To inform clinical practice, the AFTER trial evaluated the clinical and cost-effectiveness of supervised versus self-directed rehabilitation in improving ankle function for adults aged 50 years and over with ankle fractures.
The AFTER multicentre, parallel-group, individually randomised controlled superiority trial recruited patients aged 50 years and older with an ankle fracture treated surgically or non-surgically from 28 NHS hospitals in the UK. Participants were randomised 1:1 using a web-based service to Supervised Rehabilitation - four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise, or Self-directed Rehabilitation - provision of high-quality advice and exercise materials that allow participants to manage their recovery independently. The primary outcome was participant-reported ankle-related symptoms and function six months after randomisation, measured by the Olerud and Molander Ankle Score (OMAS; 0 to 100, higher scores better). Secondary outcomes at two, four, and six months included health-related quality of life and resource use. A within-trial cost-utility analysis comparing the cost-effectiveness of the interventions was conducted under the NHS and personal social services perspective. Registration: ISRCTN11830323.
Of the 377 participants, 188 were allocated to Supervised Rehabilitation, 189 were allocated to Self-directed Rehabilitation. Participants were 75% (282/377) female and mean age was 62 (SD 8.3) years, 45% received surgical treatment for their fracture. At six months, 314 participants (83%) completed the OMAS. Mean OMAS scores at six months were 75.3 (SD 22.8) for the Supervised Rehabilitation group and 73.7 (SD 21.1) for the Self-directed Rehabilitation group. There was no evidence of a difference between the intervention groups at six months, OMAS mean difference -0.245 (95%CI -4.940; 4.450). No differences in the OMAS were found at the earlier timepoints at two and four months post-randomisation or at any timepoints for quality of life. The cost-effectiveness base-case analysis showed that Supervised Rehabilitation had a significantly higher mean cost (£1571, 95%CI 320;2823) and almost the same QALYs (0.008, 95%CI -0.006;0.022) relative to Self-directed Rehabilitation (incremental cost-effectiveness ratio: £198,022/QALY); this finding remained robust in sensitivity and subgroup analyses.
Supervised rehabilitation is not superior to self-directed rehabilitation in terms of ankle-related symptoms and function after ankle fracture. Supervised rehabilitation is also unlikely to be cost-effective relative to self-directed rehabilitation.
Provision of high-quality self-directed rehabilitation advice and materials is the preferred approach to support recovery for people aged 50 years and over after ankle fracture. This alternative to supervised rehabilitation is likely to have an important impact on healthcare and rehabilitation resources.
Randomised controlled trial
Rehabilitation
