Physical Functioning and Prediction of Physical Activity After Total Hip Arthroplasty: Five-Year Followup of a Randomized Controlled Trial

Incorporating Functional Strength Integration Techniques During Total Hip Arthroplasty Rehabilitation: A Randomized Controlled Trial

OBJECTIVE

Total hip arthroplasty (THA) is a common orthopedic procedure that alleviates pain for millions of individuals. Yet, persistent physical function deficits, perhaps associated with movement compensations, are observed after THA. These deficits negatively affect quality of life and health for many individuals. Functional strength integration (FSI) techniques combine muscle strength training with specific movement retraining to improve physical function. This study aimed to determine if FSI would improve functional performance through remediation of movement compensations for individuals after THA.

METHODS

A double-blind randomized controlled trial was conducted. Ninety-five participants were randomized to either the FSI or control (CON) group for an 8-week intervention. The FSI protocol included exercise to improve muscular control and stability around the hip to minimize movement compensation during daily activity. The CON protocol included low-load resistance exercise, range-of-motion activities, and patient education. Functional performance, muscle strength, and self-reported outcomes were measured preoperatively, midway and after intervention, and 6 months after THA. Change from preoperative assessment to each time point was measured, and between-group differences were assessed.

RESULTS

There were minimal differences in outcomes between groups at the first postoperative assessment. There were no statistically significant between-group differences in the later assessments, including the primary endpoint. Both groups improved functional outcomes throughout the study period.

CONCLUSION

The FSI intervention did not result in greater improvements in function after THA compared to the CON intervention. Future work should further investigate additional biomechanical outcomes, timing of the FSI protocol, effective dosing, and patient characteristics predictive of success with FSI.

IMPACT

Recovery after THA is complex, and individuals after THA are affected by persistent movement deficits that affect morbidity and quality of life. The present study suggests that either approach to THA rehabilitation could improve outcomes for patients, and that structured rehabilitation programs may benefit individuals after THA.

Short versus conventional straight stem in uncemented total hip arthroplasty: functional outcomes up to 5 years and survival up to 12 years: secondary results of a randomized controlled trial

BACKGROUND AND PURPOSE

To date, the mid- and long-term outcomes of the Collum Femoris Preserving (CFP) stem compared with conventional straight stems are unknown. We aimed to compare physical function at a 5-year follow-up and implant survival at an average of 10-year follow-up in an randomized controlled trial (RCT).

METHODS

This is a secondary report of a double-blinded RCT in 2 hospitals. Patients aged 18-70 years with hip osteoarthritis undergoing an uncemented primary THA were randomized to a CFP or a Zweymüller stem. Patient-reported outcomes, clinical tests, and radiographs were collected at baseline, 2, 3, 4, and 5 years postoperatively. Primary outcome was the Hip disability and Osteoarthritis Outcome Score (HOOS) function in activities of daily living (ADL) subscale. Secondary outcomes were other patient-reported outcomes, clinical tests, adverse events, and implant survival. Kaplan-Meier and competing risk survival analyses were performed with data from the Dutch Arthroplasty Registry.

RESULTS

We included 150 patients. Mean difference between groups on the HOOS ADL subscale at 5 years was -0.07 (95% confidence interval -5.1 to 4.9). Overall survival was 92% for the CFP and 96% for the Zweymüller stem. No significant difference was found.

CONCLUSION

No significant differences were found in physical function at 5-year and implant survival at 10-year follow-up between the CFP and Zweymüller stems. When taking cup revisions into account, the CFP group showed clinically inferior survival.

Effectiveness of the perioperative encounter in promoting regular exercise and physical activity: a systematic review and meta-analysis

BACKGROUND

Low levels of physical activity (PA) are associated with poorer health outcomes. The perioperative encounter (extending from initial contact in primary care to beyond discharge from hospital) is potentially a good time to intervene, but data regarding the effectiveness of interventions are scarce. To address this, we systematically reviewed existing literature to evaluate the effectiveness of interventions applied perioperatively to facilitate PA in the medium to long-term (at least six months after the intervention).

METHODS

In this systematic review and meta-analysis, we searched Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, CINAHL, Embase, PsycInfo, and SPORTDiscus from database inception to October 22nd 2020, with an updated search done on August 4th 2022. We searched clinical trials registers, and conducted forward- and backward-citation searches. We included randomised controlled trials and quasi-randomised trials comparing PA interventions with usual care, or another PA intervention, in adults who were scheduled for, or had recently undergone, surgery. We included trials which reported our primary outcomes: amount of PA or whether participants were engaged in PA at least six months after the intervention. A random effects meta-analysis was used to pool data across studies as risk ratios (RR), or standardised mean differences (SMDs), which we interpreted using Cohen. We used the Cochrane risk of bias tool and used GRADE to assess the certainty of the evidence. This study is registered with PROSPERO, CRD42019139008.

FINDINGS

We found 57 trials including 8548 adults and compared 71 interventions facilitating PA. Most interventions were started postoperatively and included multiple components. Compared with usual care, interventions may slightly increase the number of minutes of PA per day or week (SMD 0.17, 95% CI 0.09-0.26; 14 studies, 2172 participants; I² = 0%), and people's engagement in PA at the study's end (RR 1.19, 95% CI 0.96-1.47; 9 studies, 882 participants; I² = 25%); this was moderate-certainty evidence. Some studies compared two different types of interventions but it was often not feasible to combine data in analysis. The effect estimates generally indicated little difference between intervention designs and we judged all the evidence for these comparisons to be very low certainty. Thirty-six studies (63%) had low risk of selection bias for sequence generation, 27 studies (47%) had low risk of bias for allocation concealment, and 56 studies (98%) had a high risk of performance bias. For detection bias for PA outcomes, we judged 30 studies (53%) that used subjective measurement tools to have a high risk of detection bias.

INTERPRETATION

Interventions delivered in the perioperative setting, aimed at enhancing PA in the medium to long-term, may have overall benefit. However, because of imprecision in some of the findings, we could not rule out the possibility of no change in PA.

FUNDING

National Institute for Health Research Health Services and Delivery Research programme (NIHR127879).

Rehabilitation for Total Hip Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefits and harms of rehabilitation interventions for patients who have undergone elective, unilateral THA surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. Large heterogeneity across evaluated rehabilitation programs limited conclusions. Evidence from 15 studies suggests that diverse rehabilitation programs may not differ in terms of risk of harm or outcomes of pain, strength, activities of daily living, or quality of life (all low strength of evidence). Evidence is insufficient for other outcomes. In conclusion, no differences in outcomes were found between different rehabilitation programs after THA. Further evidence is needed to inform decisions on what attributes of rehabilitation programs are most effective for various outcomes.

Can Patient-Reported Outcome Measurement Information System Measures Differentiate Patients Who Will Undergo Hip and Knee Total Joint Arthroplasty: A Retrospective Case-Control Study

BACKGROUND

The Patient-Reported Outcome Measurement Information System (PROMIS) can be used to monitor patients in population-health-based programs. However, it is unknown which measures are most appropriate to differentiate patients who will undergo hip or knee total joint arthroplasty (TJA) in a cohort of patients with osteoarthritis.

METHODS

A retrospective cohort of new patients consulting for treatment from November 17, 2017 to April 20, 2020 (cases: hip: n = 157, knee: n = 112; randomly selected nonsurgical controls: hip: n = 314, knee: n = 224) was extracted from the electronic health record. We recorded demographics, comorbidity, and PROMIS scores for 8 domains (physical function, pain interference, pain intensity, anxiety, depression, sleep disturbance, ability to participate in social roles and activities, and fatigue). We performed descriptive statistics to characterize the cohorts and baseline PROMIS scores and conducted logistic regression models to determine which PROMIS domains differentiated patients undergoing hip and knee TJA.

RESULTS

In univariate comparisons of PROMIS domains, the hip and knee surgical cohorts differed from controls in physical function (P < .01), pain interference (P < .01), and ability to participate in social roles and activities (P < .02). In logistic regression models informed by univariate analyses, PROMIS physical function was the only PROMIS measure to differentiate undergoing surgery in both hip and knee cohorts (P < .01).

CONCLUSION

PROMIS physical function can differentiate TJA cases from nonsurgical controls in both hip and knee patients. These findings have implications for considering which PROMIS measures to administer in patients with hip and knee osteoarthritis.

Development of a clinical prediction rule to identify physical activity after total hip arthroplasty

OBJECTIVE

To develop clinical prediction rule (CPR) of physical activity at 1-year after total hip arthroplasty (THA).

DESIGN

Retrospective cohort study.

SETTING

University hospital with orthopedic surgery.

PARTICIPANTS

The study group included 321 patients (56 men) who underwent primary THA.

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

The data collected included age, body mass index, clinical score from the questionnaires, hip pain, range of motion, muscle strength, and Physical functions (10-Meter Walk Test, Timed Up and Go test and Sit-to-stand). Patients were classified into sufficient and insufficient activity groups based on their University of California, Los Angeles (UCLA) activity score 1 year after THA. Variables measured preoperatively and at 3 weeks postoperatively were analyzed using univariate and multivariate methods to derive CPR for physical activity.

RESULTS

A CPR was developed using the following five factors and cut-offs: age, ≤70.5 years; preoperative UCLA activity score, ≥3.5; preoperative hip abduction strength, ≥0.54 Nm/kg; preoperative knee extension strength, ≥1.04 Nm/kg; and 10-Meter Walk Test, ≤8.49 s at 3 weeks after surgery. The presence of four of the five factors predicted a sufficient physical activity level at 1-year, with a positive likelihood ratio of 5.94 and probability of 85.4%. The presence of five predictor variables increased the probability of sufficient physical activity after THA to 94.7%.

CONCLUSION

This study developed a CPR for physical activity at 1-year after THA. Having four or more of the five measurements were useful indicators for predicting of physical activity at 1 year postoperatively.

Being active with a total hip or knee prosthesis: a systematic review into physical activity and sports recommendations and interventions to improve physical activity behavior

Objectives

Regular physical activity (PA) is considered important after total hip and knee arthroplasty (THA/TKA). Objective was to systematically assess literature on recommendations given by healthcare professionals to persons after THA and TKA and to provide an overview of existing interventions to stimulate PA and sports participation.

Methods

A systematic review with a narrative synthesis including articles published between January 1995 and January 2021 reporting on recommendations and interventions. The PubMed, Embase, CINAHL and PsycInfo databases were systematically searched for original articles reporting on physical activity and sports recommendations given by healthcare professionals to persons after THA and TKA, and articles reporting on interventions/programs to stimulate a physically active lifestyle after rehabilitation or explicitly defined as part of the rehabilitation. Methodological quality was assessed with the Mixed Methods Appraisal Tool (MMAT). The review was registered in Prospero (PROSPERO:CRD42020178556).

Results

Twenty-one articles reported on recommendations. Low-impact activities were allowed. Contact sports, most ball sports, and martial arts were not recommended. One study informed on whether health-enhancing PA recommendations were used to stimulate persons to become physically active. No studies included recommendations on sedentary behavior. Eleven studies reported on interventions. Interventions used guidance from a coach/physiotherapist; feedback on PA behavior from technology; and face-to-face, education, goal-setting, financial incentives and coaching/financial incentives combined, of which feedback and education seem to be most effective. For methodological quality, 18 out of 21 (86%) articles about recommendations and 7 out of 11 (64%) articles about interventions scored yes on more than half of the MMAT questions (0–5 score).

Conclusion

There is general agreement on what kind of sports activities can be recommended by healthcare professionals like orthopedic surgeons and physiotherapists. No attention is given to amount of PA. The same is true for limiting sedentary behavior. The number of interventions is limited and diverse, so no conclusions can be drawn. Interventions including provision of feedback about PA, seem to be effective and feasible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11556-022-00285-1.

Amount and type of physical activity and sports from one year forward after hip or knee arthroplasty-A systematic review

INTRODUCTION

After rehabilitation following total hip or knee arthroplasty (THA/TKA), patients are advised to participate in physical activity (PA) and sports. However, profound insight into whether people adopt a physically active lifestyle is lacking. Aim is to gain insight into the performed amount and type of PA (including sports) and time spent sedentarily by persons after THA/TKA.

METHODS

A systematic review (PROSPERO: CRD42020178556). Pubmed, Cinahl, EMBASE and PsycInfo were systematically searched for articles reporting on amount of PA, and on the kind of activities performed between January 1995-January 2021. Quality of the articles was assessed with the adapted tool from Borghouts et al.

RESULTS

The search retrieved 5029 articles, leading to inclusion of 125 articles reporting data of 123 groups; 53 articles reported on subjects post-THA, 16 on post-hip-resurfacing arthroplasty, 40 on post-TKA, 15 on post-unicompartimental knee arthroplasty and 12 on a mix of arthroplasty types. With respect to quality assessment, 14 articles (11%) met three or fewer criteria, 29 (24%) met four, 32 (26%) met five, 42 (34%) met six, and 6 (5%) met seven out of the eight criteria. PA levels were comparable for THA and TKA, showing a low to moderately active population. Time spent was mostly of low intensity. Roughly 50% of -subjects met health-enhancing PA guidelines. They spent the largest part of their day sedentarily. Sports participation was relatively high (rates above 70%). Most participation was in low-impact sports at a recreational level. Roughly speaking, participants were engaged in sports 3 hours/week, consisting of about three 1-hour sessions.

CONCLUSION

Activity levels seem to be low; less than half of them seemed to perform the advised amount of PA following health-enhancing guidelines Sports participation levels were high. However, many articles were unclear about the definition of sports participation, which could have led to overestimation.

The Symmetry and Predictive Factors in Two-Stage Bilateral Hip Replacement Procedures

Background: Approximately 10–25% of total hip replacement patients undergo a bilateral procedure. The purpose of this study was to compare selected parameters associated with the first and second hip arthroplasty in patients undergoing two-stage treatment due to bilateral hip osteoarthritis and establish the predictive factors for the second procedure. Methods: This study compared the data on bilateral total hip replacement surgeries conducted in the period between 2017 and 2021 (42 patients). The following parameters from the first and second procedure were compared: the prosthetic stem, head, and insert cup size; type of cup insert; duration of anesthesia; duration of hospitalization; and the number of complications. Results: The mean duration of hospital stay at the time of the first total hip arthroplasty was 5.83 days and 5.4 days during the second stay. The mean stem sizes used during the first and second total hip replacement procedures were 7.11 and 7.09, respectively. The mean sizes of endoprosthetic cups used at the first and second total hip replacement procedures were 52.64 and 53.04, respectively. There were no significant differences between the mean prosthetic head size at the first and second surgery. The cup type used during the first and second surgery showed no difference. The mean duration of anesthesia used during the first and second total hip replacement surgery was 108.09 min and 104.52 min, respectively. We recorded a mean of 0.07 complications per patient at the first surgery and 0.02 at the second surgery. Conclusions: Our study results showed symmetry duration of anesthesia, length of hospital stay, number of complications per patient, stem size, prosthetic head size, cup insert size, and cup insert type at the first and second surgery in patients with two-stage bilateral total hip arthroplasty. We observed a strong correlation between the stem sizes of the first and second hip endoprostheses. There was also a strong correlation between the cup sizes used during the first and second surgery.

Physical activity patterns, adherence to using a wearable activity tracker during a 12-week period and correlation between self-reported function and physical activity in working age individuals with hip and/or knee osteoarthritis

Background

A majority of individuals with osteoarthritis (OA) are insufficiently physically active. Self-monitoring with wearable activity trackers (WAT) could promote physical activity (PA), and increased knowledge of PA patterns and adherence to using a WAT is needed. The aim of this study was to describe PA patterns and adherence to WAT-use during an intervention among participants of working age with hip and/or knee OA. The study further explores the correlation between self-reported joint function and PA.

Methods

Individuals of working age with hip and/or knee OA who used a WAT, Fitbit Flex 2, for 12 weeks were included. Participants monitored their PA in the Fitbit-app. An activity goal of 7,000 steps/day was set. Steps and minutes in light (L), moderate and vigorous (MV) PA were collected from the Fitbit. Self-reported joint function (HOOS/KOOS) was completed. Data was analyzed with linear mixed models and Spearman’s rank correlation.

Results

Seventy-five participants (45–66 years) walked on average 10 593 (SD 3431) steps/day, spent 248.5 (SD 42.2) minutes in LPA/day, 48.1 (SD 35.5) minutes in MVPA/day, 336.0 (SD 249.9) minutes in MVPA/week and used the Fitbit for an average of 88.4 % (SD 11.6) of the 12-week period. 86.7 % took > 7,000 steps/day and 77.3 % spent > 150 min in MVPA/week. Mean daily steps/week decreased significantly over the 12 weeks (β-coefficient − 117, 95 % CI -166 to -68, p = < 0.001) as well as mean daily minutes in LPA/week (β-coefficient − 2.3, 95 % CI -3.3 to -1.4, p = < 0.001), mean daily minutes in MVPA/week (β-coefficient − 0.58, 95 % CI -1.01 to -0.16, p = 0.008) and mean adherence to Fitbit-use per week (β-coefficient − 1.3, 95 % CI -1.8 to -0.8, p = < 0.001). There were no significant correlations between function (HOOS/KOOS) and PA.

Conclusions

The majority of participants reached 7,000 steps/day and the recommended 150 min in MVPA per week. However, PA decreased slightly but gradually over time. Adherence to using the Fitbit was high but also decreased during the intervention. Understanding PA patterns and the use of a Fitbit to promote PA could be beneficial in tailoring interventions for individuals with hip and/or knee OA.

Activity Recommendations After Total Hip and Total Knee Arthroplasty

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A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).

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In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.

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For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.

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Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.

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No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.

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Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.

Incidence and Associated Risk Factors for Falls in Older Adults Postdischarge Who Undergo Elective Total Hip Replacement Surgery—A Prospective Cohort Study

Background

Hip replacement surgery improves health-related quality of life; however, it has been suggested that falls rates increase after hospital discharge. The aim of the study was to determine the incidence and associated risk factors for falls in older adults in the 12 months after undergoing elective total hip replacement surgery.

Methods

A prospective observational cohort study was conducted. Participants were adults aged 60 years or older who underwent primary elective total hip replacement surgery in a private tertiary hospital in Perth, Australia. Baseline data collected immediately prior to discharge included use of walking aids, medications, and functional level of independence (using Katz and Lawton scales). Falls data were collected for 12 months using calendars and monthly phone calls. Data were analyzed using logistic and negative binomial regression modeling.

Results

Participants’ ([n = 167], 54.4% female) mean age was 71.2 (±6.9) years. There were 51 (31%) participants who used a walking aid prior to surgery. There were 140 falls reported over 12 months by 67 (42%) participants, of which 90 (64.3%) were injurious (n = 9 fractures). The fall rate was 2.6 per 1000 patient-days. Age (adjusted odds ratio 1.10, 95% confidence interval 1.01–1.20) and hospital length of stay (adjusted odds ratio 1.24, 95% confidence interval 1.00–1.54).were significantly associated with sustaining multiple falls.

Conclusions

More than 40% of older adults fell in the 12 months after elective hip replacement surgery although the cohort had low fall risk prior to surgery. Rehabilitation after hip replacement surgery should consider fall prevention.

The role of health literacy in orthopaedic rehabilitation after total knee and hip arthroplasty: A scoping review

BACKGROUND

Health literacy (HL) is a key aspect in empowering patient education as part of orthopaedic rehabilitation after total knee or hip arthroplasty (TKA/THA).

OBJECTIVES

This scoping review aims to demonstrate the prevalence of patient-related outcome measures in studies on the effectiveness of orthopaedic rehabilitation of older people after TKA/THA. The review also focuses on the identification of outcome measures that assess patients' HL or HL-related aspects.

METHODS

A scoping literature search was conducted using the JBI methodology for scoping reviews. The databases MEDLINE (PubMed), CINAHL Complete, The Cochrane Library, Academic Search Elite, and ERIC were searched with keywords and phrases to find relevant literature. Identified outcome measures were conceptually analysed in a peer reviewed procedure. Those with suspected HL-related content were analysed at item level. Text analyses were performed using MAXQDA.

RESULTS

117 papers were included in this review. 45 patient-related outcome measures could be found, 2 of which assess HL-related aspects. No paper could be found that assessed patients' HL in orthopaedic rehabilitation after TKA/THA.

CONCLUSIONS

HL has hitherto been of limited importance in orthopaedic rehabilitation. Health professionals are responsible for assessing patients' health literacy and developing appropriate strategies for patient education in the context of orthopaedic rehabilitation.

Relationship between vertical ground reaction force and muscle strength while climbing stairs after total hip arthroplasty

BACKGROUND

Little is known about the relationship between vertical ground reaction force (vGRF) and muscle strength while climbing stairs after total hip arthroplasty (THA).

METHODS

We investigated the relationship between muscle strength and vGRF during stair climbing in 21 women with THA. Differences in the time required to climb stairs and side-to-side differences in muscle strength and vGRF during climbing were examined at 6 and 12 months. The relationship between climbing time and vGRF variables and that between vGRF and muscle strength were analyzed using Spearman's rank correlation coefficient at 6 and 12 months. First peak force (Fz1) was defined as the peak vGRF at heel strike normalized by body weight.

FINDINGS

Climbing time was related to the time to Fz1 at 6 and 12 months post-THA (r = 0.50-0.64). At 6 months, time to Fz1 was related to the strength of muscles involved in hip extension in the operated limb (r = -0.46). At 12 months, time to Fz1 was related to the strength of muscles responsible for knee extension in the operated limb (r = -0.45).

INTERPRETATION

At 6 months, climbing stairs depended on muscle strength in the hip extensors. Conversely, at 12 months, the functional recovery of knee extensors was important for transferring weight upward while climbing stairs. Therefore, to improve the climbing function of patients with THA, it is important to not only focus on the recovery of muscle strength in the hip extensors but also improve muscle strength in the knee extensors.

The Role of Physical Activity and Rehabilitation Following Hip and Knee Arthroplasty in the Elderly

Hip and knee replacement is an effective treatment for symptomatic, end-stage hip and knee osteoarthritis, aiming to relieve pain and restore joint function. Several postoperative rehabilitation protocols and physical activities are proposed in routine clinical practice. However, their effect on clinical outcome and implant revision in patients undergoing joint replacement is still unclear. A systematic review of the literature was performed through a comprehensive search on online databases including Pubmed-Medline, Cochrane central, and Google scholar. We included all the available studies on postoperative physical activity and rehabilitation protocols after total knee and total hip arthroplasty in patients older than 65 years. The primary endpoint was to evaluate the effect of physical activity and rehabilitation on clinical outcome; the secondary outcome was to determine the effect on patients' quality of life (QoL) and implant survival. Although the heterogeneity of the rehabilitation protocols and outcome measures did not allow to draw definitive conclusions, most studies suggested that aquatic therapy, ergometer cycling, and fast-track protocols have a beneficial effect on muscle strength, gait speed, and main clinical scores after total hip arthroplasty. Similarly, enhanced rehabilitation protocols produced an improvement in primary and secondary outcomes after total knee arthroplasty.

The Hierarchical Assessment of Balance and Mobility (HABAM): a useful tool to estimate length of hospital stay following hip and knee replacement

Background/Aims

The Hierarchical Assessment of Balance and Mobility is a measure of balance and mobility that can detect recovery of physical function, and can be used to identify patients at risk of delayed discharge. The aim of this study was to investigate the use of Hierarchical Assessment of Balance and Mobility scores as a predictor of length of hospital stay in patients following hip and knee replacement.

Methods

Hierarchical Assessment of Balance and Mobility scores were collected on 191 patients following primary total joint replacement. Regression and receiver operating characteristic curve analyses were conducted to assess the relationship between Hierarchical Assessment of Balance and Mobility and length of stay.

Results

Hierarchical Assessment of Balance and Mobility scores of <31 on the first post-operative day predicted longer than mean length of stay (4 days) with sensitivity and specificity of 79% and 83%. Receiver operating characteristic curve analyses showed that a Hierarchical Assessment of Balance and Mobility score of 50 was the optimal cut-off point for discharge.

Conclusions

Hierarchical Assessment of Balance and Mobility offers a practical way to quantify and objectively track patients' physical function, and can help identify patients at risk of an increased length of stay on post-operative day one.

Incorporating Specific Functional Strength Integration Techniques to Improve Functional Performance for Veterans After Total Hip Arthroplasty: Protocol for a Randomized Clinical Trial

BACKGROUND

Total hip arthroplasty (THA) is a common procedure, yet persistent deficits in functional performance exist after surgery. These deficits may be related to movement compensations observed after THA, which negatively affect quality of life and may increase morbidity and health care utilization, including in the veteran population. However, the best rehabilitative approach to remediating movement compensations and physical function deficits has not been determined.

OBJECTIVE

The objective is to determine if a functional strength integration intervention (FSI), as part of a post-THA rehabilitation program, improves movement compensation, physical function, muscle strength, and self-reported outcome measures more than a control group (CON) undergoing a standard of care exercise program.

DESIGN

This is a 2-arm randomized, controlled clinical trial.

SETTING

The Veteran Affairs outpatient physical therapy clinics and academic research laboratory will be the settings.

PARTICIPANTS

One hundred veterans undergoing THA for hip osteoarthritis will be included in the study.

INTERVENTIONS

Participants will be randomized to either the FSI or CON group and participate in visits of physical therapy over 8 weeks. The FSI protocol will include targeted exercise to improve muscular control and stability around the hip and trunk to minimize movement compensation during daily activity combined with progressive resistance exercise. The CON protocol will include patient education, flexibility activity, and low load resistance exercise.

MEASUREMENTS

Functional performance, muscle strength and endurance, and self-reported outcomes will be measured at baseline (prior to surgery), midway through intervention (6 weeks after surgery), at the end of intervention (10 weeks after surgery), and 26 weeks after THA.

LIMITATIONS

The inability to blind treating therapists to study arm allocation is a limitation.

CONCLUSIONS

The proposed study aims to determine if targeted FSI can affect movement compensation to improve functional outcomes after THA more than traditional rehabilitation paradigms.

The therapeutic validity and effectiveness of physiotherapeutic exercise following total hip arthroplasty for osteoarthritis: A systematic review

Objective

To assess the therapeutic validity and effectiveness of physiotherapeutic exercise interventions following total hip arthroplasty (THA) for osteoarthritis.

Data sources

The databases Embase, MEDLINE, Cochrane Library, CINAHL and AMED were searched from inception up to February 2017.

Eligibility criteria

Articles reporting results of randomized controlled trials in which physiotherapeutic exercise was compared with usual care or with a different type of physiotherapeutic exercise were included, with the applied interventions starting within six months after THA. Only articles written in English, German or Dutch were included.

Study appraisal

Therapeutic validity (using the CONTENT scale) and risk of bias (using both the PEDro scale and the Cochrane Collaboration’s tool) were assessed by two researchers independently. Characteristics of the physiotherapeutic exercise interventions and results about joint and muscle function, functional performance and self-reported outcomes were extracted.

Results

Of the 1124 unique records retrieved, twenty articles were included. Only one article was considered to be of high therapeutic validity. Description and adequacy of patient selection were the least reported items. The majority of the articles was considered as having potentially high risk of bias, according to both assessment tools. The level of therapeutic validity did not correspond with the risk of bias scores. Because of the wide variety in characteristics of the physiotherapeutic exercise and control interventions, follow-up length and outcome measures, limited evidence was found on the effectiveness of physiotherapeutic exercise following THA.

Conclusion

The insufficient therapeutic validity and potentially high risk of bias in studies involving physiotherapeutic exercise interventions limit the ability to assess the effectiveness of these interventions following THA. Researchers are advised to take both quality scores into account when developing and reporting studies involving physiotherapeutic exercise. Uniformity in intervention characteristics and outcome measures is necessary to enhance the comparability of clinical outcomes between trials.

Sports Participation in Patients After Total Hip Arthroplasty vs Periacetabular Osteotomy: A Propensity Score-Matched Asian Cohort Study

BACKGROUND

No studies have compared sports participation between total hip arthroplasty (THA) and periacetabular osteotomy (PAO) in matched Asian cohorts. We investigated sports participation and activity levels in Asian THA cohort, and compared them between THA and PAO cohorts.

METHODS

Multivariate analyses were applied to determine which factors were associated with postoperative sports participation and University of California-Los Angeles (UCLA) activity score in (1) 524 THA patients and (2) 487 acetabular dysplasia patients (295 THA patients and 192 PAO patients). In addition, postoperative sports participation and UCLA score were compared between 62 THA and 62 PAO patients after adjusting for baseline characteristics with propensity score matching.

RESULTS

Sports participation and UCLA score significantly increased after THA (P < .001 in both analyses). Preoperative sports participation was the factor most associated with both postoperative sports participation and UCLA score in both 524 THA patients and 487 acetabular dysplasia patients (P < .001 in all analyses). Multivariate analysis in 487 acetabular dysplasia patients demonstrated that THA, compared with PAO, was negatively associated with postoperative sports participation (P < .001), but not postoperative UCLA score (P = .22). THA patients showed significantly lower rate of postoperative sports participation (32.3% and 51.6%, respectively, P = .046), but not postoperative UCLA score (5.0 ± 1.6 and 5.2 ± 1.9, respectively, P = .47) compared with matched PAO patients.

CONCLUSION

THA significantly increased both sports participation and activity levels. Both multivariate and propensity score-matched analyses showed that postoperative activity levels were comparable between THA and PAO cohorts.

Comparison of postarthroplasty functional outcomes in skilled nursing facilities among Medicare and Managed Care beneficiaries

Background

After home health care, the skilled nursing facility (SNF) is the most commonly used postacute care modality, among Medicare beneficiaries, after total joint arthroplasty. Prior studies demonstrated that a loss in postsurgical ambulatory gains is incurred in the interval between hospital discharge and arrival at the SNF. The aim of this present study is to determine the consequences of that loss in function, as well as compare SNF-related outcomes in patients with Medicare vs Managed Care (MC) insurance.

Methods

We conducted a retrospective analysis of 80 patients (54 Medicare and 26 MC) who attended an SNF after hospitalization for total joint arthroplasty. Outcomes from physical therapy records were abstracted from each patient's SNF file.

Results

There was an approximately 40% drop-off in gait achievements between hospital discharge and SNF admission. This decline in ambulation was significantly greater in Medicare patients (Medicare: 94.6 ± 123.2 ft, MC: 40.0 ± 48.9 ft, P = .034). Larger reductions in gait achievements between hospital discharge and SNF admission were significantly correlated with longer SNF lengths of stay and poorer gait achievements by SNF discharge. Patients with MC insurance made significant improvements in gait training at the SNF beyond that which was acquired at the hospital, whereas Medicare patients did not (P_Medicare = .28, P_MC = .003).

Conclusions

Large losses in motor function between hospital discharge and SNF admission were associated with poor functional outcomes and longer stays at the SNF. These effects were more pronounced in Medicare patients than those with MC insurance.

Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty

BACKGROUND

The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.

METHODS

We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.

RESULTS

LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.

CONCLUSION

Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.