The effect of preoperative physical therapy on patients with end-stage knee osteoarthritis

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The Effect of Preoperative Physical Therapy on Total Knee Arthroplasty in Patients with End-Stage Knee Osteoarthritis

By Jeremy Evans, SPT

Background

In the spring of 2015, I was fortunate to gain orthopedic physical therapy experience while on a clinical rotation at an outpatient clinic. During my time there, I had opportunities to work with many patients who were in various stages of knee osteoarthritis (OA). I was also involved in the rehabilitation of patients who had received a total knee arthroplasty (TKA) as treatment for their OA. This rehabilitation was often difficult and painful for the patients. In fact, I had one former Navy SEAL report that despite everything he had endured in his life, rehabilitating after his TKA was the hardest thing he had ever done.

Thankfully, not all individuals have quite that much difficulty when recovering from TKA. However, while on this clinical rotation, I often thought about what could be done to best treat patients with knee OA, and what might be integrated for these patients to have easier recoveries after surgery. Fortuitously, I was made aware soon after my clinical rotation of a study that Dr. Deborah Givens was working on as a co-investigator, concerning preoperative physical therapy for patients with knee OA. I subsequently became involved in recruiting patients and collecting data for this study, spending many hours with an orthopedic surgeon and his team in their outpatient clinic. I also performed an appraisal of current research on this topic for my Critically Appraised Topic (CAT) paper in the Evidence-Based Practice II (EBP II) course, as well as a thorough literature review as part of a research experience course with Dr. Givens.

Overview and Purpose

Knee OA is one of the more prevalent chronic musculoskeletal pathologies throughout the world, and it can be a painful and debilitating condition. ^{1, 2} Physical therapy has been shown to be beneficial for patients with knee OA, although the most successful studies generally apply to subjects in milder stages of the disease. ^{3, 4}  While patients may attempt many forms of symptom management throughout the course of the disease, quite often TKA is considered in an effort to regain lost physical function. In the United States alone, there were 710,000 TKAs performed in the year 2010 in inpatient hospital settings. ⁵ Over ten years ago, in 2005, it was estimated that the number of TKAs performed in the U.S. would rise 673% by the year 2030. ⁶ Clearly, this represents a large patient population accruing a great amount of financial impact from surgery costs, hospital care, and rehabilitative services. ⁷

Physical rehabilitation following TKA is commonplace, and efforts have been made to evaluate the effectiveness of “prehabilitation”, or preoperative exercise for patients with knee OA. ^{8, 9, 10} These studies have demonstrated benefits such as decreased hospital length of stay and improved functional status. Unfortunately, many of the previously completed studies vary greatly in the type, duration, and frequency of the interventions. For example, the reviewed studies varied in the length of the program, one only including 3 weeks of physical therapy. The purpose of the study I became involved with is to evaluate the pre- and post-operative benefits of 12 weeks of physical therapy compared to no treatment in patients indicated for TKA.  The purpose of my capstone was to take pilot data from this study to determine if PT improves preoperative clinical status in patients who are medically indicated for TKA.

Products

Although the aforementioned research study is ongoing, I decided to take available pilot data and do data analyses to see if some conclusions could be drawn from an initial sample of subjects. The product of the data collection and analyses is an abstract to be submitted for the NCPTA’s Fall Conference in 2016 and the APTA’s Combined Sections Meeting in 2017. This capstone experience has also prepared me for further work as I plan to utilize the data from the finished study and submit a manuscript to a peer reviewed journal. These products will provide insight for an audience of health care professionals to assist with delivery of optimal care for patients with knee OA.

The specific physical therapy protocol used in the research study can be found here:

Knee OA Study Protocol (created by Dr. Deborah Givens, PT, PhD, DPT)

As mentioned previously, I have also put work into creating a CAT paper for the EBP II course (PHYT 752), and a literature review for my research experience course (PHYT 754). These documents can be found here:

EBP II Critically Appraised Topic – TKA Prehab

Research Experience Lit Review – TKA Prehab

Assessment and Reflection

To evaluate my product, I utilized guidelines and requirements for abstract submission to Combined Sections Meeting and NCPTA Fall Conference. I have also been in consistent communication with my project advisor, Dr. Givens, and have submitted to my capstone committee for feedback. This capstone project has been an eye-opening experience, to say the least. What started out as an interest in physical therapy intervention for patients with knee OA turned into an 8-month learning experience. Not only do I better appreciate the work done by researchers considering the difficulty of running a successful high quality study, but I am also more aware of what results mean and how data analyses are completed. I also plan to continue with this effort as the study continues and accumulates more patients, and I now have a solid foundation to build from going forward.

Acknowledgements

This project has been made possible through a collaborative team effort. I would first like to thank my project advisor, Dr. Debby Givens, PT, PhD, DPT. She has been consistently helpful, supportive, and encouraging. It has been a great experience to interact with her on a regular basis and learn from her. I would also like to thank Dr. Richard Faldowski, PhD, for patiently working with me on understanding the statistical aspect of my project. I am grateful for the willingness of Dr. Scott Eskildsen, MD and Dr. Justin Wilhelm, PT, DPT, OCS to serve on my capstone advisory committee. My involvement in this research project would not have been possible without the welcoming arms of Dr. Dan Del Gaizo, MD and Kaitlin Healy, MPH who both work in UNC Orthopedics. Thank you as well to all of the faculty in the Division of Physical Therapy who have contributed to my growth over the last few years. Lastly, I thank my family, and especially my wife Karlee, for all of the love and support I’ve received throughout my education.

References

1. Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults – United States, 1999. Morbidity and Mortality Weekly Report. 2001; 50: 120-125.
2. Dunlop D, Manheim LM, Yelin EH, Song J, Chang RW. The costs of arthritis.Arthritis & Rheumatism.2003; 49: 101–113.
3. Lange AK, Vanwanseele B, Fiatarone Singh MA. Strength training for treatment of osteoarthritis of the knee: a systematic review. Arthritis Rheum. 2008 Oct 15;59(10):1488-94.
4. King LK, Birmingham TB, Kean CO, Jones IC, Bryant DM, Giffin JR. Resistance training for medial compartment knee osteoarthritis and malalignment. Med Sci Sports Exerc. 2008;40(8):1376-1384.
5. Centers for Disease Control and Prevention/National Center for Health Statistics. Inpatient Surgery Data for the U.S. Last updated April 29, 2015. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed October 28, 2015.
6. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030. J Bone Jt Surg. 2007; 89(4): 780-785.
7. Dunlop D, Manheim LM, Yelin EH, Song J, Chang RW. The costs of arthritis.Arthritis & Rheumatism.2003;49:101–113.
8. Silkman Baker C, McKeon JM. Does preoperative rehabilitation improve patient-based outcomes in persons who have undergone total knee arthroplasty? a systematic review. PM R. 2012;4(10):756-767.
9. Beaupre LA, Lier D, Davies DM, Johnston DBC. The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty. J Rheumatol. 2004;31(6):1166-1173.
10. Rooks DS, Huang J, Bierbaum BE, et al. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis Rheum. 2006;55(5):700-708.