Journal Article

Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial

Stoddart, Andrew, Barker, Karen L, Hutchinson, James D, Tuck, Christopher E, Beard, David J, Simpson, A Hamish R W, Hamilton, David F, Wilton, Timothy, Macfarlane, Gary J, Murray, Gordon D

2020

Overview

AbstractObjectiveTo evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty.DesignParallel group randomised controlled trial.Setting13 secondary and tertiary care centres in the UK providing postoperative physiotherapy.Participants334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol.InterventionsAll participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist).Main outcome measuresPrimary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery.Results334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval −0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, −0.78 to 0.28, P=0.36) or worst pain (0.22 points, −0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval −14.25 to 4.96, P=0.34).ConclusionsOutpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures.Trials registrationCurrent Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445.

• Publisher: BMJ Publishing Group LTD,BMJ Publishing Group Ltd
• Subject: Arthritis / Arthroplasty (knee) / Clinical outcomes / Clinical trials / Intervention / Joint replacement surgery / Joint surgery / Likert scale / Osteoarthritis / Pain / Patients / Range of motion / Registration / Rehabilitation / Surgery / Therapists