Pilot study of methods to document quantity and variation of independent patient exercise and activity after total knee arthroplasty

Outcomes Vary by Pre-Operative Physical Activity Levels in Total Knee Arthroplasty Patients

Physical activity (PA) is suggested to reduce osteoarthritis pain; however, it may be avoided by patients requiring arthroplasty. Our goal was to investigate objective and patient-reported outcomes as a function of pre-operative PA levels in patients undergoing total knee arthroplasty (TKA). A total of 1941 patients enrolled in a multicenter prospective cohort study investigating a smartphone-based care management platform for self-directed rehabilitation underwent TKA and were included in the analysis. Activity was categorized based on the cohort's step count quartiles into low, moderate, and high pre-operative PA. Pre-operative and post-operative pain, EQ5D5L, KOOS JR, and step counts were compared by ANOVA according to activity group. Pre-operative pain scores increased with the decreasing activity level (all, p < 0.05) and were most improved post-operatively in the low PA group. High PA patients demonstrated the smallest improvements in EQ-5D-5L and KOOS JR. Low and moderate PA patients increased physical activity by three months, reaching 176% and 104% of pre-operative steps; high PA patients did not return to full step counts by one year post-operatively. Patients undergoing TKA who present with higher levels of physical activity report lower levels of pain and higher function pre-operatively but appreciate less improvement up to one year post-operatively. These results may be helpful in appropriate counseling of patient expectations before TKA.

Total Knee Arthroplasty: Fitness, Heart Disease Risk, and Quality of Life

Total knee arthroplasty (TKA) may decrease coronary heart disease (CHD) risk in patients with advanced osteoarthritis by reducing pain and allowing for a more active lifestyle. We examined cardiovascular fitness, CHD risk factors, and quality of life in patients for 1 year after TKA compared with matched controls who did not undergo surgery. A total of 14 patients, 7 surgery patients and 7 matched controls, were tested for measurements of body composition, knee range of motion, resting blood pressure, strength testing, a maximal exercise test, quality-of-life questionnaires (Medical Outcomes Study Short Form-36 and Knee Osteoarthritis Outcome Score [KOOS]), and activity monitoring, fasting blood glucose, and lipids at 0, 3, 6, and 12 months after surgery or baseline testing. Comparison between the two groups was analyzed. Twelve months after surgery, patients with TKA had significantly (p < 0.05) lower pain scores, increased fat free mass, lower resting mean arterial pressure, and improved scores on the KOOS for pain, symptoms, activities of daily living, and quality of life. Initially, total cholesterol, high-density lipoprotein cholesterol, triglycerides, and body fat percentage were reduced in the TKA group but returned to baseline at 12 months. The results of this study indicate that there are immediate and long-term improvements in pain and quality of life in patients with TKA, but physical function, exercise capacity, leg strength, and some lipid profiles may take longer than 12 months to improve. This is a level II, prospective, Therapeutic study, comparative study.

What Adherence Measures Should Be Used in Trials of Home-Based Rehabilitation Interventions? A Systematic Review of the Validity, Reliability, and Acceptability of Measures

OBJECTIVE

To systematically review methods for measuring adherence used in home-based rehabilitation trials and to evaluate their validity, reliability, and acceptability.

DATA SOURCES

In phase 1 we searched the CENTRAL database, NHS Economic Evaluation Database, and Health Technology Assessment Database (January 2000 to April 2013) to identify adherence measures used in randomized controlled trials of allied health professional home-based rehabilitation interventions. In phase 2 we searched the databases of MEDLINE, Embase, CINAHL, Allied and Complementary Medicine Database, PsycINFO, CENTRAL, ProQuest Nursing and Allied Health, and Web of Science (inception to April 2015) for measurement property assessments for each measure.

STUDY SELECTION

Studies assessing the validity, reliability, or acceptability of adherence measures.

DATA EXTRACTION

Two reviewers independently extracted data on participant and measure characteristics, measurement properties evaluated, evaluation methods, and outcome statistics and assessed study quality using the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

DATA SYNTHESIS

In phase 1 we included 8 adherence measures (56 trials). In phase 2, from the 222 measurement property assessments identified in 109 studies, 22 high-quality measurement property assessments were narratively synthesized. Low-quality studies were used as supporting data. StepWatch Activity Monitor validly and acceptably measured short-term step count adherence. The Problematic Experiences of Therapy Scale validly and reliably assessed adherence to vestibular rehabilitation exercises. Adherence diaries had moderately high validity and acceptability across limited populations. The Borg 6 to 20 scale, Bassett and Prapavessis scale, and Yamax CW series had insufficient validity. Low-quality evidence supported use of the Joint Protection Behaviour Assessment. Polar A1 series heart monitors were considered acceptable by 1 study.

CONCLUSIONS

Current rehabilitation adherence measures are limited. Some possess promising validity and acceptability for certain parameters of adherence, situations, and populations and should be used in these situations. Rigorous evaluation of adherence measures in a broader range of populations is needed.

Force-plate analyses of balance following a balance exercise program during acute post-operative phase in individuals with total hip and knee arthroplasty: A randomized clinical trial

Objectives:

Typical rehabilitation programs following total hip arthroplasty and total knee arthroplasty include joint range of motion and muscle-strengthening exercises. Balance and balance exercises following total hip arthroplasty and total knee arthroplasty have not received much attention. The purpose of this study was to determine whether an intervention of balance exercises added to a typical rehabilitation program positively affects patients’ balance.

Methods:

A total of 63 patients were provided with outpatient physical therapy at their home. Patients were randomly assigned to either typical (n = 33) or balance (n = 30) exercise group. The typical group completed seven typical surgery-specific joint range of motion and muscle-strengthening exercises, while the balance group completed the typical exercises plus three balance exercises. After 5 weeks of administering the rehabilitation program, patients’ balance was assessed on a force plate using 95% ellipse area of the center of pressure amplitude.

Results:

Patients in the balance group demonstrated significant reduction in the 95% ellipse area for the anterior and posterior lean standing conditions (p < 0.01).

Conclusion:

Balance exercises added to the typical outpatient physical therapy program resulted in significantly greater improvements in balance for participants with total hip arthroplasty or total knee arthroplasty, compared to the typical exercise program alone. Physical therapists might consider the use of balance exercises to improve balance in individuals in the acute post-operative phase following total hip arthroplasty or total knee arthroplasty.

Physical activity after total knee arthroplasty: A critical review

Total knee arthroplasty (TKA) is the most commonly performed elective surgery in the United States. TKA typically improves functional performance and reduces pain associated with knee osteoarthritis. Little is known about the influence of TKA on overall physical activity levels. Physical activity, defined as “any bodily movement produced by skeletal muscles that results in energy expenditure”, confers many health benefits but typically decreases with endstage osteoarthritis. The purpose of this review is to describe the potential benefits (metabolic, functional, and orthopedic) of physical activity to patients undergoing TKA, present results from recent studies aimed to determine the effect of TKA on physical activity, and discuss potential sources of variability and conflicting results for physical activity outcomes. Several studies utilizing self-reported outcomes indicate that patients perceive themselves to be more physically active after TKA than they were before surgery. Accelerometry-based outcomes indicate that physical activity for patients after TKA remains at or below pre-surgical levels. Several different factors likely contributed to these variable results, including the use of different instruments, duration of follow-up, and characteristics of the subjects studied. Comparison to norms, however, suggests that daily physical activity for patients following TKA may fall short of healthy age-matched controls. We propose that further study of the relationship between TKA and physical activity needs to be performed using accelerometry-based outcome measures at multiple post-surgical time points.

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.

Patients receiving inpatient rehabilitation for lower limb orthopaedic conditions do much less physical activity than recommended in guidelines for healthy older adults: an observational study

QUESTION

Are ambulant patients who are admitted for inpatient rehabilitation for a lower limb orthopaedic condition active enough to meet current physical activity guidelines?

DESIGN

Prospective observational study.

PARTICIPANTS

Adults admitted for inpatient rehabilitation for a lower limb orthopaedic condition who were cognitively alert and able to walk independently or with assistance.

OUTCOME MEASURES

Participants wore an activity monitor for three full days. Daily time spent in moderate intensity physical activity was used to determine whether the levels of physical activity recommended in clinical guidelines were achieved.

RESULTS

Fifty-four participants with a mean age of 74 years (SD 11) took a median of 398 (IQR 140 to 993) steps per day and spent a median of 8 (IQR 3 to 16) minutes walking per day. No participant completed a 10-minute bout of moderate intensity physical activity during the monitoring period. One participant accumulated 30 minutes of moderate intensity physical activity and nine participants accumulated 15 minutes of moderate intensity physical activity in a day. Physical activity was associated with shorter length of stay (r=-0.43) and higher functional status on discharge (r=0.39).

CONCLUSIONS

Adults with lower limb orthopaedic conditions in inpatient rehabilitation are relatively inactive and do not meet current physical activity guidelines for older adults. Results of this study indicate that strategies to increase physical activity are required.

A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement

BACKGROUND

Total knee replacement (TKR) is a common and effective surgical procedure to relieve advanced knee arthritis that persists despite comprehensive medical treatment. Although TKR has excellent technical outcomes, significant variation in patient-reported functional improvement post-TKR exists. Evidence suggests that consistent post-TKR exercise and physical activity is associated with functional gain, and that this relationship is influenced by emotional health. The increasing use of TKR in the aging US population makes it critical to find strategies that maximize functional outcomes.

METHODS/DESIGN

This randomized clinical trial (RCT) will test the efficacy of a theory-based telephone-delivered Patient Self-Management Support intervention that seeks to enhance adherence to independent exercise and activity among post- TKR patients. The intervention consists of 12 sessions, which begin prior to surgery and continue for approximately 9 weeks post-TKR. The intervention condition will be compared to a usual care control condition using a randomized design and a probabilistic sample of men and women. Assessments are conducted at baseline, eight weeks, and six- and twelve- months. The project is being conducted at a large healthcare system in Massachusetts. The study was designed to provide greater than 80% power for detecting a difference of 4 points in physical function (SF36/Physical Component Score) between conditions (standard deviation of 10) at six months with secondary outcomes collected at one year, assuming a loss to follow up rate of no more than 15%.

DISCUSSION

As TKR use expands, it is important to develop methods to identify patients at risk for sub-optimal functional outcome and to effectively intervene with the goal of optimizing functional outcomes. If shown efficacious, this peri-TKR intervention has the potential to change the paradigm for successful post-TKR care. We hypothesize that Patient Self-Management Support to enhance adherence to independent activity and exercise will enhance uniform, optimal improvement in post-TKR function and patient autonomy, the ultimate goals of TKR.

Step activity monitoring to assess ambulation before and after total ankle arthroplasty

BACKGROUND

The study objective was to compare walking activity before and after total ankle arthroplasty (TAA).

METHODS

Nineteen patients who underwent TAA were prospectively reviewed with a dedicated ambulatory activity-monitoring device. Patients were tested 1 month prior to surgery, and at least 18 months post-operative. Ambulatory parameters included number of steps at different cadences and time spent walking at different paces. The American Orthopaedic Foot and Ankle (AOFAS) hindfoot scale was assessed at similar intervals.

RESULTS

Following TAA, there was significant improvement in the number of steps walked at normal cadence, while importantly the number of steps walked at low and medium cadence decreased. There was no significant difference between the time actually spent walking at any cadence after arthroplasty. The mean AOFAS hindfoot scale significantly improved.

CONCLUSIONS

Following TAA, patients show an improved walking pace and AOFAS hindfoot scale, but no difference in the amount of time spent walking.

The Chitranjan Ranawat Award: functional outcome after total knee replacement varies with patient attributes

Total knee replacement effectively relieves arthritis pain but improvement in physical function varies. A clearer understanding of the patient attributes associated with differing levels of functional gain after TKR is critical to surgical decision making. We reviewed 8050 primary, unilateral TKR patients enrolled in a prospective registry between 2000 and 2005 who had complete data. We evaluated associations between 12-month function (SF12/PCS) and preoperative gender, age, BMI, emotional health (MCS), knee diagnosis, quadriceps strength, and physical function (PCS). More than 98% of patients reported pain relief (KS pain score). At 12 months, mean PCS gain was 13.6 points, but the distribution was bimodal. The mean gain in PCS in the 63% of patients with greater improvement was 21 (SD = 7), and 4.1 (SD = 7) in the remaining 37%. Increased likelihood of poor functional gain was associated with older age, body mass index (BMI) over 40, lower MCS, and poor quadriceps strength. While two-thirds of patients reported functional gain well above national average at 12 months post-TKR, 37% reported limited functional improvement. Further understanding of the patient attributes associated with limited improvement will guide the design of innovative strategies to improve functional outcomes.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

A Cross-Sectional Investigation of Status Post–Lower Extremity Joint Replacement Patients

The objective of this cross-sectional investigation is to describe a cohort of 275 status post joint replacement patients who received home health services from an orthopedic home health agency in St. Louis, Missouri. This study also aims to determine if these patients achieved statistically significant improvements in their functional mobility skills, pain, and emotional status. Demographic data were collected together with functional mobility elements from the Outcome and Assessment Information Set pertinent to the rehabilitation of status post joint replacement patients on admission and discharge from home care. Because of the limited nature of participant selection and convenience sampling, no correlations or trends were established among the data collected. However, this cross-sectional analysis validated the incidence of a patient subpopulation that is admitted directly to home care after undergoing joint replacement surgery and demonstrated that these patients achieved significant positive outcomes in functional measures.