The post operative outpatient physiotherapy treatment of Total Knee Replacement (TKR)
Date First Published:
March 20, 2007
Last Updated:
March 22, 2007
Report by:
Michael Callaghan & Claire Suff, Physiotherapists (Manchester Royal Infirmary)
Three-Part Question:
in [adults following TKR] in [a home exercise programme better than an outpatient programme] at improving [function and range of movement]
Clinical Scenario:
A 65 year old lady has had a total knee replacement for osteoarthritis. She has had an uneventful post op recovery and, as per protocol, has an appointment for outpatient physiotherapy. With the pressure on appointments you wonder whether a home exercise programme will be just as effective as outpatient programme at improving function and knee flexion range of movement.
Search Strategy:
MEDLINE 1966-03/07, CINAHL 1982 –03/07, AMED 1985-03/07, SPORTDiscus 1830-03/07, EMBASE 1996-03/07, via the OVID interface. The Cochrane database, March 2007 and PEDro database, March 2007.
Search Details:
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, Cochrane database: [{(exp arthroplasty replacement knee) AND (exp.physical therapy OR exp.exercise OR exp.therapeutic exercise OR exp.group exercises OR physiotherapy.mp})]
Medline, AMED [{(exp.physical therapy techniques)}]
SPORTSDiscus [{(exp.arthroplasty)}]
EMBASE [{( syn physiotherapy)}]
PEDro [arthroplasty, knee]
LIMIT to human AND English language.
Medline, AMED [{(exp.physical therapy techniques)}]
SPORTSDiscus [{(exp.arthroplasty)}]
EMBASE [{( syn physiotherapy)}]
PEDro [arthroplasty, knee]
LIMIT to human AND English language.
Outcome:
147 papers were retrieved, of which 3 were relevant to the 3 part question comparing a home based exercise programme with an outpatient rehabilitation programme.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of clinic and home based rehabilitation programs after total knee arthroplasty Kramer JF, Speechley M, Bourne R, Roraback , Vaz M. 2003 Canada | N = 160 primary TKR for OA Group 1: (n=80) 12 wks x 2 1 hr clinic based PT Group 2: (n=80) 12 wks x 3 daily home based exercise. Monitored by log sheets & weekly 15 min phone call. |
Single blinded, randomised group comparison | 1. 6min walk test | NSS (P >0.01) | 16% drop out Group1 added other physio modalities (U/S, ice, heat) No data tables (mean SD). Figures presented only |
| 2. WOMAC | NSS (P >0.01) | ||||
| 3. SF-36 | NSS (P >0.01) | ||||
| 4. K S score | NSS (P >0.01) | ||||
| 5. Knee range of motion | NSS (P >0.01) | ||||
| 6. 30s stair test | NSS (P >0.01) | ||||
| Effectiveness of intensive rehabilitation of functional ability and quality of life after first total knee arthroplasty: a single blind randomised controlled trial Moffet,H, Collet J-P, Shapiro SH, Paradis,G, Marquis, F, Roy,L 2004 Canada | N = 77 primary TKR for OA Group 1: standard home exercise programme Group 2: standard care + x12 supervised outpatient intensive rehab programme |
Single blinded RCT | 1: 6 min walk test | 1: Sig (P < 0.05) treatment effects in favour of Group 2 immed post rehab (22.5m); @ 2 mth (25.4m); @ 8 mth (26.4) | Large variability in Group 2 post primary outcome (95% CI 1.1 – 44m) Compliance of home programme not monitored. 26% of Group1 had a physio home visit to supervise exercises |
| 2: WOMAC | 2: Sig (P < 0.05) effect for Group 2 in total score immed post (7.9); @ 2 mth (8.4); but NSS @ 8 mth(4.3 p=0.19) | ||||
| 3: SF-36 (11 scales) | 3: NSS in 9 scales. P<0.05 in other 2 for Group 2 but have small treatment effects. | ||||
| No need for outpatient physiotherapy following total knee arthroplasty. Rajan,RA, Pack,Y, Jackson,H, Gillies C, Asirvatham,R. 2004 UK | N = 116 primary TKR for OA Group 1: (n=60) Home exercise programme Group 2: (n=56) home exercises + 4-6, 20 min outpatient physio sessions |
PRCT | 1: Knee RoM | 1: NSS between groups @ 3,6 months & 1 year post op.(Max Difference= 4 degrees) | No functional outcome Home Compliance not monitored. Exercise programmes not described |
Author Commentary:
Personnel communication with all 3 sets of authors clarified that their outpatient programmes did not take place in a gym-class environment but was a 1-to-1 with the therapist. Rajan et al also clarified that their 1-to-1 sessions lasted 20 minutes each.
There are no published studies on the effect of a gym-class rehabilitation programme.
There are no published studies on the effect of a gym-class rehabilitation programme.
Bottom Line:
There is no clear evidence of the benefit on function and range of movement from a 1-to-1 outpatients programme compared to a home based exercise programme post TKR.
References:
- Kramer JF, Speechley M, Bourne R, Roraback , Vaz M.. Comparison of clinic and home based rehabilitation programs after total knee arthroplasty
- Moffet,H, Collet J-P, Shapiro SH, Paradis,G, Marquis, F, Roy,L. Effectiveness of intensive rehabilitation of functional ability and quality of life after first total knee arthroplasty: a single blind randomised controlled trial
- Rajan,RA, Pack,Y, Jackson,H, Gillies C, Asirvatham,R.. No need for outpatient physiotherapy following total knee arthroplasty.