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  • Patients with TKA Who Receive Outpatient Physical Therapy Soon After Surgery Recover More Quickly Than Patients Who Receive Home Physical Therapy First

    In brief:

    • Retrospective cohort study focused on 109 TKA patients
    • One group (87) received outpatient physical therapy beginning within a week of discharge; a second group (22) received 2-3 weeks of home physical therapy before entering an outpatient physical therapy program
    • While 6MWT and KOOS outcomes were the same for both groups at completion of outpatient physical therapy, the home health group took average of 20 days longer to reach benchmarks
    • Authors believe results point to need for patient education and choice; potential cost savings of immediate outpatient physical therapy

    A new study finds that when it comes to results, patients who undergo total knee arthroplasty (TKA) and engage in home physical therapy before participating in outpatient physical therapy ultimately wind up doing just about as well as patients who proceed directly to physical therapy sessions. The time it takes them to reach those outcomes, however, is another story.

    Writing in a recent issue of Orthopedic Nursing (abstract only available for free), researchers report on the results from an analysis of 109 TKA patients who participated in a hospital's joint replacement program, and who had the option of entering into outpatient physical therapy beginning within a week after surgery (87 individuals, called the OP group) or receiving home health care for 2 to 3 weeks before moving on to outpatient physical therapy (22 individuals, labeled the HH group). Researchers reviewed medical records from 2005 to 2010 to find out if the 2 paths resulted in different outcomes and what those outcomes were after completion of outpatient physical therapy.

    Researchers found that in terms of outcomes as measured by the 6-minute walk test (6MWT) and the Knee Injury Osteoarthritis Outcome Score (KOOS), both groups ultimately achieved similar scores (adjusted for age and other variables). Patients averaged nearly 80% of age and sex-predicted distances on the 6MWT and registered KOOS subscale scores (activities of daily living, pain, symptoms, and quality-of-life) that didn't vary significantly between groups.

    When they looked at the time it took for patients to reach those outcomes, however, the researchers found that patients in the OP group reached postoperative milestones about 20 days sooner, on average, than their HH counterparts. Additionally, both groups averaged about the same number of outpatient physical therapy sessions, "pointing to the fact that home health [physical therapy] did not accelerate recovery (with the possible exception of knee flexion [range of motion])," authors write.

    The outpatient track consisted of 2 to 3 physical therapy sessions per week for 4 to 6 weeks, plus a daily exercise program focused on range of motion, stretching, low-impact cardiovascular conditioning, and lower extremity strengthening and endurance. The HH program was harder to discern through medical records, authors write, but likely included physical therapy 3 times a week for 2 to 3 weeks, "with the ultimate goal of tolerance for outpatient [physical therapy] to complete rehabilitation."

    In the end, authors write, the decision as to whether to pursue immediate outpatient physical therapy or a period of home health physical therapy may depend on individual patient circumstances; still, they assert, "the results of this study provide evidence to the importance of patient education and shared decision-making between patients and the multidisciplinary team."

    "If the patient and the clinician determine that home health is necessary, then no loss of functional gains should be expected," authors write. "However, it may take a longer time period, and perhaps expense, to achieve those gains."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • QUESTION: Would you kindly consider publically clarifying if this referenced study of physical therapy service location provided in the "outpatient" and "home" settings discriminated between: 1) outpatient clinic physical therapy; 2) outpatient home physical therapy (e.g. provided by a self-employed independent PT); and 3) home physical therapy (i.e. provided by as nurse-owned/operated home health agency staff PT). Thanks for sharing this study with us!

      Posted by Lise McCarthy, PT, DPT, GCS on 1/23/2017 6:45 PM

    • Do you have results as to how many comorbid diagnosis these patients had and also what was the readmission rate with the 2 groups?

      Posted by Dawn Brooks on 1/23/2017 8:18 PM

    • I would think looking at a VERY small sample size and not even looking at factors like co-morbidities, age, etc of patients would lead to many conclusions. But it does not mean they are valid. There are a bunch of studies regarding the need for home care with joints saving money and increasing quality care. Home health care has a role with total joints just the same as outpatient and acute care. Studies like these poorly looking at all factors of the patient and drawing quick conclusions is poor practice. I agree more properly performed studies with controls and bigger sample size is needed in all areas of practice. But living home health everyday I can tell you we are solving many things you would not see in the clinic. Yes the young, healthy knee or hip could go to outpatient safely. We need to foster better assessments to identify post acute discharge to limit hospitalizations and increase safety and compliance of the patient. We just cannot paint a broad stroke of this is what should be done with xyz patient. Good care starts with good assessment leading to an individualized POC for that patient.

      Posted by Nikki Gilroy on 1/23/2017 8:29 PM

    • Couldn't agree more with the above comments. It would be good to give a distinction in the HH services provided as there is a significant difference between HH PT services provided which probably should be so especially the documentation as mentioned in the article. It is also a very small sample size and as mention can have a plethora of variables depending on the criteria/methodology set on inclusion criteria of the participants in the study.

      Posted by Adam Sheppard on 1/25/2017 5:47 PM

    • Another TKA retrospective study: Brennan Gerard P., Fritz Julie M., Houck L.T.C. Kevin, Hunter Stephen J., " Outpatient Rehabilitation Care Process Factors and Clinical Outcomes Among Patients Discharged Home following Unilateral Total Knee Arthroplasty," Journal of Arthroplasty (2014), doi:10.1016/j.arth.2014.12.013. Retrospective study with 321 patients.

      Posted by Kim M. Yearout on 1/25/2017 5:52 PM

    • Every setting for the delivery of care from physical therapy has a place, i.e. hospital, inpatient rehab, outpatient, SNF or home health. It's truly about the assessment and what is the best setting for the patient. Some patients will thrive at home with one on one care and the ability to be home, and some will thrive with another setting. The opposite is true as well. To paint the picture that one gives better outcomes than the other will probably always be biased as to who is preforming the study. There are too many dynamics. I have worked in every setting in my 21 year career and in my opinion for the "over 60 yr old patient with a TKA" is that they do well in home health and outpatient, but every patient and therapist is different. Let the patient be part of the decision as well. Just my opinion.

      Posted by Barry Wade on 1/25/2017 6:10 PM

    • I might have missed something in the brief review above but there was an interesting finding not included. Per the methods section: "The criteria for home health PT were as follows: (a) Homebound or (b) receiving care in an outpatient setting was excessively burdensome for the patient. Home health PT was continued until the patient was able to continue rehabilitation in an outpatient setting." I don't think the groups were equivocal - one group was homebound and one group was not homebound. In fact, preoperatively, the homecare patients had a decreased 6 MWT distance compared to the outpatient group (230.6 m versus 314.1 m) - they were more debilitated at baseline. At the completion of the outpatient program, the 6 MWT distance was equivocal (approx 360 m). I would argue that the homecare patients had a more significant improvement. Food for thought!

      Posted by Daniel Malone on 1/25/2017 6:31 PM

    • This is not a randomized controlled trial, only a cohort study, and there is a clear skew in the distribution to the two groups being roughly 4:1. Without being able to view the full article and see the methods, I can only guess that patients went to either home health or outpatient based on clinical factors. Therefore, those going to home health likely had more significant mobility deficits, co-morbidities, and other factors and barriers that could delay their rate of progression.

      Posted by Chris Franz, PT on 1/25/2017 7:57 PM

    • Those qualifying for home health would by definition be home bound. It may take them longer to recover from any procedure. It is a taxing effort for our HH patients to leave the home for any reason. When they can leave the home without a taxing effort they can go anywhere including out patient physical therapy. Most of my Hip replacement , hip fractures, and knee replacement patients also need to see a nurse to help manage their many diseases and medications. With out HH they would not be in out patient they would be in hospital or nursing home.

      Posted by Kathleen Hope Curry on 1/25/2017 8:29 PM

    • HH patients are home bound and could not do out patient therapy. The choice is between nursing home or hospital and home health. You are comparing the wrong things. Those lucky patients who can get home health get to come home earlier from in patient hospital or from a skilled nursing facility.

      Posted by Kathleen Hope Curry on 1/25/2017 8:36 PM

    • .."However, it may take longer time period and perhaps expense, to achieve those gains" Here are some points/questions that I ponder upon as I read the article. 1. 87 OP vs 22 HH: From statistical standpoint can this skew the results? 2. Age range and status of 87 OP group: Are they possibly younger and healthier and have the ability to drive safely or get driven to OP right after surgery? 3. Age range and status of 22 HH group : Are they possibly older and more likely to have comorbities making them "homebound" thus the need for HH? In the home health set up you will see other factors you will not necessary see in the clinical OP set up. You can help ease up pt's apprehension of limited mobility to a familiar environment yet with an unfamiliar day to day expectation post joint replacement. You can identify home modifications needed to enhance safety and quality of recovery..and ultimately possibly minimize setbacks and complications and rehospitalizations. " Yes, it may take longer time and possibly expense if HH is utilized prior to OP. But does it really?" Thank you for the study.

      Posted by Roselyn Ursua PT on 1/26/2017 12:11 AM

    • As someone who is both a consumer of research and who has published research, I am disappointed in this study and frankly, in its coverage in PT News in Motion. Functional status, medical complexity, physical structure of the home and support available at home are all critical considerations in discharge planning following joint replacement. In addition to the sample size issue of this retrospective study, neither the reporting here nor the abstract give any information about the patient populations of the two groups. The implication here suggest that these two patient groups are equivalent. Yet there is no analysis available to suggest that these groups of patients are in fact similar. Most patients who receive physical therapy in the home following joint replacement due so because they are unable functionally to access outpatient services. A primary goal of physical therapy in the home is to restore function sufficient to accomplish transition to outpatient services. Were the two groups reported on in this study equivalent, these findings would be valuable. In the absence of establishing that these are equivalent populations, the reported findings are at best irrelevant, and at worst misleading. There is an urgent need for clinical research in this population and in these settings. However, we need to make sure that our eagerness to report results doesn't cause us to overlook the validity of the findings. Thank you for the reminder this provides of the need for well designed clinical research, and of the need to be discerning consumers of published research.

      Posted by Jeff Child, PT, MPT on 1/26/2017 8:44 AM

    • Our pts who are considered for Homecare are more complex, more compromised, it's not just about the total joint replacement. More complex, more compromised individuals undergoing knee replacement will take longer to achieve goals.

      Posted by Cynthia Teske, PT on 1/26/2017 10:32 AM

    • Hello I had TKR July 11 , left hospital Weds Jul 12 , they were amazed How well I was doing , I was walking As though I didn't Have Surgery My bend was at 110 , on Thursday A PT came to my house and took My bend , once again 110 she had Asked if I had a robe tie , I said upstairs So she asked if I could lift my leg up while lying On my back to the height of my other knee and The pain was instant so she ran upstairs and grabbed The robe tie , with support it was easier but then I Was in excruciating pain all night , next day I couldn't Get off the bed and she did my extension and it was A 3 and she said oh that is good , I just did too much. Would that be correct ? That was on Fri I've been doing All of the program that she was having me Do and it's getting slightly better , But was that normal ? To be 110 and drop To a three with one lift that was not supported .

      Posted by Kim Joseph on 7/16/2017 10:51 AM

    • This comment is intended for Kim, the above poster. I had a TKR 7/7/17, and I can tell you that what you experienced is absolutely normal. I've had eight previous knee surgeries (sports injuries) before my TKR and one thing that you have to remember is that recovery is process that is not always linear. You will have good days & bad days. I have a high pain tolerance & hit my PT hard. I have always been ahead of schedudule with my rehab w/every surgery, but days I push it too hard/fast... like you, I can barely walk the next day, and my range of motion will be significantly reduced for a short period of time. I think you are confusing extension vs. flexation. Being @ a 3 (extension) & 110 (flexation) that soon out of surgery is great. You didn't however go from 110 to a 3. Those measurements were of 2 different things. Best of luck w/ your recovery.

      Posted by Jennah Livingood on 7/27/2017 11:57 AM

    • I had TKR on 6/6/17. Came home to HH and PT in home. Was doing great progressing quickly and by week 3 I was using a cane outside and nothing in home. My PT took my therapy a step further that day and had me doing lunges with a resistance band. Bent down on my new knee and everything was fine, bent down on my other knee and heard a "pop" that the PT confirmed she heard as well. That lunge literally changed my life. That knee had been my good knee for so long although it had arthritis too it was not ready for a replacement yet. My good knee immediately swelled up and a huge golf ball size spot on my knee appeared. Went to the MD and was told that was just enough to need another replacement this year. It has been absolutely everything I can do to walk and do life since that. I even went to Outpatient Therapy after Home Health and they treated both knees and my injured knee is not easy to live with at all. My new knee now hurts because it is compensating for the inured knee. So with the next replacement I will be going straight to outpatient rehab.

      Posted by Savinia Rice on 10/11/2017 10:23 AM

    • i would prefer to go to inpatient rehab after my knee replacement but i have a dog so is it ok if i do home health?

      Posted by linda wylie on 6/16/2018 1:50 PM

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