This thesis aims to present a multi-dimensional instrument for self-assessment of progress in postoperative recovery. The author employs different research paradigms and methodologies to achieve this aim. Walker and Avant’s approach to concept analysis was used to examine the basic elements of postoperative recovery (Study I). The analysis identified different recovery dimensions and developed a theoretical definition showing postoperative recovery to be an energy-requiring process of returning to normality and wholeness, defined by comparative standards. Fourteen patients and 28 staff members participated in individual and focus group interviews aimed at describing patient and staff experiences of patient recovery (Study II). The essence of the postoperative recovery process was described as a desire to decrease unpleasant physical symptoms, reach a level of emotional wellbeing, regain functions, and re-establish activities. In Study III, 5 dimensions and 19 items were identified as a part of the operationalization process of the concept postoperative recovery. Fifteen staff members and 16 patients participated in the evaluation of content validity. On average, 85% of the participants considered the items as essential to the recovery process. In a test run of the questionnaire, 14 of 15 patients considered the questionnaire to be easy to understand and easy to complete. Twenty-five patients participated in the evaluation of intra-patient reliability. Percentage agreement (PA), systematic disagreement (RP, RC), and individual variability (RV) between the two assessments were calculated. PA measures ranged from 72% to 100%. The observed disagreement could be explained mainly by systematic disagreement. In total, 158 patients participated in the evaluation of construct validity, the ability to discriminate between groups, and the investigation of important item variables (Study IV). A rank-based statistical method for evaluation of paired, ordered categorical data from rating scales was used to evaluate consistency between the assessments of the Postoperative Recovery Profile (PRP) questionnaire and a global recovery scale. The number of months needed by participants to be regarded as fully recovered was studied by means of recovery profiles displayed by the cumulative proportion of recovered participants over time. A ranking list based on the participant’s appraisal of the five most important item variables in the PRP questionnaire was compiled to illustrate the rank ordering of the items. In comparing the assessments from the PRP questionnaire and the global recovery scale, 7.6% of all possible pairs were disordered. Twelve months after discharge 73% in the orthopaedic group were regarded as fully recovered, compared to 51% of the participants in the abdominal group (95% CI: 6% to 40%). The pain variable appeared among the top five most important items on eight measurement occasions, of eight possible, in both study groups. In conclusion, the PRP questionnaire was developed and support was given for validity and reliability. The questionnaire enables one to evaluate progress in postoperative recovery.

Il existe différents facteurs pouvant altérer la récupération fonctionnelle de patients souffrant de traumatismes orthopédiques (TO), dont le fait de subir un traumatisme craniocérébral (TCC) concomitant. Le profil de traumatismes combinés (TCC et TO) a principalement été étudié en contexte de blessures jugées sévères (TCC modéré/sévère et multiples fractures), notamment dans un souci de maximiser la récupération de ces patients et le déploiement des ressources médicales. Par ailleurs, la littérature demeure limitée en ce qui a trait à l’impact de subir un TCC en contexte de blessures jugées moins sévères, soit un TCC léger (TCCL) et une fracture isolée (un seul os fracturé), bien qu’il s’agisse de deux blessures à très forte incidence et qu’elles partagent diverses similarités (p.ex. : mécanismes d’accidents et physiologiques communs). Ainsi, la présente thèse s’est spécifiquement intéressée à cette population aux prises avec une fracture isolée avec, ou sans, TCCL concomitant. Dans un premier temps, les travaux de la thèse ont permis d’investiguer la fréquence de TCCL concomitant en contexte de fracture isolée (article 1) ainsi que son impact sur la récupération post-fracture selon diverses mesures cliniques (articles 2, 3, 4). Les résultats ont démontré que le TCCL était fréquent, quoique fortement sous-diagnostiqué, chez des patients vus au département d’urgence (DU) pour une fracture isolée et que sa présence avait un impact significatif sur le niveau de douleur perçu, le délai pour retourner au travail et le risque de développer de l’ossification hétérotopique (forme de complications orthopédiques). Dans un deuxième temps, la présente thèse a utilisé une approche théorique (article 5) et clinique (article 6) afin d’étudier les mécanismes physiologiques sous-tendant la perception de douleur, symptôme clé suite à une fracture, dans un souci de limiter les risques de chronicisation de la douleur et de proposer des méthodes d’intervention ciblées selon la population étudiée. Les travaux ont notamment mis en lumière une association entre l’intensité de douleur rapportée par des patients en phase aiguë post-fracture et le degré d’atteintes des mécanismes d’excitabilité corticale du cortex moteur primaire mesurées par l’entremise de la stimulation magnétique transcranienne (SMT). Enfin, sur la base d’évidences théoriques soulevées dans un article de revue de la présente thèse, il semble y avoir une pertinence dans l’utilisation de la SMT auprès de la population orthopédique comme méthode d’investigation et d’intervention, considérant sa capacité à cibler les mécanismes physiologiques impliqués dans la transition de la douleur aiguë à la douleur chronique. / A variety of factors can affect the functional recovery of patients with an orthopedic trauma (OT), including concomitant traumatic brain injuries (TBI). The recovery profile of patients with combined traumas (OT and TBI) has been studied primarily in the context of severe injuries (moderate/severe TBI and multiple fractures), in order to maximize recovery and medical resources. On the other hand, there is limited evidence on the impact of concomitant TBI in the context of milder injuries, such as in patients sustaining a mild TBI combined with an isolated limb fracture, despite both injuries being highly prevalent and sharing various similarities (e.g., overlapping injury mechanisms and physiological mechanisms). The current thesis sought to bridge this knowledge gap via a multifaceted approach. We first investigated the risk of sustaining a concomitant mild TBI in patients with an isolated limb fracture (article 1) as well as its impact on post-fracture recovery according to various clinical measures (articles 2, 3, 4). The results showed that mild TBI was frequent, although highly underdiagnosed, in patients seeking care for an isolated limb fracture in the emergency department. Moreover, the presence of a concomitant mild TBI had a significant detrimental impact on the level of perceived pain, on return to work delays, and on the risks of developing heterotopic ossification (a type of orthopedic complication). Secondly, this thesis used a theoretical (article 5) and a clinical (article 6) approach to study the physiological mechanisms underlying pain perception, a key symptom following a fracture, in order to limit the risks for pain chronification and to propose intervention methods tailored to the studied population. In particular, results highlighted an association between pain intensity as perceived by patients in the acute phase post-fracture and the degree of cortical excitability impairments of the primary motor cortex, as measured by transcranial magnetic stimulation (TMS). Finally, based on theoretical evidence highlighted in a review article included in this thesis, there are evidence supporting the use of TMS in a traumatically injured population as a method to investigate and intervene given its ability to target key physiological mechanisms involved in the transition from acute to chronic pain.