Quality of Life of Patients after Musculoskeletal Surgery and Rehabilitation

1 Maja Majetić

2,3Nikolina Farčić

3 Ana Ljubojević

2 Marin Kovač

3 Ivana Barać

3,4Zvjezdana Gvozdanović

1 Bizovačke Toplice Rehabilitation Centre, Bizovac, Croatia

2 University Hospital Centre Osijek, Osijek, Croatia

3 Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University, Osijek, Croatia

4 General Hospital Našice, Našice, Croatia 

https://doi.org/10.24141/2/8/1/2

Author for correspondence:

Nikolina Farčić

University Hospital Centre Osijek, Osijek, Croatia Faculty of Dental Medicine and Health,

Josip Juraj Strossmayer University, Osijek, Croatia E-mail: nikfarcic@gmail.com

Keywords: quality of life, musculoskeletal system, rehabilitation, SF-36

Abstract

Introduction. Rehabilitation implies a form of healthcare aimed at restoring and maintaining physi- cal strength and mobility with the ultimate goal of achieving the best possible results.

Aim. To examine the quality of life of patients after musculoskeletal surgery and rehabilitation in terms of age, sex, diagnosis, and comorbidities.

Methods. The research was conducted as a cross- sectional study. It included patients who underwent musculoskeletal surgery and rehabilitation at the inpatient treatment facility in the Bizovačke Toplice Spa for 21 days. An anonymous survey questionnaire was used with demographic data and the SF-36 self- assessment questionnaire on the quality of life.

Results. A total of 96 participants took part in the study, 62 (64.6%) were female, 44 (45.8%) had hip surgery and 43 (44.8%) had no comorbidities. The mean age of the participants is 63 years (range from 18 to 91 years). The participants aged 50 and younger have a significantly lower assessment of their limita- tions due to physical difficulties. Male participants estimated a statistically significantly better quality of life after surgery and rehabilitation compared to fe- male participants, in terms of better physical function- ing, assessments of greater vitality and energy, better psychological health, better social functioning, and a better perception of general health. The different diag- noses of the participants and the performed surgical procedures are not significantly related to the quality of life after musculoskeletal surgery and rehabilitation.

Conclusion. The lowest assessment of the quality of life of the participants was expressed in the aspect of limitations due to physical difficulties. Female participants, younger participants, and participants without comorbidities estimated a worse quality of life.

Introduction

Medical rehabilitation plays an important role in today’s healthcare system, but also in society as a whole. Rehabilitation implies a form of healthcare aimed at restoring and maintaining physical strength and mobility with the ultimate goal of achieving the best possible results. The importance of rehabilita- tion is in achieving the greatest possible independ- ence and quality of life for the individual after op- erations, injuries, and illnesses. After the surgery, patients, following the recovery period and the sur- geon’s approval, begin a 21-day rehabilitation pro- gram as part of the protocol determined according to the Ordinance on conditions and methods of exer- cising rights in the compulsory health insurance for hospital treatment with medical rehabilitation and physical therapy at home. The insured person will be eligible to hospital inpatient rehabilitation if they meet the legal conditions and if it is considered that the implementation of the rehabilitation program will improve the person’s functional status. Also, an indi- vidual has the right to undergo the rehabilitation if there are no contraindications such as infectious dis- eases, febrile conditions, decubitus wounds, malig- nant disease in a state of progression, heart decom- pensation, post-operative wounds which have not healed, and other conditions which make it impossi- ble to carry out physical therapy (1). In the context of healthcare, rehabilitation is defined as a process of active changes by which a disabled person acquires the skills and knowledge necessary for normal social, psychological, and physical functioning (2). Early re- habilitation of the postoperative patient is the key to successful rehabilitation. Successful rehabilitation implies a motivated patient, continuous and adequate therapeutic exercises, prevention and suppression of possible complications, and treatment with a reha- bilitation team (3). The aim of medical rehabilitation

is for the patient to acquire the skills to live with new conditions and to teach them how to continue living with the current disability in their environment. Dur- ing rehabilitation, the entire rehabilitation team, the patient, including the patient’s family, should set a realistic goal together for the outcome of the reha- bilitation to preserve the current and improve the fu- ture quality of life. Each person is unique, therefore the rehabilitation plan should be adapted to and indi- vidualized according to the individual (4). Also, for a person with a long-term disability, regardless of the disease, stage of the disease or age, rehabilitation can affect the improvement of the current condition. General interventions consist of rehearsing tasks and exercises, conducting education, and psychosocial support for patients. In addition, some unpredictable interventions can be involved, which makes rehabili- tation a complex process and represents a challenge for the entire multidisciplinary team (5).

Musculoskeletal system

The musculoskeletal system, or the locomotor sys- tem, consists of bones in the body, muscles, liga- ments, tendons, cartilage, joints, and other connec- tive tissue. The skeleton serves as a support for the body and gives it shape, while the muscles are responsible for moving a certain part of the body and together ensure movement and stability (6). The damage which affects the musculoskeletal sys- tem includes many conditions/diseases which affect daily life and lead to temporary or permanent limita- tions in a person’s mobility and functioning. Altered states in bone, muscle, joint, and connective tissue damage are often characterized by long-term and frequent pain that affects mobility and reduces peo- ple’s ability to participate in social activities and daily work. Damage to the musculoskeletal system occurs throughout life, from early childhood to old age. Changes can be short-term and occur suddenly (frac- ture, sprain, strain) or long-term, chronic conditions such as osteoarthritis or primary back pain. Disorders of the musculoskeletal system bring the necessary need for rehabilitation. People exposed to damage/ diseases of the musculoskeletal system are often ex- posed to the risk of developing problems related to mental health or other comorbidities (7).

Quality of life

Quality of life plays an important role in the field of medicine and healthcare. It is considered a complex concept which is interpreted differently within and between disciplines, including the fields of medicine and health (8). In the literature, we come across nu- merous definitions of the quality of health, but there is still no universally accepted definition, which is why there are numerous instruments and questionnaires which are used to assess the quality of life. The World Health Organization (WHO) defines the quality of life as an individual’s perception of life in a social, specific cultural, and environmental context (9). The quality of life which we associate with health refers specifically to the health of the individual and indicates a measure of well-being, functioning, and general perception of health, and is divided into three phases: mental, so- cial, and physical. The instruments used to measure health-related quality of life are based on the concept of health, and the patient is the source of information. In today’s modern medicine, there is a growing inter- est in examining the cost-effectiveness and efficien- cy of new treatment methods which, apart from the benefit-cost ratio, include the patient’s perception of health as a measure of successful treatment (10).

The role of the nurses in patient rehabilitation

Nowadays, patients have the right to and the need for adequate medical rehabilitation, for which the indis- pensable cooperation of health and non-health work- ers, health associates, and adequate medical space, accessories, and equipment are responsible. The team of rehabilitation health workers consists of specialists in physical and rehabilitation medicine - physiatrists, nurses, caregivers, physiotherapists, orthopedic tech- nicians, occupational therapists, and others (11). The nurse in the rehabilitation team specializes in helping patients with certain disabilities and comorbidities with the aim to achieve health, functioning, and adap- tation to a changed lifestyle. Nurses and technicians are part of a multidisciplinary team and often coordi- nate team activities and patient care, provide health- care which promotes maintenance and restoration of function and prevention of complications, and provide education and counseling for both patients and fami- lies (12). When patients become unable to indepen- dently perform their daily activities and take care of their basic needs, the role of the nurse plays an impor- tant role in their lives (13).

Today, with the progress of nursing and the em- phasis on active and independent care, the patient is actively involved in rehabilitation, and nursing interventions are no longer focused only on provid- ing care, but also training, education, and support for the patient aimed at achieving the ultimate goal. This approach to nursing care is the main role of re- habilitation. The role of the nurse in rehabilitation includes maintaining basic physical functions such as breathing, and skin function, preventing compli- cations from prolonged lying down, cardiovascular functions, taking care of adequate nutrition, and training self-care functions (14). Nurses do not only meet physical needs but also support patients in other aspects, such as social, psychological, and spir- itual dimensions.

To fulfill the abovementioned needs, the equipment for healthcare and the environment in which the patient is located is also important (13). In the first place, the nurse is responsible for the patient’s care and, depending on the patient’s individual needs car- ries out adequate medical rehabilitation interven- tions (14). Nurses are often present with the patient “24/7” and thus spend more time with the patient than other team members. Currently, there is a shift towards a proactive approach in rehabilitation care in the sense that nurses provide healthcare to the patient, not just for him, thus encouraging him to par- ticipate in his care as much as possible (15). Research indicates that patients after musculoskeletal surgery need multidisciplinary care due to their low quality of life (16), which is lower than the quality of life of the general population (17). Diseases of the muscu- loskeletal system limit the ability to move through joint dysfunction and pain. Surgery and postopera- tive rehabilitation improve the above but do not en- sure complete recovery and mobility (18).

Aim

The aim of this research was to examine the quality of life of patients after musculoskeletal surgery and rehabilitation and to examine the quality of life after musculoskeletal surgery and rehabilitation concern- ing gender, age, diagnosis, and comorbidities.

Methods

The research was conducted in the Bizovačke Toplice Spa during March and April 2023 as a cross-sectional study (19). The participants are patients after mus- culoskeletal surgery and rehabilitation at the inpa- tient treatment in the Bizovačke Toplice Spa for 21 days. The inclusion criteria were: 18 years of age and above, cognitively preserved, understanding and speaking the Croatian language, and voluntarily agreeing to fill out the survey questionnaire. The par- ticipants filled out the questionnaire upon discharge.

Ethics

The research was conducted under all valid guide- lines, including the basics of good clinical practice, the Declaration of Helsinki, the Health Care Act of the Republic of Croatia, and the Patients’ Rights Protection Act of the Republic of Croatia. The Ethics Committee of the Bizovačke Toplice Spa (14/2023/1) and the Ethics Committee of the Faculty of Dental Medicine and Health (2158/97-97-10-23-33.) gave their consent and approval for the implementation of this research.

Procedure

The research was explained to the participants in a way they could understand, and if they agreed to participate in the study, they were given an informed consent form to sign. After signing the informed con- sent form, the participants filled out the question- naire independently. The completed questionnaire was returned in sealed envelopes to ensure anonym- ity. An anonymous questionnaire consisting of two parts was used as a research instrument. In the first part, the respondents answered questions about age, gender, place of residence, type of surgery, and comorbidities. In the second part of the survey, a Croatian example of a questionnaire licensed by the School of Public Health “Andrija Štampar” was used. The questionnaire is related to the self-assessment of the quality-of-life SF-36 (Short form 36 Health Survey Questionnaire) (17). The questionnaire has a total of 36 questions covering: the way of physical functioning, limitations caused by physical problems, physical pain, overall health, vitality, social function- ing, limitations caused by psychological problems,

and psychological health. The SF-36 questionnaire is a very popular instrument for assessing quality of life and is used worldwide to assess health-related quality of life (20).

Statistics

Descriptive statistical methods were used to de- scribe the frequency distribution of the investigated variables. Mean values are expressed as arithmetic mean, minimum and maximum value, and standard deviation. The t-test for independent samples was used to examine the differences in results between two independent groups of subjects, while the one- way analysis of variance was used to examine the differences between several independent variables. The Kolmogorov-Smirnov test was used to test the normality of the distribution. A value of p<0.05 was taken as the level of statistical significance. The statistical package IBM SPSS 25, Chicago, USA, was used for processing.

Results

A total of 96 participants took part in the research, 62 (64.6%) were female, 53 (55.2%) lived in urban

areas, 44 (45.8%) had hip surgery and 43 (44.8%) had no comorbidities. The mean age of the parti- cipants is 63 years (ranging from 18 to 91 years) (Table 1).

The best assessment of the participants was ex- pressed in the aspect of mental health M=58.20 (SD=17.84), while the lowest was in the limitation due to physical difficulties M=32.81 (SD=42.03) (Table 2).

The results showed that there is a significant differ- ence according to the gender of the participants in physical functioning (T=2.318; p=0.02), vitality and energy (T=3.351; p=0.001), mental health (T=2.310; p=0.003), social functioning (T=2.044; p=0.04), per- ception of general health (T=2.739; p=0.007), sig- nificantly better physical functioning, vitality and energy, psychological health, social functioning and perception of general health are shown by male par- ticipants compared to female participants (Table 3).

The participants were divided into three categories according to age, which were determined so that there would be an approximately equal number of participants in each group.

The Tukey post hoc test showed that participants aged 50 years and younger were significantly worse (One-way analysis of variance; F=2.540; p=0.01; Tukey post hoc; p<0.05) when their limitation due to physical disabilities according to the condition of participants aged 51 to 60 and 61 and older was as- sessed. The Tukey post hoc test showed that there were no significant differences between the groups of 51 to 60 years and 61 years and older (Table 4).

The results showed that participants who have co- morbidities evaluate their physical functioning sig- nificantly better (t-test; T=2.044; p=0.04) and that participants who had no comorbidities estimate a significantly higher limitation due to physical difficul- ties (t-test; T=2.357; p= 0.01) (Table 5).

No significant difference was obtained concerning the type of surgery performed in physical func- tioning (One-way analysis of variance; (F=1.240; p=0.30), limitation due to physical difficulties (F=0.617; p=0.60), limitation due to emotional difficulties (F=2.070; p=0.11), vitality and en- ergy (F=0.053; p=0.98), mental health (F=0.576; p=0.63), social functioning (F=1.131; p=0.34), body pain (F=1.321; p=0.27), and perception of general health (F=0.731; p=0.53) after musculoskeletal sur- gery and rehabilitation.

Discussion

The lowest assessment of the quality of life of the participants in this research was expressed in the aspect of limitations due to physical difficulties. Male participants rated a higher quality of life after surgery and rehabilitation compared to female par- ticipants. Also, the participants who have various

comorbidities evaluate their quality of life as higher than the participants without comorbidities.

Through general demographic data, a difference in diseases of the musculoskeletal system by gender is visible. Women at an older age are often affected by osteoarthritis, caused by the aging process itself, but additionally stimulated by menopause and the lack of hormones which enhance bone health (21). The num- ber of women undergoing musculoskeletal system surgeries is significantly higher than the number of men (21). In addition to the above, women also expe- rience more serious symptoms and disability caused by the disease, and despite that, women often avoid visiting the doctor due to problems with movement and pain, although they decide to undergo surgery in equal numbers as members men (21). The results of this research indicate that significantly better physical functioning is shown by male participants compared to women. Global research indicates that a greater number of comorbidities is associated with an increased level of pain, reduced physical function, and a worse quality of life (22, 23).

There are no significant differences in limitations due to emotional difficulties according to demo-

graphic and surgery-related variables. The results are the identical according to the type of surgery as well as according to comorbidities, which means that emotional difficulties in this study are lower in diseases, surgery, and rehabilitation of the mus- culoskeletal system compared to other difficulties. However, emotional difficulties are present and are estimated to be lower than in the general population

(17). The results of this research indicate that male participants show significantly better mental health, vitality, and energy compared to female participants. Also, women lose vitality as a result of the surgical procedure, and they often develop depression due to a change in condition or dissatisfaction with their abilities (24, 25).

Significantly better social functioning in this re- search is shown by male participants compared to women. Rehabilitation after orthopedic surgery is not a guarantee of the return of total mobility, and in combination with the age of the participants, there is a decline in physical function. In women, it often implies the loss of the family role as a caregiver, and beginning of taking care of themselves (26).

There are no significant differences in physical pain according to demographic data and variables related to surgery in this study, but pain is present and other studies indicate that pain is the cause of a large num- ber of other problems (27).

In this research, male participants showed a signifi- cantly better perception of general health compared to female participants. Other studies show equal re- sults between the sexes, without significant differ- ences in the perception of health (28).

The results of the research by Gordon et al. (2014) indicate that the age of the participants is negatively related to physical functioning, vitality and energy, psychological health, and general health, that is, the older the participants are, the worse the physi- cal functioning, vitality and energy, psychological and general health. Older people assess their health worse than younger people. The greater the differ- ence in age, the greater the difference in assessment

(29). In this research, the younger participants esti- mated their limitations due to physical difficulties as significantly worse than the older participants. The results obtained indicate that younger participants perceive their condition and quality of life as worse because they are suddenly limited in performing ac- tivities due to poor health, while older participants

have come to terms with the fact that they are lim- ited due to physical difficulties and do not perceive their current condition as dramatically. Furthermore, the results of other research indicate that problems arise through the perception of one’s state and the influence of one’s thoughts on the quality of life (30).

The participants with comorbidities rate their physi- cal functioning significantly better compared to par- ticipants without comorbidities. Other studies indi- cate the opposite: comorbidities reduce the quality of life and physical function (31). The opposite as- sessment of the participants in this study compared to the results of other studies could be explained through the subjectivity of the assessment, meaning that people with comorbidities better assess their physical function as part of reduced function follow- ing surgery due to a previous worse condition caused by comorbidities. A significantly higher limitation due to physical difficulties is estimated by participants without comorbidities compared to the participants with comorbidities. The reduction of physical func- tion and movement limitation is directly related to comorbidities (32, 33). The participants without co- morbidities have a harder time accepting new diffi- culties and adapting, and thus negatively assess the quality of life, which is a subjective assessment (34).

The limitation of this research is that the participants came to rehabilitation at different times, between six and twelve weeks after the surgery, which could af- fect the perception of the quality of life.

Conclusion

The results of the conducted research indicate that after musculoskeletal system surgery and rehabilita- tion, the participants assess the quality of life at the lowest level in terms of limitations due to physical difficulties. Male participants estimate a higher quali- ty of life after surgery and rehabilitation compared to females, through better physical functioning, assess- ment of greater vitality and energy, better psycho- logical health, better social functioning, and a better perception of general health. Poorer quality of life is assessed by younger participants and participants without comorbidities.

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KVALITETA ŽIVOTA BOLESNIKA NAKON OPERACIJE LOKOMOTORNOG SUSTAVA I PROVEDENE REHABILITACIJE

Sažetak

Uvod. Rehabilitacija podrazumijeva oblik zdravstve- ne zaštite koji je usmjeren na vraćanje i održavanje tjelesne snage i mobilnosti s krajnjim ciljem postiza- nja najboljih mogućih rezultata.

Cilj. Ispitati kvalitetu života bolesnika nakon operaci- je lokomotornog sustava i provedene rehabilitacije u odnosu na dob, spol, dijagnozu i komorbiditete.

Metode. Ispitivanje je provedeno kao presječna studija. Sudionici su bolesnici nakon operacije loko- motornog sustava i provedene rehabilitacije na sta- cionarnom liječenju u Lječilištu Bizovačke toplice u trajanju od 21 dan. Primijenjen je anonimni anketni upitnik s demografskim podacima te upitnik samo- procjene kvalitete života SF-36.

Rezultati. U istraživanju je sudjelovalo 96 sudionika, ženskog spola bilo ih je 62 (64,6 %), operaciju kuka imalo je 44 (45,8 %) te ih 43 (44,8 %) nema komorbi- diteta. Srednja je vrijednost dobi sudionika 63 godine (raspona od 18 do 91 godine). Sudionici u dobi od 50 godina i mlađi znatno lošije procjenjuju svoje ogra- ničenje zbog tjelesnih poteškoća. Sudionici muškog spola procjenjuju statistički značajno bolju kvalitetu života nakon operacije i rehabilitacije u usporedbi sa ženskim spolom, kroz bolje tjelesno funkcionira- nje, procjenu veće vitalnosti i energije, bolje psihičko zdravlje, bolje socijalno funkcioniranje te bolju per-

Zaključak. Najniža procjena kvalitete života sudionika iskazana je u aspektu ograničenja zbog tjelesnih po- teškoća. Lošiju kvalitetu života procjenjuju sudionici ženskog spola, mlađi te sudionici bez komorbiditeta.

cepciju općeg zdravlja. Različite dijagnoze sudionika i       

provedeni operacijski zahvati nisu značajno povezani s kvalitetom života nakon operacije lokomotornog su-

Ključne riječi: kvaliteta života, lokomotorni sustav, reha- bilitacija, SF-36

stava i provedene rehabilitacije.