The case for physiotherapy following discharge after arthroplasty surgery

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Information about The case for physiotherapy following discharge after arthroplasty surgery
Health & Medicine

Published on February 4, 2014

Author: enhancedrecoveryblog

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

Current Controversies in Orthopaedic Enhanced Recovery The case for physiotherapy following discharge after arthroplasty surgery 31st January 2014, Glasgow, Scotland. Tom Wainwright @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

The next step in enhanced recovery. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Enhanced Recovery is an ongoing process… Recovery does not stop from the patient’s perspective when they go home “Enhanced Recovery is an evidence“Enhanced Recovery is an evidencebased approach to care. It is designed based approach to care. It is designed to prepare patients for, and reduce to prepare patients for, and reduce the total impact of, surgery, helping the total impact of, surgery, helping them to recover more quickly. It is aa them to recover more quickly. It is multi-modal approach similar to that multi-modal approach similar to that of care bundles” of care bundles” @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Improvements are the result of the aggregation of marginal gains – what can we optimize further? ‘you can achieve optimal performance by the aggregation of marginal gains. It means finding a 1 per cent margin for improvement in everything you do’ Dave Brailsford @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Influencing outcome measures • • • • • • Length of stay Re-admissions Mortality Complications Patient Experience PROMs @twwainwright @twwainwright The outcomes focused on to date in ERAS Have we focused enough on these areas to date? enhancedrecoveryblog.com enhancedrecoveryblog.com

Patient Experience @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

• 35% of patients thought that physiotherapy provision was inadequate. • Analysis of patient explanations about why the physiotherapy was inadequate found that the main theme was there was not enough physiotherapy provided @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Improving PROMs scores @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

RBCH 2012-13 Oxford Hip Score @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

RBCH 2012-13 EQ5D Hip Score @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Improvement will be when we out perform current models of recovery of physical and functional performance • Limited research evidence on the potential, and time period for improvement post THR and TKR @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Why it is time for reconsideration? • The two latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA does either not work, or is not very effective. • The reason for this may be that the “pill” of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity), or is offered at the wrong time (too late after surgery). Bandholm T, Kehlet K (2012) Physiotherapy Exercise After Fast-Track Total Hip and Knee Arthroplasty: Time for Reconsideration? Archives of Physical Medicine and Rehabilitation Vol. 93, Issue 7, Pages 1292-1294, DOI: 10.1016/j.apmr.2012.02.014. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Physiotherapy post-discharge @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

@twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

What does physiotherapy include? • Study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education following THR does not significantly improve patient function or quality of life. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

What could/should physiotherapy include? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Improving functional capacity with enhanced rehabilitation at both pre and post-discharge @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Unilateral hip OA is characterized by generalized muscle weakness of the affected leg. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Exercise reduces pain and improves physical function for people awaiting hip replacement surgery @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Preoperative greater knee extensor strength of the operated site is associated with better physical function at 12 weeks post-op @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Example - “Size of dose” What does cycling have to offer? Participants significantly improved in the timed chair rise, in the 6minute walk test, in the range of walking speeds, in the amount of overall pain relief, and in aerobic capacity. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

@twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Areas for optimisation - example 682 Acta Orthopaedica 2011; 82 (6): 679–684 679 Why still in hospital after fast-track hip and knee arthroplasty? Table 2. Reasons for patients not being able to be discharged at 9 a.m. and 2 p.m. on various days. The accumulated proportions of patients not discharged are shown at the top of the table. Below that, reasons for not ful lling the speci ed discharge criteria are shown (as number of patients with each clinical problem divided by the number of patients remaining in hospital) Henrik Husted1,4, Troels H Lunn2,4, Anders Troelsen 1,4, Lissi Gaarn-Larsen 4, Billy B Kristensen2,4, and Henrik Kehlet 3,4 Op-day 2 p.m. Evaluation 2D e p a r t m e n t o f O r t h o p a e d i c S u r g e r y a n d e p a r t m e n t o f A n a e s t h e s i o lo g y , H v i d o v r e U n i v e r s it y H o s p i t a l; U n i v e r s it y ; 4 T h e L u n d b e c k C e n t r e fo r F a s t - t r a c k H i p a n d K n e e A r t h r o p l a s t y , C o p e n h a g e n , D e n m a r k . C o r r e s p o n d e n c e : h e n r i k h u s t e d @ d a d l n e t .d k S u b m it t e d 1 1 - 0 5 - 2 4 . A c c e p t e d 1 1 - 0 8 - 0 2 • • • • • • Pain Dizziness PONV Confusion Sedation Muscle Weakness • Logistical B a c k g r o u n d a n d p u r p o s e L e n g th o f s ta y (L O S ) fo llo w in g to ta l h ip a n d k n e e a r th r o p la s ty (T H A a n d T K A ) h a s b e e n r e d u c e d to a b o u t 3 d a y s in f a s t -t r a c k s e t u p s w ith fu n c tio n a l d is c h a r g e c r it e r ia . E a r lie r s t u d ie s h a v e id e n t ifi e d p a t ie n t c h a r a c t e r is t ic s p r e d ic tin g L O S , b u t little is k n o w n a b o u t s p e c ifi c r e a s o n s fo r b e in g h o s p ita liz e d fo llo w in g fa s t-tr a c k T H A a n d T K A . P a tie n ts a n d m e th o d s T o d e te r m in e c lin ic a l a n d lo g is tic a l fa c t o r s t h a t k e e p p a t ie n t s i n h o s p i ta l fo r t h e fi r s t p o s t o p e r a t iv e 2 4 – 7 2 h o u r s , w e p e r fo r m e d a c o h o r t s tu d y o f c o n s e c u tiv e , u n s e le c te d p a tie n ts u n d e r g o in g u n ila te r a l p r im a r y T H A (n = 9 8 ) o r T K A ( n = 1 0 9 ) . M e d ia n le n g th o f s ta y w a s 2 d a y s . P a tie n ts w e r e o p e r a t e d w it h s p in a l a n e s th e s ia a n d r e c e iv e d m u lt im o d a l a n a l g e s ia w ith p a r a c e ta m o l, a C O X - 2 in h ib it o r, a n d g a b a p e n t in — w ith o p io id o n ly o n r e q u e s t . F u lfi llm e n t o f f u n c tio n a l d is c h a r g e c r ite r ia w a s a s s e s s e d t w ic e d a ily a n d s p e c ifi e d r e a s o n s fo r n o t a l lo w in g d is c h a r g e w e r e r e g is te r e d . R e s u lt s P a in , d iz z in e s s , a n d g e n e r a l w e a k n e s s w e r e th e m a in c lin ic a l r e a s o n s fo r b e in g h o s p ita liz e d a t 2 4 a n d 4 8 h o u r s p o s to p e r a t iv e ly w h ile n a u s e a , v o m iti n g , c o n f u s io n , a n d s e d a ti o n d e la y e d d is c h a r g e to a m in im a l e x te n t. W a itin g fo r b lo o d tr a n s fu s io n (w h e n n e e d e d ), fo r s ta r t o f p h y s io th e r a p y , a n d fo r p o s to p e r a tiv e r a d io g r a p h ic e x a m in a tio n d e la y e d d is c h a r g e in o n e fi fth o f th e p a tie n ts . I n te r p r e ta tio n F u tu r e e ffo r ts to e n h a n c e r e c o v e r y a n d r e d u c e le n g th o f s t a y a f te r T H A a n d T K A s h o u ld fo c u s o n a n a lg e s ia , p r e v e n tio n o f o r th o s ta tis m , a n d r a p id r e c o v e r y o f m u s c le fu n c tio n . Total hip and total knee arthroplasty (THA and TKA) are frequent operations with an average length of stay (LOS) of about 6–12 days in the United Kingdom, Germany, and Denmark (Husted et al. 2006, Bundesauswertung 2009, NHS 2010). During the last decade, however, there has been increased interest in optimal multimodal perioperative care to enhance recovery (the fast-track methodology). Improvement of anal- 3 S e c t io gesia; reduction of surgical stress responses and organ dysfunctions including nausea, vomiting, and ileus; early mobilization; and oral nutrition have been of particular interest (Kehlet 2008, Kehlet and Wilmore 2008). These principles have also been applied to THA and TKA, resulting in improvements in pain treatment with multimodal opioid-sparing regimens including a local anesthetic infiltration technique (LIA) or peripheral nerve blocks to facilitate early mobilization (Ilfeld et al. 2006a, b, 2010a, Andersen et al. 2008, Kerr and Kohan 2008), and allowing functional rehabilitation to be initiated a few hours postoperatively (Holm et al. 2010)—ultimately leading to a reduction in LOS (Husted et al. 2008, Barbieri et al. 2009, Husted et al. 2010a, b). Using these evidence-based regimens combined with an improved logistical setup, LOS is reduced to about 2–4 days (Kerr and Kohan 2008, Husted et al. 2010 a,b,c, Lunn et al. 2011). H a v in g w e ll-d e fi n e d fu n c tio n a l d is c h a rg e c rite ria is im p e ra tiv e in o r d e r to e n s u r e a s a f e d is c h a rg e — a n d it is m a n d a to r y if m e a n in g f u l c o m p a ris o n o f L O S is d o n e fo llo w in g a lte ra tio n s in th e tra c k (H u s te d e t a l. 2 0 0 8 ). In th e s a m e fa s t- tra c k s e ttin g , a n e a rlie r s tu d y fo c u s e d o n p a tie n t c h a ra c te ris tic s p r e d ic tin g L O S (H u s te d e t a l. 2 0 0 8 ). H o w e v e r, little is k n o w n a b o u t th e s p e c ifi c re a s o n s fo r w h y p a tie n ts a re h o s p ita liz e d d u rin g th e fi rs t 1 – 3 d a y s a fte r T H A o r T K A ; i.e . w h y c a n p a tie n ts n o t b e d is c h a rg e d ? We therefore analyzed clinical and organizational factors responsible for being hospitalized in a well-defined prospective setup in a fast-track unit. This unit had previously documented LOS of about 2–3 days (Andersen et al. 2008, Holm et al. 2010, Husted et al. 2010b, c, Lunn et al. 2011). Day 1 2 p.m. Day 2 9 a.m. Day 2 2 p.m. Day 3 9 a.m. Day 3 2 p.m. Not discharged TKA THA Pain a TKA THA Dizziness TKA THA PONV c TKA THA Confusion TKA THA Sedation TKA THA Muscle weakness d TKA THA Technical e TKA THA “Logistics” f TKA THA 100% 100% 94% 87% 80% 60% 33% 22% 27% 20% 7% 9% 5% 6% 53% 47% 43% b 24% b 29% 22% 19% 18% 0% b 20% b 0% 11% 0% 0% 11% 15% 24% 21% 15% 17% 17% 14% 17% 20% 13% 11% 0% 0% 13% 11% 8% 5% 7% 5% 3% 5% 7% 5% 0% 0% 0% 0% 1% 2% 0% 2% 0% 2% 3% 0% 4% 0% 0% 0% 0% 0% 3% 1% 5% 7% 6% 5% 6% 5% 4% 0% 13% 0% 20% 0% 16% b 29% b 18% 28% 13% b 26% b 25% 18% 8% 13% 13% 44% 20% 17% 16% 15% 10% 12% 2% 9% 0% 5% 8% 0% 13% 0% 20% 0% 22% 18% 27% 35% 20% 20% 33% 36% 21% 20% 25% 44% 40% 50% a Pain > 5 with activity b Signi cant di erence between TKA and THA Patients and methods According to Danish law, this quality-assurance study did not require approval by an ethics committee. It was registered at ClinicalTrials.gov (NTC01047371). Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. DOI 10.3109/17453674.2011.636682 @twwainwright @twwainwright Day 1 9 a.m. n o f S u r g i c a l P a t h o p h y s i o l o g y , R ig s h o s p i t a l e t , C o p e n h a g e n Acta Orthop Downloaded from informahealthcare.com by 82.20.71.193 on 02/21/12 For personal use only. 1D Acta Orthopaedica 2011; 82 (6 c Postoperative nausea and vomiting d or lack of su cient control to ambulate e Ongoing intravenous transfusion of blood or plasma e xpander, or urinary catheter due to urinary retention f Waiting for physiotherapy or postoperative radiographs 2008, 2010a) but the drawback is a risk of muscle weakness, a need for adjustment of infusion dose of local anesthetics, and risk of falls (Kandasami et al. 2009, Ilfeld et al. 2010b, Sharma et al. 2010). Optimization of analgesia may include a high dose of glucocorticoids preoperatively (Lunn et al. 2011) or use of other In other studies, short hospital stays of 1–2 days h achieved in selected patients, but no specific inf was provided on potential discharge problems (Ilfe 2006a,b, Kerr and Kohan 2008), except in one study et al. 2009). In this latter study on THA patients o charge criteria were similar to ours, but patients we enhancedrecoveryblog.com enhancedrecoveryblog.com

Exercise prescription: Progressive strength training (10 RM) commenced immediately after fast-track total knee arthroplasty: is it feasible? • • • The training load increased progressively (p < 0.0001). Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p < 0.0001) were unchanged or decreased over the six training sessions. Isometric knee-extension strength and maximal walking speed increased by 147 and 112%, respectively. @twwainwright @twwainwright Linding Jakobson et al. 2012 enhancedrecoveryblog.com enhancedrecoveryblog.com

Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme. Barker et al. (2013) Clin Rehabil published online 10 April 2013 DOI: 10.1177/0269215513478437 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Loss of Knee-Extension Strength Is Related to Knee/Thigh Swelling After TKR • Measures: knee-joint circumference, knee-extension strength, Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking test, and knee pain • Knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength • Decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Holm et al. 2012 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Cryo-therapy can be effective @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Cryo-compression Therapy Hip Int. 2012 Sep-Oct;22(5):527-33. doi: 10.5301/HIP.2012.9761. Cryocompression therapy after elective arthroplasty of the hip. Leegwater NC, Willems JH, Brohet R, Nolte PA. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

New Modalities such as the Geko Device can also help to reduce swelling http://gekodevices.com/ @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

The Geko - How it works and mechanism of action • The gekoTM device stimulates the common peroneal nerve to activate the calf muscle pumps • Increases blood flow volume and velocity • Achieves a blood flow rate of 50-70% of walking - measured by duplex ultrasound in the femoral vein A. T. Tucker, A. Maass, D. S. Bain et al. Augmentation of venous, arterial, and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. Int. J. Angiol. 2010; 19 (1): e31-e37 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

• Results: A statistically significant increase in walking speed was observed in the treatment group in relation to the control group at both 6 weeks (P=0.0002) and 12 weeks (P=0.0001) postoperatively @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Alter-G Anti-gravity treadmill @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

• Strength is lost rapidly. Longitudinal studies show that at age 75 years, strength is lost at a rate of 3–4% per year in men and 2.5–3% per year in women. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

• We should consider the effect of Sarcopenia in patients undergoing hip and knee replacement surgery • Conclusions of the above study - Adaptations to RET are markedly blunted in the elderly @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Differences in Muscle Protein Synthesis and Anabolic Signaling in the Postabsorptive State and in Response to Food in 65–80 Year Old Men and Women Gord on I. Smit h 1 . , Philip At hert on 2 . , Dennis T. Villareal 1 , Tiff any N. Frimel 1 , Deb bie Rank in 2 , Michael J. Rennie2 , Bet t ina Mit t end orfer 1 * 1 School of Medicine, Washington University, St. Louis, Missouri, United States of America, 2 School of Graduate Entry Medicine and Health, University of Nottingham, Derby, United Kingdom Abst ract Women have less muscle than men but lose it more slowly during aging. To discover potential underlying mechanism(s) for this we evaluated the muscle protein synthesis process in postabsorptive conditions and during feeding in twenty-nine 65– 80 year old men (n = 13) and women (n = 16). We discovered that the basal concentration of phosphorylated eEF2T h r 5 6 was , 40% less (P, 0.05) and the basal rate of MPSwas , 30% greater (P= 0.02) in women than in men; the basal concentrations of muscle phosphorylated Akt T h r 3 0 8 , p70s6kT h r 3 8 9 , eIF4ES e r 2 0 9 , and eIF4E-BP1T h r 3 7 / 4 6 were not different between the sexes. Feeding increased (P, 0.05) Akt T h r 3 0 8 and p70s6kT h r 3 8 9 phosphorylation to the same extent in men and women but increased (P, 0.05) the phosphorylation of eIF4ES e r 2 0 9 and eIF4E-BP1T h r 3 7 / 4 6 in men only. Accordingly, feeding increased MPS in men (P, 0.01) but not in women. The postabsorptive muscle mRNA concentrations for myoD and myostatin were not different between sexes; feeding doubled myoD mRNA (P, 0.05) and halved that of myostatin (P, 0.05) in both sexes. Thus, there is sexual dimorphism in MPS and its control in older adults; a greater basal rate of MPS, operating over most of the day may partially explain the slower loss of muscle in older women. Elderly individuals have an ‘anabolic resistance’ which is essentially a concept of having a diminished response to exercise and feeding (protein) Citat ion: Smith GI, Athert on P, Villareal DT, Frimel TN, Rankin D, et al. (2008) Differences in Muscle Protein Synthesis and Anabolic Signaling in the Postabsorptive State and in Response to Food in 65–80 Year Old Men and Women. PLoS ONE 3(3): e1875. doi:10.1371/journal.pone.0001875 Ed itor: Alejandro Lucia, Universidad Europea de Madrid, Spain Received January 3, 2008; Accept ed February 21, 2008; Published March 26, 2008 Copyright : ß 2008 Smith et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The study was supported by US National Institutes of Health grants AR 49869, AG 025501, RR 00036 (General Clinical Research Center), RR 00954 (Biomedical Mass Spectrometry Resource), and DK 56341 (Clinical Nutrition Research Unit), the University of Nottingham, the UK Biotechnology and Biological Sciences Research Council grants BB/XX510697/1 and BB/C516779/1, and a European Union EXEGENESISprogram grant. Philip Atherton is a designated Research Councils UK fellow. Compet ing Int erest s: The authors have declared that no competing interests exist. * E-mail: mittendb@ wustl.edu . These authors contributed equally to this work. Int roduct ion Adequate maintenance of muscle mass throughout life is @twwainwright locomotor functions and diminish the risk @twwainwright important to preserve The fact that no sex differences in MPS have been reported in the literature might be because these studies were conducted in young and middle-age adults with a constant muscle mass during postabsorptive conditions, when sex differences may be small or enhancedrecoveryblog.com enhancedrecoveryblog.com

The next step in the evolution of enhanced recovery? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

@twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

@twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Summary • Rehabilitation pathways need to change if we are to improve function, activity levels and outcomes further • Changing the type, dose, timing of interventions is vital if outcomes are to be optimised @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

One final thought… What rehabilitation pathway would you like your mum to have? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

Thank you @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com

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