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Three Part Question

in [adults following TKR] in [a home exercise programme better than an outpatient programme] at improving [function and range of movement]

Clinical Scenario

A 65 year old lady has had a total knee replacement for osteoarthritis. She has had an uneventful post op recovery and, as per protocol, has an appointment for outpatient physiotherapy. With the pressure on appointments you wonder whether a home exercise programme will be just as effective as outpatient programme at improving function and knee flexion range of movement.

Search Strategy

MEDLINE 1966-03/07, CINAHL 1982 –03/07, AMED 1985-03/07, SPORTDiscus 1830-03/07, EMBASE 1996-03/07, via the OVID interface. The Cochrane database, March 2007 and PEDro database, March 2007.
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, Cochrane database: [{(exp arthroplasty replacement knee) AND (exp.physical therapy OR exp.exercise OR exp.therapeutic exercise OR exp.group exercises OR physiotherapy.mp})]
Medline, AMED [{(exp.physical therapy techniques)}]
SPORTSDiscus [{(exp.arthroplasty)}]
EMBASE [{( syn physiotherapy)}]
PEDro [arthroplasty, knee]
LIMIT to human AND English language.

Search Outcome

147 papers were retrieved, of which 3 were relevant to the 3 part question comparing a home based exercise programme with an outpatient rehabilitation programme.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kramer et al. 2003 Canada	N = 160 primary TKR for OA Group 1: (n=80) 12 wks x 2 1 hr clinic based PT Group 2: (n=80) 12 wks x 3 daily home based exercise. Monitored by log sheets & weekly 15 min phone call.	Single blinded, randomised group comparison	1. 6min walk test	NSS (P >0.01)	16% drop out Group1 added other physio modalities (U/S, ice, heat) No data tables (mean SD). Figures presented only
			2. WOMAC	NSS (P >0.01)
			3. SF-36	NSS (P >0.01)
			4. K S score	NSS (P >0.01)
			5. Knee range of motion	NSS (P >0.01)
			6. 30s stair test	NSS (P >0.01)
Moffet et al 2004 Canada	N = 77 primary TKR for OA Group 1: standard home exercise programme Group 2: standard care + x12 supervised outpatient intensive rehab programme	Single blinded RCT	1: 6 min walk test	1: Sig (P < 0.05) treatment effects in favour of Group 2 immed post rehab (22.5m); @ 2 mth (25.4m); @ 8 mth (26.4)	Large variability in Group 2 post primary outcome (95% CI 1.1 – 44m) Compliance of home programme not monitored. 26% of Group1 had a physio home visit to supervise exercises
			2: WOMAC	2: Sig (P < 0.05) effect for Group 2 in total score immed post (7.9); @ 2 mth (8.4); but NSS @ 8 mth(4.3 p=0.19)
			3: SF-36 (11 scales)	3: NSS in 9 scales. P<0.05 in other 2 for Group 2 but have small treatment effects.
Rajan et al. 2004 UK	N = 116 primary TKR for OA Group 1: (n=60) Home exercise programme Group 2: (n=56) home exercises + 4-6, 20 min outpatient physio sessions	PRCT	1: Knee RoM	1: NSS between groups @ 3,6 months & 1 year post op.(Max Difference= 4 degrees)	No functional outcome Home Compliance not monitored. Exercise programmes not described

Comment(s)

Personnel communication with all 3 sets of authors clarified that their outpatient programmes did not take place in a gym-class environment but was a 1-to-1 with the therapist. Rajan et al also clarified that their 1-to-1 sessions lasted 20 minutes each. There are no published studies on the effect of a gym-class rehabilitation programme.

Clinical Bottom Line

There is no clear evidence of the benefit on function and range of movement from a 1-to-1 outpatients programme compared to a home based exercise programme post TKR.

References

1. Kramer JF, Speechley M, Bourne R, Roraback , Vaz M. Comparison of clinic and home based rehabilitation programs after total knee arthroplasty Clin Orthop Rel Res 2003;410: 225-234
2. Moffet,H, Collet J-P, Shapiro SH, Paradis,G, Marquis, F, Roy,L Effectiveness of intensive rehabilitation of functional ability and quality of life after first total knee arthroplasty: a single blind randomised controlled trial Arch.Phys.Med. Rehab. 2004; 85: 546-556
3. Rajan,RA, Pack,Y, Jackson,H, Gillies C, Asirvatham,R. No need for outpatient physiotherapy following total knee arthroplasty. Acta Orthop Scand 2004;75(1): 71-73