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Prehabilitation for Total Knee Arthroplasty: �Preoperative Physical Therapy May Improve Postoperative Outcomes

Ellie Rubin, SPT

Class of 2018

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Learning objectives:

At the completion of the program, the participant will be able to:

1. Identify and differentiate between primary postoperative issues faced by TKA patients.

2. Relate the effects of these postoperative issues on patient outcomes.

3. Summarize the current scope of evidence on TKA prehabilitation.

4. Associate trends in TKA procedural demand with consumer and health system need

for advancement of rehabilitation services.

5. Establish a meaningful preoperative plan of care for patients indicated for TKA based

on current research findings.

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Theory of Prehabilitation

Theoretic model of surgical prehabilitation based on the concept of

increasing functional capacity before surgery.

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Optimization of Surgical Outcomes with Prehabilitation

Prehabilitation: Needs Assessment

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Primary Postoperative Complications

��

�

Surgical site infection
Venous thromboembolism
Knee stiffness
Lower extremity weakness
Persistent post-surgical pain
Prolonged inpatient stay

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�Surgical Site �Infection (SSI)�

Left: PET CT of knee prosthesis with septic loosening.

Right: Fluorodeoxyglucose tracer shows extensive inflammation.

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Venous thromboembolism (VTE)

Left: Incidence of venous thromboembolism (VTE), deep venous thrombosis (DVT), and pulmonary embolism (PE) within 90 days after primary TKA from 2012-2016.

VTE:^9-15

Increased length of tourniquet time during the TKA procedure causes venous status and potential damage to blood vessels, inducing an inflammatory response and thrombi formation, usually immediately after surgery, within the deep distal calf veins. If the thrombus breaks off and travel to the lungs it can result in pulmonary embolism, which can be fatal. Most VTE after TKA are diagnosed within the first 21 days after surgery and are the most common reason for extended period of inpatient hospitalization or post-TKA hospital readmission.

Incidence: Even with prophylactic regimens, approximately 1 in every 100 patients undergoing primary TKA will develop a symptomatic VTE incidence before hospital discharge.

Risk factors: History of VTE (RR > 10.6), varicose veins (RR > 2.7), Congestive heart failure (RR 2), Obesity (also more likely to require longer period of inpatient stay or hospital readmission as a result of DVT/PE), Age (Risk of DVT increases by 15% for every decade after 50 years of age), Lack of ambulation following surgery.

Photo credit: Left: Higuera-Rueda C. “Incidence of venous thromboembolism (VTE), deep venous thrombosis (DVT) and pulmonary embolism (PE) within 90 days after total knee arthroplasty (TKA).” Aspirin dose and venous thromobemoblism prevention after total hip and knee arthroplasties. Cleveland Clinic Consult QD. Oct. 16, 2017. Retrieved from: https://consultqd.clevelandclinic.org/aspirin-dose-and-venous-thromboembolism-prevention-after-total-hip-and-knee-arthroplasty/. Accessed March 29, 2018.

Right: Kohan L. Total Knee Replacement surgery. Joint Orthopaedic Center: 2018. Retrieved from: http://www.jointreconstruction.com/knees/total-knee-replacement-surgery/. Accessed March 28, 2018.

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Knee Stiffness

Knee joint stiffness^20–24

Description: Severe knee stiffness following TKA is most often caused by arthrofibrosis, resulting in inability to regain functional knee range of motion. Inability to achieve 90° of knee flexion than 90°, an arc of flexion less than 70°, or a flexion contracture of more than 15° are all indications of severe post-operative knee stiffness.

Post-op goal is usually 90 degrees actively in 2 weeks; 115-125° in 3 months, but no later than within the initial post-op year, as knee ROM plateaus at 12 months after TKA.

This degree of impairment occurs in 5-7% of TKA patients, resulting in long-term mobility limitations (usually painful), altered gait, and decreased ability to complete daily activities. Knee stiffness may also be caused by SSI or improper sizing, mal-positioning of hardware components, or poor patient motivation post-operatively to be aggressive with regaining knee ROM. Stiff knee often requires manipulation under anesthesia or, in more extreme cases, TKA revision surgery, in order to correct.

Associated risk factors:

Limited range of motion preoperatively²⁰

Preoperative ROM reduction is the most important risk factor for postoperative stiffness.

Photo credit: The Fundamental Importance of the Range of Motion. x10Therapy: 2017. Retrieved from: https://x10therapy.com/knee-range-of-motion/. Accessed March 29, 2018

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Postoperative muscle weakness

The gold standard medial parapatellar surgical approach, while allowing for good exposure and optimization of alignment, highly compromises the quads muscle and tendon, resulting in inhibition of this muscle group and dramatic loss of strength post-operatively. Following surgery, the involved limb suffers significant reduction of voluntary muscle activation by an average of 17% and reduction in lower extremity muscle strength by up to 60%. Strength loss following TKA occurs not only in the knee extensors but also in the knee flexors and ankle plantar flexors. Post-operative muscle weakness is associated with knee joint malalignment, instability, reduced physical function, and increased disability. Post-operative asymmetry in lower extremity strength has been associated with weight-bearing asymmetry, limited functional mobility, and increased risk for additional orthopedic problems and increased risk for falls, Bone loss at the hip with associated muscle loss is a consequence of TKR that, in addition to poor patient outcomes in function and activity, potentially contributes to increased hip fracture risk in the year following surgery. ^24–26

Photo credit:

Left: Abbasi D, Snow T, Incavo S. Knee Medial Parapatellar Approach. Orthobullets: 2012. Retrieved from: https://www.orthobullets.com/approaches/12028/knee-medial-parapatellar-approach. Accessed April 1, 2018.

Right: Leopold S. Minimally-Invasive Surgery (MIS) Quadriceps-Sparing Total Knee Replacement. Figure 21. UW Medicine Orthopaedics and Sports Medicine. Last updated: January 9, 2015. Retrieved from: http://www.orthop.washington.edu/?q=patient-care/articles/knee/minimally-invasive-surgery-mis-quadriceps-sparing-total-knee-replacement. Accessed April 1, 2018.

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Postoperative muscle weakness cont.

Quadriceps

NMVIC = Normalized force of max voluntary isometric contraction (N/BMI)

CAR = Central activation ratio (1.0 = complete activation)

CSA= Max cross-sectional area (cm²)

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Persistent post-surgical pain (PPSP)

Description: The International Association for the Study of Pain (IASP) has defined PPSP as “pain that develop[s] after surgery and is present for at least 3 months, an interval which is considered to be beyond the time for normal healing”.²⁷

Most commonly, PPSP has been reported to interfere with functional walking ability, general activity, and ability to complete normal occupational work; less commonly, PPSP has also been reported to impact mood, sleep, and quality of life. PPSP is the strongest predictor of lower patient satisfaction following TKA.

Incidence/Prevalence:

At 1-year post-op, 50% of patients undergoing TKA may not experience clinically important improvements in pain.²⁸

Multiple Causes and factors involved:^30-34

Impairment of early fixation or prosthetic migration.

Pre-morbid obesity.

Auto-Immune or inflammatory reactions to the prosthesis materials.

Surgical site infection or post-surgical prosthesis related infection.

Iatrogenic neuropathic pain (accidental nerve damage during surgery)

Post-op knee stiffness.

Low pre-operative physical function.

Patients with depression or increased sensitivity to pain.

Requiring pre-operative assistance from another person for completing ADLs.

Pain is the greatest reported barrier to engaging in physical rehabilitation.

Although the degree of pain is usually mild and an improvement in pain level from pre-operative condition is achieved, patients are often expecting complete resolve of their pain symptoms.³⁰

As a result, ongoing pain is the strongest predictor of a lower level of patient satisfaction with their TKA.³⁵

Photo credit: Hip and Knee: Basics of Arthroplasty Testbook. Bert Parcells and Stephen Kayiaros, editors. Arthroplasty Education Foundation. TJABook.com. Available at: http://hipandkneebook.com. Accessed Apr 6. 2018.

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Prolonged Inpatient Stay

Can be the result of any/all of the previously described complications.

Longer duration of inpatient stay is also the primary cost driver of the TKA episode.¹⁴

Total 90-day costs by point-of-care (2013)

While different hospitals have varying lengths of inpatient stay after TKA, at any hospital, discharge is based, in large part, on swift recovery of relevant activities (transferring from bed to a chair, ambulation, and climbing stairs). If the patient is unable to demonstrate functional independence with these activities, then hospital length of stay (LOS) will be prolonged and/or non-home discharge to a skilled nursing facility or rehabilitation center. Longer duration of inpatient hospital stay increases the risk of adverse events after TKA including infection, VTE, persistent post-surgical pain,¹⁶ worse functional recovery after hospital discharge¹⁷ and is the primary cost driver of the TKA episode and is associated with worse functional recovery. ⁷

Risk factors: Age >70 years (Slow functional recovery during hospitalization occurs generally in 30% of patients over 70 years old undergoing major surgery, regardless of the success of the surgical procedure.)¹⁸, Obesity^16,9, Female gender^19,9, smoking history, diabetes, pulmonary disease, hypertension.⁹

Photo credit:Nichols CI, Vose JG. Clinical Outcomes and Costs Within 90 Days of Primary or Revision Total Joint Arthroplasty. J Arthroplasty. 2016;31(7):1400-1406.e3. doi:10.1016/j.arth.2016.01.022.

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1. Participation in prehabilitation can reduce length of hospital stay:

Fernandes et al (2017⁾⁴³ Avg reduction in hospital LOS by 2.4 days.

Calatayud et al (2017⁾⁴⁴Avg reduction in hospital LOS by 1.95 days.

Beaupre et al (2004⁾⁴⁶ Hospital LOS 1 day less on average.

In 2016: $1,462.00 /day for a total joint

patient on the orthopaedic floor at UNC.

Prehab for TKA: Current Scope of Evidence

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Image from: Topp R, Swank AM, Quesada PM, Nyland J, Malkani A. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. PM R. 2009;1(8):729-735. doi:10.1016/j.pmrj.2009.06.003.

2. Higher frequency and intensity of prehab intervention has greater effect on post-op quad strength and lower extremity functional strength.

Calatayud et al (2017^{) 44}

Topp et al (2009) ⁴⁷

3. Prehab duration of >6

weeks may have greater

short-term treatment effect

on post-op ADLs and pain.

Calatayud et al (2017)⁴⁴

Villadsen et al (2014^{) 48}

Prehab Evidence Cont.

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�Current Scope of Prehab Evidence: �Other Take-Away’s �

4. Prehab without PT-supervision:

Can improve patient function pre-operatively, but treatment effect may not be sustained post-operatively.⁴⁵

5. Prehab with PT-supervision:

Is associated with pre- AND post-operative treatment effect, which may be sustained for up to 12 months. ^43,44,46

6. 12 or more supervised PT sessions appears to have greatest magnitude of

effect on pain and physical function outcomes for up to 6 months postoperatively.^44,47

7. Treatment effect of prehabilitation is not maintained at 12-months post-op.^43,45

8. Subjects had the best outcomes when prehab protocol was composed of flexibility

and strengthening exercises, aerobic endurance training, and functional training.

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Supply and Demand

“Demand for rehabilitation services after [TKA] is increasing and innovative approaches to care delivery are required to align increasing demand with supply.”

(Landry, et al)

Prehabilitation: Needs Assessment Cont.

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Recent Trends: Chronic Knee Pain

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Number of TKA’s performed in 2011

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Growth Trends in Demand for TKA

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Future Growth Trends in TKA Demand

Historical (1993–2012) and projected (2015–2050) volume and 95% prediction intervals of primary TKA procedures in citizens 40 years and older from logistic model.

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“Prehabilitation is a key to mediating demand for rehabilitation services after TKA in the short term...” (Landry, et al)

Increased demand for TKA

=

Increased demand for Prehabilitation

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General Guidelines for Prehabilitation

Treatment Frequency and Duration

Two (2) PT-supervised sessions per week during the final 8 weeks (16 sessions

total) leading up to surgery.

Provides adequate exposure to achieve significant strength gain as a result of

hypertrophy of muscle tissue.^50,51

Twelve (12) or more supervised PT sessions appears to have greater

magnitude of effect on pain and physical function outcomes for up to 6

months postoperatively.^44,47,48

Moderate to High intensity and volume of activity.

Frequency and duration:

This frequency and duration provides adequate exposure needed to achieve significant strength gain as a result of hypertrophy of muscle tissue.^50,51

Individualized and supervised exercise programs have shown greater efficacy at reducing pain and improving physical function in patients with knee OA, compared with community-based or home-based exercise programs.^45,47 Clinical benefit of exercise intervention for patients with knee OA appears to impacted Some form of ongoing monitoring or supervision may better optimize clinical benefits of exercise treatment in this patient population.⁵²

Effect of prehabilitation treatment appears to be influenced, in large part, by the number of face-to-face sessions with the supervising rehabilitation professional; 12 or more supervised sessions appears to have greater magnitude of effect on pain and physical function outcomes for up to 6 months post-operatively, compared with less than 12 supervised prehabilitation sessions. ^44,47,48,52

Volume and Intensity:

The intensity at which exercise is performed is a key variable in maximizing strength and performance improvements. Greater volume and higher intensity progressive exercise is required to induce a neural drive that maximizes neuromuscular activation of the targeted muscle fibers, especially when the goal is to promote the greatest possible gain in muscle strength over a short period of time.^50,51

Prehabilitation programs composed of higher intensity exercise have demonstrated greater improvement and significant treatment effect on lower extremity muscle strength, knee ROM, performance-based functional measures, and reduced pain for up to 6-months postoperatively, as well as shorter length of inpatient hospital stay, compared with lower intensity programs.^42,44

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Patient-reported outcome measures

Oxford Knee Score (OKS)
Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC)
The Risk Assessment and Prediction Tool (RAPT)

Performance-based measures

More responsive to acute changes in patient impairments and limitations than patient-reported measures.¹⁷

OARSI “minimal core set” of performance-based measures:

30-second Chair-Stand Test
40 Meter Fast-Paced Walk Test
Stair-Climb Test

Single-Leg Stance Test
TUG
BESTests

Patient-reported Outcome Measures:

Oxford Knee Score (OKS)⁵³ is used to monitor progression of pain symptoms and function and has shown to have good psychometric properties in terms of validity, reliability, and responsiveness to clinical change in knee OA patients, both with or without TKA.

Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC)^54,55 evaluates response to treatment in terms of pain, joint stiffness, and physical function and has established cutoff points specifically for use with the TKA patient population.

The Risk Assessment and Prediction Tool (RAPT)^56,57 is a preoperative survey that has demonstrated good predictive accuracy for discharge disposition after total joint arthroplasty and may assist with discharge planning and establishing patient and family expectations related to post-operative recovery.

Performance-based Outcome Measures:

The Osteoarthritis Research Society International (OARSI) has established a recommended and minimal core set of performance-based tests to assess key domains of physical function in knee OA patients awaiting TKA or following TKA.

OARSI minimal core set of performance-based measures:⁵⁸ 30-second Chair-Stand Test, 40 Meter Fast-Paced Walk Test, and Stair-Climb Test; recommended set also includes Timed Up and Go Test (TUG), and 6-minute Walk Test.

The TUG has also shown to be an independent and stable pre-operative determinant of delayed inpatient recovery of activities after TKA, with lower preoperative scores associated with discharge to SNF as opposed to home discharge.⁵⁹

Pre-operative time on the Single-Leg Stance Test with eyes open has been associated with limited ADL in older adults 6-months post-TKA.³⁷

Additionally, the 3 BESTests are recommended as having good reliability and validity in measuring balance performance in TKA patients and do not have significant floor or ceiling effects at 6-months post-op and have moderate-to-strong correlations with the patient-reported Activity-Specific Balance Confidence Scale.⁶⁰

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Interventions

P

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Intervention 1: Progressive low-impact aerobic endurance training

Goal of maintaining RPE 4-5/10

Purpose: Improve preoperative cardiorespiratory function and endurance, bone health, physical performance with daily activities, and reduce joint pain.

Intervention 1 is to be completed in the clinic under the supervision of a PT or PTA, as well as independently by the patient outside of the clinic.

Lower preoperative physical function has been associated with delayed postoperative inpatient recovery of activities necessary for home discharge, decreased ability to perform daily activities, limited mobility, and participation restrictions at 1-year post-op.^16,17

Improved preoperative physical function has also shown to reduce the risk for persistent post-surgical pain.^44,47,48

Preoperative cardiovascular endurance contributes to performance-based physical function post-TKA.⁴⁰

Regular participation in aerobic exercise improves immune function and can reduce patient risk of post-surgical infection.¹⁰

Photo credits (L to R):

Left: Man on an exercise bike. Wiki Creative Commons.

Right: Hyatt A. Gait Analysis Clinic Helps Improve Running, Prevent Injuries. U.S. Air Force photo. Photo by Staff Sgt. Anthony Hyatt. Joint Base Charleston; January 10, 2013. Retrieved from: http://www.jbcharleston.jb.mil/News/Features/Display/Article/238686/gait-analysis-clinic-helps-improve-running-prevent-injuries/. Accessed April 6, 2018.

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Intervention 2: Strength Training�

Open-chain exercise

Purpose: Address preoperative impairments in motor function, control, and weakness through targeted lower extremity muscle strengthening.

Strength loss following TKA occurs in the quadriceps, hamstrings, ankle plantar flexors, and hip abductors.

Increased preoperative quadriceps and hamstrings strength improves postoperative knee joint stability.

Preoperative lower extremity strength is a strong predictor of functional performance at one and two years after TKA as well as postoperative activity participation.^39,40

Special considerations: With all strengthening activities, prehabilitation should also focus on improving the strength of the non-injured limb.

Photo credits (clockwise starting from upper left): Lange AK, Vanwanseele B, Foroughi N, et al. Resistive Exercise for Arthritic Cartilage Health (REACH): a randomized double-blind, sham-exercise controlled trial. Figure developed by Dr. Nathan de Vos. BMC Geriatr. 2009;9:1. doi:10.1186/1471-2318-9-1; Prone knee flexion. Wiki Creative Commons; Image from Therapeutic Exercise: Foundations and Techniques, 5^th Edition, Kisner and Colby, ISBN 0803615841, Publisher F.A. Davis Company.; Hand weights. Wiki Creative Commons.; Exercise Straight Leg Raises. Wiki Creative Commons.

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Examples of Strength Training

Closed-chain dynamic exercise

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Examples of Functional

Strengthening

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Intervention 3: Increase �Flexibility and Range of Motion��Self-stretching activities��

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Intervention 4: Balance Training�

Static balance

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Motor Control�

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Dynamic balance��

Dual-Task Training

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Mediate patient expectations

Although degree of postoperative pain is usually mild and significantly improved from baseline, patients are often expecting complete resolve of pain symptoms following TKA.^30,35

Unmet patient expectations are strongly associated with postoperative dissatisfaction; preoperative management of patient expectations related to recovery progression and duration has been correlated with improved postoperative patient satisfaction.^30,35

Patients with milder radiographic knee OA before TKA (using the Kellgren-Lawrence Grading System) are more likely to report inadequate pain relief and dissatisfaction with functional improvement following surgery.Compared to patients with severe joint degeneration on X-ray, knee pain in patients with only modest radiographic change appears to be driven more by pain central sensitization than by nociceptive input from the joint.³⁶Early identification of these patients allows for adequate time to provide chronic pain education and mediate expectations.

Photo credit: Petersen, W., Rembitzki, I.V., Brüggemann, GP. et al. International Orthopaedics (SICOT) (2014) 38: 319. https://doi.org/10.1007/s00264-013-2081-4.

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Prehab Home Exercise Program

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Flexibility

*Hamstrings and calf stretch

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Thank you for your attention!

Questions?

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