1. Optimizing function in a patient following a total knee replacement
CPS II Presentation
By: Devin Henry

2. purpose Summarize a patient case
To investigate whether the addition of balance training to a traditional rehabilitation program following a total knee replacement optimizes functional outcomes

3. Total knee replacement
First performed in 1968 and has become one of the most successful surgeries in medicine
Greater than 600,000 knee replacements occur each year in the US
A common reason people undergo this procedure is due to osteoarthritis

4. Patient information Demographics: > 65 year-old Caucasian female
Referring diagnosis: Status-post right total knee replacement due to osteoarthritis
History of present illness: She received past treatment of the same knee prior to opting for a TKR. Following discharge from the hospital, she went to a skilled nursing and rehabilitation facility. She then received 7 visits of home health therapy upon returning home.
Past medical history: Osteoarthritis, low back pain, left bunionectomy, hypothyroidism, left posterior tibialis tendon rupture with surgical repair
Outpatient PT
Surgery
SNF
Home Health

5. Subjective findings Chief complaint: Right knee pain and stiffness
Outcome measures
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)*: 28/96 (29% disabled)
Pain rating using VAS: Best 0/10 Worst 4/10 Currently 1/10 Average 2/10
Aggravating factors: Sitting for extended periods of time
Relieving factors: Moving around/walking for short distances
Social History: Patient lives by herself with no immediate family in the area
28/96 = 29% disabled
WOMAC is reliable and valid for patients undergoing TKA due to knee OA
* Whitehouse et al demonstrated the WOMAC is a reliable and valid tool in assessing function in patients following total knee replacement.

6. Objective findings Outcome Measures
TUG test: 9 seconds
13.5 seconds = high risk for future falls (Barry et al. 2014)
Gait: Patient ambulates with an antalgic gait favoring the LLE characterized by right hip circumduction during RLE swing phase and left weight shift during RLE stance phase
Stair navigation: Decreased stability when on RLE, right hip circumduction during RLE advancement
A TUG score of ≥13.5 seconds was used to identify individuals at higher risk of falling (Barry et al. 2014)

7. Objective findings Motion AROM PROM Strength (MMT) Left knee flexion
100
103
5/5
Right knee flexion
101
106
4/5
Left knee extension
Right knee extension -8 -6

8. S/P right total knee replacement
Icf model
Health Condition:
S/P right total knee replacement
Body Structure and Function:
Joint pain/stiffness
Decreased range of motion
Muscle weakness
Activity Limitations:
Sitting for > 45 minutes
Walking long distances
Ascending/descending stairs
Squatting
Participation Restrictions:
Water aerobics
Occupational responsibilities
Walking her dog
BMI does not influence post-operative functional outcome (Oneil et al. 2016)
Environmental Factors:
Social support
Adaptive equipment
Insurance
Personal Factors:
Motivated personality
Overweight
Older

9. prognosis Good on returning to PLOF (moderately active)
Few comorbidities
BMI does not affect functional outcome (O’Neill 2016)
Motivated
Received therapy before

10. Patient & therapy goals
Patient Goal:
The patient wants to navigate stairs with normal gait pattern and without assistance from crutch
Therapy Goals:
STG: In four weeks, the patient will…
demonstrate home exercises to promote independence with HEP
report an absence of right knee pain during the most recent 24 hour period to increase tolerance for activity
demonstrate a significant improvement* on WOMAC score compared to initial evaluation score to validate functional improvement
WOMAC: Clinically significant improvement is a 16% reduction in WOMAC score (15 points)
* Hmamouchi et al demonstrated the MCID of the WOMAC is a 16% (~15 points) reduction in score.

11. Patient & therapy goals
LTG: In eight weeks, the patient will…
demonstrate greater than 120 degrees of knee flexion AROM to promote functional movement during ADLs
demonstrate right knee extension strength that is equal to the contralateral extremity to efficiently navigate stairs
demonstrate a significant improvement* on WOMAC score compared to 1-month assessment score to validate functional improvement
* Hmamouchi et al demonstrated the MCID of the WOMAC is a 16% (~15 points) reduction in score.

12. Plan of care Plan to see patient 2x/week for 8 weeks
Her therapy may include instruction of HEP, therapeutic exercise, manual therapies, and modalities for pain management PRN

13. interventions Warm up on NuStep or Stepper Manual therapy
Tibiofemoral and patellofemoral joint mobilization combined with knee ranging
Scar tissue mobilization
Therapeutic exercise
Strengthening & stretching of knee and hip musculature
Functional mobility training
Balance training: SLS, side-stepping, BOSU ball exercises, tilt-board exercises
Cryotherapy
Patient education

14. Does the addition of balance training to a conventional therapeutic exercise program rather than a therapeutic exercise program alone optimize functional outcomes for my older adult female patient who received a total knee replacement?

15. Article 1 Published in Clinical Rehabilitation in 2015
Journal Impact Factor: 2.823

16. overview
(Liao et al. 2015)
Design: A prospective intervention study and randomized control trial
Longer period follow-up of a previous study (32-week follow up)
Purpose: evaluate whether balance training after total knee replacement surgery improves long-term outcomes and to determine if postoperative balance is associated with functional mobility

17. methods
(Liao et al. 2015)
130 participants
Inclusion criteria: aged years old who were scheduled to undergo unilateral total knee replacement
Exclusion criteria: uncontrolled hypertension, diabetes, body mass index (BMI) > 40 kg/ m2, other lower extremity orthopedic problems that limited the patient’s function, or neurological impairment
Functional training only: warm-up, strengthening exercises, functional task-oriented exercises, endurance exercises, and cool down (based on the protocol published by Moffet et al.)
Balance training: above plus protocol established by Fitzgerald et al, and Gsoettner et al. which included static stabilization of stance (SLS, foam activities etc) and dynamic stabilization of stance such as tilt board activities

18. methods Outcome measures Statistical analyses
(Liao et al. 2015)
Outcome measures
Balance: functional reach test and single-leg stance test
Mobility: 10-m walk test, Timed Up and Go Test, stair-climb test, 30-sec timed chair-stand test
Functional outcome: WOMAC
Statistical analyses
Independent t-tests and chi-squared analyses
Intention-to-treat analysis
Analysis of covariance (ANCOVA)
Independent t-tests and chi-squared analyses to compare the two groups at baseline
ITT analysis: manage any missing data and minimize bias associated with loss to follow up
Controls for anything that happens following randomization (noncompliance, withdrawal, protocol deviations)
ANCOVA: analyze the difference in outcome measures between the groups at baseline, 8 and 32 week follow up)

19. results
(Liao et al. 2015)
53 patients in the experimental group and 55 patients in the control group completed the 32-week follow-up assessment
No significant difference of patient characteristics between groups (t-test and chi- squared test)
Significant differences (p <0.001) in outcome measures between groups following the intervention
Significant correlation between the improvement in the balance measures and that in the mobility outcomes and WOMAC physical function scores at 32-week follow-up assessment
Experimental group better than controls (all p < 0.001) for distance of functional forward reach; single leg stance (eyes closed and open); timed sit-to-stand test; stair climbing test; timed 10-m walk; timed up- and-go test and the WOMAC

20. Measures that apply to my patient

21. Discussion
(Liao et al. 2015)
The experimental group patients exhibited greater improvement in balance, mobility, and functional outcomes at the 32-week follow up than the control group
Balance outcomes were markedly associated with improved mobility and physical function outcomes
Benefits last 6 months following intervention
Limitations:
No true control group (non-intervention)
Did not assess pre-operative functional status
Experimental group had longer duration sessions

22. Article 1I Published in Physiotherapy in 2016
Journal Impact Factor: 3.010

23. overview Design: Systematic review
(Moutzouri et al. 2016)
Design: Systematic review
Purpose: Analyze all published RCTs that have included sensori-motor components in TKR patients’ rehabilitation program in order to assess the effect of this training
Sensori-motor training: emphasizes challenging the sensorimotor system by progressing through static, dynamic, and functional phases of balance exercises (Page 2016)

24. methods
(Moutzouri et al. 2016)
Searched the following electronic databases: Cochrane Library, MEDLINE, EMBASE, Biomed Central, Cinahl, and PEDro
Two evaluators:
Reviewed the studies to determine if inclusion criteria were fulfilled
Analyzed structure of each study
Assessed methodological quality using the PEDro criteria
(disagreements were resolved by a third reviewer)

25. methods Screened 276 articles and only included 6 in the review
(Moutzouri et al. 2016)
Screened 276 articles and only included 6 in the review
Inclusion criteria:
Randomized study design published in English
Participants with knee OA undergoing primary TKR
Exercise-based intervention with sensorimotor components compared to another intervention, placebo, or control
Used balance and/or functional performance as outcome measures
Exclusion criteria:
Cadaver or animal study
Patients with rheumatoid arthritis in sample

26. All studies scored 5-7 (adequate) with small to medium effect sizes.
results
(Moutzouri et al. 2016)
All studies scored 5-7 (adequate) with small to medium effect sizes.

27. Results
(Moutzouri et al. 2016)
Sensori-motor training induces equivalent improvement between intervention and control group
No adverse effects
Initiation within the first 2-months post-surgery is acceptable and essential
Optimal frequency, time, and progression of dosage remain obscure

28. discussion
(Moutzouri et al. 2016)
Conclusion: Limited robust (1a) evidence supports equal effectiveness of functional rehabilitation program enhanced with sensori-motor components compared to a functional rehabilitation program alone
Limitations
Methodological heterogeneity
‘Generalizability’
Underpowered evidence

29. APPLICATION TO PATIENT

30. Patient Outcomes Initial Evaluation Reassessment Discharge

31. Goal check Patient Goal:
The patient wants to navigate stairs with normal gait pattern and without assistance from crutch
Therapy Goals:
STG: In four weeks, the patient will…
demonstrate home exercises to promote independence with HEP
report an absence of right knee pain during the most recent 24 hour period
demonstrate a significant improvement on WOMAC score compared to initial evaluation score to validate functional improvement

32. Goal check Therapy Goals: LTG: In eight weeks, the patient will…
demonstrate greater than 120 degrees of knee flexion AROM to promote functional movement during ADLs
demonstrate right knee extension strength that is equal to the contralateral extremity to efficiently navigate stairs
demonstrate a significant improvement on WOMAC score compared to 1-month assessment score to validate functional improvement

33. So did my patient benefit from the addition of balance training?
Yes!
We saw improvements following rehab
Stair navigation
Subjective & objective measures
History of falls
Added variety and increased her confidence

34. Lessons learned What I would change after investigating the evidence:
Balance-specific goal
Assessed SLS on initial evaluation
Altered WOMAC goal

35. references
Barry, E., Galvin, R., Keogh, C., Horgan, F., & Fahey, T. (2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC geriatrics, 14(1), 14. Hmamouchi, I., Allali, F., Tahiri, L., Khazzani, H., El Mansouri, L., Alla, S. A. O., ... & Hajjaj-Hassouni, N. (2012). Clinically important improvement in the WOMAC and predictor factors for response to non-specific non-steroidal anti-inflammatory drugs in osteoarthritic patients: a prospective study. BMC research notes, 5(1), 58. Liao, C. D., Liou, T. H., Huang, Y. Y., & Huang, Y. C. (2013). Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clinical rehabilitation, 27(8), Moutzouri, M., Gleeson, N., Billis, E., Panoutsopoulou, I., & Gliatis, J. (2016). What is the effect of sensori-motor training on functional outcome and balance performance of patients’ undergoing TKR? A systematic review. Physiotherapy, 102(2), O’Neill, S. C., Butler, J. S., Daly, A., Lui, D. F., & Kenny, P. (2016). Effect of body mass index on functional outcome in primary total knee arthroplasty-a single institution analysis of 2180 primary total knee replacements. World journal of orthopedics, 7(10), 664. Page, P. (2006). Sensorimotor training: A “global” approach for balance training. Journal of bodywork and movement therapies, 10(1), Whitehouse SL, Lingard EA, Katz JN, Learmonth ID. Development and testing of a reduced WOMAC function scale. Journal of Bone and Joint Surgery B. 2003;85(5):706–711. American Academy of Orthopedic Surgeons. (2015 August). Total Knee Replacement. Retrieved from Physiotherapy Evidence Database. PEDro Scale. (1999, June 21) Retrieved from:

36. Questions
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