Targeted rehabilitation to improve outcome after total knee replacement (TRIO): study protocol for a randomised controlled trial

Rehabilitation for Total Knee Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral total knee arthroplasty for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. The team assessed strength of evidence. Evidence from 53 studies randomized controlled trials suggests that various rehabilitation programs after total knee arthroplasty may lead to comparable improvements in pain, range of motion, and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the postacute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period after total knee arthroplasty; risk of harms among various postacute rehabilitation programs seems comparable. All findings were of low strength of evidence. Evaluation of rehabilitation after total knee arthroplasty needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

Phase 3 Trials of Enhanced Versus Usual Care Physical Therapy for Patients at Risk of Poor Outcome Following Knee Arthroplasty: A Perspective on Meaning and a Way Forward

Physical therapy is routinely delivered to patients after discharge from the hospital following knee arthroplasty. Posthospitalization physical therapy is thought to be beneficial, particularly for those patients most at risk of poor outcome, the subgroup with persistent function-limiting pain, despite an apparently successful surgery. Research teams have undertaken 3 large-scale multicenter Phase 3 randomized clinical trials designed specifically for patients at risk of poor outcome following knee arthroplasty. All 3 trials screened for poor outcome risk using different methods and investigated different physical therapist interventions delivered in different ways. Despite the variety of types of physical therapy and mode of delivery, all trials found no effects of the enhanced treatment compared with usual care. In all cases, usual care required a lower dosage of physical therapy compared with the enhanced interventions. This Perspective compares and contrasts the 3 trials, speculates on factors that could explain the no-effect findings, and proposes areas for future study designed to benefit the poor outcome phenotype.

Effectiveness of a 3-month antifalling program in the mobility, balance confidence, and muscle performance of older adults

This study determined the effectiveness of a 3-month group-based multicomponent exercise program in the mobility, balance confidence, and muscle performance of older adults. A total of 40 participants (mean age=70.60±6.25 years completed pre- and posttest clinical intervention measures of mobility using the Timed Up and Go (TUG) test, balance confidence using the Activities-specific Balance Confidence scale, upper limb strength (handgrip dynamometer), and lower limb function (30-sec chair rise test). Data were analyzed using paired t-test and based on TUG criteria for risk of fall (low- and high-risk groups). Significant improvements were found in all measures (All P<0.05) following the 3-month program. Measures according to the risk of fall categories were also significantly improved (P<0.01), except the left handgrip strength (P>0.05). The low-risk group showed a higher improvement in mobility (14.87% vs. 11.74%), balance confidence (34.21% vs. 26.08%), and lower limb function (96.87% vs. 21.20%) but was not significantly different from the high-risk group (P>0.05). A group-based multicomponent exercise program benefited the physical functions of older adults at low- or high risk of falls.

Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial

OBJECTIVE

To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty.

DESIGN

Parallel group randomised controlled trial.

SETTING

13 secondary and tertiary care centres in the UK providing postoperative physiotherapy.

PARTICIPANTS

334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol.

INTERVENTIONS

All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist).

MAIN OUTCOME MEASURES

Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery.

RESULTS

334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval -0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, -0.78 to 0.28, P=0.36) or worst pain (0.22 points, -0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval -14.25 to 4.96, P=0.34).

CONCLUSIONS

Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures.

TRIALS REGISTRATION

Current Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445.

Structured Total Knee Replacement Rehabilitation Programme and Quality of Life following Two Different Surgical Approaches - A Randomised Controlled Trial

Introduction: The key important factor influencing the outcomes following rehabilitation is the surgical approach involved in Total Knee Replacement (TKR). Most studies have analysed the functional outcome in comparing the approaches on surgical perspective rather on post-operative therapeutic interventions. The current study was to analyse the effects of structured TKR rehabilitation programme on the quality of life and joint specific outcomes between two different surgical approaches.

Materials and Methods: In this double-blind randomised controlled trial, participants were randomly allocated to one of two groups: Group 1- those who underwent medial parapatellar approach and Group 2- those who underwent mid-vastus approach. Both groups received three-phase structured rehabilitation protocol for 12 weeks. The outcome measures of SF-36, knee mobility, isometric knee musculature strength and six-minute walk distance were measured at baseline, on discharge and at review after three months.

Results: The quality of life and joint specific outcome scores were better in mid-vastus approach than the popular medial parapatellar approach. The outcomes of knee flexion mobility (p=0.04), knee extension mobility (p=0.03), isometric muscle strength of quadriceps (p=0.001), isometric muscle strength of hamstrings (p=0.03), six-minute walk distance (p=0.001) and Physical Cumulative Scores (PCS) (p=0.03) were found to exhibit significant improvements at three months follow up.

Conclusion: The mid-vastus approach was found to exhibit better improvements following structured rehabilitation care, in physical summary scores of quality of life and joint specific outcomes than medial parapatellar approach.

Exploring variation in patient access of post-discharge physiotherapy following total hip and knee arthroplasty under a choice based system in the UK: an observational cohort study

OBJECTIVES

To assess a targeted 'therapy as required' model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether accessing therapy was associated with post-arthroplasty patient reported outcomes and whether it was possible to predict which patients would access post-discharge physiotherapy from pre-operative data.

DESIGN

Prospective, observational, longitudinal cohort study.

SETTING

Single National Health Service orthopaedic teaching hospital in the UK.

PARTICIPANTS

1395 patients undergoing total hip arthroplasty and 1374 patients undergoing total knee arthroplasty.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported access of post-discharge physiotherapy, the Oxford Hip or Knee Score, EuroQol 5-dimension questionnaire and post-operative surgical episode satisfaction metric.

RESULTS

662 (48.2%) patients with TKA and 493 (35.3%) patients with THA accessed additional post-discharge physiotherapy. Patient-reported outcomes (p<0.001) and surgical episode satisfaction (p=0.001) in both THA and TKA were higher in patients that did not participate in post-discharge physiotherapy. Regression models using pre-operative symptom burden and demographic data predicted post-discharge therapy access with an accuracy of only 17% greater than chance in patients with THA and 7% greater than chance in patients with TKA.

CONCLUSIONS

In a choice-based service model of 'therapy as required' following hip and knee arthroplasty only a third of THA and half of TKA patients accessed post-discharge therapy. Patients who did not access physiotherapy reported greater post-operative outcomes. This variation in the need for post-discharge physiotherapy suggests that targeting of rehabilitation may be a cost-effective model, however it was not possible to reliably predict which patients would access post-discharge physiotherapy from pre-operative data.

Development of a clinical risk score for pain and function following total knee arthroplasty: results from the TRIO study

Objectives

The aim was to develop and validate a simple clinical prediction model, based on easily collected preoperative information, to identify patients at high risk of pain and functional disability 6 months after total knee arthroplasty (TKA).

Methods

This was a multicentre cohort study of patients from nine centres across the UK, who were undergoing a primary TKA for OA. Information on sociodemographic, psychosocial, clinical and quality-of-life measures were collected at recruitment. The primary outcome measure for this analysis was the Oxford knee score (OKS), measured 6 months postoperatively by postal questionnaire. Multivariable logistic regression was used to develop the model. Model performance (discrimination and calibration) and internal validity were assessed, and a simple clinical risk score was developed.

Results

Seven hundred and twenty-one participants (mean age 68.3 years; 53% female) provided data for the present analysis, and 14% had a poor outcome at 6 months. Key predictors were poor clinical status, widespread body pain, high expectation of postoperative pain and lack of active coping. The developed model based on these variables demonstrated good discrimination. At the optimal cut-off, the final model had a sensitivity of 83%, specificity of 61% and positive likelihood ratio of 2.11. Excellent agreement was found between observed and predicted outcomes, and there was no evidence of overfitting in the model.

Conclusion

We have developed and validated a clinical prediction model that can be used to identify patients at high risk of a poor outcome after TKA. This clinical risk score may be an aid to shared decision-making between patient and clinician.

Effectiveness of postdischarge interventions for reducing the severity of chronic pain after total knee replacement: systematic review of randomised controlled trials

OBJECTIVE

Approximately 20% of patients experience chronic pain after total knee replacement (TKR). The aim of this systematic review was to evaluate the effectiveness of postdischarge interventions commenced in the first 3 months after surgery in reducing the severity of chronic pain after TKR.

DESIGN

The protocol for this systematic review was registered on PROSPERO (registration number: CRD42017041382). MEDLINE, Embase, CINAHL, PsycINFO and The Cochrane Library were searched from inception to November 2016. Randomised controlled trials of postdischarge intervention which commenced in the first 3 months after TKR surgery were included. The primary outcome of the review was self-reported pain severity at 12 months or longer after TKR. Risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Seventeen trials with data from 2485 randomised participants were included. The majority of trials evaluated physiotherapy interventions (n=13); other interventions included nurse-led interventions (n=2), neuromuscular electrical stimulation (n=1) and a multidisciplinary intervention (n=1). Opportunities for meta-analysis were limited by heterogeneity. No study found a difference in long-term pain severity between trial arms, with the exception of one trial which found home-based functional exercises aimed at managing kinesiophobia resulted in lower pain severity scores at 12 months postoperatively compared with advice to stay active.

CONCLUSION

This systematic review and narrative synthesis found no evidence that one type of physiotherapy intervention is more effective than another at reducing the severity of chronic pain after TKR. Further research is needed to evaluate non-physiotherapy interventions, including the provision of care as part of a stratified and multidisciplinary care package.

PROSPERO REGISTRATION NUMBER

CRD42017041382.

Evaluation of the effects of a physiotherapy program on quality of life in females after unilateral total knee arthroplasty: a prospective study

[Purpose] Osteoarthritis is a chronic and degenerative joint disease and is considered to be one of the most common musculoskeletal disorders. This study evaluated the differences in the quality of life of females treated with supervised physiotherapy and a standardized home program after unilateral total knee arthroplasty. [Subjects and Methods] From January 2012 to May 2015, a total of 40 females were examined at the Central Military Hospital in Ruzomberk, Slovakia. Quality of life was assessed with the Short Form-36. Quality of life and intensity of pain after normal daily activity, according to the visual analog scale, were assessed before total knee arthroplasty, immediately after physiotherapy, 3 months after total knee arthroplasty, and 6 months after total knee arthroplasty. [Results] We found statistically significant improvement of the quality of life results and a decreased intensity of pain at each time point compared with before total knee arthroplasty. [Conclusions] The results of this study provide further evidence indicating that patients who undergo total knee arthroplasty for primary osteoarthritis of the knee can achieve a significant improvement in the quality of life by using supervised physiotherapy compared with a standardized home program.