Association Between Exercise Therapy Dose and Functional Improvements in the Early Postoperative Phase After Hip and Knee Arthroplasty: An Observational Study

Hip strengthening exercise dosage is not associated with clinical improvements after total hip arthroplasty - a prospective cohort study (the PHETHAS-1 study)

BACKGROUND

Postoperative rehabilitation exercise is commonly prescribed after total hip arthroplasty (THA), but its efficacy compared to no or minimal rehabilitation exercise has been questioned. Preliminary efficacy would be indicated if a dose-response relationship exists between performed exercise dose and degree of postoperative recovery. The objective was to evaluate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the association between performed exercise dose and change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery.

METHODS

A prospective cohort study was conducted. Following primary THA, patients were prescribed home-based rehabilitation exercise using elastic bands. Performed exercise dose (repetitions/week) was objectively measured using attached sensor technology. Primary outcome was change in gait speed (40 m fast-paced walk test). Secondary outcomes included patient-reported hip disability. In the primary analysis, a linear regression model was used.

RESULTS

Ninety-four patients (39 women) with a median age of 66.5 years performed a median of 339 exercise repetitions/week (1st-3rd quartile: 209-549). Across outcomes, participants significantly improved from 3 to 10-week follow-up. The association between performed exercise dose and change in mean gait speed was 0.01 m/s [95% CI: -0.01; 0.02] per 100 repetitions.

CONCLUSIONS

We found no indication of preliminary efficacy of home-based rehabilitation exercise using elastic bands, as no significant and clinically relevant associations between performed exercise dose and changes in outcomes were present. Trials comparing postoperative rehabilitation exercise with no exercise early after THA are warranted.

TRIAL REGISTRATION

Pre-registered: ClinicalTrials.gov (Identifier: NCT03109821, 12/04/2017).

Comparison of a fast track protocol and standard care after hip arthroplasty in the reduction of the length of stay and the early weight-bearing resumption: study protocol for a randomized controlled trial

BACKGROUND

To date, hip arthroplasty is one of the most commonly performed surgical procedures, with growing worldwide demand. In recent decades, major progress made in terms of surgical technique, biomechanics, and tribology knowledge has contributed to improve the medical and functional management of the patient. This study aims to assess if the application of a fast track protocol, consisting of a preoperative educational intervention, adequate postoperative pain control, and intensive rehabilitation intervention, reduces the length of stay (LOS) and allows the early functional recovery compared to standard clinical practice for patients undergoing hip arthroplasty.

METHODS

The study population consists of 90 patients with primary arthrosis of the hip with an anterior indication of hip arthroplasty. The exclusion criteria are older than 70 years, a contraindication to performing spinal anesthesia, and bone mass index (BMI) greater than 32. Participants, 45 for each group, are randomly allocated to one of two arms: fast track clinical pathway or standard care protocol. During allocation, baseline parameters such as Harris Hip Score (HHS) and Western Ontario and McMaster Universities (WOMAC) index are collected. On the third postoperative day, the functional autonomy for each patient is assessed by the Iowa Level of Assistance (ILOA) scale, and it is expected the discharge for patients in the fast track group (primary outcome). On the other hand, standard care patient discharge is expected after 5-7 days after surgery. During follow-up fixed at 6 weeks and 3, 6, and 12 months, HHS and WOMAC scores are collected for each patient (secondary outcomes).

DISCUSSION

Although total hip replacement has become a widespread standardized procedure, to the authors' knowledge, only few randomized controlled trials were performed to evaluate the effectiveness of fast track pathway vs. standard care procedure in the reduction of the LOS after hip arthroplasty. It is expected that our results collected by the application of minimally invasive surgical interventions with concomitant management of perioperative pain and bleeding and early functional rehabilitation will contribute to enriching the understanding of clinical and organizational aspects linked to fast track arthroplasty.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03875976 . Registered on 15 March 2019-"retrospectively registered".

Efficacy of Non-Invasive Radiofrequency-Based Diathermy in the Postoperative Phase of Knee Arthroplasty: A Double-Blind Randomized Clinical Trial

Total knee replacement (TKR) surgery ameliorates knee function and the quality of life of patients, although 20% still experience dissatisfaction due to pain limiting their function. Radiofrequency Diathermy (MDR) has shown improvements in knee osteoarthritis and patellofemoral pain syndrome. As such, this study aims to assess the effects of MDR in the postoperative treatment of TKR patients. Forty-two participants were allocated to an experimental, placebo, or control group. For two weeks, subjects performed daily knee exercises and MDR, knee exercises and placebo MDR, or only knee exercises. Data from the Visual Analogue Scale (VAS), Timed Up-and-Go (TUG) test, Five Times Sit-to-Stand Test (FSST), Western Ontario and McMaster Universities Arthritis Index (WOMAC), physical component summary (PCS), and the mental component summary (MCS) of the SF-12 questionnaire were collected. Group-by-time interaction was significant, with favorable results in the MDR group for VAS (p = 0.009) and WOMAC (p = 0.021). No significant differences were found for TUG, FSST, PCS, or MCS (p > 0.05). In conclusion, the addition of MDR to therapeutic knee exercises obtained better results for knee pain than exercise alone in patients who had recently undergone TKR surgery.

Clinical outcome of different skin closure in total-knee arthroplasty: running subcuticular closure vs intermittent closure: A retrospective study

An intermittent closure with silk suture is routinely used for closing different surgical wounds. However, subcuticular closure with absorbable sutures has gained considerable attention due to convenience and better cosmetic appearance.To compare the clinical outcomes and risk of surgical-site infection of subcuticular and intermittent closure after total-knee arthroplasty (TKA), 106 patients that underwent TKA between January 2017 to June 2019 at the Department of Orthopedics in Xiangya Hospital of Centre South University were retrospectively assessed. Forty-three had received running subcuticular closure (group A) and 58 underwent intermittent closure (group B). The Knee Society score was measured before and 6 months after operation. Inflammation markers including the serum levels of procalcitonin, interleukin-6, and C-reactive protein, and the erythrocyte sedimentation rate were evaluated before operation, 1 day after and 1 month after operation. Patient satisfaction with the closure was evaluated using the Likert scale at the last follow-up.No significant difference was seen in the 6-month postoperative Knee Society score, or in the 1-day and 6-month postoperative inflammation marker levels between both groups (P > .05). Likert scores were higher in group A compared to group B (4.0 ± 1.0 vs 3.6 ± 1.2, P < .05).Running subcuticular closure after TKA results in a better appearance compared to intermittent closure, although neither method has an advantage in terms of efficacy and risk of infection.

Pragmatic Home-Based Exercise after Total Hip Arthroplasty - Silkeborg: Protocol for a prospective cohort study (PHETHAS-1)

Introduction: Rehabilitation exercises are offered to patients after total hip arthroplasty (THA); however, the effectiveness and optimal type and dose of exercise remains unknown. The primary objective of this trial is to indicate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the relationship between the performed exercise dose and the change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery. The secondary objective is to investigate if a dose-response relationship exists between the performed exercise dose and changes in: hip-related disability, lower-extremity functional performance, and hip muscle strength Methods: In this prospective cohort study, patients scheduled for THA will be consecutively included until 88 have completed the intervention period from 3 to 10 weeks postoperatively. Participants perform the standard rehabilitation program with elastic band exercises. Exercise dose (exposure) will be objectively quantified using a sensor attached to the elastic band. The primary outcome is gait speed measured by the 40-m fast-paced walk test. Secondary outcomes include: patient reported hip disability (Hip disability and Osteoarthritis Outcome Score (HOOS)), hip muscle strength (hand-held dynamometry) and lower extremity function (30-s chair stand test). Discussion: This trial will add knowledge concerning the relationship between performed exercise dose and post-operative outcomes after THA. The protocol paper describes the study design and methods in detail, including the statistical analysis plan. Trial registration: Pre-registered on March 27, 2017 at ClinicalTrails.gov (ID: NCT03109821).

Pragmatic Home-Based Exercise after Total Hip Arthroplasty - Silkeborg: Protocol for a prospective cohort study (PHETHAS-1)

Introduction: Rehabilitation exercises are offered to patients after total hip arthroplasty (THA); however, the effectiveness and optimal type and dose of exercise remains unknown. The primary objective of this trial is to indicate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the relationship between the performed exercise dose and the change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery. The secondary objective is to investigate if a dose-response relationship exists between the performed exercise dose and changes in: hip-related disability, lower-extremity functional performance, and hip muscle strength Methods: In this prospective cohort study, patients scheduled for THA will be consecutively included until 88 have completed the intervention period from 3 to 10 weeks postoperatively. Participants perform the standard rehabilitation program with elastic band exercises. Exercise dose (exposure) will be objectively quantified using a sensor attached to the elastic band. The primary outcome is gait speed measured by the 40-m fast-paced walk test. Secondary outcomes include: patient reported hip disability (Hip disability and Osteoarthritis Outcome Score (HOOS)), hip muscle strength (hand-held dynamometry) and lower extremity function (30-s chair stand test). Discussion: This trial will add knowledge concerning the relationship between performed exercise dose and post-operative outcomes after THA. The protocol paper describes the study design and methods in detail, including the statistical analysis plan. Trial registration: Pre-registered on March 27, 2017 at ClinicalTrails.gov (ID: NCT03109821).

A professional development program increased the intensity of practice undertaken in an inpatient, upper limb rehabilitation class: A pre-post study

BACKGROUND/AIM

Increasing the intensity of practice is associated with improved upper limb outcomes, yet observed intensity levels during rehabilitation are low. The purpose of this study was to investigate: whether a professional development program would increase the intensity of practice undertaken in an inpatient, upper limb rehabilitation class; and whether any increase would be maintained six months after the cessation of the program.

METHOD

A pre-post study was conducted within an existing inpatient, upper limb rehabilitation class in a metropolitan hospital. Staff received a professional development program which included: a two day theoretical, practical and clinical training workshop covering evidence-based practice for upper limb rehabilitation after stroke; and three 1-hour meetings to revise evidence-based practice and discuss implementation of strategies. Intensity of practice, as measured by the proportion of practice time per class (%) and the number of repetitions per practice time (repetitions/min) observed during the 60-minute classes during one week, was recorded at baseline, end of program (12 months) and six months later (18 months).

RESULTS

Twenty-two (100%) staff attended at least one professional development program session; outcomes were measured across n = 15 classes (n = 30 patients). Between baseline and 12 months, the mean proportion of practice time per class increased by 52% (95% confidence interval (CI) 33-70; P < 0.001) and the mean number of repetitions per practice time increased by 5.1 repetitions/min (95% CI 1.7-8.4; P < 0.01). Between baseline and 18 months, the mean proportion of practice time per class increased by 53% (95% CI 36-69; P < 0.001) and the mean number of repetitions per practice time increased by 3.9 repetitions/min (95% CI 1.9-5.9; P < 0.001).

CONCLUSION

Providing professional development was associated with increased intensity of practice in an inpatient, upper limb rehabilitation class. The increase was maintained six months later.

Characteristics of Usual Physical Therapy Post-Total Knee Replacement and Their Associations With Functional Outcomes

OBJECTIVE

Although total knee replacement (TKR) surgery is highly prevalent and generally successful, functional outcomes post-TKR vary widely. Most patients receive some physical therapy (PT) following TKR, but PT practice is variable and associations between specific content and dose of PT interventions and functional outcomes are unknown. Research has identified exercise interventions associated with better outcomes but studies have not assessed whether such evidence has been translated into clinical practice. We characterized the content, dose, and progression of usual post-acute PT services following TKR, and examined associations of specific details of post-acute PT with patients' 6-month functional outcomes.

METHODS

Post-acute PT data were collected from patients who were undergoing primary unilateral TKR and participating in a clinical trial of a phone-based coaching intervention. PT records from the terminal episode of care were reviewed and utilization and exercise content data were extracted. Descriptive statistics and linear regression models characterized PT treatment factors and identified associations with 6-month outcomes.

RESULTS

We analyzed 112 records from 30 PT sites. Content and dose of specific exercises and incidence of progression varied widely. Open chain exercises were utilized more frequently than closed chain (median 21 [interquartile range (IQR) 4-49] versus median 13 [IQR 4-28.5]). Median (IQR) occurrence of progression of closed and open chain exercise was 0 (0-2) and 1 (0-3), respectively. Shorter timed stair climb was associated with greater total number of PT interventions and use and progression of closed chain exercises.

DISCUSSION

Data suggest that evidence-based interventions are underutilized and dose may be insufficient to obtain optimal outcomes.

Association of Physical Activity with Late-life Mobility Limitation among Women with Total Joint Replacement for Knee or Hip Osteoarthritis

OBJECTIVE

To examine the association between leisure-time physical activity (PA) and survival to age 85 with mobility limitation or death before age 85 after total knee (TKR) or total hip replacement (THR) for osteoarthritis (OA).

METHODS

This was a prospective study among participants from the Women's Health Initiative (WHI), recruited 1993-1998 (baseline age 65-79 yrs) and followed through 2012. Medicare claims data were linked to WHI data to determine TKR (n = 1986) and THR (n = 1034). Self-reported PA was collected before total joint replacement (TJR).

RESULTS

Women who were physically inactive before THR had the highest risk of mobility limitation at age 85 (OR 2.36, 95% CI 1.30-4.26) compared with women who had the highest amount of PA [> 17.42 metabolic equivalent of task (MET)-hrs/week]. Women who reported no moderate to vigorous PA (MVPA) before THR had the strongest risk of mobility limitation (OR 2.00, 95% CI 1.24-3.22) compared with women with the highest level of MPVA (≥ 15 MET-hrs/week). Women who were physically inactive before TKR had the highest risk of mobility limitation (OR 1.68, 95% CI 1.15-2.45) compared with women who had the highest PA level. Women who reported no MVPA before TKR had the strongest risk of mobility limitation (OR 1.60, 95% CI 1.16-2.19) compared with women with the highest level of MPVA. There were significant dose-response associations of lower PA levels with increased risk of late-life mobility limitation and death.

CONCLUSION

Women with lower PA levels before TJR were more likely to experience mobility limitation in late life following TJR for hip or knee OA.

Rehabilitation after total joint replacement: a scoping study

PURPOSE

The evidence supporting rehabilitation after joint replacement, while vast, is of variable quality making it difficult for clinicians to apply the best evidence to their practice. We aimed to map key issues for rehabilitation following joint replacement, highlighting potential avenues for new research.

MATERIALS AND METHODS

We conducted a scoping study including research published between January 2013 and December 2016, evaluating effectiveness of rehabilitation following hip and knee total joint replacement. We reviewed this work in the context of outcomes described from previously published research.

RESULTS

Thirty individual studies and seven systematic reviews were included, with most research examining the effectiveness of physiotherapy-based exercise rehabilitation after total knee replacement using randomized control trial methods. Rehabilitation after hip and knee replacement whether carried out at the clinic or monitored at home, appears beneficial but type, intensity and duration of interventions were not consistently associated with outcomes. The burden of comorbidities rather than specific rehabilitation approach may better predict rehabilitation outcome. Monitoring of recovery and therapeutic attention appear important but little is known about optimal levels and methods required to maximize outcomes.

CONCLUSIONS

More work exploring the role of comorbidities and key components of therapeutic attention and the therapy relationship, using a wider range of study methods may help to advance the field. Implications for Rehabilitation Physiotherapy-based exercise rehabilitation after total hip replacement and total knee replacement, whether carried out at the clinic or monitored at home, appears beneficial. Type, intensity, and duration of interventions do not appear consistently associated with outcomes. Monitoring a patient's recovery appears to be an important component. The available research provides limited guidance regarding optimal levels of monitoring needed to achieve gains following hip and knee replacement and more work is required to clarify these aspects. The burden of comorbidities appears to better predict outcomes regardless of rehabilitation approach.

The effectiveness of supplementary arm and upper body exercises following total hip arthroplasty for osteoarthritis in the elderly: a randomized controlled trial

OBJECTIVE

To determine whether arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes after hip arthroplasty.

DESIGN

Prospective, parallel, randomized, controlled trial.

SETTING

Orthopaedic and rehabilitation departments.

SUBJECTS

A total of 70 patients >60 years of age, who underwent hip replacement, out of 98 eligible candidates after exclusion criteria were implemented.

INTERVENTIONS

The study group took part in the supplementary arm and upper body exercise programme to be compared with the standard rehabilitation programme group.

MAIN OUTCOME

The primary outcome was a Harris Hip Score. Secondary outcomes were: Hand grip strength and Medical Outcomes Study 36-Item Short-Form Health Survey. Outcomes were assessed preoperatively, two weeks after surgery and at 12 weeks follow-up.

RESULTS

In the intervention group, significant improvements were found: in functional ability - Harris Hip Score after two (mean difference = 4.7 points) and 12 (mean difference = 5.85 points) weeks; in muscle strength - handgrip for both hands (mean difference for dominant hand = 4.16 and for the other hand = 2.8) after 12 weeks; and in role-physical dimension SF-36 Health Survey (mean difference = 6.42 points) after 12 weeks.

CONCLUSION

Results of this study indicate that arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes 12 weeks after hip arthroplasty.

Influence of structured telephone follow-up on patient compliance with rehabilitation after total knee arthroplasty

INTRODUCTION

To assess the effects of structured telephone follow-up on patient's home-exercise compliance after total knee arthroplasty (TKA).

METHODS

A total of 202 elderly patients who received a unilateral TKA were enrolled in this study. The participants were randomized into two groups: the intervention group that received structured telephone follow-up after discharge and the control group that received routine health care. Pain, functional ability, quality of life, and depression survey scores were measured before and after TKA. The intergroup and intragroup differences were analyzed during the 12 months following discharge.

RESULTS

There were no significant differences in the sociodemographic characteristics of both groups. The mean home-exercise time and total days in the intervention group were significantly higher than those in the control group. Variable scores differed significantly between groups. Pain, functional ability, quality of life, and depression improved significantly after TKA in both groups, and the intervention group had greater improvement in mental health and active range of motion.

CONCLUSION

Undergoing a TKA can significantly reduce the patient's pain from osteoarthritis while improving the overall physical function and quality of life. Furthermore, a structured telephone follow-up can improve patient adherence to home exercise after TKA.