Total Knee Replacement Patient Population and Physiotherapy Management Review Greater Newcastle Acute Hospital Network– Physiotherapy National Allied Health Benchmarking Consortium- Health Round Table October 2009

BACKGROUND 376 TKR patients were seen by RNC Physiotherapy as an outpatient during 2006/2007 Number of TKR procedures in Australia has increased by 152.3% over past 12 years 33,737 performed in Australia in 2005/6 FY Public hospital growth rate far greater than private (14.5% vs 1.6%) Increasing demands upon public hospital Physiotherapy services Evidence base for PT management of TKR is quite limited (Naylor et al 2006) No clinical guidelines exist for post-operative Physiotherapy Considerable variation in Physiotherapy practice (Roos 2003) Australian Orthopaedic Association National Joint Replacement Registry, 2007

AIMS To review the TKR patient population receiving physiotherapy services at the RNC To review current outcome measure utilisation throughout the clinical pathway To review current physiotherapy management strategies and resource consumption To analyse clinical outcomes

METHODOLGY Cross-Sectional Retrospective Analysis TKR patients identified via PiMS and AHMIS Random sample of 50 records Received pre-operative, in-patient and out-patient physiotherapy services at the RNC for primary TKR No post-operative complication

POPULATION CHARACTERISTICS The RNC TKR population is similar to other reported TKR populations in regards to age, gender and reason for arthroplasty Perhaps interestingly, the mean BMI in our data was found to be higher than all other reported TKR populations (by around 4 points) Previous research has identified that patient’s with higher BMI’s typically obtain poorer ROM (Anouchi et al 1996, Lizaur et al 1997) There is strong evidence that the primary patient factor influencing post-operative range of motion is pre-operative range of motion (Dennis et al 2007, Lizaur et al 1997, Parsley et al 1992, Ritter et al 2003) Considerable variance in the pre-operative flexion range of movement has been reported in the literature However the pre-operative flexion ROM in patients at the RNC approximates the central tendency of these reported figures (104.2°)

RESOURCE CONSUMPTION Standard practice at the RNC involves all patients attending a pre- operative individual consultation with a physiotherapist 50% of Hospitals in Sydney South West Area Health Service provide a similar pre-operative service Mean in-patient LOS was 7.46 days (95%CI 6.82 to 8.1 days) The last outpatient appointment was a mean of 6.86 weeks (95%CI 5.87 to7.85) from the date of surgery Comparable to the previously published figures for TKR patients in other Australian hospitals (Naylor et al 2006) A low correlation was discovered between age and duration of physiotherapy management, with younger patients attending for greater durations (r = -0.36, 95%CI –0.58 to –0.09) Age, Sex and BMI had no influence on any other measures of resource consumption.

USE OF OUTCOME ASSESSMENT

OUTCOME ASSESSMENT & PT MANAGEMENT A review of literature and analysis of the data identified an opportunity to include further outcome assessment measures Patient Perceived Function Eg. Lower Extremity Functional Scale Measures of Patient-Important Function Eg. Timed Up and Go Patient Satisfaction with Care/Outcome The nature and frequency of the interventions used at the RNC appear consistent with those reported in other sites within Australia (Naylor et al 2006, Sydney South West Area Health Service)

PHYSIOTHERAPY MANAGEMENT

PHYSIOTHERAPY MANAGEMENT

KNEE ROM OUTCOMES KNEE FLEXION KNEE EXTENSION A small correlation existed between pre-operative flexion ROM and final flexion ROM at the last OP appt (r=0.34) For each 4 increase in pre-operative flexion, the predicted flexion range at the final physiotherapy appointment increases by 1 Final flexion ROM had no relationship to the number of physiotherapy OOS (r=0.1) Those with poorer flexion ROM at their last appointment tended to have poorer extension ROM (r=0.29) KNEE EXTENSION No influence by age, sex or prosthesis type Interestingly, a small positive correlation was identified between BMI and pre-operative extension ROM (r=0.37) for every increase in BMI by 5 points, the predicted pre-operative extension improves by 2 No influence by mobility tolerance or mobility aid utilisation No relationship with the number of physiotherapy OOS

KNEE ROM OUTCOMES KNEE FLEXION Paired t-test statistical analysis identified the differences in flexion range of movement scores between all of the five time periods to be significantly different (p < 0.05)

KNEE ROM OUTCOMES KNEE FLEXION No influence by age, sex or BMI at any time point No influence by prosthesis type at any time point

KNEE ROM OUTCOMES KNEE EXTENSION No significant difference between extension ROM pre-operatively and at the final appointment (difference = 1, p=0.42)

MOBILITY AID UTILISATION OUTCOMES

Key Findings & Opportunities Fairly consistent with other populations reported in the literature Would seem reasonable to make comparisons Our sample had a higher BMI than other reported populations Similar Physiotherapy resource consumption and management strategies to comparable services Similar physical outcome measures to previously published reports Outcome Assessment Consistency throughout the clinical pathway Patient Perceived Functional Status Patient-Important Function Patient Satisfaction with Care/Outcome Investigation of opportunities for benchmarking Collaborative research initiatives

Project Team Judith Henderson Damien Smith Chris Barnett Kieren Brown Area Professional Director, Physiotherapy Damien Smith Team Leader, Royal Newcastle Centre Chris Barnett Team Leader, Outpatient Physiotherapy, Royal Newcastle Centre Kieren Brown Team Leader, Inpatient Physiotherapy, Royal Newcastle Centre Veronica Parraga Physiotherapist, Royal Newcastle Centre Robin Haskins Tim Lee