Prehabilitation & Prognosis Reid Moseley Background Knee - - PowerPoint PPT Presentation
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
○ Degeneration of articular cartilage, leading to pain &
○ Affects approx. 13% of women & 10% of men age 60 & older
○ 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
○ 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
○ Pt goal: “I want to have the same recovery as I did with my other knee.” ○ Pain = 2/10 (VAS)
○ 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, limited by p! & swelling Knee & Hip 3-/5, limited by p! & weakness L LE WFL Gross 5/5
○ 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
○ 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.
○ 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.
○ 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
○ 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.
○ 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.
○ 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)
○ 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
○ 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$)
○ 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
○ 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)
○ Identify preoperative determinants of functional status after a TKA
○ 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
○ 377 eligible patients → 276 participating patients ■ Majority tended to be elderly women with OA
○ 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)
○ See next slide
○ 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
○ 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
shorter hospital stay
for elective TKA patients
○ However, could be extremely beneficial for those with low baseline function
best post-op outcomes
○ Conversation with OA patients ○ Emphasize the importance of movement, activity & function and associations with positive TKA
○ The earlier, the better
1. Kremers, H. M., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., . . . Berry, D. J. (2015, September 2). Prevalence of Total Hip and Knee Replacement in the United
doi:10.2106/jbjs.n.01141 2. Heidari, B. (2011). Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian Journal of Internal Medicine, 2(2), 205-212. 3. Jones, C. A., Voaklander, D. C., & Suarez-Almazor, M. E. (2003, August). Determinants of Function After Total Knee Arthroplasty. Journal of the American Physical Therapy Association, 83(8). 4. Wang, L., Lee, M., Zhang, Z., Moodie, J., Cheng, D., & Martin, J. (2016). Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials. BMJ Open, 6(2). doi:10.1136/bmjopen-2015-009857