Is routine outpatient physiotherapy required post discharge after arthroplasty surgery?

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Published on February 4, 2014

Author: enhancedrecoveryblog



Presentation from the Current Controversies in Orthopaedic Enhanced Recovery. 31st January 2014, Beardmore Hotel and Conference Centre, Glasgow, Scotland.

Is routine outpatient physiotherapy required post discharge after arthroplasty surgery?......I say NO Mr David A McDonald Service Improvement Manager Whole System Patient Flow Improvement Programme QuEST Team Scottish Government

Disclaimer Personal view point I am a physiotherapist Developed the CALEDonian Programme at the GJNH

Total Hip Arthroplasty

Total Hip Arthroplasty Two good systematic reviews Both of high quality and synthesise the available evidence 13 studies in total However when you remove duplicated studies = 9

Minns Lowe et al 2009

Minns Lowe et al 2009 Only searched studies up to 2007 One study seems to have been excluded Very difficult to compare across trials – interventions/timing/ duration Tried where possible to pool data where possible Summary Not yet possible to establish the extent to which post d/c physio is effective in terms of function/ Quality of life/Mobility/ RoM/ muscle strength Poor study designs.

Coulter et al 2013

Coulter et al 2013 Searched up to 2012 Only two additional studies included Does support that post d/c exercise does improve strength and gait speed compared to no input However no difference if this was home based or outpatient based

Total Hip Arthroplasty -ERAS All papers in both reviews from before 2008 Pre-op education Multimodal analgesia Accelerated rehabilitation Enhanced Recovery

Artaban Study

National Picture • 12% Pts in Scotland are referred for OP physiotherapy on d/c • Artz et al (2013) survey of England and Wales – no routine referral for OP

Total Knee Arthroplasty

Blinded RCT – Comparing 6/52 OP physio vs Internet telerehab Conclusions: The outcomes achieved via telerehabilitation at six weeks following total knee arthroplasty were comparable with those after conventional rehabilitation. J Bone Joint Surg Am, 2011 Jan 19;93(2

Only 5 trials included All pre-date 2005 Short term benefit No difference at one year

Patient-controlled lumbar epidural versus wound infiltration for total knee arthroplasty within an ERPa randomised clinical trial. D McDonald1, AWG Kinninmonth1, A H Deakin1, B Ellis2, T Howe2, Y Robb2, NB Scott1 1Golden Jubilee National Hospital, Clydebank, Scotland 2Glasgow Caledonian University, Glasgow, Scotland 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Methods • All patients received a standardised programme of: – Pre-operative education – Multimodal analgesia (McDonald et al, 2012) – – – Premed including Gabapentin and Dexamethasone Spinal Anaesthesia (no opiods) Oxycodone/ Paracetamol/ NSAID – Accelerated Rehabilitation 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Methods - Groups • Group PCEA • Group LIA • Side-directed lumbar epidural sited in theatre • Patient-controlled system 2ml 0.125% bupivacaine epidural. • NO BACKGROUND RATE • Discontinued on the morning of POD 1 • Standard infiltration of 200ml 0.2% Ropivacaine • 3 post op boluses of 40ml at • 4-6 hrs post surgery • 11.00pm • 8.00am on POD 1 • Catheter removed following final bolus 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Outcome Measures • Statistical significance was set at p<0.01 • Primary outcome measure was the proportion of patients discharged by day 4 from rehabilitation. • Secondary Outcome Measures • • • • • • • • • Length of hospital stay Pain Scores Use of PRN Analgesia Mobilisation rates % Post-operative urinary catheterisation PONV Range of Movement Oxford Knee Scores Following randomisation 20 patients were excluded due to failed spinal anaesthesia. 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Results - Demographics PCEA LIA P value N 109 113 Age (SD,) 67 (8.1) 68 (7.3) 0.601 BMI (SD) 32 (5.2) 32 (6.1) 0.622 Gender (% Males) 46% 41% 0.466 Operative side (%Left) 50% 58% 0.171 13 (10.8) 21 (17.8) 81 (67.5) 78 (66.1) 26 (21.6) 18 (15.3) 0 1 (0.01) 43(6.6) 43(6.8) ASA 1(%) ASA 2(%) ASA 3(%) ASA 4(%) Pre Operative Oxford Score 0.946 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Primary Outcome Measure • No differences was observed between the proportion of patients discharged from rehabilitation by post-operative day four • PC-LEA = 77% vs. LIA = 82% (p=0.33) • Median hospital stay was four days for both groups (p=0.54) 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Mobilisation • No statistical difference was observed in the proportion of patients mobilised on the day of theatre (p= 0.013) • 35% vs. 51% • or within 24 hours (p=0.04) almost all patients in both groups were independently mobile (PC-LEA 96% vs. LIA 100%). 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Secondary Outcomes PCEA LIA P value Post Operative Urinary Catheterisation (%) 10 (9.2) 5 (4.4) 0.159 Total PRN usage of 10mg Oxynorm (range) 4 (0-15) 4 (0-15) 0.554 Post Operative Nausea and Vomiting (% vomiting) 16 14 D/C RoM (Range) 80 (60-100) 80 (65-105) % Outpatient Physiotherapy referral on discharge 18% 19% Follow up RoM (Range) 95 (50-120) 100 (20-120) 0.316 Follow up Oxford Score (range) 28 (13-53) 26 (13-48) 0.204 Change in Oxford Score (SD) 14 (9.3) 16 (9.9) 0.301 0.795 6 Week Follow up Data 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham

Sub data analysis NO OP PHYSIO ON D/C OP PHYSIO ON D/C Age 68 64 Sex (% Male) 44% 62% BMI 32 33 ASA Score 2 2 Pre-op Oxford 42 42 D/C RoM 84 78 Post-op LoS (median) 3 5 RoM 97 90 Oxford Score 27 29 RoM 105 100 Oxford Score 19 19.5 Six week Follow Up One Year

Patients who need OP Physio Young Male Poor Pain control day 0 Should only be ~ 20% of patients

So why the disparity?

Here ends the lesson Mr Wainwright ….If only I had a cigar

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