Physical Therapy on Postoperative Day Zero Following Total Knee Arthroplasty: A Randomized, Controlled Trial of 394 Patients

Bohl, Daniel D.; Li, Jefferson; Calkins, Tyler E.; Darrith, Brian; Edmiston, Tori A.; Nam, Denis; Gerlinger, Tad L.; Levine, Brett R.; Valle, Craig J. Della

doi:10.1016/j.arth.2019.02.010

Cited by 21 publications

(17 citation statements)

References 16 publications

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“…It stands to reason then, that a single intervention, such as trialled here, would have a smaller effect. This not withstanding, equally modest or no reductions in LOS have been observed previously [14,21,33] and we interpret this knowledge as evidence that 'context' (eg. site) likely matters when implementing evidence into practice.…”

Section: Discussionsupporting

confidence: 69%

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Chua

Brady

Farrugia

et al. 2020

BMC Musculoskelet Disord

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Background Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. Method A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. Results Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. Conclusion Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

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Section: Discussionsupporting

confidence: 69%

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Chua

Brady

Farrugia

et al. 2020

BMC Musculoskelet Disord

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“…Many hospitals follow an accelerated or enhanced recovery protocol, mobilising patients for the first time in the first 4 hours after surgery. Bohl et al 16 and Okamoto et al 17 demonstrated that early mobilisation within the first 24 hours after surgery shortened length of stay, but did not affect longerterm outcomes. Most hospitals have discharge criteria governing when patients are discharged from hospital that are based on safe mobilisation, ability to perform self-care and attainment of a minimum amount of knee flexion (commonly set at 90 degrees).…”

Section: Rehabilitation Pathwaymentioning

confidence: 99%

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

Barker

Room

Knight

et al. 2020

Health Technol Assess

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Background Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15–30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. Objectives To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. Design An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. Setting The trial took place in 14 NHS physiotherapy departments. Participants People identified as being at high risk of a poor outcome after knee arthroplasty. Interventions A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. Main outcome measures The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. Results In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4–7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2–6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval –0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. Limitations The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. Conclusions This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. Trial registration Current Controlled Trials ISRCTN13517704. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

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“…Polish experts recommended starting rehabilitation on the day of surgery. Surgeons from all over the world have increasingly emphasized early mobilization, which may produce favourable postoperative outcomes [ 33 – 35 ]. Most surgeons (92%) reported that they always recommended that their patient undergo rehabilitation with a physiotherapist after knee arthroscopy, which is now considered the gold standard, and its effectiveness has been shown by a number of control studies [ 36 – 39 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical practice and postoperative rehabilitation after knee arthroscopy vary according to surgeons’ expertise: a survey among polish arthroscopy society members

Bąkowski

Bąkowska-Żywicka

Piontek

2020

BMC Musculoskelet Disord

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Background Meniscus repair is a challenging task in knee arthroscopy. Currently, there are a variety of arthroscopic methods available for meniscus repair. The purpose of this study was to determine a consensus in meniscus tear treatment in the environment of Polish orthopaedists. Methods A total of 205 registered orthopaedic surgeons participated in the surveys. The survey consisted of 35 questions regarding general arthroscopy and postoperative management, including physicians’ level of expertise, anaesthesia, postoperative treatment, rehabilitation and procedures performed. Comparisons were made between knee arthroscopy experts (> 100 arthroscopies performed per year) and non-experts (≤ 100 cases) on aspects of patient care. Results The most important finding of this study was the agreement among almost all aspects of the knee arthroscopy approach. Consensus among Polish surgeons was noticed in choosing regional anaesthesia for knee arthroscopy, the lack of need for knee braces and knee medications, the of use of LMW heparin for thromboprophylaxis, 1–2 days of hospitalization, the recommendation of rehabilitation and the use of magnetic resonance as a diagnostic test for meniscus damage. Surgical expertise was significantly associated with the performance of meniscus suture procedures (p = 0.009). Experts recommended starting rehabilitation on the day of surgery (p = 0.007) and were more likely to use objective physical tests (p = 0.003). Non-expert surgeons recommended a longer period from meniscus suture to full-range knee motion (p = 0.001) and admitted that patient age does matter for meniscus repair qualification (p = 0.002). Conclusions There is consensus among almost all issues of meniscus tear treatment in the environment of Polish orthopaedists; however, the issues of rehabilitation and the use of advanced meniscus repair techniques are associated with surgical expertise.

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Physical Therapy on Postoperative Day Zero Following Total Knee Arthroplasty: A Randomized, Controlled Trial of 394 Patients

Cited by 21 publications

References 16 publications

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

Clinical practice and postoperative rehabilitation after knee arthroscopy vary according to surgeons’ expertise: a survey among polish arthroscopy society members

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