What is the evidence? Justine Naylor Senior Research Fellow, WORC & WJRC, SSWAHS, UNSW

Profile of current service provision Rationale for rehabilitation Evidence for rehabilitation after TKR & THR Summary and recommendations for practice and research

Regional patterns in providing a service LocalNationalInternational TKRRoutine THRVariesVaries?Routine

LocalNationalInternational TKR & THR Outpatient – 1 to1 +++ Outpatient - Group ++ (mainly public) ++ (mainly public) ? Inpatient+ (mainly private) + (mainly private + Water-basedsome Home programme NoRemote areas++ (level of monitoring varies)

Formal (supervised) rehabilitation enhances recovery beyond that which can be achieved after surgery and an unmonitored home programme alone In other words, with rehabilitation, either: performance across a range of health domains approaches or exceeds age-matched norms, or: recovery across a range of health domains is faster than it would naturally Is this true?

What is the evidence that recovery from surgery may be suboptimal (and thus rehab may have a role)?

What is the evidence that formal rehabilitation enhances recovery after TKR or THR?

Study systematic review of effectiveness of outpatient- based rehabilitation compared to other searched key electronic databases included RCTs of studies comparing: Outpatient 1-to-1 vs home programme Outpatient vs Outpatient (1-to-1 vs group) Outpatient Group vs home programme OP therapy included any modality Rehab commenced within 4 weeks post-op (ignore acute inpatient period)

No study compared all 3 gross modes -1 to 1 outpt; group-based; home programme No study evaluated group-based to home programme No study compared different types of 1to 1 treatments/modalities 1 study compared group land to group water 3 RCTs compared 1to 1 to home programme; all 3 were exercise-focused 1 study compared 1 to 1 vs usual care (late post-op period)

Results of TKR review of RCTs ControlInterventionResults Early Rajan et al 2004, n=116 No intervention1 to 1 (no details given) No diff knee ROM at 1 yr Kramer et al 2003, n=160 Monitored HP (phone), ex x3/d, 12 w HP +12 sessions 1 to 1 (mix of modalities) in 6- 8 w No diff ROM, KSS, HRQoL, stairs, 6MWD, at 1 yr Mockford et al 2008, n=143 Simple unmonitored home programme 9 sessions O/P physio (no details provided) No diff knee ROM, patient-reported fn, and mobility at 1 yr Harmer et al 2009 x12 sessions gym classes x12 water-based classes No diff knee ROM, patient-reported fn, mobility at 6m Later Moffet et al 2004, n=76 At 8 w post- surg, usual care (25% domiciliary) At 8 w post- surg, x12 1 to 1 exercise sessions Greater improvement in 6MWD and Fn at 4 and 6 months; not 1 yr

Insufficient evidence to recommend the optimum mode of delivery because not all gross modes and modalities investigated Currently, available evidence suggests that 1 to 1 programmes delivered in the early post- operative phase do not provide long-term benefit over and above what is achieved with a home programme (monitored or not monitored) We dont know if early benefits translate into faster return to work or less health resource utilisation.

Literature search of RCTs Location/Type/Mode Outpatient 1-to-1 vs group or home Group vs Home Inpatient Rehab vs Home or Group or Outpatient Timing Early (commenced within 4 weeks post-op) Late (commenced > 2 months post-op)

Emphasis on effect of adding an extra modality to standard programmes (in early post acute phase) No one study compared all 3 gross modes of delivery – 1 to 1; group-based; home Many trials looking at value of later-stage rehab (in addition to early rehab)

Location – Inpatient Rehab v Domiciliary ControlInterventionResults Mahommed et al 2008 n = 234 TKR and THR Inpatient rehab for mean 17 days Domiciliary (mean 8 treatments) 20% cheaper for domiciliary; No difference in function, HRQoL and satisfaction at 3 or 12 months

Results of THR review - Comparison of modalities (early phase) ControlInterventionResults Gremeaux et al 2008, n=29 (>70 yrs) Inpt + Outpt (2hr/d, 5d/w x5w) Same as Control + NMES (quads/calf) 1hr/d, 5d/w x 5w NMES > Control for knee ext strength and function at 8 w Maire et al 2006 n = 14 6 w General rehab Same as Control + Upper limb ergometry UL > General for function, and 6MWD, 2 and 12 months Hesse et al 2003 n=80 Inpt, 45 min 1 to 1, for 10 days Same as Control + treadmill for 10 days Treadmill> Control for gait symmetry, HHS, hip strength up to 12 m Standard care (inpt + outpt) v other 1 to 1 modality – early phase ControlInterventionResults Suetta et al 2004, n=36 Inpt + Outpt, 1 hr/d x 12 w A – resistance ex, x3/w, x12w B – NMES 1hr/d x12 w A - superior in strength and stair climb, at 12 w.

Value of later stage rehabilitation ControlInterventionResults Galea et al 2008, n = 23, 8 w post 1 to 1, 8 w ex programme Home ex programme No diff, gait, 6MWD, HRQoL, 8w White et al 2005, n = 28, 8 w post No intervention A – Treadmill + feedback B – Treadmill, no feedback, 15m/d, x3/w x6w Treadmill> Control, gait symmetry Trudelle & Jackson 2004, n = month post Simple MHPMHP with controlled wgt bearing during ex MHP (wgt bear) > Control MHP Unlu et al 2007, n=26, 1 yr post No intervention A – 6w home pr B – Inpt prog x 6w A and B > Control, strength Sashika et al 1996, n = 23, 6-48 months post No intervention A – home ex pr x6w B – as for A + eccentric ex in standing, x 6w A and B > Control, gait speed and cadence, hip abd improved in all (A,B>Control)

Early phase (within 4 weeks post-op) No studies compared Inpt or Outpt Rehab to an unsupervised or monitored home programme No studies strictly compared Inpt only to Outpatient only Inclusion of resistance training or NMES provides superior results than basic programme up to 1 yr Later phase (> 8 weeks post) Vigorous ex programme or treadmill produces improvement over and above control (no ex exposure) Long-term benefits?

TKR No recommendations for best practice Goals of rehabilitation need to be clearly defined as this will help determine how vigorous rehab needs to be Routine standardised measurement of a goal is recommended THR More vigorous programmes (early) provide superior results up to 1 yr than basic programmes Training effects seen with later programmes – could recommend continuation of rigorous HP up to 1 yr.

To determine which gross mode of delivery is superior (if any) Multi-centre RCT comparing 1 to 1, group-based and MHP post TKR and THR (early phase) To determine if later rehab is superior to early rehab Early vs late – compare same programme, 1 delivered early, 1 delivered late Other questions Does rehab have potential to improve co- morbidities? Does rehab influence prosthesis longevity by influencing long-term activity? Do some patients respond to rehab whilst other dont?