Exercise Combined With Continuous Passive Motion or Slider Board Therapy Compared With Exercise Only: A Randomized Controlled Trial of Patients Following Total Knee Arthroplasty.Total knee arthroplasty (TKA TKA Total Knee Arthroplasty TKA The Kings Academy TKA Teras Kasi Artist (Star Wars Galaxies) TKA Team Killers Anonymous (gaming clan) TKA Trochanter-Knee-Ankle ) surgery is a common orthopedic surgery Orthopedic Surgery Definition Orthopedic (sometimes spelled orthopaedic) surgery is surgery performed by a medical specialist, such as an orthopedist or orthopedic surgeon, trained to deal with problems that develop in the bones, joints, and ligaments performed to reduce pain and improve function in degenerative de·gen·er·a·tive adj. Of, relating to, causing, or characterized by degeneration. Degenerative Degenerative disorders involve progressive impairment of both the structure and function of part of the body. knee joints of geriatric populations. Because patients who receive joint arthroplasties are now being discharged from the hospital at an earlier stage in their recovery, a focus of rehabilitation rehabilitation: see physical therapy. is mobilizing the patient and regaining range of motion (ROM) in the knee. Because restricted knee ROM affects functional activities, knee ROM is still considered to be one of the primary indicators of a successful TKA.[1-4] Continuous passive motion continuous passive motion n. Abbr. CPM A technique in which a joint, usually the knee, is moved constantly in a mechanical splint to prevent stiffness and to increase the range of motion. (CPM (1) (Critical Path Method) A project management planning and control technique implemented on computers. The critical path is the series of activities and tasks in the project that have no built-in slack time. ) machines are frequently used to increase knee ROM after a TKA and to promote a rapid postoperative post·op·er·a·tive adj. Happening or done after a surgical operation. postoperative after a surgical operation. postoperative care recovery. Many clinical trials have been conducted on the efficacy and effectiveness of CPM for regaining ROM after surgery, but the results are contradictory. Some trials have shown that early postoperative knee ROM is improved with the addition of CPM,[5-11] whereas other studies have demonstrated no difference.[12-17] The variability seen with these results is, in our view, most likely the result of variation in the postoperative CPM protocols, sample sizes, and rigor rigor /rig·or/ (rig´er) [L.] chill; rigidity. rigor mor´tis the stiffening of a dead body accompanying depletion of adenosine triphosphate in the muscle fibers. of study design. The investigators in these studies, however, all concluded that the use of CPM did not affect the long-term knee ROM attained by 6 months after the operation.[5-17] Although there are no long-term physical benefits from using a CPM machine, research findings suggest that knee flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. returns more rapidly and that fewer knee manipulations under anesthesia are required with the use of CPM.[6,10] Although CPM may improve ROM during the initial postoperative phase, there are a few disadvantages associated with its use. First, patients must remain in bed while the machine is being used. Bed rest is contrary to current practice in which rehabilitation centers focus on mobilizing the patient in preparation for hospital discharge. Second, studies showing early gains in knee ROM had protocols requiring up to 20 hours of daily use of a CPM machine, which does not appear to be realistic or cost-effective.[10,12,13] Third, additional technical and nursing support are required to operate CPM machines, because patients are dependent on health care personnel to set up the device. A fourth disadvantage is the expense incurred with the purchase and regular maintenance of the machines. The slider A block of material that holds the read/write head of a magnetic disk. See flying head. board (SB) is a simple and less expensive device that was developed at a rehabilitation hospital Hospital devoted to the rehabilitation of patients with various neurologic, musculoskeletal, orthopedic and other medical conditions following stabilization of their acute medical issues. by a group of physical therapists and an engineer in the early 1990s as an alternative to CPM machines. The device consists of a movable heel-cup fixed to a low-friction sliding mechanism that allows patients to flex and extend their lower extremity lower extremity n. The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. with minimal active movement of the quadriceps femoris Noun 1. quadriceps femoris - a muscle of the thigh that extends the leg musculus quadriceps femoris, quadriceps, quad extensor, extensor muscle - a skeletal muscle whose contraction extends or stretches a body part and hamstring muscles hamstring muscle n. Any of the three muscles constituting the back of the upper leg that serve to flex the knee joint, adduct the leg, and extend the thigh. (Figure). Its developers believed that the SB would offer similar benefits to CPM in this patient population while encouraging patients to actively participate in their rehabilitation. Because the SB provides low friction, only a minimal amount of active quadriceps femoris and hamstring muscle action is required to use it, and we believe that early use of the muscles should be advantageous to recovery. In addition, the SB can be used independently in either the supine supine /su·pine/ (soo´pin) lying with the face upward, or on the dorsal surface. su·pine adj. 1. Lying on the back; having the face upward. 2. or sitting position and requires no technical maintenance and minimal nursing support. Currently, no literature is available regarding the efficacy or effectiveness of the SB. [Figure ILLUSTRATION OMITTED] We believe that the short-term benefits of the SB are similar to those of CPM. We use the SB instead of CPM machines at our facility following TKA because the physical therapists and surgeons believe this device costs less to use. The SB has been used at our facility for approximately 4 years. As both CPM machines and the SB were designed to improve knee ROM, goniometric go·ni·om·e·ter n. 1. An optical instrument for measuring crystal angles, as between crystal faces. 2. A radio receiver and directional antenna used as a system to determine the angular direction of incoming radio signals. measurements will provide an indication of the effectiveness of these 2 interventions. Knee ROM is directly related to function, as a minimum of 65 degrees of knee flexion is needed for walking and up to 105 degrees of knee flexion is required for tying shoelaces.[4,18] In addition to determining which of the 2 adjunct ROM therapies was most effective, another goal of this study was to determine whether ROM therapy in addition to daily standardized exercise (SE) sessions was necessary to attain a higher level of recovery at 6 months following surgery. The primary goal of our study was to determine whether CPM or SB therapy in addition to SE was more effective in increasing knee ROM within the first 6 months following a first-time or primary TKA than SE alone. Three treatment groups of patients who underwent a primary TKA were created. The first group received CPM and SE (CPM group CPM is a UK-based field marketing company established in 1936. It employs over 3000 people across the UK and Ireland and specialises in providing people as the face and voice of its clients' brands. CPM is owned by the world’s largest marketing communications group Omnicom. ), the second group received SB therapy and SE (SB group), and the third group received SE only (control group). The secondary purpose of this study was to determine whether there was a difference among these 3 groups in (1) joint-specific pain, stiffness, and function and (2) generic health status up to 6 months after surgery. Our hypotheses were: (1) Patients who use SB therapy with SE will attain similar knee ROM as those patients who use CPM with SE within the first 3 months after surgery. (2) Patients who use either the SB or CPM as an adjunct to SE will attain greater knee ROM than SE alone in the first 3 months after surgery. (3) Generic health status and knee ROM, pain, stiffness, and function will be similar for all 3 groups at 6 months after the operation. Method Design The study design was a single-blinded, randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. . Subjects A consecutive sample of patients who received a primary TKA at a hospital in Edmonton, Alberta, Canada, that completes an average of 400 to 500 TKAs annually was assembled between June 5, 1997, and July 17, 1998. Subjects were eligible for the study if they were scheduled for a primary TKA and were able to return for the postoperative visits. Patients undergoing revision knee surgery or receiving a unicondylar knee replacement were excluded from the trial. Twelve surgeons referred subjects. Subject demographics are presented in Table 1. The mean age was 68.4 years (SD=8.6). Among the participants, 92% (n=109) had a diagnosis of osteoarthritis osteoarthritis or osteoarthrosis or degenerative joint disease Most common joint disorder, afflicting over 80% of those who reach age 70. It does not involve excessive inflammation and may have no symptoms, especially at first. , and 56% (n=53) were women. Sixty-five percent (n=79) of the participants had no comorbidities. Sixty-one of the 120 participants had no other joint involvement (51%), whereas 9 participants had 3 or more arthritic joints (7.5%). The distribution of other arthritic joints was not different among the 3 treatment groups.
Table 1.
Subject Characteristics
Control Group
(n=40)
Variable [bar[X] SD Range
Age (y) 69 8 50-84
n %
Female sex 12 30
Diagnosis of osteoarthritis (OA) 36 90
No comorbid conditions 28 70
[is greater than or equal to] 1
other joints with OA 18 45
SB Group
(n=40)
Variable [bar[X] SD Range
Age (y) 68 9 39-83
n %
Female sex 20 50
Diagnosis of osteoarthritis (OA) 38 95
No comorbid conditions 22 55
[is greater than or equal to]
1 other joints with OA 22 54
CPM Group
(n=40)
Variable [bar[X] SD Range P
Age (y) 68 9 43-84 .09(a)
n % P
Female sex 21 52.5 .09(b)
Diagnosis of osteoarthritis (OA) 35 87.5 .50(b)
No comorbid conditions 29 73 .36(b)
[is greater than or equal to] 1
other joints with OA 19 48 .72(b)
(a) Analysis by one-way analysis of variance.
(b) Analysis by chi-square analysis.
Of the 120 participants in the study, 17 subjects were lost to follow-up. An additional 10 patients were unable to return for the follow-up visits after discharge, but completed the questionnaires by telephone. The analysis of the subjects lost to follow-up for age, sex, diagnosis, and baseline measurements revealed no differences from the participants in this study. Procedure Enrollment. When subjects attended the preadmission clinic (PAC) 1 month prior to surgery, they were asked to participate in the study. Upon agreement, written informed consent was received from all participants. Following completion of the assessment and all questionnaires, subjects were randomly assigned to 1 of the 3 treatment groups: the CPM group, the SB group, or the control group. Randomization randomization (ranˈ·d  ·m . Randomization was computer-generated in blocks of
30. Randomization codes were kept in sealed envelopes with consecutive
numbering. Subjects were enrolled sequentially at the end of the
enrollment visit.Protocol. Subjects were examined preoperatively at the PAC, 5 to 7 days following surgery, and at 3 and 6 months after surgery. During each session, knee active ROM was measured by a research physical therapist who was unaware of the subject's group assignment. At the preoperative pre·op·er·a·tive adj. Preceding a surgical operation. preoperative preceding an operation. preoperative care the preparation of a patient before operation. and the 3- and 6-month examinations, subjects completed a self-reported disease-specific questionnaire --the Western Ontario and McMaster Universities McMaster University, at Hamilton, Ont., Canada; nondenominational; founded 1887. It has faculties of humanities, science, social sciences, business, engineering, and health sciences, as well as a school of graduate studies and a divinity college. (WOMAC WOMAC Western Ontario McMaster University Osteoarthritis Index Rheumatology An arthritic pain scoring system ranging from 0–no pain/disability to 100–most severe pain/disability ) Osteoarthritis Index--and a generic health measure--the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Data regarding demographics, comorbidities (cardiovascular, renal, endocrine, neurological neurological, neurologic pertaining to or emanating from the nervous system or from neurology. neurological assessment evaluation of the health status of a patient with a nervous system disorder or dysfunction. , and hepatic systems and other arthritic joints), and in-hospital complications were also collected from the medical charts. Postoperative management. All subjects followed the institution's standardized clinical pathway clinical pathway Critical pathway, treatment pathway Clinical medicine A standardized algorithm of a consensus of the best way to manage a particular condition Modalities used Teletherapy, brachytherapy, hyperthermia and stereotactic radiation. for TKA that included medical, pharmaceutical, and rehabilitation care over a 5- to 7-day acute care hospital stay. The goal of the clinical pathway is to prepare patients for discharge from the hospital 5 to 7 days after surgery. Early mobility is encouraged throughout the hospital stay. Immediately after the operation, a Jones bandage bandage /ban·dage/ (ban´daj) 1. a strip or roll of gauze or other material for wrapping or binding a body part. 2. to cover by wrapping with such material. , which maintains the lower extremity in extension, was applied to the knee and remained in situ In place. When something is "in situ," it is in its original location. until the second postoperative day when the hemovac drain Hemovac drain A blood recovery device used during surgery. See Blood salvage. was removed from the knee joint. Subjects were allowed to sit during the first postoperative day, and they progressed to walking short distances on the second postoperative day. The SE sessions commenced on the third postoperative day for subjects in all 3 groups. The SE sessions included walking within parallel bars parallel bars Event in men's gymnastics in which a pair of wooden bars supported horizontally above the floor at the same height is used to perform acrobatic feats. Competitors combine swings and vaults with stationary positions requiring strength and balance, though swings or with a walker or crutches to each subject's tolerance. Knee active ROM exercises were performed in a sitting or lying position using the SB for 10 to 15 minutes at the subject's preferred rate of movement. In addition, short-arc quadriceps femoris muscle
i·so·met·ric adj. 1. knee extension exercises were done. Subjects attempted to complete 3 sets of exercises at 10 to 15 repetitions each. Straight leg raises The Straight leg raise also, called Lasègue sign or Lasègue test, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk. without resistance and instruction in stair climbing Stair climbing is the climbing of a flight of stairs. It is often described as a "low-impact" exercise, often for people who have recently started trying to get in shape. A common phrase in health pop culture is "Take the stairs, not the elevator". were started 4 days after the operation. Ice was applied before and after treatment each day. The exercise sessions lasted 30 minutes on average, excluding the application of ice before and after exercise. Intervention. Following hemovac removal, which occurred on the second postoperative day, CPM and SB therapy commenced. The CPM group received three 2-hour Sessions with the CPM machine each day. The starting range was 0 to 30 degrees, and the range of movement was increased as tolerated. Ward nurses recorded adherence to CPM use in logs. The CPM group participated in an average of 1.8 sessions (SD=0.6, range=0.5-3.0) per day for an average time of 1.7 hours (SD=.05, range=0.75-2.8) per session. The most commonly missed session was the morning session (61%) when subjects typically provided self-care and received daily SE sessions and any routine radiology or laboratory tests. The SB group was asked to perform a minimum of two 10-minute sessions per day in addition to the SB session during the daily SE session. Active knee flexion and extension in both sitting and lying positions were performed independently to patient tolerance. The SB group participated in an average of 1.7 sessions (SD = 0.3, range = 1-3) per day for an average time of 16.0 minutes (SD = 5.0, range = 7-27) per session. The SB group completed logs describing SB use with the assistance of ward nurses and the treating physical therapists. Postdischarge rehabilitation. Prior to their discharge from the acute care institution, all subjects who were discharged directly home had physical therapy appointments scheduled either with a home care provider or in the community. Subjects who were transferred to other institutions received further therapy at the subacute care facility. Similar numbers of subjects from each group were discharged home or transferred to other facilities. Measurement The research physical therapist measured the active ROM of the knee in flexion and extension to the nearest degree using a large standard universal goniometer goniometer /go·ni·om·e·ter/ (go?ne-om´e-ter) 1. an instrument for measuring angles. 2. a plank that can be tilted at one end to any height, used in testing for labyrinthine disease. . Previous authors[19,20] have reported the reliability and validity of goniometric measurements of the knee. Rothstein et al,[20] in a clinical setting, found intratester reliability (r) of knee goniometric measurements to be .91 to .99. Intertester reliability was slightly lower for knee flexion (r = .88-.97) and moderately lower for knee extension (r = .63-.70). The same examiner did all preoperative, 3-month, and 6-month evaluations. All discharge evaluations were performed by a different examiner. Thus, the variability seen between the 3 treatment groups should have been minimally affected by the interobserver measurements, as one person performed all measurements at each assessment. Knee ROM measurement was done with the subject lying supine for both knee extension and flexion. The WOMAC Osteoarthritis Index, which was designed to measure disability of the osteoarthritic hip and knee, has 3 subscales: pain (5 items), function (18 items), and stiffness (2 items). Each of the 25 questions is answered using a 5-point Likert scale Likert scale A subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc . Three subscale scores are obtained by adding the items in the respective subscale. Data for reliability, internal consistency In statistics and research, internal consistency is a measure based on the correlations between different items on the same test (or the same subscale on a larger test). It measures whether several items that propose to measure the same general construct produce similar scores. , and validity have been reported in clinical trials of anti-inflammatory drugs Anti-inflammatory drugs A class of drugs that lower inflammation and that includes NSAIDs and corticosteroids. Mentioned in: Antirheumatic Drugs as well as in hip and knee arthroplasty studies.[21-23] In addition, previous researchers[24] concluded that a 10-point difference in WOMAC Osteoarthritis Index scores indicates that a clinically important difference is present. The SF-36, a 36-item genetic health measure, was used to determine overall health status. Eight dimensions were measured: bodily pain, physical function, role limitations due to physical function, general health perceptions, emotional health, role limitations due to emotional health, social function, and vitality. The validity and reliability of measurements obtained with the SF-36 have been extensively tested in this patient population.[25-28] Because a profile of 8 dimensions may be difficult to interpret when the effect varies across all dimensions, 2 summary scores were developed for the SF-36.[29] The physical component summary and the mental component summary were calculated from the 8 dimensions and were standardized using norm-based methods. Summary scores describe the overall changes but do not capture the smaller changes within the specific domains. Because there is no global score for the SF-36, results are presented for each dimension and the 2 component summary measures. Statistical Analyses Summary statistics for the 3 treatment groups were calculated for knee ROM, the WOMAC Osteoarthritis Index, and the SF-36. Active knee flexion and extension measurements were analyzed with respect to treatment group. Chi-square tests chi-square test: see statistics. were used for analysis of categorical data These are statistical procedures which can be used for the analysis of categorical data:
see analysis of variance. ANOVA Analysis of variance, see there ) was used for continuous data to determine differences among the 3 treatment groups. A repeated-measures ANOVA was used for knee ROM over the 4 measurement intervals. When differences were identified, Bonferroni post hoc post hoc adv. & adj. In or of the form of an argument in which one event is asserted to be the cause of a later event simply by virtue of having happened earlier: testing was performed to determine differences between group pairings. The WOMAC Osteoarthritis Index and SF-36 scores were transformed to scores ranging from 0 (worst) to 100 (best) to aid comparison between these scales.[30] In addition to examining statistical significance, we decided a priori a priori In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. that differences between groups on the WOMAC scale had to be a minimum of 10 points to attain a clinically significant difference.[24] A repeated-measures ANOVA was also used to analyze the WOMAC Osteoarthritis Index and SF-36 scores because these data were normally distributed. For subjects who missed the 3-month follow-up, the outcome values from their last examination and the 6-month follow-up were averaged, whereas, for those subjects who missed the 6-month follow-up, the 3-month value was imputed Attributed vicariously. In the legal sense, the term imputed is used to describe an action, fact, or quality, the knowledge of which is charged to an individual based upon the actions of another for whom the individual is responsible rather than on the individual's for the 6-month measurement. All analyses were performed on an "intent-to-treat" basis[31]; that is, all subjects were analyzed in their assigned groups. Five subjects, 4 from the control group and 1 from the SB group, were reassigned by their respective surgeons to the CPM group because of poor knee ROM. In a subgroup analysis Subgroup analysis, in the context of design and analysis of experiments, refers to looking for pattern in a subset of the subjects[1]. See also
1. , these 5 subjects did not have less ROM at discharge than the other participants. Moreover, when these subjects were compared with the other 115 participants, their baseline demographics or outcome measurements were not different. The power of the statistical analysis was calculated from the standard deviation In statistics, the average amount a number varies from the average number in a series of numbers. (statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. of the preoperative knee flexion ROM of 12 to 18 degrees.[5,10] Based on a Cohen's medium effect size of 0.30, a level of significance of .05, and a power of 80%, a sample size of 120 participants was required in order to detect a difference of 5 degrees in knee ROM among the groups. Knee ROM was chosen as the primary outcome to be examined because it is considered a hallmark of success for a TKA and has important implications for functional recovery following a TKA.[3,4] Because large effect sizes have been reported for the use of health-related quality-of-life measures in people with TKAs.[32] the power analysis based on knee ROM with only a medium effect size is more conservative than one based on the health status measures. All statistical tests were 2-tailed at a level of significance of .05. Statistical analyses were performed using the SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. software version 7.5.(*) Results Knee ROM Table 2 shows the mean active flexion and extension knee ROM over the 4 measurement intervals. All groups were similar in knee ROM when the study began. No differences in flexion or extension were seen among the 3 groups over the 6-month interval when analyzed using a 2-way ANOVA for repeated measures. Participants across all 3 groups demonstrated a similar pattern of knee ROM return during the 6 months.
Table 2.
Mean Knee Extension and Flexion (in Degrees)(a)
Control Group
Extension Flexion
Assessment
Interval [bar]X SD [bar]X SD n
PAC -5 6(b) 112 15(b) 40
Discharge -8 4 65 13 40
3 months -3 6 91 11 32
6 months -2 5 94 21 32
SB Group
Extension Flexion
Assessment
Interval [bar]X SD [bar]X SD n
PAC -8 5(b) 114 15(b) 40
Discharge -8 4 62 17 40
3 months -4 3 96 14 28
6 months -2 3 96 22 28
CPM Group
Extension Flexion
Assessment
Interval [bar]X SD [bar]X SD n
PAC -6 5(b) 115 16(b) 40
Discharge -8 4 61 14 40
3 months -4 4 94 11 33
6 months -4 4 98 13 33
(a) Two-way analysis of variance for repeated measures (F=4, df=2)
showed no difference in knee extension (P=-.30) or knee flexion
(P=.69) among the 3 groups over the 6-month measurement interval.
PAC=preadmission clinic.
(b) One-way analysis of variance showed no differences in knee
range of motion at baseline among the 3 groups (P=.86).
WOMAC Osteoarthritis Index No mean group differences were seen when the study began for pain, stiffness, and function when compared using a 1-way ANOVA. Using a 2-way ANOVA for repeated measures, no difference over time among the 3 groups was detected in any of the 3 subscales (Tab. 3).
Table 3.
Scores on Western Ontario and McMaster Universities (WOMAC)
Osteoarthritis Index by Group Over Time
PAC(a)
Control SB CPM
Group Group Group
(n=39) (n=40) (n=38)
Subscale [bar]X SD [bar]X SD [bar]X SD
Pain 51 15 46 13 47 14
Stiffness 49 18 50 22 44 15
Function 53 15 41 13 51 14
3 Months
Control SB CPM
Group Group Group
(n=34) (n=32) (n=34)
Subscale [bar]X SD [bar]X SD [bar]X SD
Pain 73 18 75 19 73 17
Stiffness 62 18 63 21 63 18
Function 72 17 72 17 73 13
6 Months
Control SB CPM
Group Group Group
(n=34) (n=32) (n=34)
Subscale [bar]X SD [bar]X SD [bar]X SD P(b)
Pain 79 16 85 15 76 15 .62
Stiffness 69 19 73 19 65 21 .38
Function 77 18 81 15 74 15 .71
(a) One-way analysis of variance showed no difference at baseline
among the 3 groups of pain (P=.20), stiffness (P=.38), or function
(P=.64).
(b) Analysis by 2-way analysis of variance for repeated measures
(F=3, df=2).
SF-36 No differences among the treatment groups were seen in any of the 8 dimensions or the component summary scores when the study began or at any of the postoperative follow-up examinations when analyzed using a 2-way ANOVA for repeated measures (Tab. 4).
Table 4.
Scores on Medical Outcomes Study 36-Item Short-Form Health
Survey (SF-36) by Group Over Time(a)
PAC(b)
Control SB CPM
Group Group Group
(n=40) (n=40) (n=39)
Dimension [bar]X SD [bar]X SD [bar]X SD
Bodily pain 35 16 37 15 35 13
Physical functioning 31 22 31 19 31 15
Role physical 16 30 26 38 18 30
General health 73 23 75 17 73 17
Mental health 72 24 75 20 74 20
Role emotional 73 42 62 46 62 44
Social function 59 27 68 26 67 26
Vitality 49 25 50 21 45 20
PCS 29 8 30 7 29 6
MCS 53 12 53 13 53 13
3 Months
Control SB CPM
Group Group Group
(n=34) (n=32) (n=36)
Dimension [bar]X SD [bar]X SD [bar]X SD
Bodily pain 55 22 49 20 56 18
Physical functioning 45 20 45 21 46 18
Role physical 28 41 36 41 19 26
General health 69 19 68 19 69 21
Mental health 74 19 78 18 79 17
Role emotional 81 34 61 38 68 41
Social function 69 24 71 25 75 23
Vitality 56 17 59 19 53 20
PCS 34 9 35 9 34 7
MCS 55 9 53 11 54 10
6 Months
Control SB CPM
Group Group Group
(n=34) (n=32) (n=36)
Dimension [bar]X SD [bar]X SD [bar]X SD P(c)
Bodily pain 64 22 59 21 57 19 .80
Physical functioning 55 27 53 24 46 20 .79
Role physical 43 40 51 43 40 40 .12
General health 70 22 72 18 73 21 .94
Mental health 79 19 79 20 83 13 .71
Role emotional 84 32 86 31 73 39 .13
Social function 79 25 79 28 81 22 .53
Vitality 59 21 65 19 60 18 .33
PCS 38 10 38 10 36 10 .59
MCS 56 9 57 10 57 8 .99
(a) PCS=physical component summary, MCS=mental component summary.
(b) One-way analysis of variance showed no difference at baseline
among the 3 groups in any of the 8 dimensions or the summary scores
(P>.05).
(c) Analysis by 2-way analysis of variance for repeated measures
(F=3, df=2).
Discussion Our study was the first randomized controlled trial to compare the effectiveness of CPM and SB therapy added to routine SE in patients who received a TKA. Our findings suggest that the addition of either CPM or the SB to daily SE sessions is not warranted in the postoperative rehabilitation after a TKA when an early postoperative rehabilitation regimen is followed. Subjects who received daily SE sessions (ie, the control group) attained similar knee movement and reported similar pain, function, and health-related quality of life outcomes at 3 and 6 months as those subjects who received the CPM or SB. These findings agree with those of previous studies of long-term follow-up to CPM use for rehabilitation after a TKA.[9-12,14-18] The knee ROM attained in all 3 treatment groups at 3 and 6 months was similar to that found in other studies.[9,12,14] Researchers who have reported favorable knee ROM with the use of CPM had protocols that required longer daily use and longer average hospital stays than we did.[5,6,10,12,14] In our study, use of the CPM was within the recommended length of time for attaining treatment benefits of 3 to 5 hours per day.[16] Although some researchers instituted CPM immediately after the operation, we did not use the CPM until the second day after surgery. The use of CPM immediately after the operation was not possible at our facility because the mobilization regimen we use is designed to encourage mobility rather than bed rest. Because there were no differences among the treatment groups in terms of outcomes, we question the use of the CPM machines. We selected the SB as an adjunct therapy because it was thought to provide similar results to the CPM and yet permit the subject to perform the therapy independently. Although knee ROM at time of hospital discharge was less than that found in other studies, we had reached an expected level of knee ROM at 3 and 6 months after the operation. Complication rates were no different among the 3 treatment groups. Twenty subjects experienced in-hospital complications, with 14 of these complications directly related to the knee joint that was replaced. Four complications were reported within the CPM group (1 hematoma hematoma /he·ma·to·ma/ (he?mah-to´mah) a localized collection of extravasated blood, usually clotted, in an organ, space, or tissue. , 1 erythema erythema (ĕr'əthē`mə), more or less diffuse redness of the skin due to concentration of an abnormally large amount of blood within the small vessels of the skin (hyperemia), as in burns. [hot, red, swollen knee], and 2 cases of increased knee joint swelling [warm, swollen knee]), 6 within the SB group (4 distal deep venous thromboses, 1 hematoma, and 1 mild infection), and 4 within the control group (2 cases of increased hemovac drainage, 1 hematoma, and 1 mild infection). The remaining 6 complications were cardiovascular complications (4), postoperative confusion (1), and a pulmonary embolism Pulmonary Embolism Definition Pulmonary embolism is an obstruction of a blood vessel in the lungs, usually due to a blood clot, which blocks a coronary artery. (1). Within 6 months after hospital discharge, 5 patients reported complications directly related to the knee joint replacement. Two subjects, one from the SB group and one from the CPM group, required manipulation of the knee because of limited knee flexion at 3 months after the operation. One subject from the SB group had a deep venous thrombosis deep venous thrombosis n. Abbr. DVT A condition in which one or more thrombi form in a deep vein, especially in the leg or pelvis, resulting in an increased risk of pulmonary embolism. that required anticoagulation therapy. The control group had one subject with cellulitis Cellulitis Definition Cellulitis is a spreading bacterial infection just below the skin surface. It is most commonly caused by Streptococcus pyogenes or Staphylococcus aureus. of the knee and one subject with an infection managed by oral antibiotics. Although other authors have suggested that not using CPM may result in poor knee flexion and subsequent need for interventions such as manipulations under anesthesia,[10,12] our findings did not support this assertion. Although only the SB group reported distal deep venous thromboses, this rate is usual in patients receiving TKAs, even with routine use of anticoagulation therapy.[33] A primary limitation of our study was that all subjects, regardless of the group, received one session of approximately 15 minutes of SB use during their daily exercise session. It is unlikely, however, that one daily session would have had a meaningful effect on a subject's recovery of knee ROM. We believed that any benefits that were due to the use of the SB as an adjunct therapy within the subject's room were likely masked by the overall effect of a postoperative mobilization regimen that encourages knee active ROM during activities of daily living. A high proportion of subjects, regardless of adjunct CPM or SB use, reported pain relief (96%) and functional gains (82%) at 6 months. It is likely this patient cohort was representative of this patient population, as our findings are similar to the large gains found in previous hospital and community-based cohort studies A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design. In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute of patients receiving a TKA.[34,35] The results are also congruent con·gru·ent adj. 1. Corresponding; congruous. 2. Mathematics a. Coinciding exactly when superimposed: congruent triangles. b. with the results reported in a meta-analysis of smaller studies examining TKA.[36] Favorable outcomes reported in the systematic review of 130 studies occurred in approximately 90% of patients. Conclusion Findings from our study showed that subjects who received CPM, SB therapy, or SE did not differ in terms of knee flexion at the time of hospital discharge or at 3 and 6 months after the operation. Self-reported pain, function, or overall quality of life was also not different at either of the postoperative measurement times. Those patients who receive a TKA typically have improvements in knee ROM, pain, function, and overall quality of life after surgery regardless of receiving CPM or SB therapy as an adjunct to daily SE sessions. Our study did not support our a priori hypotheses, because the adjunct ROM therapies did not alter the postoperative recovery of knee ROM. We believe that it is difficult to justify the use of adjunct ROM therapy in addition to daily SE sessions when early mobilization regimens are being followed. As hospital stays are shortened, the rehabilitation of patients with TKA is directed toward preparing for discharge. For the physical therapist, we believe that the rehabilitation for patients recovering from a TKA should emphasize active knee movement rather than passive therapy to promote functional independence from the time of treatment initiation. (*) SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611. References [1] Finch E, Walsh M, Thomas SG, Woodhouse SJ. Functional ability perceived by individuals following total knee arthroplasty compared to age-matched individuals without knee disability. J Orthop Sports Phys Ther. 1998;27:255-263. [2] Walsh M, Woodhouse SJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998;78: 248-258. [3] Papagelopoulos PJ, Sim FH. Limited range of motion after total knee arthroplasty: etiology, treatment, and prognosis. Orthopedics. 1997;20: 1061-1065. [4] Ritter rit·ter n. pl. ritter A knight. [German, from Middle High German riter, from Middle Dutch ridder, from r MA, Campbell ED Campbell, city, United States Campbell, city (1990 pop. 36,048), Santa Clara co., W Calif., in the fertile Santa Clara valley; founded 1885, inc. 1952. . Effect of range of motion on the success of a total knee arthroplasty. J Arthroplasty. 1987;2:95-97. [5] Johnson DP, Eastwood DM. Beneficial effects of continuous passive motion after total condylar con·dy·lar adj. Relating to a condyle. condylar (kän´dilur), adj pertaining to the mandibular condyle. condylar axis, n See axis, condylar. knee arthroplasty. Ann R Coll Surg Engl. 1992;74:412-416. [6] Romness DW, Rand JA. The role of continuous passive motion following total knee arthroplasty. Clin Orthop. 1988;226:34-37. [7] Coutts RD, Kaita J, Barr R, et al. The role of continuous passive motion in the post-operative rehabilitation of the total knee patient. Orthopaedic Translations. 1982;6:277-278. [8] Jordan LR, Siegal JL, Olivo JL. Early flexion routine: an alternative method of continuous passive motion. Clin Orthop. 1995;315:231-233. [9] Ververeli PA, Sutton DC, Hearn SL, et al. Continuous passive motion after total knee arthroplasty: analysis of cost and benefits. Clin Orthop. 1995;321:208-215. [10] Johnson DP. The effect of continuous passive motion on wound healing wound healing Physiology The repair of a wound Steps Inflammation, repair and closure, remodeling, final healing; repair of incisions may be either simple–'clean' wounds with little loss of tissue heal by 'primary intention', or 'dirty' wounds heal by and joint mobility after knee arthroplasty. J Bone Joint Surg Am. 1990;72:421-426. [11] McInnes J, Larson MG, Daltroy LH, et al. A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. JAMA JAMA abbr. Journal of the American Medical Association . 1992;268:1423-1428. [12] Pope RO, Corocoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty: does it offer any benefits? J Bone Joint Surg Br. 1997;79:914-917. [13] Nadler SF, Malanga Noun 1. malanga - tropical American aroid having edible tubers that are cooked and eaten like yams or potatoes spoonflower, tannia, Xanthosoma atrovirens, Xanthosoma sagittifolium, yautia GA, Zimmerman JR. Continuous passive motion in the rehabilitation setting: a retrospective study retrospective study, a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. . Am J Phys Med Rehabil. 1993;72:162-165. [14] Colwell CW Jr, Morris BA. The influence of continuous passive motion on the results of total knee arthroplasty. Clin Orthop. 1992;276:225-228. [15] Chiarello CM, Gundersen L, O'Halloran T. The effect of continuous passive motion duration and increment To add a number to another number. Incrementing a counter means adding 1 to its current value. on range of motion in total knee arthroplasty patients. J Orthop Sports Phys Ther. 1997;25:119-127. [16] Kumar PJ, McPherson EJ, Dorr LD, et al. Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques. Clin Orthop. 1996;331:93-101. [17] Maloney WJ, Schurman DJ, Hangen D, et al. The influence of continuous passive motion on outcome in total knee arthroplasty. Clin Orthop. 1990;256:162-168. [18] Ryu Ryū (竜 or りゅう or リュウ Ryū J, Saito S Saitō (usually 斉藤 or 斎藤, but other forms are common) is the seventeenth most common Japanese surname. [1] (.XLS file) People named Saitō include:
[19] Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of goniometric measurements at the knee. Phys Ther. 1987;67:192-195. [20] Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a clinical setting: elbow and knee measurements. Phys Ther. 1983;63: 1611-1615. [21] Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes following total hip or knee arthroplasty in osteoarthritis. J Orthop Rheum rheum (rldbomacm) any watery or catarrhal discharge. rheum n. A watery or thin mucous discharge from the eyes or nose. rheum any watery or catarrhal discharge. . 1988;1:95-108. [22] Stucki G, Sangha sangha: see Buddhism. sangha Buddhist monastic order, traditionally composed of four groups: monks, nuns, laymen, and laywomen. Established by the Buddha, it is the world's oldest body of celibate clerics. O, Stucki S, et al. Comparison of the WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index and a self-report format of the self-administered Lequesne-Algofunctional Index in patients with knee and hip osteoarthritis. Osteoarthritis Cartilage. 1998;6:79-86. [23] Barr S, Bellamy N, Buchanan WW, et al. A comparative study of signal versus aggregate methods of outcome measurement based on the WOMAC Osteoarthritis Index. J Rheumatol. 1994;21:2106-2112. [24] Takeda W, Wessel J. Acupuncture acupuncture (ăk`y  pŭng'chər), technique of traditional Chinese medicine, in which a number of very fine metal needles are inserted into the skin at specially designated points. for the treatment of pain of
osteoarthritic knees. Arthritis Care Arthritis Care is the UK's largest charity dedicated to supporting people with arthritis. The organisation is staffed and led by people who also have arthritis. It provides information and support on a range of issues related to living with arthritis. Res. 1994;7:118-122.[25] Parker SG, Peet SM, Jagger jag 1 n. 1. A sharp projection; a barb. 2. a. A hanging flap along the edge of a garment. b. A slash or slit in a garment exposing material of a different color. tr.v. C, et al. Measuring health status in older patients: the SF-36 in practice. Age Ageing. 1998;27:13-18. [26] Stucki G, Liang MH, Phillips C, Katz JN. The Short Form-36 is preferable to the SIP as a generic health status measurement in patients undergoing elective total hip arthroplasty total hip arthroplasty, n total hip replacement; surgical reconstruction of the hip in which the ball-and-socket joint is replaced with a prosthesis. . Arthritis Care Res. 1995;8:174-181. [27] Hayes V, Morris J, Wolfe c, Morgan M. The SF-36 health survey SF-36 Health Survey, n.pr a widely used, valid, and standardized questionnaire used to measure an individual's overall subjective health status. The eight concepts measured by the survey are body pain, general mental health, perception of general health, questionnaire: is it suitable for use with older adults? Age Ageing. 1995;24:120 -125. [28] Lyons RA, Perry HM, Littlepage BN. Evidence for the validity of the Short-Form 36 Questionnaire (SF-36) in an elderly population. Age Ageing. 1994;23:182-184. [29] Ware JE Jr, Kosinski M, Bayliss MS, et al. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33(Suppl 4):AS264-AS279. [30] Bombardier C, Melfi CA, Paul J, et al. Comparison of a generic and a disease-specific measure of pain and physical function after knee replacement surgery. Med Care. 1995;33(suppl 4):AS131-AS144. [31] Heinreken CH, Buring JE. Epidemiology in Medicine. Boston, Mass: SL Mayrent; 1987:207. [32] Jones CA, Volklander DC, Johnston DWC DWC Division of Workers Compensation (California) DWC Daniel Webster College DWC Dubai Women's College (Dubai, United Arab Emirates) DWC Department of Workers Compensation DWC Divine Word College , Suarez-Almazor ME. Health-related quality-of-life outcomes after total hip and knee arthroplasties in a community-based population. J Rheumatol. 2000; 27:1745-1753. [33] Lynch AF, Bourne Bourne, town (1990 pop. 16,064), Barnstable co., SE Mass., crossed by Cape Cod Canal; settled 1627, inc. 1884. Bourne Bridge (1935), across the canal, made the town an entry point to Cape Cod and a resort and commercial center. RB, Rorabeck CH, et al. Deep-vein thrombosis deep-vein thrombosis Noun a blood clot in one of the major veins, usually in the legs or pelvis deep-vein thrombosis n → trombosi f inv venosa profonda and continuous passive motion after total knee arthroplasty. J Bone Joint Surg Am. 1988;70:11-14. [34] Bayley KB, London MR, Grunkemeier GL, Lansky DJ. Measuring the success of treatment in patient terms. Med Care. 1995;33(suppl 4): AS226-AS235. [35] Williams JI, Llewellyn Thomas Llewellyn Hilleth Thomas (31 October 1903- 20 April 1992) was an Anglo-American physicist and applied mathematician. He is best known for his contributions to atomic physics, in particular: [36] Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tricompartmental total knee replacement: a meta-analysis. JAMA. 1994;271:1349-1357. LA Beaupre, MSc (PT), CPTA CPTA California Physical Therapy Association CPTA Canadian Property Tax Association CPTA Council of Professional Teaching Associations CPTA Center for Practice and Technology Assessment (AHRQ) CPTA Canadian Paper Trade Association , MCPA MCPA, MCP 2-methyl-4-chlorophenoxyacetic acid; a weedkiller reported to be nontoxic at the levels likely to be encountered on pasture, though it has killed cattle dosed experimentally with large single doses. , is Orthopaedic Research Coordinator, University of Alberta Hospitals, Orthopaedic Research, 8440-112 St, Edmonton, Alberta, Canada T6G 2B7 (lbeaupre@cha.ab.ca). Address all correspondence to Ms Beaupre. DM Davies, MSc(PT), CPTA, MCPA, is an orthopaedic research associate at University of Alberta Hospitals. CA Jones, PT, PhD, CPTA, MCPA, is an epidemiologist and a postdoctoral post·doc·tor·al also post·doc·tor·ate adj. Of, relating to, or engaged in academic study beyond the level of a doctoral degree. Noun 1. fellow, Faculty of Pharmacy, University of Alberta. JG Cinats, MD, FRCS FRCS Fellow of the Royal College of Surgeons. FRCS abbr. Fellow of the Royal College of Surgeons (C), is Section Leader (Orthopaedics), Capital Health Regional Health Authority, and an orthopaedic surgeon at University of Alberta Hospitals. All authors provided writing. Ms Beaupre, Ms Davies, and Maria E Suarez-Almazor, MD, PhD, provided concept/research design. Ms Beaupre and Karin E Greaves greaves cracklings, an edible raw fat from the meat trade. The skimmings from the preparation of this fat are also called greaves. They represent a low grade of meat meal. , BPT BPT Bridgeport (Connecticut) BPT Best Practicable Control Technology BPT Best Practicable Control Technology Currently Available BPT BP Prudhoe Bay Royalty Trust (stock symbol) BPT Boston Playwrights' Theatre , provided data collection, and Ms Beaupre and Dr Jones provided data analysis. Ms Beaupre and Dr Cinats provided project management. Ms Beaupre, Ms Davies, and Dr Cinats provided fund procurement. Dr Cinats provided subjects, facilities, and institutional liaisons. Lori N Schaump provided clerical support. Ms Davies and Dr Cinats provided consultation (including review of manuscript before submission). This study was approved by the Biomedical Research Biomedical research (or experimental medicine), in general simply known as medical research, is the basic research or applied research conducted to aid the body of knowledge in the field of medicine. Ethics Panel Noun 1. ethics panel - a committee appointed to consider ethical issues ethics committee commission, committee - a special group delegated to consider some matter; "a committee is a group that keeps minutes and loses hours" - Milton Berle from University of Alberta, Capital Health Regional Health Authority, and Caritas Health Group. This project was funded by a grant from the Health Services Research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and Innovation Fund, a branch of the Alberta Heritage Foundation for Medical Research. The results of this study were presented at the Canadian Orthopaedic Association Annual Meeting, June 1999, and at the American College American College is the name of:
rheu·ma·tol·o·gy n. Annual Scientific Meeting, November 1999. This article was submitted November 19, 1999, and was accepted October 18, 2000. |
|
||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion