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ComprehensiveCareforJointReplacement(CJR)WPTAFallConference2016TiffanyHoudek,PT,OCS
RichIllgen,MDKipSchick,PT,DPT,MBA
Today’sAgenda
• CJROverview– KipSchick,PT,DPT,MBA• InnovationsinTotalJointReplacementSurgery– RichIllgen,MD
• ConsiderationswithPhysicalTherapistPractice– TiffanyHoudek,PT,OCS
LearningObjectives• Attendeeswillbeableto:
– ExplainthecoreelementsofCJR,includingtherationaleforCJRimplementation,thediagnosesincluded,themethodologyusedforCMSpaymentandadjustments,utilizationofqualitymetrics,andpartnershipconsideration
– Recognizeandunderstandhowhealthcarelawchangesmayaffectreferralpatternstophysicaltherapistpractice.
– Summarizethechallengesandopportunitiesintherehabilitationofpatientswithtotaljointreplacementsurgeryacrossthecontinuumofcareandtheutilizationofmultiplemodelsofcare.
LearningObjectives
• Attendeeswillbeableto:– Describenewsurgicaltechniquesandlistsurgicalconsiderationsthatimpactpatientoutcomesanditsimportanttophysicaltherapistpractice
– Applycurrentresearchtophysicaltherapistpracticeintheareaofpre-habilitation
– ExplaincurrenttreatmentconceptsasacomponentofphysicaltherapistpracticeandhowthisimpactshospitalsandotherstakeholdersparticipatinginCJR
– DiscussoutcomeparametersemphasizedbyCMS
CJR– What,Why,andRelevance
• CMS:“TheComprehensiveCareforJointReplacement(CJR)modelaimstosupportbetterandmoreefficientcareforbeneficiariesundergoingthemostcommoninpatientsurgeriesforMedicarebeneficiaries:hipandkneereplacements(alsocalledlowerextremityjointreplacementsorLEJR).Thismodeltestsbundledpaymentandqualitymeasurementforanepisodeofcareassociatedwithhipandkneereplacementstoencouragehospitals,physicians,andpost-acutecareproviderstoworktogethertoimprovethequalityandcoordinationofcarefromtheinitialhospitalizationthroughrecovery.”
CJR– What,Why,andRelevance
• CMS:“ThisalternativepaymentmodelwillcontributetotheMedicaregoalssetbytheAdministrationofhaving30percentofallMedicarefee-for-servicepaymentsmadeviaalternativepaymentmodelsby2016and50percentby2018.EffectiveimplementationoftheCJRmodelwillimprovethequalityandefficiencyofcareforMedicarebeneficiaries,whichisessentialtocreatingahealthcaresystemthatdeliversbettercare,spendsourdollarsmorewisely,andleadstohealthierAmericans.”
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CJR– What,Why,andRelevance
• AdditionalCMSPaymentTransitions:– 85%ofFFSpaymenttiedtooutcomemeasuresbytheendof2016
– 75%ofpaymentswillbevaluebasedby2020
• QualityData:– 85%ofFFSpaymenttiedtooutcomemeasuresbytheendof2016
– 75%ofpaymentswillbevaluebasedby2020
CJR– What,Why,andRelevance• AuthorizedbytheAffordableCareAct• FinalRulepublishedbyCMSonNovember16,2015
• Whyfocusontotaljointreplacements?MostcommoninpatientadmissionforMedicarebeneficiaries
• In2014,utilizationintheUSandWIincludedand486Kand10Kdischarges,respectivelytotalingmorethan$7Band$122M,respectively
• Despitefrequencyandcost,qualityvariancealsohigh
CJR– What,Why,andRelevance
• Rateofcomplicationslikeinfectionorimplantfailurecanbe3timeshigheratsomefacilities
• Averagecostperprocedureranges$16,500-$33,000(surgery,hospitalization,andrecovery)
• Impacts791hospitalsin67geographicareas(calledMetropolitanServiceAreas- MSAs)
• MSAsincludecountieswithmorethan50,000inpopulationandacoreurbanarea
• Wisconsinhas2MSAs:MadisonandMilwaukee
CJR– What,Why,andRelevance• MadisonMSAcounties:Dane,Columbia,Iowa,andGreene
– Participatinghospitals:MonroeClinic,DivineSavior,St.Mary’s,UWHospital
• MilwaukeeMSAcounties:Milwaukee,Ozaukee,Washington,andWaukesha– Participatinghospitals:WaukeshaMemorial,ColumbiaSt.Mary’s(Milwaukee,Ozaukee),Aurora(WashingtonCounty,St.Luke’s,WestAllis),OconomowocMemorial,St.Joseph’sWestBend,WheatonFranciscan(St.Francis,St.Joseph,Franklin),CommunityMemorial,Froedtert,OrthopedicHospitalofWI,ColumbiaCenter,MidwestOrthopedicSpecialtyHospital
CJR– What,Why,andRelevance• HospitalsaccountableforFeeforService(FFS)PartAandB
costsofsurgery,hospitaladmission,andcarefor90dayspost-dischargefromtheacutecarehospitaladmission(includesrelatedreadmissions)
• IncludesadmittingDRGs469and470• CMSsetsepisodedefinedtargetpricesforhospitals–
includesinpatientcostsandaveragepostacutecarefor90daysfollowingacutecaredischarge(year1is2/3hospitalspecific,1/3regionalandbyyear4is100%regional)
• CMSincludesexclusionsforreadmissionandPartBcareforunrelatedconditions
• CJRisa5yearpilot;yearstartedApril1,2016,andallfollowingyearsfollowthecalendaryearwithCJRprogramendingDecember31,2020
CJR– Specifics• CMSusedpastdatatodevelopatargetpricethatis
uniquetoeachindividualhospitalandincludesadiscount(i.e.savingstoCMS)
• AllprovidersandsuppliersarepaidundertheusualCMSpaymentsystemrulesandprocedures
• Attheendofamodelperformanceyear,actualspendingfortheepisode(totalexpendituresforrelatedservicesunderMedicarePartsAandB)iscomparedtotheMedicaretargetepisodepriceforeachhospital.
• Dependingontheparticipanthospital’squalityandepisodespendingperformance,thehospitalmayreceiveanadditionalpaymentfromMedicareorberequiredtorepayMedicareforaportionoftheepisodespending.
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CJR– Specifics
• Hospitalsareallowedtoenterintofinancialrelationshipswithcollaboratorsinordertoshareriskandsavings;assuch,thesecollaboratorsareincentivizedtoincreasequalityanddecreasecost
• CollaboratorsincludeInpatientRehabilitationHospitals,SNF,HomeHealth,Long-TermHospitals,physiciangrouppractices,andphysiciansandnon-physicianproviders(i.e.physicaltherapists)
CJR– Specifics
• RequiredQualityMeasures– NQF#1550(complicationrate)– HCAHPSSurvey– HLMR(HCAHPSLinearMeanRoll-Up),whichsummarizesperformanceacross11publiclyreportedHCAHPSmeasures
• VoluntaryQualityMeasures– PatientReportedOutcomes– pre-operative(90to0dayspriortotheTHA/TKAProcedure);post-operative(measured275to365daysaftertheTHA/TKAprocedure)
CJR– Specifics
• Pre-operativePROs– HospitalsneedtosubmittheVR-12OR PROMIS-Global;AND
– HOOS/KOOSJr.OR HOOS/KOOSsubscales;AND– OswestryIndexQuestion;AND– DataCollectionInformation;AND– PatientDemographics;AND– BMI,pre-operativeuseofnarcotics,pain,literacy.
• Post-operativePROs– Sameasaboveexceptlasttwosub-bulletpointslistedunderpre-operativePROs
CJR– Specifics
• QualityScore– Complicationmeasure: 50%– HCAHPSSurveyMeasure: 40%– PatientReportedOutcomes: 10%
• ReconciliationPayments– PaymentsthatCMSwillpayparticipatinghospitalsbasedontheirexpensescomparedtotheirtargetpriceandasufficientqualityscore(increasesmoneypaidbackordecreasestheamount
CJR– Specifics
• IncentivepaymentsfromCMStohospitalsbeginsyear1
• PenaltypaymentsfromhospitalstoCMSbegininyear2(2017)andarefullyimplementedinyear3(2018)
• Incentivesandpenaltieshaveasetstoplossandstopgain
PhysicalTherapyConsiderations• Cost(basedonCMSpayment,notgrosschargesbytheprovider)– Measure– Track
• Quality– UseofPROinstrumentsfortheCJRprogram– EvidenceBasedPractice– Standardizepost-operativeprotocolsthroughcarere-designandcollaborationwithhospitalsandphysicians
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PhysicalTherapyConsiderations• “Collaborator”Designation
– Inordertoshareinrisk/rewardwithahospital,anon-physicianprovider(physicaltherapist)“mustenterintoasharingarrangementbeforecareisfurnishedtoCJRbeneficiariesunderthetermsofthesharingarrangement.”
– Thetotalamountofagainsharingpaymentforacalendaryearpaidtoanindividualphysicianornon-physicianpractitionerwhoisaCJRcollaboratormustnotexceed50percentofthetotalMedicareapprovedamountsunderthePhysicianFeeSchedule(PFS)
CJR– ProposedChanges
• AllowACOs,hospitals,andCAHstobeCJRcollaborators
• Eliminatetheterm“collaboratoragreements”andreplacewith“sharingarrangements”
• Usetheterm“CJRactivities”toidentifyactivitiesthatparticipanthospitalsandtheircollaboratorsundertaketopromoteaccountabilityforquality,cost,andoverallcare”
• Consolidaterequirementsforaccesstorecordsandretentionandapplythemmorebroadly.
• Changestoreconciliationandstop-loss/stop-gain
CJR– ProposedChanges
• RemovebeneficiariesfromCJRifpartofanextgenerationACOorERSD
• Changestouseofqualitymeasuresandthecompositequalityscore
• Ensurebeneficiarynotification• NochangestotheSNF3daywaiverbutaddedprotection“toprotectbeneficiariesfromfinancialliabilityincasesofmisuseofthewaiver.”
• AdvancedAPMparticipation• CommentperiodendedOctober2,2016
SLIDETRANSITIONTORICHILLGEN,MD
HipandKneeJointReplacement:Indications,Technique,and
Rehabilitation
RichardIllgenII,MDDirectorofJointReplacementProgram
TheUniversityofWisconsinDepartmentofOrthopedicSurgery
HipDJD• Pathophysiologyofosteoarthritisofthehip– History– PE– Radiographicfindings
• Contrastclinicalfindings:– Spinalstenosis– HipDJD– Vascularclaudication
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HipDJD• CausesofHipArthritis
– Developmental• Developmentaldysplasia• PerthesDisease• SlippedCapitalFemoralEpiphysis• Femoral-acetabularimpingement(FAI)
– Traumatic- dislocations,fractures– Infectious– Inflammatory(i.e.,RA)– Idiopathic
ClinicalAssessment
• History– Groinpain– Difficultyonstairs,tyingshoes,clippingtoe-nails– Limpingcommon– Useofassistdevices(i.e.,cane)– Analgesics– Affectsqualityoflife/activitylevel
ClinicalAssessment
• PE– RestrictedandpainfulhipROM(especiallyIR)– Weakhipabductors
• Muscletesting- Trendelenburgtest• Gaitassessment- Trendelenburggait
– AssessLimblengthdiscrepancy
InternalRotation
TrendelenburgTest TrendelenburgGait
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RadiographicAssessment
• ClassicX-rayfindings– Lossofjointspace– Osteophytes– Cysts– Sclerosis
CommonDifferentialDiagnosis
• Backpainvs.Hippainvs.Vascularproblem• Locationofpain
– Hip- groin– Back- lowback/buttock– Vascularclaudication- calf
• PainRadiation– Hip- rare- sometimestotheknee– Back- frequentlyradicularpainbelowtheknee
CommonDifferentialDiagnosis
• Hippain- limp,difficultytyingshoes• Back- betterwithbackflexion(walkingwithgrocerycart)
• Vascular- calfpainafterspecificdistancewalked,relievedwithrest
CommonDifferentialDiagnosis
• PE– Hip- restrictedROMandreproducesgroinpain– Back- neurologicfindings,positiveSLR,restrictedspineROM
– Vascular- abnormalpulses,lossofhaironlegs• X-rays- Hipandspine,A/PAND LAT• WhenHistory,PE,andX-raysequivocal- hipanesthetic
arthrogram• Ifvascularcausesuspected- ankle-brachialindex-ABI
TreatmentHipOA• Non-operative- NSAIDs,PT,weightreduction,activitymodification,assist
device• Operative
– Jointsparing• Osteotomy- OA• Coredecompression- AVN
• HipArthroscopy– Reconstructiveprocedures
• THA– Salvage
• Fusion
• Resectionarthroplasty
PrinciplesandLimitationsofTHA
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THATHA
THA
ChangesinPatientDemographicsandExpectations
• TraditionalTHA- Age>65,lowdemand
ChangesinPatientDemographicsandexpectations
Increasedpercentageyoungerpatients,increaseddemands,higherexpectations
THA• OptimaltreatmentofhipDJD
– THA• MostfrequentlyperformedprocedureforhipOA
• 400,000/yrinU.S.• Usedinyoungandold• Somelimitations- wear,dislocation,needforrevisioninyoungpatients
Complications
• Dislocation• LimbLengthInequality• DVT/PE• Infection• Fracture• Bleeding• Pneumonia• Cardiac
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THA:Limitations
Osteolysis:Boneloss
Loosening
Fracture
THA
• Safereliableoperation• Improvedqualityoflifeformillionsofpatientsoverthelast40years
• Cost-effective• Limitations- Relatedtopatientselection(obesity,co-morbidconditions)andsurgicalaccuracy– PossibleRoleforComputerGuidanceandRoboticAssistance
Rehabilitation
• Significantchangesinlast10years– Shorterlengthofhospitalstay- often1day– GreaterPercentagedischargehomeandavoidNH
– AcceleratedPTprotocols– Shifttoselfdirectedrecoveryatearliertimepoints
– ImpactofComprehensiveCareforJointReplacement(CJR)- bundledpayment- 90daysofcare
Technique:
• Anteriorvs.PosteriorApproach• Roboticvs.ManualTHA
Technique• Anteriorvs.PosteriorApproach
– Similarrateofrecovery– Controversialdifferentialratesofdislocation(1-4%)– Acceleratedrehabilitationprotocolsaffectedbymanyvariables
• Patientage• Co-Morbidity• Pre-operativeeducationandexpectations
• Mostimportantpredictorofoutcomes– HospitalandSurgeonVolume(experience)
Technique
• mTHAvs.rTHA
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ManualTHATechniques:InaccurateandCostly
• 400,000ManualTHA/yearinU.S.• Dislocation:
– Medicarepatients- 4%dislocatewithin2yearsManley,JArthro2010
– MostcommoncauseforearlyTHArevisionFerhing,CORR2006
• Poorimplantplacement– Contributessignificantlytodislocationrisk– Directlyundersurgeoncontrol
ManualTHATechniques:InaccurateandCostly
• Earlydislocationincreasedcostby350%- dePalma,et.al.,HipInternational2012
• Effortstoreducedislocationrateswouldhavesignificantadvantages:– Patient- QualityofLife- Dislocationisadisablingproblemandoftenrequiresadditionalsurgery
– Healthcaresystem- Dislocationsarecostly
TraditionalmTHA– HowaccurateismTHA?Wines,JArthroplasty2006;DorrCORR
2009,DiGioiaCORR1998,HassanJArthro1998,JollesCORR2004
– Acetabulum:• Outsidetargetzone50%
• Femur:• Outsidetargetzone20-30%
• Wecanandshoulddobetter– Needmoreaccurateandreproduciblemethodthantraditionaltechniques
ManualTHA:MGHExperience• AcetabularcomponentInsidetargetrange-– Highvolumesurgeons-50%
– Lowvolumesurgeons-35%
– WorsewithMISandobesity
BetterExecution:mTHAvs.rTHA
RoboticTHA- Safe andAccurateCupReaming
•VisualFeedback– Green/White/Red
•TactileFeedback– HapticStiffness(0.5mm)
•AudibleFeedback– Beeping(0.5mm)
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RoboticTHA- Safe andAccurateCupImpaction
Robot locks in trajectory to achieve accurate component position
rTHA:MoreAccurateandReproducibleResults
Virtual X-ray- Pre-opPlan Recoveryroomreal postopX-ray
•Summary page can be recorded in EMR
EvidencetosupportrTHA
• Accuracy:rTHAvs.mTHA
• ClinicalOutcomes: rTHAvs.mTHA
rTHAvs.mTHA:MulticenterstudyMGH,UniversityofWisconsin,HSSManualTHA:N=188347%insidetargetzone
RoboticTHA: N=11996%insidetargetZone95%within4degreesofplan
rTHAvsmTHA:SingleSurgeonDataAMatched-PairStudy- Dr. Domb- CORR2013
• rTHA(N=50)vs.mTHA(N=50),X-rayanalysis(HAS)• rTHAvs.mTHA- 100% vs.80%inLewinnek“SafeZone”
59
ConventionalTHA RoboticassistedTHA
mTHAvs.rTHA:SingleSurgeon- UniversityofWisconsin
• Fellowshiptrainedarthroplastysurgeon(Illgen)– N=300
• 1st 100mTHAinclinicalpractice(year2000)• Last100mTHAperformedpriortorTHA(year2011)• 1st 100consecutiverTHA(year2012)
– Followupintervalminimum1year• Outcomes-
– Radiographic- Acetabularcomponentposition– Clinical- Infection,ORtime,EBL,Dislocation,LLD– PROM- SF-12,WOMAC,KneeSocietyScore,andUCLAActivityScores
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UWrTHAstudy rTHAvs.mTHA:ClinicalOutcomes:UniversityofWisconsin
Cases ORtime in“safezone” Dislocation EBL(cc)
LLD>15mm
1st manual100(2000) 160min 35% 5% 533 9%
Last manual100(2011) 129min 48% 3% 437 1%
1st robotic100(2012) 143min76%- X-ray96%- CT-Robot
0% 357 1%
mTHAvsrTHA:HHS mTHAvsrTHA:UCLAat1year
Summary
• THAisasafe,reliable,anddurableprocedurefortreatmentofhipDJDthathasnotrespondedtonon-operativecare
• Rehabilitationprotocolswellestablished– Rateofrecoverysignificantlyimprovedinlast10years– Morepatientsdirectlyhome,fewertoNH– MorechangescomingwithCJR(CMS)
• Recentinnovationsinvolvingrobotics- promisingearlyresultsregardingaccuracyandoutcome
EvaluationandManagementofKneeDJD
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UnicompartmentalKneeDJD
Overview
• Kneeosteoarthritis– ~800,000TKAannually
• Demandingpatients• Highexpectations
Prevalence
• Frequencyofclinicallyrelevantkneearthritis– 2%>17yo– 10%>65yo– F>Minoldergroup
• Medialcompartment10Xmorecommonthanlateral
EtiologyofArthritis
• Etiologyofarthritis– Post-traumatic– Anatomicalignment
• Varus
• Valgus
– Inflammatory– Idiopathic
UnicompartmentalArthritis
• SeveralOptionsexist– Non-operative– JointPreservation
• HTO• Arthroscopy• Biologics
– Arthroplasty• Unicompartmentalarthroplasty• Totalkneearthroplasty
ConservativeCare• Initialtreatmentinallpatients
– NSAIDs– PT– Weightloss– Bracing– Steroids– Glucosaminechondroitin– Viscosupplementation
• Injections(steroidandviscosupplementation)notrecommendedbyAAOSforroutinetreatmentofkneeDJD
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JointPreservation- HTO
• SelectPatients– Young– Male– Laborer– Intactligaments– Normalweight– Unicompartmentaldisease
HTO
• Advantages– Maintainhighlevelactivity
– CanconverttoTKA
• Disadvantages– Technicallydifficult– MoredifficultconversiontoTKA
– Limiteddurability
HTO• HTOhaspoorsurvivorship
– StudybyBillingsetalreviewedHTOandfound5and10yearsurvivorship85&53%respectively
– ConversiontoTKAmoredifficultwithresultsakintorevisionsurgery
• Acceptableprocedureinselectpatientpopulation
Arthroscopy• Arthroscopyallowsdirectexaminationofjoint
• Indicatedwhenthereispainassociatedwithmechanicalsymptoms
• Moseleydidastudywhichsuggestedaplaceboeffectforarthroscopyofarthritis
Biologics
• Biologicsatthistimearemoreexperimentalthanmainstreamtreatment
• OATSmoveshealthycartilagefromNWBregionofkneetodiseasedweightbearingregion
• Meniscaltransplant
Arthroplasty
• Totalkneearthroplastyistimetestedprocedure
• Goodlongtermresults– 94-98%successat15
yearsdocumentedinmanystudies
– Somewhatpoorerresultsreportedinyoungerpatients
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UnicompartmentalKneeArthroplasty- UKA
• Indications• Procedure• Results
UKA- Indications• Evolvingandcontroversialtopic• Presently
– Singlecompartmentarthritis– Age-
• <65- likelyUKAis1st ofmorethanoneoperation• >65- UKApotentiallylastprocedure
– Ligamentousstability- ACL– Noevidenceofinflammatoryarthritis– Nearidealbodyweight- avoidobesity– ROM- minimum5-90degreeswith<15degreesdeformity
UKA
• History• Indications• Procedure- Manualvs.Robotic
UKA• rUKAcomparedwithmUKA
• Roboticadvantages:– MoreAccurate– Betteroutcomes
• Lowerrevisionrateat3years
• BettervalidatedPROM
ManualUKA
• Surgicalaccuracyutilizingvisualalignmentandguides
SometimesGood SometimesBad
ManualInstrumentation: UKA
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PoorAlignment:Result- EarlyRevision RoboticAssistedUKA
Surgeon-interactiveRoboticArm
Intra-operativeguidance
CTbasedpre-operativeplanning
• Better Planning: CT Based planning and guidance
• Better and safer execution• Robotic burr restricted to plan area
rUKA:LowerrevisionratecomparedwithmUKA
TwoYearSurvivorshipofRoboticallyGuidedMedialMCKOnlayPrincipalInvestigators:Drs. Roche,Coon,Pearle,Dounchis
Methodology:• N= 201 patients (224 knees) from 4 surgeons
were enrolled in the study• Follow up at a minimum of 2 years
Result: REVISION RATES AT 2 YEARS• rUKA: 0.4% • mUKA: 4-6%
87
UWdata:rUKAlowerRevisionRates
SuccessfulCases
FailedCases Total FailureRates
Manual UKA 120 5 125 4.0%
RoboticUKA 121 2 126 1.6%
• RoboticUKA- SignificantlyLowerRevisionratethanmUKAat3.5years(P<0.05)
UWdata:PROM:UCLAActivityScore
45566778
Pre Post
ManualUKARoboticUKA
• R-UKAhigherpostoperatively activityscores(p=0.035)
Summary
• rUKAcomparedwithmUKA– Improvedaccuracy– Improvedclinicaloutcomes
• Reducedrevisionrates• Betterpatientreportedoutcomes
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UKAvs.TKA
• PotentialadvantagesUKAvsTKA– Lessextensivesurgicaldissection– Lessbloodtransfusionrequirements– Fewercomplications– Fasterrehab– Greatermotion- morenormalfeelingknee– Ofteneasierrevisionwhennecessary– Patientsatisfaction– Shorterhospitalization
Summary
• Manypotentialtreatmentoptionsforpatientswithunicompartmentalkneearthritis
• Conservativemeasuresshouldbeattemptedfirst
• Patientsstratifythemselvesintoanoverlappingarrayoftreatmentoptionsbasedonclinical,radiographicandlifestyledifferences
• UKAisaexcellenttreatmentoptionforanevolvingsubsetofthesepatients
TricompartmentalkneeDJD
• Conservativemanagement• TKA
TricompartmentalkneeDJD• Significantprevalence• 800,000TKAs/yr.inU.S.• Relatedtoobesityepidemic• TKA- VeryDurableProcedure
– 5%failurerateat10years– 10%at20years
• However– Oftenlongandinvolvedrehabilitation– Variablesatisfactionrates- 10-20%dissatisfied
TKA• CausesforpatientdissatisfactionafterTKA
– Stiffness– Persistentpain– Instability– Complications- infection,re-operation– Unrealisticexpectations– Technicalsurgicalerrors– Psychologicalissues- paintolerance,previousnarcoticuse,ETOH,depressionandotherpsychologicco-morbidities
TKA
• Techniquesandimplantshaveevolvedbutoutcomeschangedverylittlein40years
• Survivalratesgoodat10-20yearsinolderpatientsbutsignificantratesofdissatisfactionremain
• Failurerateshigherinyoungerpatientsandsatisfactionratesoftenlower
• SignificantopportunitytoimprovesurvivalandsatisfactionafterTKA
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TKA• Technique
– CRvs.PS- nodifference– FixedorMobileBearings- nodifference– Implantmanufacturers- nosignificantdifferences- despitemarketingoninternet
– Currentlyonlymanualtechniquesavailable– RoboticTKA
• RecentlyFDAapproved• UW- oneof10centersworldwidetointroducethistechnology(November2016)
• OptimisticrTKAwillimproveaccuracyandoutcomesimilartorTHAandrUKA
Questions?
SLIDETRANSITIONTOTIFFANYHOUDEK,PT,OCS
Summarize the challenges and opportunities in the rehabilitation of patients with total joint replacement surgery across the continuum of care and the utilization of multiple
models of care.
“MaryandSteve”– Mary,a77yearoldfemale,haschronicbilateralkneepain
• Painhasbeenworseningoverthepast6months– CurrentmanagementofchronicBkneepain
• IBU,Tylenol,activitymodification(doesless)andaquatherapyatherlocalhealthclub
– Referredbyspouse(Steve)toOrthopedicsurgeon• Stevehadmultiplejointsreplacedbysamesurgeon• Rheumatologyagreedwithreferral• SurgeondeemsTKAappropriate
– Severetricompartmentaldiseasebilateralknees» PFjointR>L» MedialcompartmentL>R» LateralcompartmentR>L
– Marytodeterminewhichkneeistobereplacedfirst» Basedonpain,lesserfunction,symptoms
Summarizethechallengesandopportunitiesintherehabilitationofpatientswithtotaljointreplacementsurgeryacrossthecontinuumofcareandtheutilizationofmultiplemodelsofcare.
Medications• Acetaminophen• Aspirin• Atenolol• Azelastinenasalspray.• CalciumplusD2tablets• Voltarentopicalgel2times• Fluticasoneinhaler• Glucosamine/chondroitin• Hydroxychloroquine.• Ipratropiumnasalspray.• Multiplevitamin• Systaneeyedrops• duloxetine• Zincasneeded.
PastMedical/SurgicalHistory• h/oCVA,brainaneurysm• s/paneurysmclipping
– PoorprognosisattimeofCVA– Howeverhasmaderemarkable
recoverywithsustainedmildspeechandmemoryimpairment
• Hypertension• Hyperlipidemia• ObstructiveSleepApnea(CPAP)• Undifferentiatedconnectivetissue
disease(Sjögren'slikely)
Summarizethechallengesandopportunitiesintherehabilitationofpatientswithtotaljointreplacementsurgeryacrossthecontinuumofcareandtheutilizationofmultiplemodelsofcare.
• Stevehasconcernsaboutupcomingsurgeryduetopatient’sstrokeandhowheisgoingtomanageeverything• Coupledecidestowaitandthinkaboutwhattodonext
• MaryandStevedecidetoschedulesurgeryfortheright knee,withsurgeryscheduledabout3monthsafterinitialorthopedicsconsultation
• MaryandSteve,careteamdiscussedpossibledischargedestination– StevefeelsunabletocareforMaryaftersurgeryduetoherstroke– SteveandMaryagreetoSNFplacementaftersurgeryhoweverMaryhashopestogohomewith
HomeHealth
• MaryandStevedidnotattendJointClass101asMaryisgoingtodischargetoSNF
– “Theywilltakecareofeverything”
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Challenges?
• Listchallengeswiththispatientcase– Pre-surgery– Postsurgery/InpatientTherapy– SNF– HomeHealth– OutpatientTherapy
Opportunities/Ideasforsuccess
• Listopportunitieswiththispatientcase– Pre-surgery– Postsurgery/InpatientTherapy– SNF– HomeHealth– OutpatientTherapy
Whatdoestheresearchsay?
• Sharareh etal(2014)foundthatpersonsthatdischargedtoaSNFs/pTJA– hadslowerTUG– lowerEQ-5Dscore– higherASAscores– Increasedlengthofstay– Increasedreportedpostoperativepain– Decreasedphysicaltherapyachievements
• Distancewalkedpostoperatively
Pre-operativeFactors—dischargedestination?
• Sharareh etal
SNF Home P-value
Livingstatus(patient livesalone)
Yes:14No:26
Yes:5No:45
P=0.04
TUG (seconds) 21.12(+/- 10.23)
15.75(+/- 6.76)
P <0.01
EQ-5E(0-100)
55.82(+/- 22.19)
68.35(+/- 18.02)
P <0.01
Post-operativeFactors—dischargedestination?
• Sharareh etal
SNF HomeGroup P-valueDistancewalked POD#1(ft)
68.95(+/- 76.12)
151.36(+/- 121.56)
P<0.01
DistancewalkedPOD#2(ft)
127.49(+/-113.13)
167.47(+/-116.73)
P<0.09
Post-operative-dischargedestination?
• Sharareh etal
SNF Home P-valueLOS 2.68
(+/-0.66, 2-4)2.39(+/-0.60, 1-4)
p= 0.02
VASPOD#1 5.71(+/- 2.46,0-10)
4.48(+/- 2.57,0-10)
p= 0.02
VASPOD#2 4.77(+/- 3.37,0-10)
3.38(+/- 2.77,0-10)
p= 0.03
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Patientwholivesalone—dischargedestination?
• Sharareh etal
LivealonedischargedtoSNF
Livealonedischarge tohome
P value
Pre-operativeEQ-5Dscore
59.00(+/- 21.45)
68.35(+/- 18.02)
P=0.02
DistancewalkedonPOD#1(ft)
54.23(+/- 73.92)
148.98(+/- 118.92)
P<0.01
Whatdoestheresearchsay?
• Binietal(2010)– Healthy patientsdischargedtoSNFsafterprimarytotaljointarthroplastyhadhigheroddsofhospitalreadmissionin90daysofsurgerythanthosedischargedhome
• Riskstopatient• Costs• Patientsatisfaction
ChallengesandOpportunities• Doesanythingchange?• Reflectionsonpractice
SurgeryRightTKA
• Pre-opappointment– DecreaseinrightkneeROM
• Initialconsult3monthsago:0-0-130degrees• Pre-operativeappointment:0-5-110degrees• Persistentrightkneeedema
– Medicallyclearedforsurgery– Scheduled16dayslater– Anticipateddischargeplan:SNF– AnticipatedLOS:2-3days
Surgery
• Surgeon’snote:– Severeendstagetricompartmentalarthritis– releasedsofttissuerestrictionsmedially– Extremewearonthepatella
• Surgerywentwell,nocomplications• Painwellcontrolledupontransfertoinpatientunit
Challenges?
• Anynewchallengesidentifiedhere?
• ImplicationsfortheInpatientPhysicalTherapist
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Opportunities
• Anyopportunitiesidentifiedhere?
• ImplicationsfortheInpatientPhysicalTherapist
ThingsforthePTtoconsider
• Incisionalhealing(drainage)• Softtissuehealing• Edemamanagement• Expertconsensus• Balance,gaitandsafety• KneeROM• Strength/Prevention(avoidanceofatrophy)
POD#0PhysicalTherapyvisit
• Fallriskfactors:post/opfatigue,pain,frail• WBAT• Standardfallsprecautionspernursingassessment
• Participationisimpairedbypain• Atrest1/10pain• Withmobilityandexercises4/10pain
InpatientPhysicalTherapyStrategies
– PTusesmultiplepaininterventiontechniques• Distraction• Mobilization• Education• Repositioning
– Result:improvementintoleratingtherapywithimprovedfunctionnoted
PhysicalExamPOD#0,PT
• RangeofMotion– LeftLE:WFL– RightLE:ankle/hipgrosslyWFL
• RightkneeROM:0-17-38degreeswithassist
• Strength– LeftLE:5/5Rightankle/foot/hipgrossly4/5– Rightquad:fairtopoorcontraction
PhysicalExamPOD#0,PT• Bedmobility
– Assistneeded,bedrails,HOBelevated– SupineàSit:Standbyassistance– Sità Supine:Minimalassistance– Scooting:supervisionandsetup
• Transfers– Sitàstand:Minimalassistance– Standà sit:Minimalassistance(pooreccentriccontrol)
– Standpivottransfer:standbyassistance– Deviceusedforstandingtransfers:walker
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Challenges?
marksanborn.com
Opportunities?
PhysicalExamPOD#0,PTContemporaryPTpractice
• Locomotion– AmbulationAbility:contactguardassist– AmbulationDistance:40feet– Gaitdescription:
• minimalsteplengthandcadence• poorrightkneeflexionthroughoutgaitcycle• verylimitedhipextension• poorrightstancetolerance• verylimitedrightkneeextensioninsupineandstanding
– Deviceused:frontwheeledwalker
Challenges?
• Doesthischange– Planofcare?– Dischargedestination?– Frequencyofintervention?– ?
Mechanical-engg.com
Opportunities? Whatdoestheresearchsay?
• PlanneddischargetoSNFappropriate(Gholson,etal)
• IfwalkingdistancecanbeimprovedbyPOD#1,mightbeabletodischargehomeinstead– ClinicalimplicationsofhomevsSNF– Supportathome?
• Isthissituationsimilartolivingalone?
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TreatmentplanPOD#0• Walkwithnursingagaintonight
– toImprovePOD#1walkingdistance• Exerciseprogram
– Anklepumps,quadandglutesets,heelslides,hipabduction
– 10repetitions,every1-2hourswhenawake• Positioningrecommendations
– Patienthadplacedpillowunderkneeforcomfort/paincontrol
– Patienteducationforpillowundercalftopromotecompletekneeextension
PhysicalTherapistImpressionPOD#0
• Secondarytoacutestageofrecoverys/prightTKA– Requiresassistx1tomobilize– Decreasedactivitytolerance– Decreasedfunctionalmobilityindependence– Decreasedstrength– Decreasedrangeofmotion
• Requiresadditionaltime,verbalcuestocompletemobilitytasks.
• Safetotransferinroom/ambulatewithnursingstaff.• Recommendcontinuedrehabinsubacutesettingto
facilitatehereventualsafeandfunctionalreturnhomewithintermittentassistfromfamily
UseofCPMs/pTKA
• PhysicianprescribedCPMforinpatientuseanduseatSNF
• 0-110degrees,increasingrangeastoleratedbypatient
Challenges?
E3ts.com
Opportunities?
Josephakustaa.com
Whatdoestheresearchsay?• Herboldetal(2014)regardingCPMuse
– EdemamanagementvsROM– Patientunderstandinganduse
• Berend etal(2004)• RapidRecoveryProtocols(THAandTKA)
– Pre-operativeeducation– Peri-operativenutrition,vitaminandherbalmedicine
supplementation– Preemptiveanalgesia– Post-operativerehabilitation
• Significantdecreasein– Lengthofstay– Lowerratesofhospitalre-admission
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Whatdoestheresearchsay?• Chenetal(2012)• Studied136patientsTJA• IsolatedPTinterventiononPOD#0shortenedhospitallengthofstay,
regardlessofinterventionperformed• POD#0patientsambulated62.9feetonPOD#1(2nd PTsession)
POD#0 POD #1 Pvalue
Lengthofstay 2.81days(+/- 0.77)
3.79days(+/- 1.74)
0.019
Lateoperativeendtime 0(0% ofcases)
14(12.6%of cases)
0.001
Distance ambulated1st PTsession
18.7feet(+/- 1.74)
37.4feet(+/- 1.74)
0.012
Whatdoestheresearchsay?
• Chenetal(2012)• NostatisticaldifferencebetweenPOD#0andPOD#1andlocationofdischarge
POD#0PT(25 patients)
Home SNF Rehabilitationfacility
DischargeDestination
22(88%) 2(8%) 1(4%)
POD#1PT(111 patients)
Home SNF RehabilitationFacility
DischargeDestination
78(70.3%) 22(19.8%) 11(9.9%)
POD#1• MaryusedCPMovernightx30-45minutesforedemamanagement• Ambulationdistance:
– 40feetinAM,21feetinPM• Gaitpatternunchanged,contactguardassist• NoflexionstretchesinAMduetoincreasedincisionaldrainage• VeryguardedminimalAAROMkneeflexionPM• Steveunabletoassistpatientathomeashehasimpairedmobility
(useswalker)• Maryneededadditionaltime,effortandwaslaboredduringPTon
POD#1– MinimumassistanceforTherapeuticExercise– Multiplestairstoenterhome
• Dischargedestinationà SNFonPOD#2
POD#1
• ParticipatedinsmallgroupphysicaltherapyonInpatientunit
• Aprile etal(2011)– GroupinpatientPTislessresourceintensivewhenusedwithacertaingroupofpatients• WBATstatus• THAandTKA
ContemporaryTreatmentPractice
• Grouptherapy• Wainright etal(2015)andHiyama etal(2016)bothfound
grouptherapytobebeneficial• Inpatient• SNF• Outpatient
– Nonegativeeffectshavebeennotedbyresearch– Possiblepositiveeffecthypothesized
• Lessresourceintensive• UseofPTAsinclinicalsetting• Encouragespositivegrouppsychology• Empowerspatient’stotakecontrolofrehabilitationprocessearlywith
improvedfollowthroughonHEP• Groupsupportsystem• Motivationaltool
SNFrehabilitation
• 10days(wasanticipatedtostay14days)• Therapyfocusedonfunctionalmobility• Proximalhipstrengthening• Kneerangeofmotion• Patientrequestedearlydischargetohome
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OutpatientConsultvisit#1• Gcodes:
– MobilityWalkingandMovingAround– 40-59%impairment,goal1-19%impairment– (PTassessment55-59%disability)
• Pain:best2/10,current4/10,worst6/10– Inconsistentlytakingpainmedication– Usingpillowunderkneeforcomfort– InconsistentHEP,prefersnottoperformkneeROMexercises– Over-ratedcurrentfunctionalstatusat32%disabilityonCare
ConnectionsFunctionalTool• Forexample:Icanwalknormallyonunevengroundwithoutlossofbalanceor
usingacaneorcrutches• ObservedbyPT:significantbalanceimpairmentwithrequireduseoffront
wheeledwalkerandstandbyassist• Daytonetal(2016)(THApopulationover-estimatedphysicalfunctiononself
reportedoutcomemeasurecomparedtodemonstratedphysicalabilities)
OutpatientConsultvisit#1
• Gaitpattern– Antalgic,FWW– Decreasedheelstrike– LackofTKE– Decreasedstridelengthbilaterally– Decreasedspeed– Flexedtrunk
OutpatientConsultvisit#1• Rangeofmotion
• Hipandanklesbilateral:WFL• Quadset:goodquality,20degreeextensorlag• Contralateralstrengthdeficits:WFL(4/5)• Balance:
– unabletoperformonright(involved)– left6secondswithsignificantposturalsway,– significantLOB,delayedreaction
Flexion ExtensionInvolved 76 degrees 3degreesshortofneutral
Uninvolved 125degrees 3degrees
Goals• ShortTermGoals:tobemetin4weeks• Shewillbeindependentwithhomeexerciseprogrambetweenvisitstoaugmentgainsachievedin
therapy.• ShewilldemonstratekneeAROM0-120degreestoallowforrisingfromsittinginachairwithuse
oftheaffectedleg.• Shewillsafelydemonstrateanincreaseinstrength,decreaseinpain,andincreaseinkneeflexion
AROMtobeabletonegotiatestairsreciprocallywitharailing.
• Goals/FunctionalOutcomestobemetin8weeks:• ShewilldemonstratekneeAROM0-120degreestoallowforrisingfromsittinginachairwithuse
oftheaffectedleg.• Shewillsafelydemonstrateanincreaseinstrength,decreaseinpain,andincreaseinkneeflexion
AROMtobeabletonegotiatestairsreciprocallywitharailing.• Shewillbeabletoambulatecommunitydistancesof500feetsafelywithoutassistivedeviceand
withnormalgaitpatternincludinguseoffullextensionatheelstrike.6MWT• ShewilldemonstratedecreaseriskoffallingonDGIto20/24.• Climb13stepsindependently toreturntoherregularweeklybiblestudy.• ReturntopriorexerciseactivitiesusingthePCEpool.
ChallengesandOpportunities
• Strategiestoaddresschallenges• Howdoyoumakeachallengeanopportunitytoachievepatientandtherapygoals?
Plan
• 8-12visitsoverthenext8weeks– Trytoincorporateaquatictherapyasatreatmentmodalityasthisisherpreferredexercisemodality
– Encourageselfreflectiontocurrentphysicalimpairmentstoaddressriskoffalling
– Encourageuseofprescribedmedicationtoimprovetolerancetophysicaltherapy• Followupwithsurgeon
– ConsistentHEPforfunctionalimprovement– PatientcontrolinROMexercises
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Contemporary treatment practice
– Useofaquatictherapypostjointreplacement• Rahmann etal(2009),Liebs etal(2012)• Managementofedema• Paincontrolforstrengthening/stretching• Bodyweightsupportedgaittraining• Rahmann focusedonhipabductorstrength• Timingofaquatictherapymaybeimportant
– Liebs notedTKAgroupbetterearly,THAbetterlate
– Edemamanagement• ROMrestrictionsandpainduetopersistentedema• Activitymodificationwithpacing• Kinesiotape vs.Tubigripvs.TEDsvsActivity• Donec etal(2014)usedKinesiotape
– OutpatientGroupTJRtreatment
ROMpre
ROMPost
Strength BalanceGait
HEPROM?
6MWT DGI PainMeds?
1 0-5-70 0-3-76 quadset: good SLB: L6 no NT 16/24 no
2 0-3-76 0-1-96 NT SLB:L10 no NT NT yes
3 0-5-75 0-1-90 Improvedquad NT no NT NT occasional use,pillow
4 0-3-80 0-3-93 NT SLB:R 2 some NT NT Yes,nopillow
5 NT 0-3-85 Improvedoverall SLB: R3 Some NT NT Rightbefore: yes
6 0-3-85 0-2-96 13degreeSLRlag NT Yes NT NT yes
7 0-5-85 0-2-95 NT SLB:R 2 Yes NT 19/24 Yes,pillow
8 0-5-95 0-2-107 15degreeSLR lag NT Yes NT NT Yes,pillow(nopain)
9 NT 0-5-102 AquaticPT Improved Yes NT NT Yes,pillow
10 NT 0-4-105 30STS:10reps SLBR2,L8 Yes 718ft 19/24 Yes,pillow
11 NT 0-4-112 NT SLB: R1 Yes NT NT Yes,pillow
12 0-15-127Left
0-0-116 2degreeSLR lag SLB:R8,L10 Yes 1240ft 20/24 Yes, nopillow
• Challenges• Opportunities
– Patienteducation– Consistency– PatientControl– Patientgoals
Whataboutprehabilitation?
• Challenges?
• Opportunities?
Whataboutprehabilitation?• Isitjusteducation?
• Isitjustexercise?
• Isitformalphysicaltherapy?
• Canyoubillforit?
• IsitincludedinCJR?
Currentmodels
• Patienthandouts– Learner– Readinglevel– Opportunitytoaskquestions?
• Meetwithclinicalstaffpriortoprocedure– Oftenperformedbynursing– MaymeetwithPT,OT,RT,socialwork,etc– Unbilledtime– Laborintensive– Performedinconjunctionwithpre-operativeappointment
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Currentmodels• Webbasededucation
– Videos• Videosfromyourfacility
– http://www.uwhealth.org/orthopedic-surgery-rehab/joint-replacement-care-plan/41070
• Videosfromothersources• Videoofyoursurgeon,rehabstaff,nursingstaff
– Websiteinformation• Googlesearch“totalkneereplacement”
– http://orthoinfo.aaos.org/topic.cfm?topic=A00389• Googlesearch“totalhipreplacement”
– http://orthoinfo.aaos.org/topic.cfm?topic=A00377– Amongmanyothers
Currentmodels
• JointClass– UsuallyacombinationofalliedhealthcareprofessionalswhoprovideeducationandanswersquestionstoagroupofpatientsundergoingTKA,THA• Challenges?
• Opportunities?
PrehabilitationEducation
• Whatdoestheresearchsay?– 1996wasthefirstthat“pre-hospitaleducation”isreallyaddressedwellintheliterature
– Butleretal.Prehospitaleducation:effectivenesswithtotalhipreplacementsurgerypatients
• BookletandNo-bookletgroups– Bookletgroup
» lessanxiousatthetimeofhospitaladmission» Morelikelytohaveperformedphysiotherapyexercises» LessOTandPTinhospital
• Nogroupdifferences• LOS
PrehabilitationEducation• Whatdoestheresearchsay?
– Gammonetal.(1996)Effectofpreparatoryinformationpriortoelectivetotalhipreplacementonpost-operativephysicalcopingoutcomes.
– Controlgroup:usualcare/adviceandmedicalsupport– Experimentalgroup:procedural,sensory,andcopinginformation
relatingtoTHR+writteninformationtosupporteducation– Informationgivenpre-op,post-opanddischarge
• Positiveeffectonphysicalrecoveryandcopingoutcomes– Measuredby“PhysicalIndicatorsofCopingQuestionnaire”– Measuredby“LinearAnalogueCopingScale”
• Experimentalgroup– Lesspostoperativeintramuscularanalgesia– Mobilizedsooner– Lengthofstay2daysshorterthancontrolgroup
• Rememberthisis1996– Lengthofstay?– PatientExpectations?– Healthofpatients?– Surgicalprocedures?– Complicationrate?
PreoperativeEducation
• Cochranereview(2014)– Todeterminewhetherpreoperative education inpeopleundergoing total hip replacement or totalknee replacement improvespostoperativeoutcomeswithrespectto
• pain• function• health-relatedqualityoflife• anxiety• lengthofhospitalstay• incidenceofadverseevents(e.g.deepveinthrombosis).
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PreoperativeEducation• Cochranereview(2014)
– 18trials(1463participants)• Althoughpreoperative education isembeddedintheconsentprocess--
– Unsureifitoffersbenefitsoverusualcare• Reducinganxiety• Decreasedpain• Improvedfunctionand• Reducedadverseevents.• Preoperative education mayrepresentausefuladjunct,withlowriskofundesirable
effects– particularlyincertainpatients,
» depression,» anxiety» unrealisticexpectations,
• preoperative education shouldbestratifiedaccordingtotheirphysical,psychologicalandsocialneed.
• Thequestionproposedis:– HowmanyofyourpatientshaveaPMHofdepression,anxietyand/orstate
unrealisticexpectations?
PrehabilitationEducation• Halawi etal.(2015)foundthatpatientexpectationisthe
mostimportantpredictorofDischargeDestinationafterprimaryTJA
• 372patinets• AverageLOS:2.9days• 29%dischargedtoextendedcarefacility• Significantvariables
– Age– Caregiversupportathome– Patientexpectations(mostimportant)
• Takehomemessage» Manageexpectations
PrehabilitationExercise/PT• Rooksetal.(2006)THA
• 6weekpre-surgicalexerciseprogram– Cansafelyimprovepre-operativefunction(notpain)– Safelyimprovemusclestrength– Dramaticallyreducesoddsofinpatientrehabilitation
• Topp etal(2009)TKA– usualcareorprehabilitationgroup
• Resistancetraining,flexibility,steptraining• 3x/week• Improvedsittostandatonemonthaftersurgery• Better6MWTthancontrols
• Swanketal(2011)TKA– Shortterm(4-8weeks)– Prehabilitationwaseffective
• Increaseinstrength• Improvefunction• SeverekneeOA• Programstudiediseasilytransferredtoahomeprogram
PrehabilitationExercise/PT
• Pilotstudy:Oosting etal.(2012)– Intensivepreoperativetrainingathomeisfeasibleforfrailelderlypatients
– ScheduledforTHA– Improvesfunction– Groupdifferencesnotedpre-operativelyonChairRiseTest,howevernotstatisticallysignificant
– Furtherresearchneeded.• TUG,6MWT,ChairRiseTime,selfreportmeasuresoffunction,activityandparticipation
PrehabilitationExercise/PT
• Desmeules etal.(2013)– Canadianstudy– Longwaittimesuntilsurgery– Eveninthemostseverelycompromisedpatients,ashortcourseofprehabilitationeducationandindividualizedexerciseimprovedphysicalfunctionwhileawaitingTJA• Rationale:minimizefunctionaldeteriorationwhileawaitingsurgeryandimprovepostoperativerecovery
PrehabilitationExercise/PT
• Kamimura etal.(2014)– Pre-operativekneestrength– Pre-operativehipabductorstrength– Age– Predictiveofambulationabilityearly,middle,latetimepointsafterTHA• 48womeninstudy• VAS• TUG
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PrehabilitationExercise/PT• Snowetal.(2014)
– Theuseofpreoperativephysicaltherapywasassociatedwitha29%decreaseintheuseofanypost-acutecareservices
– Associationwassustainedafteradjustingforcomorbidities,demographiccharacteristics,andproceduralvariables
– THRandTKApatients• 4733caseswithin39countyMedicarehospitalreferralcluster
• Postacutecarewasasignificantvariableinthetotalcostofcareforthe90dayepisode
PrehabilitationExercise/PT• Wangetal(2015)(ArticlesuptoNovember2015,includingpreviouslycitedstudies)
– SystematicReview• 22studies(1492patients),18hadhighriskofbias• Existingevidencesuggeststhat prehabilitation mayslightlyimprove
– Earlypostoperativepain– Earlyfunction
» Relatestodischargebutnotoverallfunctionalimprovement• “However,effectsremaintoosmallandshort-termtobeconsideredclinically-important”
» WhataboutdischargedestinationandoverallcostofcareinCJRmodel?• Didnotaffectkeyoutcomesofinterest
– lengthofstay,qualityoflife,costs– Isthereconflictingevidence,biasofresearchers,poorstudy
design,etc?
PrehabilitationExercise/PT
• Oosting etal.(2016)– Prospectivecohortstudy,followupofpilotstudy– TwofunctionalperformancebasedtestsaddedsignificantvaluetoconventionalscreeningwithageandcomorbiditiestopredictrecoveryoffunctioningimmediatelyafterTHA
• Slowwalkingspeed• TUG• Age,CharnleyscoreofC
• Thisisourrealm– improvingwalkingspeedandTUG
PrehabilitationTakeHomeMessage
• Education• Educationshouldbetailoredtothepatient• Bestforpatientswithdepression,anxietyorunrealisticexpectations
• Patientexpectationfordischargeisimportantandshouldbeaddressedbeforesurgery
• ExerciseorPhysicalTherapy• Evidencetosupportdecreasedcostwithprehabilitationexercise• Maybenefitfromtailoringexerciseprogramtothepatient• Focusshouldbetoimprove:
– strength– TUG– walkingspeed– balance
Summarize the challenges and opportunities in the rehabilitation of patients with total joint replacement surgery across the continuum of care and the utilization of multiple
models of care.
• “Lois”– 63yearoldfemale,chronicmultiplejointpain– Progressivehippainoverlast6months– SignificantDJDofthelefthip– Recentlyretiredclinicalneuropsychologist– ReferredtoOrthopedicsbyPhysicalTherapistforcontinuedpaindespitePTintervention
Pre-operativeEducation
• Pre-operativeappointment• Nurse/SWscreeningpriortosurgery
– Needsassessment• JointClass101
– AlliedHealthProfessionals
• TotalCare• www.uwhealth.org/orthopedics• Patienthandouts• PhysicaltherapistandsurgeonQ&A
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Whatdoestheresearchsay?
• Reayetal(2015)– Forearlyd/cafterTHR
• PreparepatientsforstressorsrelatedtoTHR– Reviewdischargeprocess– Assessmentanduseofadaptiveaidspriortosurgery– Assessmentofpersonalneeds– Copingskillsforthephysicalandmobilitychanges
– Limitedsocialinteraction
Whatdoesresearchsay?
• Stocken,etal.(2009)– Twotimeperdayinpatientphysicaltherapyissuperiortoonceaday• Trendtowardearlierachievementoffunctionalmilestones
• NochangeinLOS
Whatdoesresearchsay?
• Robbinsetal(2014)• Retrospectiveanalysis
– EffectofPOD#0vsPOD#1physicaltherapyonLOS• POD#0physicaltherapy
– 2.06days(190patients)– 96%dischargedtohome– 1re-admission(0.52%)
• POD#1physicaltherapy– 3.38days(400patients)– 62%dischargedtohome– 19re-admission(4.72%)
Inpatient
• POD#0– Ambulationdistance:200feet– Deviceused:walker– Bedmobility:minimumassist– Transferability:moderateassist– Painratings:4-6/10
• POD#1– Ambulationdistance:300feet– Deviceused:crutches
– Bedmobility:Independent– Transferability:Minimum
assistance– Painratings:3-5/10
• DischargetohomeonPOD#1
OutpatientConsultVisit#1
• POD#3• Currentsymptoms/concerns
– Soreness/stiffness– Unsureofhowtousecrutches– Unsureofhowtoprogressexercise– Stiffenupfast—isthisnormal?– HowcanIgetmyleginto/outofbedwithoutaggravatingmysymptomssomuch?
– Pain4/10(cuttingpainpillinhalf)
OutpatientConsultVisit#1• PerformingHEP3x/day• Usingiceoccasionally• ReviewofSystems
• fatiguebutseemsappropriate• justsurprisingtome
• Functionallimitations• CareConnectionsscore:78%disability
• Patientgoals• Returntoactivitieswithoutpain
– taichiexerciseprogram,walking,hiking,traveling• AvoidworseningofchronicLBP,Neckpain
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OutpatientConsultVisit#1
• PhysicalExamination– Bilateralaxillarycrutches
• Decreasedstridelength,4pointpattern
– Incision:coveredindressing,noexcessivedrainage
– ROMmeasuredindegreesHipPROM Flexion ER IR Abduction Extension
Involved 80 40 Deferreddue toprecautions
15, 30posttreatment
0,10posttreatment
Uninvolved 120 60 45 35 15
OutpatientConsultVisit#1• SurgicalLegStrength
– Quadset: good– SLR—deferredduetohipflexorirritability
• Trainedinhookwithcontralateralanklefortransfers• Reviewtransfersforsupineßàsit,sitßàstand
– Gluteusmedius:fair– Gluteusmaximus:poor
• Contralateralstrengthdeficits• Gmed,Gmax4-/5• Quad/hamstrings4/5• AnkleWNL
OutpatientConsultVisit#1
• Flexibilitydeficits– LeftAdductors– Lefthipflexors:one>twojoint– Moderaterestrictionnotedespeciallyproximally
• Balancedeferred– Abletowalkwithhandholdassist
Whatdoestheresearchsay?• Janetal(2004)
– Subjectsinhighexercisecompliancegroupshowedsignificantlygreaterimprovement
• Musclestrengthofoperatedhip• Fastwalkingspeed• Functionalscore• 3x/week
• Trudelle-Jacksonetal(2004)– Exerciseprogramemphasizingweightbearingandposturalstability
• Significantlyimprovedmusclestrength,posturalstabilityandself-perceivedfunctioninpatient4to12monthsaftersurgery
Whatdoestheresearchsay?
• Smithetal(2008)– Additionofbedexercisesdoesnotsignificantlyimprovepatientfunctionorqualityoflifewhenaddedtostandardgaitre-educationprogram
• Larsenetal(2010)– IfHRQOLisused
• additionalPTforfasttrackTHAisquestionablewhencomparedat12months
• However,if3monthisusedpre- orearlypost-operativephysicalinterventionshouldbeconsidered
Whatdoestheresearchsay?
• Galenaetal(2008)– Afterinitialinstruction
• Supervisedcenter-basedexercisegroup– 4.7exercisesessions
» 2supervisedsessions,2.7independentsessions
• Unsupervisedhome-basedexercisegroup– 5.8timesperweekexercisesessions
• Nosignificantdifferencebetweenexercisefrequencybetweengroups
• Targetedstrengtheningwaseffectiveforbothgroups– Nodifferencewasfoundinthemajorityofoutcomemeasures
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Whatdoestheresearchsay?• Mikkelsen,etal.(2014)
– Examineif2weeklysessionsofPRTincombinationwith5weeklyofunsupervisedhomebasedexerciseismoreeffectivethan7weeklyunsupervisedhomebasedexerciseafterfasttrackTHR
• Variable:legextensionpoweroftheoperativeleg– Measuredat10weekss/pTHR
• Secondaryvariables– Maximumwalkingspeed– Hipabductionstrength– Hipflexionstrength– Sittostandtest– Stairclimbtest
– Studydesignlimitationsandbias– Criticalanalysisofresearch
Whatdoesresearchsay?• Umpierres etal(2014)• 106patientTHA
– Assessedpostoperativelyandat15dayspost-operatively– THAgroup:verbalinstructionsandexercisedemonstrations– THAPCP:samewithdailytreatmentguidedbyaPhysicaltherapist
• Higherstrengthforcescores• Improvedrangeofmotion• GreaterimprovementinMerle-d’AubigneandPostelscore• Improvedfunctionalcapacity• ImprovedQOL• Improvedmobility• Improvedstrength• Improvedpain
– Conclusion:THAPCPsafetoolforacceleratingrecoverys/pTHA
Whatdoesresearchsay?
• Eulenburgetal(2015)– Germany
– Attempttoidentifyprescriptionstandardsamongdifferentrehabilitationprofessionals• Considerabledifferencesnoted• Physiotherapistandexercisephysiologisttendedtobemoreconservative
• SurgeonsrecommendedfasterprogressionofWB,exerciseprescriptionandgait
Whatdoesresearchsay?
• GuidelineRecommendationsforpost-acutePost-operativePhysiotherapyinTotalHipandKneeArthroplasty:AreTheyUsedinClinicalPractice?– Peter,etal(2014)– Dutchstudy
• Responsetosurvey• Billedservices• Reconciliationofdata
Patientoutcome
• 5visitstooutpatientphysicaltherapy– Completedin5weeks– Focusedonstrengthening– Balanceandbalancereactions– Neuromuscularre-education– Addressedquestions,concerns,disabilityperception
• Metallgoalsforreturntopriorleveloffunction• Walkedup2flightsofstairsfor2weekpost-operativefollowup
Takehomemessage• StarttherapyonPOD#0
– 2x/daytherapy– UseofgrouptherapyonIPand/orOPsettings
• Prehabilitationmaybebeneficial– Focusonstrengthening,TUG,balance,walkingspeed– Painreductionisnotthegoal
• Pre-operativeeducationmaybebeneficial• Setexpectationsforsurgeryanddischarge• Setrehabilitationexpectationspriortosurgery• Considerhowamajorsurgeryaffectsapatient’smentalhealth
– Whatcanwedoasphysicaltherapists?• Outpatientcaretoaddresscurrentlimitationsingoldstandardfor
practice– TUG,gaitspeed,balance,strengthdeficits