Understanding the Patient Perspective When Designing Future Rehabilitation Interventions after Hip or Knee Replacement Surgery-A Patient and Public Involvement Exercise.

Background and Objectives: Following discharge from hospital, there can be variability in the rehabilitation of patients who have undergone total hip or knee replacement surgery. We invited patients who had had hip or knee replacement surgery to take part in patient and public involvement sessions to help us understand their recovery needs and how rehabilitation services could potentially be improved to meet these needs better. Materials: Patients (n = 14) were invited to one of two patient advisory group sessions which took place in a university setting. Results: Feedback from patients highlighted the need for an inclusive, evidence-based intervention that would benefit patients experiencing all levels of pain, with differing motivations for recovery. Patients desired social support with others who have had similar surgery to reduce the burden of isolation during rehabilitation. Furthermore, patients valued the involvement of their partners and carers in their rehabilitation, to provide social support and guidance on recovery. Patients also expressed a need for consistent information and expert guidance on all aspects of their recovery. Conclusions: These findings can be used to guide the design of rehabilitation interventions following hip and knee replacement and ensure that patient perspectives inform future practice.

Strength and endurance deficits in adults with moderate-to-severe hip osteoarthritis, compared to healthy, older adults.

PURPOSE: This study compares lower limb muscle strength and endurance in adults with hip osteoarthritis, to an age-matched control group. METHODS: Thirteen adults with moderate-to-severe hip osteoarthritis (as graded by the Oxford Hip Score) and fifteen older adults participated. Maximal voluntary isometric contraction of the knee extensors, knee flexors and hip abductors and isotonic endurance of the knee extensors were measured using a dynamometer. Function was assessed using the 30-second chair stand test, the 40 m fast-paced walk test and a stair negotiation test. Data were compared between groups using t-tests. RESULTS: Participants with hip osteoarthritis demonstrated weakness in the affected limb when compared to the control limb during knee flexion (34%, p = 0.004) and hip abduction (46%, p = 0.001). Weakness was also observed in the contralateral knee flexors (31%, p = 0.01). When compared to the control limb, the knee extensors of the hip osteoarthritis group were exhausted prematurely in the affected (70%, p = 0.001) and contralateral limb (62%, p = 0.005). The hip osteoarthritis group took twice as long to stair climb (p = 0.002), walked 40% slower, (p < 0.001), and had a 35% lower sit-stand performance (p < 0.001). CONCLUSIONS: Moderate-to-severe hip osteoarthritis may be characterised by bilateral deficits in lower-limb maximal strength, markedly lower knee extensor endurance and impaired functional performance.Implications for rehabilitationIn addition to bilateral deficits in maximal strength of the hip and knee muscles, moderate-to-severe hip osteoarthritis may be characterised by markedly lower muscular endurance of the knee extensors and impaired functional performance.The endurance capacity of the knee extensors can play an important role in daily function, and thus it is important to consider endurance training principles when prescribing exercise for this patient group.Research studies evaluating exercise programmes underpinned by endurance training principles are required to understand the benefits to patients with hip osteoarthritis, and to inform specific exercise prescription in clinical practice.

Adherence to Neuromuscular Electrical Stimulation Interventions for Muscle Impairment in Hip and Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Neuromuscular electrical stimulation (NMES) provides a promising approach to counteract muscle impairment in hip and knee osteoarthritis, and to expedite recovery from joint replacement surgery. Nonetheless, application into clinical orthopaedic practice remains limited, partly due to concerns regarding patient tolerance. OBJECTIVES: This systematic review aimed to quantify levels of adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis and identify strategies to increase compliance. DATA SOURCES: Randomised controlled trials (RCTs) were identified in a web-based literature review, completed in December 2020. The databases sourced included the Cochrane Library, CINAHL Complete, Medline Complete and PubMed. ELIGIBILITY CRITERIA: Studies were included if they were: (i) conducted in cohorts of adults with hip or knee osteoarthritis; (ii) a protocol of electrical muscle stimulation prescribed to treat muscle impairment; and (iii) reported intervention adherence or attrition rate. Data were extracted on adherence rate, reasons for non-adherence and potential strategies to increase adherence. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale. RESULTS: The search yielded 120 articles, of which 15 studies were considered eligible and included in the analysis (n = 922). All NMES treatment was applied to the quadriceps, with 1 study targeting the quadriceps and calves. The mean PEDRO score of the included studies was 6.80 out of a possible 10 (range 6-8). Mean adherence did not differ between groups receiving treatment with NMES (85% ± 12%) and control groups receiving voluntary exercise or education (84% ± 9%) (P = .97). Reasons for non-adherence or attrition included a dislike of the device, dizziness, pain and discomfort. Strategies to increase adherence included NMES education, a familiarisation period, supervision, setting thresholds based upon patient tolerance, monitoring pain levels during stimulation and using built-in adherence trackers. CONCLUSIONS: This systematic review indicates that adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis in clinical trials does not differ to control groups receiving education or voluntary exercise, and hence should not be a barrier to application in clinical practice.

The quality of intervention reporting in trials of therapeutic exercise for hip osteoarthritis: a secondary analysis of a systematic review.

BACKGROUND: Therapeutic exercise is recommended as a core treatment for hip osteoarthritis (HOA). Whilst it is widely accepted that exercise can improve pain and disability, optimal type and dose of exercise are yet to be agreed upon. This may, in part, be attributed to the wide variation and inadequate reporting of interventions within the literature. This study evaluates the quality of intervention reporting among trials of therapeutic exercise in HOA. METHODS: Randomised controlled trials (RCTs) were sourced in a systematic review, completed in August 2020. Two raters independently used the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT) to evaluate intervention reporting. Correlations between quality assessment scores and CERT and TIDieR scores evaluated the relationship between internal validity and external applicability. The year of publication was compared to the quality of reporting scores. RESULTS: Fourteen RCTs were included in the analysis. On average, studies were awarded 9.43 ± 1.95 out of 12 points for the TIDieR checklist (range 4-12) and 13.57 ± 4.01 out of 19 points for the CERT (range 5-19). Pearson's correlation coefficient suggested that the quality of reporting had improved over time and that there was a fair, positive relationship between internal validity and external applicability. DISCUSSION: Whilst the quality of intervention reporting is improving, many RCTs of therapeutic exercise in HOA lack the detail necessary to allow accurate evaluation and replication. Researchers are encouraged to utilise the standardised reporting guidelines to increase the translation of effective interventions into clinical practice.

Lab-based feasibility and acceptability of neuromuscular electrical stimulation in hip osteoarthritis rehabilitation.

INTRODUCTION: Neuromuscular electrical stimulation (NMES) could provide an alternative or adjunct treatment modality to induce muscle hypertrophy in the hip osteoarthritis population. This preliminary study evaluates the feasibility and acceptability of NMES to evoke involuntary muscle contractions in adults with advanced hip osteoarthritis. METHODS: Thirteen adults with moderate-to-severe hip osteoarthritis and fifteen healthy, older adults were invited to a lab-based testing session. NMES was applied unilaterally to the knee extensors and hip abductors for one continuous, five-minute testing session. Data were collected on device acceptability, tolerability and muscle contractile force, and compared between groups. RESULTS: Electrical stimulation of the knee extensors elicited a visible muscular contraction in 11 participants (85%) with hip osteoarthritis and 15 controls (100%) at an intensity acceptable to the participant. Electrical stimulation of the hip abductors elicited a muscular contraction in eight participants (62%) with osteoarthritis, and ten controls (67%). Muscle contractile force, pain, discomfort and acceptability did not differ between groups, however NMES of the knee extensors was favoured across all measures of assessment when compared to the hip abductors. CONCLUSIONS: Electrical stimulation of the knee extensors may be a feasible and acceptable treatment modality to address muscle atrophy in adults with advanced hip osteoarthritis.

Effect of neuromuscular electrical stimulation on the recovery of people with COVID-19 admitted to the intensive care unit: A narrative review.

The rehabilitation of patients with COVID-19 after prolonged treatment in the intensive care unit is often complex and challenging. Patients may develop a myriad of long-term multiorgan impairments, affecting the respiratory, cardiac, neurological, digestive and musculoskeletal systems. Skeletal muscle dysfunction of respiratory and limb muscles, commonly referred to as intensive care unit acquired weakness, occurs in approximately 40% of all patients admitted to intensive care. The impact on mobility and return to activities of daily living is severe. Furthermore, many patients experience ongoing symptoms of fatigue, weakness and shortness of breath, in what is being described as "long COVID". Neuromuscular electrical stimulation is a technique in which small electrical impulses are applied to skeletal muscle to cause contractions when voluntary muscle contraction is difficult or impossible. Neuromuscular electrical stimulation can prevent muscle atrophy, improve muscle strength and function, maintain blood flow and reduce oedema. This review examines the evidence, current guidelines, and proposed benefits of using neuromuscular electrical stimulation with patients admitted to the intensive care unit. Practical recommendations for using electrical muscle stimulation in patients with COVID-19 are provided, and suggestions for further research are proposed. Evidence suggests NMES may play a role in the weaning of patients from ventilators and can be continued in the post-acute and longer-term phases of recovery. As such, NMES may be a suitable treatment modality to implement within rehabilitation pathways for COVID-19, with consideration of the practical and safety issues highlighted within this review.

A cycling and education intervention for the treatment of hip osteoarthritis: A quality improvement replication programme.

OBJECTIVES: The Cycling against Hip Pain programme is a 6-week exercise and education treatment pathway for people with hip osteoarthritis. Preliminary results of the Cycling against Hip Pain programme found significant improvements in clinical and patient-reported outcome measures for patients referred from primary care. This article evaluates the effectiveness of the changes made to the pathway in a quality improvement replication programme. METHODS: The replicated Cycling against Hip Pain programme was delivered between February 2018 and September 2019 in a region of England with a high percentage of adults aged over 65 years. All participants were referred from the orthopaedic outpatient department of the funding hospital (secondary care). The programme was delivered at a local leisure centre and combined 30 min of education on osteoarthritis with 30 min of progressive static cycling, once a week for 6 weeks. RESULTS: The participants on the replicated Cycling against Hip Pain programme did not differ from the original cohort in terms of age or pre-programme weight, however, presented with worse hip symptoms at baseline. Consistent with the findings from the original cohort, participants demonstrated significant improvements to their Oxford Hip Score, 30-s chair stand performance, Timed Up and Go score, Hip Osteoarthritis Outcome Score function and pain, EQ5D health rating, EQ5D-5L score and pain at rest and on weight bearing. In addition, participants reported an increase in knowledge, confidence and motivation to exercise. CONCLUSION: A 6-week cycling and education intervention for the treatment of hip osteoarthritis provided benefits to function, pain and quality of life for patients referred from secondary care. These results are consistent with findings from patients who were referred from primary care and further support the potential of the pathway in the conservative management of hip osteoarthritis.

A Single-Centre Feasibility Randomised Controlled Trial Comparing the Incidence of Asymptomatic and Symptomatic Deep Vein Thrombosis Between a Neuromuscular Electrostimulation Device and Thromboembolism Deterrent Stockings in Post-Operative Patients Recovering From Elective Total Hip Replacement Surgery.

BACKGROUND: Total hip replacement is recognised as a major risk factor for deep vein thrombosis (DVT). The aim of this study was to investigate the feasibility of using a novel neuromuscular electrical stimulation device (NMES) for DVT prevention in patients recovering from elective hip replacement surgery. METHODS: Twenty-eight patients undergoing total hip replacement were randomised to receive postoperative treatment with either the NMES device or compression stockings continually from post-surgery until discharge (day 4). The primary outcome measure was the presence of symptomatic or asymptomatic DVT at 48 hours post-surgery and on the day of discharge from hip replacement surgery, as assessed by Duplex ultrasound. Secondary outcomes included hemodynamic responses to the devices, lower limb oedema, sit-to-stand and timed-up-and-go (TUG) scores, and hip range of motion. RESULTS: In the compression stockings group, two cases of asymptomatic DVT were identified by Duplex ultrasound at 48 hours post-surgery. No cases were found in the NMES group. Patients in the NMES group demonstrated a general trend of a decrease in leg volume from post-surgery to discharge, whereas leg volume largely remained static for the compression stockings group. In addition, positive hemodynamic effects were found in favour of the NMES group in the non-operated leg. The change in TUG scores also favoured the NMES group (NMES: 150 ± 152%, compression stockings: 363 ± 257% (p=0.03)), whereas no differences in sit-to-stand scores or hip range of motion were observed. CONCLUSIONS: This study supports the feasibility of NMES as an alternative mechanical prophylaxis worn in the postoperative phase until discharge and provides important findings for clinicians considering novel mechanical prophylaxis options.

Self-Management of Hip Osteoarthritis Five Years After a Cycling and Education Treatment Pathway.

The Cycling against Hip Pain (CHAIN) programme is a six-week cycling and education treatment pathway for people with hip osteoarthritis. Preliminary results demonstrated significant improvements in clinical and patient-reported outcome measures following the course. Whilst the benefits of exercise for osteoarthritis are often reported in the short term, less is known about the long-term effects for this patient group. This study explores whether participants continued to self-manage their hip osteoarthritis five years after completing the course. A cross-sectional survey was conducted to collect data from participants who completed the CHAIN programme between October 2013 and February 2015 (n = 96). Questionnaires were sent by post in April 2019, and then non-responders were followed up again four weeks later. Eighty-three (87%) participants responded to the survey. Five years (range 4-6) after completion of a six-week cycling and education programme, 37 (45%) participants had not returned to their general practitioner for further treatment of their hip pain, and 47 (57%) had not pursued surgical intervention. All participants were still engaged in at least one physical activity per week and many reported that they had purchased a bike (29%), joined a gym (30%) or cycled regularly (indoor cycling 25%, outdoor cycling 24%). Eighty (96%) participants reported an increase in knowledge of self-managing their symptoms. The findings from this study suggest that many patients are motivated to self-manage their hip osteoarthritis, five years following a six-week cycling and education treatment pathway that encourages lifestyle change.

Patient Information Leaflets for Lumbar Spine Surgery: A Missed Opportunity.

BACKGROUND: High-quality patient information is recommended to help reduce procedure-related anxiety and encourage patients to become active participants in their recovery. The objective of this study was to analyze the quality of patient information leaflets (PILs) given to National Health Service (NHS) patients ahead of lumbar spine surgery. METHODS: The DISCERN tool was used to evaluate the quality of PILs, sourced from NHS websites. RESULTS: Thirty-two PILs on lumbar surgery were included. Two (6%) leaflets were considered poor, 13 (41%) were marked as fair, 14 (44%) were of good quality, and 3 (9%) were scored as excellent. The total mean score was 55 (30-74), which corresponds to good quality. The lowest scoring questions were sources of information (Q4), balanced/unbiased content (Q6), and explanation of no treatment (Q12). CONCLUSIONS: There is considerable variation in the quality of PILs provided ahead of lumbar spine surgery. The scope for improvement is clear, and as the move toward patient-centered, evidence-based care continues, it is important that hospital resources provide recommendations based upon evidence of clinical effectiveness.

A preoperative education class reduces length of stay for total knee replacement patients identified at risk of an extended length of stay.

OBJECTIVE: To establish whether attendance at an education class prior to total hip or knee replacement surgery as part of an enhanced recovery after surgery pathway could decrease length of hospital stay. METHODS: A single-site, retrospective cohort study comparing length of stay in hospital for patients who attended and did not attend an education class prior to hip or knee replacement surgery. Patients were stratified into 3 groups according to the predicted likelihood of an extended inpatient hospital stay using the Risk Assessment Predictor Tool. RESULTS: Mean length of stay reduced by 0.37 days for patients who received hip replacement (n = 590) (95% confidence interval (95% CI) -0.74, -0.01, p = 0.05) and by 0.77 days for patients who underwent knee replacement (n = 643) (95% CI -1.23, -0.31, p = 0.001) following attendance at a preoperative education class. Patients undergoing knee replacement who were considered at high risk of an extended hospital stay stayed, on average, 2.59 days less in hospital after attending the class (mean length of stay: 4.52 (standard deviation (SD) 1.26) vs 7.11 (SD 4.18) days (95% CI -4.62, -0.54, p < 0.02). CONCLUSION: This study supports the inclusion of a preoperative education session in this context for both hip and knee replacement procedures, and indicates that this may be most beneficial for patients undergoing knee replacement who are at risk of an extended length of stay.

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review.

Early mobilisation is a cornerstone of Enhanced Recovery after Surgery (ERAS) and is encouraged following spinal procedures. However, evidence of its implementation is limited and there are no formal guidelines on optimal prescription. This narrative review aimed to evaluate the evidence for the effect of early mobilisation following elective spinal surgery on length of stay, postoperative complications, performance-based function and patient-reported outcomes. Four trials (five articles) that compared a specific protocol of early in-hospital mobilisation to no structured mobilisation or bed rest were selected for inclusion. Nine studies that investigated the implementation of a multimodal intervention that was inclusive of an early mobilisation protocol were also included. Results suggest that goal-directed early mobilisation, delivered using an evidence-based algorithm with a clear, procedure-specific inclusion and exclusion criteria, may reduce length of stay and complication rate. In addition, there is evidence to suggest improved performance-based and patient-reported outcomes when compared to bed rest following elective spinal surgery. Whilst this review reveals a lack of evidence to determine the exact details of which early mobilisation protocols are most effective, mobilisation on the day of surgery and ambulation from the first postoperative day is possible and should be the goal. Future work should aim to establish consensus-based, best practice guidelines on the optimal type and timing of mobilisation, and how this should be modified for different spinal procedures.

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery.

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

Does Neuromuscular Electrical Stimulation Improve Recovery Following Acute Ankle Sprain? A Pilot Randomised Controlled Trial.

AIM: Following soft tissue ankle injury, patients are often referred for out-patient physiotherapy and present symptoms including pain, reduced range of movement and function, and oedema. In this study, we assess the use of a neuromuscular electrical stimulation (NMES) device as an adjunctive therapy to reduce oedema in patients recovering from grade I and II ankle sprains. METHODS: This was a single-centre, pilot randomised controlled study, recruiting patients referred to physiotherapy following an ankle sprain. Participants presenting with oedema were randomised to one of two treatment groups: (1) the current standard of care and (2) the current standard of care plus NMES use. Participants were identified in an emergency department and referred to a physiotherapy department for treatment 1 to 5 days following the injury and returned to clinic 7 days later. RESULTS: Twenty-two participants completed the study and had full data sets for analysis (11 in each group). Mean volumetric displacement was reduced in the intervention group in comparison to the standard care group (P = .011); however, there were no between-group differences in figure of eight measurements, function or pain scores. The device was well tolerated, with no device-related adverse events recorded. CONCLUSIONS: In this pilot, randomised controlled trial, NMES was well tolerated by patients following ankle sprain and demonstrated statistically significant improvements in oedema reduction as measured by fluid displacement. No other changes were observed. Further work will need to confirm the clinical significance and effect on longer term recovery post-ankle sprain.

The Effect of Preoperative Education on Psychological, Clinical and Economic Outcomes in Elective Spinal Surgery: A Systematic Review.

Psychosocial factors related to different degrees of clinical impairment and quality of life in the preoperative period may influence outcomes from elective spine surgery. Patients have expressed a need for individualized information given in sufficient quantities and at the appropriate time. Therefore, this review article aims to determine whether a preoperative education session improves clinical, psychological and economic outcomes in elective spinal surgery. PubMed, Cochrane Library, CINAHL Complete, Medline Complete and PsychINFO were searched in July 2018 for randomized clinical trials to evaluate the effects of a preoperative education intervention on psychological, clinical and economic outcomes in spinal surgery. The search yielded 78 results, of which eleven papers (seven studies) were relevant for inclusion. From these results, there is limited, fair-quality evidence that supports the inclusion of a preoperative education session for improving clinical (pain, function and disability), economic (quality-adjusted life years, healthcare expenditure, direct and indirect costs) and psychological outcomes (anxiety, depression and fear-avoidance beliefs) from spinal surgery. Other benefits are reported to be improved patient knowledge, feelings of better preparation, reduced negative thinking and increased levels of physical activity after the intervention. No differences in quality of life, return to work, physical indicators or postoperative complications were reported. From the limited evidence, it is not possible to conclusively recommend that preoperative education should be delivered as a standalone intervention before elective spine surgery; however, given the low risk profile and promising benefits, future research in this area is warranted.

Effectiveness of neuromuscular electrical stimulation for reducing oedema: A systematic review.

OBJECTIVE: This systematic review aimed to assess the clinical impact of neuromuscular electrical stimulation as a treatment modality for patients with oedema. DATA SOURCES AND STUDY SELECTION: PubMed was searched up to July 2018 for randomized and non-randomized clinical trials comparing neuromuscular electrical stimulation vs no stimulation following the formation of oedema. A modified Downs and Black checklist was used to evaluate the quality of the evidence. DATA SYNTHESIS: Initial searches yielded 150 results. Removal of duplicates reduced this number to 97 results. Seventy-five studies were excluded following a review of titles and abstracts. Full-text screening eliminated 15 studies. A final total of 7 studies met the inclusion criteria. Six studies supported the use of neuromuscular electrical stimulation for oedema reduction, and one study did not find an effect, but reported inter-group variance. CONCLUSION: The results of this systematic review support the use of neuromuscular electrical stimulation for ameliorating the abnormal accumulation of interstitial fluid, which is clinically shown as oedema. Neuromuscular electrical stimulation is effective in a number of rehabilitation settings and patient groups, for treatment of both upper and lower limb oedema. However, further trials are needed to reinforce these findings.

A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery.

AIM: The aim of this feasibility study was to investigate the potential role of a novel neuromuscular electrical stimulation (NMES) device in preventing the formation of oedema following total hip replacement (THR). METHODS: Successive primary THR patients were recruited into a randomised controlled trial. Participants were randomised to wear either the NMES device or compression stockings continually from post-surgery until discharge.The main outcome measure was presence of lower limb oedema, assessed by taking measurements of the circumference of the ankle, knee and thigh on the operated leg and non-operated leg, pre-operatively, post-operatively, at two days post-operatively and every day until discharge. Secondary objectives were to compare adverse events, the presence of asymptomatic and symptomatic deep vein thrombosis (DVT) and device tolerability between groups. RESULTS: Data from 40 participants were analysed (NMES (n = 20), compression stockings (n = 20)). The NMES group had significantly less oedema and the device was found to be tolerable and safe. CONCLUSION: The results of this study suggest that the NMES is a safe and well tolerated alternative to compression stockings, which should be considered by clinicians seeking the additional benefit of reducing post-operative oedema. In addition the NMES device should be considered as part of a DVT prophylaxis.

To what extent do current total hip and knee replacement patient information resources adhere to enhanced recovery after surgery principles?

OBJECTIVES: Total hip replacement (THR) and total knee replacement (TKR) are two of the most common orthopaedic surgeries that occur in the United Kingdom (UK) annually. Enhanced recovery after surgery (ERAS) programmes aim to decrease convalescence across procedures. It has been highlighted that post operative physiotherapy routines may not contain the correct ingredients for promoting acceleration of return to function. This research aims to analyse if current THR and TKR patient information resources adhere to ERAS principles, thus optimising post operative recovery. DATA SOURCES: Twenty hip and knee replacement patient information booklets were sourced using a UK Google search. A flowchart of exercise prescription components was formulated from a review of 5 trial booklets. A content analysis was utilised to assess the information included within the patient information booklets. RESULTS: Forty percent of patient information booklets identified their pathways to be ERAS. Fifty five percent of the hospitals stated their patients would be mobilised on the day of surgery. Ninety percent of THR and 100% of TKR guidelines suggested the use of bed exercises for rehabilitation. Fifteen percent of THR and 35% of TKR booklets suggested functional exercise as a method of rehabilitation. Strength or resistance based exercises were proposed in 40% of THR and 55% of TKR booklets. CONCLUSION: Many patient information booklets do not follow ERAS principles for fast-track rehabilitation and the exercise prescription procedure is non-specific. This must be considered within post operative rehabilitation in order to enhance recovery and reduce length of stay following THR or TKR surgery.

What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review.

Nutritional supplements can influence outcomes for individuals undergoing major surgery, particularly in older persons whose functional reserve is limited. Accelerating recovery from total hip replacement (THR) and total knee replacement (TKR) may offer significant benefits. Therefore, we explored the role of nutritional supplements in improving recovery following THR and TKR. A systematic review was conducted to source randomized clinical trials that tested nutritional supplements in cohorts of THR or TKR patients. Our search yielded nine relevant trials. Intake of a carbohydrate-containing fluid is reported to improve insulin-like growth factor levels, reduce hunger, nausea, and length of stay, and attenuate the decrease in whole-body insulin sensitivity and endogenous glucose release. Amino acid supplementation is reported to reduce muscle atrophy and accelerate return of functional mobility. One paper reported a suppressive effect of beta-hydroxy beta-methylbutyrate, L-arginine, and L-glutamine supplementation on muscle strength loss following TKR. There is limited evidence for nutritional supplementation in THR and TKR pathways; however, the low risk profile and potential benefits to adjunctive treatment methods, such as exercise programs, suggest nutritional supplements may have a role. Optimizing nutritional status pre-operatively may help manage the surgical stress response, with a particular benefit for undernourished, frail, or elderly individuals.