Comparing a 12-month home exercise program with usual care for post-TKA rehabilitation .
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OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2014;2(7):18 J Rehabil Med. 2014 Jan 30;46(2):166-72. doi: 10.2340/16501977-1242108 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.
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?
- 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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