Abstract
Physiotherapy is a critical component in the multidisciplinary team approach to supporting patients to achieve optimal outcomes after the onset of knee osteoarthritis and progression to total knee replacement (TKR) surgery. Physiotherapists possess a wide range of scientifically-informed and evidence-based intervention techniques that can be combined to differing degrees and integrated in differing contexts for the multi-modal, personalized and holistic rehabilitation of patients after TKR surgery. The purpose of this paper is to offer the reader advice and instruction on specific considerations in physiotherapy practice for people preparing for and recovering from TKR surgery. Emphasis is placed on a clinically-reasoned and rational approach with a solid foundation in science and pragmatic clinical practice. Specific comments and recommendations are made regarding defining optimal outcomes after TKR surgery, framing optimal outcomes relative to models of clinical reasoning, the association between impairments (e.g. quadriceps muscle weakness) and physical activity limitations (e.g. inability to walk), physiotherapy intervention techniques in personalized medicine, physiotherapy intervention techniques in prehabilitation and rehabilitation, physiotherapy effectiveness after TKR surgery, and physiotherapy rehabilitation session design and progression. The ideal approach to physiotherapy practice for people preparing for and recovering from TKR surgery is also considered, along with the contribution of outpatient physiotherapy to post-surgery patient satisfaction. Collaboration between the general practitioner, surgeon, physiotherapist, other allied health professionals and the patient is necessary to best influence the probability for optimal outcomes after TKR surgery.
Introduction
The prevalence of tibiofemoral joint (hereafter, ‘knee’) primary osteoarthritis (OA) in the UK has increased steadily over time. Correspondingly, the frequency of total knee replacement (TKR) surgery in the UK has also increased steadily over time. Given that both knee OA and TKR surgery have become more common in the UK in recent years, it follows that the demand for pre- and post-surgery interventions will also grow. Physiotherapy, specifically, is a critical component in the multidisciplinary team (MDT) approach to supporting patients to achieve optimal outcomes after the onset of knee OA and progression to TKR surgery. As there is a high risk for the onset of serious medical disease (e.g. heart failure, dementia) after the onset of knee OA, physiotherapy interventions both before and after TKR surgery can be viewed as being more important than ever for supporting patients to achieve optimal post-surgery outcomes whilst simultaneously deterring the progression of multimorbidity.
The purpose of this paper is to offer the reader advice and instruction on specific considerations in physiotherapy practice for people preparing for and recovering from TKR surgery. This paper will both ‘zoom in’ on specific clinical concepts and ‘zoom out’ to consider a broader perspective relevant to holistic patient healthcare in the short- and long-term. Emphasis is placed on a clinically-reasoned and rational approach, with a solid foundation in science and pragmatic clinical practice. Emphasis is also placed on presenting the reader with a model for the ideal approach to physiotherapy practice for people preparing for and recovering from TKR surgery; here, the term ‘ideal’ is used simply to represent a clinical environment where the reader has access to all the necessary resources to deploy all the interventions as and when indicated for an individual patient, rather than being limited in intervention options due to insufficient local resources (e.g. time, space, equipment, personnel, money).
The author encourages the reader to recognize that although there will be ‘generic’ needs for all patients before and after TKR surgery, there will also be ‘unique’ needs for individual patients, depending on their specific clinical presentation before and after surgery, alongside their personality and wider life circumstances. Therefore, the author proposes that the days of standardized post-surgery protocols for all patients undergoing TKR surgery should be past: a more personalized approach to physiotherapy interventions should now be the norm, being consistent with wider recommendations for personalized medicine in modern-day healthcare.
Optimal outcomes after total knee replacement surgery
Defining optimal outcomes
An outcome is a measure of change where the end-point of an intervention is compared to the start-point of an intervention. An ‘optimal’ outcome, therefore, can be viewed as the best or most favourable change in some measurement of outcome across an episode-of-care. Outcomes can be clinical (e.g. range-of-motion [ROM]), functional (e.g. walking velocity), and subjective (e.g. patient quality-of-life [QoL] questionnaire) in nature. Outcomes can also be short-term (e.g. ≤ 2 months) and long-term (e.g. > 12 months) in nature. Therefore, optimal outcomes can be defined by the surgeon (e.g. clinical, functional), the physiotherapist (e.g. clinical, functional), or the patient (e.g. functional, QoL questionnaire) at different timepoints after TKR surgery; what represents ‘the best’ or ‘the most favourable’ change can be viewed differently by each. Ultimately, given that patients seek help consistently when they are in pain and their QoL is affected negatively by some health condition, it would seem most appropriate for an ‘optimal’ outcome to be defined by the patient relative to their unique personal circumstances and desired post-surgery QoL.
Framing optimal outcomes relative to models of clinical reasoning
Having stated the above, to assist in framing outcomes in a way that considers those viewed as most important by all members of the MDT (e.g. including the general practitioner [GP], the surgeon, the physiotherapist and the patient), different models of clinical reasoning can be employed.
Biopsychosocial model of healthcare (BPS): this was developed by Engel in the late 1970s. It balances the narrow focus of the biomedical model of healthcare by employing a systems approach that also considers the patient’s psychoemotional status within the patient’s wider personal (social) circumstances. Thus, optimal outcomes can be defined using outcome measures relative to three different domains: biomedical (e.g. passive ROM, muscle strength), psychoemotional (e.g. level of anxiety, fear of movement), and social (e.g. QoL).
World Health Organization model of healthcare: the World Health Organization takes the BPS perspective of healthcare and applies it within its International Classification of Functioning, Disability, and Health (hereafter, ‘ICF’). The ICF includes impairments, activity limitations and participation restrictions. An impairment is an abnormality in, or problem with, body structure or function. An impairment can be physiological (e.g. pain, joint stiffness, muscle weakness) or psychoemotional (e.g. anxiety, depression, fear) in nature. Consistent with the temporality principle in epidemiology and causation theory, impairments can be further classified into primary impairments or secondary impairments according to which are evident in close temporal proximity to a disease or injury, and which manifest at a later point in time, respectively ( Figure 1 ). Due to the widespread physiological effects of a relatively ‘localised’ skeletal system problem (e.g. knee OA), and to support clinicians’ learning and application of clinical reasoning processes, impairments can also be sub-grouped into local impairments and remote impairments . Local impairments are at or close to (e.g. immediately adjacent to) the disease or injury site (e.g. adjacent to the tibial component of a TKR prosthesis). Remote impairments are distant from the disease or injury site, manifesting in a separate part of the same body segment or an entirely different body segment (e.g. neck of femur of the TKR limb, neck of femur of the non-operated contralateral limb, respectively). An activity limitation is, essentially, a ‘functional’ limitation (e.g. inability to stand, to walk, to climb stairs). A participation restriction is a problem a patient has with participating in their daily life and wider society (e.g. inability to work). In real-world clinical practice, the most common observation is that impairments feed in to activity limitations ( Figure 1 ), which then, in turn, feed in to participation restrictions and a reduced QoL. Thus, optimal outcomes can also be defined relative to three different categories: impairments (e.g. quadriceps muscle weakness, fear of movement), activity limitations (e.g. inability to ascend stairs), and participation restrictions (e.g. inability to go shopping for food).
Association between impairments, activity limitations and participation restrictions
Although bivariate correlation ( r ) does not equal causation, it is important to remember that statistics are simply a tool that should be used and interpreted on a foundation of what is known presently in biology and what is logical from a clinical reasoning perspective. Correlation studies, therefore, are useful for understanding the association between impairments ( x ) and activity limitations ( y ); if there is a change in an impairment-related measure (e.g. quadriceps muscle strength), is there a change in an activity limitation-related measure (e.g. a functional task)? Such understanding informs the selection and justification of outcome measures along with the prioritization of interventions at a specific point-in-time (e.g. 1-month post-surgery).
For example, following TKR surgery, knee flexion active ROM on the operated side is significantly and negatively correlated with performance of the Timed Up-and-Go (TUG) test ( r = −0.39, P < 0.05) and a timed stair climbing test (SCT) ( r = −0.35, P < 0.05); as knee flexion active ROM increases, the time taken to perform walking and stair climbing functional tasks decreases. For further example, following TKR surgery, quadriceps muscle strength on the operated side is significantly and negatively correlated with performance of the TUG test ( r = −0.64, P < 0.05) and the SCT ( r = −0.63, P < 0.05); as quadriceps strength increases, the time taken to perform walking and stair climbing functional tasks decreases.
Correlation studies are also useful for understanding the association between activity limitations ( x ) and participation restrictions and QoL ( y ); if there is a significant change in an activity limitation-related measure (e.g. TUG test), is there a significant change in a participation restriction- or QoL-related measure (e.g. patient questionnaire)? Following TKR surgery, performance of the TUG test is significantly and negatively correlated with the QoL scale of the Knee Injury and Osteoarthritis Outcome Score ( r = −0.69, P < 0.05); as the time taken to perform the TUG test decreases, the patient’s QoL increases.
Interestingly, bivariate correlation (and multivariate regression [ R ]) analyses can also be used to inform a perspective across a period-of-time; an x measure/variable can be set at one point in time (e.g. pre-surgery) and a y measure/variable can be set at another point in time (e.g. post-surgery). For patients undergoing TKR surgery, preoperative quadriceps muscle strength is significantly associated with the postoperative performance of the TUG test ( R = 0.41, P < 0.05) and SCT ( R = 0.54, P < 0.05); as preoperative quadriceps muscle strength increases, the time taken to perform postoperative walking and stair climbing functional tasks decreases. Beyond informing the selection and justification of outcome measures and the prioritization of interventions, an understanding of the association between impairments, activity limitations and participation restrictions is also useful for better comprehending the critical role of physiotherapy in healthcare for people preparing for or recovering from TKR surgery.
Physiotherapy
Physiotherapy core skills and intervention techniques
Physiotherapy is the process by which movement and physical function are treated when a person experiences some disease, injury, illness or disability. Historically, the core practical skills of physiotherapy include manual therapy and therapeutic handling, electrotherapy (including diagnostic and therapeutic technologies), exercise therapy and adjunct/allied approaches ( Table 1 ). Manual therapy and therapeutic handling refer to assessment and treatment of the patient using the hands: the physiotherapist applies forces to the patient as part of passive examination and rehabilitation procedures, respectively. Electrotherapy refers to assessment and treatment of the patient using electrophysical interventions to determine the existence of or deliberately modify specific physiological processes, respectively. Exercise therapy includes the use of sustained or repeated movements as components of a goal-directed training programme performed by the patient as part of active rehabilitation. Adjunct/allied approaches include passive rehabilitation procedures applied to the patient or used by the patient to support or facilitate rehabilitation or activities-of-daily living (ADLs), respectively. ,
| Core practical skills | Example physiotherapy intervention techniques |
|---|---|
| Manual therapy a | Joint mobilization |
| Soft tissue massage | |
| Lymphatic drainage | |
| Electrotherapy (electrophysical interventions) | TENS |
| NMES | |
| Thermotherapy (cold therapy, heat therapy) | |
| Exercise therapy a | Joint mobility exercise (passive, active) b |
| Nerve mobility exercise | |
| Muscle extensibility (stretching) exercise | |
| Strength training | |
| Balance training | |
| Gait training | |
| Agility training | |
| Aerobic training | |
| Adjunct/allied approaches | Taping |
| Elastic bandaging | |
| Bracing (soft, hard) | |
| Walking aid prescription |
a Both manual therapy and exercise therapy techniques can be performed on land and in a hydrotherapy pool.
b Passive joint mobility exercise is when a joint’s surrounding muscles are relaxed and the patient uses a different part of the body or an external piece of equipment to self-mobilize a joint; active joint mobility exercise is when a patient activates a specific joint’s surrounding muscles to self-mobilize that same joint.
In addition to the core practical skills , there are two other categories of core skills, both of which are the foundation for and precede the use of practical skills: human skills and cognitive skills . Human skills refer to, for example, rapport building, empathetic communication, education and advice skills, and negotiation skills. Cognitive skills refer to, for example, cognitive processing, metacognitive processing, clinical data interpretation and clinical reasoning.
The example intervention techniques listed in Table 1 can be reasonably expected of all physiotherapists who have completed pre-qualification training. For physiotherapists who have completed post-qualification training, other intervention techniques can then also be listed under each practical skills category (e.g. manual therapy, joint manipulation; electrotherapy, extracorporeal shockwave therapy [ESWT]; adjunct/allied approaches, acupuncture). Physiotherapists, therefore, possess a wide range of scientifically-informed and evidence-based intervention techniques that can be combined to differing degrees and integrated in differing contexts for the multi-modal, personalized and holistic rehabilitation of patients after TKR surgery. These intervention techniques should be applied within a framework of basic principles that underpin and steer the safe and effective physiotherapy practice with people preparing for or recovering from TKR surgery ( Box 1 ).
Related posts:
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Unicondylar knee replacements: the Oxford perspective
Patellofemoral joint replacement: the Bristol perspective
Technical challenges in revision total knee arthroplasty
The National Joint Registry 22 years on: what have we learned about knee replacements?
The infected total knee replacement: the worst and unfortunately most frequent complication
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