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Physiotherapy rehabilitation after knee and hip replacement

Physiotherapy rehabilitation after knee and hip replacement. What is the evidence? Justine Naylor Senior Research Fellow, WORC & WJRC, SSWAHS, UNSW. Outline. Profile of current service provision Rationale for rehabilitation Evidence for rehabilitation after TKR & THR

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Physiotherapy rehabilitation after knee and hip replacement

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  1. Physiotherapy rehabilitation after knee and hip replacement What is the evidence? Justine Naylor Senior Research Fellow, WORC & WJRC, SSWAHS, UNSW

  2. Outline • Profile of current service provision • Rationale for rehabilitation • Evidence for rehabilitation after TKR & THR • Summary and recommendations for practice and research

  3. Current service provision • Regional patterns in providing a service

  4. Current service provision – gross modes

  5. Background – Rationale for rehab • Formal (supervised) rehabilitation enhances recovery beyond that which can be achieved after surgery and an unmonitored home programme alone • In other words, with rehabilitation, either: • performance across a range of health domains approaches or exceeds age-matched norms, or: • recovery across a range of health domains is faster than it would naturally • Is this true?

  6. What is the evidence that recovery from surgery may be suboptimal (and thus rehab may have a role)?

  7. What is the evidence that formal rehabilitation enhances recovery after TKR or THR?

  8. Effectiveness of Rehabilitation after TKR? Study • systematic review of effectiveness of outpatient-based rehabilitation compared to other • searched key electronic databases • included RCTs of studies comparing: • Outpatient 1-to-1 vs home programme • Outpatient vs Outpatient (1-to-1 vs group) • Outpatient Group vs home programme • OP therapy included any modality • Rehab commenced within 4 weeks post-op (ignore acute inpatient period)

  9. Results of TKR review • No study compared all 3 gross modes -1 to 1 outpt; group-based; home programme • No study evaluated group-based to home programme • No study compared different types of 1to 1 treatments/modalities • 1 study compared group land to group water • 3 RCTs compared 1to 1 to home programme; all 3 were exercise-focused • 1 study compared 1 to 1 vs usual care (late post-op period)

  10. Summary of evidence concerning rehab post TKR • Insufficient evidence to recommend the optimum mode of delivery because not all gross modes and modalities investigated • Currently, available evidence suggests that 1 to 1 programmes delivered in the early post-operative phase do not provide long-term benefit over and above what is achieved with a home programme (monitored or not monitored) • We don’t know if early benefits translate into faster return to work or less health resource utilisation.

  11. Effectiveness of Rehabilitation after THR? • Literature search of RCTs • Location/Type/Mode • Outpatient 1-to-1 vs group or home • Group vs Home • Inpatient Rehab vs Home or Group or Outpatient • Timing • Early (commenced within 4 weeks post-op) • Late (commenced > 2 months post-op)

  12. Results of THR review of RCTs • Emphasis on effect of adding an extra modality to standard programmes (in early post acute phase) • No one study compared all 3 gross modes of delivery – 1 to 1; group-based; home • Many trials looking at value of later-stage rehab (in addition to early rehab)

  13. Results of THR review • Location – Inpatient Rehab v Domiciliary

  14. Summary of THR rehab • Early phase (within 4 weeks post-op) • No studies compared Inpt or Outpt Rehab to an unsupervised or monitored home programme • No studies strictly compared Inpt only to Outpatient only • Inclusion of resistance training or NMES provides superior results than basic programme up to 1 yr • Later phase (> 8 weeks post) • Vigorous ex programme or treadmill produces improvement over and above control (no ex exposure) • Long-term benefits?

  15. Recommendations for practice • TKR • No recommendations for best practice • Goals of rehabilitation need to be clearly defined as this will help determine how vigorous rehab needs to be • Routine standardised measurement of a goal is recommended • THR • More vigorous programmes (early) provide superior results up to 1 yr than basic programmes • Training effects seen with later programmes – could recommend continuation of rigorous HP up to 1 yr.

  16. Recommendations for research • To determine which gross mode of delivery is superior (if any) • Multi-centre RCT comparing 1 to 1, group-based and MHP post TKR and THR (early phase) • To determine if later rehab is superior to early rehab • Early vs late – compare same programme, 1 delivered early, 1 delivered late • Other questions • Does rehab have potential to improve co-morbidities? • Does rehab influence prosthesis longevity by influencing long-term activity? • Do some patients respond to rehab whilst other don’t?

  17. Thank you

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