Expert Consensus for the Use of Outpatient Rehabilitation Visits After Total Knee Arthroplasty: A Delphi Study.

OBJECTIVE: There is no consensus for how to use rehabilitation visits after total knee arthroplasty (TKA). We sought to develop expert recommendations for outpatient rehabilitation visit usage after TKA. DESIGN: Delphi study. METHODS: First, we developed a broad list of preliminary visit usage recommendations, which were specific to patients' recovery status (ie, slow, typical, or fast recovery) and time since surgery. We then invited 49 TKA experts to participate on a Delphi panel. During round 1, we surveyed panelists regarding their level of agreement with each preliminary recommendation. We conducted additional Delphi rounds as needed to build consensus, which we defined using the RAND/UCLA method. We updated the survey each round based on panelist feedback and responses from the previous round. RESULTS: Thirty panelists agreed to participate, and 29 panelists completed 2 Delphi rounds. The panel reached consensus on recommendations related to visit frequency, visit timing, and the use of telerehabilitation. The panel recommended that outpatient rehabilitation should begin within 1 week after surgery at a frequency of 2 times per week for the first postoperative month regardless of recovery status. The panel recommended different visit frequencies depending on the patient's recovery status for postoperative months 2 to 3. The panel agreed that telerehabilitation can be recommended for most patients after TKA, but not for patients recovering slowly. CONCLUSION: We used the Delphi process to develop expert recommendations for the use of outpatient rehabilitation visits after TKA. We envision these recommendations could help patients decide how to use visits based on their own preferences. J Orthop Sports Phys Ther 2023;53(9):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11840.

Quality Improvement Content in Physical Therapist Education: A Scoping Review.

OBJECTIVE: The purpose of this study was to systematically review the literature regarding teaching quality improvement (QI) in physical therapist education based on the Institute of Medicine's 6-element definition of QI. Educational activities in QI methods in physical therapist professional education curricula, their developmental stage, and their level of evaluation were described. METHODS: Keywords related to physical therapist students and QI educational activities were used to search studies indexed in PubMed, CINAHL, and ERIC published from 2004 through November 2020. This search yielded 118 studies. After applying inclusion and exclusion criteria, 13 studies were retained for full-text review, which was conducted independently by 2 reviewers. The University of Toronto framework was used to assess developmental stage, and Kirkpatrick's taxonomy was used to assess the evaluation level of 4 retained studies. RESULTS: The scope of QI educational activities in the 4 retained studies was limited to 3 of the 6 elements of QI: identifying opportunities for improvement, designing and testing interventions, and identifying errors and hazards in care. None of the studies included educational activities to teach understanding and measuring quality of care. Three of the 4 studies spanned the first 2 stages of the University of Toronto framework (exposure and immersion); 1 study was limited to exposure. None of the studies assessed competence in QI methods. Evaluation of QI education was limited to Kirkpatrick levels 1 (reaction) or 2 (learning). None of the studies evaluated activities at level 3 (transfer of new behaviors) or level 4 (results). CONCLUSION: Education in QI methods in professional physical therapist curricula may be limited in scope due to constraints in physical therapist education and the strategic objective of the profession to differentiate itself from other professions. IMPACT: Entry-level physical therapists might not be educated to fully participate in interprofessional teams that use QI methods to continuously improve the quality of patient-centered care.

Physical therapy to address fall risk in an individual with neurofibromatosis.

BACKGROUND: While physical therapy may help improve function and quality of life in patients with neurofibromatosis (NF), a standard of care remains to be established. This case report describes the physical therapy management of an individual with NF who was at high fall risk. CASE DESCRIPTION: A 61-year-old male with NF and multiple comorbidities was determined to be at high fall risk by the Dynamic Gait Index, Berg Balance Scale, and Modified Falls Efficacy Scale. Deficits included coordination and strength which limited his ability to ascend and descend stairs or walk on uneven terrain. This reduced his independence at home and in his rural community. Interventions incorporated components of hip and trunk coordination, and addressed balance, strength, and functional mobility. OUTCOMES: The patient scored above the cutoff for high fall risk on all outcome assessments. DISCUSSION: This case report describes physical therapy management to reduce fall risk for an individual with NF. Due to the limited research on NF, the treatment plan was developed using evidence-based practice for fall-risk reduction in other neurological disorders.

Knowledge and Attitudes of Physical Therapy Students Across a Longitudinal Healthcare Systems-Focused Patient Safety Curriculum.

BACKGROUND: Most professions increased system-focused safety competencies after the release of the Institute of Medicine reports on errors, patient safety, and core competencies for health professions beginning in 1999. The physical therapy profession remained focused on individual safety, driven by accreditation requirements. PURPOSE: To describe change in the knowledge and attitudes Doctor of Physical Therapy (DPT) students following a longitudinal system-focused patient safety curriculum and 22 weeks of clinical education. METHODS: Nine sessions of systems-focused patient safety discipline-specific and interprofessional curricular content. Knowledge/attitude change assessed via a modified Attitudes of Patient Safety Questionnaire (APSQ-III) and culture and professional questions from the Patient Safety Attitudes, Skills and Knowledge Scale (PS-ASK) questionnaire. RESULTS: There was a 100% and 97% survey response rate to pre and post surveys, respectively. Statistically significant changes in the mean response pre to post-survey were found for four of nine APSQ-III subscales. Eighteen of the 25 APSQ-III questions improved towards the desired direction, while 2 remained unchanged at 100%. Culture-focused attitude questions on the PS-ASK remained very low or did not change. CONCLUSION: Student knowledge and attitudes improved in several important domains of patient safety including patient safety training, situational awareness, role of provider competence, and disclosure responsibility. Challenges remain in understanding professional responsibility and healthcare culture and its connection to error.

Performance on a Clinical Quadriceps Activation Battery Is Related to a Laboratory Measure of Activation and Recovery After Total Knee Arthroplasty.

OBJECTIVE: To determine the relation between performance on a clinical quadriceps activation battery with (1) activation measured by doublet interpolation and (2) recovery of quadriceps strength and functional performance after total knee arthroplasty (TKA). DESIGN: Planned secondary analysis of a randomized controlled trial. SETTING: University research laboratory. PARTICIPANTS: Patients (N=162; mean age, 63±7y; 89 women) undergoing TKA. MAIN OUTCOME MEASURES: Patients were classified as high (quadriceps activation battery ≥4/6) or low (quadriceps activation battery ≤3/6) based on performance on the quadriceps activation battery measured 4 days after TKA. Differences between groups in activation and recovery at 1, 2, 3, 6, and 12 months after TKA were compared using a repeated-measures maximum likelihood model. RESULTS: The low quadriceps activation battery group demonstrated poorer quadriceps activation via doublet interpolation (P=.01), greater quadriceps strength loss (P=.01), and greater functional performance decline (all P<.001) at 1 month after TKA compared with the high quadriceps activation battery group. Differences between low and high quadriceps activation battery groups on all measures did not persist at 3 and 12 months (all P>.05). CONCLUSIONS: Poor performance on the quadriceps activation battery early after TKA is related to poor quadriceps activation and poor recovery in the early postoperative period. Patients in the low quadriceps activation battery group took 3 months to recover to the same level as the high quadriceps activation battery group. The quadriceps activation battery may be useful in identifying individuals who need specific interventions to target activation deficits or different care pathways in the early postoperative period to speed recovery after TKA.

Early High-Intensity Versus Low-Intensity Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial.

OBJECTIVE: To examine the safety and efficacy of a high-intensity (HI) progressive rehabilitation protocol beginning 4 days after total knee arthroplasty (TKA) compared to a low-intensity (LI) rehabilitation protocol. METHODS: A total of 162 participants (mean ± SD ages 63 ± 7 years; 89 women) were randomized to either the HI group or LI group after TKA. Key components of the HI intervention were the use of progressive resistance exercises and a rapid progression to weight-bearing exercises and activities. Both groups were treated in an outpatient setting 2 to 3 times per week for 11 weeks (26 total sessions). Outcomes included the stair climbing test (SCT; primary outcome), timed-up-and-go (TUG) test, 6-minute walk (6MW) test, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-item Short Form health survey (SF-12), knee range of motion (ROM), quadriceps and hamstring strength, and quadriceps activation. Outcomes were assessed preoperatively and at 1, 2, 3 (primary end point), 6, and 12 months postoperatively. RESULTS: There were no significant differences between groups at 3 or 12 months in SCT, TUG, 6MW, WOMAC scores, knee ROM, quadriceps and hamstrings strength, quadriceps activation, or adverse event rates. By 12 months, outcomes on the 6MW, TUG, WOMAC, SF-12, quadriceps and hamstring strength, and quadriceps activation had improved beyond baseline performance in both groups. CONCLUSION: Both the HI and LI interventions were effective in improving strength and function after TKA. HI progressive rehabilitation is safe for individuals after TKA. However, its effectiveness may be limited by arthrogenic muscular inhibition in the early postoperative period.

Does delay in total knee arthroplasty impact postoperative performance? A case-based illustration.

Optimal timing of TKA surgery is not clear. This report describes a patient's tested strength and function deficits before and after a surgical delay compared with a comparable cohort. TKA for OA was postponed due to non-health issues. Strength and functional performance were tested at 3 points preoperatively and 4 points postoperatively. Preoperative strength and functional performance precipitously declined during surgical delay. Quadriceps strength declined 47% from 6 months to one week pre-operatively, with the majority of this decline in the last 3 months. Pain levels peaked preoperatively, averaging 8.3/10. After 6 weeks of TKA, quadriceps recovered to immediate preoperative strength, but was 47% less than 6 months preoperatively. Function improved to 6 months preoperative levels by 6 weeks. Functional performance recovered to immediate preoperative levels by 6 months, while muscle strength (quadriceps and hamstrings) did not. This case describes a precipitous decline in strength and function during a 6-month surgical delay, with poorer recovery compared with a cohort without delay. While this case only describes a single individual, the results highlight the need for further research on optimal surgical timing for total knee arthroplasty, considering function, strength and pain levels, especially because strength recovery can have long-term implications.