Improving patient outcomes following total knee arthroplasty with by lindahy

VIEWS: 111 PAGES: 12

More Info
									       Improving patient outcomes following total knee arthroplasty with perioperative exercise

                          B. Robertson*, T. Ackland & D. Wood                  The University of Western Australia


INTRODUCTION
Arthritis of the knee is prevalent in the community with nearly 1000 cases of primary total knee arthroplasty (TKA) performed annually in
Western Australia. While the TKA surgical procedure is successful at relieving pain and restoring mobility, there is a growing awareness that
clinical results can be further improved by a pre- and/or post-operative physical conditioning program (NIH, 1995). Whilst research has shown
that patients accrue rehabilitation benefits as a result of exercise both before and after joint replacement surgery (Zavadak et al., 1995; Gilbey
et al., 1999), this outcome has yet to be demonstrated in relation to TKA.

The purpose of this study was to investigate the benefits to patient outcomes prior to, and following TKA by the implementation of a perioperative
exercise program. In particular, this study examined:
•      the extent to which arthritic subjects tolerate the exercise intervention;
•      the value of exercise on the subjects rate of improvement in strength, active range of motion (AROM) and physical function after
       surgery;
•      the value of exercise on the subjects rate of improvement in walking gait function and other aspects related to quality of life after surgery;
       and
•      the value of exercise on the subjects ability to adhere to the hospital clinical pathway for routine discharge.


METHODS
This was a prospective investigation of 12 subjects requiring primary, unilateral TKA. The identification of exercise group subjects was made
from elective surgery waiting lists, while control group subjects were selected from a private hospital hip and knee registry. Each control subject
was selected to match an exercise group subject based on gender, age and body weight.

Subjects meeting the following criteria were eligible for inclusion in this study:
•     Demographics – male and female residents of the Perth metropolitan area;
•     Diagnosis


                                                                                                                                                 ➔
                                                                              Print           Index           Table of Contents                Quit
       Improving patient outcomes following total knee arthroplasty with perioperative exercise

                         B. Robertson*, T. Ackland & D. Wood                The University of Western Australia


– osteoarthritis, post-traumatic arthritis, inflammatory arthritis;
•     Indications – pain and disability with unsuccessful conservative treatment;
•     General – stable health and fit for anaesthesia;
•     Requiring unilateral primary TKR.

Subjects with the following exclusion criteria were not eligible:
•     Requiring revision knee surgery;
•     Malignancy in the area of the knee or hip joint;
•     Requiring bilateral knee replacement (within six months of the first operation);
•     Unstable health, unfit for anesthesia; and/or
•     Significant neuromuscular disease.

Subjects in the exercise group participated in an eight-week presurgery exercise program and a six-week postsurgery program under the
supervision of an exercise rehabilitation specialist. These programs were individually tailored to suit the capabilities of each participant. The
presurgery program consisted of two 60min training sessions per week using variable resistance machines for upper and lower body strength
as well as aerobic fitness training using a cycle, arm or rowing ergometer. If subjects were unable to participate in the standard exercises due
to pain or functional limitation, hydrotherapy and aerobic training were implemented. Hydrotherapy was continued until pain levels had reduced
or physical function had improved sufficiently to take part in a clinic-based program. Subjects were also required to complete three exercise
sessions per week at ‘home’ using a training kit consisting of light dumbbells and ankle weights. This home-based training was explained fully
at the start of the program. Control group subjects were only obliged to undertake the routine physiotherapy and allied health care offered by
their hospital.

The following tests were administered to exercise group subjects eight weeks and one week prior to surgery (pre-8 and pre-1 respectively), and
again six weeks post surgery (post+6). The WOMAC domains of pain, stiffness and physical function (Bellamy et al., 1988) were evaluated,
together with the SF-36 mental and physical capacities (Ware & Sherbourne, 1972). Subjects also completed a series of musculoskeletal
capacity tests, including bilateral AROM of the knee in the sagittal plane, and leg flexion and extension strength using a Keylink dynamometer.


                                                                                                                                       ➔➔
                                                                            Print           Index          Table of Contents               Quit
       Improving patient outcomes following total knee arthroplasty with perioperative exercise

                          B. Robertson*, T. Ackland & D. Wood                  The University of Western Australia


Functional tests, including a 6min walk test, a 3RM straight leg raise test and a functional step test were also administered. Control group
patients completed the WOMAC and SF-36 questionnaires at pre-1 and post+6 only.

In order to determine the efficacy of the presurgery program, series of one-way ANOVAs were conducted in conjunction with paired t-test post-
hoc comparisons for results obtained at the pre-8, pre-1 and post+6 time points. When comparing the effectiveness of the surgery plus exercise
intervention, with surgery plus routine postoperative care, a series of two-factor ANOVAs were conducted using the pre-1 and post+6 assessment
data.


RESULTS AND DISCUSSION
The eight-week presurgery exercise program was well tolerated by arthritic the end-stage osteoarthritic (OA) subjects, as there were no
training-related injuries, nor did any of the subjects withdraw from the study. The aim of the exercise intervention was to break the pain-inactivity
cycle in end-stage OA knee subjects. That is, increased pain generally leads to reduced activity levels, strength and range of motion, as well
as increases joint stress. In turn, this often stimulates high levels of pain and so the cycle continues.

Clearly the effect of surgery on subjects’ levels of pain and physical function is profound. Significant differences (p<0.05) were demonstrated
(despite the small sample) pre- to postsurgery for WOMAC total score, as well as for the domains of pain and difficulty with physical function
(Table 1). Improvements were also noted for the straight leg raise, step test and range of motion about the knee.

Many improvements were also demonstrated among the exercise group prior to surgery, with strength gains reaching significance (p<0.05)
and a trend (p=0.055) noted for the 6-min walk test. Unfortunately, statistical power was low due to the small sample, and therefore other
changes in mean scores presurgery did not reach significance.




                                                                                                                                           ➔➔
                                                                              Print           Index           Table of Contents                Quit
      Improving patient outcomes following total knee arthroplasty with perioperative exercise

                          B. Robertson*, T. Ackland & D. Wood                             The University of Western Australia


                     Table 1. Descriptive statistics and ANOVA summary for WOMAC, strength and physical function tests over time
                                                                  mean       mean     mean                                  pre-8 v   pre-8 v
                                 Variable                         pre-8      pre-1    post+6    F         p      power       pre-1    post+6
                     WOMAC – total score                           43.83      43.17    25.67   26.13    0.004     0.980       ns         *
                     WOMAC – pain                                   9.17       8.17     5.50   10.25    0.024     0.726       ns         *
                     WOMAC – stiffness                              3.50       3.50     3.33    0.02    0.886     0.052       ns        ns
                     WOMAC – physical function                     29.67      30.17    16.50   36.93    0.002     0.997       ns         *
                     Straight leg raise (kg)                        4.70      12.00    11.00    8.08    0.036      0.627       *         *
                     Flexion + extension torque (Nm)               54.82      70.63    55.72    0.04    0.853      0.053       *        ns
                     6-min walk test (m)                             285.7    350.2    324.4    0.46    0.528      0.086       t        ns
                     Step test – flexion (%BW)                        87.3     93.2     96.6    5.61    0.064      0.482      ns         *
                     Step test – extension (%BW)                      76.8     86.4     96.1    5.42    0.067      0.469      ns         *
                     Range of motion (deg)                            99.2    105.2     87.0    2.64    0.165      0.263      ns         *
                     ns = not significant; t = trend; * = sig at p<0.05


The benefits of preoperative exercise intervention programs must not be underestimated; this study has shown that improvements in levels of
strength, mobility and function can be gained by sufferers of endstage OA of the knee. In turn, this afforded subjects in the exercise group a
higher baseline from which to rehabilitate following the trauma of TKA. The implementation of a presurgery exercise program has the potential
to accelerate the achievement of postoperative clinical pathway goals such as bed to chair transfers, sit to stand activities and the use of
crutches, thereby attaining the criteria for earlier discharge.

As a result of subject matching, no differences in age (mean = 68.5 & 71.0y) or weight (mean = 85.0 & 84.0kg) were found between the
exercise and control groups respectively at baseline. Following surgery, exercise group patients recorded improved WOMAC total score and
for the physical function domain (Figure 1). A significant main effect for time (p<0.05) was noted for these parameters, with the interaction
effect approaching significance (p=0.057). Clearly, these trends would have reached significance with a larger sample. No significant group
differences were noted for the other WOMAC domains of pain or stiffness.



                                                                                                                                                 ➔➔
                                                                                         Print             Index             Table of Contents   Quit
       Improving patient outcomes following total knee arthroplasty with perioperative exercise

                                         B. Robertson*, T. Ackland & D. Wood         The University of Western Australia




                                   100                                    Surgery                                        70                                Surg
                                                                          Exercise                                                                         Exer




                                                                                       WOMAC - Physical Function Scale
                                                                                                                         60
                                                                          Control                                                                          Cont
                                    75
                                                                                                                         50
               WOMAC Total Score




                                                                                                                         40
                                    50
                                                                                                                         30

                                                                                                                         20
                                    25
                                                                                                                         10

                                     0                                                                                    0
                                           Pre-1            Post+6                                                             Pre-1          Post+6


Figure 1. WOMAC total score and physical function (mean ± SE) for exercise and control patients pre- and postsurgery. Note that a lower score
denotes an improvement.

Similar findings were noted for the SF-36 physical capacity scores (Figure 2). A significant group main effect (p<0.05) indicated greater physical
capacity among exercise subjects compared to controls. This difference was not dependant on the time of test. Importantly, there was no
difference in physical capacity score between the exercise group at baseline and that for controls at pre-1, meaning that both groups were
similar prior to the intervention. No group effect differences were noted for the SF-36 mental capacity parameter.




                                                                                                                                                           ➔➔
                                                                                     Print                                    Index    Table of Contents     Quit
       Improving patient outcomes following total knee arthroplasty with perioperative exercise

                         B. Robertson*, T. Ackland & D. Wood                  The University of Western Australia


                                                               50
                                                                                                  Surgery




                                    SF36 - Physical Capacity
                                                                                                  Exercise
                                                               40                                 Control

                                                               30



                                             Score
                                                               20

                                                               10

                                                                0
                                                                    Pre-1     Post+6
Figure 2. SF-36 physical capacity (mean ± SE) for exercise and control patients pre- and postsurgery. Note that a higher score denotes an
improvement.

Postoperatively, results from this study have shown that the early recovery of strength, ambulatory status and the subsequent improvements
in knee related quality of life could readily be achieved through the implementation of a perioperative exercise program. Though mitigated by
a small sample, these results demonstrate the enormous potential for improved patient outcomes by combining TKA with appropriately
graduated and supervised perioperative exercise.

The effective lengths of stay (LOS) for exercise and control subjects are shown in Figure 3, and these are compared to current data for
Western Australian hospitals. The exercise group attained eligibility for discharge (by achieving 90 degree knee flexion and a straight leg raise
from the bed) significantly earlier (p<0.05) than the control subjects, though the actual day on which subjects left hospital was often determined
by other, unrelated factors: Such as, superficial wound infection, wound ooze and the fact that it was uncommon for subjects to be discharged
over weekends. The exercise group subjects had a reduced effective LOS (mean = 8.6 days) compared to control subjects (mean = 15.0
days). This was two days shorter than the average for Perth teaching hospitals, and more than three days shorter than for all hospitals state-
wide.
                                                                                                                                         ➔➔
                                                                             Print           Index          Table of Contents                Quit
      Improving patient outcomes following total knee arthroplasty with perioperative exercise

                         B. Robertson*, T. Ackland & D. Wood                                  The University of Western Australia


Improved hospital services, patient management, surgical procedures and implementation of clinical pathways has resulted in a reduced LOS
from a mean of 21.7 days in the early 1970’s to a mean of 12.1 days for all hospitals in W.A. for the year 1998/1999. Moreover, Perth teaching
hospitals for 1998/1999 exhibited an even lower mean LOS of 10.6 days for patients aged 20-70+ years.

                                                                    24

                                                                    22
                                                                    20
                                   Length of Hospital Stay (Days)   18

                                                                    16

                                                                    14
                                                                                                W estern Australian Hospitals
                                                                    12
                                                                                                Mean LOS (12.1 days)
                                                                    10                         Perth Metropolitan Tertiary
                                                                     8                         Hospitals Mean LOS (10.6 days)
                                                                     6

                                                                     4
                                                                     2

                                                                     0
                                                                         Exercise   Control

Figure 3. Effective length of hospital stay (mean ± SE) for exercise and control patients


CONCLUSIONS
This study demonstrated that the exercise program was well tolerated by sufferers of end-stage osteoarthritis of the knee, and increased the
rate at which subjects returned to normal activities after leaving hospital and regained functional independence. It therefore provided exercise
subjects with the capacity to return to recreational activities sooner than routine subjects.


                                                                                                                                                    ➔➔
                                                                                              Print           Index             Table of Contents   Quit
     Improving patient outcomes following total knee arthroplasty with perioperative exercise

                       B. Robertson*, T. Ackland & D. Wood                 The University of Western Australia


REFERENCES:
1.   Bellamy, N., Buchanan, W., Goldsmith, C., Campbell, J. & Sitt, L. (1988) Validation study of WOMAC: A health status instrument for
     measuring clinically-important patient-relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
     Journal of Rheumatology, 15:1833-1840.

2.   Gilbey, H. (1999) Accelerated Rehabilitation following Total Hip Arthroplasty: The Role of Perioperative Exercise. Unpublished PhD
     thesis, The University of Western Australia, Perth, Australia.

3.   N.I.H. (1995) NIH Consensus Conference: Total hip replacement. J.A.M.A., 273(24):1950-1956.

4.   Ware, J. & Sherbourne, C. (1992) The MOS-36 item short form health survey (SF-36): Conceptual framework and item selection.
     Medicine and Care, 30:473-483.

5.   Zavadak, K., Gibson, K., Whitley, D., Britz, P. & Kwoh, C. (1995) Variability in the attainment of functional milestones during the acute
     care admission after total joint replacement, The Journal of Rheumatology, 22(3):482-487.




                                                                                                                                     ➔
                                                                           Print          Index          Table of Contents               Quit
        Improving patient outcomes following total knee arthroplasty with
                             perioperative exercise
                                            B. Robertson*, T. Ackland & D. Wood
                                             The University of Western Australia

     INTRODUCTION: Arthritis of the knee is prevalent in the community with nearly 1000 cases of primary total knee
arthroplasty (TKA) performed annually in Western Australia. While the TKA surgical procedure is successful at
relieving pain and restoring mobility, there is a growing awareness that clinical results can be further improved by a
pre- and/or post-operative physical conditioning program (NIH, 1995). Whilst research has shown that patients
accrue rehabilitation benefits as a result of exercise both before and after joint replacement surgery (Zavadak et al.,
1995; Gilbey et al., 1999), this outcome has yet to be demonstrated in relation to TKA.
     The purpose of this study was to investigate the benefits to patient outcomes prior to, and following TKA by the
implementation of a perioperative exercise program. In particular, this study examined:
     • the extent to which arthritic subjects tolerate the exercise intervention;
     • the value of exercise on the subjects rate of improvement in strength, active range of motion (AROM) and
          physical function after surgery;
     • the value of exercise on the subjects rate of improvement in walking gait function and other aspects related
          to quality of life after surgery; and
     • the value of exercise on the subjects ability to adhere to the hospital clinical pathway for routine discharge.
     METHODS: This was a prospective investigation of 12 subjects requiring primary, unilateral TKA. The
identification of exercise group subjects was made from elective surgery waiting lists, while control group subjects
were selected from a private hospital hip and knee registry. Each control subject was selected to match an exercise
group subject based on gender, age and body weight.
     Subjects meeting the following criteria were eligible for inclusion in this study:
     • Demographics – male and female residents of the Perth metropolitan area;
     • Diagnosis – osteoarthritis, post-traumatic arthritis, inflammatory arthritis;
     • Indications – pain and disability with unsuccessful conservative treatment;
     • General – stable health and fit for anaesthesia;
     • Requiring unilateral primary TKR.
     Subjects with the following exclusion criteria were not eligible:
     • Requiring revision knee surgery;
     • Malignancy in the area of the knee or hip joint;
     • Requiring bilateral knee replacement (within six months of the first operation);
     • Unstable health, unfit for anesthesia; and/or
     • Significant neuromuscular disease.
     Subjects in the exercise group participated in an eight-week presurgery exercise program and a six-week
postsurgery program under the supervision of an exercise rehabilitation specialist. These programs were individually
tailored to suit the capabilities of each participant. The presurgery program consisted of two 60min training sessions
per week using variable resistance machines for upper and lower body strength as well as aerobic fitness training
using a cycle, arm or rowing ergometer. If subjects were unable to participate in the standard exercises due to pain
or functional limitation, hydrotherapy and aerobic training were implemented. Hydrotherapy was continued until pain
levels had reduced or physical function had improved sufficiently to take part in a clinic-based program. Subjects
were also required to complete three exercise sessions per week at ‘home’ using a training kit consisting of light
dumbbells and ankle weights. This home-based training was explained fully at the start of the program. Control group
subjects were only obliged to undertake the routine physiotherapy and allied health care offered by their hospital.
     The following tests were administered to exercise group subjects eight weeks and one week prior to surgery (pre-
8 and pre-1 respectively), and again six weeks post surgery (post+6). The WOMAC domains of pain, stiffness and
physical function (Bellamy et al., 1988) were evaluated, together with the SF-36 mental and physical capacities
(Ware & Sherbourne, 1972). Subjects also completed a series of musculoskeletal capacity tests, including bilateral
AROM of the knee in the sagittal plane, and leg flexion and extension strength using a Keylink dynamometer.
Functional tests, including a 6min walk test, a 3RM straight leg raise test and a functional step test were also
administered. Control group patients completed the WOMAC and SF-36 questionnaires at pre-1 and post+6 only.
     In order to determine the efficacy of the presurgery program, series of one-way ANOVAs were conducted in
conjunction with paired t-test post- hoc comparisons for results obtained at the pre-8, pre-1 and post+6 time points.
When comparing the effectiveness of the surgery plus exercise intervention, with surgery plus routine postoperative
care, a series of two-factor ANOVAs were conducted using the pre-1 and post+6 assessment data.
    RESULTS AND DISCUSSION: The eight-week presurgery exercise program was well tolerated by arthritic the
end-stage osteoarthritic (OA) subjects, as there were no training-related injuries, nor did any of the subjects withdraw
from the study. The aim of the exercise intervention was to break the pain-inactivity cycle in end-stage OA knee
subjects. That is, increased pain generally leads to reduced activity levels, strength and range of motion, as well as
increases joint stress. In turn, this often stimulates high levels of pain and so the cycle continues.
    Clearly the effect of surgery on subjects’ levels of pain and physical function is profound. Significant differences
(p<0.05) were demonstrated (despite the small sample) pre- to postsurgery for WOMAC total score, as well as for the
domains of pain and difficulty with physical function (Table 1). Improvements were also noted for the straight leg
raise, step test and range of motion about the knee.
    Many improvements were also demonstrated among the exercise group prior to surgery, with strength gains
reaching significance (p<0.05) and a trend (p=0.055) noted for the 6-min walk test. Unfortunately, statistical power
was low due to the small sample, and therefore other changes in mean scores presurgery did not reach significance.

Table 1. Descriptive statistics and ANOVA summary for WOMAC, strength and physical function tests over time
                                             mean       mean      mean                                        pre-8 v      pre-8 v
            Variable                         pre-8      pre-1     post+6       F          p       power        pre-1       post+6
WOMAC – total score                           43.83      43.17     25.67      26.13     0.004      0.980        ns            *
WOMAC – pain                                   9.17       8.17      5.50      10.25     0.024      0.726        ns            *
WOMAC – stiffness                              3.50       3.50      3.33       0.02     0.886      0.052        ns           ns
WOMAC – physical function                     29.67      30.17     16.50      36.93     0.002      0.997        ns            *
Straight leg raise (kg)                        4.70      12.00      11.00      8.08     0.036       0.627        *            *
Flexion + extension torque (Nm)               54.82      70.63      55.72      0.04     0.853       0.053        *           ns
6-min walk test (m)                             285.7    350.2      324.4      0.46     0.528       0.086        t           ns
Step test – flexion (%BW)                        87.3     93.2       96.6      5.61     0.064       0.482       ns            *
Step test – extension (%BW)                      76.8     86.4       96.1      5.42     0.067       0.469       ns            *
Range of motion (deg)                            99.2    105.2       87.0      2.64     0.165       0.263       ns            *
ns = not significant; t = trend; * = sig at p<0.05

     The benefits of preoperative exercise intervention programs must not be underestimated; this study has shown
that improvements in levels of strength, mobility and function can be gained by sufferers of endstage OA of the knee.
In turn, this afforded subjects in the exercise group a higher baseline from which to rehabilitate following the trauma
of TKA. The implementation of a presurgery exercise program has the potential to accelerate the achievement of
postoperative clinical pathway goals such as bed to chair transfers, sit to stand activities and the use of crutches,
thereby attaining the criteria for earlier discharge.
     As a result of subject matching, no differences in age (mean = 68.5 & 71.0y) or weight (mean = 85.0 & 84.0kg)
were found between the exercise and control groups respectively at baseline. Following surgery, exercise group
patients recorded improved WOMAC total score and for the physical function domain (Figure 1). A significant main
effect for time (p<0.05) was noted for these parameters, with the interaction effect approaching significance
(p=0.057). Clearly, these trends would have reached significance with a larger sample. No significant group
differences were noted for the other WOMAC domains of pain or stiffness.
                    100                                                            Surgery                                      70                        Surgery
                                                                                   Exercise                                                               Exercise




                                                                                              WOMAC - Physical Function Scale
                                                                                                                                60
                                                                                   Control                                                                Control
                     75
                                                                                                                                50
WOMAC Total Score




                                                                                                                                40
                     50
                                                                                                                                30

                                                                                                                                20
                     25
                                                                                                                                10

                      0                                                                                                          0
                          Pre-1                                   Post+6                                                               Pre-1   Post+6




             Figure 1. WOMAC total score and physical function (mean ± SE) for exercise and control patients pre- and
         postsurgery. Note that a lower score denotes an improvement.
             Similar findings were noted for the SF-36 physical capacity scores (Figure 2). A significant group main effect
         (p<0.05) indicated greater physical capacity among exercise subjects compared to controls. This difference was not
         dependant on the time of test. Importantly, there was no difference in physical capacity score between the exercise
         group at baseline and that for controls at pre-1, meaning that both groups were similar prior to the intervention. No
         group effect differences were noted for the SF-36 mental capacity parameter.


                                                             50
                                                                                                                                               Surgery
                                  SF36 - Physical Capacity




                                                                                                                                               Exercise
                                                             40                                                                                Control

                                                             30
                                           Score




                                                             20

                                                             10

                                                              0
                                                                           Pre-1                                                     Post+6


             Figure 2. SF-36 physical capacity (mean ± SE) for exercise and control patients pre- and postsurgery. Note that a
         higher score denotes an improvement.
             Postoperatively, results from this study have shown that the early recovery of strength, ambulatory status and the
         subsequent improvements in knee related quality of life could readily be achieved through the implementation of a
         perioperative exercise program. Though mitigated by a small sample, these results demonstrate the enormous
         potential for improved patient outcomes by combining TKA with appropriately graduated and supervised perioperative
         exercise.
             The effective lengths of stay (LOS) for exercise and control subjects are shown in Figure 3, and these are
         compared to current data for Western Australian hospitals. The exercise group attained eligibility for discharge (by
         achieving 90 degree knee flexion and a straight leg raise from the bed) significantly earlier (p<0.05) than the control
         subjects, though the actual day on which subjects left hospital was often determined by other, unrelated factors: Such
as, superficial wound infection, wound ooze and the fact that it was uncommon for subjects to be discharged over
weekends. The exercise group subjects had a reduced effective LOS (mean = 8.6 days) compared to control
subjects (mean = 15.0 days). This was two days shorter than the average for Perth teaching hospitals, and more than
three days shorter than for all hospitals state-wide.
    Improved hospital services, patient management, surgical procedures and implementation of clinical pathways
has resulted in a reduced LOS from a mean of 21.7 days in the early 1970’s to a mean of 12.1 days for all hospitals
in W.A. for the year 1998/1999. Moreover, Perth teaching hospitals for 1998/1999 exhibited an even lower mean LOS
of 10.6 days for patients aged 20-70+ years.


                                           24

                                           22
                                           20
          Length of Hospital Stay (Days)




                                           18

                                           16
                                           14
                                                                     W estern Australian Hospitals
                                           12
                                                                     Mean LOS (12.1 days)
                                           10                        Perth Metropolitan Tertiary
                                            8                        Hospitals Mean LOS (10.6 days)
                                            6

                                            4
                                            2

                                            0
                                                Exercise   Control




    Figure 3. Effective length of hospital stay (mean ± SE) for exercise and control patients
    CONCLUSIONS: This study demonstrated that the exercise program was well tolerated by sufferers of end-stage
osteoarthritis of the knee, and increased the rate at which subjects returned to normal activities after leaving hospital
and regained functional independence. It therefore provided exercise subjects with the capacity to return to
recreational activities sooner than routine subjects.
    REFERENCES:
    1. Bellamy, N., Buchanan, W., Goldsmith, C., Campbell, J. & Sitt, L. (1988) Validation study of WOMAC: A
         health status instrument for measuring clinically-important patient-relevant outcomes to antirheumatic drug
         therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology, 15:1833-1840.
    2. Gilbey, H. (1999) Accelerated Rehabilitation following Total Hip Arthroplasty: The Role of Perioperative
         Exercise. Unpublished PhD thesis, The University of Western Australia, Perth, Australia.
    3. N.I.H. (1995) NIH Consensus Conference: Total hip replacement. J.A.M.A., 273(24):1950-1956.
    4. Ware, J. & Sherbourne, C. (1992) The MOS-36 item short form health survey (SF-36): Conceptual
         framework and item selection. Medicine and Care, 30:473-483.
    5. Zavadak, K., Gibson, K., Whitley, D., Britz, P. & Kwoh, C. (1995) Variability in the attainment of functional
         milestones during the acute care admission after total joint replacement, The Journal of Rheumatology,
         22(3):482-487.

								
To top