A Targeted Home- and Center-Based Exercise Program for People After Total Hip Replacement: A Randomized Clinical Trial

Defining Clinically Meaningful Cut Points for Leg Power Impairment Using Physical Performance in Older Adults: A Secondary Analysis From Boston RISE

OBJECTIVE

To identify clinically meaningful thresholds of leg power impairment identified by the stair climb power test (SCPT).

DESIGN

Cross-sectional analysis using the baseline data from an observational cohort study.

SETTING

The Boston Rehabilitative Impairment Study of the Elderly.

PARTICIPANTS

Community-dwelling older adults (N=413).

MAIN OUTCOME MEASURES

SCPT and the Short Physical Performance Battery (SPPB).

RESULTS

Using the receiver operating characteristic curves and Youden's J statistics, the optimal threshold for the SCPT associated with mobility limitation as defined by an SPPB score ≤9 was 3.07 Watts/kg for men with a sensitivity of 74%, a specificity of 73% and, an area under the curve (AUC) value of 0.78. For women, the optimal threshold was 2.59 Watts/kg with a sensitivity of 83%, a specificity of 69%, and an AUC value of 0.81. The classification and regression tree sensitivity analysis demonstrated similar thresholds, 2.88 Watts/kg and 2.53 Watts/kg for men and women, respectively.

CONCLUSIONS

The study identified clinically meaningful thresholds of impairment for the SCPT for mobility limited older primary care patients. These thresholds may be used to inform rehabilitation care to improve functional mobility of older adults and should be validated in larger more representative clinical trials.

The effect of a digital-assisted group rehabilitation on clinical and functional outcomes after total hip and knee arthroplasty-a prospective randomized controlled pilot study

BACKGROUND

The rising number of total hip and knee arthroplasties and the decreasing availability of physiotherapists require clinically and economically effective rehabilitation approaches. Therefore, the present pilot study investigated the effect of a novel digital-assisted individualized group rehabilitation program on clinical and functional outcomes after total hip and knee arthroplasty.

METHODS

In this randomized controlled pilot study, 26 patients undergoing total knee or hip replacement were randomly assigned to either the intervention group (IG, novel digital-assisted group therapy) or the control group (CG, standard postoperative physiotherapy currently carried out in Germany). The IG received the novel digital-assisted group therapy twice per week for a six-months period, while the CG received individual outpatient therapy depending on the prescription of the supervising physician. The number of therapy sessions was recorded. Moreover, subjective outcomes (EuroQol-5Dimensions (EQ-5D) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), functional outcome (30 s sit to stand test and timed up and go test (TUG)), as well as gait parameters were quantified preoperatively as well as at three and six months after surgery. Data were analyzed using an analysis of covariance with baseline-adjustment.

RESULTS

No patient-reported falls, pain, and hospital readmissions were recorded. On average, the IG received more therapy sessions. The clinical and functional outcomes were mainly not significantly different between groups at three- and six-months follow-up, but medium to large effect sizes for the differences in quality of life (EQ-5D) as well as pain, stiffness, and physical function (WOMAC), and TUG performance were observed in favor of the IG. However, the IG showed a higher variability of gait velocity after total joint replacement.

CONCLUSION

The digital-assisted rehabilitation had positive effects on quality of life, pain, stiffness, physical function, and TUG performance. Nevertheless, the therapy concept may be improved by adding exercises focusing on gait performance to reduce gait variability. The results indicate that the digital-assisted therapy concept is effective and safe. Therefore, a consecutive full-scaled randomized controlled clinical trial is recommended.

TRIAL REGISTRATION

This study was retrospectively registered on 14/02/2022 in the German Clinical Trial Register (DRKS00027960).

Effects of early home-based strength and sensory-motor training after total hip arthroplasty: study protocol for a multicenter randomized controlled trial

Background

Total hip arthroplasty (THA) is very effective in alleviating pain, but functional deficits persist up to a year following surgery. Regardless of standard physiotherapy programs, significant additional muscular atrophy and weakness occur. Deficits in strength have serious adverse consequences for these patients with respect to physical function, the maintenance of independence, and the requirement for revision surgery. Progressive resistance training in rehabilitation following THA has been shown to significantly enhance muscle strength and function. The fundamental principle is to progressively overload the exercised muscle as it becomes stronger. Different strength training protocols have been used at different times in the postoperative phase, in group or individual practices, with major differences being in center-based and home-based programs with or without supervision. The primary objective of our study is to evaluate whether an early postoperative home-based strength training protocol can improve patient functional outcomes at 3 months and 1 year following surgery. Secondary objectives are the feasibility of the presented protocol for all elective THA patients and its safety.

Methods/design

This study is a prospective multicenter randomized clinical trial to be conducted in the orthopedic departments of two Slovenian hospitals. In each hospital, 124 patients aged 60 or older with unilateral osteoarthritis, an ASA score between 1 and 3, a signed informed consent form, and no terminal illness disabling rehabilitation participation will be randomly assigned to the intervention or control group. THA with an anterior approach will be performed. All patients will receive current standard physiotherapy during hospitalization. Patients in the intervention group will also learn strength and sensory-motor training exercises. Upon discharge, all will receive USB drives with exercise videos, written exercise instructions, and a training diary. Physiotherapists will perform the assessments (physical tests and the maximal voluntary isometric contraction assessment), and patients will fill out outcome assessment questionnaires (the Harris Hip Score and 36-Item Short Form Health Survey) at baseline and 1, 3, and 12 months after surgery.

Discussion

The main purpose of our study is to design a new standardized rehabilitation protocol with videos that will be effective, safe, and accessible to all Slovenian THA patients.

Trial registration

ClinicalTrials.gov NCT04061993. Registered on 07 November 2019. Protocol ID: PRT_PhD. Version 1.

Unsupervised Home Exercises Versus Formal Physical Therapy After Primary Total Hip Arthroplasty: A Systematic Review

Historically, postoperative exercise and physical therapy (PT) have been viewed as crucial to a successful outcome following primary total hip arthroplasty (THA). This systematic review and meta-analysis aimed to assess differences in both short- and long-term objective and self-reported measures between primary THA patients with formal supervised physical therapy versus unsupervised home exercises after discharge. A search was conducted of six electronic databases from inception to December 14, 2020, for randomized controlled trials (RCTs) comparing changes from baseline in lower extremity strength (LES), aerobic capacity, and self-reported physical function and quality of life (QoL) between supervised and unsupervised physical therapy/exercise regimens following primary THA. Outcomes were separated into short-term (<6 months from surgery, closest to 3 months) and long-term (≥6 months from surgery, closest to 12 months) measures. Meta-analyses were performed when possible and reported in standardized mean differences (SMDs) with 95% confidence intervals (CI). Seven studies (N=398) were included for review. No significant differences were observed with regard to lower extremity strength (p=0.85), aerobic capacity (p=0.98), or short-term quality of life scores (p=0.18). Although patients in supervised physical therapy demonstrated improved short-term self-reported outcomes compared to those performing unsupervised exercises, this was represented by a small effect size (SMD 0.23 [95% CI, 0.02-0.44]; p=0.04). No differences were observed between groups regarding long-term lower extremity strength (p=0.24), physical outcome scores (p=0.37), or quality of life (p=0.14). The routine use of supervised physical therapy may not provide any clinically significant benefit over unsupervised exercises following primary THA. These results suggest that providers should reconsider the routine use of supervised physical therapy after discharge.

The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study

This study aimed to investigate the effect of a video-assisted discharge education program on activities of daily living, functionality, and patient satisfaction following total hip replacement (THR) surgery. This study included 31 patients who were randomly divided into the physiotherapy group (n = 18), and the video-assisted discharge education (VADE) group (n = 13). Both groups received a physiotherapy program. The VADE group was also received the VADE program. Face-to-face instruction was used in all of the educational programs. There was a significant difference in favor of the VADE group in Harris Hip Score, Nottingham Extended Activities of Daily Living Scale's movement score, Tampa Scale of Kinesiophobia, Patient Satisfaction Questionnaire (p < 0.05). There was a significant difference between groups on resting pain levels in the first week and on resting and activity pain levels in the third month in favor of the VADE group (p < 0.05). The results of this study demonstrated that VADE can be effective in improving patient satisfaction and functionality, reducing pain and kinesiophobia following THR.

Stabilometric assessments of two rehabilitation protocols on postural parameters after posterior total hip arthroplasty: A prospective randomized comparative study

INTRODUCTION

After total hip arthroplasty (THA), patients continue to have muscular, functional and postural deficits. The literature seems to support the use of postoperative rehabilitation, especially self-directed programs. However, there is no set protocol for the management of postural disorders. Therefore, the purpose of this study was to compare postural parameters of a group of patients who underwent posterior THA followed by 2 different types of rehabilitation (stabilometric platform (SP) and home-based self-directed protocols) with a control group of operated patients who did not undergo rehabilitation and a control group of age-matched asymptomatic subjects.

HYPOTHESIS

We hypothesized that rehabilitation would normalize the stabilometric parameters.

PATIENTS AND METHODS

A total of 67 subjects were enrolled in this study (mean age 67.85±1.22years) and divided into 4 groups. Forty-one of these subjects had undergone a posterior THA were randomly assigned between D10 and D21 to one of the following 3 groups: no rehabilitation control group (THACG=14), supervised rehabilitation with a stabilometric platform group (RSPG=16), and a self-directed home-based rehabilitation group (SDHRG=11). The 4th group was a control group made up of 26 age-matched asymptomatic nonoperated subjects (CG55-80). These rehabilitation protocols lasted 3weeks. At the end of the 3weeks, the groups performed the same stabilometric single leg and double leg stance tests (considering lower limb dominance) on an SP.

RESULTS

No significant differences were observed between groups in the bipedal stance, except between the CG55-80 and the THACG, where a higher energy expenditure was observed in the THACG during the static stance with eyes open (EO) and eyes closed (EC): increase in the path length (P_length) covered by the center of pressure (COP) (EO: p=01; EC: p=03) and the average velocity (V_avg) of the COP (EO: p=01; EC: p=03). These differences were not observed in the SDHRG and RSPG whether they were compared with one another or with both control groups. In the unipedal stance, subjects in the RSPG and SDHRG showed greater muscle activity in the anterior and posterior chains and hip abductors, and used less energy to maintain the stance than those in the CG55-80, regardless of lower limb dominance: decrease in the mediolateral range of COP displacement (X_range) (hip abductor muscles) (p=02) and anteroposterior range of COP displacement (Y_range) (anterior and posterior chains) (p=3.49.10^-3), 95% confidence ellipse area (E_area) of COP data (p=1.47.10^-3), P_length (p=04) and V_avg (p=04). The RSPG had a smaller E_area than the SDHRG (p=04), demonstrating a better postural stability during the unipedal stance performed on the dominant operated leg.

DISCUSSION

Our results were consistent with the literature on the benefits of rehabilitation after THA, thus confirming our hypothesis that rehabilitation normalized stabilometric parameters between D31-D45, depending on the subjects. These results provide new information regarding rehabilitation techniques to be implemented postoperatively after a THA. A home-based self-directed rehabilitation program is just as effective as an SP program in managing postural disorders.

LEVEL OF EVIDENCE

II; randomized controlled trial with low statistical power.

Immediate Effects of Single-Session High-Velocity Training for Lateral Trunk Movement on Gait Function in Early Postoperative Patients after Total Hip Arthroplasty: A Nonrandomized Controlled Trial

Background: Total Hip Arthroplasty (THA) is an effective method for relieving pain and improving gait function. However, THA patients demonstrate slow gait speed at discharge. Rehabilitation programs after THA require the immediate improvement of gait speed early in the postoperative period. To examine the immediate effects of seated side tapping training (SSTT), which focuses on lateral trunk movement and movement velocity, on gait function in early postoperative THA patients, the methods were as follows: The SSTT group performed five repetitions of a task in which they moved their trunks laterally to alternately touch markers to their left and right side as quickly as possible 10 times in a seated position. One set of SSTT lasted approximately 3 min. The control group rested in a seated position for 10 min. Results: Significant interactions were observed for gait speed, stride time, and stride time coefficient of variability. The SSTT group demonstrated significant pre-post-intervention improvement in gait speed, stride time, and coefficient of variability. Conclusions: SSTT improved both gait speed and gait stability and can be performed easily and safely. Therefore, single-session high-velocity trunk training may be an effective method to improve gait function immediately in early postoperative THA patients.

The impact of direct oral anti-coagulants on hip fracture management : a systematic review and meta-analysis

Hip fractures are a common presentation in the elderly, a group who commonly have co-morbidities requiring the use of anticoagulants. Recently, direct oral anti-coagulants (DOAC) have become a popular method of anticoagulating patients. The primary aim of this review is to determine if the use of DOAC in elderly patients with hip fractures results in delays to theatre and/or an increased mortality risk. Major databases including Pubmed, MEDLINE and Embase were searched for relevant studies and the included studies reference lists were screened for further studies. A total of 6 studies were included in meta-analysis which was undertaken using RevMan software with 95% confidence interval (CI). Compared to control groups, patients who were anticoagulated with DOAC and required operative management of a hip fracture experienced a statistically significant delay to treatment. However independent analysis showed these patients did not experience an increased mortality risk when compared to the control group. While data is limited, treating clinicians should be comforted by these findings as operative manage- ment can be safely delayed to reduce the risk of intraoperative bleeding.

Worse Preoperative Pain and Higher Activity Levels Predict Patient Choice of Formal Physical Therapy After Primary Anterior Total Hip Arthroplasty

BACKGROUND

The purpose of this randomized controlled trial is (1) to compare the efficacy of supervised formal physical therapy (PT) and self-directed home exercises and (2) to identify independent predictors of transitioning from self-directed home exercises to supervised formal PT following total hip arthroplasty (THA) via an anterior approach.

METHODS

After Institutional Review Board approval, 147 patients undergoing primary unilateral THA through anterior approach were enrolled and randomized to receive either clinic or home-based PT. Surveys with Hip Disability Osteoarthritis Outcome Scores (HOOS) and Short Form-12 Health Survey scores for both groups were obtained before surgery and at 6, 14, and 24 weeks after surgery. Patients had the option to transition into the other study group at their 6-week follow-up visit.

RESULTS

Of the 147 patients enrolled, final analysis included scores for 136 patients. Forty-two (63.6%) of the 66 patients randomized to the supervised formal PT group crossed over to self-directed home exercise group and 12 (17.1%) of the 70 patients randomized to the self-directed home exercise group crossed over to supervised formal PT group. There were no significant (P > .05) differences between groups at all time points for the overall HOOS and Short Form-12 Health Survey. Subjects with worse preoperative pain scores (P = .005) and higher HOOS preoperative activity of daily living scores (P = .015) were more likely to transition from the home exercise group to formal PT group.

CONCLUSION

There were no significant outcome score differences between subjects undergoing supervised formal PT and self-directed home exercises. However, patients reporting worse preoperative pain and higher preoperative activity levels may prefer supervised formal PT compared to self-directed home exercises after undergoing primary anterior THA.

Evaluation of the Efficacy and Safety of an Exercise Program for Persons with Total Hip or Total Knee Replacement: Study Protocol for a Randomized Controlled Trial

Total hip replacement (THR) and total knee replacement (TKR) are among the most common elective surgical procedures. There is a large consensus on the importance of physical activity promotion for an active lifestyle in persons who underwent THR or TKR to prevent or mitigate disability and improve the quality of life (QoL) in the long term. However, there is no best practice in exercise and physical activity specifically designed for these persons. The present protocol aims to evaluate the efficacy and safety of an exercise program (6 month duration) designed for improving quality of life in people who had undergone THR or TKR. This paper describes a randomized controlled trial protocol that involves persons with THR or TKR. The participant will be randomly assigned to an intervention group or a control group. The intervention group will perform post-rehabilitation supervised training; the control group will be requested to follow the usual care. The primary outcome is QoL, measured with the Short-Form Health Survey (SF-36); Secondary outcomes are clinical, functional and lifestyle measures that may influence QoL. The results of this study could provide evidence for clinicians, exercise trainers, and policymakers toward a strategy that ensures safe and effective exercise physical activity after surgery.

Exercise as Medicine During the Course of Hip Osteoarthritis

Exercise is now considered medicine in numerous chronic conditions and is essentially without side effects. We hypothesize that exercise is primary, secondary, and tertiary prevention at different stages of hip osteoarthritis (preclinical, mild-moderate, and severe hip osteoarthritis) and after total hip arthroplasty.

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.

Evaluation of Exercise Interventions and Outcomes After Hip Arthroplasty: A Systematic Review and Meta-analysis

IMPORTANCE

Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy.

OBJECTIVE

To explore clinical outcomes associated with exercise training before and after hip arthroplasty.

DATA SOURCES

PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Google Scholar were searched from their inception to March 2020. Reference lists of included trials and related reviews were also searched.

STUDY SELECTION

Randomized clinical trials of land-based exercise interventions before or after total hip arthroplasty were included.

DATA EXTRACTION AND SYNTHESIS

This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was independently performed in duplicate. Random-effects meta-analyses with restricted maximum likelihood were performed for pooling the data.

MAIN OUTCOMES AND MEASURES

The primary prespecified outcome was self-reported physical function. Secondary prespecified outcomes were self-reported pain intensity, quality of life, gait speed, lower body muscle strength, lower body flexibility, anxiety, hospital length of stay, and adverse events.

RESULTS

A total of 32 randomized clinical trials with 1753 patients were included in the qualitative synthesis, and 26 studies with 1004 patients were included in the meta-analysis. Compared with usual care or no or minimal intervention, postoperative exercise training was not associated with improved self-reported physical function, with a moderate level of certainty, at 4 weeks (standardized mean difference [SMD], 0.01; 95% CI, -0.18 to 0.20), 12 weeks (SMD, -0.08; 95% CI, -0.23 to 0.07) and 26 weeks (SMD, -0.04; 95% CI, -0.31 to 0.24) postoperatively, and low level of certainty at 1 year after surgical treatment (SMD, 0.01; 95% CI, -0.09 to 0.12). For preoperative exercise interventions, there was no association of exercised training with self-reported physical function compared with the control at the 12-week (SMD, -0.14; 95% CI, -0.61 to 0.32) or 1-year follow-ups (SMD, 0.01; 95% CI, -0.37 to 0.40) with very low certainty, and no association with length of stay (mean difference, -0.21; 95% CI, -0.74 to 0.31) at moderate certainty. Results for postoperative hip muscle strength were rated at very low certainty, with no statistical significance. Meta-analysis could not be performed for other outcomes.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found low- to moderate-quality evidence that postoperative exercise interventions were not associated with improved self-reported physical function compared with usual care or no or minimal intervention. Furthermore, there was very low-quality evidence that preoperative exercise programs were not associated with higher self-reported physical function and hospital length of stay compared with usual care or no or minimal intervention.

The Effect of Resistance Training on the Function after Hip Replacement: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of resistance training for hip replacement remains controversial. We conducted a systematic review and meta-analysis to explore the influence of resistance training on functional recovery for hip replacement.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases through April 2018 for randomized controlled trials (RCTs) assessing the effect of resistance training on hip replacement.

RESULTS

Five RCTs involving 251 patients are included in the meta-analysis. Overall, compared with the control group for post-hip replacement patients, resistance training can significantly improve hip-related quality of life (standard mean difference [SMD] = 0.35; 95% CI = 0.02 to 0.68; p = 0.04), symptoms (SMD = 0.41; 95% CI = 0.08 to 0.74; p = 0.02), sports and recreation (SMD = 0.41; 95% CI = 0.08 to 0.75; p = 0.01), and reduce pain scores (SMD = 0.41; 95% CI = 0.08 to 0.74; p = 0.02), but has no remarkable impact on activities of daily living function (SMD = 0.48; 95% CI = 0 to 0.96; p = 0.05), sit to stand (SMD = 0.17; 95% CI = - 0.25 to 0.59; p = 0.44), stair climb performance (SMD = 0.06; 95% CI = - 0.36 to 0.48; p = 0.77), and leg extension power (SMD = 0.42; 95% CI = - 0.17 to 1.01; p = 0.17).

CONCLUSIONS

Resistance training is associated with significantly improved hip-related quality of life, symptoms, and sports and recreation, and decreased pain scores in post-hip replacement patients.

Clinical and cost-effectiveness of physiotherapy interventions following total hip replacement: a systematic review and meta-analysis

To examine the reported clinical and cost-effectiveness of physiotherapy interventions following total hip replacement (THR). A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). MEDLINE, CINAHL, AMED, Scopus, DARE, HTA, and NHS EED databases were searched for studies on clinical and cost-effectiveness of physiotherapy in adults with THR published up to March 2020. Studies meeting the inclusion criteria were identified and key data were extracted. Risk of bias was assessed using the Cochrane Risk of Bias Tool and a Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Data were summarised and combined using random-effect meta-analysis. A total of 1263 studies related to the aim of the review were identified, from which 20 studies met the inclusion criteria and were included in the review. These studies were conducted in Australia (n = 3), Brazil (n = 1), United States of America (USA) (n = 2), France (n = 2), Italy (n = 2), Germany (n = 3), Ireland (n = 1), Norway (n = 2), Canada (n = 1), Japan (n = 1), Denmark (n = 1), and United Kingdom (UK) (n = 1). The duration of follow-up of the included studies was ranged from 2 weeks to 12 months. Physiotherapy interventions were found to be clinically effective for functional performance, hip muscle strength, pain, and range of motion flexion. From the National Health Service perspective, an accelerated physiotherapy programme following THR was cost-effective. The findings of the review suggest that physiotherapy interventions were clinically effective for people with THR. However, questions remain on the pooled cost-effectiveness of physiotherapy interventions, and further research is required to examine this in patients with THR. Future studies are required to examine the cost-effectiveness of these interventions from patients, caregivers, and societal perspectives.Registration Prospero (ID: CRD42018096524).

Patients' narratives of patient education in physiotherapy after total hip arthroplasty

OBJECTIVE

The aim of this study was to explore patients' narratives of patient education in physiotherapy after a total hip arthroplasty (THA).

METHOD

The data was collected via open thematic interviews from ten patients who had had a primary THA. The interviews were analysed using a qualitative, narrative method.

RESULTS

Three story models of patient education in physiotherapy were identified: Supportive patient education in physiotherapy, Co-operative patient education in physiotherapy and Contradictory patient education in physiotherapy. The emphasis of narration in the first story model was on the trust in the guidance, functioning interaction in the second and insufficient patient education in physiotherapy in the third story model.

DISCUSSION

According to the results of this study, patients with THA experience functioning interaction and trust in the patient education in physiotherapy as enhancing the rehabilitation process. Conversely insufficient patient education about exercising and follow-up physiotherapy made the patients feel insecure and according to them might have slowed down the rehabilitation process. These findings can be utilized in planning and improving patient education in physiotherapy after THA.

Effectiveness of a Home-Based Rehabilitation Program After Total Hip Arthroplasty Driven by a Tablet App and Remote Coaching: Nonrandomized Controlled Trial Combining a Single-Arm Intervention Cohort With Historical Controls

Background

Recent technological developments such as wearable sensors and tablets with a mobile internet connection hold promise for providing electronic health home-based programs with remote coaching for patients following total hip arthroplasty. It can be hypothesized that such a home-based rehabilitation program can offer an effective alternative to usual care.

Objective

The aim of this study was to determine the effectiveness of a home-based rehabilitation program driven by a tablet app and remote coaching for patients following total hip arthroplasty.

Methods

Existing data of two studies were combined, in which patients of a single-arm intervention study were matched with historical controls of an observational study. Patients aged 18-65 years who had undergone total hip arthroplasty as a treatment for primary or secondary osteoarthritis were included. The intervention consisted of a 12-week home-based rehabilitation program with video instructions on a tablet and remote coaching (intervention group). Patients were asked to do strengthening and walking exercises at least 5 days a week. Data of the intervention group were compared with those of patients who received usual care (control group). Effectiveness was measured at four moments (preoperatively, and 4 weeks, 12 weeks, and 6 months postoperatively) by means of functional tests (Timed Up & Go test and the Five Times Sit-to Stand Test) and self-reported questionnaires (Hip disability and Osteoarthritis Outcome Score [HOOS] and Short Form 36 [SF-36]). Each patient of the intervention group was matched with two patients of the control group. Patient characteristics were summarized with descriptive statistics. The 1:2 matching situation was analyzed with a conditional logistic regression. Effect sizes were calculated by Cohen d.

Results

Overall, 15 patients of the intervention group were included in this study, and 15 and 12 subjects from the control group were matched to the intervention group, respectively. The intervention group performed functional tests significantly faster at 12 weeks and 6 months postoperatively. The intervention group also scored significantly higher on the subscales “function in sport and recreational activities” and “hip-related quality of life” of HOOS, and on the subscale “physical role limitations” of SF-36 at 12 weeks and 6 months postoperatively. Large effect sizes were found on functional tests at 12 weeks and at 6 months (Cohen d=0.5-1.2), endorsed by effect sizes on the self-reported outcomes.

Conclusions

Our results clearly demonstrate larger effects in the intervention group compared to the historical controls. These results imply that a home-based rehabilitation program delivered by means of internet technology after total hip arthroplasty can be more effective than usual care.

Trial Registration

ClinicalTrials.gov NCT03846063; https://clinicaltrials.gov/ct2/show/NCT03846063 and German Registry of Clinical Trials DRKS00011345; https://tinyurl.com/yd32gmdo

Influência da reabilitação física sobre aspectos funcionais em indivíduos submetidos à artroplastia total de quadril: uma revisão sistemática

Resumo Objetivo: Avaliar, por meio de revisão sistemática, a influência do tratamento fisioterapêutico sobre a funcionalidade, amplitude de movimento articular e força muscular em pacientes submetidos à artroplastia total de quadril devido à osteoartrite. Métodos: A busca sistemática de ensaios clínicos randomizados e não randomizados foi conduzida utilizando os bancos de dados eletrônicos PubMed, Web of Science, PEDro, Cochrane, Clinical Trials e SciELO, com base nas estratégias de pesquisa recomendadas pelos itens de relatórios preferenciais para análises sistemáticas e metanálises (PRISMA). Resultados: Em geral, protocolos supervisionados por fisioterapeutas associados à realização de exercícios ativos da musculatura periarticular do quadril e de extensores de joelho têm propiciado importante prognóstico físico e funcional. Exercícios resistidos (dinâmicos e isométricos) de alta intensidade são mais eficazes para a funcionalidade. Para a força muscular e Amplitude de movimento (ADM), exercícios dinâmicos com 3 a 5 séries de 8 a 12 repetições com baixa e alta intensidade promoveram ganhos mais expressivos em relação a outras modalidades terapêuticas. Conclusões: As técnicas e os protocolos utilizados pela fisioterapia para o tratamento da ATQ são variados e possuem importante eficácia clínica comprovada na literatura.

Digital Versus Conventional Rehabilitation After Total Hip Arthroplasty: A Single-Center, Parallel-Group Pilot Study

Background

The demand for total hip arthroplasty (THA) is rising. In the face of rapidly increasing health care costs, ensuring widespread, cost-effective rehabilitation is a priority. Technologies allowing independent home-based rehabilitation may be the key to facilitate access, improve effectiveness, and lower costs of care.

Objective

The aim of this study was to assess the feasibility of a novel artificial intelligence–powered digital biofeedback system following THA and compare the clinical outcomes against supervised conventional rehabilitation.

Methods

This was a single-center, parallel-group pilot study, with an 8-week intervention program. Patients were assessed at baseline, during the program (at 4 and 8 weeks), and 3 and 6 months after surgery. The primary outcome was the Timed Up and Go (TUG) score and secondary outcomes were the Hip dysfunction and Osteoarthritis Outcome Scale (HOOS; a patient-reported outcome) and hip range of motion (ROM).

Results

A total of 66 patients were included: 35 digital physiotherapy (PT) versus 31 conventional. There were no differences at baseline between groups except for lower HOOS quality of life (QoL) subscale scores in the digital PT group. Clinically relevant improvements were noted in both groups at all time points. The digital PT group showed a retention rate of 86% (30/35). Per-protocol analysis revealed a superiority of the digital PT group for all outcome measures. Intention-to-treat analysis revealed the superiority of the digital PT group at all time points for TUG (change between baseline and 4 and 8 weeks: P<.001; change between baseline and 3 and 6 months: P=.001 and P=.005, respectively), with a difference between median changes of −4.79 seconds (95% CI −7.24 to −1.71) at 6 months post-THA. Between baseline and month 6, results were also superior in the digital PT group for the HOOS sports and QoL subscales and all ROM except for standing flexion.

Conclusions

This study demonstrates this novel solution holds promise in rehabilitation after THA, ensuring better clinical outcomes than conventional rehabilitation while reducing dependence on human resources.

Trial Registration

ClinicalTrials.gov NCT03045549; https://clinicaltrials.gov/ct2/show/NCT03045549

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

Background

High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.

Methods

Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.

Results

After excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P <  0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P <  0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].

Conclusions

Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2570-8) contains supplementary material, which is available to authorized users.

Web-Based, Self-Directed Physical Therapy After Total Hip Arthroplasty Is Safe and Effective for Most, but Not All, Patients

BACKGROUND

Recent data suggested that unsupervised, self-directed physical therapy (SDPT) is both safe and efficacious for patients undergoing total hip arthroplasty (THA) and that formal outpatient physical therapy (OPPT) may not be routinely required. The purpose of this study was to evaluate the routine use of an SDPT program in a nonselect patient population.

METHODS

This is a multi-surgeon, single-institution, retrospective study of 941 consecutive patients discharged home, from January 2016 to December 2016, after primary, unilateral THA and enrolled in a web-based SDPT program. Patients were seen 4 weeks after surgery and OPPT was prescribed for perceived need, patient request, or if unable to use the web-based program. Patient-reported outcomes, medical comorbidities, and assessment of home environment were prospectively recorded.

RESULTS

Overall, 646 of 941 patients (68.7%) were not prescribed OPPT (SDPT-only group) while 295 of 941 patients (31.3%) were prescribed OPPT (SDPT + OPPT group). In the SDPT + OPPT group, 88.2% were for perceived need, 10.8% for patient request, and 1.0% due to inability to use the web-based platform. Multivariate analysis identified male sex (odds ratio, 0.64; 0.45-0.90; P = .012) and a higher preoperative Short Form-12 physical component (odds ratio, 0.98; 0.96-0.99; P = .036) as independent variables protective against requiring OPPT. At a minimum 6-month follow-up, the SDPT-only group had statistically higher hip disability and osteoarthritis outcome score junior compared to the SDPT + OPPT cohort (85.0 vs 80.9; P = .012).

CONCLUSION

Web-based SDPT is safe and effective for most, but not all, patients eligible for home discharge after THA. It is critical to preserve OPPT services for the one-third of patients who require them.

LEVEL OF EVIDENCE

Level III.

Spatiotemporal gait analysis of older persons in clinical practice and research : Which parameters are relevant?

For older persons walking is a basic activity of daily life which characterizes the person's functional mobility. Therefore, the improvement of walking performance is a major clinical outcome during geriatric rehabilitation. Furthermore, walking performance is relevant for several geriatric research issues. Quantitative gait analysis can describe walking performance in detail. Besides gait speed, various qualitative parameters related to different aspects of walking performance, such as symmetry, regularity, coordination, dynamic balance and foot movement during the swing phase, can serve as outcome parameters in geriatric research and in clinical practice. Clinicians and researchers have to decide which parameters are appropriate to be used as relevant outcome parameters in the investigated person or group of persons.

Feasibility and Patient Experience of a Home-Based Rehabilitation Program Driven by a Tablet App and Mobility Monitoring for Patients After a Total Hip Arthroplasty

Background

Recent developments in technology are promising for providing home-based exercise programs.

Objective

The objective of this study was to evaluate the feasibility and patient experience of a home-based rehabilitation program after total hip arthroplasty (THA) delivered using videos on a tablet personal computer (PC) and a necklace-worn motion sensor to continuously monitor mobility-related activities.

Methods

We enrolled 30 independently living patients aged 18-75 years who had undergone THA as a treatment for primary or secondary osteoarthritis (OA) between December 2015 and February 2017. Patients followed a 12-week exercise program with video instructions on a tablet PC and daily physical activity registration through a motion sensor. Patients were asked to do strengthening and walking exercises at least 5 days a week. There was weekly phone contact with a physiotherapist. Adherence and technical problems were recorded during the intervention. User evaluation was done in week 4 (T1) and at the end of the program (T2).

Results

Overall, 26 patients completed the program. Average adherence for exercising 5 times a week was 92%. Reasons mentioned most often for nonadherence were vacation or a day or weekend off 25% (33/134) and work 15% (20/134). The total number of technical issues was 8. The average score on the user evaluation questionnaire (range 0-5) was 4.6 at T1 and 4.5 at T2. The highest score was for the subscale “coaching” and the lowest for the subscale “sensor.”

Conclusions

A home-based rehabilitation program driven by a tablet app and mobility monitoring seems feasible for THA patients. Adherence was good and patient experience was positive. The novel technology was well accepted. When the home-based rehabilitation program proves to be effective, it could be used as an alternative to formal physiotherapy. However, further research on its effectiveness is needed.

Physical activity levels after hip and knee joint replacement surgery: an observational study

Usual care after hip or knee joint replacement does not adequately address the problem of low physical activity levels. We aimed to determine whether exercise delivered in a group setting in the early stage of outpatient rehabilitation influenced self-reported physical activity levels after hip or knee joint replacement. A case series of 79 participants referred to a 6-week outpatient orthopaedic exercise group after total hip or knee replacement were evaluated using the International Physical Activity Questionnaire (IPAQ) short form. Physical function was evaluated using Osteoarthritis Research Society International (OARSI) recommended performance-based tests (30 s Chair Stand Test, 40 m Fast Pace Walk Test, Stair Climb Test, Timed Up and Go Test, 6 Minute Walk Test). Measures were assessed at admission, discharge and 6 weeks after group discharge. Non-parametric analysis was conducted for IPAQ scores. Analysis of functional measures was conducted with linear mixed models with time modelled as a repeated measure. Standard multiple regression and correlation analysis were conducted. Fifty-four participants completed the study. Self-reported activity levels improved significantly at program discharge but not at 6-week follow-up. All performance-based measures improved significantly at program discharge. Fast-paced walking and 6 Minute Walk Test measures continued to improve at 6-week follow-up. Group dynamics present in an outpatient rehabilitation exercise program may increase physical activity levels during group participation but not after group cessation. Performance in all functional measures improved at group discharge.

Patient education in physiotherapy in total hip arthroplasty (THA) - The perspective of physiotherapists

BACKGROUND AND PURPOSE

There is limited knowledge about patients' and physiotherapists' perceptions of patient education in physiotherapy in hip arthroplasty. The aim of this study was to describe physiotherapists' conceptions of the patient education in physiotherapy needed by patients undergoing total hip arthroplasty.

METHODS

The data for this qualitative study were collected using group and individual semi-structured interviews. Seven physiotherapists were interviewed. The research data were analyzed using a phenomenographic method.

RESULTS

Three categories of patient education in physiotherapy in hip arthroplasty were produced and the categories formed a hierarchy. The narrowest descriptive category was Schematic physiotherapy complying with the protocol. Identifying individual rehabilitation needs was the second category, and the third, widest category was Coaching home rehabilitation. The differences between the categories were described in four themes: 1) Moving; 2) Exercising; 3) Interaction in relation to patient; and 4) Health care system.

CONCLUSION

According to the results, patient education in physiotherapy optimally aims to identify patients' individual rehabilitation needs, advice on coping at home and especially helping patients to be prepared for and capable of long rehabilitation for which they are themselves responsible. These findings resulting from descriptive categories can be utilized in developing education methods and physiotherapists' competence in patient education.

Effects of supervised exercise compared to non-supervised exercise early after total hip replacement on patient-reported function, pain, health-related quality of life and performance-based function – a systematic review and meta-analysis of randomized controlled trials

Background:

The rehabilitation after a total hip replacement varies in degree of supervision; however, it remains unknown whether supervised programmes are more effective than non-supervised.

Objective:

This study compared the effectiveness of supervised exercise compared to non-supervised home-based exercise after total hip replacement on patient-reported function, hip-pain, health-related quality of life and performance-based function.

Methods:

A systematic review and meta-analysis of randomized controlled trials investigating the effect of supervised exercise compared to non-supervised home-based exercise. An electronic search was performed in Medline, Embase and CINAHL on 14 March 2018. The methodological quality was assessed using the Cochrane Risk of Bias tool.

Results:

Seven studies were included with a total of 389 participants. A small and non-significant difference in favour of the supervised groups was found in patient-reported function (standardized mean difference (SMD) −0.22 (95% confidence interval (CI) −0.46 to 0.02)), hip-related pain (SMD −0.03 (95% CI −0.27 to 0.21)), health-related quality of life (mean difference (MD) −3.08 (95% CI −6.29 to 0.14)) and performance-based function (SMD −0.26 (95% CI −0.68 to 0.17)) at end of treatment and in patient-reported function (MD −1.31 (95% CI −3.79 to 1.16)) at the 6- to 12-month follow-up.

Limitations:

The literature search was systematic, but limited to three databases. The overall quality of evidence was downgraded to moderate due to lack of blinding in included studies.

Conclusion:

Supervised exercise was not significantly effective compared to non-supervised home-based exercise on patient-reported function, pain, health-related quality of life and performance-based function after primary total hip replacement.

Others:

PROSPERO registration number: CRD42017055604.

Home Health Services Are Not Required for Select Total Hip Arthroplasty Candidates: Assessment and Supplementation With an Electronic Recovery Application

BACKGROUND

At our institution, all postoperative total hip arthroplasty (THA) candidates have received home health services (HHS), consisting of visiting nurses, physical and occupational therapists. However, with a more technologically inclined patient population, electronic patient rehabilitation applications (EPRAs) can be used to deliver perioperative care at the comfort of the patient's home. The aim of this study is to investigate the clinical utility and economic burden associated with digital rehabilitation applications in primary THA recipients.

METHODS

We conducted a single-center, retrospective review of patients operated between November 2016 and November 2017. Before surgery, and at the discretion of the surgeon, patients were assigned to EPRA with HHS or EPRA alone. Patient baseline demographics, EPRA engagement, and validated patient-reported outcomes (PROs) were collected (Veterans Rand 12-Item Health Survey [VR-12] and Hip Disability and Osteoarthritis Outcome Score Junior) at baseline and 12 weeks. These PRO scores were correlated with cohort assignments to assess noninferiority of EPRA alone.

RESULTS

In total, 268 patients received either EPRA-HHS (n = 169) or EPRA (n = 99) alone. Patients receiving EPRA only were on average younger (60.8 vs 65.8; P < .0001), but otherwise similar to patients in the EPRA-HHS cohort. EPRA-only patients demonstrated no differences in VR-12 (P > .05) and Hip Disability and Osteoarthritis Outcome Score Junior (P > .05) when compared with EPRA-HHS.

CONCLUSION

The integration of electronic rehabilitation tools is gaining acceptance within the orthopedic community. Our study demonstrated that EPRA alone was clinically noninferior while substantially less costly than EPRA-HHS.

Unassisted quiet standing and walking after crutch usage in patients with total hip replacements: Does crutch length matter?

BACKGROUND

Crutch use is prescribed early in the rehabilitation process following total hip replacement (THR) surgery to improve safety and promote return to active living.

RESEARCH QUESTION

Purpose of this study was to understand mid-term effects of crutch length setup on quiet standing and walking two months post-op when crutch use was no longer required.

METHODS

Thirty patients were evaluated 2 months post-surgery when they had been walking without crutch for a month. The patients had previously been assigned randomly to elbow flexed (EF) or elbow extended (EE) crutch set-ups and evaluated 3 days post-surgery. Quiet standing stability was assessed with participants standing in a comfortable position with each foot on separated force platforms, facing forward for 10 s. In addition, participants walked on the laboratory path, instrumented with motion tracking system and force platforms. For the quiet standing trial, centre of pressure measure, acromial height and lower limbs load bearing symmetry were evaluated. For the walking trial, spatiotemporal and ground reaction force (GRF) parameters were evaluated together with side symmetry indices.

RESULTS

Results showed no significant differences in any standing trial variables between groups. For walking, GRF parameters and symmetry indices were similar for both groups. However, increased base of support width, reduced self-selected walking speed and stride length were found for the EF group.

SIGNIFICANCE

This study showed that crutch set-up influenced gait after patients started to walk unassisted. Patients that previously used crutch adjusted according to the EE setup, demonstrated a more efficient gait with higher self-selected speed and longer and narrower stride. Clinicians may use these results for a proper crutch height adjustment, which improves walking and, in turn, functional recovery in post THR patients.

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.

Does crutch length influence gait parameters after total hip replacement surgery?

After total hip replacement surgery, crutches are often prescribed to enable patients to walk independently. Purpose of this study was to evaluate possible crutch length influence on gait performance and symmetry, including spatiotemporal and kinetics parameters. Thirty patients were randomly assigned to elbow flexed (EF) or elbow extended (EE) crutch setup. Subjects were asked to walk on the laboratory path, instrumented with motion tracking system and force platforms. Spatiotemporal gait parameters and ground reaction force (GRF) parameters for both limbs and crutch support were evaluated. In addition, limb symmetry was evaluated for both gait and force parameters using the symmetry index. Variability was quantified for base of support width, stride time and length as the coefficient of variation. Results showed that cadence and walking speed were not significantly different, but stride length significantly decreased and base of support width increased for the EF group when compared to the EE group. Operated limb GRF parameters were significantly decreased for the EF group, while crutch force parameters decreased for the EE group. Furthermore, the EF group showed greater stride length variability and asymmetry of force and spatiotemporal parameters than EE group did. The results of the present study showed that EF and EE setups did not assist patients equally during walking, with EE setup allowing more load bearing on the operated side, reducing load on the crutch and asymmetries in gait parameters when compared to the EF setup. This may help clinicians in rationalizing crutch setup for patients after total hip replacement surgery.

Reliability, Validity, and Minimal Detectable Change of Four-Step Stair Climb Power Test in Community-Dwelling Older Adults

BACKGROUND

Stair climb power is an important clinical measure of lower-extremity power. The stair climb power test (SCPT) was validated by requiring individuals to climb a full flight of stairs. A 4-step SCPT (4SCPT) would be more clinically feasible and easier to perform, yet its reliability and validity are unknown.

OBJECTIVE

To evaluate reliability, validity, and minimal detectable change of 4SCPT among community-dwelling older adults.

DESIGN

This study is a cross-sectional analysis of baseline data from a clinical trial.

METHODS

Fifty older adults ≥65 years of age, at risk for mobility decline, consented to participate in this ancillary study. Test-retest reliability was derived from 2 measurements within each participant measured by a single assessor. Pearson correlation analyses among leg power measures (4SCPT, SCPT, single leg press power at 40% and 70% of the 1-repetition maximum [SLP40, SLP70]) were performed. Separate multivariate linear regressions were conducted evaluating the associations between each leg power measure and 2 mobility outcomes, the Short Physical Performance Battery (SPPB) and habitual gait speed (HGS). Minimal detectable change was based on a 90% confidence interval (MDC 90 ).

RESULTS

The 4SCPT had excellent test-retest reliability (ICC(2,1) = 0.951), and strong correlation with SCPT, SLP40, and SLP70 ( r = 0.85-0.96). The 4SCPT explained a greater amount of variance in the SPPB (R 2 = 0.31) than other leg power measurements (R 2 = 0.23-0.25). The 4SCPT (R 2 = 0.41) and SCPT (R 2 = 0.42) described equivalent amounts of variance in HGS, and greater than that with SLP40 (R 2 = 0.28) and SLP70 (R 2 = 0.30). The MDC 90 for 4SCPT was 44.0 watts.

LIMITATIONS

This was a cross-sectional analysis within a small, nonrepresentative sample. Interrater reliability was not evaluated.

CONCLUSIONS

The 4SCPT shows scientific promise as a valid and reliable leg power measurement among community-dwelling older adults.

The influence of the crutch setup on stability and weight-bearing parameters in post total hip replacement surgery patients during quiet standing

PURPOSE

The purpose of this study is to evaluate the influence of the crutch setup on standing, in post total hip replacement (THR) surgery patients.

MATERIALS AND METHODS

Thirty patients after THR were randomly assigned to walking with the elbow flexed (EF) or elbow straight (ES) crutch setup. Subjects were asked to stand on a force platform in a comfortable position with the crutch positioned on the unaffected side, facing forward for 10 seconds. Centre of pressure total path and maximal excursion were evaluated in both medio-lateral and anterior-posterior planes. Difference in the asymmetry of left/right acromial height, measured with and without the crutch, was calculated (ACdiff). Percentage of body weight borne by the crutch (Fcr), symmetry (SIload) between operated and healthy limbs loading during the trial, together with shoulder forces and moments were measured.

RESULTS

No significant differences between the two groups (p > .05) were found for stability parameters. ACdiff, Fcr and shoulder load increased significantly (p < .05) in EF group compared to ES group. In addition leg loading symmetry was significantly reduced in the EF group.

CONCLUSIONS

The present study showed that the ES setup reduced the force borne by the crutch, the load on the shoulder joint and it minimized postural and loading asymmetries when compared to EF setup. Conversely, postural stability was not influenced by the crutch setup. Implications for Rehabilitation Static posture and weight-bearing parameters are influenced by crutch setup during quiet standing. Crutch setup does not influence postural stability. Adjusting the crutch according to the elbow straight setup reduces the force borne by the crutch and the asymmetry in lower limbs loading. Forces and moments at the shoulder joint were reduced for the elbow straight setup group.

Formal Physical Therapy After Total Hip Arthroplasty Is Not Required: A Randomized Controlled Trial

BACKGROUND

The value of formal physical therapy after total hip arthroplasty is unknown. With substantial changes that have occurred in surgical and anesthesia techniques, self-directed therapy may be efficacious in restoring function to patients undergoing total hip arthroplasty.

METHODS

We conducted a single-center, randomized trial of 120 patients undergoing primary, unilateral total hip arthroplasty who were eligible for direct home discharge. The experimental group followed a self-directed home exercise program for 10 weeks. The control group received the standard protocol for physical therapy that included in-home visits with a physical therapist for the first 2 weeks followed by formal outpatient physical therapy for 8 weeks. Functional outcomes were measured using validated instruments including the Harris hip score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 Health Survey (SF-36) preoperatively, at 1 month postoperatively, and at 6 to 12 months postoperatively.

RESULTS

Of 120 randomized patients, 108 were included in the final analysis. Ten patients (19%) were randomized to unsupervised home exercise and 20 patients (37%) were randomized to formal outpatient therapy crossed over between groups. There was no significant difference in any of the measured functional outcomes between patients receiving formal therapy (n = 54) and those participating in unsupervised home exercise (n = 54) at any time point (HHS, p = 0.82; WOMAC, p = 0.80; and SF-36 physical health, p = 0.90).

CONCLUSIONS

This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Stair negotiation as a rehabilitation intervention for enhancing recovery following total hip and knee replacement surgery

BACKGROUND

Total hip replacement (THR) and total knee replacement (TKR) are common orthopaedic procedures. However, an optimal programme for post-operative rehabilitation has yet to be established. Stair negotiation is a challenging, habitual task, regularly used as a post-operative functional outcome measure; yet as a physical rehabilitation intervention it appears to be rarely used.

AIM

The review purpose was to investigate the effectiveness of stair climbing as a rehabilitation intervention for THR and TKR patients.

METHODS

MEDLINE, PsycINFO, Science Citation Index, CINAHL, SPORTDiscus and the Cochrane Database of Systematic Reviews were searched. The systematic review targeted studies using stair negotiation as a rehabilitation intervention. Randomised and non-randomised controlled trials, pilot studies, and case studies were included; systematic reviews and meta-analyses were excluded.

RESULTS

Of 650 articles identified, ten studies were eligible for review. A predefined data table to extract information from selected studies was used. Of the ten identified reports, two prehabilitation and eight rehabilitation studies included stair negotiation exercises as part of multi-modal physical interventions. Outcome measures were classified as: functional self-reported, perceptual, psychological and those relating to quality of life.

CONCLUSION

Studies were methodologically heterogeneous and typically lacked adequate control groups. It was not possible to determine the impact of stair negotiation exercise on the positive outcomes of interventions. Stair negotiation warrants further investigation as a rehabilitation activity.

Greek Physiotherapists' Perspectives on Rehabilitation Following Total Knee Replacement: a Descriptive Survey

BACKGROUND AND PURPOSE

In Greece, as in many countries, there is a scarcity of evidence in the type of physiotherapy services offered for the rehabilitation of total knee replacement (TKR). Despite the number of TKRs annually performed in Greece (over 10,000), there are no available clinical guidelines as to the content of best physiotherapy practice. The aim of this nationwide survey undertaken by physiotherapists treating TKR patients post-operatively was to record standard practice and services available in Greece.

METHODS

Design: cross-country survey Ten per cent of all registered physiotherapists working in public/private sectors were recruited. The developed survey comprised of questions regarding therapists' profile, protocols implemented at different stages of rehabilitation and the aims and modalities used.

RESULTS

A 58.7% response rate was achieved, where 36% (47/132) of respondents were treating patients in the inpatient phase and 64% (85/132) after hospital discharge. Patients in Greece are discharged with a home-based exercise program (56.7%) and, to a lesser extent, are referred to rehabilitation centres (13.3%). Strengthening, range of movement and functionality seemed to be the primary goals especially in the inpatient phase, whereas in the outpatient phase, apart from the larger differences identified, functionality and balance training were more frequently reported.

CONCLUSIONS

No significant variations in practice were found during inpatient rehabilitation, whilst there seemed to be diversity across outpatient physiotherapy programs. The current survey suggests that patient's general health and psychological and behavioural issues are the criteria by which physiotherapists select the volume of implemented exercise and progression. However, no specific guidelines were followed. Copyright © 2016 John Wiley & Sons, Ltd.

Does an early home-based progressive resistance training program improve function following total hip replacement? Results of a randomized controlled study

BACKGROUND

In-hospital progressive resistance training (PRT) has been shown to be an effective method of rehabilitation following hip surgery. The aim of this study was to assess whether a home-based PRT program would be beneficial in improving patients' muscle strength and physical function compared to standard rehabilitation.

METHODS

Subjects (n = 49) either received home-based PRT rehabilitation (n = 25) or standard rehabilitation (n = 24) in a prospective single blinded randomized trial carried out over a two-year period. The primary outcome measure was the maximal voluntary contraction of the operated leg quadriceps (MVCOLQ) with secondary measures of outcome being the sit to stand score (ST), timed up and go (TUG), stair climb performance (SCP), the 6 min walk test (6MWT), and lean mass of the operated leg (LM).

RESULTS

Twenty-six patients completed follow up at 1 year (n = 13 per group) for the final comparative analysis. All the outcome measures showed marked progressive improvements from the baseline measures at 9-12 months post op (Estimated effect (std error); p value)- MVCOLQ 26.50 (8.71) N p = 0.001; ST 1.37 (0.33) p = 0.0001; TUG -1.44 (0.45) s p =0.0001; SCP -3.41(0.80)s p = 0.0001; 6MWT 45.61 (6.10)m p = 0.0001; LM 20 (204)g p = 0.326) following surgery for both groups. Overall, there was no significant effect for participation in the exercise regime compared with standard care for all outcomes assessed.

CONCLUSIONS

Overall, this study demonstrated that there is no significant difference between the two groups for participation in the home-based PRT exercise programme when compared to standard care for all outcomes.

TRIAL REGISTRATION

ISRCTN 1309951. Registered February 2011.

Effectiveness of balance exercises in the acute post-operative phase following total hip and knee arthroplasty: A randomized clinical trial

Objectives:

To determine the effectiveness of balance exercises in the acute post-operative phase following total hip arthroplasty or total knee arthroplasty.

Methods:

Patients who had total hip arthroplasty (n = 30) or total knee arthroplasty (n = 33) were seen in their residence 1–2 times per week for 5 weeks. At the first post-operative home visit, patients were randomly assigned to either typical (TE, n = 33) or typical plus balance (TE + B, n = 30) exercise groups. The TE group completed seven typical surgery-specific joint range-of-motion and muscle strengthening exercises, while the TE + B group completed the typical exercises plus three balance exercises. Patients were assessed before and 5 weeks after administering the rehabilitation program using four outcome measures: (1) the Berg Balance Scale, (2) the Timed Up and Go test, (3) the Western Ontario McMaster Universities Osteoarthritis Index, and (4) the Activities-specific Balance Confidence Scale.

Results:

Post-intervention scores for all four outcome measures were significantly improved (p < 0.01) over baseline scores. Patients who participated in the TE + B group demonstrated significantly greater improvement on the Berg Balance Scale and the Timed Up and Go tests (p < 0.01).

Conclusion:

Balance exercises added to a typical rehabilitation program resulted in significantly greater improvements in balance and functional mobility compared to typical exercises alone.

Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review

BACKGROUND

Existing review required updating.

OBJECTIVE

To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis.

DESIGN

Systematic review from January 2007 to November 2013.

DATA SOURCES

AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied.

ELIGIBILITY CRITERIA

Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed.

OUTCOMES

Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion.

STUDY APPRAISAL

Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered.

RESULTS

11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.

LIMITATIONS

The overall quality and quantity of trials, and their diversity, prevented meta-analyses.

CONCLUSIONS

Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.

Effects of preoperative physiotherapy in hip osteoarthritis patients awaiting total hip replacement

INTRODUCTION

The World Health Organization (WHO) claimed osteoarthritis as a civilization-related disease. The effectiveness of preoperative physiotherapy among patients suffering hip osteoarthritis (OA) at the end of their conservative treatment is rarely described in the literature. The aim of this study was to assess the quality of life and musculoskeletal health status of patients who received preoperative physiotherapy before total hip replacement (THR) surgery within a year prior to admission for a scheduled THR and those who did not.

MATERIAL AND METHODS

Forty-five patients, admitted to the Department of Orthopaedics and Traumatology of Locomotor System for elective total hip replacement surgery, were recruited for this study. The assessment consisted of a detailed interview using various questionnaires: the Harris Hip Score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the 36-Item Short Form Health Survey (SF-36), and the Hip disability and Osteoarthritis Outcome Score (HOOS), as well as physical examination. Patients were assigned to groups based on their attendance of preoperative physiotherapy within a year prior to surgery.

RESULTS

Among patients who received preoperative physiotherapy a significant improvement was found for pain, daily functioning, vitality, psychological health, social life, and (active and passive) internal rotation (p < 0.05).

CONCLUSIONS

Patients are not routinely referred to physiotherapy within a year before total hip replacement surgery. This study confirmed that pre-operative physiotherapy may have a positive influence on selected musculoskeletal system status indicators and quality of life in hip osteoarthritis patients awaiting surgery.

Neurobehavioral Mechanisms of Traumatic Stress in Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric disorder that develops following trauma exposure. It is characterized by four symptom clusters: intrusion, avoidance, negative alteration in cognitions and mood, and alterations in arousal and reactivity. Several risk factors have been associated with PTSD, including trauma type and severity, gender and sexual orientation, race and ethnicity, cognitive reserve, pretrauma psychopathology, familial psychiatric history, and genetics. Great strides have been made in understanding the neurobiology of PTSD through animal models and human imaging studies. Most of the animal models have face validity, but they have limitations in the generalization to the human model of PTSD. Newer animal models, such as the "CBC" model, have better validity for PTSD, which takes into account the different components of its diagnostic criteria. To date, fear conditioning and fear extinction animal models have provided support for the hypothesis that PTSD is a dysregulation of the processes related to fear regulation and, especially, fear extinction. More research is needed to further understand these processes as they relate not only to PTSD but also to resilience. Further, this research could be instrumental in the development of novel effective treatments for PTSD.

Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review

QUESTION

In people who have been discharged from hospital after a total hip replacement, do rehabilitation exercises directed by a physiotherapist improve strength, gait, function and quality of life? Are these exercises as effective in an unsupervised home-based setting as they are in a supervised outpatient setting?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adult patients after elective total hip replacement.

INTERVENTION

Physiotherapist-directed rehabilitation exercises after discharge from hospital following total hip replacement.

OUTCOME MEASURES

Hip and knee strength, gait parameters, functional measures, and quality of life.

RESULTS

Five studies comprising 234 participants were included in the review. Sufficient data for meta-analysis were only obtained for hip and knee strength, gait speed and cadence. Physiotherapy rehabilitation improved hip abductor strength by a mean of 16Nm (95% CI 10 to 22), gait speed by 6 m/min (95% CI 1 to 11) and cadence by 20 steps/min (95% CI 8 to 32). Favourable but non-significant improvements in strength were noted for other muscle groups at the hip and knee. Function and quality of life could not be meta-analysed due to insufficient data and heterogeneity of measures, but functional measures tended to favour the physiotherapy rehabilitation group. Most outcomes were similar between outpatient and home-based exercise programs.

CONCLUSION

Physiotherapy rehabilitation improves hip abductor strength, gait speed and cadence in people who have been discharged from hospital after total hip replacement. Physiotherapist-directed rehabilitation exercises appear to be similarly effective whether they are performed unsupervised at home or supervised by a physiotherapist in an outpatient setting.

A non-invasive biomechanical device and treatment for patients following total hip arthroplasty: results of a 6-month pilot investigation

BACKGROUND

The purpose of the study was to examine the effect of a foot-worn biomechanical device on the clinical measurements and gait patterns of patients with total hip arthroplasty (THA).

METHODS

Nineteen patients, up to 3 months post-THA, were enrolled to the study. Patients underwent a computerized gait analysis to calculate spatiotemporal parameters and completed the Western Ontario and McMaster Universities osteoarthritis index and the SF-36 health survey. Patients then began therapy with a non-invasive foot-worn biomechanical device coupled with a treatment methodology (AposTherapy). Patients received exercise guidelines and used the device daily during their regular activities at their own environment. Follow-up examinations were conducted after 4, 12, and 26 weeks of therapy. Repeated measures ANOVA was used to evaluate changes over time. The clinical significance of the treatment effect was evaluated by computing the Cohen's effect sizes (ES statistic).

RESULTS

After 26 weeks of therapy, a significant improvement was seen in gait velocity (50.3%), involved step length (22.9%), and involved single limb support (16.5%). Additionally, a significant reduction in pain (85.4%) and improvement in function (81.1%) and quality of life (52.1%) were noted.

CONCLUSIONS

Patients following THA demonstrated a significant improvement in gait parameters and in self-assessment evaluations of pain, function, and quality of life. We recommend further RCTs to examine the effect of this therapy compared to other rehabilitation modalities following THA and compared to healthy matched controls.

TRIAL REGISTRATION

Clinical trial registration number NCT01266382.