6 Weeks After Knee Surgery Carrie Was Blank Again

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J Orthop Sports Phys Ther. Writer manuscript; available in PMC 2011 Aug 31.

Published in final edited form as:

PMCID: PMC3164265

NIHMSID: NIHMS315631

Outcomes Before and After Total Knee Arthroplasty Compared to Healthy Adults

MICHAEL J. BADE

^oneDoctoral educatee, University of Colorado, School of Medicine, Aurora, CO

WENDY M. KOHRT

ⁱⁱProfessor, Academy of Colorado, School of Medicine, Aurora, CO

JENNIFER East. STEVENS-LAPSLEY

³Associate Professor, University of Colorado, School of Medicine, Aurora, CO

Abstract

STUDY Design

Prospective accomplice written report.

OBJECTIVES

To measure changes in muscle strength, range of movement, and role from ii weeks before to 6 months after total knee joint arthroplasty (TKA) and compare outcomes with data from a control grouping consisting of healthy adults.

BACKGROUND

Total knee arthroplasty successfully alleviates pain from knee osteoarthritis, simply deficits in function tin can persist long term. How impairments and functional limitations change over the first 6 months afterwards TKA, compared to information from salubrious adults, has not been well reported in the literature.

METHODS

Twenty-iv patients who underwent a primary unilateral TKA were compared to healthy adults (due north = 17). All patients participated in a standardized rehabilitation program following surgery. Isometric quadriceps torque was assessed using an electromechanical dynamometer. Range of motion was measured actively and passively. Functional performance was assessed using the stair-climbing test, timed up-and-go test, 6-minute walk test, and single-limb stance time. Patients underwent testing at ii weeks preoperatively and at 1, three, and 6 months postoperatively.

RESULTS

Compared to salubrious older adults, patients performed significantly worse at all times for all measures (P<.05), except for single-limb opinion time at 6 months (P>.05). One month postoperatively, patients experienced significant losses from preoperative levels in all outcomes. Patients recovered to preoperative levels by half dozen months postoperatively on all measures, except human knee flexion range of motion, but notwithstanding exhibited the same extent of limitation they did prior to surgery.

CONCLUSION

The persistent impairments and functional limitations 6 months after TKA with standard rehabilitation suggest that more than intensive therapeutic approaches may be necessary to restore function of patients following TKA to the levels of healthy adults.

Keywords: joint replacement, older adults, osteoarthritis, rehabilitation

Arthritis is the leading crusade of disability in America.⁵ Osteoarthritis (OA) is the virtually common blazon of arthritis and affects nearly 27 million Americans.¹⁷ Total human knee arthroplasty (TKA) is routinely performed to alleviate the pain associated with knee OA. In 2006, the number of TKA surgeries performed in the The states was 516 000,^ane and this number is projected to grow to three.48 1000000 past the twelvemonth 2030 because of an increasing number of older adults, increasing prevalence of obesity, and increasing utilization of this surgery.¹⁶

Total knee arthroplasty reliably reduces pain and improves wellness-related quality of life in 90% of patients.²⁴ All the same, functional performance in patients 1 twelvemonth after TKA remains lower than for healthy adults, with reports of an 18% slower walking speed, 51% slower stair-climbing speed, and deficits of nearly 40% in quadriceps strength.⁴³ One year after TKA, patients report having greater difficulty with kneeling, squatting, moving laterally, turning, cutting, carrying loads, stretching, performing lower extremity strengthening exercises, playing lawn tennis, dancing, gardening, and participating in sexual activity, when compared to healthy adults.²⁵

Although there have been numerous studies on patients later TKA with a comparison to healthy adults, many of these studies were cross-sectional in nature or, if longitudinal, examined only long-term (greater than 6 months postoperative) outcomes.^{2–iv,8,12,25,31,35,43–44} Thus, inference into how and when impairments and functional limitations develop in the first 6 months after TKA is lacking. A better understanding of impairments and functional limitations preoperatively and how these change postoperatively would help clinicians design rehabilitation programs that more fully restore physical function in patients afterwards TKA to the levels of their salubrious peers.

To date, there accept been only 2 longitudinal studies that have assessed impairments and functional limitations during the 6-calendar month interval later TKA.^22,44 Withal, both studies had limitations. In the study past Mizner et al,²² there was no comparison of patients with healthy adults. Thus, the magnitude of deficits compared to healthy adults was not documented. The second study had limitations in generalizability because of (one) strict inclusion criteria (lower torso mass index [BMI] and at least neutral knee extension), (2) pocket-size sample size (northward = 12), and (3) no measurements earlier than 3 months after TKA.⁴⁴

The purpose of this study was to assess muscle strength, range of motion (ROM), and functional operation of patients prospectively from earlier to later on TKA for comparison with good for you older adults. Our hypothesis was that patients would perform more than poorly preoperatively and at 6 months postoperatively on muscle strength, ROM, and functional tests compared to healthy adults. Furthermore, we hypothesized that patients would experience pregnant losses in all outcomes 1 calendar month postoperatively so recover to preoperative levels by half-dozen months.

METHODS

Study Design

This was a prospective cohort study of patients undergoing TKA, evaluated at 2 weeks preoperatively, likewise every bit at 1, 3, and half-dozen months postoperatively, with a cantankerous-sectional comparison to a cohort of healthy adults. The six-month fourth dimension point was chosen because patients recovering from TKA typically plateau in strength and functional gains past this time point.^vii,xv,22 The study was canonical by the Colorado Multiple Institutional Review Board. Informed consent was obtained from all participants and the rights of participants were protected.

Participants

20-4 patients (12 females, 12 males) who underwent a chief unilateral TKA were compared to a healthy cohort of 17 adults (8 females, 9 males). Patients undergoing TKA were consecutively recruited from 3 orthopaedic surgeons at the University of Colorado Hospital from June 2006 to June 2008 and were control subjects in an ongoing clinical trial. Patients were included if they were between the ages of 50 and 85 years and were undergoing a primary unilateral TKA for stop-stage genu OA. Patients undergoing TKA were excluded if they had uncontrolled hypertension, uncontrolled diabetes, BMI greater than 35 kg/g², meaning neurologic impairments, meaning contralateral articulatio genus OA (every bit defined by pain greater than 4/10 with activity), or other unstable, lower extremity orthopaedic conditions. All patients participated in a standardized rehabilitation program following surgery. Inpatient rehabilitation at the University of Colorado Hospital was conducted twice daily for an average ± SD length of stay of 3.2 ± 1.1 days (APPENDIX). Following discharge from the hospital, patients were treated in the home setting for 2 weeks (half dozen to 7 visits), later on which patients were treated in outpatient physical therapy for eleven.5 ± 6.2 visits. All home health and outpatient concrete therapists followed a standardized rehabilitation protocol as previously described (APPENDIX).²¹ Interventions targeted genu ROM, incision mobility, hurting command, gait deviations, and strength of the quadriceps, hamstrings, hip abductors, hip extensors, and ankle plantar flexors. Both weight-bearing and non–weight-bearing exercises were initiated with 2 sets of 10 repetitions and so progressed to 3 sets of x repetitions. For strengthening exercises, weights were increased to maintain a ten-repetition maximum targeted intensity level. Patients were besides given a dwelling exercise program to be performed twice daily that consisted of end-range knee flexion and extension stretching, as well as weight-bearing and non–weight-bearing strengthening exercises for the quadriceps, hamstrings, hip abductors, hip extensors, and talocrural joint plantar flexors. The intensity of the habitation practise programme was similar to that performed during the supervised home and outpatient physical therapy sessions. No patients were lost to follow-up evaluation.

Healthy adults were consecutively recruited from the community from December 2008 to March 2009. Healthy adults were included if they exercised a minimum of 3 days per week for at least 30 minutes per day and were between the ages of 50 and 85 years. Salubrious adults were excluded if they had any of the exclusion criteria listed above for the patients receiving TKA or if they had genu pain greater than two/10 on an intermittent basis or average knee pain greater than 0/10 with daily activities based on cocky-study. Both correct and left lower extremities were tested for the unilateral measurements of quadriceps strength and ROM.

Outcomes

Isometric Muscle Torque Testing

To exam isometric quadriceps musculus torque, patients were seated and stabilized on a HUMAC NORM (CSMi, Stoughton, MA) electromechanical dynamometer with threescore° of human knee flexion. Following ii warm-up contractions, a practice maximal voluntary isometric contraction (MVIC) was performed against the dynamometer's forcefulness transducer. Data were caused using a Biopac information acquisition system (Biodex Systems, Inc, Goleta, CA) at a sampling frequency of 2000 Hz, and analyzed using AcqKnowledge software, Version three.8.two (Biodex Systems, Inc), which allowed for gravity correction. Verbal encouragement was given during each maximum attempt. Visual torque targets were attack the feedback monitor at slightly higher torques than those produced during the practice MVIC trial. Data for 3 maximum trials were collected, unless maximal torque for the second trial was within 5% of the first trial, in which case simply 2 trials were performed. Immediately post-obit each MVIC, pain was recorded using an eleven-point verbal numerical hurting rating scale from 0 (no pain) to ten (worst pain imaginable). Torque from quadriceps MVIC was normalized to body weight for between-subject area comparisons.

Range of Motion

Knee ROM was measured in the supine position, both actively and passively, using a longarm goniometer. The proximal arm of the goniometer was aligned with the greater trochanter, and the distal arm was aligned with the lateral malleolus. For active human knee extension, the heel was placed on a raised block and the participant was cued to actively extend the knee. This was followed by passive overpressure for measurement of passive knee joint extension ROM. For active knee flexion, the participant was cued to actively flex the knee every bit far as possible, keeping the heel on the supporting surface. This was followed by passive overpressure for measurement of passive knee flexion ROM. At that place is fantabulous intrarater reliability for measurements of knee flexion (intraclass correlation coefficient [ICC] = 0.97–0.99) and knee extension (ICC = 0.91–0.97), besides as excellent interrater reliability for knee flexion (ICC = 0.91–0.99) and pocket-size interrater reliability for knee extension (ICC = 0.64–0.71).³² Negative values of extension represent hyperextension.

Functional Functioning Measures

Measures of functional performance included the timed up-and- go test (TUG), stair climbing test (SCT), 6-infinitesimal walk test (6MW), and single-limb stance (SLS) fourth dimension. The TUG measures the time to rising from an arm chair (seat height, 46 cm), walk 3 k, plough, and return to sitting in the same chair, without physical assistance.²⁸ This examination has excellent interrater and intrarater reliability, with an ICC of 0.99, every bit measured in a group of 60 community-domicile older adults.²⁸ The SCT measures the time to ascend and descend a flight of stairs. The SCT measures a college level of activity and has been shown to correlate to the TUG test.¹³ Because this test is considered more than challenging than the TUG, it reduces the possibility of a ceiling effect. Patients were tested on 1 of 2 staircases during the study due to a change in facilities. 9 patients were tested on a x-pace stair instance with 17.1-cm footstep height. 15 patients and all healthy adults were tested on a 12-step staircase with 17.one-cm stride height. The accented times of the x- step information were adjusted by a factor of ane.2 to let for comparison betwixt groups. The 6MW measures the total altitude walked in meters over 6 minutes. This test has been used extensively to measure endurance and has been validated as a measure of functional performance post-obit knee arthroplasty.²⁶ The 6MW test has splendid test-retest reliability, with ICCs from 0.95 to 0.97, and a low coefficient of variation (x.4%).³⁶ Single-limb stance fourth dimension was used to appraise static postural control of the surgical side. The test duration was limited to a maximum of 30 seconds, and the longest duration of the 2 trials was recorded. This measure is used commonly for clinical assessment and has exam-retest reliability of 0.78.²⁹

Statistical Methods

The sample size estimate for the healthy adults was determined utilizing published normative values for the TUG and 6MW test in elderly adults.³⁶ Utilizing 6-calendar month outcome data from our patients subsequently TKA, an α level of .05, and a 2-tailed cypher hypothesis, calculations indicated that we needed xiv good for you adults for 80% power to determine an anticipated group difference in means of 1.ane seconds on the TUG at half dozen months. Only 3 healthy adults were necessary for fourscore% power on the 6MW to determine an predictable deviation of 122 k between group means. Seventeen healthy adults were recruited to ensure that nosotros were powered to detect differences.

Statistical analysis of differences between groups was carried out using an independent samples diff variance t test, except for sex distribution between groups, which was tested using a Pearson chi-squared statistic. SAS Version 9.2 (SAS Establish Inc, Cary, NC) was used for all statistical analyses. There were no differences in the right and left lower extremities of healthy controls (P>.05). After establishing that in that location were no differences between sides, all analyses between groups for strength and ROM were washed using the right side of the salubrious adults. But patients with complete information for a given time point were used for comparison to healthy adults. Missing data were present when patients declined to participate in a item test at a given time point, secondary to either discomfort or a limitation in fourth dimension available for testing. Comparisons of the preoperative and 1-, 3-, and half-dozen-calendar month postoperative data for patients were performed utilizing a one-fashion repeated-measures analysis of variance (ANOVA). If a significant effect of fourth dimension was found, postal service hoc testing was performed using linear contrasts of pairwise comparisons. Unless specified, mean values are reported with standard deviation. For all statistical tests, the α level was ready to .05.

RESULTS

There were no differences betwixt healthy adults and patients receiving TKA for age or sex (P>.05). BMI was greater in patients receiving TKA past an average of 3.5 kg/g² (P<.05) (TABLE 1). Average testing time postoperatively for the one-calendar month time point was 25.half dozen ± 2.vii days, 92.2 ± 7.9 days for the 3-month time bespeak, and 186.8 ± 18.nine days for the 6-month time point.

Tabular array 1

Patient Characteristics at the Preoperative Time Signal

Variable	TKA Group (n = 24)	Good for you Adults (n = 17)	Differences (95% CI)
Historic period (y)	65.0 ± 9.four*	66.viii ± vi.v*	i.eight (−3.50, vii.15)
Sex (female person, male)	12, 12	8, 9
BMI (kg/mtwo)	30.7 ± four.ane*	27.2 ± three.5*	−3.v (−5.95, −1.00)†

Average verbal numerical pain rating scores for patients during quadriceps MVIC testing (0–10) were two.3 ± 2.7 preoperatively, 2.8 ± 2.5 at i month, 0.four ± 0.8 at three months, and 0.5 ± one.three at 6 months postoperatively. Pain was similar preoperatively and 1 month postoperatively (P>.05), then decreased at 3 months postoperatively (P<.05). Pain levels and then remained similar betwixt iii and 6 months postoperatively (P>.05). None of the salubrious adults experienced pain during quadriceps MVIC testing.

Compared to healthy adults, patients awaiting TKA had 36.1% ± 24.7% less quadriceps torque, 19.7° ± x.9° less active knee flexion, and iv.6° ± 4.5° less active knee extension (TABLE 2), and were 74.7% ± 42.4% slower on the TUG, had 160.0% ± 150.two% longer SCT times, walked 31.0% ± 16.one% less altitude on the 6MW, and had 29.0% ± 35.6% shorter SLS times (P<.05) (TABLE 3) (FIGURES i–two).

Comparison of timed upwardly-and-go and stair-climbing test over time to good for you adults. Lower times on the TUG and SCT tests betoken improved function. Abbreviations: SCT, stair climbing test; TUG, timed up-and-go test.

^* Different from good for you adults (P<.05). Error bars signal SD.

Comparison of half dozen-minute walk test distance over time to salubrious adults.

^* Different from healthy adults (P<.05). Error bars indicate SD.

TABLE two

Impairments in Patients Before and After TKA Compared to Healthy Adults^*

Variable	Healthy Adults (n = 17)	TKA Preoperative (northward = 24)	Difference From Healthy Adults at Preoperative (95% CI)	TKA at 1 mo (n = 24)	TKA at iii mo (n = 24)	TKA at vi mo (due north = 24)	Difference From Good for you Adults at 6 mo (95% CI)
Normalized quadriceps torque (Nm/kg)	ii.1 ± 0.v	ane.3 ± 0.5	−0.eight (−1.1, −0.iv)†	0.vi ± 0.3	one.1 ± 0.five	1.2 ± 0.5‡	−0.9 (−1.2, −0.v)†
Agile knee flexion (°)	139.seven ± four.6	120.0 ± 13.6	−19.7 (−25.8, −13.six)†	96.1 ± 13.0	111.5 ± 10.2	113.iv ± 8.9	−26.3 (−xxx.7, −22.0)†
Passive knee joint flexion (°)	143.iv ± 5.0	123.3 ± 12.half-dozen	−twenty.i (−25.9, −14.3)†	99.6 ± 13.1	114.8 ± ten.7	117.eight ± viii.six§	−25.6 (−29.nine, −21.1)†
Agile knee extension (°)	−0.9 ± ii.0	3.7 ± 5.6	−4.6 (−7.2, −2.0)†	6.4 ± five.1	2.iii ± iv.1‡	1.7 ± five.8‡	−two.6 (−5.3, −0.05)†
Passive knee extension (°)	−3.7 ± 2.ix	1.three ± 5.5	−5.0 (−seven.7, −2.3)†	3.8 ± 4.9	−0.3 ± four.0‡	−0.iii ± 6.7‡	−3.four (−6.6, −0.3)†

TABLE 3

Functional Limitations of Patients Earlier and After TKA Compared to Healthy Adults^*

Variable	Healthy Adults (n = 17)	TKA Preoperative (n = 24)	Deviation from Healthy Adults at Preoperative (95% Ci)	TKA at 1 mo (n = 24)	TKA at iii mo (n = 24)	TKA at 6 mo (n = 24)	Deviation from Healthy Adults at 6 mo (95% CI)
TUG (due south)	5.6 ± 1.0	9.viii ± 3.two	iv.two (ii.7, 5.6)†	fourteen.6 ± 12.3	nine.vii ± 2.vii‡	ix.1 ± 2.4‡	3.5 (ii.4, 4.six)†
SCT (south)	8.9 ± one.seven	23.1 ± 17.iii	xiv.2 (6.ix, 21.half dozen)†	43.4 ± 24.iv	18.8 ± viii.four‡ §	xviii.2 ± 10.ane‡ §	nine.3 (4.nine, 13.eight)†
6MW (g)	600.1 ± 76.0	414.one ± 109.i||	−185.ix (−248.five, −123.4)†	255.4 ± 156.2	412.ix ± 109.7‡	432.6 ± 106.7‡ §	−165.7 (−229.0, −106.0)†
SLS (s)	26.6 ± 7.6	xviii.eight ± 10.6||	−7.viii (−13.7, −1.9)†	14.1 ± 12.ix¶	twenty.9 ± xi.4‡ ¶	21.vi ± 10.four‡ ¶	−5.0 (−11.0, 1.0)

Ane month afterward surgery, compared to preoperative levels, patients decreased in quadriceps torque by 55.ix% (95% CI: 42.7, 69.1), lost 24.0° of active knee flexion (95% CI: 19.2, 28.8), lost two.6° of active knee extension (95% CI: 0.four, iv.8), took 49.0% longer on the TUG (95% CI: 36.2, 61.8), had 87.9% longer SCT times (95% CI: 59.v, 116.3), walked 38.5% less distance on the 6MW (95% CI: xxx.i, 46.9), and decreased in SLS time past 25.2% (95% CI: 2.4, 48) (P<.05).

Three months after surgery, compared to their preoperative levels, patients still exhibited decreased quadriceps strength by twenty.0% (95% CI: 6.8, 33.2), as well as decreased active knee flexion by 8.5° (95% CI: iii.7, thirteen.iii) (P<.05). However, patients did recover to preoperative levels of active knee extension, as well equally to preoperative performance levels on the TUG, SCT, 6MW, and SLS tests (P>.05).

Half-dozen months after surgery, compared to preoperative levels, patients recovered to preoperative levels of quadriceps force (P>.05) simply even so exhibited deficits in active genu flexion of 6.half dozen° (95% CI: ane.8, xi.4) (P<.05). There was no farther recovery of active knee flexion between three and 6 months (P>.05). Furthermore, betwixt 3 and 6 months, patients had reached a plateau in recovery of their active articulatio genus extension and operation on the TUG, SCT, 6MW, and SLS tests (P>.05).

Compared to healthy adults, at 6 months subsequently surgery, patients had a mean ± SD of forty.9% ± 23.1% less quadriceps torque, 26.3° ± 7.5° less active knee flexion, 2.6° ± 4.half dozen° less active knee extension, took 62.9% ± 35.i% longer on the TUG, had 105.0% ± 87.7% longer SCT times, and walked 27.ix% ± fifteen.eight% less altitude on the 6MW (P<.05). Patients did non differ from healthy adults in SLS time (P>.05).

DISCUSSION

This report examined outcomes of patients 2 weeks before and one, 3, and vi months after TKA compared to good for you older adults. There were still pregnant deficits in quadriceps strength, knee ROM, stair-climbing speed, TUG time, and 6MW distance in patients six months after TKA compared to salubrious adults. Patients were able to recover to their preoperative levels past half-dozen months postoperatively for all measures except knee flexion ROM. Patients in this report completed a standardized rehabilitation plan post-obit surgery. Although in that location are minimal data on referral patterns following TKA, Lingard et al^xviii reported that only 26% of patients receive outpatient physical therapy afterward TKA. Because physical therapy is not routinely prescribed following TKA, it is possible that the patients in the current study represented a grouping of individuals with higher functional levels than those previously reported in cantankerous-sectional comparing studies.^xviii

The outcome measures called for this study are mutual clinical measures and their associated impairments are theoretically addressable by targeted rehabilitation techniques. Although sex, age, BMI greater than forty kg/mⁱⁱ, comorbidities, and social support can affect outcomes post-obit TKA, these variables are not equally hands addressable in the physical therapy setting.^ix,14,37,43 Most previous studies that compared patients after TKA with good for you controls used cocky-reported measures of function, such as the Medical Outcomes Study Brusque Form-36, Western Ontario and McMaster University Osteoarthritis Index, Lower Extremity Activeness Profile, Knee Social club Scores, or Knee Outcome Survey activities of daily living.^{iii,8,25,35,44} However, these self-report measures are based on patient perceptions of function and accept not been shown to relate well to objective measures of concrete performance.^{23,38–39,41} An overly optimistic perception of functional ability is probable to result from decreased pain levels after TKA.⁴¹ Therefore, the current study focused on impairment and functional consequence measures. Previous studies have also assessed quadriceps strength and functional outcomes at 1 year or more following TKA.^{2–4,31,35,43} Our data add to the literature past focusing on the preoperative and early postoperative periods to narrate recovery and by including comparisons with salubrious, older adults without human knee pain. Additionally, this study examined a variety of harm and functional outcome measures that will aid to evaluate the effectiveness of future studies examining different concrete therapy interventions for patients after TKA.

At all time intervals of assessment, patients with TKA demonstrated decreased quadriceps strength compared to healthy adults. The greatest deficits in strength occurred 1 month after surgery. Although patients recovered to preoperative levels by 6 months later on TKA, they still exhibited the aforementioned level of limitation that they did prior to surgery. This is consequent with previous studies that establish decreased quadriceps strength of the surgical limb at six months,¹² ane year,^43–44 2 years,³⁵ and three yearsⁱⁱ later on TKA. The failure to achieve normal levels of strength is particularly of import because quadriceps strength is highly correlated with functional performance.²² Based on the present findings and those of previous cohort studies, current TKA rehabilitation strategies are ineffective in restoring muscle strength to normal levels, and research efforts should be directed at designing more-effective programs to address these deficits. There is a profound loss of quadriceps strength in the showtime month post-obit surgery, suggesting that this menses may be an advisable target for more aggressive strategies to mitigate the early decline in muscle function. The use of neuromuscular electrical stimulation to the quadriceps within the first calendar month after TKA may help mitigate this strength loss.²¹ More than aggressive early intervention may allow for a more rapid recovery of function and likewise enable patients to achieve higher levels of function.

Preoperatively and at 6 months, articulatio genus ROM was express both actively and passively when compared with healthy controls. Patients were able to recover their knee extension ROM by half-dozen months compared to preoperative ROM; however, knee flexion did not recover to preoperative levels by 6 months. The boilerplate active knee flexion observed in this written report (113.4°) is plenty to complete about activities of daily living, except squatting and getting into a bath.³³ If patients achieve college than 125° postoperatively, they can further optimize stair-climbing operation, as well as squatting and getting into a bath, but this may not lead to higher cocky-written report of role.^xix Although ROM is oftentimes the focus of rehabilitation programs, strength appears to exist a more limiting factor than ROM for the recovery of function.

Function, as assessed by the TUG, SCT, and 6MW, decreased in the first month after TKA and so recovered to preoperative levels by 3 months. Withal, at all time points, patients with TKAs performed more poorly on all functional tests than healthy adults. This is consistent with the results of previous studies by Walsh et al⁴³ and Boonstra et al,³ who institute decreased performance in gait speed, increased TUG times, and increased stair climbing times at 1 yr or more after TKA compared to healthy adults. In dissimilarity, Yoshida et al⁴⁴ constitute that one year later TKA, patients had equivalent scores on the TUG, SCT, and 6MW compared to healthy adults. Nonetheless, Yoshida et al used a small sample size (north = 12), matched patients and healthy adults using BMI, and excluded patients with decreased knee ROM, which decreased the generalizability of their results. In the current study, patients had substantially poorer performance 1 month after surgery on all three of these functional measures compared to the preoperative time bespeak. This suggests that an increased focus on functional grooming in the early on postoperative period may help to restore office more quickly in this grouping.

Patients with knee OA are at risk for falls, and 24.vii% of patients will fall in the first yr post-obit TKA.⁴⁰ Previous studies on balance following TKA have focused on joint proprioception, as well as positional sway.^x–xi,42 To our cognition, this was the first study to examine change in SLS duration over time in patients undergoing TKA. In this study, SLS duration was decreased compared to good for you adults prior to surgery and increased to the level of healthy adults by 6 months following TKA. Knowing that individuals after TKA are at increased risk for falls, demonstrate increased postural sway, and have decreased knee proprioception, it is likely that they as well exhibit decreased static postural control. Still, this was not seen in this experiment utilizing SLS time. This could be due to a possible ceiling effect from our 30-second cutting-off time, as well every bit the need for a more challenging test to clinically asses these deficits.

A potential limitation of this study was the length of fourth dimension patients were followed postoperatively. With a longer follow-up, some patients might have continued to recover. Notwithstanding, it has been shown that patients generally plateau in their recovery by 6 months and that function begins to decline by 2 years after their surgery.^7,15,22,30 In this study, we found that patients plateau in their recovery from 3 to 6 months on virtually measures; yet, patients could have shown some improvements beyond this point with continued rehabilitation. This study demonstrated that patients undergoing TKA do not recover to normal levels of function by 6 months. A persistent deficit in functional abilities can pb to premature disability, adventure for falls, and loss of independence. Moreover, incomplete recovery of office could be an important cistron in the development of contralateral knee hurting and subsequent joint replacement. In a previous written report of patients undergoing primary TKA, 50% had pain in their contralateral knee prior to surgery, and this prevalence increased to 69% past 12 months after surgery.⁶ The most common joint to be replaced in the body following unilateral chief knee replacement is the contralateral knee joint, followed past the contralateral hip.³⁴ More research is needed to determine if recovery of normal levels of function is not simply possible, merely as well protective of futurity deterioration of other joints in the lower extremities.

Some other potential limitation of the current study is the lack of a detailed assessment of activity level for both patients and healthy adults. It is possible that the healthy adults in the present written report represent a population of older adults that are higher functioning than average but, nonetheless, nevertheless at a functional level that is worth attempting to achieve in patient recovery.

Current rehabilitation strategies in patients after TKA typically focus heavily on ROM exercises and underemphasize resistance training or functional training.^xx A recent study demonstrated that a more intensive rehabilitation programme that incorporated resistance training and functional training can pb to better results.²⁷ However, the programme was initiated i calendar month after surgery and comparisons were made to a cohort of patients who received community rehabilitation. The results of the current study advise that by 1 month, the deficits in function and strength are meaning. Thus, it is important to decide whether rehabilitation programs can be effective in attenuating the large declines in the start month to enable faster and perhaps meliorate long-term recovery.

CONCLUSIONS

This study indicates that, preoperatively, individuals with unilateral knee OA have deficits in strength, ROM, remainder, and function compared to good for you adults. Following TKA, deficits in force, ROM, and function became dramatically worse at the 1-calendar month time signal, despite initiating a standard rehabilitation protocol the day afterwards surgery. Patients recovered to preoperative levels by 6 months after TKA in all measures except knee flexion ROM. However, they withal exhibited the aforementioned level of limitation that they did prior to surgery, compared to healthy adults.

Physical therapy for patients recovering from TKA across the acutecare setting is not routinely prescribed in the Usa.¹⁸ Even when therapy is prescribed, as it was in this study, outcomes are notwithstanding suboptimal. Given the substantial impairment and functional deficits present prior to knee surgery, forth with the additional trauma of surgery itself, more aggressive rehabilitation may be needed to remediate these impairments and functional deficits to the levels of salubrious adults. More interventional inquiry following TKA is needed to address how this can most effectively be accomplished.

​

Fundamental POINTS

FINDINGS

Individuals with unilateral knee OA exhibit meaning impairments and limitations compared to healthy adults. These impairments and limitations become dramatically more than pronounced by one month post-obit surgery, despite initiating rehabilitation within the first solar day after surgery. Patients recovered to preoperative levels by 6 months afterwards TKA, but nonetheless exhibited the same level of limitation that they did prior to surgery.

IMPLICATION

Current rehabilitation methods do not finer restore patients to the level of their healthy peers. Moreover, current rehabilitation methods exercise non prevent the dramatic decrease in strength and role in the first month later on TKA. New rehabilitative methods need to be developed to more effectively rehabilitate this patient population.

Circumspection

Express long-term follow-upward may limit the strength of conclusions from this study.

Acknowledgments

This study was approved by the Colorado Multiple Institutional Review Board. This inquiry was supported by the Foundation for Physical Therapy (Marquette Claiming Award). Salary support was provided for Dr Jennifer East. Stevens-Lapsley by the National Institutes of Wellness (K23 AG029978).

APPENDIX

Inpatient Rehabilitation Practice Program

Postoperative day i

• Bedside exercises: talocrural joint pumps, quadriceps sets, gluteal sets, hip abduction (supine), short-arc quads, direct-leg raise (if able)

• Knee range of move (ROM): heel slides

• Bed mobility and transfer preparation (bed to/from chair)

Postoperative solar day 2

• Exercises for agile ROM, active-assisted ROM, and terminal knee extension

• Strengthening exercises (eg, ankle pumps, quadriceps sets, gluteal sets, heel slides, short-arc quads, directly-leg raises, supine hip abduction), 1–3 sets of 10 repetitions for all strengthening exercises, twice per day

• Gait grooming with assistive device on level surfaces and functional transfer training (eg, sit down-to/from-stand, toilet transfers, bed mobility)

Postoperative days 3–v (or on discharge to rehabilitation unit)

• Progression of ROM with active assisted exercises and transmission stretching, equally necessary

• Progression of strengthening exercises to the patient's tolerance, 1–iii sets of 10 repetitions for all strengthening exercises, twice per twenty-four hour period

• Progression of ambulation distance and stair training (if applicative) with the least restrictive assistive device

• Progression of activities-of-daily-living training for belch to dwelling house

Outpatient Rehabilitation Exercise Programme

Range of motion

• Exercise bike (x–fifteen min), to be started with forrad and backward pedalling with no resistance until enough ROM for full revolution

  • Progression: lower seat peak to produce a stretch with each revolution

• Active assisted ROM for human knee flexion, sitting or supine, using other lower extremity to assist

• Genu extension stretch with manual pressure (in clinic) or weights (at home)

• Patellar mobilization as needed

Strength

• Quad sets, straight leg raises (without knee extension lag), hip abduction (sidelying), hamstring curls (continuing), sitting knee extension, terminal articulatio genus extensions from 45° to 0°, step-ups (5- to 15-cm block), wall slides to 45° knee flexion, i–three sets of 10 repetitions for all strengthening exercises

  • Criteria for progression: exercises are to be progressed (eg, weights, footstep meridian, etc) only when the patient tin complete the do and maintain command through three sets of 10 repetitions

Pain and swelling

• Ice and compression as needed

Incision mobility

• Soft tissue mobilization until incision moves freely over subcutaneous tissue

Functional activities

• Ambulation training with assistive device, as appropriate, with accent on heel strike, push button-off at toe-off, and normal genu joint excursions

• Emphasis on heel strike, push-off at toe-off, and normal knee joint excursions when able to walk without assistive device

• Stair ascending and descending step over step when patient has sufficient concentric/eccentric strength

Cardiovascular practice

• 5 min of upper body ergometer until able to pedal full revolutions on exercise cycle, then exercise bicycle

  • Progression: duration of exercise progressed up to ten–15 min as patient improves endurance; increase resistance as tolerated

Monitoring vital signs

• Claret pressure level and heart charge per unit monitored at initial evaluation and equally advisable

Reproduced from Mintken PE et al.²¹

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164265/

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