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Aggressive Rehab Safe After Knee Replacement

Discussion in 'Knees - TKR' started by Josephine, Jul 26, 2017.

  1. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator
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    Aggressive Rehab Safe After Knee Replacement
    American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting
    Abstract P183. Presented March 4, 2016.

    This difference could be attributed to the fact that patients in the historic control group never went directly to outpatient therapy or received a high level of care. "They had more directed therapy for their specific problem," she explained. In their current study, Dr Stevens-Lapsley and her colleagues evaluated 89 women and 73 men who were 56 to 70 years of age. All patients received an intervention two or three times a week for 12 weeks.

    One group was randomly assigned to perform high-intensity progressive resistance exercise on lower-extremity muscle groups, which included balance exercises and agility exercises. They progressed as quickly as possible — depending on their pain, surgical knee range of motion, swelling, and functional performance— to weight-bearing strengthening exercises.

    The other group followed a standard low-intensity total knee arthroplasty rehabilitation program, which consisted of stretching, light resistive exercises with ankle weights or resistive bands, and lower-demand functional exercises. Progression was based on the synthesis of previously published standard total knee arthroplasty rehabilitation programs, and was time-based.

    Outcomes were assessed 1, 2, 3, 6, and 12 months after surgery. Performance improved sooner in the high-intensity group than in the low-intensity group, and high quadriceps activation led to earlier functional recovery. The results were similar in the two groups at 12 months, and results were better in both groups than in historic control subjects.

    It is the nuances of this study that stand out.

    "Surgeons will tell us that there should be no resistive exercise before range of motion is restored. That's because increased swelling with more intense exercise can permanently jeopardize the ability of patients to get their range of motion back. We showed that does not occur," Dr Stevens-Lapsley told Medscape Medical News. However, she pointed out, it is dependent on quadriceps activation.

    Still, surgeons are wary.

    "For the first 2 weeks, I'm pretty much a cookbook; pretty standardized," said Jason Michael Jennings, MD, an orthopedic surgeon from Denver. He said he gives his patients standard rehab right after total knee arthroplasty and is sticking with that. After 2 weeks, "you pretty much know who's going to need more or less," he told Medscape Medical News. "There are certain patients who may benefit from high intensity," Dr Jennings explained. "We don't know who those patients are before, but 2 or 3 weeks after, they tell you they've walked a mile with no swelling, no pain. I wait to see how patients are doing," he reported.

    Status Quo Rehab Not Good Enough

    This research is important because more young patients are now lining up for total knee arthroplasty, and they are demanding higher function after surgery, said study investigator Douglas Dennis, MD, an orthopedic surgeon from Colorado Joint Replacement in Denver.

    "Patients expect more than they used to," he explained. This means better long-term and functional outcomes need to be examined. "An 80-year-old who wants to walk to Nellie's house to play bridge does fine with current rehab," Dr Dennis said. "But we're doing more total knees on young people. The activities they want to perform require better quadriceps performance. "Quad power" is the key factor blocking functional outcome improvements, he said. In fact, "another important finding" of this study is that patients who had bigger quad activation deficits before surgery struggled more with rehab, he added.

    In the randomized controlled trial that Dr Stevens-Lapsley was involved in, neuromuscular electrical stimulation of quadriceps after total knee arthroplasty showed positive results (Phys Ther. 2012;92:210-226).

    There is a lot of room for improvement in outcomes after total knee arthroplasty, Dr Stevens-Lapsley and her colleagues report. Overall, the single largest residual deficit after surgery is in the stair-climbing performance test; 75% of patients reported difficulty negotiating stairs years after the procedure. In addition, postoperative walking speed was 20% slower and stair-climbing speed was 50% slower.

    Dr Dennis said he thinks that rehab after total knee arthroplasty should become more personalized, especially for those who are more active. "We're essentially treating those who are at a lower level of function," he told Medscape Medical News. "We do think some patients could get to rehab earlier and start firing their quads earlier on."

    Dr Stevens-Lapsley reports that she is a consultant for DJO Global. Dr Jennings has disclosed no relevant financial relationships. Dr Dennis reports that he is a paid consultant for DePuy; receives royalties from DePuy, Innomed, and Wolters Kluwer Health; and owns stock options in Joint Vue.
     

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