Physiotherapy rehabilitation after knee and hip replacement
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Physiotherapy rehabilitation after knee and hip replacement. What is the evidence? Justine Naylor Senior Research Fellow, WORC & WJRC, SSWAHS, UNSW. Outline. Profile of current service provision Rationale for rehabilitation Evidence for rehabilitation after TKR & THR

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Physiotherapy rehabilitation after knee and hip replacement

Physiotherapy rehabilitation after knee and hip replacement

What is the evidence?

Justine Naylor

Senior Research Fellow,

WORC & WJRC, SSWAHS, UNSW


Outline
Outline

  • Profile of current service provision

  • Rationale for rehabilitation

  • Evidence for rehabilitation after TKR & THR

  • Summary and recommendations for practice and research


Current service provision
Current service provision

  • Regional patterns in providing a service



Background rationale for rehab
Background – Rationale for rehab

  • 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?


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

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



Effectiveness of rehabilitation after tkr
Effectiveness of Rehabilitation after TKR? recovery after TKR or THR?

Study

  • systematic 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 modality

  • Rehab commenced within 4 weeks post-op (ignore acute inpatient period)


Results of tkr review
Results of TKR review recovery after TKR or THR?

  • 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)


Summary of evidence concerning rehab post tkr
Summary of evidence concerning rehab post TKR recovery after TKR or THR?

  • 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.


Effectiveness of rehabilitation after thr
Effectiveness of Rehabilitation after THR? recovery after TKR or THR?

  • 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)


Results of thr review of rcts
Results of THR review of RCTs recovery after TKR or 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
Results of THR review recovery after TKR or THR?

  • Location – Inpatient Rehab v Domiciliary


Summary of thr rehab
Summary of THR rehab recovery after TKR or THR?

  • 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?


Recommendations for practice
Recommendations for practice recovery after TKR or THR?

  • 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 research
Recommendations for research recovery after TKR or THR?

  • 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?


Thank you

Thank you recovery after TKR or THR?


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