Effect of adding one 15-minute-walk on the day of surgery to fast-track rehabilitation after total knee arthroplasty: a randomized, single-blind study.

ABSTRACT

BACKGROUND: Earlier and more intensive physiotherapy exercise after total knee arthroplasty (TKA) enhance recovery, but the best combination of intensity and duration has not been determined. AIM: To determine whether adding a single, 15-minute walk on the day of surgery to a fast-track rehabilitation protocol would reduce knee pain and improve knee function after TKA. DESIGN: A randomized single-blind study. SETTING: Inpatient. POPULATION Patients with primary osteoarthrosis after TKA. METHODS: Patients undergoing TKA were randomly assigned to a standard, fast-track rehabilitation protocol consisting of a single, 15-minute walk with a high-rolling walker 4 to 6 hours after recovery from spinal anesthesia or to an intensive protocol, in which patients took a second 15-minute walk at least 3 hours after the first, only on the day of surgery. Outcomes were pain measured on a visual analog scale, Knee Society's (KSS) clinical and functional scores, Oxford knee scores, and Spielberger State-Trait Anxiety Inventory scores. Patients were blinded to group assignment. Since most data were non-normally distributed non-parametric tests were used. Groups were compared with Mann-Whitney U test (for continuous variables). Association between continuous variables was evaluated with Spearman`s rank correlation coefficient. Chi-square or Fisher's exact test was used to assess differences in categorical variables. RESULTS: Of 86 patients assessed for eligibility, 66 were randomly assigned. The 31 evaluable patients on the intensive protocol (mean age, 68 years; 18 women) did not differ significantly from the 31 (mean age, 70 years; 20 women) on the standard protocol on any baseline characteristic or on any outcome measure on any day. On the second postoperative day, pain while walking dropped from a mean of 6.1 to a mean of 4.9 in the intensive group and from 6.4 to 5.4 in the standard group. Results for pain at rest were 3.3 to 2.2, respectively, for the intensive group and 4.0 to 3.0 for the standard group. At 2 weeks, pain at rest was 2.8 in both groups, and pain while walking was 3.0, respectively, for the intensive group and 3.4 for the standard group. At 2 weeks, mean (SD) KSS clinical and KSS function scores were, respectively, 74.9 (12.5) and 51.6 (16.2) in the intensive group and 71.2 (14.3) and 46.3 (16.1) in the standard group. Older age correlated with decreasing knee function (rS=-0.43, P<0.001), and less knee flexion correlated with preoperatively higher state anxiety (rS=-0.37, P=0.005) and trait anxiety (rS=-0.29, P=0.027). The study is limited by its small sample. The fast-track program was not in line with the best available evidence following knee arthroplasty, because patients did not undergo such treatment as NMES. Finally, the intervention itself was modest. CONCLUSION: Adding an additional 15-minute walk to a fast-track rehabilitation protocol did not increase pain, but neither did it improve functional recovery. CLINICAL REHABILITATION IMPACT A 15-minute walk immediately after recovery from spinal anesthesia did not increase pain in patients with TKA. More intense exercise during this period might improve functional recovery without increasing pain.