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					                                                                                       Effects of Pre-Operative Exercise Instruction in Improving Post-Operative Functional Outcomes and Reducing
                                                                                                      Outpatient Physical Therapy Visits on Patients Receiving Total Knee Arthroplasty
                                                                                                                                                                                               Megan Pline, PT, DPT, Edwin James, BS, PT, Claire Kalpakjian, PhD
                                                                                                                                                                                                              University of Michigan, Ann Arbor, MI

                                                                            BACKGROUND & OBJECTIVE                                                                                                                    HOME EXERCISE PROGRAM                                                                                   RESULTS
As the prevalence of total knee arthroplasties increases, ways to improve outcomes and                                                                                                       The treatment group was instructed in a detailed home exercise program that they were to                                                 Figure 3. Mean WOMAC scores across
return patients to their previous functional status quicker are constantly being developed.                                                                                                  perform at least two times per day until day of surgery.                                                                                 assessment periods. Both groups
The purpose of this research was to test the effectiveness of a new structured pre-                                                                                                                                                                                                                                                   experienced similar drops in WOMAC scores
operative home exercise program with respect to pain rating and functional outcomes as                                                                                                       For each exercise subjects were instructed in the frequency, intensity, and duration.                                                    across the study period with the treatment
measured by Knee Society Clinical Rating scores and WOMAC scores in patients                                                                                                                                                                                                                                                          group generally scoring lower than the control
receiving total knee arthroplasty.                                                                                                                                                           The home exercise program was provided to the subjects in a paper format and through an
                                                                                                                                                                                             instructional DVD that they could re-watch as needed at home.
                                                                                                                                                                                             Weekly phone calls were made to the treatment group to see how the home exercise
Eighteen adults (7 males, 11 females) aged 52-87 years old, scheduled for total knee                                                                                                         program was going and to make sure the subjects were preforming the exercises.
arthroplasties (TKA) with the Department of Orthopedic Surgery Adult Lower Extremity
Reconstruction Clinic at the University of Michigan, were involved in this study. Exclusion                                                                                                  Subjects were also given a tracking log for performance of exercises and instructed to
criteria included: diabetes, cardiovascular disease, morbid obesity (BMI>40), current                                                                                                        check off on a chart each time they completed the exercises.
tobacco use, TKA secondary to avascular necrosis or traumatic injury, post-operative                                                                                                                                                                                                                                                  Figure 4. Mean pain rating across
                                                                                                                                                                                                                                                                                                                                      assessment periods. Both groups
complications including a prolonged hospital stay (>5 days) , and complications due to                                                                                                       The home exercise program (HEP) included the following exercises: heel slides, straight                                                  experienced similar drops in pain rating
surgery (deep vein thrombosis/es, cardiac arrhythmia, infection).                                                                                                                            leg raises, short arc quads, hook-lying resisted hip abduction, clams, long arc quads,                                                   across the study period with the treatment
                                                                                                                                                                                             seated hamstring stretch, standing resisted hip abduction, and standing heel raises.                                                     group generally rating their pain lower than
                                                                                                                                                                                                                                                                                                                                      the control group.
       Enrollment                             Assessed for eligibility (n=252)
                                                                                                                                                        Intervention Group   Control Group
                                                                                                                          Demographic Characteristics
                                                                             Excluded (n=234)
                                                                                                                                                              (N = 9)           (N = 6)
                                                                              Scheduled with the wrong physician
                                                                              Scheduled less than 1 month in             Age (mean, SD)                      71, 7.5           71, 6.4
                                                                                 advance (n=112)
                                                                              Not living close enough to the clinic
                                                                                                                          Gender (N, %)
                                                                                                                            Male                              3, 33%            3, 50%
                                                    Randomized (n=18)
                                                                                                                            Female                            6, 67%            3, 50%

                                                    Allocation                                                            BMI (N, %)
 Allocated to intervention (n=10)                                      Allocated to control (n=8)                          15 through   20                    1, 11%            0, 0%
  Received allocated intervention (n=10)                                 Received standard of care (n=8)                 21 through   25                     0, 0%            1, 17%
                                                                                                                           26 through   30                    1, 11%            3, 50%
                                                                                                                           31 through   35                    1, 11%            2, 33%
                                                    Follow-Up                                                              36 through   40                    6, 67%            0, 0%
                                                                                                                                                                                                                                                                                                                                      Figure 5. Mean Knee Society Rating across
                                                                                                                                                                                                                                                                                                                                      assessment periods. Across the study
 Lost to follow-up (had outpatient physical                            Lost to follow-up (had outpatient physical
 therapy at a different location) (n=1)                                therapy at a different location) (n=2)             Surgical Knee (N, %)                                                                                                                                                                                        period, Knee Society Ratings were highly
                                                                                                                                                              4, 44%            2, 33%
                                                                                                                                                              5, 56%            4, 67%                                                                                                                                                variable though the parallel lines by group

 Analysed (n=9)                                                        Analysed (n=6)
                                                                                                                                                                                                                                                                                                                                      indicate that the variability was similar
                                                                                                                                                                                                                                                                                                                                      between groups. It is interesting to note that
                    Figure 1. CONSORT Table                                                                                               Figure 2. Sample Characteristics                                                                                                                                                            for both groups the lowest Knee Society
                                                                                                                                                                                                                                                                                                                                      Rating was found immediately after surgery.

                                                                                       METHODS & MATERIALS
This study was a randomized controlled clinical trial using parallel group randomization to
allocate participants to receive the new pre-operative home program or standard of care.
The standard of care for rehabilitation of a TKA is to have only post-operative physical
therapy and to not have any pre-operative therapy. Participants underwent a baseline
assessment one month prior to surgery completing the following:                                                                                                                                                                                                                                               DISCUSSION & CONCLUSIONS
                                                                                                                                                                                                                                                                                        There was no statistical difference in the outcomes of total knee arthroplasty subjects that
              Knee range of motion (flexion and extension)                                                                                                                                                                                                                              receive a pre-operative exercise program compared to subjects that do not. This may in
              Single leg stance time                                                                                                                                                                                                                                                    part be due to the small sample size and it may also be due to the length of the
              Gait velocity                                                                                                                                                                                                                                                             intervention. One month of a HEP may not have been long enough to produce differences
              Berg balance scores                                                                                                                                                                                                                                                       in strength and range of motion between the groups. It would be worthwhile to look at a
              Western Ontario and McMaster (WOMAC) Universities Arthritis Index                                                                                                                                                                                                         longer pre-operative program.
              Knee Society Clinical Rating scores
              Pain rating using a visual analog scale (0-10)                                                                                                                                                                                                                            There was a statistically significant change within the treatment group for the WOMAC
                                                                                                                                                                                                                                                                                        score between the second pre-surgery measurement and the one month follow-up post-
Follow up assessments of both groups were performed one week prior to surgery, at the                                                                                                                                                                                                   therapy. This was not true for the control group. The WOMAC score is a subjective
start of outpatient physical therapy, and weekly until discharge criteria was met (from                                                                                                                                                                                                 measurement given by the patient. It may be that the treatment group had greater
outpatient physical therapy).                                                                                                                                                                                                                                                           confidence in their ability to perform activities of daily living after spending time pre-
                                                                                                                                                                                                                                                                                        operatively on the home exercise program.
Discharge criteria from outpatient physical therapy included achieving knee flexion of at
least 110 degrees, knee extension of at least 0 degrees,                                                                                                                                                                                                                                There were multiple limitations with this study including a small sample size due to
                                           AND                                                                                                                                                                                                                                          difficulties of recruiting. There was a large percentage of TKA subjects scheduled less than
                                                                                                                                                                                                                                                                                        one month prior to surgery which made them ineligible for the study as well as a large
meeting at least two of the following criteria:                                                                                                                                                                                                                                         percentage of patients scheduled with the surgeon not included in the study. One other
     Single leg stance time of 30 seconds or greater                                                                                                                                                                                                                                    limitation was the fact that the researchers were not blinded to the groups.
     Berg Balance Test score of 45 or greater
     Gait velocity of at least 0.8 meters/second                                                                                                                                                                                                                                        The outcomes of this study also indicate the need for additional research into providing a
                                                                                                                                                                                                                                                                                        longer lead time for conducting pre-op exercises and the incorporation of additional direct
The final assessment was one month post-discharge from outpatient physical therapy.                                                                                                                                                                                                     Physical Therapy interventions pre-operatively.

All physical therapy was performed at the University of Michigan MedRehab physical                                                                                                                                                                                                                                   ACKNOWLEDGMENTS
therapy clinic in Canton, MI.                                                                                                                                                                                                                                                           This study was funded by a grant from the University of Michigan Practice-Oriented
                                                                                                                                                                                                                                                                                        Research Training (PORT) Program and the Department of Physical Medicine and
During physical therapy sessions all participants received the same type of treatment for                                                                                                                                                                                               Rehabilitation. The PORT Program is part of the Michigan Institute for Clinical and Health
rehabilitation of a total knee arthroplasty. A combination of manual therapy as well as                                                                                                                                                                                                 Research at the University of Michigan and supported by a grant from the National
therapeutic exercise and activity was done.                                                                                                                                                                                                                                             Institutes of Health Clinical and Translations Sciences Award (#UL1RR024986).

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