Recovery And The Use Of Postoperative Physical Therapy After Total Hip Or Knee Replacement

Background: To investigate the relation between recovery and postoperative physical therapy (PT) usage, including the presence of comorbidities, 6 months after total hip or knee arthroplasties (THA/TKA). Methods: Multicenter, observational study in primary THA/TKA patients who completed preoperative and 6 months postoperative assessments. The assessments included questions on PT use (yes/no and duration; long term use defined as ≥12 weeks), comorbidities (musculoskeletal, non-musculoskeletal, sensory comorbidities). Recovery was assessed with the HOOS/KOOS on all 5 subdomains. Logistic regression with long term PT as outcome was performed adjusted for confounding including an interaction term (comorbidity*HOOS/KOOS-subdomain).Results: In total, 1289 THA and 1333 TKA patients were included, of whom 95% received postoperative PT, 56% and 67% received postoperative PT ≥12 weeks respectively. In both THA and TKA group, less improvement on all HOOS/KOOS domain scores was associated with ≥12 weeks of postoperative PT (range Odds Ratios 0.97-0.99). In the THA group the impact of recovery was smaller in patient with comorbidities as non- musculoskeletal comorbidities modified all associations between recovery and postoperative PT duration (Odds Ratios range 1.01-1.05). Musculoskeletal comorbidities modified the associations between Function-in-Daily-Living-and Sport-and-recreation recovery and postoperative PT. Sensory comorbidities only had an effect on Sport-and-recreation recovery and postoperative PT. In the TKA group comorbidity did not modify the associations. Conclusion: Worse recovery was associated with longer duration of postoperative PT suggesting that PT provision is in line with patients’ needs. The impact of physical recovery on the use of long-term postoperative PT was smaller in THA patients with comorbidities. Trial registration: Registered in the Dutch Trial Registry on March 13, 2012. TRIAL ID NTR3348; registration number: P12.047. https://www.trialregister.nl/trial/3197.

Effects of adding neural mobilization to traditional physical therapy on pain, functional disability, and H-reflex in patients after lumbar laminectomy: A randomized controlled trial

Objective: To investigate whether adding neural mobilization to a standard postoperative physical therapy program could improve the outcomes of patients after lumbar laminectomy. Design: A single blinded randomized controlled trial. Setting: Outpatient setting. Participants: Sixty participants of both sexes who had undergone lumbar laminectomy. Interventions: Participants were allocated randomly to two groups; study and control groups. All patients received a standard postoperative physical therapy program. Those in the study group received additional neural mobilization in the form of straight leg raising and dorsiflexion with two-ended slider. Treatment was administered three times/week for six successive weeks. Outcome measures: Visual analog scale (VAS), Oswestry disability index (ODI), and H-reflex latency were measured pre and post-treatment. Results: The mean age of participants was 44.23 ± 4.64 and 45.3 ± 5.3 in study and control groups respectively ( P > 0.05). There were statistically significant differences in VAS, ODI, and H-reflex latency in favor of the study group ( P < 0.05). The mean ± SD for VAS, ODI, and H-reflex latency pre vs post treatment was 6.13 ± 1.22 vs 1.40 ± 0.77, 64.46 ± 4.05 vs 16.86 ± 2.55, and 32.07 ± 2.76 vs 27.46 ±1.79 in study group and 5.86 ± 1.07 vs 2.46 ± 0.73, 63.93 ± 3.91 vs 23.40 ± 2.93, and 31.76 ± 2.69 vs 29.4 ± 1.94 in control group, respectively. Conclusions: Neural mobilization combined with traditional physical therapy program achieved better improvement in pain, functional disability and H-reflex in patients who underwent decompressive laminectomy than traditional physical therapy program only.

High incidence of acute self-reported sleep disturbances in patients following arthroscopic-assisted knee surgery

ObjectivesTo evaluate the self-reported incidence of sleep disturbances, defined as ≤7 hours of sleep per 24-hour period, in patients undergoing arthroscopic-assisted knee surgery.MethodsPatients who underwent arthroscopic knee surgery over the course of a 4-month period were prospectively included. Patients were excluded if a history of insomnia or other sleep altering medical history was reported. Self-reported sleep metrics included average number of hours of sleep per night, average number of awakenings during sleep per night, perceived quality of sleep, average pain level during sleep and number of hours of physical activity/therapy per week. Data were collected at weeks 1, 3, and 6 postoperatively. Joint circumference was measured on postoperative day 1 and served as an indicator of a knee effusion. Paired t-tests were used to compare preoperative to postoperative hours of sleep. Simple and multiple linear regression were used to evaluate relationships between surgical variables and postoperative sleep metrics.ResultsThere were 123 patients who underwent arthroscopic knee surgery during the prospective enrolment period; 83 patients were included in the final analysis. The overall incidence of preoperative sleep disturbances was 20% (n=17). The overall incidence of self-reported postoperative sleep disturbances was 99%, 96% and 90% at weeks 1, 3 and 6, respectively. The average number of hours slept was significantly reduced at 1, 3 and 6 weeks postoperatively compared with the preinjury state (p<0.001). Knee joint circumference had a significantly negative correlation with average number of hours of sleep in the first 6 weeks postoperatively (R=−0.704; p=0.001). Surgical variables including severity of surgery, weekly postoperative pain level and weekly hours of postoperative physical therapy were not significant independent predictors of acute postoperative sleep disturbances (p>0.05).ConclusionSleep disturbances were commonly reported in patients following arthroscopic knee surgery without correction of sleep metrics by 6 weeks postoperatively. The majority of sleep disturbances in this cohort correlated with an increased knee effusion. A multidisciplinary team approach is recommended to counsel patients regarding the potential for and problems with acute sleep disturbances following arthroscopic knee surgery.Level of evidence: 3.

Safer return to jazz dance instruction after simultaneous bilateral total hip arthroplasty

To describe the case of a 48-year-old Japanese female patient with more than two decades of experience in jazz dance instructor returning to work after simultaneous bilateral total hip arthroplasty (SBTHA). We provided her with a tailored postoperative physical therapy programme considering her preoperative activity level and skills using three-dimensional motion analysis for guidance. The patient returned to jazz dance instruction 8 months after undergoing SBTHA, and her disease-specific quality of life assessment score at 1-year postsurgery was almost perfect. Use of three-dimensional motion analysis helped facilitate our assessment of whether her hip angle was within the acceptable range for teaching the compound movements necessary in jazz dance, but her preoperative experience was crucial in determining her full-scale participation in jazz dance. At present, 7 years since the surgery, the patient is able to continue jazz dancing, the THA component remains stable.

The Effects of Perioperative Peripheral Nerve Blocks on Peri- and Postoperative Opioid Use and Pain Management

Introduction The amount of peri- and post-operative use of opioids for pain management, and the duration in which they are used following surgery, are positively associated with the likelihood of subsequent opioid use and addiction. Aware of this issue, many clinicians are seeking ways to reduce opioid use while maintaining adequate pain management. Recent evidence suggests that peripheral nerve block utilization may present a viable mechanism by which clinicians can accomplish this goal. Methods Ovid MEDLINE and Pubmed databases were searched to identify relevant articles. Using the advanced search option, the key terms “opioid,” “morphine,” “nerve block,” “peripheral anesthesia,” “pain management,” “preoperative,”, “intraoperative,” and “postoperative” were used and combined with the Boolean terms “AND” and “OR.” This review examines the extant literature surrounding the use of peripheral nerve blocks in relation to patient-reported pain scores, intraoperative opioids, postoperative opioids, patient-controlled analgesic with opioids, and opioid consumption once the patient has left the hospital. Further, the effect peripheral nerve blocks have on postoperative physical therapy, surgery related complications, and overall patient satisfaction are briefly discussed. Results The use of perioperative peripheral nerve blocks decreases opioid consumption not only in the postoperative period, but also intraoperatively as well. The most significant decrease in opioid consumption is seen in the first 24-72 hours postoperatively. Patient reported pain scores were also lower in patients who received peripheral nerve blocks. Discussion Despite relatively robust efficacy data, utilization of peripheral nerve blocks is not ubiquitous; the potential reasons for which are also discussed. Lastly, clinical recommendations based on the available data are provided.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: A Randomized Controlled Trial

Background: Previous observational studies have suggested poor results of arthroscopic surgery for the treatment of acetabular labral tears in patients older than 40 years. Purpose: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients older than 40 years who have limited radiographic osteoarthritis. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In this single-surgeon, parallel randomized controlled trial, patients older than 40 years who had symptomatic, MRI-confirmed labral tears and limited radiographic osteoarthritis (Tönnis grades 0-2) were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA) using an electronic randomization program. PTA patients who achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy. The primary outcomes were International Hip Outcome Tool (iHOT-33) and modified Harris Hip Score (mHHS) at 12 months after randomization, and secondary outcomes included other patient-reported outcome measures and the visual analog scale. Outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Primary analysis was performed on an intention-to-treat basis using linear mixed-effect models. Sensitivity analyses included modified as-treated analysis and treatment-failure analysis. Due to infeasibility, patients and health care providers were both unblinded. Results: The study enrolled 90 patients (46 [51.1%] SPT; 44 [48.9%] PTA); of these, 81 patients (42 [51.9%] SPT; 39 (48.1%) PTA) completed 12-month follow-up. A total of 28 of the 44 PTA patients crossed over to SPT within the study period (63.6% crossover). Intention-to-treat analysis revealed significantly greater iHOT-33 scores (+12.11; P = .007) and mHHS scores (+6.99 points; P = .04) in the SPT group than the PTA group at 12 months. Modified as-treated analysis revealed that these differences exceeded the minimal clinically important difference of 10.0 points (SPT-PTA iHOT-33, +11.95) and 8.0 points (SPT-PTA mHHS, +9.76), respectively. Conclusion: In patients older than 40 years with limited osteoarthritis, arthroscopic acetabular labral repair with postoperative physical therapy led to better outcomes than physical therapy alone. Thus, age over 40 years should not be considered a contraindication to arthroscopic acetabular labral repair. Registration: NCT03909178 (ClinicalTrials.gov identifier)

Assessment of Effectiveness of 15 Weeks of Physical Therapy on Biplanar Ankle Mobility, Gait and Pain Level in Patients Following Operative Repair of the Achilles Tendon

Background. The aim of the study was to assess the effectiveness of 15 weeks of physical therapy on biplanar ankle mobility, gait and pain level in patients following operative repair of the Achilles tendon. Material and methods. The study enrolled two groups of patients; a group of men (n=40) after operative repair of the Achilles tendon, who underwent 15 weeks of postoperative physiotherapy (Group I) and a group of men (n=40) without Achilles tendon injury (Group II). The ranges of motion for supination, pronation, plantar and dorsiflexion of the foot were measured in both groups. The ankle and shin circumferences were also measured. 10-meter unassisted walking, the Thom­son test results and pain according to a VAS scale were assessed. In Group I the tests were carried out after 5 and 20 weeks following open Achilles tendon repair. A test for dependent samples was used to compare within-group statistics and the ANOVA and Tukey’s tests were used for between-group comparison. Results. After 15 weeks of postoperative physical therapy, the patients in Group I had regained the ability to walk unassisted, all measured ranges of motion had improved significantly (from p=0.0001 to p=0.001), the ankle circumference on the operated side had decreased (p=0.002) and no pain was reported. However, the between-group comparison showed persistent, significantly decreased values of supination and plantar flexion on the operated side (p=0.001). Conclusions. 1. 15 weeks of postoperative physical therapy after open Achilles tendon repair restored painless function of the ankle joint and unassisted walking. 2. Despite a significant improvement in the range of motion, supination and plantar flexion of the foot on the operated side were not fully restored.

Comparison of the Therapeutic Alliance Indicators according to the Results of the Survey of Cardiosurgical Patients and their Physical Therapists

The purpose of the study was to determine and compare the indicators of the therapeutic alliance based on the results of a survey of cardiac surgery patients and their physical therapists. Material and methods. The survey involved 100 patients (over 18 years old, without cognitive impairment) who underwent cardiac surgery. The Working Alliance Inventory questionnaire was used to assess the level of therapeutic alliance formation. The SF Hatcher Client form (which consists of 12 questions) was used for the patient. These questions were divided into three groups / domains: "goal items", "task items" and "bond items". The questionnaire was filled in on the seventh postoperative day. The SF Hatcher Client form, which consisted of 12 questions, was used for the patient. Intervention: before surgery, patients received a short consultation with a physical therapist regarding the goals and content of physical therapy, the algorithm for activation after surgery; the postoperative physical therapy protocol included early mobilization, therapeutic gymnastics, the use of respiratory physical therapy techniques, and therapeutic walking under the supervision of a physical therapist. Patients were provided with information and tasks on therapeutic walking, a small set of therapeutic exercises and breathing physical therapy for independent implementation. Results and discussion. The indicators of the therapeutic alliance between physical therapists and cardiac surgery patients confirmed its high level, both according to the results of the questionnaire survey of patients and the results of the survey of specialists. The "goal items" domain had the highest score in the patient's assessment of therapeutic alliance. Since the patient and specialist questionnaires had a different number of questions and a different maximum score, it was decided to make comparisons of the overall estimates of the level of therapeutic alliance after converting them to a percentage of the maximum. A significantly better overall score for the therapeutic alliance was established according to the results of the questionnaire survey of physical therapists: 87.5 (82.5; 95) % of the maximum versus 81.25 (66.67; 89.58) % of the maximum (p = 0.000). Conclusion. Physical therapists rated the therapeutic alliance for a higher score

Postoperative Management for Articular Cartilage Surgery in the Knee

The postoperative rehabilitation team plays a crucial role in optimizing outcomes after articular cartilage surgery. A comprehensive approach to postoperative physical therapy that considers the type of surgery, location in the knee, concurrent procedures, and patient-specific factors is imperative. While postoperative rehabilitation protocols should be specific to the patient and type of surgery performed and include phased rehabilitation goals and activities, the key principles for postoperative rehabilitation apply across the spectrum of articular cartilage surgeries and patients. These key principles consist of preoperative assessments that include physical, mental, and behavioral components critical to recovery; education and counseling with respect to expectations and compliance; and careful monitoring and adjustments throughout the rehabilitation period based on consistent communication among rehabilitation, surgical, and imaging teams to ensure strict patient compliance with restrictions, activities, and timelines to optimize functional outcomes after surgery.