Comparing outcomes of patients following total knee replacement: does frequency of physical therapy treatment affect outcomes in the acute care setting? A case study.
Knee osteoarthritis is a common cause of disability today. (6) Patients with end-stage osteoarthritis experience a significant reduction in pain and disability following total joint replacement. The American Academy of Orthopaedic Surgeons estimates more than 365,000 total knee replacements are performed in the United States every year. (7) The Centers for Disease Control estimates that by 2030 nearly 41.1 million people ages 65 and older will have arthritis, almost double the 21.4 million reported in 2005. (8) Projected public demand for total knee replacement by 2030 is 3.48 million procedures. (9) This significant increase in the incidence of arthritis will have a large impact on utilization of the health care system.
Given the large number of patients opting for elective total knee arthroplasty, efforts are being made to decrease hospital length of stay. (10) Patients benefit from shorter hospital stays after surgery due to decreased risk of hospital-acquired infections and improved comfort in their own homes. Patients are likely to be more active and have improved functional recovery when they return home. (11) Hospitals benefit from shorter LOS including increased bed availability and decreased costs. (1,2)
During fiscal year 2000, Medicare paid $3.2 billion for major joint replacement, diagnosis related group (DRG) 209. Consequently, Medicare has made an effort to control health care expenditures for joint replacement. Since 1998, payments for DRG 209 have decreased. The estimated average payment to hospitals for a total knee replacement procedure in 2002 was $9,057, compared with $9,223 in 2001. (12) Subsequently, hospitals have experienced strong financial pressure to reduce costs primarily through the reduction of length of stay (LOS) and greater reliance on post acute care. (13)
Many factors inherent to the patient can contribute to an increased LOS following elective total knee replacement. These factors include patient age, sex, prior level of function, severity of pain, co-morbidities, post-operative complications, and lack of family support. Patients who are older and who live alone are predicted to have longer LOS and require discharge to rehabilitation facilities. (14) LOS is longest in patients older than 70 years. (14) Women and patients who have had a revision TKR also have been found to have longer LOS. (15)
Factors intrinsic to the hospital setting can affect LOS. These factors include surgical technique, analgesia, type of prosthesis, and critical pathways. Minimally-invasive procedures and improved analgesia have contributed to decreased LOS. Critical pathways are treatment algorithms designed to standardize patient care. These multidisciplinary management plans establish patient goals and determine the actions required and the sequence of timing necessary to efficiently obtain these goals. Critical pathways are designed to minimize variation in service delivery in an attempt to reduce cost and improve quality. (16) Multidisciplinary critical pathways have been found to significantly shorten LOS. (1) Physical therapy plays an important role in early mobilization of the patient within the critical pathway.
Utilization of physical therapy services following knee arthroplasty is one of the most understudied aspects in the literature. (17) Much of the literature examines long-term outcomes following outpatient rehabilitation. Few published studies have examined the relationship between delivery of physical therapy services and outcomes in the acute setting for patients following TKR. Kirk-Sanchez et al found a positive relationship between the number of hours of physical and occupational therapy services received and the functional mobility scores of patients with orthopedic diagnoses in an inpatient rehabilitation setting. (18) Boxall et al found that patients receiving TKR achieved independent transfers significantly sooner with 7-day per week physical therapy treatment compared with 5-day per week treatment in an acute setting. (19)
Several studies have shown a positive relationship between physical therapy utilization and patient outcomes, but were not exclusive to patients who had received TKR procedures. Roach et al found a positive relationship between the amount of physical therapy a patient receives and the degree of functional improvement attained. Although this research occurred in the acute setting, it included other lower extremity orthopedic conditions such as hip, pelvic, and ankle fractures, as well as TKR. (20) Freburger examined total hospital cost in relation to total acute physical therapy charges and discharge destination for patients after total hip replacement. The study concluded that the total costs of physical therapy services were less than expected and patients receiving PT treatments had an increased probability of discharge directly home. (21) These studies clearly demonstrate a positive relationship between receiving PT services and positive patient outcomes.
One study was found in the literature review that specifically addressed intensity of PT intervention on outcomes in the acute care setting following TKR. In a randomized clinical trial, Lessen et al concluded that twice daily PT sessions did not produce different outcomes than once daily PT sessions. (3) In this study the QD patients received 20 minutes of treatment daily, and BID patients received 40 minutes of treatment daily. Range of motion (ROM), functional mobility, and LOS all were found to be similar between the groups. Treatment consisted of active and passive ROM, quadriceps strengthening, transfer, gait and stair training. The limitations of the study were the small sample size and the primary outcome being passive flexion. In Lenssen's research, PT services where delivered on a time-based model. The BID treatment group received twice the total number of therapy minutes compared with the QD group, regardless of whether it was indicated. The once daily patients requiring more than 20 minutes of treatment did not receive more PT minutes. Lessen concluded in the discussion that this was not an optimal patient care design.
Kennedy et al reported that the greatest functional improvement occurs within the first 9 weeks postoperatively after TKR. (22) Since the acute care setting is where rehabilitation begins, more research is necessary to determine the most appropriate frequency of physical therapy intervention. The purpose of this multiple-patient case report is to examine whether outcomes differ depending on the frequency of physical therapy interventions following TKR in the acute care setting. Outcomes specific to this study are ROM, FIM scores, NRS (numerical rating scale) pain scores, and LOS. Our case report examines the dosage, or utilization, of PT services within this framework. The present study differs from Lenssen's in that therapy provided is goal-based; therefore, the QD and BID groups receive an equal number of total therapy minutes throughout the entire LOS.
A convenience sample of 6 patients (3 women, 3 men), ranging in age from 44-73 years, was taken. The mean age for the QD group was 65 years, compared with 54 for the BID group. Patients were screened by a physician and diagnosed with osteoarthritis. Patients complained of pain when walking and decreased ability to participate in activities of daily living (ADLs) affecting their quality of life. Patients elected to undergo TKR by one of three experienced orthopedic surgeons in an acute hospital in northern Virginia. Once referral to physical therapy was obtained, patients were selected randomly to receive either QD (Patients 1, 2, & 3) or BID (Patients A, B, & C) treatments. See Tables 1 and 2 for patient demographics and characteristics. Patients admitted to the intensive care unit (ICU) after TKR surgery, or who experienced complications due to co-morbidities that increased their LOS, were excluded from the study. Only one patient, a 78-year-old man who experienced atrial fibrillation and subsequently was transferred to the ICU, was excluded from the study.
Physical therapy examination and treatment was initiated the day after surgery, postoperative day 1. All patients were examined and treated by the author. A systems review was performed to determine whether the patient was an appropriate rehabilitation candidate. On examination all patients demonstrated significant post-surgical edema, limited active range of motion of the surgical knee, poor quadriceps activation, significant pain with movement and with weight bearing, and decreased functional mobility and independence. None of the patients were able to perform a straight leg raise (SLR) on examination post-operative day one, or at discharge.
Positional blood pressures were taken on each patient prior to initiation of any significant mobility assessment. Oxygen saturation and heart rate was assessed both at rest and on exertion. Once these variables were within normal limits they were not reassessed each visit unless a patient's hematocrit or hemoglobin values were low on the daily laboratory report, or unless a patient was symptomatic.
Sensation and skin integrity assessment was performed locally at the surgical lower extremity and globally. Patients who had received femoral block during surgery demonstrated deficits with light touch sensation and functional proprioception for approximately 24 hours following surgery on that lower extremity. The therapist performed a visual inspection of the spine and lower extremities for skin break down and anomalies with the patient sitting on edge of the bed and when standing. All incisions were dressed in bulky bandages, so the therapist was unable to visually assess the surgical incision. Girth measurements for edema were not taken due to the dressings.
Ankle and hip active range of motion (AROM) and manual muscle strength were assessed on the surgical lower extremity to determine any deficits. Knee ROM was measured with a goniometer only at the surgical joint. The majority of patients in the study were unable to perform knee extension in sitting due to quadriceps weakness; therefore extension was measured in the supine gravity-lessened position. Knee flexion was measured in sitting. Due to pain and weakness, evident as inability to perform a SLR, manual muscle testing was not performed at the surgical joint. AROM and manual muscle strength at all joints on the non-surgical lower extremity were assessed.
Homan's test to rule out deep venous thrombosis (DVT) was performed if the patient complained of calf pain with active or passive ankle dorsiflexion, or with weight bearing. None of the subjects in this study had a positive Homan's sign. Upper extremity AROM and strength were assessed to insure the ability to use a walker safely. Mobility assessment was performed each treatment including bed mobility, supine-to-sit transfers, sitting balance, sit-to-stand transfer with walker, standing balance, bed-to-chair transfer, toilet transfer, ambulation with walker, and stair negotiation.
Tests and Measures
Functional Independence Measure (FIM) is part of the Uniform Data Set (UDS) (23) used by physical and occupational therapists to measure physical disability and outcomes for rehabilitation. (24) The FIM instrument includes 18 items in the motor and cognitive domain. Self-care, sphincter control, transfers, locomotion, communication, and social cognition are assessed on a 7-point scale. A score of 7 represents independence, and 1 indicates complete dependence, or inability to perform the task. Median interrater reliability has been reported as 0.95 for the total FIM and median test-retest and equivalence reliability as 0.95 and 0.92, respectively. (5) The cognitive and motor subscales of the FIM have been used to predict LOS and disability. (26) The FIM has been shown to provide clinically appropriate validity. (27)
Goniometric assessment of knee flexion and extension has been found to have good reliability when taken by the same therapist (28) and good criterion-related validity in goniometric assessment has been reported when compared with radiographic assessment. (29) The twelve-inch universal goniometer was chosen due to high intratester reliability (ICC = 0.91-0.96). (30) The numeric rating scale (NRS) is an 11-point scale for pain that generates good sensitivity and statistically sound data. (31) 0 represents no pain, and 10 indicates the worst possible pain. Although the patient's perception of pain may be considered subjective, the validity of NRS has been well documented.(32) The NRS was chosen due to clinical ease of use and scoring.(33)
Length of stay (LOS) was calculated in the manner in which charges are assessed at the hospital where the study was performed. Patient charges are dropped at midnight. A patient occupying a bed at midnight is charged for one day. For example, if the patient had surgery at 8:00 am on Monday and was discharged at 8:00 pm on Wednesday, LOS is two days. The orthopedic surgeons at the study facility request initiation of PT services to begin the day after TKR surgery. Therefore, this patient would receive two full days of therapy services. LOS and number of treatment days were equal in all cases.
Evaluation and Diagnosis
All patients demonstrated "impaired joint mobility, motor function, muscle performance, and range of motion associated with joint arthroplasty" classified under preferred practice pattern 4H according to the Guide to Physical Therapy Practice.(34) These impairments created deficits in transfers, balance, ambulation, stair climbing, and performing ADLs.
Goals of physical therapy following TKR include increased ROM, knee extensor force production, functional independence, and pain management. Physical therapy interventions consisted of patient and family education, therapeutic exercise, sitting and standing balance activities, bed mobility, transfer, gait, and stair training.(3) The primary focus of acute physical therapy treatment following TKR was regaining independent functional mobility; therefore, the majority of treatment time, greater than 75% in most cases, was spent on mobility training. All physical therapy treatment provided to the patient was individualized treatment. No group treatment occurred during this study.
Physical therapy treatment provided was goal-based, not time-based. The therapist had a mobility objective to achieve each day with each patient. The time provided to each patient was determined by the patient's ability and timing to achieve objectives. Therefore, an increase in treatment frequency did not necessarily increase the patient's total treatment time.
Therapeutic exercise handouts were provided and reviewed with each patient. Exercises included ankle pumps, isometric quadriceps sets, knee flexion in supine and seated positions, short arc quadriceps (SAQ), long arc quadriceps (LAQ), hip abduction and adduction in supine, and straight leg raises (SLR). If the patient was unable to actively complete arc of motion, the therapist provided active assistance. Patients were shown how to use a sheet, or belt, to assist with ROM during their exercises, and were instructed to perform all exercises 1015 repetitions, 3-4 times daily.
The physical therapist instructed patients in the use of ice and elevation to control edema and pain. Patients were educated on the risks and complications of bed rest, as well as the signs and symptoms of infection. Per physician order, all patients used continuous passive motion (CPM) machines twice daily. However, either the vendor or nursing staff applied this equipment for the patient. Physical therapy instructed the patient and nursing to increase ROM 10 degrees daily to ultimately achieve 0-110 degrees. PT was involved in education of CPM progression only.
Mean LOS for the QD treatment group was 2.7 days, compared with 2.0 days for the BID group. Patients in the QD group received an average of 3 total PT treatments, whereas patients in the BID group received 4 total treatments. Discharge destination for all patients in both treatment groups was home with family plus home health physical therapy services.
Mean total billable PT treatment time throughout entire LOS for the QD group was 135 minutes, compared with 132 minutes for the BID group. Treatment minutes were not predetermined; the apparent equivalence between groups in number of minutes to achieve the mobility objectives appears to be coincidental (see Table 3).
The mean FIM score on evaluation of the QD group was 81 points out of 126 possible. The BID group's mean FIM score was 89. The mean FIM score at discharge was 99 points for the QD group, compared with 109 for the BID group (see Figure 1). After physical therapy treatment was delivered, the QD group showed a mean increase in FIM score of 18-points, compared with a 20-point increase for the BID group. Functionally, the difference in 2 points relates to the amount of assistance required for transfers and/or gait on two items of the FIM assessment. Patients in the BID group were able to walk longer distances than those in the QD group. Patients in the BID group required standby assistance or were modified independent in transfers and gait, whereas the QD patients were more likely to require minimal assist or stand by assistance with verbal cueing. Patients in both groups required the use of a walker for transfers and gait.
[FIGURE 1 OMITTED]
Patients in the QD group reported lower pain. Worst pain was reported with end range passive flexion and weight bearing in all cases. ROM was greatest in the QD group. Mean increase in total available ROM from evaluation to discharge in the QD group was 23 degrees, whereas the BID group showed only a 12-degree mean increase in ROM. This was calculated by subtracting the extension measurement from the flexion measurement on post-operative day one and at discharge to determine available range. The post-operative day one range was then subtracted from the total available range at discharge. Then the mean was calculated for the two groups (see Table 4). ROM was limited by pain in all cases.
Discussion and Conclusion
Benefits of QD compared with BID physical therapy treatments following TKR in the acute care setting differ depending on which variables are examined. Patients in the BID group demonstrated higher FIM scores at discharge and experienced shorter length of stay by approximately one day. Patients who received QD physical therapy treatments had lower pain reports and improved ROM. All patients in the study were discharged directly home and received home health physical therapy services.
As discussed in the introduction, a number of factors intrinsic to the patients affect outcomes following TKR. (14,15) The subjects included in this case report were screened carefully by the surgeons, and were excellent surgical candidates. All patients in the study were able to ambulate independently without assistive device prior to surgery and were independent with their ADLs.
Baseline function prior to surgery is a large determinant of function after TKR.(35) Prior level of function appears to have been a significant contributing factor in the positive outcomes achieved by patients during this case study.
LOS and FIM outcomes are least favorable in older patients.(15) The mean age for the QD group in this study was 65 years, compared with 54 years for the BID group. The 11year mean age discrepancy between the two groups may account for the lower FIM scores and longer LOS for the QD group. Had the mean age between the two groups in this study been more similar, LOS and FIM results may have been comparable.
Patient 2, the oldest patient in the study at 73 years, had significantly altered mental status related to anesthesia post-operative day one, which delayed her progress with mobility training. Her initial FIM score was lowest due to decreased cognition. This is a common occurrence with elderly patients following orthopedic surgery. Due to cognitive and sedative deficits from anesthesia, once daily treatment would have been most appropriate early, then once her cognitive status improved, twice daily PT treatment may have been more beneficial.
Multiple co-morbidities may be a factor in determining appropriate frequency of post-operative physical therapy intervention. Patient 3, a 69-year-old man, experienced significant oxygen desaturation on exertion with supplemental oxygen following TKR. Respiratory impairments limited the distance he was able to ambulate and his tolerance of stair climbing, significantly lowering his FIM scores in those categories. Further studies may find that patients who are identified with multiple co-morbidities would benefit from twice daily treatment in the acute setting. Shorter duration more frequent treatment may be better tolerated by certain populations.
One possible explanation for improved ROM and lesser pain in patients who received therapy once daily was increased rest and elevation time between PT sessions. Acute pain and edema following the invasive TKR procedure was a major limiting factor in achieving mobility goals. If goals could be achieved in once daily treatment, the majority of patients stated they would prefer it.
For acute rehabilitation staffing purposes, hospital physical therapists would be more effective in treating a larger number of patients if orthopedic patients received QD treatment. With current acute care staffing shortages, this is worthy of further consideration. The numbers of billable minutes were documented for study purposes. However, a number of minutes were non-billable with the treatment of each patient. This time included chart review, communication with nurses, physicians, and discharge planners regarding the patient, and scheduling conflicts with other disciplines.
The limitations of this case report were small sample size and the lack of blinding of the treating therapist to the treatment groups. Although patients were assigned randomly into treatment groups, the two groups were not homogeneous in regard to age, which may account for differences in FIM and LOS outcomes.
Further research is required to determine the optimal frequency of physical therapy treatment in the acute care setting following TKR. Surgeons currently dictate frequency of therapy services in the post-operative referrals to physical therapy. During this study the physical therapist spent an average of 133 total treatment minutes with each patient during the LOS. This was more individual treatment time provided to the patient for mobility training and assessment than given by any other single discipline following surgery. Frequency, duration, and intensity of physical therapy services in an acute care setting should be based on achieving mobility outcomes with consideration given to medical status and patient tolerance. As physical therapists move toward autonomous practice, they are best equipped to determine frequency, intensity, and duration of physical therapy services.
I would like to thank to Barbie Kazan, PT, Lynda Rhea, PT, DPT, MBA and Karon Goggins, PT, DPT for their contributions to the editing and design of this research article.
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Debra Lawson, PT, DPT lives in Virginia where she practices at Potomac Hospital as an acute care physical therapist. She is a 2002 graduate of East Carolina University and a 2008 graduate of Shenandoah University's transitional DPT program.
Table 1. Patient Profiles QD Treatment Group Patient 1 Patient 2 Patient 3 Gender female female male Age 52 73 69 BM1 38 22 35 Lives with family with family with family Occupation retired retired teacher laborer hairdresser Diagnosis osteoarthritis osteoarthritis osteoarthritis Surgical knee right right left Table 2. Patient Profites BID Treatment Group Patient A Patient B Patient C Gender male female male Age 56 44 63 BMI 35 35 32 Lives with family with family with family Occupation manager UPS worker administrator Diagnosis osteoarthritis osteoarthritis osteoarthritis Surgical knee left right left Body Mass Index (BMI) = weight (kg)/height[(meter).sup.2]] Table 3. Outcome Comparison QD group BID group Mean LOS (days) 2.7 2.0 Mean total minutes * 135 132 Mean FIM score on evaluation 81 89 Mean FIM score at discharge 99 109 Mean increase in FIM score 18 20 Mean change in total ROM + 23 degrees + 12 degrees Mean pain at discharge ** 1/6 4/7 Mean age 65 54 * PT treatment minutes for entire LOS ** best/worst Table 4. Patient Outcomes AROM AROM at Pain Pain at FIM Post-op Discharge Post-op 1 Discharge Post-op Day 1 Supine least/worst least/worst Day 1 Ext / Sit Flex Patient 1 8-55 8-70 1/10 2/6 89 Patient 2 15-80 0-90 2/7 0/5 61 Patient 3 10-60 0-80 3/6 0/7 93 Patient A 8-50 5-50 3/10 6/10 97 Patient B 10-35 10-50 4/10 3/7 89 Patient C 10-70 3-80 1/6 3/5 81 FIM at LOS Total Discharge Discharge Days PT Destination minutes Patient 1 105 2 90 home Patient 2 96 3 165 home Patient 3 96 3 150 home Patient A 109 2 110 home Patient B 111 2 120 home Patient C 106 2 165 home Patients 1, 2, 3 received QD treatments. Patients A, B, C received BID treatments.