What recovery domains are important following a total knee replacement? A qualitative, interview-based study.

OBJECTIVES: To explore people's views of recovery from total knee replacement (TKR) and which recovery domains they felt were important. DESIGN: Semi-structured interviews exploring the views of individuals about to undergo or who have undergone TKR. A constant-comparative approach with thematic analysis was used to identify themes. The process of sampling, collecting data and analysis were continuous and iterative throughout the study, with interviews ceasing once thematic saturation was achieved. SETTING: Tertiary care centre. PARTICIPANTS: A purposive sample was used to account for variables including pre, early or late postoperative status. RESULTS: 12 participants were interviewed, 4 who were preoperative, 4 early postoperative and 4 late postoperative. Themes of pain, function, fear of complications, awareness of the artificial knee joint and return to work were identified. Subthemes of balancing acute and chronic pain were identified. CONCLUSIONS: The results of this interview-based study identify pain and function, in particular mobility, that were universally important to those undergoing TKR. Surgeons should consider exploring these domains when taking informed consent to enhance shared decision-making. Researchers should consider these recovery domains when designing interventional studies.

Total knee arthroplasty: does ultra-early physical therapy improve functional outcomes and reduce length of stay? A retrospective cohort study.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) Society recommends that after total knee arthroplasty (TKA), patients should be mobilized early. However, there is no consensus on how early physical therapy should be commenced. We aim to investigate whether ultra-early physical therapy (< 12 h postoperatively) leads to better outcomes. METHODS: This is a retrospective cohort study of 569 patients who underwent primary TKA from August 2017 to December 2019 at our institution. We compared patients who had undergone physical therapy either within 24 h or 24-48 h after TKA. Further subgroup analysis was performed on the < 24 h group, comparing those who had undergone PT within 12 h and within 12-24 h. The outcomes analyzed include the Oxford Knee Scoring System score, Knee Society Scores, range of motion (ROM), length of stay (LOS) and ambulatory distance on discharge. A student's t test, chi-squared test or Fisher's exact test was used where appropriate, to determine statistical significance of our findings. RESULTS: LOS in the < 24 h group was shorter compared to the 24-48 h group (4.87 vs. 5.34 days, p = 0.002). Subgroup analysis showed that LOS was shorter in the ultra-early PT (< 12 h) group compared to the early PT (12-24 h) group (4.75 vs. 4.96 days, p = 0.009). At 3 months postoperatively, there was no significant difference in ROM, ambulatory distance or functional scores between the < 24 h group and 24-48 h group, or on subgroup analysis of the < 24 h group. CONCLUSION: Patients who underwent physical therapy within 24 h had a shorter length of stay compared to the 24-48 h group. On subgroup analysis, ultra-early (< 12 h) physical therapy correlated with a shorter length of stay compared to the 12-24 h group (4.75 vs. 4.96 days, p = 0.009) - however, the difference is small and unlikely to be clinically significant. Ultra-early (< 12 h) physical therapy does not confer additional benefit in terms of functional scores, ROM or ambulatory distance. These findings reinforce the importance of early physical therapy after TKA in facilitating earlier patient discharge.

Robotic exoskeletons and total knee arthroplasty: The future of knee rehabilitation and replacement - A meta-analysis.

OBJECTIVE: Exoskeletons can play a crucial role in post-TKA rehabilitation by accelerating recovery, improving mobility, and reducing further injury risk. This meta-analysis evaluated the effectiveness of exoskeletons in post-total knee replacement (TKR) rehabilitation. DESIGN: Comprehensive searches were conducted on PubMed, OVID Medline, Cochrane Collaboration Library, and Embase (period: database inception to March 2023). Randomized controlled trials enrolling patients who underwent TKR and studies examining the effect of robot-assisted rehabilitation on physical function and pain outcomes were eligible for inclusion. Eight studies (302 patients) were thus included. RESULTS: Exoskeletons significantly improved active range of motion (ROM) (SMD: 10.98, 95% confidence interval (CI): 7.81-14.16, P < .001), passive ROM (SMD: 4.11, 95% CI: 1.02-7.20, P = .009), Hospital for Special Surgery scores (SMD: 7.78, 95% CI: 5.87-9.68, P < .00001), and hospital stay length (SMD: -3.19, 95% CI: -4 to -2.38, P < .00001) compared with conventional rehabilitation. Active and passive ROM improvements suggest that exoskeletons aid knee function restoration and mobility post-TKR, whereas Hospital for Special Surgery score improvements support exoskeleton use in TKR rehabilitation. A shorter hospital stay was an important finding which could potentially reduce healthcare costs and improve outcomes. CONCLUSION: Despite the inclusion of a limited number of studies, our findings suggest that exoskeletons can enhance post-TKR rehabilitation outcomes and improve quality of life. Robot-assisted rehabilitation may be effective following TKR. Further research should confirm these findings.

Perioperative experiences of patients with high pain catastrophizing and knee arthroplasty after receiving or not preoperative physiotherapy: Qualitative study.

BACKGROUND: Among the risk factors studied for persistent pain after total knee arthroplasty (TKA), pain catastrophizing stands out above the others. In this regard, preoperative interventions based on pain neuroscience education or multimodal physiotherapy have been shown to be effective in reducing pain catastrophizing. OBJECTIVES: The present qualitative study aims to explore the perioperative experiences of high pain catastrophizing participants undergoing total knee arthroplasty surgery. Comparisons will be made between those who received, and those who did not receive a preoperative physiotherapy intervention. METHODS: Based on the purposive sampling approach, participants from a randomized controlled trial were selected. In total, 14 persons participated in face-to-face semi-structured interviews. RESULTS: Following a thematic analysis, the results were divided into two themes: 1) The preoperative experiences of patients with symptomatic knee arthroplasty, covering aspects related to health, functioning, cognition, and behaviour; and 2) The perioperative TKA rehabilitation process, illustrating differing experiences between individuals who received the preoperative physiotherapy interventions and those who did not. CONCLUSIONS: While participants who received no preoperative physiotherapy intervention showed limited coping strategies during post-surgery rehabilitation and the same cognitions as before (hypervigilance, rumination, or avoidance of activities), those participants who received the preoperative physiotherapy showed abilities to cope with their pain, felt empowered and were involved in their rehabilitation.

Incorporating Wearable Technology for Enhanced Rehabilitation Monitoring after Hip and Knee Replacement.

Osteoarthritis (OA) poses a growing challenge for the aging population, especially in the hip and knee joints, contributing significantly to disability and societal costs. Exploring the integration of wearable technology, this study addresses the limitations of traditional rehabilitation assessments in capturing real-world experiences and dynamic variations. Specifically, it focuses on continuously monitoring physical activity in hip and knee OA patients using automated unsupervised evaluations within the rehabilitation process. We analyzed data from 1144 patients who used a mobile health application after surgery; the activity data were collected using the Garmin Vivofit 4. Several parameters, such as the total number of steps per day, the peak 6-minute consecutive cadence (P6MC) and peak 1-minute cadence (P1M), were computed and analyzed on a daily basis. The results indicated that cadence-based measurements can effectively, and earlier, differ among patients with hip and knee conditions, as well as in the recovery process. Comparisons based on recovery status and type of surgery reveal distinctive trajectories, emphasizing the effectiveness of P6MC and P1M in detecting variations earlier than total steps per day. Furthermore, cadence-based measurements showed a lower inter-day variability (40%) compared to the total number of steps per day (80%). Automated assessments, including P1M and P6MC, offer nuanced insights into the patients' dynamic activity profiles.

Efficacy and safety of continuous passive motion and physical therapy in recovery from knee arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Continuous passive motion (CPM) is commonly used as a postoperative rehabilitation treatment, along with physical therapy, for postoperative knee rehabilitation. However, the comparison between the two in terms of efficacy in postoperative knee replacement recovery is unclear. PURPOSE: To compare efficacy and safety of combined CPM versus physical therapy alone in postoperative rehabilitation after knee arthroplasty. METHODS: PubMed, Embase, and Web of Science databases were used to retrieve and access clinical studies on the efficacy of CPM compared with physical therapy. Review Manager software was used for study publication bias assessment and data analysis based on inclusion criteria. RESULTS: A total of 6 articles covering 557 patients were included in the study. In terms of range of motion (ROM), passive knee flexion was similar between CPM and physical therapy (PT) (WMD, - 0.17; 95% CI, - 0.98-0.64; p = 0.68). At long-term follow-up, passive knee extension was similar between CPM and physical therapy (PT) (WMD, - 0.28; 95% CI, - 1.47 to - 0.92; I2 = 65%, p =0.65). In addition, CPM generates significantly higher in length of stay (WMD, 0.50; 95% CI, - 0.31 to 0.69; I2 = 3%, p < 0.001). CPM generates significantly higher treatment costs and incurs more care costs relative to physical therapy. CONCLUSION: Compared to PT, combined with CPM failed to significantly improve ROM of the knees and patient's satisfaction. In addition, CPM treatment significantly increased the cost of hospitalization.

Association Between Patient and Facility Characteristics and Rehabilitation Outcomes After Joint Replacement Surgery in Different Rehabilitation Settings for Older Adults: A Systematic Review.

BACKGROUND AND PURPOSE: In the United States, an exponential increase in total hip arthroplasty (THA) and total knee arthroplasty (TKA) demand has occurred over the last 2 decades. Evidence suggesting patients receiving inpatient rehabilitation following a TKA or THA experience similar outcomes as those with rehabilitation in other settings led to dramatic shifts in postsurgical care settings owing to Centers for Medicare & Medicaid Services (CMS) payment reforms. A contemporary synthesis of evidence about the association between patient and facility factors and outcomes from older adults undergoing THA or TKA in the United States is needed. METHODS: To identify eligible studies, we searched PubMed, Scopus, and CINAHL. We followed PRISMA guidelines to identify articles evaluating either patient or facility factors associated with outcomes after THA or TKA for older adults who may have been cared for in inpatient settings (ie, inpatient rehabilitation or skilled nursing facility [SNF]). Eligible articles were conducted in the United States and were published between January 1, 2000, and December 31, 2021. RESULTS: We included 8 articles focused on patient factors and 9 focused on facility factors. Most included older adults and the majority were White (in those reporting race/ethnicity). Most studies evaluated outcomes at discharge and showed that patients admitted to inpatient rehabilitation facilities had either similar or better functional outcomes (mobility, self-care, and functional independence measure (FIM) score) and lower length of stay compared with those in SNFs. Few studies focused on home health care. CONCLUSIONS: The systematic review focused on older adults showed that findings in these patients are consistent with previous research. Older adults undergoing THA/TKA had acceptable outcomes regardless of postsurgical, inpatient setting of care. Research conducted after CMS payment reforms, in home health care settings, and in more diverse samples is needed. Given the known racial/ethnic disparities in THA/TKA and the shifts to postsurgical home health care with little regulatory oversight of care quality, contemporary research on outcomes of postsurgical THA/TKA outcomes is warranted.

Enhanced recovery after surgery combined with quantitative rehabilitation training in early rehabilitation after total knee replacement: a randomized controlled trial.

BACKGROUND: The number of patients undergoing total knee replacement (TKR) is increasing yearly; however, there is still a relative lack of specific, individualized, and standardized protocols for functional exercise after TKR. Quantitative rehabilitation training was developed to improve the recovery of postoperative joint function, increase patient satisfaction, shorten the length of the hospital stay, improve the quality of life, and promote rapid patient recovery. AIM: We aimed to compare the effectiveness of quantitative rehabilitation training based on the enhanced recovery after surgery (ERAS) concept with conventional rehabilitation training in the early rehabilitation of patients with TKR. DESIGN: This was a single-centre, prospective, randomized controlled trial. SETTING: Inpatient department. POPULATION: Participants were patients who underwent unilateral total knee replacement. METHODS: Based on the ERAS concept, a quantitative rehabilitation training program was developed for the quantitative group, and the control group underwent conventional rehabilitation training. Seventy-eight patients undergoing TKR were randomly divided into two blinded groups: the quantitative rehabilitation group and the conventional rehabilitation group. The analysis was performed according to per-protocol practice. The primary outcome metric was the Hospital for Special Surgery Knee Score (HSS Score), and secondary outcomes included patient satisfaction, Visual Analog Pain Score (VAS), time to get out of bed for the first time after surgery, 6-minute-walk test (6MWT), quality-of-life score (SF-36), and number of days in the hospital. The incidence of postoperative complications was also recorded. RESULTS: There was no significant difference in HSS scores between the two groups before surgery (P=0.967), but the quantitative rehabilitation training group had significantly higher scores at two weeks (P=0.031), 3 months (P<0.01), and 12 months (P<0.01) after surgery than did the conventional rehabilitation training group, and both groups had higher HSS scores than before surgery. The quantitative training group had significantly higher VAS scores at 24 hours and three days postoperatively than the conventional training group (P<0.01), while there was no statistical significance at any other time points. The quantitative rehabilitation group had an earlier time to get out of bed for the first time after surgery (P<0.01), a longer 6MWT distance (P=0.028), and higher patient satisfaction and quality of life scores (SF-36) (P<0.01) that did the control group. The number of days in the hospital was lower in the quantitative training group than in the control group (P<0.001). There was no significant difference in the incidence of postoperative complications between the two groups. CONCLUSIONS: Compared with conventional rehabilitation training, quantitative rehabilitation training based on the ERAS concept was found to be safe and effective and can accelerate the recovery of joint function after surgery, shorten hospitalization time, improve patient satisfaction, and promote rapid recovery. CLINICAL REHABILITATION IMPACT: The quantitative rehabilitation training based on the ERAS concept provides a new program for rehabilitation exercises after total knee arthroplasty, which is safe and reliable, accelerates the recovery of joint function, and should be considered for clinical promotion.

Reliability, Concurrent Validity, and Minimal Detectable Change of the Hand-Held Dynamometry for the Assessment of Knee Muscle Strength in Patients With Revision Total Knee Arthroplasty.

OBJECTIVE: To determine the concurrent validity, reliability, and minimal detectable change (MDC) of the hand-held dynamometry (HHD) for knee strength measurement in patients with revision total knee arthroplasty (r-TKA). DESIGN: A reliability and validity analysis. SETTING: Orthopedic and physical therapy services of university hospital. PARTICIPANTS: The study included 42 patients with r-TKA (N=42). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Knee muscle strength assessments were performed by 2 physiotherapists in 3 different sessions by using HHD. Participants were instructed to exert a maximal force for lasting 5 seconds against HHD. The first examiner performed the strength testing, and after 30-minutes rest, the second examiner performed the same procedure for inter-examiner reliability. One hour after the initial testing, the first examiner reperformed the strength testing for intra-examiner reliability. The correlations of the knee extensors and knee flexors strength with 50-foot walking test and 30-second chair stand test were assessed for concurrent validity. RESULTS: The inter-examiner reliabilities of knee extensors and flexors strength measurements were 0.97 and 0.95, respectively. The SEM and the minimal detectable changes at 95% confidence level (MDC95) for knee extensors were 10.39 and 28.65 Newton-meters (Nm), and SEM and MDC95 for knee flexors were 8.70 and 23.99 Nm, respectively. The intra-examiner reliabilities of knee extensors and flexors strength measurements were 0.96. SEM and MDC95 for knee extensors were 12.00 and 33.09 Nm, and SEM and MDC95 for knee flexors were 7.78 and 21.45 Nm, respectively. The knee muscle strength showed strong significant correlations with physical performance tests (all, P<.05). CONCLUSIONS: The HHD is a reliable and valid method for assessment of static knee strength after r-TKA. The HHD can be used to quantify changes in knee strength and also assists the clinicians to determine the effect of rehabilitation programs on muscle strength following r-TKA surgery.

Effects of a Hybrid Teaching Program on Lower Limb Muscle Strength, Knee Function, and Depression in Older Adults After Total Knee Replacement: A Randomized Controlled Trial.

The aim of the current study was to evaluate the effects of a nurse-led hybrid teaching program on lower limb strength, knee function, and depression in older adults after total knee replacement (TKR). This was a single-blind, randomized controlled trial. Fifty-two patients who underwent TKR were randomly assigned to either the experimental group (EG; n = 26), which received routine care plus 16 weeks of home rehabilitation through a hybrid teaching program, or the control group (CG; n = 26), which received routine care only. The intervention included pre-discharge face-to-face education, video instructions to follow at home after discharge, and four monthly telephone-based follow ups during the 16 weeks post-surgery. After the 16-week intervention, participants in the EG exhibited improved quadriceps strength, hamstring strength, and Knee Injury and Osteoarthritis Outcome Score (KOOS) compared to those in the CG. Generalized estimating equation analyses revealed a significant group-by-time interaction effect on quadriceps strength, overall KOOS score, and Geriatric Depression Scale-Short Form score. Findings suggest that a nurse-led hybrid teaching program enhances physical and psychological function after TKR when compared to routine care. This hybrid teaching program, involving exercise and postoperative education, proves to be a feasible and cost-effective intervention for improving outcomes in older adults following TKR. Health care teams should consider it as a viable home rehabilitation option for older adults who undergo TKR. [Research in Gerontological Nursing, 17(1), 31-40.].

A Smartphone Application-Based Remote Rehabilitation System for Post-Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Trial.

BACKGROUND: Remote rehabilitation after total knee arthroplasty has gradually gained popularity in recent years. This study aimed to determine whether smartphone application-based remote rehabilitation could outperform home-based rehabilitation and outpatient guidance in terms of 12-week outcomes following primary unilateral total knee arthroplasty. METHODS: Patients who underwent primary unilateral total knee arthroplasty were recruited and randomly divided into a telerehabilitation group and a control group. A total of 100 patients were examined, with 50 each assigned to the telerehabilitation and control groups. In the telerehabilitation group, a telerehabilitation application was installed on the smartphones of the participants to allow postdischarge guidance. The primary outcomes were knee range of motion (ROM) at 12 weeks postoperatively. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score, The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Five Times Sit-to-Stand Test (5xSST), Single-Leg Stance Test (SLST), satisfaction, rehabilitation costs, complication rate, and 90-day readmission rate. All outcomes were collected at 2, 6, and 12 weeks after surgery. RESULTS: At 12 weeks postoperatively, the telerehabilitation patients significantly outperformed the controls in terms of knee ROM (124 ± 8.7 versus 119 ± 5.5 P = .01), SF-36 (physiological function) (61.5 ± 20.3 versus 45.5 ± 18.1 P = .000), SF-36 (role-physical) (49.3 ± 41.5 versus 27.7 ± 28.9 P = .012), SLST (13.0 ± 9.1 versus 9.1 ± 5.9 P = .026), and 5xSST (17.7 ± 4.3 versus 19.4 ± 3.5 P = .043). No significant differences were found between groups in the Western Ontario and McMaster Universities Osteoarthritis Index score, Knee Society Score, rehabilitation costs, 90-day readmission rate, or incidence of adverse events. CONCLUSION: Our study showed that smartphone app-based remote rehabilitation worked better than home-based rehabilitation with outpatient guidance in terms of short-term results in ROM, SLST, and 5xSST.

High-Intensity Progressive Rehabilitation Versus Routine Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: This study aimed to compare the effectiveness of high-intensity progressive rehabilitation training with routine training in the early treatment of patients undergoing total knee arthroplasty. METHODS: There were 78 patients who underwent total knee arthroplasty and were randomized into high-intensity progressive training and routine rehabilitation training groups (RRT). The primary outcome measures were the American Hospital for Special Surgery Knee Score (HSS), with secondary outcomes including patient satisfaction, visual analog pain score, first time of standing after surgery, 6-minute walk test, 36-Item Short Form Survey (SF-36), and length of hospital stay. The incidence of postoperative complications were recorded. RESULTS: The HSS scores were higher in the intervention group at 2 weeks, 3 months, and 12 months postoperatively (P < .001). The RRT group had higher visual analog pain scores than the intervention group at 24 hours, 3 days, and 2 weeks after surgery (P < .001). The intervention group had an earlier the first time of standing after surgery and a longer 6-minute walk test distance (P < .001, P = .028, P < .001, P < .001). Patient satisfaction was higher in the intervention group, with a higher quality of life rating at 3 months postoperatively (P < .001). However, 1 year after surgery, the 2 groups had no significant differences in mental component summaries. The length of hospital stay was shorter in the intervention group than in the RRT group. CONCLUSION: Compared to routine training, high-intensity progressive rehabilitation training is more effective. It reduces postoperative patient pain, accelerates recovery of joint function, increases patient satisfaction, improves quality of life, shortens hospital stays, and promotes rapid recovery.

Effectiveness of an online management platform (Joint Cloud) versus standard process for patients undergoing total knee arthroplasty: study protocol for a prospective randomised controlled trial.

INTRODUCTION: Osteoarthritis (OA) is one of the main causes of mobility impairment in the elderly worldwide. Therefore, total knee arthroplasty (TKA) is often performed and is one of the most successful surgery and has resulted in substantial quality-of-life gains for people with end-stage arthritis. There is still room for improvement in the standard treatment process in the preoperative, intraoperative and postoperative period of TKA. Telerehabilitation has the potential to become a positive alternative to face-to-face rehabilitation nowadays. But it remains unclear how well telemedicine interventions cover the entire surgical pathway (preoperation, intraoperation, postoperation). This study aims to explore the effectiveness of Joint Cloud (JC, an online management platform) compared with existing standard process in regulating functional recovery, pain management, muscle strength changes and other health-related outcomes in patients undergoing total knee arthroplasty preoperation, intraoperation and postoperation. METHODS AND ANALYSIS: A randomised controlled trial was designed to compare the online management platform (JC) with standard process (SP) in patients undergoing TKA. A total of 186 TKA patients will be randomly assigned to the intervention (n=93) or control (n=93) group. Patients in the intervention group will receive access to the 'JC' mini-program. This mini-program provides popular science information (eg, information about OA and TKA), functional exercise information and communication channels. Patients evaluate their condition and functional level through standardised digital questionnaires. The control group of patients will not accept any functions of this mini-program. The primary outcome is knee functional recovery, and the secondary outcomes are pain management, isometric knee extensor muscle strength, patient satisfaction and cost-benefit analysis. Assessments will be performed 1 month and 3 days before surgery (T0) and 1 month and 3 months after surgery. Data analysis will be performed according to the intent-to-treat (ITT) principle. Repeated measures of linear mixed models and parametric and non-parametric testing will be used for statistical analysis. ETHICS AND DISSEMINATION: The study was reviewed and approved by the Tianjin Hospital Medical Ethics Review Committee on 10 February 2023 (2022YLS155). Test data are considered highly sensitive but are available upon request. The findings will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER: ChiCTR2300068486.

Preoperative carbohydrate drink in fast-track primary total knee arthroplasty: a randomized controlled trial of 168 patients.

A key component in fast-track total knee arthroplasty (TKA) is early mobilization. Preoperative fasting might cause orthostatic hypotension and -intolerance which both can interfere with early mobilization. It was hypothesized that consuming a carbohydrate drink 2-3 hours prior to surgery is a viable option to reduce orthostatic hypotension, and as a result, improve rehabilitation. In this randomized controlled trial, all consecutive unilateral primary TKA patients were reviewed for eligibility. Exclusion criteria were American Society of Anesthesiologists (ASA) class above 3, older than 80 years of age, Diabetes Mellitus, and an insufficient comment of Dutch language. Patients were distributed in two groups. The control group was allowed to eat till 6 hours and drink clear fluids till 2 hours before surgery (standard treatment). The intervention group consumed, additionally to the standard treatment, a carbohydrate drink 2-3 hours before surgery. Blood pressure was measured both lying and standing as a measure for orthostatic hypotension during first time postoperative mobilization on day of surgery. A total of 168 patients were included. Prevalence of orthostatic hypotension in the control- and intervention group was 24 patients (34%) and 14 patients (19%) respectively, (p=0.05). Prevalence of orthostatic intolerance was 13 patients (19%) in the control group and 9 patients (13%) in the intervention group (p=0.32). No drink related adverse events occurred. In conclusion, taking a carbohydrate drink 2-3 hours before TKA significantly lowers the number of patients with orthostatic hypotension in early mobilization. However, the clinical relevance of the carbohydrate drink has to be studied further.

Early application of extracorporeal shock wave therapy improves pain control and functional scores in patients undergoing total knee arthroplasty: a randomized controlled trial.

PURPOSE: The use of biophysical stimuli produced by extracorporeal shock wave therapy (ESWT) can improve the rehabilitation treatment of patients undergoing total knee arthroplasty (TKA). The aim of our study is to evaluate the short-term efficacy of early postoperative ESWT in combination with physiotherapy in terms of pain reduction and motor function recovery of patients undergoing TKA and compare it with conventional physiotherapy treatment. METHODS: Fifty-six patients undergoing TKA were enrolled in the study from January 2019 to February 2020. Patients received two sessions of physiotherapy daily, with (experimental group) or without (control group) four sessions of ESWT within seven days after surgery. Patients were prospectively evaluated at baseline and at post-operative day two and seven. Assessment included active knee range of motion (aROM), timed up and go (TUG) test, visual analogue scale (VAS) for pain, and Borg scale. RESULTS: Fifty patients completed the study. Both treatments proved to be effective in reducing pain and improving the knee range of motion and functional scores at seven days after surgery: the aROM in the ESWT group was 36.8 ± 11.0 grades (p < 0.001), while in control group was 19.8 ± 7.8 grades (p < 0.001). TUG, VAS, and BORG scores showed a similar trend. Comparative analysis revealed superior clinical results for the experimental group in all the outcomes, in particular aROM (96.0 ± 5.40 vs. 81.20 ± 11.01, p < 0.001) and TUG test (17.4 ± 5.61 vs. 21.24 ± 5.88, p < 0.001), at day seven after surgery. CONCLUSION: Early application of ESWT in addition to physiotherapy can positively influence the rehabilitation process after TKA. The treatment proved to be well tolerated and safe. Preliminary results demonstrated better pain control and functional scores compared to physiotherapy alone.

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.

Effectiveness of using a chatbot to promote adherence to home physiotherapy after total knee replacement, rationale and design of a randomized clinical trial.

BACKGROUND: Rehabilitation is essential to optimize outcomes after surgical procedures in musculoskeletal disorders. However, adherence to rehabilitation continues to be an important barrier, since compliance with the programs is not always as desired, which may have a negative impact on clinical results. METHODS: Randomized controlled trial aimed at to determining the effectiveness of using a virtual assistant (i.e., chatbot) to promote adherence to home rehabilitation. Overall, seventy patients under 75, undergoing total knee replacement, who have a personal smartphone and are familiar with its use, will be assigned into the control (standard care) or the experimental (standard care plus virtual assistant) group. Adherence (primary outcome) will be assessed three months after surgery. The WOMAC questionnaire, knee pain and system usability scale will be also outcomes of interest at three months and one year. Overall, an analysis of variance will look for possible time, group and time*group interactions. DISCUSSION: The expected result is to determine whether the use of a chatbot that interacts with the patient can increase adherence to post-surgical home physiotherapy, and result in better clinical results (functional and pain) than standard care. TRIAL REGISTRATION: clinicaltrials.gov id. NCT05363137.

Cost, time savings and effectiveness of wearable devices for remote monitoring of patient rehabilitation after total knee arthroplasty: study protocol for a randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is a surgical procedure primarily used to treat patients with end-stage knee osteoarthritis (KOA). Postoperative physical exercise is a critical part of the overall treatment of KOA and can bring significant benefits to the patients' recovery. Wearable devices can monitor patients' exercise data and upload it to the physician's workstation. This allows the rehabilitation physician to make timely adjustments based on the patients' movement feedback, and the surgeon can be informed of the patients' functional status. Overall, this study aims to evaluate the effectiveness of using wearable monitoring devices for rehabilitation exercise after TKA, with a focus on cost, time savings, and patient outcomes. METHOD/DESIGN: This is a single-center, single-blinded, parallel randomized controlled trial conducted at Xi'an Honghui Hospital, a regional orthopedic medical center. Eligible patients will be recruited to participate in the study, and baseline data collection and clinical assessments will be conducted at the time of admission. Using the principle of random allocation, recruited patients will be divided into either the experimental or control group. Both groups will undergo a standard, widely promoted rehabilitation program. The patients in the experimental group will wear equipment to detect and track mobility in the lower limbs. All patients will return to the outpatient clinic for follow-up assessments at 2 weeks, 12 weeks, and 24 weeks after discharge, where outcome indicators will be measured. The primary outcome will be the cost and time after discharge, while secondary outcomes will include the 6-min walk test (6MWT), range of motion (ROM), visual analog scale (VAS), American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). DISCUSSION: We should encourage the adoption of novel, easy-to-use, supervised devices if they prove to be beneficial for patients in terms of cost, time, and effectiveness after TKA. This type of device is particularly important for people in remote rural areas, those with limited financial resources, and those who are reluctant to return to hospitals for follow-up care. Trial registration Chinese Clinical Trial Registry ChiCTR2300068418. Registered on 17 February 2023.

Heterogeneous trajectories of kinesiophobia and their effects on rehabilitation outcomes after total knee arthroplasty: a prospective cohort study.

BACKGROUND: Kinesiophobia is one of the most common and aversive psychological phenomena among patients after total knee arthroplasty (TKA). This study aimed to identify trajectories of kinesiophobia, examine factors distinguishing these trajectories, and clarify the association between trajectories of kinesiophobia and rehabilitation outcomes. METHODS: In this prospective cohort study, the patients who underwent TKA were recruited between December 2021 and April 2022 from three orthopedic wards of a tertiary hospital in China. Kinesiophobia was measured using the Tampa Scale for Kinesiophobia at baseline (T0), and then at 1 month (T1) and 3 months (T2) after TKA to perform latent class growth analysis. Meanwhile, rehabilitation outcomes were assessed at 3 months after TKA, using the Kessler Psychological Distress Scale, the Hospital for Special Surgery-Knee Scale, Barthel Index, and the Impact on Participation and Autonomy questionnaire. RESULTS: The four kinesiophobia trajectories identified were as follows: low stable group (n = 120), rapid recovering group (n = 31), slow recovering group (n = 48), and stable moderate group (n = 58). Body mass index, employment status, heart disease, and pain degree significantly predicted trajectory groups (all p < 0.05). Analysis of variance revealed significant differences between the four kinesiophobia trajectories concerning all rehabilitation outcomes, except for the activities of daily living. CONCLUSION: Distinct kinesiophobia trajectories were identified, and nurses should assess the kinesiophobia of patients after TKA in the early phase. Patients in the slow recovering group are worthy of a specific focus because of their poor recovery after undergoing TKA. As important sources of psychosocial care, nurses need to customize psychological interventions for patients after TKA depending on each kinesiophobia trajectory.

Preoperative Exercise Has a Modest Effect on Postoperative Pain, Function, Quality of Life, and Complications: A Systematic Review and Meta-Analysis.

OBJECTIVE: Preoperative exercise (prehabilitation) is commonly used as a method to reduce pain and improve function postoperatively. The purpose of this systematic review was to determine therapeutic benefits of preoperative exercise on postoperative pain, function, quality of life (QOL), and risk of complications across various types of surgeries. METHODS: Three electronic databases were used to perform a literature search. Full articles with randomized designs comparing a preoperative exercise program vs no formal program were included. The primary outcome was postoperative pain. QOL, function, and postoperative complications were analyzed as secondary outcomes. The primary meta-analysis was performed in those with joint replacement surgery because there were only 5 with other surgical types. RESULTS: A total of 28 articles were included, of which 23 were from individuals with total joint replacement surgery. Preoperative exercise resulted in lower pain ≤2 months and 3 to 5 months after joint replacement surgery with a moderate standardized mean difference (95% CI at <2 months = -0.34 [-0.59 to -0.09]; at 3 to 5 months = -0.41 [-0.70 to -0.11]) compared with nonexercised controls. However, ≥6 months after joint replacement surgery, preoperative exercise groups showed no significant differences in postoperative pain (standardized mean difference = -0.17 [-0.35 to 0.01]) compared with nonexercised controls. QOL and subjective and objective function were improved ≤2 months after joint replacement surgery but were not different ≥6 months post-surgery. Reduction in risk of postoperative complications was favored with preoperative exercise. CONCLUSION: Preoperative exercise has a modest effect on postoperative pain, function, and quality of life within the first 6 months after surgery and reduces the risk of developing postoperative complications in individuals undergoing joint replacement surgery. The effect of preoperative exercise on other surgery types is inconclusive. IMPACT: This systematic review supports using preoperative exercise to improve pain and function outcomes for those with joint replacement surgery.