Does the addition of hip strengthening exercises improve outcomes following total knee arthroplasty? A study protocol for a randomized trial

Effects of telerehabilitation-implemented core stability exercises on patient-reported and performance-based outcomes in total knee arthroplasty patients: randomised controlled trial

BACKGROUND

Face-to-face access to exercise programs, including standard exercises (SE) and core stability exercises (CSE), can be challenging for many total knee arthroplasty (TKA) patients.

OBJECTIVES

To investigate the effects of adding CSE to SE on patient-reported and performance-based outcomes in TKA patients using telerehabilitation (TR).

METHODS

Group 1 (SE, n = 21) and Group 2 (SE+CSE, n = 21). Follow-up included videoconferences (1-8 weeks) and telephone calls (9-12 weeks). Assessments (preoperatively and at 1st, 2nd, and 3rd postoperative months) included; Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): functional level, Visual Analogue Scale (VAS): pain intensity, Copenhagen Knee Range of Motion (ROM) Scale (CKRS): knee ROM, Short Form-12 (SF-12) and World Health Organization Quality of Life Brief Version (WHOQOL-BREF): quality of life, 30-s Chair-Stand Test: muscle strength, and Stair Climb Test: locomotor performance.

RESULTS

All assessments showed a significant improvement after treatment in group 1 (p < .001, Cohen's d = 0.315 to 0.959) and group 2 (p < .001, d = 0.445 to 0.901). There was no significant difference between groups in knee flexion ROM (p > .05). Group 2 achieved better results in functional level (p = .001 to 0.003,d = -0.334 to 1.207), pain intensity (p = .030,d = -0.334), knee extension ROM (p = .015,d = -0.374), quality of life (p = .001 to 0.046,d = -0.308 to -1.366), muscle strength (p = .002 to 0.016,d = -0.779 to -1.030), and locomotor performance (p = .004 to 0.009, d = 0.404 to 0.954).

CONCLUSION

SE and SE+CSE via TR enhance patient-reported and performance-based outcomes in post-operative TKA patients, with CSE providing additional benefits. These results support using CSE in TR programs for TKA and encourage further research on TR.

Skin Temperature Following Total Knee Arthroplasty: A Longitudinal Observational Study

BACKGROUND

Total knee arthroplasty (TKA) is the most effective method of pain relief and increased functional status for end-stage knee arthritis. We aimed to assess in patients undergoing unilateral, primary TKA whether the temperature of the operated limb, compared to the nonoperative limb, remains elevated up to 1 year postoperatively.

METHODS

Using a prospective, longitudinal, observational study design, 1,094 patients were enrolled, and 889 patients completed a minimum of 4 out of 5 follow-up appointments. There were 864 patients who had a normal postoperative course, while 25 patients were deemed to have a superficial or deep infection. Skin temperatures were measured using an infrared thermometer on the operated and nonoperated knees preoperatively, at 2, 6, 12 weeks, and 1 year postoperatively. A subgroup analysis was performed on the 25 patients deemed to have a superficial or deep infection.

RESULTS

There was a statistically significant increase in skin temperature in the operated versus nonoperated knee at every follow-up, with a P < .001. However, the effect size was small at the 1-year follow-up, with a mean difference in skin temperature of 0.3 °C. In the infected subgroup, there was a statistically significant difference in skin temperature at 2, 6, and 12 weeks, with a greater difference in skin temperature between the operated and nonoperated knees (4.05 versus 3.78 °C in the noninfected). However, there was little clinical difference (0.27 °C) at 2 weeks between infected and noninfected patients.

CONCLUSIONS

This study could improve postoperative interactions between patients and surgeons. It is normal for skin temperature post-TKA to increase initially and improve over time, but it can take up to 1 year before there is little clinical difference. Because of the small difference in the rise of skin temperature between infected and noninfected patients, there is little indication that skin temperature is a reliable indicator of infection.

Effects of lower-limb active resistance exercise on mobility, physical function, knee strength and pain intensity in patients with total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis, but muscle strength and function are reduced for a long period postoperatively. Postoperative active resistance exercise may play a relevant role.

PURPOSE

To systematically evaluate effects of lower-limb active resistance exercise (ARE) on mobility, physical function, muscle strength and pain intensity in patients with TKA.

METHODS

A search was conducted in PubMed, EMBASE, and Cochrane Library databases from inception to September 2023. Only randomized controlled trials (RCTs) that compared the effects of ARE and no intervention or other rehabilitation program without PRE were included. The outcome variables were mobility (Maximal walking speed [MWS]/6-Minute Walk Test[6MWT]), physical function (Stair Climb Test [SCT]/Timed Up and Go [TUG]), knee extension/ flexion power(KEP/KFP), joint range of motion (ROM) and pain. Standardized Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals (CI) were calculated and combined in meta-analyses. The Cochrane Collaboration's Handbook were used for the methodological quality assessments. GRADE was used to assess the quality of evidence. The meta-analysis was performed using the RevMan 5.4 software.

RESULTS

A total of 14 randomized controlled trials, involving 880 patients, were finally included. The lower-limb ARE exhibited significantly greater improvement in MWS (MD 0.13, 95%CI 0.08-0.18, P < 0.00001), TUG(MD -0.92, 95%CI -1.55- -0.28, P = 0.005), KEP (SMD 0.58, 95%CI 0.20-0.96, P = 0.003), KFP (SMD 0.38, 95%CI 0.13-0.63, P = 0.003), ROM-flexion (MD 2.74, 95%CI 1.82-3.67, P < 0.00001) and VAS (MD - 4.65, 95% CI - 7.86- -1.44, p = 0.005) compared to conventional exercise(CE) immediately post-intervention. However, there were no statistically significant differences between both groups in regard to 6MWT (MD 7.98, 95%CI -4.60-20.56, P = 0.21), SCT (MD -0.79, 95%CI -1.69-0.10, P = 0.08) and ROM-extension (MD -0.60, 95%CI -1.23-0.03, P = 0.06).

CONCLUSIONS

According to the results of meta-analysis, patients undergoing TKA who receive the lower extremity ARE show better clinical effects in terms of pain relief, strength recovery and knee ROM. Simultaneously, it may be beneficial to improve mobility and physical function of patients after TKA.

Effect of adding hip exercises to general rehabilitation treatment of knee osteoarthritis on patients' physical functions: a randomized clinical trial

BACKGROUND

Hip adductor and abductor strength were both reduced in KOA patients. But to date, most of the researches have only focused on quadriceps combined with hip abductor strengthening versus quadriceps strengthening.

OBJECTIVE

The aim of the study is to evaluate the effect of adding hip abductor and adductor strengthening to quadriceps strengthening on lower limb strength, knee pain and physical function in patients with medial compartmental knee osteoarthritis.

METHODS

In this study, 42 participants, were randomly divided into two groups: the general treatment group (GT group) and the added-hip-exercise group (AH group). All participants were given a general rehabilitation treatment. The AH group performed hip abductor and adductor strengthening in addition to the general rehabilitation treatment. Knee and hip muscle strength, Five Times Sit-to-Stand Test (FTSST), the Timed Up and Go Test (TUGT), Numerical Rating Scale (NRS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were assessed at baseline and 6 weeks. A two-sided 2-sample unpaired t test was performed to compare the difference in mean change scores between AH and GT groups.

RESULTS

Finally, 36 participants completed the study: both groups consist of 18 participants. In the per-protocol analysis, the AH group had a greater improvement in knee extension strength (mean changes, 7.84 versus 36.48; P < 0.001) and hip abduction strength (mean changes, 5.05 versus 26.62; P = 0.001) than the control group. Similarly, the AH group had a greater improvement in the FTSST time (mean changes, 0.40 s versus 3.57 s; P < 0.001) and the TUFT time (mean changes, 0.18 s versus 1.67 s; P = 0.002) than the GH group. No statistical difference was found in the change of WOMAC pain scores and NRS between the 2 groups.

CONCLUSIONS

Older adults with knee OA in the AH group had superior muscle strength, symptoms and daily activity performance at the 6th week than those in the GT group. And adding hip exercises could expedite improvement of pain at the 2th week, but not at the 6th week.

TRIAL REGISTRATION

Clinical trial registration numbers and date of registration: ChiCTR-IOR-16009124, Registered 30 August 2016.

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.

Assessing the Efficacy of the Early Rehabilitation Pathway in Combination with Morita Therapy after Hip and Knee Arthroplasty

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective methods for the treatment of end-stage osteoarthritis. Furthermore, rehabilitation training and psychological interventions play significant roles in the recovery of hip and knee joint function after THA and TKA. A total of 46 patients who received hip replacement and knee replacement are equally divided into two groups, with the control group being prescribed routine rehabilitation intervention and the observation group prescribed an early rehabilitation pathway with Morita therapy intervention. According to the results, the observation group displayed a significantly decreased incidence of deep venous thrombosis, while simultaneously reducing the recovery time of lower limb function (P < 0.05), including straight leg raising time, walking time, and vertical knee flexion time. In addition, the treatment program demonstrates a significant ability to improve the joint function score, pain score, quality of life score, and range of motion score (P < 0.05). Moreover, serum D-dimer, fibrin degradation products (FDP), and femoral vein blood flow peak also are significantly reduced (P < 0.05). Therefore, we have determined that an early rehabilitation pathway combined with Morita therapy can effectively reduce stress pain, improve the recovery process of joint motor function, and reduce the incidence of thrombosis. However, an increased sample size would facilitate the confirmation of the safety and efficacy of the program. In addition, the overall financial expenditure and feasibility of the treatment need to be considered.

The role of the lower extremity functional scale in predicting surgical outcomes for total joint arthroplasty patients

Background

The purpose of this study was to evaluate the relationship between lower extremity functional scale (LEFS) scores with postoperative functional outcomes for total joint arthroplasty (TJA) patients and to investigate the utility of this tool to create an individualized plan of care perioperatively.

Methods

Patients undergoing primary TJA at a single institution from 2016 to 2019 was retrospectively reviewed by a univariate analysis in terms of patient characteristics and outcomes across LEFS quartiles. Multivariate regression models were constructed to evaluate the association between the LEFS quartile and outcomes after controlling for confounding factors.

Results

A total of 1389 patients were included. All patients had a documented LEFS pre- and postoperatively with the last value documented at least 60 days to a maximum of 1 year after surgery. The following cutoffs for LEFS quartiles were observed: quartile 1 preoperative LEFS ≤27, quartile 2 ranges from 28 to 35, quartile 3 ranges from 36 to 43, and quartile 4 ≥ 44. Patients with a higher comorbidity burden and ASA score were more likely to have a lower LEFS. Higher levels of preoperative function were significantly associated with shorter LOS and higher rates of same day discharge, independent ambulation, mobility and activity scores, and rates of discharge home.

Conclusion

These findings suggest that LEFS is a useful tool for aiding clinical resource allocation decisions, and incorporation of the measure into existing predictive models may improve their accuracy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-021-00106-3.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Age-Related Decline in Patient-Reported Outcomes 2 and 5 Years Following Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) help assess therapeutic effectiveness. This study assessed the effect of advanced age on the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Lower Extremity Activity Scale (LEAS) after total hip arthroplasty (THA).

METHODS

A prospective cohort of patients underwent primary THA at our institution between May 2007 and December 2011. Exposure was age at the time of surgery and outcomes were HOOS and LEAS scores 2 and 5 years postsurgery. We used a multivariable longitudinal generalized estimating equation to elucidate the effect of age on PROM scores.

RESULTS

Our analysis of 3700 THA patients (mean age, 66 years; 56.4% female) demonstrated a decline in scores by age for the LEAS, HOOS Activities of Daily Living, and HOOS Sport and Recreation domains. There was also association between age and HOOS Symptoms and HOOS Quality of Life domains, but not between age and the HOOS Pain domain. Critical ages at which the relationship between age and outcome changed was 63 years for the HOOS Pain, Symptom, Activities of Daily Living, and Quality of Life domains, and 72 years for the HOOS Sport and Recreation domain and the LEAS.

CONCLUSION

Patients undergoing THA at older ages reported lower activity and sports and recreation scores than younger patients, but similar pain, symptoms, and quality of life scores. This knowledge can help physicians guide patients' expectations before THA. Our findings also indicate that PROM scores should be age adjusted when used for quality or value comparisons between hospitals or physicians.

[The efficiency and expediency of different rehabilitation approaches after knee replacement]

The paper reviews the literature on the efficiency of different rehabilitation methods after knee arthroplasty, such as continuous passive motion (CPM) therapy, exercises for balance and strengthening of hip muscles on the postoperative leg, and aquatic rehabilitation. It analyzes the optimal periods of rehabilitation initiation and continuance, studies of the Pilates system for patients after knee arthroplasty, kinesiotaping, fast-track rehabilitation, and Locomat robotic system. Various functional tests and questionnaire surveys are considered as performance measures. CPM therapy and the Pilates method are shown to require an additional investigation for inclusion in the standard rehabilitation program. Balance exercises have a positive impact on functional status and mobility in patients after surgery. Exercises for strengthening the hip muscles on the postoperative leg and aquatic training are recommended for use in routine practice. Kinesiotaping is successfully used to more effectively perform exercises, by reducing pain, edema and to improve a patient's psychological status. The Locomat can be used for walking technology training, which will be able to enhance the structure of a step and amortization function. The time taken in the rehabilitation center can be reduced using the fast-track rehabilitation program.

Incorporating hip abductor strengthening exercises into a rehabilitation program did not improve outcomes in people following total knee arthroplasty: a randomised trial

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.

The effect of intensive exercise program and kinesiotaping following total knee arthroplasty on functional recovery of patients

Background

Total knee arthroplasty (TKA) is a gold standard for terminal term gonarthrosis patients in order to diminish pain, correct deformities, and regain stability. Postoperative functional recovery of patients depends on the current postoperative rehabilitation program to an important extent. The purpose of our study is to compare midterm functional level of gonarthrosis patients who were included in physiotherapy rehabilitation program following TKA with people in similar ages without any surgical indication nor intervention. We have aimed also to compare functionality of people who had additional kinesiotaping (KT) treatment with people who had conservative treatment only after knee arthroplasty.

Methods

Functional level and knee functionality of people in study were evaluated at the end of postoperative first month by 6-min walk test and Lysholm knee score respectively.

Results

There was no statistical difference between groups with and without TKA in terms of height, weight, body mass index, Lysholm score, and 6-min walk test score (p > 0.05). In patient group with TKA, people with postoperative KT treatment had greater 6-min walk test score for postoperative first month (p = 0.005).

Conclusion

TKA is considered a gold standard procedure in order to increase the quality of life and improve functionality of terminal term gonarthrosis patients. It is necessary to immediately control pain and edema of knee and apply intensive rehabilitation program aimed at muscle strengthening around hip and knee in order to increase the success of operation.

Structure, function, and control of the human musculoskeletal network

The human body is a complex organism, the gross mechanical properties of which are enabled by an interconnected musculoskeletal network controlled by the nervous system. The nature of musculoskeletal interconnection facilitates stability, voluntary movement, and robustness to injury. However, a fundamental understanding of this network and its control by neural systems has remained elusive. Here we address this gap in knowledge by utilizing medical databases and mathematical modeling to reveal the organizational structure, predicted function, and neural control of the musculoskeletal system. We constructed a highly simplified whole-body musculoskeletal network in which single muscles connect to multiple bones via both origin and insertion points. We demonstrated that, using this simplified model, a muscle's role in this network could offer a theoretical prediction of the susceptibility of surrounding components to secondary injury. Finally, we illustrated that sets of muscles cluster into network communities that mimic the organization of control modules in primary motor cortex. This novel formalism for describing interactions between the muscular and skeletal systems serves as a foundation to develop and test therapeutic responses to injury, inspiring future advances in clinical treatments.