Research challenges common rehabilitation standards

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Research presented at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) challenges two common rehabilitation standards: physical therapy following total hip replacement (THR) at an outpatient facility, and gradual movement of the quadriceps tendon following total knee replacement (TKR) surgery.

In the first study, researchers found that patients who performed prescribed exercises at home without a physical therapist progressed comparably as those who received physical therapy at an outpatient facility.

The study followed 89 patients who had THR surgery followed by 10 weeks of physical therapy. Of those patients, 48 received two-to-three weekly therapy sessions in outpatient facilities with out-of-pocket costs ranging from $10-$60 per session for non-Medicare patients. The other 41 patients used written instructions and illustrations to perform the same exercises on their own at no extra cost.

Patients were assessed at one and six months after their procedures using standardised tests assessing levels of pain, activity, range-of-motion and stiffness. The study found no significant differences between patients in both groups.

“Most patients can do physical therapy on their own after total hip replacement,” said senior study author Dr Matt Austin, an orthopaedic surgeon with the Rothman Institute. “This study also demonstrates how we can more optimally utilize health resources and lower costs.”

In the second study, researchers found that activating and exercising the quadriceps muscles as soon as possible after TKR may be the key to regaining optimal, post-surgical function in the knee and legs.

The quadriceps muscles in the front of the thigh are important for straightening and stabilising the leg during movement. Most patients have difficulty fully activating (contracting the quadriceps during the first month after surgery), which results in pronounced quadriceps weakness. Quadriceps activation may be improved through strengthening exercises or neuromuscular electrical stimulation, said senior author and orthopaedic surgeon Dr Douglas Dennis.

The study followed 162 patients at the University of Colorado who received a total knee replacement at Colorado Joint Replacement, the University of Colorado Hospital, or Panorama Orthopaedics & Spine Centre. Patients were divided into two groups for high and low-intensity therapy, with all patients receiving 25 physical therapy sessions over 12 weeks. Patients who activated more of their quadriceps or “quad” muscles earlier in their therapy showed better rehabilitation progress when it came to their abilities to climb stairs, a telltale sign of recovery after knee replacement.

“Quad activation is the biggest thing we have got to change to improve recovery and long-term function for knee replacement patients,” said Dennis.

These findings may be especially important for patients under age 59 – the fastest growing population undergoing knee replacement – who want to remain active after total knee replacement.

Abstract 1
INTRODUCTION: Many surgeons and patients believe that formal outpatient physical therapy (OPT) is necessary in order to optimize the functional outcome of patients undergoing total hip arthroplasty (THA). Limited evidence currently exists to support this belief. The purpose of this prospective, randomized study was to determine the effect of formal OPT on the functional outcome of THA.
METHODS: We randomized 77 patients into one of two groups. In Group I, 39 patients received two months of formal OPT, with two to three sessions per week. In Group II, 38 patients received no formal OPT, but followed a prescribed exercise program on their own for a two-month duration. Harris Hip Score (HHS), WOMAC, and SF-36 were recorded preoperatively and postoperatively at one month and six months. The results were analyzed using a linear mixed model with patients as a random effect, and treatment time and treatment group as independent variables.
RESULTS: Preoperative functional scores and demographics between the two groups were similar. There were no significant differences in any measured outcomes at one month or six months postoperatively. HHS for Group I were 67.67 ± 3.00 at one month and 80.19 ± 4.33 at six months. Group II had HHS scores of 71.26 ± 3.24 at one month and 84.68 ± 3.32 at six months (95% CI -12.44, 5.25 and -15.62, 6.63 respectively). Similarly, there were no significant differences in the WOMAC or SF-36 scores at either postoperative interval. Cost to the patient for OPT visits ranged from $10-$60 per session for non-Medicare patients.
CONCLUSION: These findings suggest that formal OPT is not superior to prescribed, patient-directed home exercises. The value of formal OPT for all patients undergoing primary THA needs to be examined. Based on the findings of this study, we have moved away from routinely prescribing formal OPT for all patients after THA.

Abstract 2
INTRODUCTION: Total knee arthroplasty (TKA) reduces pain and improves self-reported function compared to preoperative levels, but postoperative deficits in walking speed (20% slower) and stair climbing speed (50% slower) compared to healthy age-matched norms can persist for years. Stair climbing performance is the single largest residual deficit after TKA, with 75% of patients reporting difficulty negotiating stairs years after TKA. Collectively, these findings suggest that current rehabilitation does not adequately target the impairments that lead to long-term deficits in functional mobility after TKA. Although some studies suggest that rehabilitation after TKA has no long-term benefit, emerging evidence suggests that more aggressive rehabilitation, using intensive progressive resistance exercise and functional strengthening, may substantially improve patient function without compromising safety. Yet, to date, there are no prospective, randomized clinical trials examining the safety and efficacy of progressive rehabilitation beginning immediately after TKA. Therefore, the purpose of this prospective, randomized clinical trial was to examine the safety and efficacy of a high-intensity progressive rehabilitation protocol (HI) compared to a lower intensity (LI) rehabilitation protocol in individuals after TKA.
METHODS: One-hundred-sixty-two participants (aged 63±7 years; 89 females) were randomized to either the HI group or LI groups after TKA. The HI intervention consisted of early initiation of an intensive rehabilitation using progressive resistance exercise targeting all lower extremity muscle groups, balance exercise, agility exercises, and faster progression to weight-bearing strengthening exercises, and a higher ultimate level of progression of exercise compared to the LI group. Progression in the HI group was based upon clinical findings of pain, surgical knee range of motion (ROM), swelling, and functional performance. The LI intervention was based on the synthesis of previously published standard TKA rehabilitation programs, and consisted of ROM, stretching, light resistive exercises utilizing ankle weights or resistive bands, and lower demand functional exercises. Progression in the LI group was time-based. Both groups were treated two to three times per week for 12 weeks (25 total sessions). Outcomes included the stair climbing test, timed-up-and-go (TUG) test, five-times sit-to-stand (FTSTS) test, six-minute walk (6MW) test, isometric quadriceps and hamstring strength, quadriceps activation, surgical knee range of motion (ROM), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Outcomes were assessed preoperatively and at 1, 2, 3, 6, and 12 months postoperatively. Secondary analysis evaluated whether postoperative quadriceps activation deficits contributed to altered functional performance after TKA.
RESULTS: There were no significant differences between groups at any time point in functional performance, strength, activation, knee ROM, WOMAC score, or adverse events. A planned secondary analysis indicated that there were differential effects of the HI intervention depending on postoperative quadriceps activation. Individuals in the HI group with higher postoperative activation demonstrated improved functional performance earlier after TKA compared to those individuals with lower activation in the HI group or all individuals in the LI group regardless of postoperative activation levels.
DISCUSSION: High-intensity progressive rehabilitation is safe for individuals after TKA, does not compromise ROM recovery, and may lead to earlier functional recovery depending on postoperative quadriceps activation.

American Academy of Orthopaedic Surgeons material
AAOS annual meeting abstract 1
AAOS annual meeting abstract 2

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