Effect of Comprehensive Behavioral and Exercise Intervention on Physical Function and Activity Participation After Total Knee Replacement: A Pilot Randomized Study

Training of Peer Coaches to Assist Individuals with Knee Osteoarthritis Prepare and Recover From Total Knee Replacement

OBJECTIVE

The objective of this study is to outline the training of peer coaches in the Moving Well intervention, which was designed to reduce anxiety, depression, and pain catastrophizing in patients before and after total knee replacement (TKR).

METHODS

Selected peer coaches had a history of knee osteoarthritis (KOA), a TKR of 12 months or more before training, and were 60 or older. Training was primarily conducted virtually, with a later addition of one in-person session. Training centered on developing skills in motivational interviewing (MoI), encompassing techniques like open-ended questions, affirmations, reflective listening, and summarization. It also covered the MoI processes of engagement, focus, evocation, and planning. Coaches were required to discuss at least 90% of session-specific topics, which were monitored using checklists for each certification, and to complete individual MoI training, which was not graded. The evaluation of peer coach training involved surveys and a focus group.

RESULTS

Three women and two men, averaging 75 years in age, completed the peer coach training for the Moving Well intervention. An in-person training session was added to address technology and MoI skill concerns, greatly enhancing their grasp of MoI skills and their ability to guide others through the program effectively. Peer coaches stressed the importance of live feedback, in-person training, and incorporating personal experiences into the program content during their training.

CONCLUSION

To effectively train older adults as peer coaches for the Moving Well intervention, flexibility in learning formats, personalized guidance, peer support, and regular evaluations were essential in building the necessary MoI competencies to guide research participants in the program.

A Systematic Review of the Effectiveness of Rehabilitation Programmes or Strategies to Treat People With Persistent Knee Pain Following a Total Knee Replacement

BACKGROUND

Persistent high levels of knee pain after a total knee replacement have been estimated to affect 5%-10% of people and this is related to dissatisfaction with surgery, reduced function and reduced quality of life. This systematic review aims to evaluate the effectiveness of rehabilitation programs or strategies to reduce persistent pain and improve function and quality of life in people following a total knee replacement.

METHODS

The systematic review was conducted following PRISMA guidelines with a search of relevant online databases up to 17 July 2024. The search criteria included English language randomised controlled trials of rehabilitation programs or strategies in any setting to treat people with persistent knee pain more than 3 months after a total knee replacement. Rehabilitation could include exercise, education, cognitive strategies and self-management programs and excluded medication trials, procedural techniques and complementary therapies.

RESULTS

After removal of duplicates, there were 468 abstracts screened for eligibility with 23 remaining for full-text screening and finally, one study meeting the eligibility criteria. This study's interventions were pain neuroscience education alone and pain neuroscience education plus neuromuscular exercise. There were no statistically significant between-group differences for pain reduction or functional improvement.

CONCLUSION

The evidence examining the value of rehabilitation programs or strategies for pain reduction and functional improvement in people with persistent pain following total knee replacement is deficient. Given the high number of people affected annually, further research concerning both prevention and management of persistent pain after knee replacement is warranted.

Resistance exercise training to improve post-operative rehabilitation in knee arthroplasty patients: A narrative review

Knee osteoarthritis is associated with deficits in muscle strength, muscle mass, and physical functioning. These muscle-related deficits are acutely exacerbated following total knee arthroplasty (TKA) and persist long after surgery, despite the application of standardized rehabilitation programs that include physical/functional training. Resistance exercise training (RET) has been shown to be a highly effective strategy to improve muscle-related outcomes in healthy as well as clinical populations. However, the use of RET in traditional rehabilitation programs after TKA is limited. In this narrative review, we provide an updated view on whether adding RET to the standard rehabilitation (SR) in the recovery period (up to 1 year) after TKA leads to greater improvements in muscle-related outcomes when compared to SR alone. Overall, research findings clearly indicate that both muscle strength and muscle mass can be improved to a greater extent with RET-based rehabilitation compared to SR. Additionally, measures of physical functioning that rely on quadriceps strength and balance (e.g., stair climbing, chair standing, etc.) also appear to benefit more from a RET-based program compared to SR, especially in patients with low levels of physical functioning. Importantly though, for RET to be optimally effective, it should be performed at 70%-80% of the one-repetition maximum, with 3-4 sets per exercise, with a minimum of 3 times per week for 8 weeks. Based upon this narrative review, we recommend that such high-intensity progressive RET should be incorporated into standard programs during rehabilitation after TKA.

Promoting physical activity via physical therapist following knee replacement: A pilot randomized controlled trial

BACKGROUND

Outpatient physical therapy may be an opportune time to promote aerobic physical activity after knee replacement; however, it is unknown if it is feasible to integrate a physical activity intervention within standard physical therapy.

OBJECTIVE

To examine the feasibility and acceptability of a physical activity intervention delivered within outpatient physical therapy for adults after knee replacement.

METHODS

As part of a cluster randomized trial, adults with knee replacement starting outpatient physical therapy were recruited across four physical therapy sites. Sites were randomized and physical therapists delivered either an enhanced physical activity intervention or a control condition. The enhanced physical activity intervention consisted of standard postoperative physical therapy plus goal setting, problem-solving, and use of motivational interviewing techniques to promote 150 minutes/week of aerobic moderate intensity physical activity. The control group received standard postoperative physical therapy only. Feasibility and acceptability were determined based on recruitment and retention rates at 12 weeks after surgery. Outcomes including objectively measured physical activity, pain, and self-reported function were examined at the baseline postoperative visit and 12 weeks later.

RESULTS

Thirty-three percent of candidates screened were randomized (n = 45) and retention at 12 weeks after surgery was 91% (no difference by condition). Moderate-intensity activity increased, pain decreased, and self-reported function improved, but there were no statistically significant group differences between baseline and 12 weeks.

CONCLUSION

Implementing a physical activity intervention within outpatient physical therapy for adults after knee replacement is feasible; however, in this pilot study, changes were not observed in moderate intensity physical activity as compared to standard postoperative physical therapy. Future studies are needed to explore additional low-cost strategies and the optimal time to promote physical activity after knee replacement.

Effects of strength training on functional ambulation following knee replacement: a systematic review, meta-analysis, and meta-regression

Strength training is recommended by the American Physical Therapy Association to improve muscle strength, mobility, and balance following knee replacement. Few studies have focused on the direct effects of strength training on functional ambulation, and potential dose-response relationships between strength training parameters and the effect remain unclear. The aim of this systematic review, meta-analysis, and meta-regression was to evaluate the effects of strength training on functional ambulation following knee replacement (KR). We also aimed to explore potential dose-response relationships between strength training parameters and performance in functional ambulation. A systematic literature search of eight online databases was performed on March 12, 2023, for randomized controlled trials evaluating the effects of strength training on functional ambulation by six-minute walk test (6MWT) or timed-up and go test (TUG) after KR. Data were pooled by random-effect meta-analyses and presented as weighted mean difference (WMD). A random-effect meta-regression was performed for four predetermined training parameters, namely, duration (weeks), frequency (sessions per week), volume (time per session), and initial time (after surgery) separately to explore dose-response relationships with WMD. Fourteen trials encompassing 956 participants were included in our study. Meta-analyses showed an improvement in 6MWT performance after strength training (WMD: 32.15, 95% CI 19.44-44.85) and a decrease in time to complete TUG (WMD: - 1.92, 95% CI - 3.43 to - 0.41). Meta-regression revealed a dose-response relationship only between volume and 6MWT, with a decreasing trend (P = 0.019, 95% CI - 1.63 to - 0.20). Increasing trends of improvement in 6MWT and TUG were observed with increasing training duration and frequency. A slight decreasing trend of improvement was observed in 6MWT with postponed initial time, while an opposite trend was observed in TUG. Based on existing studies, moderate-certainty evidence suggests that strength training could increase 6MWT distance, and low-certainty evidence shows that strength training could decrease the time to complete TUG after KR. Meta-regression results only suggested a dose-response relationship between volume and 6MWT with a decreasing trend.Registration: PROSPERO: CRD42022329006.

Rehabilitation for Total Knee Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral total knee arthroplasty 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. The team assessed strength of evidence. Evidence from 53 studies randomized controlled trials suggests that various rehabilitation programs after total knee arthroplasty may lead to comparable improvements in pain, range of motion, and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the postacute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period after total knee arthroplasty; risk of harms among various postacute rehabilitation programs seems comparable. All findings were of low strength of evidence. Evaluation of rehabilitation after total knee arthroplasty needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

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.

Effect of Communication and Education within the Rehabilitation Team: Therapists' and Nurses' Views

Objective

To improve the rehabilitation team's awareness of patient mobility and participation by improving communication between therapists and nurses and conducting patient education.

Design

This study used a non-equivalent control group with a nonsynchronized design. To facilitate communication between therapists and nurses, we used a manual for mobility management to improve the sharing of information on the functional status of patients. We also implemented patient education to improve their awareness of mobility and participation. Finally, we conducted newly devised surveys related to patient functional status and awareness that were applied by therapists and nurses.

Results

The nurses reported significantly lower functional levels of patients compared to those assessed by therapists. After the intervention, the kappa values representing the concordance between therapists and nurses improved to almost perfect agreement for transfer ability (κ=0.836), mobility (κ=0.664), and toileting (κ=1.000). We also observed a statistically significant increase in questionnaire scores with respect to nurses' awareness (p < 0.05).

Conclusion

Improving communication among the rehabilitation team, including nurses through the use of a continuous education program, was effective in promoting the mobility and functional level of patients in the inpatient ward.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

OBJECTIVE

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

DESIGN

Scoping review LITERATURE SEARCH: A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

STUDY SELECTION CRITERIA

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

DATA SYNTHESIS

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

RESULTS

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88-99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

CONCLUSION

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

PRE-REGISTRATION

OSF: https://osf.io/9ku8a/.

Effect of acupuncture combined with early rehabilitation training on postoperative dysfunction and quality of life of patients undergoing total knee arthroplasty

OBJECTIVE

This research was designed to determine the effect of acupuncture combined with early rehabilitation training on dysfunction and quality of life of patients after total knee arthroplasty (TKA).

METHODS

Eighty-nine TKA patients admitted to our hospital from January 2018 to January 2020 were recruited as the research objects. Among them, 44 patients in the control group (CG) were given early rehabilitation training, and 45 in the research group (RG) were given acupuncture treatment additionally. Clinical efficacy, knee-joint visual analogue scale (VAS) score, American Knee Joint Society (AKSS) score, hemorheological indexes, modified Barthel index (BI) scale and SF-36 health survey of both groups were compared.

RESULTS

The effective rate of treatment in the RG was dramatically higher than that in the CG. After treatment, the whole blood high, middle and low-shear viscosities, plasma viscosity and erythrocyte aggregation exponent of patients decreased, while these indexes in the RG were remarkably lower than those in the CG. In addition, after treatment, VAS score and knee circumference in the RG were markedly lower than those in the CG, and AKSS score and knee range of motion (ROM) were markedly better. Follow-up showed that BI and SF-36 health survey scale scores of patients increased after treatment, especially in the RG.

CONCLUSION

Acupuncture combined with early rehabilitation training can relieve the pain of patients after TKA, promote the rehabilitation of knee joint function and improve their quality of life.

Reducing sedentary time using an innovative mHealth intervention among patients with total knee replacement: Rationale and study protocol

INTRODUCTION

Although knee replacement is effective for improving pain and physical function, subsequent improvements in physical activity typically do not follow. As a result, many patients spend most of their day engaged in sedentary behavior, which may put them at higher risk of experiencing poor function and disability. Intervening on sedentary time, rather than physical activity, may be a more feasible first-step approach for modifying activity-related behaviors in adults who received knee replacement.

OBJECTIVE

The purpose of this study is to examine the use of a mobile health (mHealth) intervention to reduce sedentary time among adults who received a knee replacement at 3 and 6 months after surgery.

METHODS

Patients (n = 92) scheduled for knee replacement will be recruited and at 4 weeks after surgery, they will be randomized to either NEAT!2 or Control. NEAT!2 participants will use the NEAT!2 smartphone app, which provides a vibration and/or audible tone to interrupt prolonged bouts of sitting detected from the smartphone's internal accelerometer, until 3 months after surgery. NEAT!2 participants will receive biweekly coaching calls between 4 and 12 weeks after surgery. Control participants will receive an education control app and receive non-intervention calls to assess general surgery recovery. Both groups will receive 3 retention calls between 3 and 6 months. Data collection will occur pre-operatively and at 3 and 6 months after surgery.

DISCUSSION

The results of this study will help to determine whether an innovative remotely-delivered, mHealth sedentary reduction intervention can decrease sedentary time in adults after knee replacement.

The influence of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty

Our aim was to assess the effect of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty (TKA). We searched studies on the effect of perioperative interventions focused on psychological distress used in conjunction with TKA on pain, function, and quality of life (QoL) on PubMed, Embase.com, PsycINFO/OVID, CENTRAL, the Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included 40 studies (22 RCTs, ten cohort studies, and eight quasi-experimental studies) with a total of 3846 patients. We graded the quality of evidence as low for pain and function and as moderate for QoL. Patients receiving music, education, cognitive behavioural therapy, guided imagery, pain coping skills training, Reiki, occupational therapy with self-monitoring, and biofeedback-assisted progressive muscles relaxing training had lower pain scores or declined opioid prescriptions after TKA. Pain coping skills training, audio recording-guided imagery scripts, video promoting self-confidence, psychological therapies by video, Reiki, music, occupational therapy with self-monitoring, education, and psychotherapy improved postoperative functional outcome. Education through an app improved QoL after TKA. The studies in our systematic review show that perioperative interventions targeting psychological distress for patients receiving TKA seem to have a positive effect on postoperative pain, function, and QoL. RCTs with strict methodological safeguards are still needed to determine if perioperative interventions focused on psychological distress should be used in conjunction with TKA. These studies should also assess which type of intervention will be most effective in improving patient-reported outcome measures and declining opioid prescriptions.

Isokinetic Strength Test of Muscle Strength and Motor Function in Total Knee Arthroplasty

Objective

To use isokinetic strength testing system to test and analyze the relationship between changes in muscle strength before and after knee replacement in patients undergoing total knee arthroplasty (TKA).

Methods

A total of 200 patients with advanced knee osteoarthritis treated from June 2018 to June 2019 were selected for TKA. The patient's isokinetic muscle strength test was performed in the first, third, and the sixth month before and after the operation. The knee hamstring peak torque (PT value), quadriceps peak torque (PT value), and total work were mainly measured. The knee joint was evaluated at the hospital for special surgery score, range of motion and other knee function standards, and then healthy limbs and normal people were tested with the same method. Statistical data was used to analyze and deal with the data, evaluate the muscle strength and motor function changes with time progressing, then compare the differences to the healthy limb. From P < 0.05, we can see that the differences have some statistical significance. The influences that TKA has on motor function changes of lower limbs were also observed.

Results

Among the 200 subjects, 162 completed all follow‐up tests, and the remaining 38 were lost to follow‐up for various reasons. The rate of loss of follow‐up was approximately 19%. The isokinetic muscle strength test system and the knee joint function scoring standard were used to record the knee joint muscle strength and function changes before and after knee joint replacement. Statistical analysis was performed to show the knee joint hamstring muscle force and quadriceps muscle strength and joint mobility in the first month after the surgery. The knee joint muscle strength and joint mobility were significantly improved after the third month after the surgery, but there were still some differences compared with normal people. The knee function index was significantly improved in the sixth month after operation (P < 0.05), and there were no significant differences compared with normal people.

Conclusions

Knee joint strength and knee function after TKA are significantly improved compared with preoperative function, which is of great significance for the treatment of knee osteoarthritis. The constant velocity muscle strength test system has the advantages of safety, accuracy, repeatability and easy operation. It is a good method to evaluate the knee joint's muscle strength and function after the knee joint replacement.

Intensive, personalized multimodal rehabilitation in patients with primary or revision total knee arthroplasty: a retrospective cohort study

Background

Recent evidence has shown that many patients suffer from persistent pain and impaired function after primary or revision total knee arthroplasty (TKA). Post-surgical complications may in addition decrease physical performances and lead to more pain and impacted quality of life.

The purpose of the study was to assess the changes in pain intensity and functional capacity among patients with post-surgical complications after TKA three weeks of intensive, personalized multimodal rehabilitation.

Methods

A retrospective cohort study consisting of 217 patient of which 166 had primary TKA and 51 had revision TKA was conducted. On average, primary TKA patients and revision TKA patients were 3.7 and 2.7 months post-surgical, respectively. All patients have had post-surgical complications and were referred to an inpatient rehabilitation department, where they received a personalized three-week intensive, multimodal rehabilitation protocol. The rehabilitation consisted of sessions targeting neuromuscular function, postural control, and flexibility, sessions focusing on improving muscle strength and cardiovascular function and sessions with focus on gait retraining. The frequency of training was 2–4 sessions/day. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS) and secondary outcomes were pain intensities measured using numerical rating scale, 6 min. walking test, stair-climbing test and range of motion for knee flexion and extension. Outcome measures were assessed at baseline upon referral and at follow-up before discharge.

Results

All outcomes, except pain at rest in the revision group, improved significantly. KOOS subscales, improved 8.5 to 14.2 in the primary TKA group (p < 0.001) and 6.9 to 10.8 in the revision group (p < 0.001). For the TKA group, effect sizes were medium-to-large for all KOOS subscales, 6 min. walking test, stair-climbing test, and pain intensity during activity. For the revision group, effect sizes were medium-to-large for KOOS subscales symptoms and activity of daily living, 6 min. walking test, stair-climbing test, and knee flexion.

Conclusion

Patients with post-surgical complications after primary or revision TKA experienced clinical relevant improvement in self-reported outcomes, pain relief, and improved physical performances after three weeks of personalized multimodal rehabilitation. The results suggest that an intensive, multimodal approach might be useful to obtain clinically relevant improvements.

Effectiveness of behavioural interventions on physical activity levels after hip or knee joint replacement: a systematic review

Purpose: To evaluate the effect of behavioural interventions on levels of physical activity after hip or knee joint replacement.Materials and methods: A systematic review with meta-analysis of randomised controlled trials to determine the effectiveness of behavioural interventions to increase physical activity levels after hip or knee joint replacement. Six databases were searched. Standardised mean differences (SMD) were calculated. The GRADE approach was used to evaluate the level of evidence of each meta-analysis.Results: From a yield of five trials, physical activity was quantified as active minutes per day, daily energy expenditure and daily steps. There was low to moderate-quality evidence from three meta-analyses with observed positive effects that could not conclude whether behavioural interventions increased physical activity in active minutes per day (SMD = 0.18, 95% CI -0.14, 0.51), daily energy expenditure (SMD = 0.31, 95% CI -0.24, 0.87) or daily steps (MD = 844.7, 95% CI -178.6, 1,868.0).Conclusions: The effectiveness of behavioural interventions to address the low levels of physical activity levels observed after hip or knee joint replacement remains uncertain.Implications for rehabilitationPhysical activity levels after hip or knee joint replacements fail to meet recommended daily activity guidelines, increasing the associated risk of cardiovascular disease and early mortality.Rehabilitation interventions that target behaviour change may have an impact in increasing physical activity levels after hip or knee joint replacement surgery.The optimal type and timing of behavioural interventions to effectively increase physical activity levels in this cohort remains unclear.Rehabilitation professionals are advised to highlight the benefits of meeting physical activity recommendations (150 min of moderate-intensity aerobic physical activity or 75 min of vigorous-intensity aerobic physical activity per week) to people who have undergone hip or knee joint replacement, and that behavioural intervention may support patients to meet these recommendations.

The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.

OBJECTIVES

This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.

METHODS

Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion.

PARTICIPANTS

Elderly individuals (65 + years) who underwent total knee arthroplasty.

INTERVENTIONS

Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

SYNTHESIS METHODS

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I². A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.

RESULTS

Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I² = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I² = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I² = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I² = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I² = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I² = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I² = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r² = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r² = 0.02; standardised β = 0.13; P = 0.48).

LIMITATIONS

A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.

CONCLUSION

Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

Comparison of a Patient-Centered Weight Loss Program starting before versus after knee replacement: A pilot study

BACKGROUND

Most patients risk gaining weight in the years after knee replacement, adding further concern to a population that is mostly overweight/obese prior to surgery.

OBJECTIVE

Via a randomised pilot study, we assessed changes in weight during a Patient Centered Weight Loss Program (PACE) initiated either before or after knee replacement, while simultaneously examining the feasibility of recruiting and retaining participants over 26 weeks.

METHODS

Recruitment outreach was made to 133 patients scheduled for knee replacement. Sixteen participants were randomised to a 14-session weight loss program that started either ≤6 weeks before surgery (PACE) or at 12 weeks post-op (Delayed PACE). Repeated measures ANOVAs were used to examine preliminary changes in weight, function, patient-reported outcomes, and physical activity across time (baseline/pre-op, 12 and 26 weeks after surgery) and group.

RESULTS

Retention was 75% and 69% at 12 and 26 weeks after surgery, respectively. Weight significantly decreased across the 26 weeks (P<0.001). A group by time interaction (P=0.03) demonstrated Delayed PACE [-7.6±5.9kg (-7.9±5.9%)] lost significantly more weight than PACE [-2.5±2.7kg (-2.6±2.6%)] participants at 26 weeks. Significant improvements across time were seen for all function and patient reported outcomes, however activity did not change.

CONCLUSION

Conducting a behavioural intervention was challenging but feasible in a knee replacement population, with preliminary evidence suggesting that initiating a program 12 weeks after surgery produces greater weight losses at 26 weeks compared to a program starting before knee replacement.

Physical activity after total joint arthroplasty: a narrative review

Background

Total joint arthroplasty (TJA) is a common procedure to treat individuals with hip and knee osteoarthritis. While TJAs are successful in decreasing pain and improving quality of life, it is unclear whether individuals who undergo TJA become more physically active after surgery. It is possible that TJA, by itself, is not sufficient to affect the behavior of patients toward physical activity (PA) participation. To increase PA participation, individuals with TJA may need to be exposed to exercise/behavioral interventions specifically aimed to promote PA (ie, in addition to the surgery).

Objectives

This narrative review aimed to assess the evidence on 1) whether TJAs change PA participation from pre- to postsurgery and 2) whether exercise/behavioral interventions delivered before or after TJA help to promote PA in these patients.

Results

For aim 1, the studies that assessed PA from pre- to post-TJA reported that PA does not change in the first 3 months postsurgery. The results of follow-ups longer than 3 months but shorter than 12 months are contradictory, and the results of follow-ups longer than 12 months provide weak evidence of increased PA. Assessment of changes in PA due to TJA is challenged by the wide variability in demographics, methods used to assess PA, and different pathways of care used across studies. The results for aim 2 were limited by a scarcity of studies that used exercise/behavioral interventions to promote PA.

Conclusion

TJA relieves joint pain and offers a unique opportunity for patients to become more physically active. However, the current evidence is limited and unable to offer definitive results of whether TJA is effective to change PA from pre- to postsurgery. Future large studies in representative samples of patients with TJA are needed to adequately answer this question.

Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study

BACKGROUND

The physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-PF) is widely used and endorsed by professional organizations for patients with knee osteoarthritis. Its use post total knee replacement (TKR) has been challenged as it may not represent the high level of functional performance that is expected by patients who undergo contemporary TKR with more advanced techniques and care pathways.

OBJECTIVE

To assess whether the items of the WOMAC-PF reflect the activity limitations identified by patients following TKR.

DESIGN

Data for this descriptive study were obtained from baseline assessments of a randomized clinical trial comparing exercise interventions following TKR.

METHODS

Participants completed the WOMAC-PF and identified activity limitations in the Canadian Occupational Performance Measure (COPM) in the same day. The responses to both questionnaires were compared.

RESULTS

This investigation included 50 participants (36 women, mean age 63.8±6.7). The WOMAC-PF failed to capture 50% of the activity limitations identified by participants in the COPM. These activities included kneeling, squatting, carrying/lifting items, strength/endurance exercise, floor transfer, lower extremity exercise, walking up/down hills, yard work, climbing a ladder, driving, managing the environment, carrying objects up/down stairs, gait initiation, balance, and going up/down curbs. Only one activity on the WOMAC-PF (going shopping) was not identified by participant responses on the COPM.

LIMITATIONS

Participants were included if they had TKR between 3 and 6 months prior, which may limit generalizability to those immediately after TKR, and the study sample was relatively small.

CONCLUSIONS

In individuals following TKR, the WOMAC-PF failed to represent a subset of higher level, more physically demanding activities that were identified as important by patients following TKR.

Five times sit-to-stand test in subjects with total knee replacement: Reliability and relationship with functional mobility tests

The objective was to determine the inter-observer and test/retest reliability of the "Five-repetition sit-to-stand" (5STS) test in patients with total knee replacement (TKR). To explore correlation between 5STS and two mobility tests. A reliability study was conducted among 24 (mean age 72.13, S.D. 10.67; 50% were women) outpatients with TKR. They were recruited from a traumatology unit of a public hospital via convenience sampling. A physiotherapist and trauma physician assessed each patient at the same time. The same physiotherapist realized a 5STS second measurement 45-60min after the first one. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots. Pearson coefficient was calculated to assess the correlation between 5STS, time up to go test (TUG) and four meters gait speed (4MGS). ICC for inter-observer and test-retest reliability of the 5STS were 0.998 (95% confidence interval [CI], 0.995-0.999) and 0.982 (95% CI, 0.959-0.992). Bland-Altman plot inter-observer showed limits between -0.82 and 1.06 with a mean of 0.11 and no heteroscedasticity within the data. Bland-Altman plot for test-retest showed the limits between 1.76 and 4.16, a mean of 1.20 and heteroscedasticity within the data. Pearson correlation coefficient revealed significant correlation between 5STS and TUG (r=0.7, p<0.001) and 4MGS (r=-0.583, p=0.003). This study demonstrates excellent inter-observer and test-retest reliability when it is used in people with TKR, and also significant correlation with other functional mobility tests. These findings support the use of 5STS as outcome measure in TKR population.

Responsiveness of Physical Activity Measures Following Exercise Programs after Total Knee Arthroplasty

Background

Few instruments that measure physical activity (pa) can accurately quantify pa performed at light and moderate intensities, which is particularly relevant to older adults. Evidence for responsiveness of these instruments after an intervention is limited.

Objectives

o estimate and compare the responsiveness of two activity monitors and one questionnaire in assessing PA after an intervention following total knee Arthroplasty.

Methods

This one-group pretest-posttest, repeated-measures study analyzed changes in duration of daily PA and the standardized response mean (SRM) to assess internal responsiveness that were compared across instruments. Correlations between changes in PA measured by the proposed instruments and the global rating of change were used to test external responsiveness. Agreement between PA instruments on identifying individuals who changed their PA based on measurement error was assessed using weighted-Kappa (K).

Results

Thirty subjects, mean age 67(6) and 73% female, were analyzed. Changes in PA measured by each instrument were small (p>0.05), resulting in a small degree of responsiveness (SRM<0.30). Global rating of change scores did not correlate with changes in PA (rho=0.13-0.28, p>0.05). The activity monitors agreed on identifying changes in moderate-intensity PA (K=0.60) and number of steps (K=0.63), but did not agree with scores from questionnaire(K≤0.22).

Conclusion

Analyzing group-based changes in PA is challenging due to high-variability in the outcome. Investigating changes in PA at the individual-level may be a more viable alternative.