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Comparing a 12-month home exercise program with usual care for post-TKA rehabilitation
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April 2014
Comparing a 12-month home exercise program with usual care for post-TKA rehabilitation
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Efficacy of a 12-month, monitored home exercise programme compared with normal care commencing 2 months after total knee arthroplasty: A randomized controlled trial
J Rehabil Med. 2014 Jan 30;46(2):166-72. doi: 10.2340/16501977-1242Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
108 patients with diagnosed knee osteoarthritis (OA) who had underwent total knee arthroplasty (TKA) were randomized to undergo, beginning 2 months post-surgery, either a 12-month home-based exercise program, or usual care. The purpose of this study was to determine whether this long-term exercise regimen improved pain, disability, quality of life and function in these patients when compared to usual care. Upon the completion of the intervention, results indicated that the exercise and control groups displayed similar improvements in WOMAC scores (pain, stiffness and function), quality of life, knee extension strength, and range of motion. Moreover, patients in the exercise group exhibited significantly superior improvements in knee flexion strength and maximal walking speed.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Grant from the Central Finland Health Care District
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
3/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
The optimal postoperative rehabilitation regimen following total knee arthroplasty (TKA) has not yet been conclusively determined. Previous studies suggest that functional physical therapy exercises may improve patient outcome at 3-4 months, however these benefits may no longer be significant at 1 year. Furthermore, the results from one study suggest that home-based rehabilitation may yield improved pain and disability compared to in-patient rehabilitation. Home-based interventions were proposed as a means to eliminate some of the disadvantages associated with in-patient rehabilitation, such as increased cost, the requirement for trained personnel, as well as the burden of transportation and time-commitment on behalf of the patients. The present study compared the effectiveness of a long-term home-based rehabilitation protocol with that of usual care in patients who had undergone TKA.
What was the principal research question?
Does a 12-month postoperative home-based exercise program improve pain, disability and quality of life in patients who have undergone total knee arthroplasty (TKA), when compared to usual care and assessed 14 months after surgery?
Study Characteristics
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Population:
108 patients with diagnosed knee osteoarthritis, for which they had undergone primary arthroplasty. For all patients, full weight-bearing (or as much they could tolerate) was allowed on the second postoperative day. Furthermore, crutches were recommended for 4-5 weeks postoperatively, for safety reasons. Lastly, once discharged from the hospital, patients applied cold packs when necessary, and underwent a written exercise program up until 2 months post-surgery. This exercise program consisted of active and passive range of motion exercises and exercises for knee flexors and extensors, as well as hip abductors and extensors.
Intervention:
Exercise group: Patients in this group (n=53) were assigned, by a physiotherapist, an individualized exercise program each at baseline, and at 1 to 4 months thereafter. The program issued at baseline was characterized by isometric strengthening exercises for the quadriceps and hamstrings, functional exercises using the patient's body weight, and step exercises (step height of 20 cm), and was prescribed at a dose of 2 series of 10 repetitions daily, gradually increasing to a max of 20 reps and 3 series. At 3 months post-surgery (i.e. one month into the intervention), the new exercise program added squats, hack squats with back against the wall, and step exercises (step height of 30 cm), beginning at 15 reps of 1-2 kg dumbbells, 3 times a week. At 6 months post-surgery (i.e. 4 months into the intervention), patients were instructed to increase the progression of the aforementioned exercises, and exercise at a frequency of 3 times per week. (Mean age: 69 +/- 8 years; 57% female).
Comparison:
Control group: Patients in this group (n=55) did not receive any additional guidance following the baseline measurements taken at 2 months post-surgery. This protocol is in accordance with usual care. (Mean age: 69 +/- 9 years; 65% female).
Outcomes:
Outcomes included pain, disability (assessed on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), health-related quality of life (measured using the Short Form-36 Health Survey (SF-36)), basic mobility (via the Timed Up and Go (TUG) test), active and passive range of motion, maximal walking speed without shoes (using the GAITRite Walkway System (CIR Systems Inc., Sparta, USA)), as well as isometric knee flexion and extension strength (measured on a fixed dynamometer (Ds Europe, mod. 546QTD strain gauge, Milan, Italy).
Methods:
RCT; Single-blinded (assessors)
Time:
Outcomes were assessed when the intervention started (i.e. 2 months post-surgery) and once the intervention was complete (i.e. 14 months post-surgery). In addition, SF-36 and WOMAC questionnaire were filled out 6 months from baseline.
What were the important findings?
- At 14 months post-operation, WOMAC scores were significantly reduced in the exercise and control groups by -15 (95% CI -20 to -10) vs. -14 (95% CI -19 to -9) for pain, -25 (95% CI -32 to -18) vs. -17 (95% CI -24 to -9) for stiffness, and -18 (95% CI -24 to -12) vs. -13 (95% CI -19 to -8) for functional difficulty (p<0.001). These improvements were not significantly different between groups (p>0.05).
- Mean changes in the physical and mental components of the SF-36 were significant in both groups following the 12-month intervention (p<0.001); however, there were no between-group differences at any time point (p>0.05).
- Improvement in knee flexion strength was significantly better in the exercise group (4.4 [95% CI 3.1 to 5.7]) compared to the control group (2.4 [95% CI 1.3 to 3.4]) (p=0.009), improvement in knee extension strength was statistically similar between groups (Exercise group: 15.1 (95% CI 12.5 to 17.6); Control group: 13.4 (95% CI 10.1 to 16.1); p=0.50).
- Maximal walking speed improved significantly more in the exercise group (0.32 [95% CI 0.26 to 0.38]) compared to the control group (0.17 [95% CI 0.11 to 0.24]) (p<0.001).
- Passive extension deficit, active extension deficit, passive flexion and active flexion similarly improved from baseline to 12 months in both groups (p=0.72, p=0.45, p=0.86, and p=0.98, respectively).
- At 6 months, 72% of participants in the exercise group reported performing the training sessions 2x/week. At 12 months, the proportion of patients exercising at least once a week, the mean exercise frequency, and the amount of leisure-time physical activity were all similar between groups (p>0.05).
- 5 participants in the exercise group did not complete the exercise program, citing pain during exercise. An additional 5 participants in the exercise group did not complete the exercise program, citing satisfaction with painless knees, to the point where they were no longer motivated to complete exercise.
What should I remember most?
At 12 months, although the exercise and control groups displayed similar improvements in WOMAC scores (pain, stiffness and function), quality of life (both the mental and physical components), knee extension strength, and range of motion, patients in the exercise group exhibited significantly superior improvements in knee flexion strength and maximal walking speed. Adherence to the exercise program at 6 months was relatively low at 72%, and significantly more patients in the control group sought additional advice regarding their knee exercises.
How will this affect the care of my patients?
In patients with knee osteoarthritis who had undergone a total knee arthroplasty (TKA), a 12-month home-based exercise program is well-tolerated and may provide some functional benefits; however, it does not improve pain, disability or quality of life, when compared to usual care. Future studies could focus on developing strategies to increase the adherence rate for home-based exercise programs. Furthermore, a cost-effective analysis for long-term home-based interventions following TKA is warranted.
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