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A biopsychosocial approach to optimising rehabilitation after upper extremity fracture

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences

Friday, January 08, 2021 Competition Funded PhD Project (Students Worldwide)

About the Project


Dr Steve Gwilym (;
Dr David Keene (;
Dr Bethany Fordham (

Research Project Outline:

Upper extremity fractures represent over 20% of all fractures requiring hospital treatment in the UK. After initial management with casts or surgery people are advised to rehabilitate the injured limb with exercises. Our research has shown that psychosocial factors, such as fear of movement, low self-efficacy and poor social support are consistently more predictive of poor outcome after upper extremity fracture than the details of the initial fracture treatment or severity of the injury. It was previously recognised there should be increased focus on addressing these modifiable psychosocial factors.

Since the COVID-19 pandemic, trauma services in the UK have undergone a major change in service delivery. Prior to COVID-19, patients were seen several times face-to-face by a health professional following injury/surgery. Despite this, feelings of anxiety, fear of movement and low social support were highly prevalent. Now, most upper extremity fractures are diagnosed and treated in the emergency department but then patients are advised to self-manage their recovery independently with remote contact with health professionals via telephone or videoconferencing. These service changes to reduce hospital contact will stay in place for the foreseeable future. Despite obvious economic and convenience benefits, these changes could exacerbate the psychosocial issues previously highlighted.

Our group has experience in developing biopsychosocial behaviour change interventions to increase exercise adherence and address barriers to recovery in other clinical populations. A behaviour change intervention has the potential to modify these psychosocial factors and reduce disability after upper extremity fracture.

The focus of this project is to investigate this pressing clinical challenge and draw upon an extensive evidence base to develop a novel rehabilitation intervention specifically designed for delivery via telephone or videoconferencing.

The aims of the study are to:
• Examine predictors and outcomes of patients with an upper extremity fracture within the new model of peri/post-COVID-19 fracture care, and compare this with data collected prior to COVID-19, with the associated critical changes in service delivery
• Synthesise evidence on behaviour change techniques suitable for the target population
• Develop a behaviour change rehabilitation intervention using an established theoretical framework methodology
• Assess the delivery of the developed novel behaviour change rehabilitation intervention in the clinical setting and determine feasibility for a later clinical trial

Details of Research Group:

The DPhil will be jointly supervised by Dr Steve Gwilym, Dr David Keene, and Dr Bethany Fordham, based across the Oxford Trauma and Emergency Care Group and the Centre for Rehabilitation Research in the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS -, University of Oxford.

• Dr Steve Gwilym is a clinician scientist orthopaedic surgeon with a specialist interest in upper limb injuries. He has supervised previous DPhil students investigating recovery after upper limb fractures and currently holds a number of national and international research grants in these areas.
• Dr David Keene is a clinical academic physiotherapist. His research focusses on the development and evaluation of complex interventions to optimise recovery and rehabilitation after musculoskeletal injury and has published work in leading journals such as the Journal of the American Medical Association and the British Medical Journal.
• Dr Bethany Fordham is a health psychologist. Her research interests are the integration of psychosocial theory and evidence-based techniques into the management of physical health conditions. Currently she is undertaking a meta-review of systematic review evidence of cognitive behavioural therapy, and is developing and testing, theoretically underpinned, behaviour change interventions within rehabilitation programmes.


The Oxford Trauma and Emergency Care Group ( is based in the Kadoorie Research Centre and the Centre for Rehabilitation Research ( is based in the Botnar Research Centre. The groups work collaboratively to produce internationally leading applied health research into musculoskeletal injury management.

Training will be provided in relevant clinical research methodology, including evidence synthesis, handling and analysis of datasets, complex intervention development, qualitative methods, and statistical techniques. In addition, courses from Oxford University Computer Sciences on key skills for the completion of a successful DPhil thesis will be available. Additional on the job training opportunities will arise, and the supervisors will encourage the student to pursue such opportunities.

A core curriculum of lectures will be taken in the first term to provide a solid foundation in a broad range of subjects including musculoskeletal biology, inflammation, epigenetics, translational immunology, data analysis and the microbiome. Students will also be required to attend regular seminars within the Department and those relevant in the wider University. Students will be expected to present data regularly in Departmental seminars, the Oxford Trauma & Emergency Care group and Centre for Rehabilitation Research meetings, and to attend external conferences to present their research globally, with limited financial support from the Department.

Students will also have the opportunity to work with the wider clinical trial investigators and teams within the groups, who work closely with colleagues in the Centre for Statistics in Medicine ( and the Oxford Clinical Trials Research Unit (, that are based within NDORMS. Students will have access to various courses run by the Medical Sciences Division Skills Training Team ( and other Departments. All students are required to attend a 2-day Statistical and Experimental Design course at NDORMS and run by the IT department (information will be provided once accepted to the programme).

Further academic/project specific queries: Please contact Steve Gwilym ()

How to Apply:

The Department accepts applications throughout the year but it is recommended that, in the first instance, you contact the relevant supervisor(s) or the Graduate Studies Officer, Sam Burnell (), who will be able to advise you of the essential requirements.

Interested applicants should have, or expect to obtain, a first or upper second-class BSc degree or equivalent in a relevant subject and will also need to provide evidence of English language competence (where applicable). The application guide and form is found online ( and the DPhil will commence in October 2021.

Applications should be made to the following programmes using the specified course code:

D.Phil in Musculoskeletal Sciences (course code: RD_ML2)

For further information, please visit


Recommended reading:
• Relationship Between Magnitude of Limitations and Patient Experience During Recovery from Upper-Extremity Fracture. Jayakumar P, Teunis T, Vranceanu AM, Lamb S, Ring D, Gwilym S. JBJS. 2019 Jul 22;4(3):e0002.1-7.
• The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Susan Michie, Maartje M van Stralen, and Robert West. Implementation Science. 2011; 6: 42.

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