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Annaswamy TM, Grover P, Douglas NF, Poploski KM, Anderson CA, Clark MA, Flores AM, Hafner BJ, Hoffman JM, Kinney AR, Ressel K, Sánchez J, Whitten MJ, Resnik L, McDonough CM. Relevance of learning health systems to physiatrists and its synergy with implementation science: A commentary. PM R 2024. [PMID: 38967539 DOI: 10.1002/pmrj.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 01/17/2024] [Accepted: 02/25/2024] [Indexed: 07/06/2024]
Abstract
As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs.
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Affiliation(s)
- Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Prateek Grover
- Department of Physical Medicine & Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Natalie F Douglas
- Department of Communication Sciences and Disorders, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Kathleen M Poploski
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Catherine A Anderson
- Department of Counseling, Rehabilitation and Human Services, College of Education, Hospitality, Health and Human Sciences, University of Wisconsin, Stout, Wisconsin, USA
| | - Melissa A Clark
- Departments of Health Services Policy and Practice and Obstetrics and Gynecology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ann Marie Flores
- Departments of Physical Therapy and Human Movement Sciences and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Brian J Hafner
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeanne M Hoffman
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Adam R Kinney
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Kristin Ressel
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer Sánchez
- Department of Counselor Education, College of Education, Florida Atlantic University, Boca Raton, Florida, USA
| | - Margarite J Whitten
- Departments of Health Services Policy and Practice and Obstetrics and Gynecology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Linda Resnik
- Departments of Health Services Policy and Practice and Obstetrics and Gynecology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Christine M McDonough
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Wu C, McAdam A, Siverling S, Nguyen J, Edwards D. Factors Associated With Higher Utilization of Outpatient Physical Therapy for Patients Who Have Undergone Primary Total Joint Arthroplasty: A Retrospective Cohort Study. HSS J 2024; 20:51-56. [PMID: 38356743 PMCID: PMC10863595 DOI: 10.1177/15563316231210556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 02/16/2024]
Abstract
Background Research has identified predictive factors for inpatient complications and short-term recovery following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Predictors that may influence length of care in outpatient physical therapy (PT) have yet to be examined. Doing so may improve the quality and efficiency of PT care following TKA and THA. Purpose The aim of this study was to determine factors associated with a higher utilization of outpatient PT visits for patients who have had primary THA or TKA. Methods A retrospective cohort study was performed using a population of 5147 patients who underwent THA and TKA between January 2017 and October 2022. Demographic and clinical factors were analyzed to determine which factors influenced PT utilization. Results Our multivariable linear regression model revealed that female sex, need for inpatient PT visits, and TKA as opposed to THA were significantly associated with an increase in outpatient PT visits. Older age, number of telerehabilitation visits, and history of depression were associated with fewer outpatient PT visits while accounting for all other variables. Conclusions The results of this retrospective analysis may help to identify some potential factors including TKA vs THA, patient age, and a history of depression that can be evaluated prospectively in future studies to determine whether they predict subsequent outpatient PT utilization.
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Affiliation(s)
- Curtis Wu
- Rehabilitation and Performance, Hospital for Special Surgery, New York, NY, USA
| | - Ashleigh McAdam
- Rehabilitation and Performance, Hospital for Special Surgery, New York, NY, USA
| | - Scott Siverling
- Rehabilitation and Performance, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Nguyen
- Rehabilitation and Performance, Hospital for Special Surgery, New York, NY, USA
| | - Danielle Edwards
- Rehabilitation and Performance, Hospital for Special Surgery, New York, NY, USA
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Graber J, Churchill L, Struessel T, O'Malley S, Bade M, Stevens-Lapsley J. Expert Consensus for the Use of Outpatient Rehabilitation Visits After Total Knee Arthroplasty: A Delphi Study. J Orthop Sports Phys Ther 2023; 53:566–574. [PMID: 37428802 DOI: 10.2519/jospt.2023.11840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
OBJECTIVE: There is no consensus for how to use rehabilitation visits after total knee arthroplasty (TKA). We sought to develop expert recommendations for outpatient rehabilitation visit usage after TKA. DESIGN: Delphi study. METHODS: First, we developed a broad list of preliminary visit usage recommendations, which were specific to patients' recovery status (ie, slow, typical, or fast recovery) and time since surgery. We then invited 49 TKA experts to participate on a Delphi panel. During round 1, we surveyed panelists regarding their level of agreement with each preliminary recommendation. We conducted additional Delphi rounds as needed to build consensus, which we defined using the RAND/UCLA method. We updated the survey each round based on panelist feedback and responses from the previous round. RESULTS: Thirty panelists agreed to participate, and 29 panelists completed 2 Delphi rounds. The panel reached consensus on recommendations related to visit frequency, visit timing, and the use of telerehabilitation. The panel recommended that outpatient rehabilitation should begin within 1 week after surgery at a frequency of 2 times per week for the first postoperative month regardless of recovery status. The panel recommended different visit frequencies depending on the patient's recovery status for postoperative months 2 to 3. The panel agreed that telerehabilitation can be recommended for most patients after TKA, but not for patients recovering slowly. CONCLUSION: We used the Delphi process to develop expert recommendations for the use of outpatient rehabilitation visits after TKA. We envision these recommendations could help patients decide how to use visits based on their own preferences. J Orthop Sports Phys Ther 2023;53(9):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11840.
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Affiliation(s)
- Jeremy Graber
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Laura Churchill
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Tamara Struessel
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Shane O'Malley
- Physical Medicine and Rehabilitation Services, VA Eastern Colorado Health Care System, Aurora, CO
| | - Michael Bade
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Jennifer Stevens-Lapsley
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
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Zhang L, Li H, Bai L, Ji N. Patients with Kashin-Beck Disease Obtained Lower Functional Activities but Better Satisfaction Than Patients with Osteoarthritis After Total Knee Arthroplasty: A Retrospective Study. Clin Interv Aging 2022; 17:1657-1662. [DOI: 10.2147/cia.s388401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
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Capin JJ, Bade MJ, Jennings JM, Snyder-Mackler L, Stevens-Lapsley JE. Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures. Phys Ther 2022; 102:6556168. [PMID: 35358318 PMCID: PMC9393064 DOI: 10.1093/ptj/pzac033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/29/2021] [Accepted: 02/02/2022] [Indexed: 11/14/2022]
Abstract
Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy.
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Affiliation(s)
- Jacob J Capin
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA,Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, USA
| | - Michael J Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado, USA,Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado, USA
| | - Lynn Snyder-Mackler
- Department of Physical Therapy, Department of Biomedical Engineering, and Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA,Address all correspondence to Dr. Stevens-Lapsley at ; Follow the author(s): @JacobCapin, @PhysioBade, @DocLSmack, @JSLapsley
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Aoyagi K, Neogi T, Peloquin C, Dubreuil M, Marinko L, Camarinos J, Felson DT, Kumar D. Association of Physical Therapy Interventions With Long-term Opioid Use After Total Knee Replacement. JAMA Netw Open 2021; 4:e2131271. [PMID: 34705013 PMCID: PMC8552057 DOI: 10.1001/jamanetworkopen.2021.31271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Many individuals who undergo total knee replacement (TKR) become long-term opioid users after TKR. Associations of physical therapy (PT) interventions before or after TKR with long-term use of opioids are not known. OBJECTIVES To evaluate associations of PT interventions before and after TKR with long-term opioid use after TKR. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the OptumLabs Data Warehouse on 67 322 individuals aged 40 years or older who underwent TKR from January 1, 2001, to December 31, 2016, stratified by history of opioid use. The analyses for the study included data from January 1, 1999, to December 31, 2018. EXPOSURES Any PT interventions within 90 days before or after TKR, post-TKR PT dose as number of sessions (ie, 1-5, 6-12, and ≥13 sessions), post-TKR PT timing as number of days to initiation of care (ie, <30 days, 31-60 days, or 61-90 days after TKR), and post-TKR PT type (ie, active vs passive). MAIN OUTCOMES AND MEASURES The association of pre- and post-TKR PT with risk of long-term opioid use occurring more than 90 days after TKR was assessed using logistic regression while adjusting for confounders, including age, sex, race and ethnicity (Asian, Black, Hispanic, or White), obesity, type of insurance, geographical location, and physical and mental health comorbidities. RESULTS A total of 38 408 opioid-naive individuals (21 336 women [55.6%]; mean [SD] age, 66.2 [9.2] years) and 28 914 opioid-experienced individuals (18 426 women [63.7%]; mean [SD] age, 64.4 [9.3] years) were included. Receipt of any PT before TKR was associated with lower odds of long-term opioid use in the opioid-naive (adjusted odds ratio [aOR], 0.75 [95% CI, 0.60-0.95]) and opioid-experienced (aOR, 0.75 [95% CI, 0.70-0.80]) cohorts. Receipt of any post-TKR PT was associated with lower odds of long-term use of opioids in the opioid-experienced cohort (aOR, 0.75 [95% CI, 0.70-0.79]). Compared with 1 to 5 sessions of PT after TKR, 6 to 12 sessions (aOR, 0.82 [95% CI, 0.75-0.90]) and 13 or more sessions (aOR, 0.71 [95% CI, 0.65-0.77) were associated with lower odds in the opioid-experienced cohort. Compared with initiation of PT within 30 days after TKR, initiation 31 to 60 days or 61 to 90 days after TKR were associated with greater odds in the opioid-naive (31-60 days: aOR, 1.45 [95% CI, 1.19-1.77]; 61-90 days: aOR, 2.15 [95% CI, 1.43-3.22]) and opioid-experienced (31-60 days: aOR, 1.10 [95% CI, 1.02-1.18]; 61-90 days: aOR, 1.32 [95% CI, 1.12-1.55]) cohorts. Compared with passive PT, active PT was not associated with long-term opioid use in the opioid-naive (aOR, 1.00 [95% CI, 0.81-1.24]) or opioid-experienced (aOR, 0.99 [95% CI, 0.92-1.07]) cohorts. CONCLUSIONS AND RELEVANCE This cohort study suggests that receipt of PT intervention before and after TKR, receipt of 6 or more sessions of PT care after TKR, and initiation of PT care within 30 days after TKR were associated with lower odds of long-term opioid use. These findings suggest that PT may help reduce the risk of long-term opioid use after TKR.
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Affiliation(s)
- Kosaku Aoyagi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Tuhina Neogi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Christine Peloquin
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Maureen Dubreuil
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- OptumLabs, Eden Prairie, Minnesota
| | - Lee Marinko
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
| | - James Camarinos
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
| | - David T. Felson
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Deepak Kumar
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
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Physical Therapy Use, Costs, and Value for Latent Classes of Good vs Poor Outcome in Patients Who Catastrophize About Their Pain Prior to Knee Arthroplasty. Arch Phys Med Rehabil 2021; 102:1347-1351. [PMID: 33689694 DOI: 10.1016/j.apmr.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine use, costs, and value of physical therapy (PT) among subgroups. DESIGN We conducted an observational study of data from a randomized trial of a pain coping skills intervention. Good and poor outcome subgroups were determined based on Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) Pain and Physical Function scores. The use and costs of PT care as well as changes in WOMAC Pain and Physical Function scores over 4 time periods during a 1-year follow-up were reported. We compared the number of PT visits, total PT costs, and cost per 1-unit improvement in WOMAC scores for the 2 latent subgroups. SETTING Five academic medical centers. PARTICIPANTS Patients who catastrophized about their pain prior to knee arthroplasty (N=384). INTERVENTIONS Pain coping skills training, arthritis education, and usual care. MAIN OUTCOME MEASURES The WOMAC Pain Scale was the primary outcome. RESULTS The value of PT was lower and the cost of PT was higher for poor vs good outcome subgroups beginning 2 months after knee arthroplasty. For example, during the 2- to 6-month period, participants in the poor outcome subgroup incurred a PT cost of $5181.22 per 1-unit improvement in WOMAC Pain compared with $437.87 per 1-unit improvement in WOMAC Pain for the good outcome subgroup (P<.001). From the 6- to 12-month period, WOMAC scores worsened for the poor outcome subgroup, indicating no benefit from PT. CONCLUSIONS Patients in 2 latent classes demonstrated clinically important differences in value of PT. Future research should identify rehabilitation-based interventions that reduce utilization and enhance effectiveness for patients at high risk for poor outcome.
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Orndahl CM, Perera RA, Riddle DL. Associations Between Physical Therapy Visits and Pain and Physical Function After Knee Arthroplasty: A Cross-Lagged Panel Analysis of People Who Catastrophize About Pain Prior to Surgery. Phys Ther 2020; 101:5912802. [PMID: 32990311 PMCID: PMC8325107 DOI: 10.1093/ptj/pzaa182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Physical therapy visit number and timing following knee arthroplasty (KA) are variable in daily practice. The extent to which the number and timing of physical therapy visits are associated with current and future pain and function-and, alternatively, whether pain and function are associated with the number of future physical therapy visits following KA-are unknown. The purpose of this study was to determine temporal and reciprocal associations between the number of physical therapy visits and future pain and function in people with KA. METHODS A cross-lagged panel design was applied to a secondary analysis of data from a randomized clinical trial of patients with pain catastrophizing. The 326 participants underwent KA and completed at least 7 of 9 health care diaries over the year following surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function subscales were completed preoperatively and multiple times during follow-up. Separate cross-lagged panel analyses were conducted for WOMAC pain and physical function. RESULTS From surgery to 2 months postsurgery, reciprocal associations were generally not found between physical therapy visit number and future pain or function. From 2 to 6 months postsurgery, a greater number of physical therapy weekly visits were associated with higher (worse) 6-month pain and function. Higher (worse) WOMAC pain at 2 and 6 months led to more visits from 2 to 6 and 6 to 12 months, respectively. CONCLUSIONS Higher pain scores 2 months postsurgery were associated with higher physical therapy use in the 2 to 6 months following surgery. However, patients with increased physical therapy use from 2 to 6 months had significantly higher pain scores 6 months postsurgery. Those patients with persistent pain 6 months postsurgery were higher users of physical therapy 6 to 12 months postsurgery. This reciprocal positive association between pain and physical therapy during this time period suggests minimal benefit of physical therapy despite an increased physical therapy use for patients with higher pain. IMPACT This is the first study to determine the association between the number and timing of physical therapy visits and current and future pain and function. Based on the results, physical therapy might not be a cost-effective strategy to treat patients with persistent pain following KA.
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Affiliation(s)
- Christine M Orndahl
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel L Riddle
- Departments of Physical Therapy, Orthopedic Surgery, and Rheumatology, Virginia Commonwealth University, Richmond, VA 23298-0224, USA,Address all correspondence to Dr Riddle at:
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Jette DU, Hunter SJ, Burkett L, Langham B, Logerstedt DS, Piuzzi NS, Poirier NM, Radach LJL, Ritter JE, Scalzitti DA, Stevens-Lapsley JE, Tompkins J, Zeni Jr J. Physical Therapist Management of Total Knee Arthroplasty. Phys Ther 2020; 100:1603-1631. [PMID: 32542403 PMCID: PMC7462050 DOI: 10.1093/ptj/pzaa099] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.
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Affiliation(s)
- Diane U Jette
- FAPTA, MGH, Institute of Health Professions, Boston, Massachusetts
| | | | - Lynn Burkett
- ONC, National Association of Orthopaedic Nurses (NAON), Wyomissing, Pennsylvania
| | - Bud Langham
- Home Health and Hospice Services, Encompass Health, Birmingham, Alabama
| | - David S Logerstedt
- Department of Physical Therapy, University of the Sciences, Philadelphia, Pennsylvania
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Noreen M Poirier
- Department of Orthopedics and Rehabilitation, University of Wisconsin (UW) Health, Madison, Wisconsin
| | - Linda J L Radach
- Consumers United for Evidence Based Healthcare, Lake Forest Park, Washington
| | - Jennifer E Ritter
- Department of Rehabilitation Services/Physical Therapy, University of Pittsburgh Medical Center (UPMC) St Margaret Hospital/Catholic Relief Services, Pittsburgh, Pennsylvania
| | - David A Scalzitti
- OCS, School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado at Denver & Health Sciences Center, Denver, Colorado
| | - James Tompkins
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona
| | - Joseph Zeni Jr
- Department of Physical Therapy, University of Delaware, Newark, Delaware
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Tawy GF, Rowe P, Biant L. Advanced functional biomechanical analysis of medial rotation knee arthroplasty. Knee 2020; 27:854-862. [PMID: 32037233 DOI: 10.1016/j.knee.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 01/08/2020] [Accepted: 01/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Medacta GMK-Sphere total knee arthroplasty (TKA) is designed to mimic the movements and stabilimidty of a natural knee for optimal post-operative function and mobility. This study aimed to quantify the early functional outcome of patients with this implant. METHODS Patients due to undergo TKA to treat end-stage osteoarthritis were recruited into this study. Functional tests of knee range of motion (ROM), strength, and gait kinematics were carried out pre-operatively and one year post-operatively at routine clinics. Motion capture technology and a force transducer were used to collect all data. Normality tests were completed on all data sets to confirm normal distribution of the data, then paired t-tests were used to statistically compare the results. The level of significance was set as α = 0.05. RESULTS Sixty-three patients underwent pre-operative assessments; of which 30 returned one year post-operatively and consented to have follow-up testing. The operative knee was found to have poorer function than the contralateral knee pre-operatively (p < 0.05). Post-operatively, knee ROM significantly improved on the operative side to a mean of 116.1 ± 19.0. Gait kinematics also improved, especially in the frontal plane, but some abnormal traits remained in the sagittal plane. Knee strength decreased post-operatively. CONCLUSIONS The Medacta GMK-Sphere TKA improves knee range of motion sufficiently within the first postoperative year to allow patients to carry out most activities of daily living (>110° knee flexion), but continued poor knee strength may limit their abilities to complete tasks which are more biomechanically demanding than walking.
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Affiliation(s)
- Gwenllian Fflur Tawy
- The Division of Cell Matrix Biology & Regenerative Medicine, University of Manchester, Stopford Building, 99 Oxford Road, Manchester M13 9PG, United Kingdom; The Department of Biomedical Engineering, University of Strathclyde, Wolfson Centre, 106 Rottenrow, Glasgow G4 0NW, United Kingdom.
| | - Philip Rowe
- The Department of Biomedical Engineering, University of Strathclyde, Wolfson Centre, 106 Rottenrow, Glasgow G4 0NW, United Kingdom.
| | - Leela Biant
- The Division of Cell Matrix Biology & Regenerative Medicine, University of Manchester, Stopford Building, 99 Oxford Road, Manchester M13 9PG, United Kingdom.
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Incorporating hip abductor strengthening exercises into a rehabilitation program did not improve outcomes in people following total knee arthroplasty: a randomised trial. J Physiother 2019; 65:136-143. [PMID: 31208916 DOI: 10.1016/j.jphys.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 12/22/2022] Open
Abstract
QUESTION In adults following primary total knee arthroplasty, does the incorporation of hip abductor strengthening exercises into a 6-week rehabilitation program improve muscle strength, functional performance and patient-reported outcomes at the end of rehabilitation and at 26 weeks? DESIGN Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS One hundred and five adults admitted to an inpatient rehabilitation facility immediately following total knee arthroplasty. INTERVENTION Participants in both groups attended 12 days of inpatient physiotherapy followed by 6 weeks of outpatient physiotherapy, which aimed to improve knee range of movement, strength and mobility. The experimental group completed a standard rehabilitation protocol with the addition of hip abductor strengthening. The control group completed the same standard rehabilitation protocol, with the addition of 15 minutes of general functional exercises. OUTCOME MEASURES Primary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) and isometric hip abductor muscle strength normalised to body mass index. Secondary outcome measures included the stair climb test, 6-minute walk test, Timed Up and Go test, 40-m fast-paced walk test, 30-second chair stand test, step test, isometric quadriceps muscle strength, Lower Extremity Functional Scale, and Short Form-12. RESULTS The experimental intervention did not result in significantly greater improvements in hip strength, KOOS or any of the secondary outcome measures than the control intervention at 6 weeks or 26 weeks. CONCLUSION Similar improvements in muscle strength, functional performance and patient-reported outcomes were observed whether specific hip-strengthening exercises were incorporated or general functional exercises were continued instead as part of a postoperative rehabilitation program for participants after total knee arthroplasty. REGISTRATION ANZCTR 12615000863538.
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Effect of Physical Therapy Visits on Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction With and Without Concurrent Meniscal Repair. J Sport Rehabil 2019; 28:24-32. [PMID: 28787223 DOI: 10.1123/jsr.2017-0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/18/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Health care payment reform has increased employers and health insurance companies' incentive to take measures to control the rising costs of medical care in the United States. To date, limited research has investigated the influence outpatient physical therapy (PT) visits have on clinical outcomes following anterior cruciate ligament reconstruction (ACLR) with and without a concurrent meniscal repair. OBJECTIVE To examine the relationship between the number of PT visits and patient-reported outcome scores following ACLR outpatient rehabilitation. STUDY DESIGN Retrospective cohort. LEVEL OF EVIDENCE 2b. METHODS Patients following ACLR with (n = 62) and without (n = 328) meniscal repair were identified through an electronic medical record database. RESULTS Patients with more PT visits had higher knee outcome survey-activities of daily living (KOS-ADL) change scores (P = .01) following ACLR without meniscal repair. Younger patients yielded significantly higher KOS-ADL change scores (P = .05) in the same cohort. Patients in the semisupervised PT visit strata recorded an 11.1 higher KOS-ADL change score compared with patients within the unsupervised PT visit stratum (P = .02). Younger patients also yielded significantly larger reductions in numeric pain (P = .01) following ACLR without meniscal repair. No significant differences were found between PT visits and either patient-reported outcome following ACLR with meniscal repair. CONCLUSIONS Our findings suggest that younger patients and those in a semisupervised PT visit model have superior patient-reported outcomes following ACLR without meniscal repair. Preliminary findings indicate no relationship with PT visits and patient-reported outcomes in patients after ACLR with meniscal repair surgery. CLINICAL RELEVANCE These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.
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Adelani MA, Nunley RM, Clohisy JC, Barrack RL. Patient Perceptions of Home Health Care Services After Total Joint Replacement. Orthopedics 2018; 41:e713-e717. [PMID: 30168837 DOI: 10.3928/01477447-20180828-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/23/2018] [Indexed: 02/03/2023]
Abstract
Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].
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Copay AG, Eyberg B, Chung AS, Zurcher KS, Chutkan N, Spangehl MJ. Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part II: Lower Extremity. JBJS Rev 2018; 6:e2. [DOI: 10.2106/jbjs.rvw.17.00160] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Jin ZK, Yang Y, Xu CX, Yang B, Lammi MJ, Chang YH, Ling M, Guo X, Wang XQ. Outcomes of total knee arthroplasty in the adult Kashin-Beck disease with severe osteoarthritis. INTERNATIONAL ORTHOPAEDICS 2018; 43:323-331. [PMID: 29971707 DOI: 10.1007/s00264-018-4029-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 06/11/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Kashin-Beck disease (KBD) is an endemic osteoarthropathy, and the severe knee pain and functional limitations were seriously affecting the quality of life in patients with end-stage KBD. We retrospectively evaluated the clinical outcomes and the quality of life in KBD patients with total knee arthroplasty (TKA). METHODS A total of 22 subjects (25 knees) suffered KBD with severe knee pain and underwent primary TKA. Knee pain was measured by visual analogue scale (VAS), and the knee function was evaluated by Knee Society Clinical Rating System Score (KSS). KBD Quality of Life (KBDQOL) was used to evaluate the quality of life in KBD patients before and after TKA. RESULTS There were no major complications after TKA. The levels of VAS score were obviously deceased in post-operation than that in pre-operation. The levels of KSS score were increased in one year after TKA compared with the pre-operative values, and it maintained a higher level on three years after TKA. The average KBDQOL score level of each domain in pre-operation and one and three years after TKA was increased accordingly. The average scores of physical function, activity limitation, support of society, mental health, and general health in one year after TKA were significantly higher than those in pre-operation. CONCLUSIONS TKA can reduce knee pain, improve knee function, and improve the quality life in KBD patients. KBDQOL questionnaire may be a promising instrument for assessing the quality life in KBD patients.
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Affiliation(s)
- Zhan-Kui Jin
- Department of Orthopaedics, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China
| | - Ying Yang
- Xi'an Medical University, Xi'an, 710021, China
| | - Cui-Xiang Xu
- Center of Shaanxi Provincial Clinical Laboratory, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China
| | - Bo Yang
- Department of Orthopaedics, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China
| | - Mikko J Lammi
- Institute of Endemic Diseases, School of Public Health of Health Science Center, Xi'an Jiaotong University, Key Laboratory of Trace Elements and Endemic Diseases, National Health and Family Planning Commission, Xi'an, 710061, China
| | - Yan-Hai Chang
- Department of Orthopaedics, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China
| | - Ming Ling
- Department of Orthopaedics, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China
| | - Xiong Guo
- Institute of Endemic Diseases, School of Public Health of Health Science Center, Xi'an Jiaotong University, Key Laboratory of Trace Elements and Endemic Diseases, National Health and Family Planning Commission, Xi'an, 710061, China
| | - Xiao-Qing Wang
- Department of Orthopaedics, Shaanxi Provincial People's Hospital (the Affiliated Hospital of Xi'an Medical University), Xi'an, 710068, China. .,Xi'an Medical University, Xi'an, 710021, China.
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Pozzi F, White DK, Snyder-Mackler L, Zeni JA. Restoring physical function after knee replacement: a cross sectional comparison of progressive strengthening vs standard physical therapy. Physiother Theory Pract 2018; 36:122-133. [PMID: 29877749 DOI: 10.1080/09593985.2018.1479475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: The purpose of this study is to compare the functional status of patients 12 months after total knee arthroplasty (TKA) who underwent progressive strengthening or standard of care rehabilitation to older adults without knee joint pain. Methods: This cross-sectional design study included 165 participants in the progressive strengthening group, 40 participants in the standard of care group, and 88 older adults (control group). The Knee Outcome Survey - Activity of Daily Living, knee active range of motion (ROM), quadriceps strength, and performance tests were compared between groups using a one-way ANOVA. The proportions of participants in both TKA groups who achieved the lower bound of the 95% confidence interval of the control group were compared using a Fisher's exact test. Results: Significant between-group effects were found for all variables (p < 0.001). The control group had better outcomes than both the progressive strengthening and standard of care groups (p < 0.001). Compared to the standard of care group, a higher proportion of participants in the progressive strengthening group achieved the lower bound cutoff for active knee extension ROM (p = 0.042), quadriceps strength (p = 0.032), and stair climbing time (p = 0.029). Conclusion: More participants in the progressive strengthening group had physical function that was similar to the healthy control group, when compared to the standard of care group. Progressive strengthening rehabilitation may be more effective in restoring normative levels of function after TKA than standard of care.
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Affiliation(s)
- Federico Pozzi
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Daniel K White
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | | | - Jospeh A Zeni
- Department of Physical Therapy, Rutgers University, Newark, NJ, USA
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Lentschener C, Gaujoux S, Mion G, Dousset B, Baillard C. Most patients undergoing phaeochromocytoma removal could be safely discharged from the post-anaesthesia care unit to the ward after three hours monitoring. Br J Anaesth 2018; 120:879-880. [PMID: 29576133 DOI: 10.1016/j.bja.2017.12.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 11/26/2022] Open
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Joice MG, Bhowmick S, Amanatullah DF. Perioperative Physiotherapy in Total Knee Arthroplasty. Orthopedics 2017; 40:e765-e773. [PMID: 28530765 DOI: 10.3928/01477447-20170518-03] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/31/2016] [Indexed: 02/03/2023]
Abstract
Total knee arthroplasty has a high success rate. In the interest of enhancing patient outcomes, numerous perioperative interventions have been studied, including preoperative education, preoperative rehabilitation, postoperative inpatient rehabilitation, continuous passive motion, postoperative outpatient rehabilitation, unsupervised in-home exercises, telerehabilitation, and various combinations of these. This comprehensive review analyzes the existing body of evidence on these perioperative interventions and examines some burgeoning opportunities in rehabilitation after total knee arthroplasty in the interest of improving patient outcomes and ensuring sustainable health care utilization for the future of total knee arthroplasty. [Orthopedics. 2017; 40(5):e765-e773.].
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Bade MJ, Struessel T, Dayton M, Foran J, Kim RH, Miner T, Wolfe P, Kohrt WM, Dennis D, Stevens-Lapsley JE. Early High-Intensity Versus Low-Intensity Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2017; 69:1360-1368. [PMID: 27813347 DOI: 10.1002/acr.23139] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/20/2016] [Accepted: 11/01/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine the safety and efficacy of a high-intensity (HI) progressive rehabilitation protocol beginning 4 days after total knee arthroplasty (TKA) compared to a low-intensity (LI) rehabilitation protocol. METHODS A total of 162 participants (mean ± SD ages 63 ± 7 years; 89 women) were randomized to either the HI group or LI group after TKA. Key components of the HI intervention were the use of progressive resistance exercises and a rapid progression to weight-bearing exercises and activities. Both groups were treated in an outpatient setting 2 to 3 times per week for 11 weeks (26 total sessions). Outcomes included the stair climbing test (SCT; primary outcome), timed-up-and-go (TUG) test, 6-minute walk (6MW) test, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-item Short Form health survey (SF-12), knee range of motion (ROM), quadriceps and hamstring strength, and quadriceps activation. Outcomes were assessed preoperatively and at 1, 2, 3 (primary end point), 6, and 12 months postoperatively. RESULTS There were no significant differences between groups at 3 or 12 months in SCT, TUG, 6MW, WOMAC scores, knee ROM, quadriceps and hamstrings strength, quadriceps activation, or adverse event rates. By 12 months, outcomes on the 6MW, TUG, WOMAC, SF-12, quadriceps and hamstring strength, and quadriceps activation had improved beyond baseline performance in both groups. CONCLUSION Both the HI and LI interventions were effective in improving strength and function after TKA. HI progressive rehabilitation is safe for individuals after TKA. However, its effectiveness may be limited by arthrogenic muscular inhibition in the early postoperative period.
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Affiliation(s)
| | | | | | - Jared Foran
- The Steadman Clinic and The Steadman Philippon Research Institute, Vail, Colorado
| | - Raymond H Kim
- The Steadman Clinic and The Steadman Philippon Research Institute, Vail, Colorado
| | - Todd Miner
- Colorado Joint Replacement, Denver, Colorado
| | - Pamela Wolfe
- University of Colorado Anschutz Medical Campus, Aurora
| | - Wendy M Kohrt
- University of Colorado Anschutz Medical Campus, Aurora, and Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado
| | | | - Jennifer E Stevens-Lapsley
- University of Colorado Anschutz Medical Campus, Aurora, and Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado
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A Comparative Study to Determine Functional and Clinical Outcome Differences Between Patients Receiving Outpatient Direct Physical Therapy Versus Home Physical Therapy Followed by Outpatient Physical Therapy After Total Knee Arthroplasty. Orthop Nurs 2016; 35:382-390. [DOI: 10.1097/nor.0000000000000295] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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