The term "Orthopaedic" refers to surgeons who deal with bone surgery. The field of medicine known as orthopaedics, or orthopaedics, focuses on the identification, management, and avoidance of musculoskeletal illnesses and injuries. Orthopaedic includes these components: tendons, ligaments, muscles, joints, and nerves. Performing surgical methods to address these diseases is the specialty of orthopaedic surgeons. Orthopaedic surgeries encompass various procedures such as joint replacement, soft tissue repair, fusion and excision surgeries, arthroscopy, bone grafting, open and closed reduction of fractures, fixation procedures and soft tissue release [1].

Physiotherapy is defined as "providing services to people and populations to develop, maintain, and restore maximum movement and functional ability throughout their lives" by the World Confederation for Physical Therapy (WCPT) [2]. Globally, the number of orthopaedic procedures is rising. In most western countries, including the UK, between 150 and 250 people per 100,000 undergo TKR each year [3]. The World Journal of Surgery reports that Pakistan’s annual surgical shortfall is 17 million. These include orthopaedic procedures that prevent permanent disability [4].

Physical therapy (PT) following orthopaedic surgeries has been found to be a critical component of a favourable patient outcome. Following surgeries, physiotherapy is generally advised to enhance daily life activities. These consist of a variety of therapies to help patients develop self-management skills, including manual approaches, taping, electrotherapeutic modalities, exercise, and education [5]. The Normalization Process Theory provides a framework for understanding the practices of physiotherapists to integrate the interventions following surgeries into standard clinical practice. Four characteristics of integrating a practice into "work as usual" are listed by this theory:  cognitive (engaging and participating with the practice); collective action required to enact the practice; reflexive monitoring the practice over time to ensure it becomes routinely embedded and coherence (understanding and making sense of practice) [6].

The implication of physical therapy on joint replacement surgeries has been the subject of numerous studies.  There are few researches on pain treatment strategies for orthopaedic patients recovering from surgery.  Nevertheless, no study was carried out in the Hazara division of KPK on the physiotherapy practices for various kinds of post-operative orthopaedic patients. Based on the perspectives of physiotherapists throughout the Hazara Division, the study aims to ascertain the prevalence of physiotherapy practices and the association of type of surgery, work environment, and location with patients' recovery.

This observational, cross-sectional study recruited both male and female physiotherapists who involved in managing post-operative orthopedic patients through non-probability convenient sampling technique. Physiotherapists’ minimum work experience was 1 year and work duration per day was at least 6 hours. The interns and those who were on extra-ordinary medical leave were not included. Following areas of Hazra Division were covered: Abbottabad, Mansehra, Haripur, Havelian, Battagram, and Qalanderabad. Torghur and Kohistan were not included.

Using the Raosoft sample size calculator, the estimated sample size was 377; where the population was assumed to be 20,000 because the precise size was unknown, and the response rate, margin of error, and confidence interval were all assumed to be 50%, 5%, and 95%, respectively [7,8].

Data was collected from 104 physiotherapists available throughout the Hazara division. The study was carried out between October 2021 and March 2022. The questionnaire was devised for this particular study after a thorough analysis of prior surveys and the literature on physiotherapy treatment following orthopedic surgeries [9].

Ethical Approval: The Institutional Review Board (IRB) and Ethical Research Committee of the Women Institute of Rehabilitation Sciences, Abbottabad gave their approval to this study.

Consent of Participants: The participants were given a consent letter and requested not to reveal any personal information on the questionnaire in order to protect their anonymity. Only the researchers had access to the secured file containing the data.

Data Collection Procedures: After obtaining participant permission and institutional approval, subjects were assessed for inclusion and exclusion criteria. The questionnaire was distributed to participants in order to collect primary data.

Data Analysis Procedure: SPSS version 27.0 and Microsoft Excel 2010 were used to help in data analysis. Frequencies of physiotherapy practices were calculated and shown as charts and frequency tables. The chi square test was used to see if these practices were related to patients' recovery response, and a p-value of less than 0.05 was considered statistically significant.

Table 1: Demographic Characteristics of Research Participants.

Table 1 shows that this study included 104 people. There were 50% females and 50% males. 52.9% of participants were between the ages of 24 and 29, 30.8% were between the ages of 30 and 35, 7.7% were between the ages of 36 and 41, and 8.7% were older than 42. In Abbottabad, 64.4% of participants were working, compared to 7.7% in Mansehra, 3.8% in Battagram, 20.2% in Haripur, 1.9% in Havelian, and 1.9% in Qalanderabad. 48.07% of participants had a bachelor's degree, 49% had a master's degree, and 2.9% had a doctorate. Cardio-respiratory PT specialization accounted for 1.9% of the participants, orthopaedic and manual PT for 30.8%, musculoskeletal PT for 11.5%, neurological PT for 5.8%, sport PT for 1.9%, and non-specialized individuals made up 50%. 20.2% of physiotherapists had their own clinical setting, 56.7% worked in private hospitals, and 23.1% worked in government institutions.

Table 2: Physiotherapy Practices for Post-operative Orthopedic Patients.

Table 2 shows that 27.88% physiotherapists treated four to six post-operative orthopedic patients per day, 25.96% treated seven to ten, 20.19% treated more than seven, while 25.96% treated one to three patients per day.  3.85% of physiotherapists treated patients who had experienced replacement surgery, 67.31% treated post fracture reduction patients, 8.65% treated those who underwent excision surgery, 11.54% applied treatment to patients who underwent soft tissue repair or release, and 8.65% gave treatment to those who underwent other orthopedic procedures.  In the case of physiotherapy treatment given to post-operative orthopedic patients, 3.85% of participants reported applying modalities, 25% reported using manual therapy, 33.62% utilized range-of-motion exercises, and 37.50% reported using a combination of all these therapies. While 1.92% did not discuss the treatment strategy with patients, 98.08% did. Among the participants, 13.46% reported applying treatment for 15 minutes per session, 75% for 30 minutes, 9.62% for 45 minutes, and 1.92% for 60 minutes.  90.38% of participants reported treating both referred and direct contact patients, 2.88% reported treating patients with direct contact, and 6.73% reported solely treating referred patients.  Patients' recovery responses were rated as poor by 1.92%, excellent by 40.38%, and satisfactory by 57.69% of respondents.

Table 3: Association of Work Practices of Physiotherapists with Recovery Response of Post-operative Orthopedic Patients.

Table 3 demonstrates that Physiotherapists' areas of practice were not linked to the type of post-operative orthopedic patients they treated, as evidenced by a p value of 0.197 greater than 0.05. Additionally, work environments and access to physiotherapists were not associated to patients' recovery responses, as p values of 0.659 and 0.350 are greater than the level of significance of 0.05.

Williamson E, conducted study on 87 physiotherapy departments across the United Kingdom. Senior physiotherapists who treated patients undergoing spine surgery participated. Most patients underwent physiotherapy during the hospital phase, receiving exercises and education. Not all patients had access to physiotherapy after being discharged, and when they did, the type and quantity of treatment varied [10]. Wang H, split individuals who had undergone spinal fusion surgeries into two groups; depending on whether they had undergone postoperative rehabilitation training. Following surgery, the intervention group's recovery outcomes were better than those of the control group (P < 0.05) [11].

 Physical therapy was administered to half of the group both before and after surgery, whereas the other half only received treatment following the procedure in a study by Paswan S. had no statistically significant difference in the two groups' outcomes was observed [12]. Passive range of motion was started in the first postoperative week by 35% of patients, whereas 49.2% began in the second or third week.  After surgery, 41.1% of patients commenced overhead movements, while the majority introduced active mobilization in a study carried out by Brindisino F [13].

Purcell K, in their study found that each weekday, 356 patients (84%; range: 60% Ireland to 100% Spain) received physiotherapy to mobilize. A small percentage of patients (175, 40%, range: 0% Spain to 81% Brazil) were mobilized by physiotherapy on weekends; however, 298 patients (70%) mobilized with non-physiotherapy staff (range: 0% Spain to 96% Denmark/Ireland). Range-of-motion exercises, gait training, and mobility were all part of the physiotherapy treatments. There were few referrals to fall prevention programs (93, 22%, range: 0% Spain to 76% Ireland) [14]. In another study by Houchen-Wolloff, 55 AHPs and 117 surgeons participated. The two groups' survey replies agreed well with one another. Not all patients were recommended for post-operative rehabilitation, according to more than half of respondents (57%) to the survey. The time point at which patients were told to bear weight varied greatly, ranging from two weeks to more than twelve weeks. Sixty-two percent of respondents cited non-union as a concern for early mobilization [15].

3.85% of participants reported using modalities, 25% reported using manual therapy, 33.62% used range-of-motion exercises, and 37.50% reported using a combination of all these therapies in the context of physiotherapy treatment for post-operative orthopedic patients in this study. Among responders, 1.92% assessed the patients' recovery answers as poor, 40.38% as good, and 57.69% as satisfactory. 9.62% of participants reported using treatment for 45 minutes, 1.92% for 60 minutes, 75% for 30 minutes, and 13.46% for 15 minutes each session. 90.38% of participants said they treated patients who were referred and those who had direct contact, 2.88% said they treated patients who had direct contact, and 6.73% said they only treated referred patients. In addition, p values of 0.659 and 0.350 are higher than the significance level of 0.05, indicating that work settings and the accessibility to physiotherapists were not linked to patients' recovery responses.

Limitations of Study: Only participants who were available at the time of data collection were included in this study, which was conducted using a convenient sampling strategy.  Furthermore, the perspectives of orthopaedic surgeons and post-operative patients regarding recovery were not dealt with.

The results of the study show that physiotherapy services are available to post-operative orthopaedic patients in the Hazara division both directly and through referrals.  Physiotherapy was used to treat a variety of post-orthopaedic patients; the most common operations were fracture reductions, soft tissue restoration and excision surgery.  Many patients responded favourably to the implications of physiotherapy treatment in terms of their recovery.

Acknowledgement

Every author contributed significantly to the study work, helping with data collection and analysis, manuscript composition, and final version approval for publishing. Dr. Umber Fatima (PT) is the supervisor of the research team as well.

Source of Funding

No funding has been provided for this study.

Conflict of Interest

There are no conflicts of interest related to this research project.

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