Therapist-led rehab had similar outcomes to home regimen after knee replacement
High-risk patients had similar knee function and pain at one year whether they received weekly sessions with a physiotherapist or were assigned to a home exercise program, according to a U.K. trial.
For patients at risk for poor outcomes after total knee arthroplasty, outpatient rehab led by a therapist was not superior to a home exercise regimen, a British study found.
To evaluate the two regimens, researchers conducted a parallel-group randomized controlled trial in 13 secondary and tertiary care centers in the U.K. that provide postoperative physiotherapy. Three hundred thirty-four participants with knee osteoarthritis were defined as at risk of a poor outcome, based on the Oxford knee score, at six weeks after total knee arthroplasty. They were randomized to either therapist-led outpatient rehabilitation involving a progressive goal-oriented functional rehabilitation protocol, modified weekly in one-on-one contact sessions (n=163), or physiotherapy review followed by a home exercise regimen without progressive input from a physiotherapist (n=171). All participants received physiotherapist review and took 18 sessions of rehabilitation over six weeks. Results were published Oct. 13 by The BMJ.
The primary outcome was the Oxford knee score at 52 weeks. Scores ranged from 0 (worst) to 48 (best), with 4 points being the minimum clinically important difference. Secondary outcomes included patient-reported measures of pain and function at 14, 26, and 52 weeks after surgery. Global knee pain severity was assessed using an 11-point visual analogue scale, where 0 represented no pain and 10 represented the worst possible pain, with 1.1 points being the minimum important clinical difference.
Eight patients were lost to follow-up, and adherence to the intervention was more than 85%. No clinically relevant differences between the interventions were found for primary or secondary outcomes. The between-group difference in Oxford knee score at 52 weeks was 1.91 points (95% CI, −0.18 to 3.99 points), favoring the outpatient rehabilitation arm (P=0.07). When all time point data were analyzed, the between-group difference in Oxford knee score was not significant, at 2.25 points (95% CI, 0.61 to 3.90, P=0.01). No between-group differences were found for average pain (0.25 point [95% CI, −0.78 to 0.28 point]; P=0.36) or worst pain (0.22 point [95% CI, −0.71 to 0.41 point]; P=0.50) at 52 weeks or earlier time points.
Postoperative differences in the timed get-up-and-go test were not significant when accounting for baseline scores (4.64 s [95% CI, −14.25 to 4.96s]; P=0.34). Overall satisfaction did not differ between the groups (odds ratio [OR], 1.07; 95% CI, 0.71 to 1.62); however, greater satisfaction with pain relief (OR, 1.66; 95% CI, 1.10 to 2.52), ability to perform daily functional tasks (OR, 1.66; 95% CI, 1.09 to 2.51), and ability to perform heavy functional tasks (OR, 1.57; 95% CI, 1.02 to 2.42) was reported in the therapist-led group.
The authors noted that physiotherapy may have a marginal influence on the underlying causes of poor postoperative outcomes, for example, functional limitations that might relate to implant positioning and intraoperative factors that might not be modifiable. “Although targeting rehabilitation interventions to at risk patients is a feasible delivery method, the content of the rehabilitation seems to have minimal influence on patient outcomes,” they concluded.