Physiotherapy rehabilitation after knee

and hip replacement What is the evidence?

Justine Naylor Senior Research Fellow,

WORC & WJRC, SSWAHS, UNSW

Profile of current service provision Rationale for rehabilitation Evidence for rehabilitation after TKR & THR Summary and recommendations for

practice and research

Outline

Regional patterns in providing a service

Current service provision

Local National International

TKR Routine Routine Routine

THR Varies Varies? Routine

Current service provision – gross modes

Local National International

TKR & THR

Outpatient – 1 to1

+++ +++ +++

Outpatient - Group

++ (mainly public)

++ (mainly public)

?

Inpatient + (mainly private)

+ (mainly private

+

Water-based some some some

Home programme

No Remote areas ++(level of monitoring varies)

Formal (supervised) rehabilitation enhances recovery beyond that which can be achieved after surgery and an unmonitored home programme alone

In other words, with rehabilitation, either:performance across a range of health domains

approaches or exceeds age-matched norms, or:recovery across a range of health domains is

faster than it would naturally

Is this true?

Background – Rationale for rehab

What is the evidence that recovery from surgery may be suboptimal (and thus rehab may have a role)?

PRE 1 YR0

10

20

30

40

50

60

70

80

Physical Function: Healthy v TKR v THR

NS TKRSSW TKRNORMSSW THRNS THR

Physic

al Functi

on (

0-1

00)

2 W 8W 26W0

100

200

300

400

500

600

6-Minute walk distance: Healthy v TKR

NORMTKR

Dis

tance (

m)

3 Months 12 Months0

5

10

15

20

25

30

35

40

Quadriceps maximal voluntary isometric con-traction: Healthy v TKR

NORMTKR OPTKR NON OP

Axis Title

0 2W 6W 12W 26W 52W0

5

10

15

20

25

Timed Up-and-Go: Norm v TKR v THR

NormTKRTHR

Seconds

Peak torque/body wgt (%)

Power (W)0

5

10

15

20

25

Peak torque & Power: Healthy v THR

HealthyTHR

Total work (ft-lbs), Flexion Total work (ft-lbs), Abduction0

100

200

300

400

500

600

700

800

Total work Flexion & Abduction:Healthy v THR

HealthyTHR

0 2W 6W 12W 26W 52W0

5

10

15

20

25

Timed Up-and-Go TKR & THR: Obese v Non-Obese

OBESENON OBESE

Seconds

0 2W 6W 12W 26W 52W0

5

10

15

20

25

30

Timed Up-and-Go THR & TKR: Severe other joint disease v Non-severe other joint

disease

SEVERENON SEVERE

Seconds

What is the evidence that formal rehabilitation enhances recovery after TKR or THR?

Studysystematic review of effectiveness of outpatient-

based rehabilitation compared to other searched key electronic databases included RCTs of studies comparing:

Outpatient 1-to-1 vs home programme Outpatient vs Outpatient (1-to-1 vs group)Outpatient Group vs home programme

OP therapy included any modalityRehab commenced within 4 weeks post-op

(ignore acute inpatient period)

Effectiveness of Rehabilitation after TKR?

No study compared all 3 gross modes -1 to 1 outpt; group-based; home programme

No study evaluated group-based to home programme

No study compared different types of 1to 1 treatments/modalities

1 study compared group land to group water

3 RCTs compared 1to 1 to home programme; all 3 were exercise-focused

1 study compared 1 to 1 vs usual care (late post-op period)

Results of TKR review

Results of TKR review of RCTs

Control Intervention Results

Early

Rajan et al 2004, n=116

No intervention 1 to 1 (no details given)

No diff knee ROM at 1 yr

Kramer et al 2003, n=160

Monitored HP (phone), ex x3/d, 12 w

HP +12 sessions 1 to 1 (mix of modalities) in 6-8 w

No diff ROM, KSS, HRQoL, stairs, 6MWD, at 1 yr

Mockford et al 2008, n=143

Simple unmonitored home programme

9 sessions O/P physio (no details provided)

No diff knee ROM, patient-reported fn, and mobility at 1 yr

Harmer et al 2009

x12 sessions gym classes

x12 water-based classes

No diff knee ROM, patient-reported fn, mobility at 6m

Later

Moffet et al 2004, n=76

At 8 w post-surg, usual care (25% domiciliary)

At 8 w post-surg, x12 1 to 1 exercise sessions

Greater improvement in 6MWD and Fn at 4 and 6 months; not 1 yr

Insufficient evidence to recommend the optimum mode of delivery because not all gross modes and modalities investigated

Currently, available evidence suggests that 1 to 1 programmes delivered in the early post-operative phase do not provide long-term benefit over and above what is achieved with a home programme (monitored or not monitored)

We don’t know if early benefits translate into faster return to work or less health resource utilisation.

Summary of evidence concerning rehab post TKR

Literature search of RCTs◦ Location/Type/Mode

Outpatient 1-to-1 vs group or home Group vs Home Inpatient Rehab vs Home or Group or Outpatient

Timing◦ Early (commenced within 4 weeks post-op)◦ Late (commenced > 2 months post-op)

Effectiveness of Rehabilitation after THR?

Emphasis on effect of adding an extra modality to standard programmes (in early post acute phase)

No one study compared all 3 gross modes of delivery – 1 to 1; group-based; home

Many trials looking at value of later-stage rehab (in addition to early rehab)

Results of THR review of RCTs

Location – Inpatient Rehab v Domiciliary

Results of THR review

Control Intervention Results

Mahommed et al 2008n = 234 TKR and THR

Inpatient rehab for mean 17 days

Domiciliary (mean 8 treatments)

20% cheaper for domiciliary; No difference in function, HRQoL and satisfaction at 3 or 12 months

Results of THR review - Comparison of modalities (early phase)

Control Intervention Results

Gremeaux et al 2008, n=29 (>70 yrs)

Inpt + Outpt (2hr/d, 5d/w x5w)

Same as Control + NMES (quads/calf) 1hr/d, 5d/w x 5w

NMES > Control for knee ext strength and function at 8 w

Maire et al 2006 n = 14

6 w General rehab

Same as Control + Upper limb ergometry

UL > General for function, and 6MWD, 2 and 12 months

Hesse et al 2003 n=80

Inpt, 45 min 1 to 1, for 10 days

Same as Control + treadmill for 10 days

Treadmill> Control for gait symmetry, HHS, hip strength up to 12 m

Standard care (inpt + outpt) v other 1 to 1 modality – early phase

Control Intervention Results

Suetta et al 2004, n=36

Inpt + Outpt, 1 hr/d x 12 w

A – resistance ex, x3/w, x12wB – NMES 1hr/d x12 w

A - superior in strength and stair climb, at 12 w.

Value of later stage rehabilitation

Control Intervention Results

Galea et al 2008, n = 23, 8 w post

1 to 1, 8 w ex programme

Home ex programme

No diff, gait, 6MWD, HRQoL, 8w

White et al 2005, n = 28, 8 w post

No intervention

A – Treadmill + feedbackB – Treadmill, no feedback, 15m/d, x3/w x6w

Treadmill> Control, gait symmetry

Trudelle & Jackson 2004, n =34 4-12 month post

Simple MHP MHP with controlled wgt bearing during ex

MHP (wgt bear) > Control MHP

Unlu et al 2007, n=26, 1 yr post

No intervention

A – 6w home pr B – Inpt prog x 6w

A and B > Control, strength

Sashika et al 1996, n = 23, 6-48 months post

No intervention

A – home ex pr x6wB – as for A + eccentric ex in standing, x 6w

A and B > Control, gait speed and cadence, hip abd improved in all (A,B>Control)

Early phase (within 4 weeks post-op)◦ No studies compared Inpt or Outpt Rehab to an

unsupervised or monitored home programme◦ No studies strictly compared Inpt only to

Outpatient only◦ Inclusion of resistance training or NMES provides

superior results than basic programme up to 1 yr Later phase (> 8 weeks post)

◦ Vigorous ex programme or treadmill produces improvement over and above control (no ex exposure)

◦ Long-term benefits?

Summary of THR rehab

TKR◦ No recommendations for best practice◦ Goals of rehabilitation need to be clearly defined

as this will help determine how vigorous rehab needs to be

◦ Routine standardised measurement of a goal is recommended

THR◦ More vigorous programmes (early) provide

superior results up to 1 yr than basic programmes◦ Training effects seen with later programmes –

could recommend continuation of rigorous HP up to 1 yr.

Recommendations for practice

To determine which gross mode of delivery is superior (if any)◦ Multi-centre RCT comparing 1 to 1, group-based

and MHP post TKR and THR (early phase) To determine if later rehab is superior to

early rehab◦ Early vs late – compare same programme, 1

delivered early, 1 delivered late Other questions

◦ Does rehab have potential to improve co-morbidities?

◦ Does rehab influence prosthesis longevity by influencing long-term activity?

◦ Do some patients respond to rehab whilst other don’t?

Recommendations for research

Thank you