The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial

Abstract

Purpose: To examine the immediate and long-term effects of a walking-skill program compared with usual physiotherapy on physical function, pain and perceived self-efficacy in patients after total knee arthroplasty (TKA). Method: A single blind randomized controlled trial design was applied. Fifty-seven patients with primary TKA, mean age of 69 years (SD?±?9), were randomly assigned to a walking-skill program emphasizing weight-bearing exercises or usual physiotherapy. Outcomes were assessed before the interventions started at 6 weeks postoperatively (T1), directly after the interventions at 12–14 weeks (T2) and 9 months after the interventions (T3). Walking was the primary outcome, assessed by the 6?min walk test (6MWT). The secondary outcomes were timed stair climbing, timed stands, Figure-of-eight test, Index of muscle function, active knee range of motion, Knee Injury and Osteoarthritis Outcome Score and self-efficacy score. Results: From T1 to T2, a better 6MWT score was found in favor of the walking-skill program of 39?m (2–76), p?=?0.04. The difference between the groups in 6MWT persisted at T3, 44?m (8–80), p?=?0.02. No differences in other outcome measures were found. Conclusion: The walking-skill program had better effect on walking than usual physiotherapy. Weight bearing was tolerated.

• Implications for Rehabilitation

• Weight-bearing exercises are tolerated by the patients in the early stage after TKA.

• Physiotherapy that focuses on learning different ways of walking through practice may be a plausible way to train patients after TKA.

     

Review article: A scoping review of physiotherapists in the adult emergency department

To provide an overview of the literature that considers physiotherapists working in the ED in relation to their roles, training levels, patient profile, safety, effectiveness, efficiency, cost-effectiveness and the provision of low-value care. We performed a scoping review of the literature. Four databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched from their inception to December 2016 and we updated searches on PubMed in September 2017. Two reviewers independently screened studies for eligibility. We performed a narrative synthesis of quantitative data. We included 27 studies: five randomised controlled trials (n = 1434), 12 prospective observational studies (n = 153 767), six retrospective studies (n = 9968), two survey studies (n = 61), one case report (n = 3) and one qualitative study (n = 11). Physiotherapists primarily managed patients with low urgency musculoskeletal conditions. Physiotherapists appeared to have similar clinical effectiveness and costs compared to other health providers (four randomised controlled trials). Physiotherapists were associated with increased efficiency (eight observational studies) and reduced low-value care (one observational study). Three observational studies reported very low adverse event rates. However, none of the studies followed participants to measure adverse events that became apparent after the ED visit, nor did they consider unsafe discharge decisions or suboptimal follow-up care. The available evidence suggests that physiotherapists may be as effective as other health providers in managing low urgency musculoskeletal conditions in the ED. There is uncertainty about appropriate training and a lack of robust studies investigating the efficiency, safety and cost-effectiveness of this model of care.     

The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: A randomised controlled trial

ObjectiveTo evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA).DesignTwo-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017.SettingSingle centre study conducted at a University-affiliated, tertiary hospital.InterventionPeople with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU).Outcome MeasuresSelf-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire).Results127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed.ConclusionMBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.     

Factors associated with stair climbing ability in patients with knee osteoarthritis and knee arthroplasty: a systematic review

Abstract

Purpose: People with knee osteoarthritis (OA) report ongoing limitations in climbing stairs, even after total knee arthroplasty (TKA). The aim of this systematic review was to synthesise the available evidence of factors affecting stair climbing ability in patients with knee OA before and after TKA. Method: A systematic search was conducted of common electronic databases. All English language abstracts where stair-climbing was assessed in patients with either knee OA or at least 6 months after TKA, and a relationship to any physical, psychological or demographic factors was reported. Results: Thirteen studies were included in the final review, nine investigated a knee OA population, and four investigated a TKA population. For patients with knee OA there was consistent and convincing evidence that greater stair-climbing ability was related to stronger lower limb muscles and less knee pain. For patients with TKA there was much less research, and no conclusions could be reached. Conclusions: For people with knee OA there is evidence that some physical, demographic and psychosocial factors are related to stair-climbing ability. However, the evidence for similar relationships in the TKA population is scarce and needs more extensive research.

• Implications for Rehabilitation

• People with knee osteoarthritis experience difficulty when climbing stairs, and this remains challenging even after knee replacement.

• For people with knee osteoarthritis, a range of physical, demographic and psychosocial factors contribute to stair-climbing ability, however, evidence for similar relationships in the TKA population is scarce.

• Rehabilitation that is multi-faceted may be the best approach to improve stair-climbing in people with knee osteoarthritis.

     

Challenges of total knee arthroplasty in osteogenesis imperfecta: case report and literature review

The majority of adults with mild osteogenesis imperfecta report significant functional impairment due to musculoskeletal concerns. Knee osteoarthritis is common in these patients. Although total knee arthroplasty has become a highly efficient surgical technique for osteoarthritis, this procedure remains uncommon in patients with osteogenesis imperfecta. This current case report describes the important clinical aspects of osteogenesis imperfecta that must be considered during the planning and performance of a total knee replacement. A 62-year-old female patient with a history of osteogenesis imperfecta suffered from severe osteoarthritis of the knee with valgus deformity. Two years after posterior stabilized total knee arthroplasty, her Hospital for Special Surgery knee score had improved from preoperative 53 points to 85 points at the final follow-up. The current case report describes the crucial technical aspects of a successful total knee replacement in this uncommon scenario. Underlying deformities and concomitant pathologies constitute specific surgical challenges. Special care should be taken to protect the patient from potential complications.     

Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review

Rationale, aims and objectives Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? Method Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. Results Joint arthroplasty clinical pathways address pre‐admission education, pre‐admission exercises, pre‐admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home‐based physiotherapy and continuous follow‐up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. Conclusions A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta‐analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.     

Anterior dislocation of a total knee arthroplasty in a patient with postoperative delirium: a case report

We report a rare case of traumatic anterior dislocation in a patient with postoperative delirium following total knee arthroplasty. The patient was successfully treated by open reduction of the dislocation and polyethylene liner change. Recognition of risk factors for postoperative delirium is important for the prevention of this uncommon injury.     

Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis

Background

Physiotherapy is a routine component of postoperative management following total knee arthroplasty (TKA). As the demand for surgery increases it is vital that postoperative physiotherapy interventions are effective and efficient.

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: a systematic review of available evidence

Purpose. To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction. Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method. A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results. Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions. The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Effective exercise intervention period for improving body function or activity in patients with knee osteoarthritis undergoing total knee arthroplasty: a systematic review and meta-analysis

Background

Various systematic reviews and/or meta-analyses examining the effects of pre- or postoperative exercise on body function or activity in patients undergoing total knee arthroplasty (TKA) have been published. However, the interventional period needed to at least improve outcomes is unknown.

Knowledge,behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review

Purpose: To systematically review and analyze the literature exploring the knowledge, behaviors, attitudes, and beliefs of physiotherapists towards the use of psychological interventions in their practice.

Methods: A systematic search was conducted, of articles published between January 1996 and February 2016, using selected electronic databases followed by crosschecking of reference and citation lists. Articles were selected on the basis of the research reported relating to knowledge, behaviors, attitudes or beliefs of physiotherapists towards using a number of different psychological interventions. Quality assessment was conducted by three reviewers independently, and thematic analysis of the included studies was performed.

Results: Fifteen studies were included in the analysis. Results indicate that physiotherapists are aware of psychological interventions, are using a variety within practice, and have positive attitudes and beliefs towards their use. However, there are barriers to the incorporation of psychological interventions into their practice, including lack of knowledge, time constraints, and role clarity. The desire for further training was also evident.

Conclusion: Notwithstanding the reported awareness and use of psychological interventions in physiotherapy practice, barriers to implementation exist indicating that further research is necessary to address how to effectively equip physiotherapists, to employ such techniques within their scope of practice.

• Implications for rehabilitation

• Physiotherapists use and have positive attitudes and beliefs towards a variety of psychological interventions including goal setting, positive, and motivational talk, cognitive behavioral therapy strategies and offering social support.

• Barriers preventing the incorporation of psychological interventions in practice include, lack of knowledge, time constraints, and role clarity.

• Despite the use of such interventions, physiotherapists identify the need for further training, to be better equipped to confidently utilize these in practice.

• These results justify the incorporation of training in psychological interventions in physiotherapist qualifying studies, but also as continued professional development opportunities for physiotherapists currently working in the field.

     

Cost effective interprofessional training: An evaluation of a training unit in Denmark

In 2004, the first Danish undergraduate interprofessional training unit (ITU) was established at the Regional Hospital Holstebro, inspired by experiences from Sweden. In this unit, medical, nursing, occupational therapy and physiotherapy students are given responsibility, under supervision by trained and motivated personnel, for rehabilitation and care of patients in a subunit of an orthopaedic department. The aim of this study was to see whether the ITU was cost effective in treating patients compared with a conventional orthopaedic ward. One-hundred and thirty-four patients admitted for primary hip or knee replacement surgery were included in the study. All costs were recorded in the ITU and in the conventional ward. Follow-up was done by a quality of life questionnaire three months after the operation. Comparison was done by univariable and multivariable testing of costs and effect. In both, the ITU was more cost effective than the conventional ward. No difference was found in complications and patient-reported quality of life. In conclusion, clinical training can be given to students in an ITU without reducing productivity in a hospital environment if pedagogic principles, clinical tutors and patient logistics all adapt to the challenge of the teaching environment.     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

Purpose.?To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction.?Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method.?A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results.?Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions.?The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Biopsychosocial predictors of prognosis in musculoskeletal disorders: a systematic review of the literature (corrected and republished)

Purpose: To review the prognostic factors of musculoskeletal disorders while adopting a multidimensional perspective and including studies on various pertinent outcomes to the adjustment process. We also aimed to highlight the overall and phase-specific evidence. Method: We searched the Psychinfo and Ovid Medline(R) databases as well as pertinent periodicals and reviews and retained prospective studies of subjects suffering from specific or non-specific musculoskeletal pain that adopted multivariate statistical analysis. Results: We selected 105 studies, of which 68 included biopsychosocial and sociodemographic variables. For those studies using a biopsychosocial framework, we determined the level of evidence for every prognostic factor with each outcome. Strong evidence was found for recovery expectations and disability management with work participation outcomes. With disability outcomes, strong evidence was also found for recovery expectations, coping and somatization. Comorbidity and duration of episode strongly predicted pain outcomes. Some differences coinciding with phases of chronicity were also identified. Conclusion: Although uncertainty remains about the role of many prognostic factors, we found strong evidence to support the predictive value of clinically significant variables. There is, however, a need for additional research and replication, adopting more homogenous models and measurement methods.

Implications for Rehabilitation

• Despite numerous studies, it remains difficult to identify a clear set of prognostic factors in musculoskeletal disorders.

• Outcomes in musculoskeletal disorders are determined by biopsychosocial prognostic variables although psychosocial factors appear predominant, as early as in the acute phase.

• There appears to be negligible differences between prognostic factors in acute, subacute and chronic phases and a biopsychosocial approach should be considered from the acute phase in rehabilitation practice.

• Outcomes in rehabilitation practice should also be evaluated from a biopsychosocial perspective.

     

Biomechanical evaluation of different reconstructive techniques of proximal tibia in revision total knee arthroplasty: An in-vitro and finite element analysis

Background

Bone loss and subsequent defects are often encountered in revision total knee arthroplasty. In particular, when the cortical rim of proximal tibia is breached, the surgical decision on the reconstructive options to be taken is challenging due to the variety of defects and the lack of data from clinical or experimental studies that can support it. The purpose of this study is to assess how different reconstructive techniques, when applied to an identical defect and bone condition, can be associated to dissimilar longevity of the revision procedure, and the role of a stem in this longevity.

Methods

Proximal cortex strains and implant stability were measured in ten reconstructive techniques replicated with synthetic tibiae. The cancellous bone strains under each construct were assessed with finite element models which were validated against experimental strains.

Findings

The measured strains and stability showed that the proximal cortex is not immune to the different reconstructive techniques when applied to an identical defect. The largest cancellous strain differences between modular and non-modular techniques indicate a distinct risk between reconstructive techniques, associated to the supporting capacity of cancellous bone at long term.

Interpretation

The main finding of the present study is the observation that modular augments increases, on a long term basis, the potential risk of bone resorption relative to the non-modular techniques. In addition, the use of a press-fit stem in the scope of non-modular techniques can lead to improved stability and load transfer, which can contribute positively to the life expectancy of these techniques.     

Total knee arthroplasty in motivated patients with knee osteoarthritis and athletic activity approach type goals: a conceptual decision-making model

Knee osteoarthritis is one of the most common disabling medical conditions. With longer life expectancy the number of total knee arthroplasty ((TKA)) procedures being performed worldwide is projected to increase dramatically. Patient education, physical activity, bodyweight levels, expectations and goals regarding the ability to continue athletic activity participation are also increasing. For the subset of motivated patients with knee osteoarthritis who have athletic activity approach type goals, early TKA may not be the best knee osteoarthritis treatment option to improve satisfaction, quality of life and outcomes. The purpose of this clinical commentary is to present a conceptual decision-making model designed to improve the knee osteoarthritis treatment intervention outcome for motivated patients with athletic activity approach type goals. The model focuses on improving knee surgeon, patient and rehabilitation clinician dialogue by rank ordering routine activities of daily living and quality of life evoking athletic activities based on knee symptom exacerbation or re-injury risk. This process should help establish realistic patient expectations and goals for a given knee osteoarthritis treatment intervention that will more likely improve self-efficacy, functional independence, satisfaction and outcomes while decreasing the failure risk associated with early TKA.