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  • What's the Best Post-TKA Intervention in the Acute Care Setting? There's No Easy Answer, Say Researchers

    For patients who undergo total knee arthroplasty (TKA), this much is known: physical therapy in the acute care setting is a key component in successful rehabilitation. What's not so easy to pinpoint are the individual interventions associated with the best outcomes, according to authors of a new systematic review. Their investigation into 20 years' worth of clinical trials and other studies revealed no clear standout interventions but did find "very low" evidence for the use of cryotherapy, accelerated rehabilitation, and neurostimulation within the first 7 postoperative days (PODs).

    The study, published in the Journal of Acute Care Physical Therapy, involved extensive reviews of research published between 1996 and 2016 on various physical therapy-related interventions used in the acute care setting post-TKA. Authors were on the lookout for evidence of effectiveness of a particular approach, because, they write, "despite seemingly routine use of physical therapy and its potential importance in reducing complications after [total joint replacement] in the acute hospital setting, no approach to rehabilitation in this setting appears to be standard."

    In the end, through a review process that pared down a list of 686 research titles to 40 studies that met inclusion criteria, authors were able to come up with a definitive conclusion, albeit not the most rewarding one for those looking for guidance: existing evidence isn't strong enough to support any clear winners when it comes to post-TKA physical therapist interventions in the acute care setting.

    The studies that yielded no or weak evidence looked at approaches including additional sessions of rehabilitation, compression and manual lymph drainage, knee range-of-motion (ROM), continuous passive motion, knee ROM manual passive exercise, knee ROM-active assistive exercise, biofeedback, and acupressure, acupuncture, and traditional Chinese medicine. According to authors, evidence either was insufficient or included a significant risk of bias, or both.

    Three other interventions fared somewhat better than the rest, although none were supported by strong evidence. They were:

    Cryotherapy. Reviewers identified 2 systematic reviews supporting the use of cryotherapy to reduce early postoperative pain and improve ROM, though evidence was described as "very low" quality by authors of both reviews.

    "Early" or "enhanced" physical therapy—for example, having patients walk within hours after surgery. Authors identified "very low level" evidence supporting these approaches to improve ROM and walking ability, and to reduce length-of-stay.

    Neurostimluation. "Very low level" evidence suggested that neurostimulation may help to reduce pain—but only when electrodes were placed near the surgical site, according to authors.

    Further clouding the evidence in most (31 of the 40) studies was the fact that some form of "physical therapy" or exercise intervention was used—in both the special intervention group and the comparison group—in addition to the intervention being studied. "Possibly, the lack of evidence for the effectiveness of most of the studied interventions is due to similar management of the intervention and comparison groups, and that changes in the outcomes studied are largely affected by various forms of interventions suggested by the term 'physical therapy' or 'standard care,'" authors write. In addition, they point out, all study participants likely received medical pain management, which makes it even harder to isolate the effects of a particular intervention.

    Authors say there's a clear need for more research on interventions in the acute setting, but acknowledge that such research may be challenging "because of the difficulty controlling for all the variables that may influence outcomes that affect function."

    For now, authors say, don't count on any clear recommendations on the single best intervention to use for patients post-TKA in the acute care setting.

    "Given the state of the evidence, physical therapists will need to rely on empirical evidence and physiologically plausible rationales for selecting type, intensity, frequency, and duration of interventions," authors write. "In addition, given the likely symbiotic relationship between pain management and physical therapy interventions, peri- and postoperative medical management may have important effects on the immediate gains in patients' function after TKA that cannot be separated from the effects of interventions provided by physical therapists."

    APTA members Alisa Curry, PT, DPT; Meri Goehring, PT, PhD; and Diane Jette, PT, DSc, FAPTA, were among the coauthors of the study.

    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

    • Our hospital shifted from ambulation on POD 1 to POD 0 and saw a significant decrease in length of stay. This is of course multifactorial and is also due to the adoption of a multimodal pain approach, but our length of stay is now 1.0 days for both hips and knees.

      Posted by Jessie Fisher on 7/17/2018 10:05 PM

    • I have been involved in OP TKA and THA for 3 years now. Patient's do well with immediate post op PT the day of and the next day forward. I have also experienced a true "control group" as there is a practice in our area that experimented with NO post op PT. These patients always have ROM and mobility issues. More significant than any other post op "group". We also have better success with patient's that have the opportunity to attend pre op therapy

      Posted by Sue on 7/19/2018 7:12 AM

    • I would ask that those of you who have programs that have significant success publish case studies and start research into this population. Surgeons have been publishing on these patients for years but we are the front line and we see correlations that support positive factors influencing outcome. Our practice is being driven by others and by incomplete research.

      Posted by Alisa Curry PT DPT GTC GCS on 8/10/2018 4:28 PM

    • As a recent ( 7/17) recipient of a TKA I can report little pain post surgery on day of surgery and had PT one day post-op to check me out for safety and mobility issues I might have at home. I was discharged after one night in hospital. Swelling occurred later and I still use ice for pain. Obviously, I worked on all ROM and still do. I was not using adaptive devices before surgery and only use a cane when safety is an issue.

      Posted by Edith Buchan on 8/11/2018 8:30 AM

    • For all the researchers out there: why can't you find the place where they have the best outcomes post op ie shortest length of stay, least complications etc and find out what they do Then take that to multiple centers and see if the same results are reached. After 30 years as a PT I am so tired of health care rejecting examining the places doing it right, meeting the triple aim and then just repeating their success. Plenty of best practices out there such that the delay of waiting for "good"research is somewhat irrelevant. Best practice is where the value is. Find that and publish that.

      Posted by Thomas M. Howell on 8/12/2018 12:26 AM

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