Prehabilitation & Prognosis Reid Moseley
Background ● Knee osteoarthritis: ○ Degeneration of articular cartilage, leading to pain & other structural changes ○ Affects approx. 13% of women & 10% of men age 60 & older ● Total knee arthroplasty: ○ Replacement of diseased articular cartilages with artificial components ○ Estimated 4.7 million Americans with TKA ○ High success rate: 89.3% of patients reported good to excellent results at 4.1 year avg. follow-up
Patient Demographics & History ● Age: 67 years old ● Gender: female ● Occupation: interior decorator ● Lives with husband in 1 story house, 2 steps to enter ● PMH: ○ Left TKA , AFib, HTN, open cholecystectomy, incisional hernia repair ○ Independent PTA ○ Pt attended 6 wk prehabilitation program ○ No medications, except for pain medications administered by hospital ● Dx = elective right TKA due to severe right knee OA
Physical Therapy Exam ● Subjective ○ Pt goal: “I want to have the same recovery as I did with my other knee.” ○ Pain = 2/10 (VAS) ● Objective ○ Swelling in R knee, incision/dressing intact ○ No sensation deficits ROM MMT R UE WFL Gross 5/5 L UE WFL Gross 5/5 R LE Knee grossly 0-70 deg, Knee & Hip 3-/5, limited by limited by p! & swelling p! & weakness L LE WFL Gross 5/5
PT Exam ● Objective ○ Transfers: Mod Assist for sit to supine & supine to sit, Supervision assist for sit to stand ○ Balance: Sitting balance = good, Standing balance = fair ○ Gait: Ambulated 10 feet with rolling walker and contact guard assistance, slow cadence, no buckling noted in R knee ● Assessment ○ Patient presents with impaired functional mobility and strength related to recent R TKR and will benefit from additional PT to promote return to maximal functional independence. ○ Prognosis is good due to high treatment tolerance & high prior level of function.
PT Exam ● Plan of Care ○ Patient will be seen BID for length of stay to address gait, transfers, strength & stair climbing ○ Goals: ■ Patient will be able to ascend 2 stairs with supervision assist and bilateral railings upon discharge ■ Patient will be able to ambulate 100 feet with supervision assist & a rolling walker upon discharge ■ Patient will improve standing balance to fair upon discharge ■ Patient will improve all transfers to supervision assist upon discharge.
Interventions & Outcomes ● Rx: ○ Gait & stair training ○ Exercises: quad sets, SAQ’s, ankle pumps, heel slides, sitting knee flex/ext, supine hip abd/add ○ Game Ready: ice & compression ○ Pt education: HEP, use of Game Ready, transfers, gait with assistive device, stairs ● Outcomes ○ Patient pain level never surpassed 6/10 (even with activity) ○ Patient discharged home post-op day 3 ○ Supervision assist for all transfers ○ Patient standing static balance improved to “good”. ○ Patient could ambulate 130 feet with supervision assist & a rolling walker. ○ Patient could ascend 3 steps with supervision assist and bilateral railings.
Is participation in a prehabilitation program a positive prognostic indicator for shorter hospital stays in elective TKR patients?
Article 1 Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials
Article 1 ● Purpose: ○ The clinical impact of physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement. ● Participants: ○ Searched PubMed, Embase, and the Cochrane Central Registry of Controlled Trials ○ Had to be randomized controlled trials comparing preoperative rehabilitation programs v.s. No formal preoperative program, reporting at least 1 clinical relevant outcome of interest ■ Outcomes of interest: post-op VAS pain scores or pain subcomponents of WOMAC, patient functionality (WOMAC, SF-36, etc.), time to resume ADL’s, quality of life, patient satisfaction & post-op complications ■ Resource outcomes: hospital length of stay , readmissions, & total hospital or total health system costs ○ 399 titles/abstracts screened → 110 full text articles → 22 studies met the criteria (1492 pt’s)
Methods & Results ● Methods: ○ 2 reviewers screened articles by title & abstract (based on predetermined eligibility criteria) → 2 reviewers screened for bias → 3 reviewers extracted data & data was verified by 4th viewer ○ Meta-analysis performed using the random effects model, RR & 95% CI for discrete outcomes, WMD & 95% CI for continuous outcomes ○ WOMAC was preferred measure, so all pain & function scores were converted to WOMAC ● Results: ○ Improvements in WOMAC pain score @ 4 wks (WMD -6.1), but not statistically significant after 4 wks (WMD -1.4) ○ Improvements in WOMAC function score @ 6-8 wks (WMD -3.9) & 12 wks (WMD -4.0), but statistically different after 12 wks (24 wks, WMD -0.5) ○ No significant differences in length of hospital stay (WMD -0.3 days) ○ No significant reductions in cost (WMD +0.5$)
Article 1 ● Conclusion: ○ Effects of prehabilitation on pain & function are too small to be considered clinically important ○ Did not result in clinically significant differences in most measures of patient recovery, quality of life, length of stay & costs ● Strength/Limitations ○ Strengths: ■ systematic review of randomized controlled trials ■ Used standardized measurement of WOMAC pain & function scores ○ Limitations: ■ Lack of large randomized controlled trials ■ Definitions for prehabilitation and for outcomes measurements were heterogeneous across studies ■ Most studies provided an inadequate description of the components of the prehabilitation programmes provided (including frequency, intensity & duration)
Article 2 Determinants of Function After Total Knee Arthroplasty
Article 2 ● Purpose: ○ Identify preoperative determinants of functional status after a TKA ● Participants: ○ Eligibility criteria: (1). Scheduled for elective primary TKA, (2). Placed on joint arthroplasty waiting list at least 7 days before surgery, (3). Resided in the health region, (4). 40 years of age or older, (5). Spoke English ○ 377 eligible patients → 276 participating patients ■ Majority tended to be elderly women with OA
Article 2 ● Methods: ○ Prospective cohort study ○ In-person interviews completed 31 days before and 6 months after surgery ■ questions regarding demographic information, joint pain, function and stiffness, HRQL, comorbid conditions, medical status, and ambulatory status ■ Knee PROM measured ■ SF-36 → overall function & quality of life (measured 0-100) ■ WOMAC → joint function & pain (measured 0-100) ○ Multiple linear regression performed for SF-36 & WOMAC ○ Functional improvement from baseline defined as 60% increase (~10 point increase) ● Results: ○ See next slide
Article 2
Article 2 ● Conclusions: ○ Preoperative joint function, BMI, type of walking device used before surgery, & preoperative walking distance were found to be predictors of joint & overall function @ 6 mo’s post-op ○ Patients with greater dysfunction prior to surgery will not attain comparable functional outcomes to those with less preop dysfunction ● Strengths/limitations: ○ Strengths: ■ Large number of participants ■ Univariate regression used to identify statistically significant variables → statistically significant variables then ran through multivariate regression ○ Limitations: ■ Accuracy of self-report measures of function ■ Only 1 follow-up ■ Lack of standardized post-op treatment
Implications For My Patient ● Participation in a prehabilitation program was not associated with a signifcantly shorter hospital stay ● Participation in a prehabilitation program may not be most cost effective option for elective TKA patients ○ However, could be extremely beneficial for those with low baseline function ● Long term exercise program to increase baseline function will likely yield the best post-op outcomes ● Patient education: ○ Conversation with OA patients ○ Emphasize the importance of movement, activity & function and associations with positive TKA outcomes ○ The earlier, the better ● Can help identify patients who might require additional inpatient rehab
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