Aggressive rehab safe after knee replacement

Aggressive rehabilitation after total knee arthroplasty is safe and could lead to earlier functional recovery without compromising range of motion, new research shows.

Ingrid Hein, Medscape Multispecialty March 09, 2016

“If surgeons are completely holding patients back from more aggressive exercise, they may end up with worse outcomes or miss an opportunity to intervene early for more optimal outcomes,” said lead investigator Jennifer Stevens-Lapsley PhD, from the University of Colorado Denver.

“Rehab is a highly understudied component of surgery,” she told Medscape Medical News. “It’s still in its infancy, but we’re finally gaining some momentum to ask some important questions.”

Results from the study on rehab intensity were presented here at the American Academy of Orthopaedic Surgeons 2016 Annual Meeting in Orlando, Florida.

There was no significant difference between high-intensity and low-intensity rehabilitation. However, the study showed that aggressive high-intensity rehab after total knee arthroplasty does not affect range of motion.

Rehab is a highly understudied component of surgery

What’s more, no matter what the intensity of the rehabilitation, overall performance was much better than that seen previously.

Dr Stevens-Lapsley and her colleagues compared the performance they saw in both the high- and low-intensity groups with that in the control group from a randomized controlled trial Dr Stevens-Lapsley was involved in. In that trial, the historic control group underwent standard rehabilitation after total knee arthroplasty.

“Both high- and low-intensity therapy showed a 34% improvement in stair-climbing test performance over the previously documented outcomes with traditional standards of care at 1 month,” she reported, and the difference was significant.

Timeline	Current Cohort, s	Historic Control Cohort, s
1 month	25	38
2 months	17	25
3 months	13	18
6 months	12	16
Table. Comparison of Stair-Climbing Times After Knee Arthroplasty

This difference could be attributed to the fact that patients in the historic control group never went directly to outpatient therapy or received a high level of care. “They had more directed therapy for their specific problem,” she explained.

In their current study, Dr Stevens-Lapsley and her colleagues evaluated 89 women and 73 men who were 56 to 70 years of age. All patients received an intervention two or three times a week for 12 weeks.

One group was randomly assigned to perform high-intensity progressive resistance exercise on lower-extremity muscle groups, which included balance exercises and agility exercises. They progressed as quickly as possible — depending on their pain, surgical knee range of motion, swelling, and functional performance — to weight-bearing strengthening exercises.

The other group followed a standard low-intensity total knee arthroplasty rehabilitation program, which consisted of stretching, light resistive exercises with ankle weights or resistive bands, and lower-demand functional exercises. Progression was based on the synthesis of previously published standard total knee arthroplasty rehabilitation programs, and was time-based.

Outcomes were assessed 1, 2, 3, 6, and 12 months after surgery. Performance improved sooner in the high-intensity group than in the low-intensity group, and high quadriceps activation led to earlier functional recovery. The results were similar in the two groups at 12 months, and results were better in both groups than in historic control subjects.

It is the nuances of this study that stand out.

“Surgeons will tell us that there should be no resistive exercise before range of motion is restored. That’s because increased swelling with more intense exercise can permanently jeopardize the ability of patients to get their range of motion back. We showed that does not occur,” Dr Stevens-Lapsley told Medscape Medical News. However, she pointed out, it is dependent on quadriceps activation.

Still, surgeons are wary.

“For the first 2 weeks, I’m pretty much a cookbook; pretty standardized,” said Jason Michael Jennings, MD, an orthopedic surgeon from Denver. He said he gives his patients standard rehab right after total knee arthroplasty and is sticking with that.

After 2 weeks, “you pretty much know who’s going to need more or less,” he told Medscape Medical News.

“There are certain patients who may benefit from high intensity,” Dr Jennings explained. “We don’t know who those patients are before, but 2 or 3 weeks after, they tell you they’ve walked a mile with no swelling, no pain.”

“I wait to see how patients are doing,” he reported.

Status Quo Rehab Not Good Enough

This research is important because more young patients are now lining up for total knee arthroplasty, and they are demanding higher function after surgery, said study investigator Douglas Dennis, MD, an orthopedic surgeon from Colorado Joint Replacement in Denver.

“Patients expect more than they used to,” he explained. This means better long-term and functional outcomes need to be examined.

“An 80-year-old who wants to walk to Nellie’s house to play bridge does fine with current rehab,” Dr Dennis said. “But we’re doing more total knees on young people. The activities they want to perform require better quadriceps performance.”

We do think some patients could get to rehab earlier and start firing their quads earlier on

“Quad power” is the key factor blocking functional outcome improvements, he said. In fact, “another important finding” of this study is that patients who had bigger quad activation deficits before surgery struggled more with rehab, he added.

In the randomized controlled trial that Dr Stevens-Lapsley was involved in, neuromuscular electrical stimulation of quadriceps after total knee arthroplasty showed positive results.

There is a lot of room for improvement in outcomes after total knee arthroplasty, Dr Stevens-Lapsley and her colleagues report. Overall, the single largest residual deficit after surgery is in the stair-climbing performance test; 75% of patients reported difficulty negotiating stairs years after the procedure. In addition, postoperative walking speed was 20% slower and stair-climbing speed was 50% slower.

Dr Dennis said he thinks that rehab after total knee arthroplasty should become more personalized, especially for those who are more active. “We’re essentially treating those who are at a lower level of function,” he told Medscape Medical News. “We do think some patients could get to rehab earlier and start firing their quads earlier on.”

Dr Stevens-Lapsley reports that she is a consultant for DJO Global. Dr Jennings has disclosed no relevant financial relationships. Dr Dennis reports that he is a paid consultant for DePuy; receives royalties from DePuy, Innomed, and Wolters Kluwer Health; and owns stock options in Joint Vue.

Source Medscape Multispecialty

References

American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting: Abstract P183. Presented March 04, 2016.

Early-Neuromuscular-Electrical-Stimulation-to-Improve-Quadriceps-Muscle-Strength-After-TKA

Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial, Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Phys Ther. 2012 Feb;92(2):210-26. doi: 10.2522/ptj.20110124. Epub 2011 Nov 17.

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