© Arthritis Research UK 2010

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EFFECTIVENESS OF INTENSIVE PHYSIOTHERAPY INTERVENTIONS FOR PATIENTS INDICATING

POOR OUTCOME POST KNEE REPLACEMENT SURGERY.

FEEDBACK FOLLOWING PRELIMINARY SEARCH

QUERY: REF OA-002

Received: 18th February 2010 Feedback to CSG: June 2010 (latest), 1st April 2010(sent)

SEARCH METHODOLOGY

The content of this feedback report refers only to the most relevant material located under each of the evidence headings and is drawn predominantly from author abstracts or research recommendations within Guidelines. The question is posed in the context of head-to-head studies that consider the comparative effectiveness of postoperative rehabilitation programs, especially physiotherapy, exercise regimes and care packages, for patients with osteoarthritis of the knee indicating poor outcome following unicompartmental or total knee replacement surgery. However, all studies comparing different perioperative and postoperative rehabilitation regimes (including pain management programs) following knee replacement have been included to provide a complete overview of the current literature; as have studies which explore factors determining patient outcomes following knee replacement surgery. Material prior to 2005 has also been excluded from the main report; however, a list of relevant references is given in Appendix A. Where no specific detail of review methodology is given, these reviews are collected in section D. Further details of all the studies included in this report are shown in the Appendix B, sorted by report section and author name.

Criteria used (PICO): Who? (population) Patients with osteoarthritis affecting the knee who undergo unicompartmental or total knee replacement surgery. What? (intervention/exposure/measure) Postoperative rehabilitation programs, especially physiotherapy, exercise regimes and packages of care. Comparison Standard/usual or other post-operative care/rehabilitation programs.

What is measured? What are the outcomes? Self-reported pain; physical function; range of movement; muscle strength; activity; return to work; patient satisfaction; other relevant measures.

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Location and setting Worldwide; Home-based, community-based or in/out patient rehabilitation programmes.

Exclusion Criteria Rheumatoid arthritis; secondary joint replacements Databases Searched NHS Evidence: Health Information Resources (Bandolier, National Library of Guidelines, NICE Guidance, International Guideline, CKS, Clinical Evidence, DUETS, NHS Evidence Specialist Collections); EMBASE; MEDLINE; CINAHL; AMED; OT Seeker; PEDro; TRIP; Centre for Reviews and Dissemination (DARE, NHS EED and HTA); MetaRegister of Clinical Trials (active registers); ClinicalTrials.gov; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Studies. Types of Study Head-to-head, controlled or outcome trials/studies. Keywords searched Osteoarthritis, knee, replacement, arthroplasty, rehabilitation, exercise, physiotherapy, training, rehabilitation, program(s)/programme(s), package, physical therapy, occupational therapy.

Keywords were used in combination or separately; truncation was used where possible; MESH words included where possible.

Date limits 2000 to date for searches to scope background; 2005 to date for general inclusion in feedback (see Methodology) Language limits No restriction: studies primarily reported in other languages have English abstracts to be included in the databases used. Summary of available evidence

EVIDENCE TYPE

INCLUDED IN FEEDBACK

A Controlled trials (Current and Closed) 31

B Systematic reviews 4

C Evidence summaries 1

D Non-systematic reviews 4

E Case Studies 741

F Peer-reviewed articles 5

G Intellectual Property Office 0

1 Number of independent studies, corresponding to 78 articles

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RESULTS

Whilst a number of studies focus specifically on patients with osteoarthritis that undergo unicompartmental or total knee arthroplasty, also included are those with patients that undergo hip or knee arthroplasty due to osteoarthritis, or studies where a diagnosis of osteoarthritis is not part of the inclusion criteria but is, in fact, the main reason patients undergo joint arthroplasty. A: Controlled Trials

Includes details from: ISRCTN Register (including. Action Medical Research; The Wellcome Trust; Medical Research Council (MRC); NHS R&D HTA); NIH records on ClinicalTrials.gov; Arthritis Research UK.

Of the 31 trials included in this report, 14 are randomized controlled trials (RCTs) that focus on the effectiveness of various pain management interventions after knee arthroplasty including drug (A3, A12, A13, A15, A16, A17, A18, A19, A20, A23), cold and compression (A9) and acupuncture (A1, A4, A11 [knee or hip]) therapies. Other trials focus on perioperative interventions following TKA (A5, A29), postoperative rehabilitation/exercise regimes (A2, A6, A7, A8, A14, A21 [hip or knee], A24, A27, A28, A31) and the (cost) effectiveness of clinical pathways for patients undergoing hip or knee replacement surgery (A22, A25 [observational study], A26). One RCT focuses specifically on quadriceps activation deficit following TKR (A10). Whilst a cohort study examines predictors of short-term outcomes following TKA and THA (A30) Whilst the majority of the trials appear completed, publications linked to only one study were found (A27) (Lenssen et al., 2006, 2008) – for details see Section E.1

ID Trial Details: title, main sponsor and web-link Period

A1 Management of Postoperative Pain Following Total Knee Arthroplasty by Using Acupuncture-moxibustion Therapy Chang Gung Memorial Hospital http://ClinicalTrials.gov/show/NCT01047384

2010-2011

A2 Effectiveness of in-home telerehabilitaiton service following knee arthroplasty: a multicentric clinical trial Laval University (Canada) http://www.controlled-trials.com/ISRCTN66285945

2009-2011

A3 Local Infiltration Analgesia or Intrathecal Morphine in Total Knee Arthroplasty University Hospital Orebro http://ClinicalTrials.gov/show/NCT00992082

2009-2011

A4 Effectiveness of Acupuncture as an Adjunct to Rehabilitation After Knee Arthroplasty Back and Rehabilitation Center, Copenhagen http://ClinicalTrials.gov/show/NCT00935155

2009-2011

A5 Perioperative Intervention to Improve Post-TKR Support and Function National Institute of Arthritis and Musculoskeletal and Skin Diseases http://ClinicalTrials.gov/show/NCT00566826

2008-2011

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A6 Progressive Exercise After TKA Jyväskylä Central Hospital http://ClinicalTrials.gov/show/NCT00605124

2008-2011

A7 Effectiveness of two types of treatment in restoring muscle after hip or knee Surgery. National Institute of Arthritis and Musculoskeletal and Skin Diseases http://ClinicalTrials.gov/show/NCT00393848

2006-2011

A8 Hydrotherapy Versus Physiotherapy for Short-Term Rehabilitation After Primary TKR Hadassah Medical Organization http://ClinicalTrials.gov/show/NCT00878358

2009-2010

A9 Use of cold and compression therapy with total knee replacement patients CoolSystems, Inc. http://ClinicalTrials.gov/show/NCT00712816

2008-2010

A10 Early Neuromuscular Electrical Stimulation For Quadriceps Muscle Activation Deficits Following Total Knee Replacement National Institute on Aging (NIA) http://ClinicalTrials.gov/show/NCT00800254

2008-2010

A11 Acupuncture for Pain Management After Hip or Knee Arthroplasty HealthEast Care System http://ClinicalTrials.gov/show/NCT00455182

2007-2010

A12 Efficacy of Multimodal Peri- and Intraarticular Drug Injections in Total Knee Arthroplasty Asker & Baerum Hospital http://ClinicalTrials.gov/show/NCT00562627

2007-2009

A13 Do Corticosteroid Injections During Total Knee Replacement Improve Early Clinical Results? New Lexington Clinic http://ClinicalTrials.gov/show/NCT00492973

2006-2009

A14 Comparison of post-discharge physiotherapy versus usual care following total knee replacement: a randomised clinical trial Department of Health (UK) http://www.controlled-trials.com/ISRCTN07624314

2003-2009

A15 Efficacy and Safety of Pregabalin for Pain following total Knee Replacement Pfizer http://ClinicalTrials.gov/show/NCT00442546

2007-2008

A16 The short and long term effects of perioperative gabapentin use on functional, rehabilitation and pain outcomes following total knee arthroplasty: a randomised, double-blind, placebo-controlled trial Sunnybrook Health Sciences Centre (Canada) http://www.controlled-trials.com/ISRCTN34631378

2007-2008

A17 Evaluation of Diprospan Injection to the Knee on Rehabilitation of Patients After TKR of the Contralateral Knee Hadassah Medical Organization http://ClinicalTrials.gov/show/NCT00542139

2007-2008

A18 The Role of Intra-Operative Intracapsular Blocks in Post-Operative Pain Management Following Total Knee Arthroplasty Duke University http://ClinicalTrials.gov/show/NCT00620828

2007-2008

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A19 Perioperative Pain Control With Celecoxib (Celebrex) in Total Knee Arthroplasty National Taiwan University Hospital http://ClinicalTrials.gov/show/NCT00598234

2006-2008

A20 Continuous Femoral Nerve Block Following Total Knee Replacement National Institute of General Medical Sciences (NIGMS) http://ClinicalTrials.gov/show/NCT00135889

2005-2008

A21 Ergometer cycling after replacement of the hip or knee joint. Verein zur Förderung der Rehabilitationsforschung in Schleswig-Holstein http://ClinicalTrials.gov/show/NCT00951990

2005-2008

A22 Cost efficacy of a clinical pathway to patients undergoing hip and knee replacement surgery. University of Aarhus http://ClinicalTrials.gov/show/NCT00175201

2005-2008

A23 Celebrex Total Knee Arthroplasty Study Pfizer http://ClinicalTrials.gov/show/NCT00359151

2006-2007

A24 Effects of progressive aquatic exercise on mobility ability and neuromuscular performance Kymenlaakso Central Hospital (Finland) http://www.controlled-trials.com/ISRCTN50731915

2005-2007

A25 JOINTS Study - Joint Replacement Outcome in Inpatient Rehabilitation Facilities and Nursing Treatment Sites National Rehabilitation Hospital http://ClinicalTrials.gov/show/NCT00499278

2005-2007

A26 Alberta hip and knee replacement project. Alberta Bone and Joint Health Institute http://ClinicalTrials.gov/show/NCT00277186

2005-2006

A27 Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy following total knee arthroplasty (TKA) University Hospital Maastricht (The Netherlands) http://www.controlled-trials.com/ISRCTN85759656

2005-2006

A28 Multidisciplinary rehabilitation after primary total knee arthroplasty Oulu University Hospital (Finland) http://www.controlled-trials.com/ISRCTN74292386

2002-2006

A29 The Effect of Perioperative Neuromuscular Training on the Outcome of Total Knee Arthroplasty Assaf-Harofeh Medical Center http://ClinicalTrials.gov/show/NCT00492674

?2007 not yet recruiting

A30 Arthroplasty Rehabilitation Score - Can we Predict the Short Term Postoperative Outcome? Hadassah Medical Organization http://ClinicalTrials.gov/show/NCT00668915

?2008 not yet recruiting

A31 Electrical Stimulation After Total Knee Arthroplasty Eunice Kennedy Shriver National Institute of Child Health and Human Development http://ClinicalTrials.gov/show/NCT00224913

?2002 still recruiting in 2005

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B: Systematic reviews

Only those reviews with a detailed methodology were considered for this section. Other literature reviews considered relevant have been shown under section D.

There are no systematic reviews that specifically focus on intensive physiotherapy inventions for patients indicating poor outcome after knee replacement surgery (due to osteoarthritis). However, a recent review of physiotherapy interventions following discharge after elective knee replacement surgery for osteoarthritis concludes that programs involving functional physiotherapy exercises have small to moderate short-term, but no long-term, benefit (Minns Lowe & Bourne, 2008). A Cochrane review examines multidisciplinary rehabilitation programs following hip or knee joint replacement surgery and concludes home-based care may be beneficial but stresses the low quality of the current evidence-base and surmises that further high quality research is needed (Khan, Ng, Gonzalez, Hale, & Turner-Stokes, 2008). Whilst, a review of supervised physical therapy versus unsupervised home therapy programs, following a myriad of knee surgeries, concludes that for older populations with comorbidities or undergoing complex surgery i.e. TKA and ACL reconstruction, the current evidence base is lacking (Coppola & Collins, 2009). The use of surface neuromuscular electrical stimulation (NMES) for quadriceps strengthening before or after total knee replacement was the focus of a recent review, however, only two studies were included (both considered to carry a high risk of bias) and it was concluded that currently its benefit remains unclear (Monaghan, Caulfield, & O'Mathuna, 2010). Another systematic review which may be of interest, but not included in the appendix, reviews performance based methods for assessing physical function of patients with hip or knee osteoarthritis (Terwee, Mokkink, Steultjens, & Dekker, 2006). Whilst, text for one study pertinent to this section of the report was unattainable: Effect of continuous passive motion after total knee arthroplasty: a systematic review (van Dijk, Elvers, & Oostendorp, 2007).

C: Good Quality Evidence summaries (inc. guidelines)

Recently published guidelines from the National Institute for Health and Clinical Excellence (NICE) for the care and management of adults with osteoarthritis (The National Collaborating Centre for Chronic Conditions, 2008), and from the Osteoarthritis Research Society International (OARSI) for hip and knee osteoarthritis (Zhang et al., 2007, 2008) make no mention of postoperative rehabilitation protocols or best practice.

A single French paper provides guidelines on the provision of rehabilitation specifically in physical medicine and functional rehabilitation wards following total knee arthroplasty. It recommends post-TKA rehabilitation in such wards for patients with preoperative joint stiffness and/or associated comorbidities with the potential to improve functional outcomes (Barrois, Ribinik, Gougeon, Rannou, & Reve, 2007).

D: Non-Systematic Reviews

Four non-systematic reviews are pertinent to this report. One considers physical rehabilitation prior to and following hip and knee arthroscopy and suggests postoperative regimes are beneficial following hip replacement (Dauty, Genty, & Ribinik, 2007). A review of evidence for continuous passive motion (CPM) as an adjunct to early mobilization following TKA, does not support its use in early mobilization regimes (Grella, 2008). The third review examined whether age affected early

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recovery following total knee arthroplasty, concluding that it did not appear to be a determining factor (Monaghan & Baxter, 2005). The three aforementioned reviews all highlight the lack of good quality evidence and the need for further quality research. The last paper2, reviewed rehabilitation programs following total knee replacement to establish a definitive protocol. It was concluded that postoperative rehabilitation is necessary, that a stage program should be implemented and must include exercises to ensure power, good range of motion, proprioception and gate (Li, Cheng & Yu, 2006).

E: Case Studies

E.1: Rehabilitation following knee arthroscopy

See Appendix B: Section E.1 Two studies only, focus on poor outcome following knee arthroplasty. The first, a small RCT (n=17) found that 12 weeks resistance training redresses muscle and mobility deficits 1-4 years after TKA: with greater improvement if the regime includes eccentric resistance training (la Stayo et al., 2009). The second, a cohort study, reports immediate benefits of manipulation under anaesthesia for knee stiffness following knee arthroplasty and recommends this as first line treatment for stiff knee arthroplasties (Mohammed, Syed, & Ahmed, 2009). Other studies included in this review focus on a diverse range of perioperative and postoperative rehabilitation regimes, and for clarity have been subdivided into inpatient and outpatient or community based programs. Perioperative and inpatient rehabilitation A total of 28 independent studies (31 articles) addressed inpatient rehabilitation programs following knee (or hip) surgery, which have been further subdivided according to therapeutic intervention. Continuous passive motion (CPM): There is consensus across 8 studies (9 articles), all RCTs, that CPM does not provide additional benefit over physical therapy alone with regard to a majority of short-term outcomes, or on a long-term basis (Alkire & Swank, 2010; Bruun-Olsen, Heiberg, & Mengshoel, 2009; Denis et al., 2006; Leach, Reid, & Murphy, 2006; Sahin et al., 2006). Studies suggest a slight short-term benefit in terms of an early improvement in ROM if the CPM protocol involves early flexion or patients have early postoperative flexion impairment (Bennett, Brearley, Hart, & Bailey, 2005; Lenssen et al., 2006, 2008), and the potential to shorten hospital stay (Ersozlu, Sahin, Ozgur, & Tuncay, 2009). Accelerated rehabilitation: A majority of studies to date suggest a clinical (and cost) benefit to accelerated rehabilitation regimes:

Three related studies (2 RCTs and 1 controlled study) examine the efficacy and (cost-) effectiveness of accelerated vs. usual perioperative rehabilitation following hip and knee replacement surgery (Larsen, Sorensen, Hansen, Thomsen, & Soballe, 2008; Larsen, Hansen,

2 placed here as only abstract available and was unable to ascertain whether SR or not.

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Thomsen, Christiansen, & Soballe, 2009; Larsen, Hvass, Hansen, Thomsen, & Soballe, 2008). Accelerated rehabilitation was more clinically and cost effective than usual care.

A retrospective controlled study found a ‘Rapid Recovery Program’ superior with regards to functional outcomes compared to a traditional rehabilitation protocol following TKA (Klika et al., 2009).

However, one RCT found no functional benefits of an accelerated protocol for patients with OA undergoing Oxford unicompartmental knee arthroplasty, although there were benefits in terms of greater patient satisfaction, shorter length of stay (LOS) and lower costs (Reilly et al., 2005). Early/acute phase rehabilitation: Two low-level studies i.e. 1 cohort and 1 case study, suggest that early physical therapy regimes improve functional status and QoL of patients with OA (and RA) following TKA (Legovic & Sestan, 2005; McQueen, 2006). Other regimes: Randomised controlled trials investigating novel inpatient rehabilitation regimes indicate benefit above that of usual rehabilitation protocols for:

Aquatic physiotherapy (McAvoy, 2009; Rahmann, Brauer, & Nitz, 2009);

Increased frequency of physical therapy immediately following TKA (Lenssen et al., 2006). Although a small cohort study (n=6) found that therapy twice a day resulted in shorter LOS and greater functional independence, whilst once a day greater ROM and less pain (Lawson, 2009);

but not for:

Acupuncture as an adjunct to usual physiotherapy (Tsang et al., 2007). Two case studies focus on Neuromuscular Electrical Stimulation (NMES). The first describes its use as an adjunct to a traditional rehabilitation regime to optimize quadriceps function following TKA. Whilst the patient showed improvement in quadriceps function this could not be attributed solely, or in part, to NMES and the need for further research was identified (Mintken, Carpenter, Eckhoff, Kohrt, & Stevens, 2007). The second reports on a patient who received a full thickness burn following NMES over the metal knee implant (Ford, Shrader, Smith, Mclean, & Dahm, 2005). Pain control: Four studies examined various interventions to manage pain following knee arthroplasty:

Randomised controlled trails o Continuous femoral nerve block provided better analgesia compared to usual

regime. This had benefit in terms of early functional recovery, but there was no long-term gain. (Kadic et al., 2009).

o Cold compressive dressing vs epidural anaesthesia vs standard care. Whilst all 3 interventions resulted in similar patient outcomes, greater morphine consumption was noted for patients receiving standard care. Cold compression was favoured as a viable and safe alternative to epidural anaesthesia to reduce pain and opioid use after surgery (Holmstrom & Hardin, 2005).

o Millimetre wave therapy has no analgesic benefit (Usichenko et al., 2008)

Prospective audit o Femoral nerve block injections (over 24 hours) provided no benefit in terms of pain

or other outcomes compared to usual analgesia (Monaghan, Harrington, & Nizai, 2007).

Deep venous thrombosis prophylaxis: Two studies examined interventions to prevent deep venous thrombosis (DVT) following TKA. A RCT concluded that enoxaparin conferred no advantage over

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aspirin (in combination with pneumatic compression and epidural anaesthesia) (Westrich et al., 2006). Whilst a prospective case series, suggested that combined pharmacological (subcutaneous nadroparin) and mechanical (intermittent foot sole pump) prophylaxis appears to reduce occurrence of DVT (Giannoni et al., 2006). Miscellaneous: A single RCT suggests that creatine monohydrate supplementation has no benefit for functional recovery after TKA (Roy, de Beer, Harvey, & Tarnopolsky, 2005). Cohort studies conclude that: knee arthroplasty could be carried out on an outpatient basis (if certain criteria are met postoperatively), although longer hospitalization reduced the rate of early readmissions (Berger, Kusuma, Sanders, Thill, & Sporer, 2009); and that for older patients undergoing TKR, early rehabilitation needs to focus on transfer and mobility activities (Unver, Karatosun, & Bakirhan, 2006). A small qualitative study (n=12) of older patients undergoing hip or knee replacement surgery suggests that patients were ill prepared for the transitional changes associated with the perioperative period, struggling to regain control of their body and lives: the need for further research to develop a care protocol to facilitate transition was highlighted (Gustafsson, Ponzer, Heikkila, & Ekman, 2007). Postoperative rehabilitation commenced after discharge from hospital A total of 18 studies (19 articles) addressed postoperative rehabilitation programs following discharge from hospital after knee (or hip) surgery, which have been further subdivided according to type of rehabilitation program and therapy. Home vs. inpatient: Studies suggest similar long-term outcomes for patients receiving home-based compared to inpatient rehabilitation regimes following knee (or hip) replacement surgery:

Randomised controlled trial (Mahomed et al., 2008)

Controlled cohort studies, patients were not randomised in these studies as to qualify for home-based rehabilitation a number of criteria had to be met (Iyengar, Nadkarni, Ivanovic, & Mahale, 2007; Tribe et al., 2005).

In addition, home-based programs appear to be significantly cheaper and therefore more cost-effective. Home vs. outpatient: Similarly, patient outcomes are comparable whether the rehabilitation regime is home-based and an outpatient program:

Randomised controlled trial of a pre- and post-op physiotherapy regime provided at home or in outpatients: home physiotherapy was more expensive (Mitchell et al., 2005).

Controlled cohort study, patients allocated to home or outpatient program depending on observed joint trajectory and patient availability for treatment (Mozo et al., 2008).

Targeted exercise: Studies suggest that targeted postoperative exercise/physiotherapy programs following discharge from hospital are effective at improving patient outcomes. Benefits appear to exceed those of traditional rehabilitation programs, and are independent of location or supervision:

Randomised controlled trails o Intensive short-term exercise vs. usual care (Bulthuis et al., 2007; Bulthuis,

Mohammad, Braakman-Jansen, Drossaers-Bakker, & van de Laar, 2008): intensive program also costs less and is therefore more cost-effective.

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o Specific kneeling advice and education (1 therapy session) vs. usual care, after partial knee replacement (Jenkins, Barker, Pandit, Dodd, & Murray, 2008)

o Land-based vs. water-based exercise classes (Harmer, Naylor, Crosbie, & Russell, 2009): comparable beneficial outcomes.

o Progressive quadriceps strengthening vs. conventional rehabilitation (Petterson et al., 2009): although neuromuscular electrical stimulation (NMES) as an adjunct to the former shows no additional benefit.

Controlled-cohort study o class-based vs. one-to-one home-based physiotherapy (Coulter, Weber, & Scarvell,

2009): comparable outcomes, although class-based protocol is significantly cheaper.

However, one RCT suggests that outpatient physiotherapy provides no benefit with regards ROM following TKA compared to no outpatient physiotherapy (Mockford, Thompson, Humphreys, & Beverland, 2008). Miscellaneous: A single RCT compares general strengthening pre-operative (3 weeks) vs specific strengthening post-operative (8 weeks) vs usual pre- and post-operative care after TKA. The pre-op intervention appears beneficial to patient mental health and early functional return, whilst the strengthening post-op regime was beneficial at increasing active range of motion (ROM) and accelerating functional recovery (Evgeniadis, Beneka, Malliou, Mavromoustakos, & Godolias, 2008). Two small controlled studies indicate a potential benefit of music therapy (Giaquinto, Cacciato, Minasi, Sostero, & Amanda, 2006) and a behavioural change intervention (Harnirattisai & Johnson, 2005) for patients’ mental (and physical/functional) health outcomes following knee surgery: although the need for further research was highlighted. Cohort studies suggest that: spousal support can have a positive effect on patient recovery and conversely that lack of support may hinder recovery following TKA for OA (Khan et al., 2009); patient concerns following TKA mirror their stage in recovery, with an increasing emphasis placed on their ability to participate in society (Rastogi, Chesworth, & Davis, 2008); and that following 6-months rehabilitation patients perceived themselves more disabled pre-operatively than they actually reported at the time (Razmjou, Yee, Ford, & Finkelstein, 2006). Finally, a case study describes a patient presenting with pain following discharge after TKA, and its eventual diagnosis as biceps femoris tendonitis (Pandher, Boparai, & Kapila, 2009). Text for two studies pertinent to this section of the report was unattainable: Can a functional rehabilitation program improve the outcomes and quality of life of patients with total knee arthroplasty? (Ibanez, 2008) and Case Report: Rehabilitation of a patient with minimally invasive total knee arthroplasty (Dean, 2007).

E.2: Factors affecting outcomes after knee arthroplasty

See Appendix B: Section E.2 Twenty-six cohort studies explore factors affecting patient outcomes following knee (and hip) arthroplasty. These can be broadly grouped according to type of outcome investigated:

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Health Related Quality of Life: knee arthroplasty/replacement alone (Bergschmidt et al., 2008; Escobar et al., 2007; Nilsdotter, Toksvig-Larsen, & Roos, 2009; Núñez, Núñez, Luis del Val, Ortega, & Segur, 2007; Núñez et al., 2009); TKA or THA (Caracciolo & Giaquinto, 2005a, 2005b; Lavernia, D'Apuzzo, Rossi, & Lee, 2009). More specifically:

Comorbidity and TKR outcomes (Ayers, Franklin, Ploutz-Snyder, & Boisvert, 2005) Morbid obesity and TKA outcomes (Rajgopal et al., 2008)

Objective Functional Measures, specifically: Functional deficits in knee extensors and flexors and TKR outcomes (Valtonen,

Poyhonen, Heinonen, & Sipila, 2009) Admission haemocrit and TKA or THA outcomes (Vincent & Vincent, 2007) Predictors of knee stiffness at 1 year post-TKA (Gandhi et al., 2006) Pre-TKA ROM as predictor of Post-manipulation ROM (Rubinstein & DeHaan,

2010)

Health Related Quality of Life and Objective Functional Measures: TKA alone (Mizner, Petterson, Stevens, Axe, & Snyder-Mackler, 2005; Park, Chang, Kang, Seong, & Kim, 2007; Rosenberg N., Nierenberg G., Lenger R., & Soudry M., 2007; Shi, Lu, & Guan, 2006); hip or knee replacement (Gandhi, Tsvetkov, Davey, Syed, & Mahomed, 2009).

Early post-op measures as predictors of 1- and 2-year functional outcomes after unilateral TKA (Zeni & Snyder-Mackler, 2010).

Length of hospital stay following TKA for OA (Dauty, Smitt, Menu, & Dubois, 2009)

Pain after TKA Acute pain (Roth, Tripp, Harrison, Sullivan, & Carson, 2007) Postoperative pain and self-reported disability: Pain-related psychological

determinants (Sullivan et al., 2009)

Patient satisfaction following knee or hip replacement (Baumann et al., 2006; Gandhi, Davey, & Mahomed, 2008).

Admission to convalescence unit after TKA (Robles et al., 2007) The inconsistent use of outcome measures coupled with the inclusion of a diverse range of potential predictors and populations precludes a definitive list of determinants of patient outcomes following knee arthroplasty. However, it is tentatively suggested that preoperative functional ability (especially if severe), (morbid) obesity and negative thoughts/perceptions impact negatively on postoperative outcomes.

E.3: Other studies

The following studies are not detailed in the appendix but may be of interest for any future research:

Effect of preoperative physiotherapy and education on postoperative outcomes following knee or hip arthroscopy (Coudeyre et al., 2007; Gill, McBurney, & Schulz, 2009; Jaggers et al., 2007; Levinger, Lai, Begg, Webster, & Feller, 2009; Rodenas-Martinez et al., 2008; Rooks et al., 2006; Topp, Swank, Quesada, Nyland, & Malkani, 2009).

Assessment tools following TKA: the reproducibility of goniometric measures (Lenssen et al., 2007) and the use of a performance battery ‘gold standard’ measure for physical function (Stratford, Kennedy, & Riddle, 2009); use of self-report and performance-based tests in TKR and THR patients (Gandhi et al., 2009).

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Modelling recovery of: physical function after hip and knee arthroplasty (Kennedy, Stratford, Hanna, Wessel, & Gollish, 2006); quadriceps strength after TKA (Mizner, Petterson, & Snyder-Mackler, 2005).

Assessing recovery and establishing prognosis following TKA (Kennedy, Stratford, Riddle, Hanna, & Gollish, 2008)

Appropriateness, sensitivity and/or roundedness of various outcome measures used for assessing patients undergoing hip (and knee) arthroscopy:

o World Health Organization Quality of Life short version instrument (WHOQOL-BREF) (Ackerman, Graves, Bennell, & Osborne, 2006);

o KOOS-Physical Function Short-form (KOO-PS) (Davis et al., 2009; Perruccio et al., 2008);

o Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (Chesworth, Mahomed, Bourne, & Davis, 2008; Rossi, Hasson, Kohia, Pineda, & Bryan, 2006; Xie et al., 2008) and SF-36 (Escobar A. et al., 2007);

o Oxford Knee Score (Ko Y. et al., 2009; Xie F. et al., 2007); o DynaPort KneeTest (Mokkink et al., 2005a, 2005b); o International Classification of Functioning, Disability and Health (ICF) (Pisoni,

Giardini, Majani, & Maini, 2008); o Hospital for Special Surgery Knee Score (HSS) and the Staffelstein Score (Slupik &

Bialoszewski, 2007); o Knee specific quality of life instruments (Tanner, Dainty, Marx, & Kirkley, 2007); o Short-form McGill Pain Questionnaire (SF-MPQ) (Strand, Ljunggren, Bogen, Ask, &

Johnsen, 2008). F: Peer-reviewed articles

One article presents a commentary on the role of perioperative physiotherapy following hip and knee surgery (Lenssen & de Bie, 2006). It indicates that postoperative Continuous Passive Motion and intense physical exercise is beneficial and that in order to maximise the benefit exercise regimes need to be maintained after discharge. A review of patient outcomes after TKA or THA for OA concludes that no single patient-related or perioperative factor clearly predicts functional outcomes or pain relief after surgery (Jones, Beaupre, Johnston, & Suarez-Almazor, 2007)3. Quadriceps muscle impairments are described and their effect on function after TKA are outlined in a recent paper, which also reviews and provides recommendations on rehabilitation regimes after surgery (Meier et al., 2008)3. Nursing care of patients undergoing knee replacement (Temple, 2006) and specifically post-operative care following TKR or THR (Lucas, 2008) was the subject of two papers, both give an overview of the procedures, nursing needs of patients postoperatively and rehabilitation programs. G: Intellectual Property Office

None

3 Unable to access a full copy of the paper, so little detail is presented here.

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CONCLUSION

The majority of articles addressing rehabilitation regimes included in this report present randomised controlled study designs and systematic reviews that rate as medium/high-level evidence: however, caution is needed as many of these studies have a small sample size. In general, the current evidence base suggests that postoperative exercise/physiotherapy regimes are beneficial for patients with knee (or hip) osteoarthritis following knee (or hip) arthroplasty, increasing functional outcomes and quality of life; at least in the short-term. Whilst, Continuous Passive Motion as an adjunct to postoperative physiotherapy regimes appears to confer no additional benefit.

Only two completed studies, one low-quality RCT with a small sample size and a cohort study focus on poor outcome after knee replacement surgery. The first study suggests resistance training, especially eccentric resistance training, can redress muscle and mobility deficits present 1-4 years after TKA. The second recommends manipulation under anaesthesia as first line treatment for knee stiffness after knee arthroplasty after finding it confers an immediate benefit. In addition, an ongoing RCT focuses specifically on quadriceps activation deficit following TKR and its potential treatment using early neuromuscular electrical stimulation (A10).

Other studies indicate that post-discharge rehabilitation programs involving targeted or intensive physiotherapy and physical exercise regimes are more effective in terms of patient outcomes than conventional programs, irrespective of location or supervision.

This report also includes a number of cohort studies, which investigate a range of factors affecting various outcomes following knee (and hip) replacement surgery. These suggest that preoperative functional ability, obesity and negative thoughts/perceptions have a negative impact on postoperative outcomes.

In summary, this report identifies the lack of high quality RCT evidence as a necessary research direction in establishing the effectiveness of intensive physiotherapy interventions for patients with osteoarthritis indicating poor outcome following knee replacement surgery.

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ABBREVIATIONS

ADL Function in Daily Living

AQMH Alberta Quality Matrix for Health

BMI Body Mass Index

C.I. Confidence Interval

CPM Continuous Passive Motion

DVT Deep Venous Thrombosis

EPMROM Escola Paulista de Medicina Range of Motion Scale

EQ-5D EuroQual-5D Health Survey

FAC Functional Ambulatory Classification

FIM Functional Independence Measure

HAD Hospital Anxiety and Depression Scale

HAQ Health Assessment Questionnaire

HRQoL Health Related Quality of Life

ICF International Classification of Functioning, Disability and Heath

HSS Hospital Special Surgery Score

KOS Knee Outcome Survey

KOOS Knee injury and Osteoarthritis Outcome Score

KSS Knee Society Score

LMWH Low Molecular Weight Herparin

LOS Length of stay

MACTAR The McMaster Toronto Arthritis Patient Preference Disability questionnaire

MMSE Mini-Mental State Examination

NSAID Non-steroidal Anti-Inflammatory drugs

NMES Neuromuscular Electrical Stimulation

NRS Numeric Rating Scale

OA Osteoarthritis

15

PT Physical therapy

QALYs Quality-Adjusted Life Years

QoL Quality of Life

RA Rheumatoid arthritis

RAND-36 Research and Development 36-item Health Survey

RCT Randomised Controlled/Clinical Trial

ROM Range of Motion

sd Standard deviation

SF-12 Short-Form-12 Health Survey

SF-36 Short-Form-36 Health Survey

SF-6D Short-Form-6D Health Survey

SF-MPQ Short Form – McGill Pain Questionnaire TKA Total knee arthroplasty

THR Total hip replacement

TJR Total joint replacement

TUG Timed Up & Go test

UKA Unicompartmental knee arthroplasty

VAS Visual Analogue Scale

WHO World Health Organization

WOMAC Western Ontario and McMaster Universities Osteoarthritis Index

16

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Shi, M. G., Lu, H. S., & Guan, Z. P. (2006). [Influence of preoperative range of motion on the early clinical outcome of total knee arthroplasty]. Chung-Hua Wai Ko Tsa Chih [Chinese Journal of Surgery], 44(16), 1101-5.

Slupik A., & Bialoszewski D. (2007). Comparative analysis of clinical usefulness of the staffelstein score and the hospital for special surgery knee score (HSS) for evaluation of early results of total knee arthroplasties. preliminary report. Ortopedia Traumatologia Rehabilitacja, 9(6), 627-635.

Strand, L. I., Ljunggren, A. E., Bogen, B., Ask, T., & Johnsen, T. B. (2008). The short-form McGill pain questionnaire as an outcome measure: Test-retest reliability and responsiveness to change. European Journal of Pain: Ejp, 12(7), 917-25.

Stratford, P. W., Kennedy, D. M., & Riddle, D. L. (2009). New study design evaluated the validity of measures to assess change after hip or knee arthroplasty. Journal of Clinical Epidemiology, 62(3), 347-352.

Sullivan M., Tanzer M., Stanish W., Fallaha M., Keefe F.J., Simmonds M., & Dunbar, M. (2009). Psychological determinants of problematic outcomes following total knee arthroplasty. Pain, 143(1-2), 123-129.

24

Tanner, S. M., Dainty, K. N., Marx, R. G., & Kirkley, A. (2007). Knee-specific quality-of-life instruments: Which ones measure symptoms and disabilities most important to patients? American Journal of Sports Medicine, 35(9), 1450-8.

Temple, J. (2006). Care of patients undergoing knee replacement surgery. Nursing Standard, 20(48), 48-56; quiz 58.

Terwee, C. B., Mokkink, L. B., Steultjens, M. P., & Dekker, J. (2006). Performance-based methods for measuring the physical function of patients with osteoarthritis of the hip or knee: A systematic review of measurement properties. Rheumatology, 45(7), 890-902.

The National Collaborating Centre for Chronic Conditions (2008). Osteoarthritis: National clinical guideline for care and management in adults. London: The Royal College of Physicians.

Topp, R., Swank, A. M., Quesada, P. M., Nyland, J., & Malkani, A. (2009). The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. Pm & R, 1(8), 729-35.

Tribe, K. L., Lapsley, H. M., Cross, M. J., Courtenay, B. G., Brooks, P. M., & March, L. M. (2005). Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: A comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis. Chronic Illness, 1(4), 289-303.

Tsang, R. C., Tsang, P. L., Ko, C. Y., Kong, B. C., Lee, W. Y., & Yip, H. T. (2007). Effects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty--a randomized controlled trial. Clinical Rehabilitation, 21(8), 719-728.

Unver B., Karatosun V., & Bakirhan S. (2006). Evaluation of early stage postoperative functional levels of geriatric patients with total knee replacement. Turk Geriatri Dergisi, 9(1), 19-24.

Usichenko, T. I., Edinger, H., Witstruck, T., Pavlovic, D., Zach, M., Lange, J., Gizhko, V., Wendt, M., Koch, B., & Lehmann, C. (2008). Millimetre wave therapy for pain relief after total knee arthroplasty: A randomised controlled trial. European Journal of Pain, 12(5), 617-623.

Valtonen, A., Poyhonen, T., Heinonen, A., & Sipila, S. (2009). Muscle deficits persist after unilateral knee replacement and have implications for rehabilitation. Physical Therapy, 89(10), 1072-9.

van Dijk, H. J. D., Elvers, J. W. H., & Oostendorp, R. A. B. (2007). Effect of continuous passive motion after total knee arthroplasty: A systematic review. Physiotherapy Singapore, 10(4), 9-19.

Vincent, H. K., & Vincent, K. R. (2007). Influence of admission hematocrit on inpatient rehabilitation outcomes after total knee and hip arthroplasty. American Journal of Physical Medicine & Rehabilitation, 86(10), 806-17.

Westrich, G. H., Bottner, F., Windsor, R. E., Laskin, R. S., Haas, S. B., & Sculco, T. P. (2006). VenaFlow plus lovenox versus VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty. The Journal of Arthroplasty, 21(6 Supplement 1), 139-143.

Xie F., Li S.-C., Lo N.-N., Yeo S.-J., Yang K.-Y., Yeo W., Chong H.-C., Fong K.-Y., & Thumboo J. (2007). Cross-cultural adaptation and validation of Singapore English and Chinese versions of the oxford knee score (OKS) in knee osteoarthritis patients undergoing total knee replacement. Osteoarthritis and Cartilage, 15(9), 1019-1024.

25

Xie, F., Li, S. C., Goeree, R., Tarride, J. E., O'Reilly, D., Lo, N. N., Yeo,S.J., Yang,K.Y., & Thumboo,J. (2008). Validation of chinese western ontario and McMaster universities osteoarthritis index (WOMAC) in patients scheduled for total knee replacement. Quality of Life Research, 17(4), 595-601.

Zeni, J.,Jr, & Snyder-Mackler, L. (2010). Early postoperative measures predict 1- and 2-year outcomes after unilateral total knee arthroplasty: Importance of contralateral limb strength. Physical Therapy, 90(1), 43-54.

Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden, N., Bierma-Zeinstra, S., Brandt, K.D., Croft,P., Doherty, M., Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S., & Tugwell, P. (2007). OARSI recommendations for the management of hip and knee osteoarthritis, part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis & Cartilage, 15(9), 981-1000.

Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden, N., Bierma-Zeinstra, S., Brandt, K.D., Croft,P., Doherty, M., Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S., & Tugwell, P. (2008). OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis & Cartilage, 16(2), 137-62.

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APPENDIX A: References 2000-2004

Postoperative (rehabilitation) interventions/protocols

Apsingi, S., & Dussa, C.U. (2004). Can peripheral nerve blocks contribute to heel ulcers following total knee replacement? Acta Orthopaedica Belgica, 70(5), 502-504.

Ask, S., Lindmark, B., & Johansson, A. (2003). [Assessment of continuous passive motion (CPM) in rehabilitation after total knee arthroplasty] [swedish]. Nordisk Fysioterapi, 7(2), 29-40.

Avramidis, K., Strike, P. W., Taylor, P. N., & Swain, I. D. (2003). Effectiveness of electric stimulation of the vastus medialis muscle in the rehabilitation of patients after total knee arthroplasty. Archives of Physical Medicine & Rehabilitation, 84(12), 1850-1854.

Beard, D.J, Murray, D.W., Rees, J.L., Price, A.J., & Dodd, C.A.F. (2002). Accelerated recovery for unicompartmental knee replacement - A feasibility study. Knee, 9(3), 221-224.

Beaupré, L. A., Davies, D. M., Jones, C. A., & Cinats, J. G. (2001). Exercise combined with continuous passive motion or slider board therapy compared with exercise only: A randomized controlled trial of patients following total knee arthroplasty. Physical Therapy, 81(4), 1029-1037.

Bell, G. K., & Goldhaber, S. Z. (2001). Cost implications of low molecular weight heparins as prophylaxis following total hip and knee replacement.6(1), 23-29.

Berend, K. R., Lombardi, A.,Jr, & Mallory, T. H. (2004). Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surgical Technology International, 13, 239-47.

Berth, A., Urbach, D., & Awiszus, F. (2002). Improvement of voluntary quadriceps muscle activation after total knee arthroplasty. Archives of Physical Medicine & Rehabilitation, 83(10), 1432-1437.

Breakwell, L. M., Getty, C. J., & Dobson, P. (2000). The efficacy of autologous blood transfusion in bilateral total knee arthroplasty. Knee, 7(3), 145-147.

Breit, R., & van der Wal, l. H. (2004). Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. The Journal of Arthroplasty, 19(1), 45-48.

Brosseau, L., Tugwell, P., Wells, G.A., Robinson, V.A., Graham, I.D., Shea, B.J., Osiri, M., McGowan, J., Peterson, J., Corriveau, H., Pelland, L., Morin, M., Poulin, L., Tousignant, M., Laferriere, L., Casimiro, L., Tremblay, L.E., Albright, J., Allman, R., Bonfiglio, R.P., Conill, A., Dobkin, B., Guccione, A.A., Hasson, S., Russo, R., Shekelle, P. and Susman, J.L. [Philadelphia Panel (Canada and the United States of America)]. (2001). Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain. Physical Therapy, 81(10), 1675-1700.

Brosseau, L., Milne, S., Wells, G., Tugwell, P., Robinson, V., Casimiro, L., et al. (2004). Efficacy of continuous passive motion following total knee arthroplasty: A metaanalysis. Journal of Rheumatology, 31(11), 2251-64.

Can, F., & Alpaslan, M. (2003). Continuous passive motion on pain management in patients with total knee arthroplasty. Pain Clinic, 15(4), 479-485.

27

Chen, B., Zimmerman, J. R., Soulen, L., & de Lisa, J. A. (2000). Continuous passive motion after total knee arthroplasty: A prospective study. American Journal of Physical Medicine & Rehabilitation, 79(5), 421-426.

Codine, P., Dellemme, Y., Denis-Laroque, F., & Herisson, C. (2004). The use of low velocity submaximal eccentric contractions of the hamstring for recovery of full extension after total knee replacement: A randomized controlled study. Isokinetics and Exercise Science, 12(3), 215-218.

Davies, D. M., Johnston, D. W., Beaupre, L. A., & Lier, D. A. (2003). Effect of adjunctive range-of-motion therapy after primary total knee arthroplasty on the use of health services after hospital discharge. Canadian Journal of Surgery, 46(1), 30-36.

Erler, K., Anders, C., Fehlberg, G., Neumann, U., Brucker, L., & Scholle, H. C. (2001). [Objective assessment of results of special hydrotherapy in inpatient rehabilitation following knee prosthesis implantation] in german . Zeitschrift Fur Orthopadie Und Ihre Grenzgebiete, 139(4), 352-358.

Frost, H., Lamb, S. E., & Robertson, S. (2002). A randomized controlled trial of exercise to improve mobility and function after elective knee arthroplasty. feasibility, results and methodological difficulties. Clinical Rehabilitation, 16(2), 200-209.

Gehrke, W., & Arnold, W. (2001). Total knee arthroplasty mobility outcomes following participation in in-patient rehabilitation: Factors influencing the rate of success. Rehabilitation, 40(3), 156-164.

Gibbons, C. E., Solan, M. C., Ricketts, D. M., & Patterson, M. (2001). Cryotherapy compared with Robert Jones bandage after total knee replacement: A prospective randomized trial. International Orthopaedics, 25(4), 250-252.

Hill, S. P., Flynn, J., & Crawford, E. J. P. (2000). Early discharge following total knee replacement -- a trial of patient satisfaction and outcomes using an orthopaedic outreach team. Journal of Orthopaedic Nursing 2000 Sep;4(3):121-126, 4(3), 121-126.

Horton, T. C., Jackson, R., Mohan, N., & Hambidge, J. E. (2002). Is routine splintage following primary total knee replacement necessary? A prospective randomised trial. The Knee, 9(3), 229-231.

Huang D., Peng Y., Su P., Ye W., & Liang A. (2003). The effect of continuous passive motion after total knee arthroplasty on joint function. Chinese Journal of Clinical Rehabilitation, 7(11), 1661-1662.

Ilieva, E., Batalov, A., Kuzmanova, St., Tokmakov, P., & Marinkev, M. (2000). Ultrasonographic and clinical monitoring of the effect of a complex rehabilitation programme after total knee arthroplasty. Rheumatology, 8(2), 58-60.

Jester, R., & Hicks, C. (2003). Using cost-effectiveness analysis to compare hospital at home and in-patient interventions. part 1. Journal of Clinical Nursing., 12, 13-19.

Jester, R., & Hicks, C. (2003). Using cost-effectiveness analysis to compare hospital at home and in-patient interventions. part 2. Journal of Clinical Nursing., 12, 20-27.

Kim, S., Losina, E., Solomon, D. H., Wright, J., & Katz, J. N. (2003). Effectiveness of clinical pathways for total knee and total hip arthroplasty: Literature review. The Journal of Arthroplasty, 18(1), 69-74.

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Kolisek, F. R., Gilmore, K. J., & Peterson, E. K. (2000). Slide and flex, tighten, extend (SAFTE): A safe, convenient, effective, and no-cost approach to rehabilitation after total knee arthroplasty. Journal of Arthroplasty, 15(8), 1013-6.

Kramer, J. F., Speechley, M., Bourne, R., Rorabeck, C., & Vaz, M. (2003). Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clinical Orthopaedics & Related Research, (410), 225-34.

Lau, S. K., & Chiu, K. Y. (2001). Use of continuous passive motion after total knee arthroplasty. The Journal of Arthroplasty 2001 Apr;16(3):336-339, 16(3), 336-339.

Legovic, A. (2003). Effects and results of rehabilitation on functional status and quality of life in patients with total knee aloartroplastics. Medicina, 39(3), 187-190.

Lenssen, A. F., de Bie, R. A., Bulstra, S. K., & van Steyn, M. J. A. (2003). Continuous passive motion (CPM) in rehabilitation following total knee arthroplasty: A randomised controlled trial. Physical Therapy Reviews, 8(3), 123-129.

Lenssen, A. F., Koke, A. J., De Bie, R. A., & Geesink, R. G. (2003). Continuous passive motion following primary total knee arthroplasty:Short- and long-term effects on range of motion. Physical Therapy Reviews, 8(3), 113-21.

Licciardone, J. C., Stoll, S. T., Cardarelli, K. M., Gamber, R. G., Nr, S. J., & Winn, W. B. (2004). A randomized controlled trial of osteopathic manipulative treatment following knee or hip arthroplasty. JAOA: Journal of the American Osteopathic Association, 104(5), 193-205.

Lin, Y. K., Su, J. Y., Lin, G. T., Tien, Y. C., Chien, S. S., Lin, C. J., et al. (2002). Impact of a clinical pathway for total knee arthroplasty. Kaohsiung Journal of Medical Sciences, 18(3), 134-140.

Lingard, E. A., Berven, S., Katz, J. N., & Kinemax, O. G. (2000). Management and care of patients undergoing total knee arthroplasty: Variations across different health care settings. Arthritis Care & Research, 13(3), 129-36.

MacDonald, S. J., Bourne, R. B., Rorabeck, C. H., McCalden, R. W., Kramer, J., & Vaz, M. (2000). Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clinical Orthopaedics & Related Research, (380), 30-5.

Mahomed, N. N., Koo Seen Lin, M. J., Levesque, J., Lan, S., & Bogoch, E. R. (2000). Determinants and outcomes of inpatient versus home based rehabilitation following elective hip and knee replacement. Journal of Rheumatology, 27(7), 1753-8.

Miao, W. (2003). Rehabilitation instruction for 34 patients after senile total knee replacement. Chinese Journal of Clinical Rehabilitation, 7(6)

Milne, S., Brosseau, L., Welch, V., Noel, M., Davis, J., Drouin, H., et al. (2003). Continuous passive motion following total knee arthroplasty. Cochrane Database of Systematic Reviews, (2), CD004260-NaN.

Moffet, H., Collet, J. P., Shapiro, S. H., Paradis, G., Marquis, F., & Roy, L. (2004). Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: A single-blind randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 85(4), 546-56.

Mullarkey, C. F., & Brander, V. (2002). Rehabilitation after total knee replacement for osteoarthritis. Physical Medicine & Rehabilitation, 16(3), 431-444.

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Oldmeadow, L.B., McBurney, H., & Robertson, V.J. (2002). Hospital stay and discharge outcomes after knee arthroplasty: Implications for physiotherapy practice. Australian Journal of Physiotherapy, 48(2), 117-121.

Oldmeadow, L. B., McBurney, H., Robertson, V. J., Kimmel, L., & Elliott, B. (2004). Targeted postoperative care improves discharge outcome after hip or knee arthroplasty. Archives of Physical Medicine & Rehabilitation, 85, 1424-1427.

Philadelphia, P. (2001). Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain.81(10), 1675-1700.

Pitimana-aree, S., Visalyaputra, S., Komoltri, C., MuangmanS, Tiviraj, S., Puangchan, S., et al. (2005). An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: A double-blinded randomized study.30(5), 446-451.

Pitto, R. P., Hamer, H., Heiss-Dunlop, W., & Kuehle, J. (2004). Mechanical prophylaxis of deep-vein thrombosis after total hip replacement a randomised clinical trial. Journal of Bone and Joint Surgery, 86(5), 639-642.

Rajan, R. A., Pack, Y., Jackson, H., Gillies, C., & Asirvatham, R. (2004). No need for outpatient physiotherapy following total knee arthroplasty: A randomized trial of 120 patients. Acta Orthopaedica Scandinavica, 75(1), 71-73.

Rasmussen, S., Kramhoft, M.U., Sperling, K.P., & Pedersen, J.H.L. (2004). Increased flexion and reduced hospital stay with continuous intraarticular morphine and ropivacaine after primary total knee replacement: Open intervention study of efficacy and safety in 154 patients. Acta Orthopaedica Scandinavica, 75(5), 606-609.

Russell, T. G., Buttrum, P., Wootton, R., & Jull, G. A. (2003). Low-bandwidth telerehabilitation for patients who have undergone total knee replacement: Preliminary results. Journal of Telemedicine and Telecare, 9(Supplement 2), S44-S47.

Salmela, L. F. T., de Macedo, B. G., de Aguiar, C. M., & Bahia, L. A. (2003). [Impact of continuous passive motion for the treatment of total knee replacement patients] in portugese. Acta Fisiatrica, 10(1), 21-27.

Silbersack, Y., Taute, B. M., Hein, W., & Podhaisky, H. (2004). Prevention of deep vein thrombosis after total hip and knee replacement. low-molecular-weight heparin in combination with intermittent pneumatic compression. Journal of Bone and Joint Surgery, 86(6), 809-812.

Smith, J., Stevens, J., Taylor, M., & Tibbey, J. (2002). A randomized, controlled trial comparing bandaging and cold therapy in postoperative total knee replacement surgery. Orthopaedic Nursing, 21(2), 61-66.

Soininvaara, T. A., Jurvelin, J. S., Miettinen, H. J., Suomalainen, O. T., Alhava, E. M., & Kröger, P. J. (2002). Effect of alendronate on periprosthetic bone loss after total knee arthroplasty: A one-year, randomized, controlled trial of 19 patients. Calcified Tissue International, 71(6), 472-477.

Weaver, F. M., Hughes, S. L., Almagor, O., Wixson, R., Manheim, L., Fulton, B., et al. (2003). Comparison of two home care protocols for total joint replacement. Journal of the American Geriatrics Society, 51, 523-528.

Weigl, M., Angst, F., Stucki, G., Lehmann, S., & Aeschlimann, A. (2004). Inpatient rehabilitation for hip or knee osteoarthritis: 2 year follow up study. Annals of the Rheumatic Diseases, 63(4), 360-8.

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Zenios, M., Wykes, P., Johnson, D. S., Clayson, A. D., & Kay, P. (2002). The use of knee splints after total knee replacements. The Knee, 9(3), 225-228.

Guidelines for total knee arthroplasty

Anonymous. (2003). NIH consensus statement on total knee replacement. NIH Consensus & State-of-the-Science Statements, 20(1), 1-34.

Bizzini, M., Boldt, J., Munzinger, U., & Drobny, T. (2003). [Rehabilitation guidelines after total knee arthroplasty]. [german] rehabilitationsrichtlinien nach knieendoprothesen. Orthopade, 32(6), 527-34.

Di, D. F., Sarzi-Puttini P., Cazzola M., Atzeni F., Cappadonia C., Caserta A., et al. (2004). Physical and rehabilitative approaches in osteoarthritis. Seminars in Arthritis and Rheumatism, 34(2), 62-69.

Jordan, K. M., Arden, N. K., Doherty, M., Bannwarth, B., Bijlsma, J. W., Dieppe, P., et al. (2003). EULAR recommendations 2003: An evidence based approach to the management of knee osteoarthritis: Report of a task force of the standing committee for international clinical studies including therapeutic trials (ESCISIT). Annals of the Rheumatic Diseases, 62(12), 1145-55.

Punzi, L., Canesi, B., Carrabba, M., Cimmino, M. A., Frizziero, L., Lapadula, G., et al. (2004). [Italian consensus on eular 2003 recommendations for the treatment of knee osteoarthritis]. [italian] consensus italiana sulle raccomandazioni dell'EULAR 2003 per il trattamento dell'artrosi del ginocchio. Reumatismo, 56(3), 190-201.

Factors affecting outcomes after total knee arthroplasty

Faller, H., Kirschner, S., & Konig, A. (2003). Psychological distress predicts functional outcomes at three and twelve months after total knee arthroplasty. General Hospital Psychiatry, 25(5), 372-373.

Fortin, P.R., Penrod, J.R., Clarke, A.E., St-Pierre, Y., Joseph, L., Belisle, P., Liang, M.H., Ferland, D., Phillips, C.B., Mahomed, N., Tanzer, M., Sledge, C., Fossel, A.H., & Katz J.N. (2002). Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis and Rheumatism, 46(12), 3327-3330.

Jones, C. A., Voaklander, D. C., Johnston, D. W., & Suarez-Almazor, M. E. (2001). The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Archives of Internal Medicine, 161(3), 454-60.

Jones, C. A., Voaklander, D. C., & Suarez-Alma, M. E. (2003). Determinants of function after total knee arthroplasty. Physical Therapy, 83(8), 696-706.

Kennedy, D., Stratford, P. W., Pagura, S. M., Walsh, M., & Woodhouse, L. J. (2002). Comparison of gender and group differences in self-report and physical performance measures in total hip and knee arthroplasty candidates. Journal of Arthroplasty, 17(1), 70-7.

Lingard, E. A., Katz, J. N., Wright, E. A., Sledge, C. B., & Kinemax, O. G. (2004). Predicting the outcome of total knee arthroplasty. Journal of Bone & Joint Surgery - American Volume, 86-A(10), 2179-86.

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Mahomed, N. N., Liang, M. H., Cook, E. F., Daltroy, L. H., Fortin, P. R., Fossel, A. H., & Katz, J.N. (2002). The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. Journal of Rheumatology, 29(6), 1273-9.

Saito, T., Takeuchi, R., Yamamoto, K., Yoshida, T., & Koshino, T. (2003). Unicompartmental knee arthroplasty for osteoarthritis of the knee: Remaining postoperative flexion contracture affecting overall results. Journal of Arthroplasty, 18(5), 612-618.

Questionnaires, assessment techniques and training

Barck, A. L. (2000). Early postoperative assessment technique: A time-to-remission technique after condylar replacement. American Journal of Knee Surgery, 13(3), 153-5.

Eisermann, U., Haase, I., & Kladny, B. (2004). Computer-aided multimedia training in orthopedic rehabilitation. American Journal of Physical Medicine & Rehabilitation, 83(9), 670-680.

Grimmig, H., Melzer, C., Ludwig, F. J., & Daalmann, H. H. (2002). [Using the lequesne questionnaires for patients with hip and knee disabilities in daily routine to reflect the quality of outcome in rehabilitation]. [german] der routinemassige einsatz des lequesne-index zur ergebnismessung in der orthopadischen rehabilitation bei huft- und knieerkrankungen. Zeitschrift Fur Orthopadie Und Ihre Grenzgebiete, 140(4), 452-9.

Lingard, E. A., Katz, J. N., Wright, R. J., Wright, E. A., Sledge, C. B., & Kinemax, O. G. (2001). Validity and responsiveness of the knee society clinical rating system in comparison with the SF-36 and WOMAC. Journal of Bone & Joint Surgery - American Volume, 83-A(12), 1856-64.

Parent, E., & Moffet, H. (2002). Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Archives of Physical Medicine & Rehabilitation, 83(1), 70-80.

Miner, A.L., Lingard, E.A., Wright, E.A., Sledge, C.B., Katz, J.N., Gillespie, W., et al. (2003). Knee range of motion after total knee arthroplasty: How important is this as an outcome measure? Journal of Arthroplasty, 18(3), 286-294.

Nicolakis, P., Nicolakis, M., Dorotka, R., Ebenbichler, G., & Uher, E. (2000). [Evaluating rehabilitation progress by measuring thigh circumference]. [german] beurteilung des rehabilitationsfortschritts mittels oberschenkelumfangmessung. Zeitschrift Fur Orthopadie Und Ihre Grenzgebiete, 138(6), 526-9.

Roos, E. M., & Lohmander, L. S. (2003). The knee injury and osteoarthritis outcome score (KOOS): From joint injury to osteoarthritis. Health & Quality of Life Outcomes, 1

Stratford, P. W., & Kennedy, D. M. (2004). Does parallel item content on WOMAC's pain and function subscales limit its ability to detect change in functional status? BMC Musculoskeletal Disorders, 5

Whitehouse, S.L., Lingard, E.A., Katz, J.N., & Learmonth, I.D. (2003). Development and testing of a reduced WOMAC function scale. Journal of Bone and Joint Surgery - Series B, 85(5), 706-711.

Wollmerstedt, N., Kirschner, S., Bohm, D., Faller, H., & Konig, A. (2003). [Design and evaluation of the extra short musculoskeletal function assessment questionnaire XSMFA-D]. [German] Zeitschrift Fur Orthopadie Und Ihre Grenzgebiete, 141(6), 718-24.

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APPENDIX B: Full text SECTION A – CONTROLLED TRIALS

ID

Title and Weblink Sponsor; Start - end date; status

Summary

A1 Management of Postoperative Pain Following Total Knee Arthroplasty by Using Acupuncture-moxibustion Therapy

http://ClinicalTrials.gov/show/NCT01047384

Chang Gung Memorial Hospital

2010-2011

Randomized controlled trial to evaluated the effectiveness of acupuncture-moxibustion therapy compared with regular postoperative pain control therapy.

Outcomes include pain VAS score (preop, immediately postop, 6, 12, 18, 24, 48 and 72 hours postop) and SF-36 (preop, immediately postop, 6 and 12 weeks postop).

Adults (18-80 years) scheduled for surgery due to OA of the knee.

A2 Effectiveness of in-home telerehabilitaiton service following knee arthroplasty: a multicentric clinical trial

http://www.controlled-trials.com/ISRCTN66285945

Laval University (Canada)

2009-2011

Multicentre randomized controlled trail to evaluate effectiveness of in-home telerehabilitation approach compared to a standard approach involving face-to-face rehabilitation and education at home in participants after a knee arthroplasty.

Outcomes WOMAC, KOOS, 6-min walk test, Timed stair test, ROM, muscle strength, knee function and patient satisfaction. Assessed preoperatively and at 4 months after surgery.

Adults (>18 years) undergoing TKA after diagnosis of osteoarthritis

A3 Local Infiltration Analgesia or Intrathecal Morphine in Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00992082

University Hospital Orebro

2009-2011

Randomized controlled trial to determine the effectiveness of local infiltration analgesia (ropivacaine, ketorolac and epinephrine) compared to intrathecal morphine in reducing postop pain following TKA.

Outcomes: morphine consumption (over 48 hours postop), pain intensity and knee function, time to home and hospital stay. Followed up 3 months postoperatively.

Patients (40-85 years) scheduled for TKA under spinal anaesthesia: nb patients with RA, chronic pain and serious liver-, heart- or renal disease specifically excluded.

A4 Effectiveness of Acupuncture as an Adjunct to Rehabilitation After Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00935155

Back and Rehabilitation Center, Copenhagen

2009-2011

Randomized controlled trial to determine the effectiveness of acupuncture as an adjunct to standard rehabilitation following knee arthroplasty.

Outcomes: pain and disability. Assessed at 3-month follow up.

Adults (18-70 years) undergoing hemi- or total-knee arthroplasty: nb patients with RA, hip- and heart disease specifically excluded.

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A5 Perioperative Intervention to Improve Post-TKR Support and Function

http://ClinicalTrials.gov/show/NCT00566826

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

2008-2011

Randomized controlled trial to evaluate the effectiveness of a patient support programme in increasing physical function after TKR.

Outcomes: SF-36, WOMAC and physical activity and exercise. Assessed at 6 and 12 months post operatively.

Adults (≥21 years) scheduled for unilateral TKR surgery

A6 Progressive Exercise After TKA

http://ClinicalTrials.gov/show/NCT00605124

Jyväskylä Central Hospital

2008-2011

Randomized controlled trial to evaluate the effectiveness of a progressive exercise program at restoring knee strength, mobility and function after TKA.

Outcomes: functional tests, pain, QoL, knee muscle strength and mobility, and gait analysis mobility of the knee. Assessed preop, at 6 weeks postop (start of training) and after 1 year of training.

Adults (≥18 years) undergoing TKA for OA.

A7 Effectiveness of two types of treatment in restoring muscle after hip or knee surgery.

http://ClinicalTrials.gov/show/NCT00393848

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

2006-2011

Randomised controlled trial to evaluate effects of two postoperative interventions aimed at preserving muscle protein following hip or knee surgery.

Primary outcomes, muscle protein synthesis and breakdown measured after hospitalisation; secondary outcomes, function and muscle mass measured prior to surgery and at 2 and 6-8 weeks post-operatively.

Adults (30-80 years) scheduled for surgery due to OA, avascular necrosis, fracture, or TJR revision of knee or hip.

A8 Hydrotherapy Versus Physiotherapy for Short-Term Rehabilitation After Primary TKR

http://ClinicalTrials.gov/show/NCT00878358

Hadassah Medical Organization

2009-2010

Randomized controlled trial to evaluate the short-term benefits of hydrotherapy compared to physiotherapy following TKR.

Outcomes: TUG, Oxford Knee Score, Pain VAS, ROM assessed at 6 week follow up.

Adults (>18 years) diagnosed with OA and undergoing primary TKR.

A9 Use of Cold and Compression Therapy With Total Knee Replacement Patients

http://ClinicalTrials.gov/show/NCT00712816

CoolSystems, Inc.

2008-2010

Randomized controlled trial to evaluate of effectiveness of a device designed to deliver cold and intermittent compression compared to ice and compression bandages after TKR.

Outcomes: physical performance and time to reach defined physical therapy milestones. Assessed 2 weeks, 6 weeks and 6 months postoperatively.

Adults (18-85 years) diagnosed with OA of knee and scheduled for TKR surgery.

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A10 Early Neuromuscular Electrical Stimulation For Quadriceps Muscle Activation Deficits Following Total Knee Replacement

http://ClinicalTrials.gov/show/NCT00800254

National Institute on Aging (NIA)

2008-2010

Randomized controlled trial to assess effectiveness of early NMES for muscle strengthening after TKR compared with voluntary exercise alone.

Outcomes: change in quadriceps muscle force, activation and size, presynapic inhibition (H-reflexes), quadriceps muscle activity during functional activities, functional performance measures (self-reports, 6-min walk distance, TUG and functional stair climbing time). Assessed at baseline and at 1 year follow up.

Patients (≥50 years) scheduled for unilateral or bilateral primary TKR.

A11 Acupuncture for Pain Management After Hip or Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00455182

HealthEast Care System

2007-2010

Randomized controlled trial to evaluate the effectiveness of post-operative acupuncture as pain control compared to sham acupuncture and standard medical care.

Patients (18-80 years) undergoing THA or TKA.

A12 Efficacy of Multimodal Peri- and Intraarticular Drug Injections in Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00562627

Asker & Baerum Hospital

2007-2009

Completed

Randomized controlled trail to compare the efficacy of two types of local infiltration analgesia, and to compare local infiltration analgesia with continuous epidural analgesia in TKA.

Outcomes: opioid use and pain (48 hours postop), time to discharge, KOOS (3-months postop), side effect and complications.

Patients (≥18 years) due to undergo elective TKA.

A13 Do Corticosteroid Injections During Total Knee Replacement Improve Early Clinical Results?

http://ClinicalTrials.gov/show/NCT00492973

New Lexington Clinic

2006-2009

Randomized controlled trial to examine the safety and efficacy of methylprednisolone acetate to treat pain and inflammation following TKR.

Outcomes: LOS, complications, pain medication use, ROM, KSS and patient satisfaction. Assess preoperatively, 6 weeks, 3 and 12 months postoperatively.

Patients (18-95 years) electing to undergo TKR. Nb: patients with RA and systemic conditions associated with chronic pain were excluded.

A14 Comparison of post-discharge physiotherapy versus usual care following total knee replacement: a randomised clinical trial

http://www.controlled-trials.com/ISRCTN07624314

Department of Health (UK)

2003-2009

Completed (n=107)

Randomized controlled trial to evaluate post-change physiotherapy compared to standard care for patients undergoing elective primary TKA for OA.

Outcomes: Oxford Knee Score, KOOS, EQ-5D, timed sit-to-stand test, timed walk test, leg extensor press and ROM (baseline, 3 and 12 months postop) and patient diaries.

Patients (No age specified) undergoing elective primary TKA for OA.

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A15 Efficacy And Safety Of Pregabalin For Pain Following Total Knee Replacement

http://ClinicalTrials.gov/show/NCT00442546

Pfizer

2007-2008

Randomized controlled trial to assess effectiveness of pregabalin as an adjunct to standard care in reducing pain following TKR.

Outcomes include pain, opioid use, LOS and patient satisfaction with pain medication.

Patients (18-80 years) with OA undergoing elective TKR.

A16 The short and long term effects of perioperative gabapentin use on functional, rehabilitation and pain outcomes following total knee arthroplasty: a randomised, double-blind, placebo-controlled trial

http://www.controlled-trials.com/ISRCTN34631378

Sunnybrook Health Sciences Centre (Canada)

2007-2008

Randomized controlled trial to evaluate effects of perioperative gabapentin on outcomes after TKA.

Outcomes: physical function, pain (NRS), morphine consumption, HADS, WOMAC (QoL subscale), sedation, presence of nausea, vomiting, pruritus and dizziness. Self-report assessments at baseline, 4 and 6 weeks, and 3 months postoperatively.

Patients (18-75 years) scheduled for TKA. Nb patients with RA and chronic pain requiring slow-release opioid preparations were excluded.

A17 Evaluation of Diprospan Injection to the Knee on Rehabilitation of Patients After TKR of the Contralateral Knee

http://ClinicalTrials.gov/show/NCT00542139

Hadassah Medical Organization

2007-2008

Completed

Randomized controlled trial to evaluate the effectiveness of diprospan injection into the knee on outcomes following TKR.

Outcomes: Pain (VAS), TUG and Functional Ambulatory Category Scale. Assessed at 6 weeks.

Patients (>50 years) with bilateral knee OA undergoing knee arthroplasty

A18 The Role of Intra-Operative Intracapsular Blocks in Post-Operative Pain Management Following Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00620828

Duke University

2007-2008

Randomized controlled trial to assess the effectiveness of intraoperative intracapsular blocks (Bupivicaine) in pain management following TKA compared with standard care.

Outcome measures: Pain (VAS), ROM, ambulation effort, time to SLR, Ramsey sedation score, total narcotic use. Assessed upto 24 hours after surgery.

Patients scheduled for elective TKR. Nb: excludes patients with history of chronic pain.

A19 Perioperative Pain Control With Celecoxib (Celebrex) in Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00598234

National Taiwan University Hospital

2006-2008

Randomized controlled trial to evaluate the effectiveness of Celecoxib to control perioperative pain following TKA.

Outcomes: Pain score (VAS), ROM and narcotic usage. Assessed 6 & 12 hours, 1, 2, 3 & 7 days postop.

Patients (≥60 years) undergoing TKR. Nb: patients excluded if long-term use of NSAIDs.

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A20 Continuous Femoral Nerve Block Following Total Knee Replacement

http://ClinicalTrials.gov/show/NCT00135889

National Institute of General Medical Sciences (NIGMS)

2005-2008

Completed

Randomized controlled trial to investigate whether continuous femoral nerve block will improve pain control during physical therapy and thus improve results of TKR surgery.

Outcomes: distance of ambulation in afternoon following surgery, time from surgical stop until three discharge criteria are met.

Patients (18-80 years) undergoing primary TKA. Nb: patients excluded if had a comorbidity which resulted in moderate or severe function limitation.

A21 Ergometer cycling after replacement of the hip or knee joint.

http://ClinicalTrials.gov/show/NCT00951990

Verein zur Förderung der Rehabilitationsforschung in Schleswig-Holstein

2005-2008

Completed (n=457)

Randomised controlled trial to evaluate the effectiveness of ergometer cycling during rehabilitation following hip or knee replacement therapy.

Assessment at 3 months to 24 months? using as primary outcome measure WOMAC Physical Function; Secondary outcome measures, WOMAC Pain and Stiffness, SF-36, Patient satisfaction and Lequesne Hip or Knee Score.

Adults (18 years and older) awaiting elective unilateral hip or knee replacement due to OA or femoral head necrosis.

A22 Cost efficacy of a clinical pathway to patients undergoing hip and knee replacement surgery.

http://ClinicalTrials.gov/show/NCT00175201

University of Aarhus

2005-2008

Completed (n=80)

Randomised controlled trial, with cost efficacy and cost effectiveness analysis, to evaluate (cost?) effectiveness of a proactive care and rehabilitation program compared to current care.

Assessed at discharge, 3, 12 and 24 months post-discharge. Primary outcome measures, LOS, QoL (EQ-5D and SF-36/SF-6D); secondary measures, pain and disability (Harris Hip Score/Danish Knee Arthroplasty Register Score).

Adults with primary OA of hip or knee and waiting for total joint replacement surgery.

A23 Celebrex Total Knee Arthroplasty Study

http://ClinicalTrials.gov/show/NCT00359151

Pfizer

2006-2007

Terminated due to slow enrolment

Randomized controlled study to investigate the benefits of Celecoxib in treating OA patients undergoing elective unilateral primary TKA.

Outcomes: cumulative opioid use, pain, function, side effects.

Patients (18-80 years) with OA of the knee scheduled to undergo unilateral primary TKA.

A24 Effects of progressive aquatic exercise on mobility ability and neuromuscular performance

http://www.controlled-trials.com/ISRCTN50731915

Kymenlaakso Central Hospital (Finland)

2005-2007

Completed (n=201)

Randomized controlled trial to evaluated the effects of progressive aquatic exercise on mobility and neuromuscular performance after unilateral knee replacement for OA.

Outcomes: WOMAC, mobility limitation and stair ascending time, knee extensor and flexor power and thigh muscle cross-sectional area. Assessments at 2-3 days before surgery and after 12 weeks training.

Patients (55-75 years) who underwent unilateral knee replacement.

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A25 JOINTS Study - Joint Replacement Outcome in Inpatient Rehabilitation Facilities and Nursing Treatment Sites

http://ClinicalTrials.gov/show/NCT00499278

National Rehabilitation Hospital

2005-2007

Completed (n=2384)

Longitudinal observational study to compare the patient characteristics and outcomes between inpatient rehabilitation facilities and nursing treatment sites.

Outcomes include: patient characteristics, interventions and processes of care, patient outcomes, cost-effectiveness and comorbidity

Patients (≥21 years) who underwent hip or knee replacement for any reason.

A26 Alberta hip and knee replacement project.

http://ClinicalTrials.gov/show/NCT00277186

Alberta Bone and Joint Health Institute

2005-2006

Completed (n=3434)

Randomised controlled trial to establish effectiveness, with regard to patient outcomes and cost-effectiveness, of a new arthroplasty care model compared to existing conventional approach.

Assessed at 3 and 12 months post surgery. Primary outcome measure, QoL; secondary outcome measures, health resource utilisation, wait time, safety, cost utility, patient and provider satisfaction.

Adults (18 years and over) undergoing hip or knee arthroplasty.

A27 Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy following total knee arthroplasty (TKA)

http://www.controlled-trials.com/ISRCTN85759656

University Hospital Maastricht (The Netherlands)

2005-2006

Randomized controlled trial to evaluate the effectiveness of CPM as an adjunct to physiotherapy after TKA for patient with knee OA.

Outcomes: functional status, ROM, perceived effect, postop medication use, satisfaction with treatment and treatment results, adherence to treatment protocol and use of CPM.

Patients (no age stated) with knee OA undergoing TKA and experiencing postoperative flexion impairment (<80° at discharge)

A28 Multidisciplinary rehabilitation after primary total knee arthroplasty

http://www.controlled-trials.com/ISRCTN74292386

Oulu University Hospital (Finland)

2002-2006

Randomized controlled trial to explore the effectiveness of a multidisciplinary outpatient rehabilitation program on patient outcomes; to examine attributes of end-stage knee OA; to identify factors determining functional outcomes of primary TKA; to assess cost and cost-effectiveness of the multidisciplinary rehabilitation program.

The primary outcome measure was WOMAC with secondary outcomes including HRQoL, demographic and physical performance tests. Assessed preop and at 2, 6 and 12 months follow-up.

Patients (60-80 years) with diagnosis of primary OA of the knee scheduled for unilateral TKA.

A29 The Effect of Perioperative Neuromuscular Training on the Outcome of Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00492674

Assaf-Harofeh Medical Center

?2007

not yet open for recruitment

Randomized controlled trail to determine the effect of pre- and post-operative training with a novel biomechanical device on outcomes for patients undergoing TKA for OA.

Outcomes: spatio-temporal measures, Aggregated Locomotor Function assessment, WOMAC and SF-36. All assessed at two months and 1 week before TKA, and at 3, 6 and 12 months post TKA.

Adults (55-75 years) with OA scheduled for TKA.

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A30 Arthroplasty Rehabilitation Score - Can we Predict the Short Term Postoperative Outcome?

http://ClinicalTrials.gov/show/NCT00668915

Hadassah Medical Organization

?2008

not yet open for recruitment

Observational cohort study to evaluate the effect of age, BMI, admission and discharge hemoglobin levels, pain perception, type of operation (TKA versus THA), intensity of postoperative physiotherapy, involvement of other joints by the primary pathology, comorbidities, and self assessed health status on patients' function following joint arthroplasty.

Outcomes: Oxford hip and knee score, Grip strength and TUG test.

Patients (≥18 years) with OA undergoing elective unilateral primary TKA or THA.

A31 Electrical Stimulation After Total Knee Arthroplasty

http://ClinicalTrials.gov/show/NCT00224913

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

?2002

still recruiting in 2005

Randomized controlled trial to evaluate the effectiveness of NMES as an adjunct to early rehabilitation programmes in restoring quadriceps strength after TKA. And to identify physiological and morphological bases of improvements in quadriceps strength and functional outcomes.

Outcomes: quadriceps strength and activation, functional tests and self-reported function. Assessed 0-2 weeks pre-op and 3-4, 6-7 and 10-12 weeks, 6 months and 1 and 2 years postoperatively.

Patients (45-85 years) with unilateral tricompartmental knee OA scheduled for TKA.

SECTION B – SYSTEMATIC REVIEWS

Year Title Sample Methodology/Comments Summary

2009 Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review (Coppola & Collins, 2009)

RCTs and controlled clinical trials comparing supervised physical therapy with an unsupervised home exercise program in patients after knee surgery (including TKA, meniscetomy or anterior cruciate ligament reconstruction).

Computerised search of Medline (1966-present), Embase (1988-present), CINAHL (1982-present), Cochrane Controlled Trials Register (to Dec 2007), PEDro (to Dec 2007). Reference lists of identified studies were also hand searched.

10 relevant studies were identified, all moderate in quality according to the PEDro quality scale. Many of the studies biased the home group in providing supervision comparable to the outpatient group. In young and healthy populations with few comorbidities and simple surgery (arthroscopic meniscetomy) home exercise and supervised outpatient programs result in comparable outcomes. In older populations with comorbidities or undergoing more complicated knee surgery (ACL reconstruction, TKA) there is currently a lack of evidence regarding comparative effectiveness of the two rehabilitation regimes.

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2008 Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. (Khan et al., 2008).

Cochrane Review RCTs comparing multidisciplinary rehabilitation programs with routine services following hip or knee replacement due to arthropathy (including OA and RA).

Computerised search of Cochrane Musculoskeletal Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL, Australian Medical Index, UK NHS National Research Register and citation search using SCISEARCH (September 2006)

50 relevant studies identified, of which only 5 met inclusion criteria for the review: covering inpatient and home-base rehabilitation. Outcomes of interest include limitation in impairment and activity/function, limitation in participation, cost of episode of care, LOS, service utilisation, readmission, mortality rates and carer burden/strain. Concludes some evidence (silver level) to suggest early multidisciplinary rehabilitation programs can improve outcomes following hip or knee replacement. Highlights the need for further high quality research.

2007 Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials (Minns Lowe, Barker, Dewey, & Sackley, 2007)

RCTs comparing physiotherapy exercise intervention and usual or standard physiotherapy care or comparing two types of exercise physiotherapy interventions after discharge from hospital after elective primary TKA for OA.

Computerised search of AMED, CINAHL, Embase, King’s Fund, Medline, Cochrane library, PEDro, Department of Health national research register. Hand searches of Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain), conference Proceedings.

6 trials identified, 5 suitable for inclusion in meta-analysis. Results suggest a small to moderate standardised effect size (0.33, 95% Confidence interval 0.07-0.58) in favour of functional exercise for function 3-4 months post-operatively. Also a small to moderate weighted mean difference of 2.9 (0.61 to 5.2) for ROM and 1.66 (-1 to 4.3) for QoL in favour of functional exercise 3-4 months post-operatively. Benefits of treatment at one year were not evident. Concluded that interventions involving physiotherapy functional exercises after discharge result in small to moderate short-term benefits, with no long term benefit following elective primary TKA.

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2010 Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement (Monaghan, Caulfield, & O'Mathuna, 2010)

RCTs and controlled clinical trials involving NMES for the purpose of strengthening the quadriceps pre- or post-TKR.

Computerised search of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to Jan 2008), EMBASE (1980 to Jan 2008), CINAHL (1982 to Nov 2007), AMED (1985 to Jan 2008), Web of Science and PEDro (to Jan 2008). Hand searches were also carried out as was contact with experts in the field and companies supplying NMES equipment.

Only 2 studies met the review’s inclusion criteria. Both studies reported no difference in maximum voluntary isometric torque or endurance between the NMES and control groups. However, significantly increased quadriceps muscle activation was reported in NMES + exercise compared to exercise only group at 6 weeks but not 12 weeks training. Both studies were identified as carrying a high risk of bias: mean values were absent for strength, endurance, cross-sectional area and QoL; outcomes for pain, patient satisfaction and adverse effects were not reported; results were presented as percentage improvement from baseline with unclear sample size. Concluded that the current evidence base for the use of NMES for quadriceps strengthening in patients undergoing TKR is unclear.

SECTION C – GUIDELINES

C1. What is the interest of rehabilitation in physical medicine and functional rehabilitation ward after total knee arthroplasty? Elaboration of French clinical

practice guidelines (Barrois et al., 2007). Considered rehabilitation practice after TKA with the aim of determining the value of rehabilitation in physical medicine and functional rehabilitation (PMR) wards in France. SOFMER (French Physical Medicine and Rehabilitation Society) 3-stage method was used to develop the guidelines, this involved: a systemic literature review (19 papers, 18 studies met inclusion criteria); collection of information about professional practice; and final scientific committee review. The main outcomes of interest were impairment, disability, medico-economic implications and postoperative complications. Recommendations: Post-TKA rehabilitation in PMR wards is recommended for patients with preoperative joint stiffness and/or associated comorbidities. Physicians also identify patients for postop rehabilitation in PMR depending on: self-governing of patient at home, patient’s wishes and surgeon’s opinion on the post-op functional evolution of the patient. Post-op rehabilitation in PMR wards could reduce length of stay in a surgical ward and increase the functional outcomes of patients with comorbidities. In patients who do not require sustained rehabilitation but cannot return home, a stay in a non-PMR postop centre is recommended. Recommend further good quality studies to evaluate the cost/benefit ratio in the French health care system.

SECTION D – NON-SYSTEMATIC REVIEWS

Year Title Sample Methodology/Comments Summary

41

2007 Physical training in rehabilitation programs before and after total hip and knee arthroplasty (Dauty, Smitt, Menu & Dubois, 2007).

Literature reviews or RCTs that investigate physical training as part of the rehabilitation regime before and/or after knee or hip arthroplasty.

Computerised search (1966-2006) of MEDLINE and Cochrane Database. Studies judged using PEDro criteria.

152 relevant studies identified of which 14 were included in the review: 2 reviews, 7 studies concerning THA and 5 TKA. Results are difficult to interpret due to sample sizes, different physical training regimes, use of different outcome measures, high drop out rates and no matched control population. Conclude that current evidence suggests no benefit to pre-operative physical training for either THA or TKA. In contrast, postoperative benefit was indicated for THA, but insufficient evidence was available regarding the effect for TKA. All studies suggested supervised physical training, and some also that training was progressive and adaptive. Further good quality research is suggested, including cost-effectiveness studies.

2008 Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation? (Grella, 2008)

Review of studies examining the effectiveness of CPM following TKA.

To determine the effectiveness of CPM compared to a rehabilitation regime involving early knee mobilisation. Assessment: short-term effects (≤7 days after surgery), long-term effects (>7 days after surgery). Outcomes: knee extension and flexion, function, quadriceps strength, pain, complications and length of hospital stay.

8 relevant studies met the inclusion criteria for the study and the relevant data extracted. Results suggest strong evidence that CPM provides no addition benefit with regards to short and long-term knee extension, long-term knee flexion and function, pain, complications and length of hospital stay. There was inconclusive/conflicting evidence regarding short-term knee flexion and function, and quadriceps strength. Preliminary evidence suggests that CPM employing high flexion arc of motion applied immediately postoperatively and for a significant amount of time each day results in better short-term knee flexion. Concludes that the current evidence does not support the use of CPM as an adjunct to early knee mobilisation protocols. However, further good quality research employing more aggressive CPM parameters is needed.

2006 Rehabilitative intervention after total knee replacement (Li, Cheng & Yu, 2006)

Review of studies to establish rehabilitation protocols following TKR and any associated research.

Computerised search of MEDLINE (Jan 1990 - Aug 2005) and Wanfang (Chinese database, Jan 90 - Dec 2004) Nb: only the abstract was obtainable and the methodology was unclear

37 relevant studies were identified of which 15 were included in the review: 3 reviews of TKR and rehabilitative treatment, 8 clinical trials examining rehabilitation treatments after TKR and 3 miscellaneous but relevant articles. Results suggest that postoperative rehabilitation regimes are necessary after TKR and that most importantly these regimes include exercises to ensure power, good ROM, proprioception and gait. Concluded that staged rehabilitation programs must be implemented early after TKR and that these are comprehensive so ensure functional recovery of the knee.

2005 Post total knee arthroplasty: age as a factor in early post-surgical outcome (Monaghan & Baxter, 2005)

Review of studies to examine effect of age on early recovery after knee arthroplasty.

N/K 13 relevant studies were assessed: 6 small clinical studies and 7 comparative studies. The evidence found no relationship between age, pre-op status or early post-op outcome, but it was noted that the evidence available was limited. In addition, the effect of age on discharge destination and rehabilitation need was also inconclusive. Concluded that there appears to be no effect of age on early recovery after knee arthroplasty, however, this conclusion is based on a limited number of quality trials.

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SECTION E – CASE STUDIES

E.1 Rehabilitation following knee arthroscopy

Year

Title Sample Methodology/ Comments

Summary

2010 Use of inpatient continuous passive motion versus no CPM in computer-assisted total knee arthroplasty (Alkire & Swank, 2010)

RCT. Patients undergoing unilateral computer-assisted TKA. Randomized to receive CPM thrice daily and physical therapy twice daily, or physical therapy alone during hospitalization. Both groups received physical therapy following discharge.

To evaluate effects of CPM for patients undergoing computer-assisted TKA. Assessed at various time points from preoperatively up to 3 months postoperatively. Outcomes: KSS, WOMAC, ROM, knee circumference, HemoVac drainage.

Control group had higher functional scores preoperatively, however, no significant differences were detected over the 3 months for flexion, oedema or drainage, function or pain. Unable to access full paper to obtain sample sizes and study conclusions.

2005 A comparison of 2 continuous passive motion protocols after total knee arthroplasty: a controlled and randomized study (Bennett, Brearley, Hart & Bailey, 2005)

RCT. 147 patients who underwent TKA assigned to either: no-CPM; CPM from 0° to 40° (increased 10° daily); and CPM from 90° to 50° (early flexion) with gradual progression to full extension over 3-days. All groups received physiotherapy postoperatively.

To compare two CPM protocols following TKA. Assessed preoperatively and at day 5, 3 months and 1 year postoperatively. Outcomes: ROM, knee flexion, extension and quadriceps lag, SF-12, knee function (KSS).

The early flexion group had significantly greater range of flexion at day 5 than either of the other groups. No other variables differed between groups and any time point.

2009 The feasibility and perioperative complications of outpatient knee arthroplasty (Berger et al., 2009)

Cohort study. 111 of all 121 patients who underwent UKA (n=25) or TKA (n=86) prior to noon. 104 met discharge criteria and were allowed home the same day.

To assess effect of same-day discharge following UKA and TKA on perioperative complication rates compared to standard-length hospital stay.

Nausea requiring treatment was the main reason for patients not being discharged the same day as surgery. Within the first week of discharge: 4 patients were readmitted (3.6%, all with TKA) and 1 (with TKA) received emergency room treatment without admission. In the following 3 months a further 4 patients were readmitted and 1 visited emergency without admission – all with TKA. No deaths, cardiac events or pulmonary complication occurred during the study. Concluded that outpatient knee arthroplasty is feasible, but longer hospitalization can reduce rates of early readmission.

44

2009 Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty (Bruun-Olsen, Heiberg, & Mengshoel, 2009)

RCT. 63 patients undergoing primary TKA, randomly assigned to received CPM and active exercise, or active exercise alone.

To examine effect of CPM as adjunct to active exercises on outcomes after primary TKA. Assessed preoperatively and at 1 week and 3 months postoperatively. Outcomes: goniometer, VAS, TUG, timed 40m walking, timed stair climbing.

No statistical difference was found across groups for any outcome measure. As a whole, patients reported significant reductions in pain, knee flexion ROM and the number of patients able to climb stairs after 3 months compared to preoperative levels. Concluded that CPM showed no additional benefit over active physiotherapy in the short-term. Patients gained considerable pain relief after TKA, but preoperative ROM was not restored and the numbers of patients able to climb stairs was reduced.

2008 Cost-effectiveness of intensive exercise therapy directly following hospital discharge in patients with arthritis: results of a randomized controlled clinical trial (Bulthuis et al., 2008)

RCT. 85 patients with arthritis (OA and RA) admitted to hospital for flare-up or elective hip or knee arthroplasty. Randomised to receive a 3-week intensive exercise training program (n=50) or usual care (n=35). Note this is part of a larger study consisting of 114 patients in total.

To evaluate cost-effectiveness and cost-utility of an intensive exercise regime directly after hospital discharge compared to usual care. Assessed at baseline and at 3, 13, 26 and 52 weeks. Costs measured prospectively on a monthly basis. Outcomes: QALYs (SF-6D and VAS personal health), HAQ, MACTAR, EPMROM, cost and incremental cost effectiveness.

Patients receiving intensive exercise training showed a significantly greater improvement in VAS personal health, MACTAR and EPMROM outcomes at 6 months compared to those receiving usual care. No significant difference in SF-6D was detected at 6 months. At 1 year outcomes were similar for both groups. At 1 year post-discharge, the intensive exercise program was substantially cheaper €718 per patient, resulting in a reduction in mean total cost per QALY. Concluded that intensive exercise training following hospital discharge results in better QoL at lower cost after 1 year than usual care. Highlights such training should be implemented after hospital discharge of patients with arthritis

2007 Arthritis patients show long-term benefits from 3 weeks intensive exercise training directly following hospital discharge (Bulthuis et al., 2007).

RCT. 114 patients with arthritis (OA and RA) admitted to hospital for flare-up or elective hip or knee arthroplasty. Randomised to receive a 3-week intensive exercise training program (n=60) or usual care (n=54).

To assess the efficacy of a short-term intensive rehabilitation regime after discharge from hospital. Assessed at baseline and at 3, 13, 26 and 52 weeks. Outcomes: EPMROM, HAQ, MACTAR, HRQoL and RAND-36.

16 patients lost to follow up. The intensive exercise program resulted in faster and greater improvement in patients compared to usual care with regards all outcome measures except HRQoL. At final follow up EPMROM and MACTAR remained significantly higher, and mean differences clinical greater, in the intensive exercise group compared to usual care. Concludes intensive short-term exercise training following discharge from hospital, improves return of function for patients with arthritis.

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2009 Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study (Coulter, Weber & Scarvell, 2009).

Controlled cohort study. 51 consecutive patients able to weight-bear following hip or knee replacement surgery for OA. Two groups those operated in first 4 months received group physiotherapy, those in second 4 months provided with individualised home physiotherapy for post-operative rehabilitation.

To compare effectiveness and efficiency (time) of class-based vs individualised home physiotherapy for patients undergoing TJR surgery. Assessed preoperatively, at discharge, 5 and 12 weeks post-op. Outcomes WOMAC, SF-36, TUG test, knee ROM, 6-m walk test, patient evaluation questionnaire and staff time costs.

Both groups showed significant improvement in outcomes at 12 weeks post-operatively compared to discharge, with no significant differences discernable between groups. Class-based physiotherapy was accessed more frequently than the individualised program, although the physiotherapist’s time was less per patients per visit in the class-based compared to home setting. Concludes that class-based physiotherapy is a more efficient service without any compromise to patient outcomes.

2007 Case Report: Rehabilitation of a patient with minimally invasive total knee arthroplasty (Dean, 2007)

Case study. 57-year-old woman with OA of the right knee who underwent minimally-invasive TKA. Referred to outpatient physical therapy 3 days postoperatively.

To describe the rehabilitation procedure and outcomes following TKA.

Rehabilitation regime involved: passive, active assistive, and active ROM; strengthening; patellar mobilizations; soft-tissue mobilizations of the incision; balance activities; gait training; oedema control using cold modalities; home exercise program; and family/patient education.

Unable to access full article to check outcomes of this.

2006 Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial (Denis et al., 2006)

RCT. 81 patients who underwent TKA for OA, assigned to one of 3 rehabilitation programs: conventional physical therapy; 35 mins CPM daily + conventional physical therapy; 2 hours CPM daily + conventional physical therapy.

To compare effectiveness of three in-hospital rehabilitation programs with and without CPM. Assessed preoperatively and at discharge. Outcomes: ROM (extension and flexion), TUG, WOMAC and LOS.

No significant differences across groups were detected for any outcome measure at baseline or discharge, including length of hospital stay. Concluded that CPM provides no additional benefit over conventional physical therapy rehabilitation and therefore its application in rehabilitation is no supported.

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2009 [The effects of two different continuous passive motion protocols on knee range of motion after total knee arthroplasty] (in Turkish) (Ersozlu, Sahin, Ozgur & Tuncay, 2009)

RCT. 86 patients with primary OA who underwent TKA, randomized to receive one of three regimes: three 1-hour sessions of CPM starting one day (n=29) or three days (n=29) postoperatively until discharge, in addition to standard physical therapy, or physical therapy alone (n=28, control).

To evaluate short- and long-term effects of two CPM regimes compared to standard physical therapy following TKA. Assessed preoperatively and at various time points postoperatively up to a minimum of 2 years (range 26-52 months). Outcomes: clinical and functional parameters (KSS).

All groups showed significant improvement in clinical and function knee scores postoperatively. However, Knee flexion was significantly greater 3-days postoperatively and at discharge for both CPM groups compared to the control, although at 1-month postoperatively no significant difference between groups was detected. Mean length of hospital stay was significantly shorter for both CPM groups compared to the control group (by 2 and 3 days). Concluded that CPM may shorten length of hospital stay following TKA, however, it does not provide any additional short- or long-term benefits over standard physical therapy.

2008 Effects of pre- or postoperative therapeutic exercise on the quality of life, before and after total knee arthroplasty for osteoarthritis (Evgeniadis et al., 2008)

RCT. 53 consecutive TKA patients randomized to receive: general strengthening exercise program for 3 weeks preoperatively (n=18); specific strengthening rehabilitation program for 8 weeks postoperatively (n=15); or standard pre- and postoperative care (n=20). Mean age = 68.76 (± 5.64) years

To evaluate a preoperative or postoperative rehabilitation program. Outcomes: SF-36, functional ability (Iowa Level of Assistance Scale), active ROM.

Patients receiving preoperative exercise showed improved mental health prior to TKA and better functional readiness at hospital discharge. Patients receiving postoperative exercise achieved significantly greater functional ability and active ROM. Concluded that a preoperative strengthening regime is feasible and appears beneficial to patients’ mental health and early functional return following TKA. A postoperative program focusing on specific strengthening is beneficial in increasing active ROM and for rapidly returning functional autonomy.

2005 Full-thickness burn formation after the use of electrical stimulation for rehabilitation of unicomparemental knee arthroplasty (Ford et al., 2005)

Case study. Patient who had undergone unicompartmental knee arthroplasty and receiving electrical stimulation and interferential current modalities in physical therapy rehabilitation.

To highlight a potential complication of electrical stimulation and interferential current used in rehabilitation following joint arthroplasty.

Details the development of a full-thickness burn over the metal implant following physical therapy rehabilitation after knee arthroplasty.

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2006 Total knee replacement: prevention of deep-vein thrombosis using pharmacological (low-molecular-weight heparin) and mechanical (intermittent foot sole pump system) combine prophylaxis: preliminary results (Giannoni et al., 2006)

Prospective case series. 38 consecutive TKAs (34 patients) between Oct 2002 and June 2003. Postoperatively patients received a daily subcutaneous injection of nadroparin calcium (dose body-weight adjusted) and an intermittent foot sole pump applied immediately after surgery in both feet for 5 hours a day and all night continued for 15 days.

To determine role of combined mechanical and pharmacological prophylaxis in prevention of DVT following TKR. Assessment: 1-2 weeks preoperatively, postoperatively before discharge, and 30 days after surgery, using echo-color flow to detect DVT.

No major complications were observed. Two patients required manual drainage of clots from the wound. Three patients had DVT (7.3%), of which one patient had a DVT prior to surgery (thus, a rethrombosis): all successfully treated with LMWH. No pulmonary embolisms or deaths occurred. Concluded that combine prophylaxis of nadroparin calcium and intermittent foot sole pump appeared to markedly reduce DVT.

2006 Effects of music-based therapy on distress following knee arthroplasty (Giaquinto et al., 2006)

Pilot, Controlled study. 12 patients (4 men, 8 women) mean age 69.2 years, referred for rehabilitation following TKA. Divided into two groups: Group 1 received 2 weeks (12 sessions) of conversation of music followed by 2 weeks of singing; Group 2 received 2 weeks of singing followed by 2 weeks of conversation.

To determine if music therapy is beneficial after TKA. Assessment: prior to intervention; at 2 weeks (after 1st modality) and 4 weeks (after 2nd modality). Outcomes: MMSE, Cumulative illness rating scale, HAD. A structured interview of three closed questions was conducted at the end of the study.

At baseline no significant differences were observed between the groups with regard age, schooling or HAD scores. Results showed group 2 (sing-conversation) gained more benefit that group 1 (conversation-sing), and that depression scores improved more than anxiety scores. Concluded that music therapy is beneficial for depression following TKA, and suggests that it may be used instead of pharmacological interventions. The authors recognise the need for further research. Nb: results only concern HAD

2007 The lived body and the perioperative period in replacement surgery: older people’s experiences (Gustafsson, Ponzer, Heikkila & Ekman, 2007)

Qualitative longitudinal study. 12 older people undergoing hip or knee replacement surgery.

To explore older people’s experiences of the lived body during the perioperative period of hip or knee arthroplasty. Patients were interviewed on five occasions during the perioperative period.

Findings indicated that the perioperative period involved a process of transition composed of 6 critical phases. The process is supported by the wish to return to being able-bodied by having the surgery. Also found that patients knew little about the surgery as a whole. Concluded that joint arthroscopy meant to overcome the confinement of a painful and unreliable body. But, patients struggled to regain control of their body and lives, and were not prepared for the transitional changes of the perioperative period. Further research is needed to develop a program of care to facilitate the process of transition.

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2009 Land-based versus water-based rehabilitation following total knee replacement: a randomized, single-blind trial (Harmer, Naylor, Crosbie & Russell, 2009)

RCT. 102 patients, who underwent TKR, were randomized to receive land-based (n=49) or water-based (n=53) exercise classes 2 weeks after surgery. Both involved 1 hour sessions twice weekly for 6 weeks, with patient-determined exercise intensity (based on current clinical practice protocol).

To compare outcomes of land- vs water-based exercise programs in the early subacute phase up to 6 months post TKR. Assessment: 2 weeks (baseline), 8 and 26 weeks after surgery. Outcomes: attendance, distance on a 6-minute walk test, stair-climbing power (SCP), WOMAC, VAS for joint pain, passive knee ROM and knee oedema (circumference).

81% of patients attended 8 or more sessions. 5% of patients were lost to follow up. At 8 weeks significant improvements were found across all 8 outcomes, with further improvement at 26 weeks for all outcomes except WOMAC. Minor between group differences were observed for SCP, WOMAC stiffness and function, and oedema, although these were clinically insignificant. Concluded that short-term programs of either land- or water- based rehabilitation delivered in the early phase following TKR provided comparable outcomes at the end of the program and extend up to 26 weeks post surgery.

2005 Effectiveness of a behavioral change intervention in Thai elders after knee replacement (Harnirattisai & Johnson, 2005)

Longitudinal quasi-experimental, pre-test-post-test control study. 63 older people undergoing knee replacement surgery. Experimental group received a behavioural change intervention based on social cognitive theory.

To examine the effects of a behavioural change intervention on patient outcomes. Outcomes: self-efficacy for exercise scale, self-efficacy for functional activity scale, outcome expectations for exercise scale, outcome expectations for functional activity scale, physical performance test and physical activity diary.

At weeks 2 and 6 postoperatively, the experimental group had significantly greater improvement in self-efficacy for exercise, outcome expectations for exercise and functional activity, physical performance, and participated more in exercise and walking than the control group. Concluded that the behavioural change intervention was effective in improving patient outcomes after knee surgery, and may be applicable to other situations where behavioural change is key to recovery. Nb: was unable to obtain full paper to check study design, results etc as unclear from abstract.

2005 Cryo/Cuff compared to epidural anesthesia after knee unicompartmental arthroplasty: a prospective, randomized and controlled study of 60 patients with a 6-week follow-up (Holmstrom & Hardin, 2005)

RCT. 60 patients (61 knees) randomized into 3 groups: cold compressive dressing, epidural anaesthesia and standard care.

To evaluate efficacy of cold compressive dressing (Cryo/Cuff) and epidural anaesthesia in postoperative management of primary unicondylar knee arthroplasty. Outcomes: pain, ROM, function, bleeding, swelling, morphine consumption.

No significant differences were detected across groups for pain, ROM, function, bleeding and swelling. However, consumption of morphine was significantly higher in the control group over the first 24 hours after surgery compared to the other two groups (which did not differ significantly in their consumption). Concluded that Cryo/Cuff appears a reliable, effective, risk-free and well-tolerated alternative to epidural anaesthesia to reduce pain and morphine after unicondylar knee arthroscopy.

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2007 Targeted early rehabilitation at home after hip and knee joint replacement: does it work? (Iyengar, Nadkarni, Ivanovic & Mahale, 2007).

Cohort study. 1034 patients undergoing THR or TKR surgery, of which 394 were eligible for the targeted early rehabilitation at home scheme (RAHS). OA was the primary diagnosis in the majority (>97%) of patients. Mean age of RAHS group=72.9 years.

To evaluate the benefit and cost effectiveness of RAHS following THR or TKR surgery. Outcomes: length of hospital stay, duration on the scheme, number of bed days saved, cost appraisal, readmission rate and complication rate.

There was a marked reduction in the length of in-patient stay for patients on the RAHS without any increase in complication rate. Patient with THR required significantly fewer visits by the rehabilitation team than those who had had TKR surgery. The RAHS resulted in significant saving for the trust without any increase in readmission or complication rates.

2008 After partial knee, patients can kneel, but they need to be taught to do so: a single-blind randomized controlled trial (Jenkins et al., 2008)

RCT. 60 adults (31 women, 29 men) with medial compartment OA suitable for partial knee replacement. 6-weeks after surgery, patients were randomly assigned to receive specific kneeling advice and education (n=30), or routine care (n=30). Mean age = 66 years

To explore whether a single physical therapy intervention would improve kneeling ability after partial knee replacement. Assessment: preoperatively, at 6-weeks and 1-year postoperatively Outcomes: patient-reported kneeling ability (Oxford Knee Score), other factors associated with kneeling including scar position, numbness, ROM, other joint involvement and pain.

At assignment at week 6 there were no significant differences between groups for any outcome measure. However at 1-year post-operatively the kneeling intervention group had significantly greater improvement in kneeling ability than the routine care group: no other outcomes differed across groups. Concluded that the physical therapy kneeling intervention given 6 weeks after surgery alone, predicted patient-reported kneeling ability 1 year post-operatively. Thus, patient advice and instruction regarding kneeling should be incorporated in postoperative rehabilitation regimes after partial knee replacement surgery.

2009 Continuous femoral nerve block after total knee arthroplasty (Kadic et al., 2009)

RCT. 53 patients undergoing TKA. Randomized to receive a basic analgesic regime (paracetamol and dicloflenac) (n=26) or basic analgesia and a continuous femoral nerve block (n=27) for 48 hours postoperatively. Rescue analgesia (morphine patient-controlled analgesia pump) was available to all.

To evaluate the analgesic effectiveness of femoral nerve block after TKA. Outcomes: NRS for pain, morphine consumption and side-effects over first 48 hours recorded. Knee flexion angles over the first week were recorded. 3 months postoperatively WOMAC and KSS.

Patients receiving continuous femoral nerve block experienced significantly less pain, used less morphine and were more satisfied with their analgesia over the first 48 hours compared to the control group. In addition fewer patients were drowsy, nauseated or vomited in the study group. They also achieved greater knee flexion in the first 6 days after surgery. However, at 3-months post-op no significant functional differences between groups were detected. Concluded that continuous femoral nerve block leads to better analgesia after TKA, resulting in less morphine consumption and related side effects. Early functional recovery is improved although after 3 months no functional benefits were found.

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2009 Spousal support following knee surgery: roles of self-efficacy and perceived emotional responsiveness (Khan, Gonzalez, Hale & Turner-Stokes, 2009)

Qualitative study (interviews). 134 married older adults with knee OA due to undergo TKR.

To investigate self-efficacy to mange recovery from surgery and perceptions of spousal emotional responsiveness. Interviews were undertaken 1-month preoperatively, and 1-month and 3-months postoperatively. Outcomes: knee limitations, depressive symptoms.

Self-efficacy mediated associations between emotional support and problematic support (e.g. showing disinterest) and improvement in knee limitations, and also emotional support and improvement in depressive symptoms. Perceptions of spousal emotional responsiveness did not mediate associations between support and recovery outcomes. Concluded that emotional support from the spouse can improve recovery outcomes partly by strengthening efficacy beliefs to manage recovery, whilst problematic support can hinder recovery through weakening efficacy beliefs.

2009 A rapid recovery program after total knee arthroplasty (Klika et al., 2009)

Retrospective review of surgeries between January 2005 and August 2006 (traditional, n=62), and between September 2006 and December 2007 (Rapid Recovery, n=54)

To examine effects of a ‘Rapid Recovery Program’ on outcomes following TKA. Outcomes: LOS, distance ambulated, KSS.

Patients who underwent Rapid Recovery were able to ambulate further, had decreased length of hospital stay, were discharged home at an increased frequency and had better knee functioning at 4 weeks post operatively.

2009 Reversing muscle and mobility deficits 1 to 4 years after TKA (la Stayo et al., 2009)

RCT (matched). 17 individuals (13 women, 4 men) with unilateral (n=10) or bilateral (n=7) TKA conducted a minimum of 12 months previously (mean = 21 months, range= 12-53 months). Mean age 68 years (range 55-80).

To determine effects of 12 weeks rehabilitation with resistance exercise on muscle and mobility 1-4 years after TKA. Also to compare effectiveness of a traditional resistance training regime to eccentric resistance training. Assessment: pre and post training. Outcomes: KOOS, SF-36, muscle volumes, Knee strength, TUG, 6-minute walk, Stair ascent and descent.

Eccentric resistance training resulted in increased quadriceps muscle size (11%) and knee extension muscle strength (15%), no change was evidence for tradition resistance training. All mobility tasks were improved for the eccentric training group (TUG, 6-minute walk, stair ascent and descent), however, traditional resistance training resulted in improvement in TUG and stair ascent only. Concluded that increased muscle size and strength together with improved mobility can occur after 12 weeks of resistance training after 1-4 years after TKA. When training involves eccentric resistance, greater improvements in muscle size/strength and mobility tasks can result.

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2009 Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty (Larsen et al., 2009).

Cost effectiveness study associated with an RCT (described in study below, see Larsen et al 2008).

To assess the cost effectiveness of an accelerated periopertive care and rehabilitation regime compared to standard rehabilitation regime for patients undergoing THA or TKA. Activity-based costing analysis conducted from patients’ visit prior to surgery to 1-year post-operatively.

The accelerated regime was significantly cheaper than the standard rehabilitation regime. Patients who had THA and received the accelerated regime had significantly greater gain in QALYs compare to patients under the standard regime. In contrast there was no clinical or significant difference in QALYs between the two regimes for patients who underwent TKA. Concludes an accelerated perioperative care and rehabilitation program can be clinically more effective and cost saving after THA, however, whilst it is cost saving following TKA no further clinical benefit (in terms of QALYs) is gained.

2008 Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up (Larsen et al., 2008).

Controlled cohort study. 247 patients undergoing elective primary THA or TKA, largely as a result of OA. 105 patients prior to, and 142 after, the implementation of an accelerate perioperative care and rehabilitation program.

To assess the effectiveness of an accelerated perioperative care and rehabilitation regime for patients following total joint replacement surgery. Outcomes: LOS in hospital, adverse effects within 3 months post surgery.

The LOS was significantly reduced with the introduction of the accelerated program. However, no significant differences in adverse effects postoperatively were found. Concludes the accelerated perioperative care and rehabilitation program following THA or TKA was effective, and the results obtained concurred with those from the efficacy study (see below).

2008 Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up (Larsen et al., 2008).

RCT. 87 patients receiving primary THR, or knee replacement surgery. Randomised to receive a new accelerated perioperative care and rehabilitation procedure, or current perioperative care.

To evaluate efficacy of an accelerated perioperative care and rehabilitation regime for patients recovering from joint replacement. Assessed at baseline and at 3-month follow up. Outcome measures: LOS and QoL (EQ-5D)

The mean LOS in hospital for patients receiving the new perioperative care and rehabilitation procedure was significantly shorter than those receiving usual care. Furthermore at follow-up there was significantly greater improvement in QoL in the new intervention group. Concludes that a novel accelerated perioperative care and rehabilitation for patients undergoing THR or knee replacement surgery is effective and has additional benefits for patients and the hospital.

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2009 Comparing outcomes of patients following total knee replacement: does frequency of physical therapy treatment affect outcomes in the acute care setting? A case study (Lawson, 2009)

Case study? 6 patients receiving once- or twice-daily physical therapy following TKR in an in-patient setting.

To compare outcomes of once daily versus twice daily physical exercise regimes following TKR. Assessed 1-day postoperatively and at discharge. Outcome measures: LOS, ROM, NRS for pain and FIM

Patients receiving twice-daily physical therapy showed decrease LOS and increased FIM, conversely once-daily physical therapy resulted in greater ROM and lower pain. Concluded that physical therapists need to assess frequency of physical therapy intervention on a case-to-case basis.

2006 Continuous passive motion following total knee replacement: a prospective randomized trial with follow-up to 1 year (Leach, Reid & Murphy, 2006)

RCT 85 patients undergoing TKR for OA were randomly assigned to receive either existing physiotherapy rehabilitation (involving active ROM exercises and mobilization) alone or with the addition of CPM for 1-hour twice daily.

To examine the effectiveness of CPM. Assessed preoperatively, at time of discharge and at 6-weeks, 6-months and 12-months postoperatively. Outcomes: ROM, pain (VAS), and analgesic use.

No significant differences were found between the two groups for any outcome at any time point. Concluded that results substantiate previous findings that short duration CPM following TKA does not effect outcomes of ROM or pain.

2005 The role of the rehabilitation after total knee arthroplasty in rheumatoid and osteoarthritis (Legovic & Sestan, 2005)

Cohort study. 102 patients with implanted total knee endoprothesis, due to OA (n=64) or RA (n=38) who underwent an early three-week rehabilitation regime.

To evaluate the effects of early rehabilitation on functional status and quality of life. Assessed preoperatively and at 3-, 6- and 12-months postoperatively. Outcome measures: VAS pain, Functional status (HAQ for RA patients and Lequesne’s index for OA) and SF-36.

Patients with both OA and RA showed significant improvements in functional status (for OA pre-op mean score = 13, and at end mean score = 7.89), this resulted in greater ease in carrying out everyday activities and a significant improvement in QoL. Concluded that early rehabilitation following TKA significantly effects improvement in functional status and QoL in patients with OA and RA.

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2008 Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy after total knee arthroplasty (Lenssen et al., 2006, 2008) [ISRCTN85759656]

RCT 60 patients who underwent TKA for OA and experienced early post-op flexion impairment. Randomized to CPM & PT for 17-days post-op, or usual care (CPM & PT as in-patient ca. 4 days followed by PT alone for 2 weeks). Both groups received PT 18-days to 3-months post-op

To investigate the effectiveness of prolonged CPM use in the home as an adjunct to standard PT. Assessed at 17 days, 6 weeks and 3 months after surgery. Outcomes: ROM and functional recovery.

Results found a significant but small improvement in ROM at discharge for patients receiving prolonged CPM in addition to PT. However, no differences between groups were detected for long-term ROM or for functional outcomes at any time point. Concluded that whilst prolonged CPM may have a slight, short-term benefit in terms of ROM for patients with limited ROM at discharge, its routine use should be reconsidered given that no long-term benefit regarding ROM or functional performance was detected.

2006 Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT (Lenssen et al., 2006)

RCT 43 of 55 consecutive patients undergoing TKA for OA randomised to receive in-patient physical therapy once daily (20 minutes, n=22) or twice daily (40 minutes, n=21)

To assess effect of physical therapy intensity on short-term recovery following TKA. Assessed at 2-weeks preoperatively, 4-days, 6-weeks & 3-months postoperatively. Outcomes: ROM, LOS, pain and satisfaction with treatment, treatment results and global perceived effect (using an 11 point scale), WOMAC and KSS

No significant differences were found in outcomes between the two groups. Patient satisfaction with both regimes and outcomes was high: 3 months after surgery 39 of 43 patients stated they had vastly improved. Concluded that the use of multiple daily physical therapy sessions is questionable as an in-hospital therapeutic regime in TKA patients with OA.

2008 Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial (Mahomed et al., 2008).

RCT. 234 patients undergoing primary unilateral total hip or knee replacement. Randomised to receive home-based or inpatient rehabilitation.

To evaluate and compare the effectiveness and costs of home-based vs. inpatient rehabilitation following TJR surgery. Assessed pre-operatively and at 3 and 12 months post-operatively. Outcomes: Cost, Patient satisfaction, WOMAC and SF-36.

The prevalence of postoperative complications was similar in both groups of patients. Patients in both groups showed significant improvement with regard to the 3 outcomes measures at 3 and 12 months follow up compared to baseline. However, no significant difference across groups was identified. In-patient rehabilitation was significantly more expensive than home-based care. Concludes that despite concerns regarding the early discharge of patients from hospital, no difference in outcomes found. Therefore, home-based rehabilitation is a more cost-effective regime following TJR surgery.

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2009 Aquatic and land based therapy vs. land therapy on the outcome of total knee arthroplasty: a pilot randomized clinical trial (McAvoy, 2009)

RCT 30 patients who underwent unilateral TKA randomized to receive aquatic and land-based PT (n=15) or land-based PT alone (n=15).

To determine the effective of combining aquatic- and land-based physical therapy compared to land-based therapy alone. Assessed at 6-weeks (at the end of the therapeutic regime) and 6-months postoperatively. Outcomes: pain, ROM, swelling, and KOOS (signs and symptoms)

Results showed significantly greater knee flexion ROM at 6-weeks for patients receiving land and aquatic PT compared to land only PT, although no differences in pain, swelling or KOOS were detected. At 6-months patients receiving land and aquatic PT showed significant improvement in symptoms (KOOS). Concluded that patients undergoing unilateral TKA would benefit from a rehabilitation regime including both aquatic and land-based PT.

2006 An acute care episode of a patient following bilateral total knee arthroplasty (McQueen, 2006)

Case study. 62-year-old man with OA in both knees who underwent bilateral TKA.

To highlight the importance of acute phase rehabilitation following bilateral TKA. Assessed: day before surgery and at discharge.

At discharge, active knee ROM was increased from –6° to 88° (right) and -6° to 83° (left). Similarly, passive ROM increased from -5° to 90° (right) and -5° to 86° (left). The patient was able to transfer from supine to sit position with supervision, and from sit to stand with contact guard assistance, whilst ambulation progressed to walking 100ft with a rolling walker and supervision. Concluded that this case highlights the potential benefits of early aggressive physical therapy and patient motivation.

2007 Early neuromuscular electrical stimulation to optimize quadriceps muscle function following total knee arthroplasty: a case report (Mintken et al., 2007)

Case study. 65-year-old woman, who underwent a right, cemented TKA. A traditional TKA rehabilitation regime was undertaken augmented by NMES initiated 48 hours after surgery, continued twice daily for 3 weeks then once daily for 3 weeks.

To describe outcomes of a rehabilitation regime involving NMES aimed at optimizing quadriceps function. Assessment: preoperatively and at 3, 6 and 12-weeks postoperatively. Outcome measures: isometric quadriceps and hamstring muscle torque, quadriceps muscle activation, KOOS, TUG, 6-minute walk test, stair-climbing test, SF-36 (physical component score).

Preoperatively the involved quadriceps muscle produced 75% torque of the uninvolved side and showed 72.9% activation. At 3, 6 and 9 weeks torque was significantly improved by 16%, 29% and 56% respectively. Activation improved to 93.4%, 94.6% and 93.5% respectively. Function measures also showed significant improvement e.g. KOOS, TUG etc. There was improved quadriceps function at all times measure, all values being superior to those previously reported in the literature. Concluded that clinical trials are required to establish whether these outcomes following TKA are specifically attributable to rehabilitation programs involving NMES.

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2005 Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial (Mitchell et al., 2005)

RCT. 160 patients with OA waiting for unilateral TKR. Randomly assigned to home (n=80) or hospital outpatient (n=80) group. Home groups received pre- and post-operative home visits for assessment and treatment by a community physiotherapist.

To investigate the effectiveness of pre- and post-operative home physiotherapy for TKR. Assessed preoperatively and at 12 weeks postoperatively. Outcomes: HRQoL, WOMAC, SF-36, patient satisfaction and NHS resource use.

No significant differences were found in WOMAC pain score or HRQoL scores across groups. The home group had significantly more sessions than the hospital group (mean difference 5.2 sessions, 95% C.I.= –6.3 to –4.1). Total NHS costs per patient were similar across groups, but home physiotherapy was significantly more expensive (mean difference £136.50, 95% C.I.= £-160 to £-113). Patients were equally satisfied with the physiotherapy received, although more patients in the home group would choose their location for physiotherapy again. Concluded that although home physiotherapy was as effective and acceptable to patients as outpatient physiotherapy for unilateral TKR, it was more expensive. Further it did not improve patient-perceived health outcomes.

2008 Does a standard outpatient physiotherapy regime improve the range of knee motion after primary total knee arthroplasty? (Mockford, Thompson, Humphreys & Beverland, 2008)

RCT 150 patients undergoing primary TKA. Randomly assigned to receive outpatient physiotherapy for 6 weeks following TKA or no outpatient physiotherapy.

To establish whether a standard outpatient physiotherapy regime improves ROM after primary TKA. Assessed preoperatively and 1 year after surgery Outcomes: ROM, validated knee scores and SF-12.

Although the group receiving outpatient physiotherapy achieved greater ROM this was not statistically significant. No other outcome differed significantly between groups. Concluded that outpatient physiotherapy does not improve knee ROM following primary TKA.

2009 Manipulation under anaesthesia for stiffness following knee arthroplasty (Mohammed, Syed & Ahmed, 2009)

Retrospective cohort study 21 patients (11 female, 10 male) who underwent MUA for knee stiffness over a 6-month period following knee arthroplasty. 16 primary and revision TKRs, 1 medial unicompartmental replacement and 1 patellofemoral arthroplasty. Mean age 62 years (range 56-80).

To describe the experience of MUA as first line treatment for stiffness following total and partial knee arthroplasty. Review of case and theatre notes. Data extracted regarding demographics, ROM (pre- and post-manipulation and follow-up). Complications and outcomes also analysed.

Mean time between arthroplasty and MUA was 13.2 weeks (range 6-32). ROM improved from mean range of 10.4-71.2° to 2.1-94.0° post-MUA and to 2.3-91.9° at follow-up. Mean arc of motion significantly improved from 60.2° (range 40-80°) to 91.9° (range 45-120°) post-MUA, with a mean improvement of 31.6°. At an average follow-up of 3 months (range 6 weeks to 8 months) the mean arc of motion was 30.2° (range 40-120°), a significant improvement from pre-MUA. No procedural complications were noted. Concluded that MUA has a role in the early treatment of knee stiffness following knee arthroplasty resulting in excellent, immediate outcomes. This should be the first line of management for stiff knee arthroplasties.

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2007 A prospective audit to evaluate the effect of femoral nerve blocks on the short term outcomes of rehabilitation following total knee arthroplasty for osteoarthritis (Monaghan, Caulfield & O’Mathuna, 2007)

Prospective audit. 26 patients who underwent TKA: 12 patients received femoral nerve blocks (over 24 hours) and 14 patients usual analgesia post-operatively

To examine effect of femoral nerve block injections on short term outcomes after TKA. Assessed: preoperatively and at 5-days postoperatively Outcomes: WOMAC, LOS, VAS pain, discharge destination, days to: first mobilisation; achieve 90° flexion; achieve a straight leg raise.

No significant differences between groups were observed across any outcome measures. Both groups showed improvement in pain, stiffness and function after surgery. Concluded that further large RCTs are needed to establish consistency of these findings and also to closer investigate outcomes over the first two days postoperatively.

2008 Comparison of two rehabilitation programs following total knee arthroplasty (Mozo et al., 2008)

Retrospective cohort study. 122 patients who underwent TKA for gonarthrosis. At discharge patients were assigned to either home (n=40) or outpatient (n=82) depending on observed joint trajectory and patient availability for treatment.

To compare the effectiveness of two rehabilitation programs following TKA. Assessed pre-op and at 8 days and 6 months post-op. Outcomes: VAS pain, HSS, independency for activities of daily living based on Barthel index, walking capacity (FAC) and SF-36.

Across all patients there was a significant improvement at 6 months follow up for pain, HSS, physical SF-36. No significant differences in FAC or Barthel index were observed. Furthermore, no significant difference in any outcome was found across groups. Concluded that TKA improved pain, functionality and QoL in patients with gonarthrosis regardless of which rehabilitation program is used.

2009 Biceps tendinitis as a cause of acute painful knee after total knee arthroplasty (Pandher, Boparai & Kapila, 2009)

Case study. 62-year-old male with advanced knee OA who underwent bilateral TKA.

To describe the diagnosis and treatment of biceps tendonitis found to be causing painful knee following TKA.

Patient was discharged 5 days after surgery following active physiotherapy and could walk with aids. At 12-day follow-up, he complained of acute pain and a snapping sensation while extending the right knee from the fully flexed position. After examination no cause could be ascertained and he was prescribe oral NSAIDs, 10 days later he attended outpatients with acute onset severe pain and inability to move the right limb. An ultrasound scan showed tendonitis of the biceps femoralis tendon and an ultrasound-guided peritendinous lignocaine injection given (physiotherapy was suspended). The patient had complete symptomatic relief from 3-days after the injection when physiotherapy recommenced and at final follow up (2-months) could walk comfortably and perform functions as per postoperative protocol.

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2006 The use of neuromuscular electrical stimulation to improve activation deficits in a patient with chronic quadriceps strength impairments following total knee arthroplasty (Petterson & Snyder-Mackler, 2006)

Case study. 62-year-old male cyclist, 12 months after bilateral TKA with impaired left quadriceps strength and volitional muscle activation, who received 6 weeks NMES and intensive volitional weight-training with emphasis on unilateral lower limb exercises.

To implement a NMES treatment and intensive weight training protocol to address persistent quadriceps muscle impairment after TKA.

At outset left quadriceps was 26% weaker than the right quadriceps and central activation ratio (CAR) was 13% lower. After 16 treatments over 6 weeks left quadriceps strength improved by 25%, and volitional muscle activation improved from a CAR of 0.83 to 0.97. At 18 months post-op left quadriceps was 4% weaker and at 24-months 6% stronger than the right. Concluded that 6 weeks of NMES and volitional strength training resulted in symmetrical quadriceps strength and complete muscle activation. Intensive strengthening regimes have the potential to reverse persistent strength-related impairments after TKA.

2009 Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort (Petterson et al., 2009)

RCT 200 patients who underwent unilateral TKA for knee OA randomized at 4 weeks after surgery to received volitional strength training alone or in combination with NMES. 41 patients eligible to enrol who did not participate in the intervention were also followed.

To assess effectiveness of progressive quadriceps strengthening with and without NMES after TKA, and to compare with conventional rehabilitation. Assessed at 3- and 12-months postoperatively. Outcomes: quadriceps strength and volitional activation, SF-36, KOS, ROM, TUG, Stair-Climbing test and 6-Minute Walk.

Both intervention groups had similar strength, activation and function at 3- and 12-months. However, the standard care group had significantly worse function and weaker quadriceps strength at 12-months compared to both intervention groups. Concluded that progressive quadriceps strengthening with or without NMES results in clinical improvement after TKA, with good short- and long-term functional recovery, both exceeding the outcomes of conventional rehabilitation programs.

2009 A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial (Rahmann, Brauer & Nitz, 2009).

RCT. 65 patients (30 men, mean age 69.6± 8.2 years) undergoing primary hip or knee arthroplasty for OA. Randomised to aquatic physiotherapy, non-specific water exercise or additional ward physiotherapy (control).

To assess effect of inpatient aquatic therapy in addition to conventional ward physiotherapy. Evaluation preoperatively and at 14, 90 and 180 days after surgery. Primary outcome measures: hip abductor strength, walking speed and WOMAC. Nb after 1st post-op assessment patient was free to undertake whatever rehabilitation they chose

Baseline demographics of the 3 groups were similar. At day 14, hip abductor strength was significantly greater in the aquatic physiotherapy group compared to the other two groups: there was no significant difference across groups for the remaining outcome measures. Although relative differences between groups favoured aquatic physiotherapy. No adverse side-effects of aquatic physiotherapy occurred. Concludes that specific inpatient aquatic physiotherapy is safe and beneficial for early recovery of hip strength following joint replacement. Highlights the need for further research to confirm the findings.

58

2008 Change in patient concerns following total knee arthroplasty described with the International Classification of Functioning, Disability and Health: a repeated measures design (Rastogi, Chesworth & Davis, 2008).

Cohort study 54 consecutive patients undergoing primary TKA.

To explore patient concerns following TKA. Assessed preoperatively and at 2, 4 and 6 weeks postoperatively. Outcomes: importance of each of 32 previously identified concerns of the International Classification of Functioning, Disability and Heath.

The importance rating of concerns in all four ICF components changed significantly from pre-op to 2 weeks post-TKA. After 2 weeks concerns in the participant component became increasingly important. Furthermore between 2 and 4 weeks postoperatively, importance ratings in Body function and Activity components also changed. No change in the Environment Factors component was observed. Concluded that changes in patient concerns following TKA mirror their recovery, in particular participation restriction become increasingly important. It was suggested that clinicians should manage patient expectations for return to societal roles early on in rehabilitation.

2006 Response shift in outcomes assessment in patients undergoing total knee arthroplasty (Razmjou, Yee, Ford & Finkelstein, 2006)

Cohort study 125 patients (91 women, 34 men) with degenerative arthritis undergoing TKA. Mean age 68 ± 9.5 (sd) years

To investigate the role of response shift in patients undergoing TKA. Assessed preoperatively and 6 months postoperatively (including retrospective assessment of preop). Outcomes: WOMAC

A significant response shift was observed with WOMAC total, pain and physical function scores indicated patients perceived themselves as being more disabled preoperatively than they actually reported at the time. Age, gender, comorbidity and amount of recovery did not affect response shift. Concluded the demonstrated response shift at 6 months post TKA is an important component in assessing success/failure of surgical interventions as quantified by QoL self-report measures

2005 Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty: a randomised controlled trial (Reilly et al., 2005)

RCT 41 patients with medial compartmental OA undergoing unicompartmental knee arthroplasty. Randomized to either accelerated discharge on day of surgery (n=21) or standard discharge around 5 days after surgery (n=20).

To evaluate the safety, effectiveness and economic viability of an accelerated rehabilitation protocol with the current standard care. Oxford Knee Assessment pre- and at 6-months postop. Cost, patient satisfaction and retrospective choice of group were recorded at 6-months. Self-report pain diary (VAS) was kept for the first 10-days postop. ROM and pain (VAS) recorded at 2 and 6 weeks. Type of walking aid and complications were also noted.

The average stay for the accelerated group was 1.5 days compared to 4.3 days for the standard group. There were no significant differences in outcomes were found between groups. The accelerated protocol resulted in a 27% saving and a significant reduction in bed occupancy. Furthermore, patient satisfaction was greater for the accelerated compared to the standard protocol.

59

2005 Creatine monohydrate supplementation does not improve functional recovery after total knee arthroplasty (Roy, de Beer, Harvey & Tarnopolsky, 2005)

RCT 37 patients (17 men, 20 women) with OA undergoing TKA who received either creatine monohydrate supplementation (10 g/d x 10 days presurgery and 5 g/d x 30 postsurgery) or placebo.

To determine if creatine monohydrate supplementation improves body composition and recovery after TKA. Assessed 7 days before (except metabolites: during surgery) and 30 days after surgery. Outcomes: body composition, muscle histomorphometery and metabolite concentrations, quadriceps, ankle dorsiflexion and handgrip strength and functional capacity.

Quadriceps and ankle dorsiflexion strength was significantly decreased at 30 days postoperatively. Creatine monohydrate supplementation had no effect on the outcomes measured. Concluded creatine monohydrate supplementation had no effect on body composition or muscle strength following TKA, neither did it benefit recovery.

2006 The effects of continuous passive motion on outcome in total knee arthroplasty (Sahin et al., 2006)

RCT 28 patients undergoing TKA for primary knee OA were randomized to receive physiotherapy (commencing on the first postoperative day), with or without CPM (5 hours per day over the first postoperative week, initiated at 0-40° flexion and increased by 10° daily).

To evaluate the effectiveness of CPM after TKA. Assessed preoperatively and at discharge, 6 weeks and 6 months postoperatively. Outcomes: ROM, pain, knee swelling at discharge, and American Knee Society Knee and Function scores.

At discharge there were no significant differences regarding ROM, pain and swelling, and additionally discharge times were similar. At 6-months active ROM, pain and American Knee Society Scores did not differ significantly. Concluded that CPM for 5 hours a day provided no additional benefit over physiotherapy alone for patients undergoing TKR.

60

2005 Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis (Tribe et al., 2005).

Cohort study? 180 patients undergoing hip or knee replacement due to OA. Following acute care in hospital, patients were either discharged immediately to return home, or admitted to inpatient rehabilitation care before discharge home.

To compare patient outcomes and out-of-pocket expenses of patient Assessed at before surgery and 1 year post-operatively. Outcomes: out-of-pocket expenses, SF-36 and WOMAC.

At 1 year post surgery, all groups showed significant improvement in patient outcome compared to at baseline. No significant differences were observed between groups. Hip home and rehabilitation, and knee home patients all reported low out-of-pocket expenses over the year following surgery. Concludes that most patients can be discharged directly home following joint replacement surgery with excellent post-operative outcomes at 1 year. Further RCTs are suggested to explore which patients are most suitable for rehabilitation.

2007 Effects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty: a randomized controlled trial (Tsang et al., 2007)

RCT 36 patients (24 women, 6 men) undergoing bilateral TKA, randomized to receive postoperative physiotherapy along with either 10 sessions over 2 weeks of acupuncture (n=18) or sham acupuncture (n=18).

To compare the acute effects of acupuncture with sham acupuncture when added to a standard postoperative physiotherapy regime. Assessed: 15 days postoperatively. Outcomes: Pain at rest and at maximum after exercise (numeric pain rating scale), active and passive ROM, and TUG.

6 patients were lost to follow up: 3 from each group. The mean differences in postoperative mean pain levels were 0.4 (95% C.I. –0.6 to 1.3) at rest, and –0.8 (95% C.I. –2.0 to 0.4) at maximum. No significant differences in active and passive ROM or TUG between the two groups. Concluded that acupuncture and sham acupuncture in combination with physiotherapy result in similar outcomes.

2006 Evaluation of early stage postoperative functional levels of geriatric patients with total knee replacement (Unver, Karatosun & Bakirhan, 2006)

Cohort study 106 patients (99 female, 7 male) who undergo TKR for gonarthrosis. Mean age 71.5 ± 4.48 (sd) years

To evaluate early postoperative function levels in geriatric patients who undergo TKR. Assessed at pre-op, 2 and 6 days post-op and at discharge. Outcomes: Iowa Level of Assistance Scale; Iowa Ambulation Velocity Scale; ROM; HSS; pain (VAS) and hospitalization period.

Functional activity and walking speed were significantly reduced at 2nd and 6th day post-op compared to pre-op levels, however both parameters were significantly improved at discharge. Rest and active pain levels were significantly reduced at all post-op time points compare to pre-op levels. Knee flexion and extension loss were reduced, whilst HSS was increased at day of discharge compared to pre-op measures (unclear if these differences were significant or not). Concluded functional activities and walking speeds of geriatric patients decline after TKR and may increase hospitalization, decrease independence and lead to the development of complications. Therefore, early rehabilitation needs to focus on transfer and mobility activities.

61

2008 Millimetre wave therapy for pain relief after total knee arthroplasty: a randomised controlled trial (Usichenko et al., 2008)

RCT 80 patients undergoing TKA randomly assigned to receive millimetre wave therapy or a sham procedure. Both groups received 6 sessions of therapy, each of 30 minutes duration. Both groups had a patient controlled analgesia pump containing piritramide for pain relief directed to achieve <40 on a 100mm VAS.

To examine if millimetre wave therapy can reduce opioid requirement following TKA. Outcomes: postoperative piritramide requirement for 3 days after surgery; total ibuprofen requirement from day 4 to discharge; success of patient blinding; patient satisfaction with pain relief; incidence of side-effects; heart rate and blood pressure.

Piritramide requirement was similar between groups and all patients reported adequate pain relief as measured using VAS. No significant differences between outcome measures were found across groups. Furthermore, a majority of people believed they had received the true intervention and wanted to repeat it in the future. Concluded that millimetre wave therapy applied over surgical wounds did not reduce opioid requirement compared to the sham procedure after TKA.

2006 VenaFlow plus Lovenox versus VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroscopy (Westrich et al., 2006)

RCT 275 patients undergoing unilateral TKA randomized to receive spinal epidural anaesthesia + VenaFlow calf compression and enoxaparin or aspirin. Aspirin was started the day of surgery and enoxaparin 48 hours after surgery. All continued anticoagulant medication for 4 weeks after surgery.

To assess whether a combination of spinal epidural anaesthesia and pneumatic compression devices with either enoxaparin or aspirin results in lower perioperative deep venous thrombosis rates in patients undergoing primary TKA.

Rates of deep thrombosis in the enoxaparin group were 14.1% compared to 17.8% in the aspirin group: this difference was not significant. Concluded that enoxaparin was not superior to aspirin in preventing DVT in patients after TKA, when used in combination with pneumatic compression devices and spinal epidural anaesthesia.

E.2 Factors affecting outcomes after knee arthroplasty

Year

Title Sample Methodology/ Comments

Summary

62

2006 Total knee replacement outcome and coexisting physical and emotional illness (Ayers, Franklin, Ploutz-Snyder & Boisvert., 2005)

Cohort study 165 patients who had primary TKR (62% women). Mean age 68 years.

To quantify the contribution of physical and emotional co-morbidities to variation of functional outcomes after TKR. Assessed preoperatively and at 1-year post surgery. Outcomes: SF-36 and WOMAC.

84% of patients had at least one co-morbidity: cardiovascular conditions the most prevalent (61%). Patients with and without co-morbidities showed similar improvements in SF-36 and WOMAC physical scores. Neither age, gender or baseline physical function affected outcome. However, poor pre-TKR emotional health (SF-36 mental component) was associated with smaller improvement in physical function. Concluded that a lack of relationship between the presence of co-morbidities and 12-month functional outcome after TKR has important implications for orthopaedic surgeons and patients.

2006 Do clinical presentation and pre-operative quality of life predict satisfaction with care after total hip or knee replacement (Baumann et al., 2006)

Cohort study 228 patients (43.8% male) with OA after THR or TKR. Mean age 69 ± 9 (sd) years.

To determine if clinical presentation and pre-op QoL predict patient satisfaction after TKR or THR. Assessed pre-and post-operatively. Outcomes: HRQoL, patient satisfaction and clinical characteristics.

Pre-operative bodily pain and social functioning were both identified as significantly predicting patient satisfaction with care, conversely pre-op HRQoL and patient (clinical) characteristics had little effect. Concluded that the impact of the care process on satisfaction appears independent of observed and perceived initial patient-related characteristics.

2008 Bicondylar knee arthroplasty: influence of preoperative functional restriction on early functional postoperative outcome (Bergschmidt et al., 2008)

Cohort study 47 patients with OA undergoing bicondylar knee arthroplasty.

To determine the effect of preoperative physical and psychological function limitation on early postoperative function. Assessed preoperatively and at 3 and 6 months postoperatively. Outcomes: HSS, WOMAC & SF-36. Allocated to “good”, “average” or “poor” groups based on preoperative HSS scores

All groups showed significant reductions in HSS and SF-36 at 3 and 6 months compared to preoperative scores. However, no significant differences between groups at either postoperative time point were evident. In addition, BMI did not influence early functional outcome. Concluded that older people should receive early TKA to regain function, in younger people consideration of limited survival rate is essential. Whilst in the case of progressive OA and extreme function limitation bicondylar knee replacement provides good early functional outcomes.

63

2005 Determinants of the subjective functional outcome of total joint arthroplasty (Caracciolo & Giaquinto, 2005a)

Prospective cohort study. 200 patients: 100 elderly inpatients with recent THA or TKA for OA; 100 age-matched consecutive outpatients.

To investigate factors affecting subjective functional outcomes of patients following THA or TKA. Assessed at admission and 6-months after surgery. Outcomes: WOMAC

Both THA and TKA showed significant improvement in WOMAC scores at follow-up, with THA patients exhibiting greater improvement. At baseline both THA and TKA patients had greater impairment that outpatients, however at follow up this was reversed with outpatients showing greater impairment. Objective functional outcome of postop rehabilitation did not predict 6-month subjective functional status. Logistic regression revealed preoperative status alone predicted WOMAC score at 6-months. Concluded that the study confirms an early benefit of THA and TKA for OA, but that poorer subjective functional outcome may be expected when preop functional status is markedly compromised.

2005 Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty (Caracciolo & Giaquinto, 2005b)

Cohort study. 36 patients undergoing TKA with a mean age of 71.3 ± 7.8 (sd) years. 36 patients undergoing THA with mean age of 67.9 ± 8.4 years.

To establish if psychological distress and depression affect functional outcome after arthroplasty. Assessed at beginning and end of rehabilitation. Outcomes: WOMAC and HAD

At admission 44% of THA and 58% of TKA patients showed over-threshold HAD scores. This proportion was greater when taking the HAD Depression subscale alone: THA – 55% and TKA 61%. Lack of depression was associated with better functional outcomes in TKA patients (even after adjusting for age and sex). No association was apparent for THA patients. Concluded that to maximise rehabilitation benefit after TKA patients should be screened at admission for distress and depression and that psychological symptoms should be treated if over threshold.

2009 Which factors affect the duration of inpatient rehabilitation after total knee arthroplasty in the absence of complications?(Dauty, Smitt, Menu & Dubois, 2009)

Cohort study 282 patients who underwent TKA for OA (without complication). Patients then received inpatient rehabilitation aimed at recovering 90° active knee flexion and functional status to enable discharge.

To determine preoperative factors predicting the duration of postoperative rehabilitation for TKA patients. Factors recorded: demography, co-morbidity, previous lower limb arthroplasty, home help, pain (VAS) and functional scores. Outcome: LOS.

Univariate analysis revealed LOS (24.1 ± 8.1 days) was dependent on gender, presence of home help, living alone or not and previous arthroplasty. However, when included in a multivariate model these factors accounted for only 2% of the variation in LOS. Concluded that inpatient rehabilitation for TKA without complications cannot be statistically modelled from the parameters considered in this study.

64

2007 Effect of patient characteristics on reported outcomes after total knee replacement (Escobar et al., 2007)

Cohort study. 640 patients (73.6% female) with a mean age of 71 years.

To investigate effect of pre-intervention factors on patient-reported outcomes at 6-months after TKA. Assessed whilst on the waiting list and 6-months after intervention. Outcomes: WOMAC (3 domains) and SF-36 (8 domains)

Multivariate analysis revealed baseline domain scores were significant predictors of postoperative domain scores. Further, social support, low pack pain and baseline mental health domain of SF-36 were predictors of the 3 WOMAC domains; whilst, baseline mental health score, comorbidities, low back pain and social support were predictors of SF-36 domains. Concluded pre-intervention scores of each domain were the main predictors of the 11 domain scores at 6-months postoperatively. Additionally presence of social support, absences of low back pack and higher baseline SF-36 mental health score were related to improvement of HRQoL.

2009 Relationship between self-reported and performance-based tests in a hip and knee joint replacement population (Gandhi et al., 2009)

Cohort study 200 patients undergoing primary hip or knee replacement surgery.

To assess the relationship between SF-36, TUG and WOMAC outcomes following hip and knee joint replacement. And to determine predictors of functional status after surgery. Assessed: preoperatively and at 12-weeks postoperatively. Outcomes: WOMAC, TUG & SF-36 Demographic data also recorded.

There was a weak but significant correlation between preoperative TUG score and preoperative SF-36 physical function and role-physical scores, and WOMAC. A stronger correlation was found between postoperative TUG scores and SF-36 physical function and role-physical scores, and WOMAC. Age and preoperative TUG scores were both significant predictors of postoperative TUG scores. Concluded that given the low/moderate relationship between self-reported and performance-based tools, both are need to assess true patient disability.

2008 Predicting patient dissatisfaction following joint replacement surgery (Gandhi, Davey & Mahomed, 2008)

Survey. 1290 patients undergoing primary hip or knee replacement surgery.

To identify pre-operative patient level predictors of patient dissatisfaction 1-year after surgery. Assessed at baseline and 1-year. Outcomes: WOMAC and SF-36, and a patient satisfaction questionnaire (at 1-year) Demography, BMI, sex, comobidities & education recorded.

There were no significant differences in demography between satisfied (n=1290) and dissatisfied (n=430) patients. Logistic regression revealed preoperative SF-36 mental health score predicted patient dissatisfaction with surgery (adjusted for all relevant covariates). No correlation between patient satisfaction and change in WOMAC score was found. Concluded preoperative mental health is an important consideration when understanding patient satisfaction with surgery. The benefits of various interventions to reduce mental distress prior to surgery require further investigation.

65

2006 Predictive risk factors for stiff knees in total knee arthroplasty (Gandhi et al., 2006)

Retrospective review and matched case-control study. 1216 patients who underwent primary TKA.

To evaluate incidence and predictors of arthrofibrosis 1 year after TKA. Assessed preoperatively, intraoperatively and 1-year postoperatively. Outcome: flexion, stiffness, patella height.

Incidence of arthrofibrosis after TKA was 3.7% (45 of 1216 patients). Pre- and intra-operative flexion significantly predicted postoperative flexion. There was also correlation between pre- and post-operative relative decreased patellar height and postoperative stiffness. No correlation between postop stiffness and specific comorbidities were found. Concluded that post-TKA stiffness is multifactoral and in order to reduce incidence of stiffness post-TKA consideration should be give to many factors including surgical exposure, restoring gap kinematics, minimizing surgical trauma, implant selection and physiotherapy.

2009 Is postoperative function after hip or knee arthroplasty influence by preoperative functional levels? (Lavernia, D’Apuzzo, Rossi & Lee, 2009)

Cohort study 127 patients undergoing unilateral THA or TKA

To investigate functional outcomes following hip and knee surgery in patients with low functional scores before surgery. Assessed preoperatively and 3 consecutive years postoperatively. Outcomes: WOMAC, SF-36 and Quality of Well-Being index.

Based on preoperative WOMAC scores patients were assigned to either low functioning (≥51 score) or high functioning (<51 score) groups. At all postop time points, for both knee and hip patients, the low functioning group performed worse on Quality of Well-Being index, WOMAC (total and pain scores) and SF-36 (social and function scores) compared to the high functioning group. Greatest improvement in outcomes occurred during the first year for both groups. Concluded that patients with severe functional impairment had worse outcomes compared with patients receiving surgery when functional levels were better.

2005 Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty (Mizner et al., 2005)

Cohort study. 40 patients undergoing TKA. Mean age 63 ± 8 (sd) years and mean BMI 29.4 ± 4.2 (sd) kg/m2.

To investigate predictors of postoperative functional ability following TKA. Assessed 2-weeks prior to and 1-year after TKA. Outcomes: quadriceps strength, SF-36, knee ROM, TUG, Stair Climbing test and KOS.

There was significant postoperative improvement in all functional measures assessed. Neither preoperative pain nor knee ROM were significant predictors of any functional measure. Preoperative quadriceps strength predicted TUG and Stair Climbing test outcomes at follow up, but was not a good predictor of self-report questionnaires.

66

2009 A 5 year prospective study of patient-relevant outcomes after total knee replacement (Nilsdotter, Toksvig-Larsen & Roos, 2009)

Prospective cohort study. 102 consecutive patients with knee OA (63 women, 39 men) awaiting TKR. Mean age 71 (range 51-86) years

To investigate patient-relevant outcomes following TKR. Assessed preoperatively and at 6- and 12-months and 1 year postoperatively. Outcomes: KOOS and SF-36

Response rate was 86% (5 years). After TKR all scores were significantly improved at all time points. The best postop scores were seen at 1-year, with a significant decline to 5 years for KOOS (ADL), SF-36 (bodily pain, physical function & vitality). Patients in the lowest quartile preop for KOOS improved most at 1 year, but also decline most from 1 to 5 years. Older age predicted lower KOOS (pain & symptoms) at 1 and 5 years. Preop SF36 did not predict postop KOOS pain or physical function scores. Concluded that to evaluate TKR with regards to physical function and pain follow-ups in excess of 2 years are required: with more demanding physical functions included. Age predicted pain and symptoms, but no predictors of post-op physical function were found. This highlights the difficulty in determining potential benefits of TKR for patients.

2009 Total knee replacement and health-related quality of life: factors influencing long-term outcomes (Núñez et al., 2009)

Cohort study Of 146 eligible patients, 112 (86 women) who underwent TKR for OA completed follow up data. Mean age 67.3 years.

To evaluate and identify predictors of HRQoL in patients with OA undergoing TKR. Assessed preoperatively and 7 years postoperatively. Outcomes: WOMAC, SF-36, patient perceptions of TKR outcomes and physical activity. Demographic, clinical, intraoperative, inpatient and postoperative data also collected.

WOMAC pain, stiffness and function scores improved significantly postoperatively. A linear regression model explained 14-32% of the variation in all WOMAC dimensions. Obesity and post-discharge complications were associated with worse scores in all WOMAC dimensions. 86% of patients were satisfied with TKR, 80% would undergo surgery again and 56% did regular physical exercise and had better WOMAC scores (all dimensions excluding stiffness). Concluded that WOMAC dimension scores were significantly improved at 7 years and were negatively affected by obesity and postdischarge complications. HRQoL measures may help in identifying an increased risk of negative outcomes after TKR.

67

2007 Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up (Núñez et al., 2007)

Cohort study 90 patients with OA undergoing TKR. 67 patients (54 females) completed follow-up assessment. Mean age 74.83 ± 5.57 (sd) years

To evaluate and identify parameters affecting HRQoL in patients with OA undergoing TKR. Assessed preoperatively and at 36-months follow-up. Outcomes: WOMAC. Demographic, clinical, intraoperative, inpatient and postoperative data also collected.

There was significant improvement in WOMAC pain, stiffness and function scores postoperatively. A linear regression model explained 15-23% of the variation in all WOMAC dimensions. Chronic pain unrelated to knee OA was associated with higher WOMAC pain, stiffness and function scores. Severe obesity was associated with more pain. Concluded in patients with OA, HRQoL significantly improved 3-years post-TKR. Lower pre-op WOMAC score, unrelated chronic pain and severe obesity negatively influenced postop WOMAC scores. WOMAC may help to identify patients at increased risk of negative outcomes after TKR.

2007 Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients (Park et al., 2007)

Cohort study. 207 patients (333 knees) undergoing TKR.

To determine correlation between maximum flexion and clinical outcomes. Assessed preoperatively and at 1 year postoperatively. Outcomes: Maximum flexion, American Knee Society Score, WOMAC and SF-36.

Maximum flexion decreased significantly from preop (mean= 140.1°, range 60-160°) to postop levels at 1 year (mean=133°, range 105-150°). Significant correlation was observed between SF-36 social function subscale and maximum flexion only. Knees were grouped according to whether maximum flexion exceeded 120° or not: these differed significantly in SF-36 social functioning score, but no other outcome measure. Knees with maximum flexion exceeding 135° had better WOMAC function score. Weak correlations between postop maximum flexion and pain, function and QoL were found. Concluded that given concerns over high-flexion activities post surgery, efforts to increase maximum flexion should be exercised with care. Nb: inconsistency in grouping based on maximum knee flexion.

2008 The impact of morbid obesity on patient outcomes after total knee arthroplasty (Rajgopal et al., 2008)

Cohort study 550 patients who underwent primary TKA with primary diagnosis of OA and had been followed up at 1-year.

To evaluate the effect of morbid obesity on outcomes after TKA. Assessed at baseline and 1-year postoperatively. Outcomes: WOMAC

Patients were stratified according to BMI classes based on the WHO classification: then dichotomized into a morbidly obese group (class III) and non-morbidly obese group for analyses. 1-year WOMAC scores were significantly worse for morbidly obese compared to healthy patients, however, morbidly obese patients showed greater improvement in function. Concluded that morbid obesity does not affect 1-year outcomes in patients undergoing TKA.

68

2007 Factors related to the admission in a geriatric convalescence unit after a total knee arthroplastia: an experience of collaboration between the geriatric services, rehabilitation and orthopaedic surgery (Robles et al., 2007)

Retrospective, cohort study. 693 patients who underwent TKA for gonarthrosis.

To investigate factors determining admission to a geriatric convalescence unit following TKA. Outcomes: demographics, KSS, BMI, duration of operation and complications.

636 patients were discharged from acute care home, whilst 57 were sent to an inpatient geriatric intermediate care unit. Significant differences between these two groups were found with regard to age, sex, BMI, single living, length of operation, complications and postoperatve KSS function subscale. Concluded the profile of individuals accessing intermediate care are: older females living alone who experience postoperative complication and reduced functional outcomes. Nb: the abstract states after identifying women as the main users of the unit that “the proportion of men is greater than in the group who goes at home” – am unable to access full article to check results/analysis.

2007 Walking ability following knee arthroplasty: a prospective pilot study of factors affecting the maximal walking distance in 18 patients before and 6 months after total knee arthroplasty (Rosenberg, Nierenberg, Lenger & Soudry, 2007)

Prospective pilot study. 18 consecutive patients with knee OA undergoing TKA.

To investigate factors affecting walking ability after TKA. Assessed preoperatively and at 6-month follow up. Outcomes: KSS, maximal distance of walking ability. Nb: specially designed walking ability grading used to evaluate walking on a walkway.

Patients showed significant improvement in knee and functional scores following surgery. However maximal walking ability grades and distances remained similar pre- and post-operatively, and were significantly correlated. The post-operative limitation in walking was attributed to additional health disability rather than the affected knee. Concluded that pre-op evaluation of walking abilities should be considered for patient selection and timing of surgery, and in addition to guide patients expectations.

2007 Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty (Roth et al., 2007)

Cohort study 99 patients enrolled but only 68 participated and these by varying degrees.

To examine the effect of psychosocial factors on acute post-op TKA pain. Assessed 2-hours pre-op and at 1, 2 and 3 days post-op.

Outcomes: SF-MPQ, Pain Catastrophizing Scale, and Profile of Mood States (shortened version), MMSE. Demographic data were also obtained.

Regression showed: younger age predicted pre-op and post-op day 1 pain; catastrophizing predicted pre-op and post-op day 2 pain; negative mood predicated post-op day 3 pain. Catastrophizing and negative mood were highly correlated. Preoperative variable did not predict post-op pain. Concluded that the results have pain management implication: attention to psychosocial variables e.g. post-op catastrophizing and negative mood, may help identify patients at risk of greater post-op pain.

69

2010 The incidence and results of manipulation after primary total knee arthroplasty (Rubinstein & DeHaan, 2010)

Cohort study 37 (of 800) knees that underwent TKA that required subsequent manipulation.

To assess whether pre-TKA ROM is associated with post-manipulation ROM. Assessed pre-TKA and post-manipulation Outcomes: arc of motion,

Data was complete for 36 knees only. Mean arc of motion for the stiff group (n=16) was 68° before and 109° after manipulation. For the non-stiff group (n=20) mean arc of motion was 80° before and 118°. On average, the stiff group had 27° less arc of motion before TKA than the non-stiff group. Arc of motion increased significantly for patients with pre-TKA stiffness (from 94° to 109°) but remained similar for patients without pre-TKA stiffness (from 121° to 118°). Concluded success of TKA can be high despite loss of motion and the need for subsequent manipulation.

2006 [Influence of preoperative range of motion on the early clinical outcome of total knee arthroplasty] in Chinese (Shi, Lu & Guan, 2006)

Retrospective cohort study. 97 knees (65 patients) that underwent primary TKA: 55 patients with OA (81 knees) and 10 patients with RA (16 knees); 33 patients underwent unilateral, and 32 patients underwent bilateral TKA. 3 days post-op CPM and active functional exercise began.

To investigate the effect of pre-op ROM and maximal flexion on clinical outcomes after TKA. Assessed preop and at average follow-up of 2 years 5 months (range 10 months to 3 years 8 months). Outcomes included: ROM, maximal flexion, KSS score and function score.

Post-operatively ROM significantly increased, maximal flexion significantly reduced, and KSS significantly improved compared to pre-op. When patients were subdivided according to pre-op ROM, there were significant differences between groups across all outcome measures both pre- and post-operatively. Further knee with good pre-op ROM tended to lose flexion, whilst those with poor pre-op ROM tended to gain flexion after TKA. Concluded that TKA is a complex procedure and outcomes are mainly determined by the skill and experience of the surgeon. When surgeon, prosthesis, and rehabilitation are held constant, post-op ROM is significantly and positively influenced by pre-op ROM.

2009 Psychological determinants of problematic outcomes following total knee arthroplasty (Sullivan et al., 2009)

Cohort study. 75 patients (46 women, 29 men) with OA of the knee scheduled for TKA.

To determine role of pain-related psychological factors in predicting pain and disability following TKA. Pain severity, pain catastrophizing, depression and pain-related fears of movement were measured prior to surgery. Pain severity and self-reported disability were measured 6 weeks after surgery.

There were significant correlations between pain severity, pain catastrophizing, depression and pain-related fears of movement pre-operatively: consistent with previous studies. Pre-op pain severity and pain catastrophizing were significant predictors of post-op pain severity. Pain-related fears of movement were predictors of post-op functional difficulties, however, but this did not hold when controlled for pre-op comorbidity. Conclude that the psychological determinants of post-op pain severity differ from those of post-op disability. It is suggested that interventions targeting pain-related psychological risk factors may improve post-op outcomes following TKA.

70

2009 Muscle deficits persist after unilateral knee replacement and have implications for rehabilitation (Valtonen, Poyhonen, Heinonen & Sipila, 2009)

Retrospective cohort study. 48 people (29 women, 19 men) who underwent unilateral knee replacement an average 10 months earlier Age range: 55 – 75 years.

To determine functional deficits in knee extensor and flexor muscles following unilateral TKR, and to investigate relationship to mobility limitations. Outcomes: muscle torque and power, extensor muscle cross-sectional area (CSA), maximal walking speed, stair- ascending and descending times.

Symmetry deficits were calculated between operated and non-operated knees. Mean deficits in extensor and flexor muscle torque and power were between 13% and 27%, whilst deficit in extensor muscle CSA was 14%. Further, a larger deficit in knee extension power predicted slower stair- ascending and descending times. Concluded that deficits in flexor and extensor muscle torque and power, and extensor CSA potentially limits stair negotiation 10 months after knee replacement. To prevent such outcomes, lower limb power need to be considered during rehabilitation following knee replacement surgery.

2007 Influence of admission hematocrit on inpatient rehabilitation outcomes after total knee and hip arthroplasty (Vincent & Vincent, 2007)

Retrospective cohort study. 400 patients who underwent TKA or THA.

To investigate the effect of admission haematocrit on rehabilitation outcomes following TKA or THA. Assessed at baseline and discharge. Outcomes: Admission Haematocrit (grouped as normal, low and very low), FIM, specific lower-body FIM motor scores, FIM efficiency, LOS and total hospital charges.

Both TKA and THA patients showed significant improvement in total FIM score, motor FIM score and specific lower-body FIM activity scores (walking, wheelchair, dressing, transfers, stairs) at discharge. Both TKA and THA patients with very low haematocrit levels showed significantly longer LOS and greater total hospital charges than patients with normal levels: haematocrit was a significant predictor of LOS and hospital charges in linear regression models. Concluded that whilst very low haematocrit levels at admission does not affect functional outcomes, it results in longer hospital stays and greater costs. This must be considered when devising care plans, rehabilitation goals and discharge plans.

2010 Early postoperative measures predict 1- and 2-year outcomes after unilateral total knee arthroplasty: importance of contralateral limb strength (Zeni & Snyder-Mackler, 2010)

Prospective cohort study. 155 patients who underwent unilateral TKA.

To investigate which early post-op functional measures might predict functional ability 1 and 2 years after TKA. Assessed at baseline (1st outpatient physical therapy appointment), and at 1 and 2 years after surgery. Outcomes: height, weight, quadriceps muscle strength, ROM, TUG, stair-climbing task, KOS.

TUG, stair-climbing task and KOS were significantly improved at 1- and 2-years compared to baseline scores. Poorer outcomes at 1- and 2-years were associated with weaker quadriceps muscle in the limb that did not undergo surgery and with older participants with higher body masses. Postoperative measures were better predictors of TUG and stair-climbing task times than of KOS scores. Concluded rehabilitation following TKA should include exercise to improve strength of the non-operated limb as well as deficits due to surgery. Emphasis on treating age-related impairment and reducing body mass may improve long-term outcomes.

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SECTION F – PEER-REVIEWED ARTICLES

Year

Title Summary

2007 Total joint arthroplasties: current concepts of patient outcomes after surgery (Jones, Beaupre, Johnston & Suarez-Almazor, 2007)

Review of patient outcomes after TKA and THA for OA, and evidence highlighting factors affecting person-centred outcomes.

Concluded that no single patient-related or perioperative factor clearly predicts functional improvement or amount of pain relief that occurs after surgery.

Nb: unable to access full copy of this to detail its content

2006 Role of physiotherapy in peri-operative management in total knee and hip surgery (Lenssen & de Bie, 2006).

Concludes that physiotherapy combined with aerobic and strength training is of benefit for patients with hip or knee OA during both pre- and post-operative stages. When surgery is imminent, physiotherapy can aid by increasing self esteem and reducing depression and anxiety associated with surgery.

Post-operatively intensive physical exercise and Continuous Passive Motion results in quicker recovery times, shorter hospital stays and increased ROM. To maximise postoperative outcomes it is recognised that maintaining exercise regimes after discharge should be encouraged.

2008 Total hip and total knee replacement: postoperative nursing management (Lucas, 2008)

Concludes that THR and TKR are very successful in improving QoL for patient with OA where conservative methods are ineffective. It is important the nurses ensure patients understand that rehabilitation may take months and that in order to achieve full long-term benefits, short-term restrictions on activity may be necessary. On occasion where complications occur it is essential that nurse and patients are aware of potential symptoms so they can be identified and managed as soon as possible.

2008 Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches (Meier et al., 2008)

Synopsis: TKA is associated with improvement in self-reported pain and function, although frequently quadriceps muscle impairments and functional limitations are recorded. Postop rehabilitation regimes tend to omit or incompletely address the muscular and functional deficits that persist after surgery, which are tentatively thought due to a combination of muscular atrophy and neuromuscular activation deficits. Failure to address these impairments has possible long-term implications for functional gains. Postop rehabilitation addressing quadriceps strength should mitigate impairments, improving functional outcomes.

Quadiceps muscle impairments are described and their effects on functional limitations after TKA are discussed. Current concepts in TKA rehabilitation are outlined and recommendations and guidelines based on current evidence are provided.

Nb: unable to access full copy of this to detail its content

2006 Care of patients undergoing knee replacement surgery (Temple, 2006)

Reviews patient nursing care following knee replacement surgery, including outlining nursing needs of patients postoperatively, including the use of CPM.