeed we'll come back to what those limitations should be.

But it's also a really distinct word from restricted or unrestricted. So so we have unrestricted and limited as opposed to unrestricted and restricted, which I was worried would be very close to each other and look messy. And then we had a really great discussion, basically finessing what those actually mean.

And then really importantly, where we came to [00:15:00] was that if you're going to put a limitation or restrict a patient to non-weightbearing, you have to quantify what that is, what that level of restriction is ,in relation to function. And this weaves in mobilization essentially removing that arbitrary percentage of weight, body weight or kilograms of force, which there's tons of literature now showing that that just doesn't translate. The patients do what they like, they put in significantly more. Certain patients can't follow said instructions. A justification needs to go in the clinical record. So you need to be able to say, why is that the case that you are limiting the patient and a duration?

And I don't think those are unreasonable things. I think, you know, if we look at most of what we do in orthopaedics, we have to justify and write, you know, if you're prescribing antibiotics, there has to be a reason and a duration and a review date. And that shouldn't be any different for a rehabilitation prescription. And I think it's really important. So there was a there was a really nice feeling in the room when we finished the consensus exercise that we'd actually landed on [00:16:00] something really positive for the future. So yeah, that was the kind of the day and as a whole. 

That's really interesting. I suppose just before we move on to some of the implications of it Just with things like, you know I don't know like, you know weightbearing is tolerated or weightbearing as pain allows with those sort of concepts or terms discussed at all just out of interest? 

They were and the problem is they're really subjective. Yeah. So you know one person's tolerated is another one's not but also again we go back to WiTS or or the other studies. There is a still a misinterpretation or difference in interpretation, should I say, between healthcare professionals on those terms. So what we've tried to do is just wipe the slate clean almost and provide a really clear set of terms.

I mean, I did a load of, as Matt said, I've done a load of sort of deep dive into the literature around this. If you look up the acronym PWB, you can find four or five different publications where the P is a different word in each one, for partial, permissive, progressive, you know, etcetera. So, even when [00:17:00] we think we know what we're saying, someone may interpret it totally differently.

So there was a real push to making this kind of totally clean and fresh and new and using English language that wasn't open to subjective interpretation. I do like the concept as well as, like you say, of, of giving a reason, giving instruction, giving a reason, and giving a duration. I think that there's something about that I think, which makes a lot of sense.

And, you know, we know you know, non- or restricting a, a patient's weightbearing is not without potential complication or issue. And so actually it's really important that that is reviewed and just not just left, isn't it, in many ways. And that makes a lot of sense. So if we sort of go on to sort of, you know, what it all means, Matt you know I'll probably come back to yourself here.

So, you know, to summarize, you know, both of you, the consensus process has found the agreement on the set of standard weightbearing terms to be used day-to-day in clinical practice in relation to both lower limb and upper limb, including non-weightbearing, as you said, Alex, limited weightbearing, and unrestricted weightbearing.

So Matt, you know, [00:18:00] as you sort of, you, you guys discussed in the paper, what are your thoughts on, on these terms, but more importantly, how do you think, how do, can they be implemented in clinical practice so we actually see change?

Well, it's it is changed my practice already. Dux, so, I mean, I obviously, I have to adopt this because I knew Alex to find out if I didn't and it, and it took me back now to, 20 years ago when I first started as a consultant and I'd I'd fixed a displaced or relatively displaced intercapsular fracture in a, in an older patient. And I was just nervous about my slightly dubious fixation. And so I put down restricted weightbearing and use one of the acronyms that no one understood to cover my tracks.

And, and the next day when the physios on the ward cornered me and said, you, you've said restricted weightbearing for Mrs. X, I can't mobilize it. Why didn't you fix the hip properly? And it really took the wind out of my sails and I felt guilty and I never wrote anything other than unrestricted weightbearing for a hip fracture afterwards.

And now, thanks to Alex, I've got that guilt every time I write any instruction for [00:19:00] any fracture that I now have to justify myself. As to why I'm, I'm writing limitations on the weightbearing or indeed non-weightbearing. And if I'm honest, I still do that. There's still fractures that, you know, when I've spent four hours doing a peel on, am I really brave enough in a young patient to let them bang around on that straight away?

Well, I'm sorry, Alex. No, still, I'm not brave enough. But I do now at least consider every single time I write an instruction that involves anything other than unrestricted weightbearing about why and how long. And that's a real big, important change for me and hopefully for everyone else. 

No, I totally agree Matt. I think that is the game changer. I think it's making us think about it rather than just being a bit, you know, gung ho or blasé, like you say, with it and actually making us think about it. And if we are going to instigate that, why and for how long? I totally agree. And so Alex, if I can come to you say, you know, you know, we've, you know, there's, we've discussed the clear strengths of the process about how you've developed these terms. Do you know, do you think there's any sort of, you know maybe caveats or put into context, do's and don'ts or any limitations to it? Having been through the process like you have been and actually know the literal like you do.

So I think [00:20:00] the first thing to say is and I, I recognize this is, this is uncomfortable for many of our orthopaedic community. I mean, I presented this at the BOA both to the orthopaedic group and then to the physio group and my reception was very different between those two rooms. I can tell you that. And I recognize it's uncomfortable, and there's, you know what we got even some comments and emails Matt and I did back fairly swiftly after publication, and I was, in some ways, I was really pleased, because even the detractors then have read this.

And if they've thought about it enough to want to email me about it, that means I've, I've must've tickled something somewhere to get them thinking. So I think that's a real positive. And it's important to note that this is not telling people what they can and can't do in terms of what they want to prescribe in terms of weightbearing so you are still allowed to restrict people and limit their weightbearing or say non-weightbearing if you want to. That's my next quest if you like, but you know, it is important because there are some cases as Matt says where where you don't and I [00:21:00] recognize some surgeons are going to be more confident than others and different situations, but I think what what this really does is you've highlighted is is make people stop and pause and think before they restrict someone where maybe they just always did because it was kind of just what they've always done, and they've never really questioned it.

And my whole sort of philosophy in orthopaedics is to question and challenge dogma. And this was, this seemed like a really, a really big area. Now, I guess that you say sort of what are the limitations or where, where, where, where are we up to with this? Well, it's only going to be as good as the people who adopt it.

So the next steps are going to be looking at that. And it's been, it's been woven into a BOASt as you, as you know which is really nice. And, and although I have a conflict, I sit in the in the BOASt panel that went through as rigorous a process for BOASt production as any other BOASt. 

So it was reviewed by the standards committee. It goes through the BOA executive and there's a real thorough process. So it wasn't just a sort of copy and paste job. But it's not, you know, I [00:22:00] guess the pushback is this is not like hard science, like a randomized trial, but then you can't really do that, that's not where this this bit of science lives, but this will allow us to research stuff at a much better level.

If we have standardized language, and I think to me, that's a real key, you know, I see so many papers coming out and being published the whole time and I review them for the journal as well comparing weightbearing and non-, but even in those which some of good studies, the terminology in the language is so confusing, or they group two sort of quite distinct limited groups together that, you know, right, right down to sort of not weightbearing at all and, and, and so on all the way up to sort of 50 percent and they're very different. So I think it will allow us to run studies with better quality data coming out of them. And I've even, you know, woven it into a couple of grant applications already using this language and terminology.

Yeah. So I think that's the, that's where I see it going forward. Yeah, no, I think that's really nice, I think that's a really nice way like you say to [00:23:00] try and drive that forward. And I think that like, yeah, going back to your point, it's not telling people what to do. I think it's just telling us how we should be looking at this, how we should be considering it both clinically and for research.

And I think probably we'll finish there, but I'll just highlight to our listeners as well that the, your paper, obviously is online, but also accompanied by a really great infographic as well. And I think it's a useful thing to use actually when trying to disseminate this as well. 

So that's all we have time for today, but thank you so much to you both for joining us and taking the time you know, congratulations on a great study, you know, which I think has really added a lot to this area and, and, and consensus to this area, which I think is much needed. And it was great to have you, have you both with us and to our listeners we do hope you've enjoyed joining us and we do encourage you all to share your thoughts and comments alike on the various platforms about what you've listened to today and feel free to post about anything we've discussed here today as well. And thanks again for joining us. Take care everyone.