Physical therapies underused following total knee replacement

Evidence-based physical therapy interventions for patients who undergo total knee replacement surgery are underused, and the dosage may not be adequate to achieve optimal outcomes, according to a retrospective review in Arthritis Care & Research.

Carrie Day, 40, had two total knee replacements this year after advanced arthritis left her in chronic pain. Younger patients represent the fast-growing demographic for knee replacements in the U.S. Spokesman-Review

by Jason Laday, Healio Rheumatology October 15, 2018

“Functional outcomes following total knee replacement are quite variable and only partially explained by patient characteristics such as pre-surgical function, co-morbidities and BMI,” Carol A. Oatis PT PhD, of Arcadia University, told Healio Rheumatology. “Little is known about the details of the physical therapy patients actually receive after surgery. At the same time, reimbursement models incentivize the reduction of post-surgical PT.”

To characterize the content, dosage and progression of physical therapy interventions and the self-reported functional outcomes and performance measures of patients after 6 months, Oatis and colleagues conducted a cross-sectional observational study of data from the Joint Action Randomized Clinical Trial at the University of Massachusetts Medical School.

The researchers analyzed records for 112 patients from 30 physical therapy sites. All patients were aged 21 years or older and were undergoing primary unilateral total knee replacement. The Joint Action Randomized Clinical Trial had been testing a phone-based coaching intervention.

Oatis and colleagues reviewed the physical therapy records for each patient to determine the number of therapy visits they participated in following surgery, as well as the frequency and dosage of each exercise during the entire period of care. In addition, they used descriptive statistics and linear regression models to describe physical therapy treatment factors and to identify associations with 6-month outcomes.

According to the researchers, the content and amount of specific exercises, as well as the incidence of progression “varied widely.” Open chain exercises, in which the patient actively moved the joint while the limb was not bearing any weight, (median 21, interquartile range 4-49) were used more frequently than closed chain, in which the limb was bearing weight (median 13, interquartile range 4-28.5). Median occurrence of progression of closed chain exercise was 0 (interquartile range 0-2), and 1 for open chain exercise (interquartile range 0-3). In addition, shorter timed stair climb exercises were associated with a greater total number of physical therapy interventions as well as use and progression of closed chain exercises.

“While further study is required, our study suggests that the details of what patients do in post-replacement PT matter,” Oatis said. “Not all PT is the same. Patients and providers must look to ensure that post-replacement rehabilitation consists of those factors that are most associated with positive functional outcomes.”

Oatis reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Source Healio Rheumatology

Characteristics of Usual Physical Therapy Post-Total Knee Replacement and their Associations with Functional Outcomes, Oatis CA, Johnson JK, DeWan T, Donahue K, Li W, Franklin PD. Arthritis Care Res (Hoboken). 2018 Oct 3. doi: 10.1002/acr.23761. [Epub ahead of print]

From early radiographic knee osteoarthritis to joint arthroplasty: Determinants of structural progression and symptoms, Roemer FW, Kwoh CK, Fujii T, Hannon MJ, Boudreau RM, Hunter DJ, Eckstein F, John MR, Guermazi A. Arthritis Care Res (Hoboken). 2018 Feb 13. doi: 10.1002/acr.23545. [Epub ahead of print]

Variations in Delivery and Exercise Content of Physical Therapy Rehabilitation Following Total Knee Replacement Surgery: A Cross-Sectional Observation Study, Oatis CA, Li W, DiRusso JM, Hoover MJ, Johnston KK, Butz MK, Phillips AL, Nanovic KM, Cummings EC, Rosal MC, Ayers DC, Franklin PD. Int J Phys Med Rehabil. 2014;Suppl 5. pii: 002. Epub 2014 Apr 22.

A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement, Rosal MC, Ayers D, Li W, Oatis C, Borg A, Zheng H, Franklin P. BMC Musculoskelet Disord. 2011 Oct 7;12:226. doi: 10.1186/1471-2474-12-226.

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Half of patients who undergo knee replacement later develop OA in Healio Rheumatology
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