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Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study.

ABSTRACT: Background:The physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-PF) is widely used and endorsed by professional organizations for patients with knee osteoarthritis. Its use post total knee replacement (TKR) has been challenged as it may not represent the high level of functional performance that is expected by patients who undergo contemporary TKR with more advanced techniques and care pathways. Objective:To assess whether the items of the WOMAC-PF reflect the activity limitations identified by patients following TKR. Design:Data for this descriptive study were obtained from baseline assessments of a randomized clinical trial comparing exercise interventions following TKR. Methods:Participants completed the WOMAC-PF and identified activity limitations in the Canadian Occupational Performance Measure (COPM) in the same day. The responses to both questionnaires were compared. Results:This investigation included 50 participants (36 women, mean age 63.8±6.7). The WOMAC-PF failed to capture 50% of the activity limitations identified by participants in the COPM. These activities included kneeling, squatting, carrying/lifting items, strength/endurance exercise, floor transfer, lower extremity exercise, walking up/down hills, yard work, climbing a ladder, driving, managing the environment, carrying objects up/down stairs, gait initiation, balance, and going up/down curbs. Only one activity on the WOMAC-PF (going shopping) was not identified by participant responses on the COPM. Limitations:Participants were included if they had TKR between 3 and 6 months prior, which may limit generalizability to those immediately after TKR, and the study sample was relatively small. Conclusions:In individuals following TKR, the WOMAC-PF failed to represent a subset of higher level, more physically demanding activities that were identified as important by patients following TKR.

SUBMITTER: Disantis AY

PROVIDER: S-EPMC6203347 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study.

Disantis Ashley Y AY Piva Sara R SR Irrgang James J JJ

Journal of exercise, sports & orthopedics 20180205 1

<h4>Background</h4>The physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-PF) is widely used and endorsed by professional organizations for patients with knee osteoarthritis. Its use post total knee replacement (TKR) has been challenged as it may not represent the high level of functional performance that is expected by patients who undergo contemporary TKR with more advanced techniques and care pathways.<h4>Objective</h4>To assess whether the ...[more]

PMID: 30370333

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Project description:BACKGROUND:Gait analysis can be used to measure variations in joint function in patients with knee osteoarthritis (OA), and is useful when observing longitudinal biomechanical changes following Total Knee Replacement (TKR) surgery. The Cardiff Classifier is an objective classification tool applied previously to examine the extent of biomechanical recovery following TKR. In this study, it is further developed to reveal the salient features that contribute to recovery towards healthy function. METHODS:Gait analysis was performed on 30 patients before and after TKR surgery, and 30 healthy controls. Median TKR follow-up time was 13 months. The combined application of principal component analysis (PCA) and the Cardiff Classifier defined 18 biomechanical features that discriminated OA from healthy gait. Statistical analysis tested whether these features were affected by TKR surgery and, if so, whether they recovered to values found for the controls. RESULTS:The Cardiff Classifier successfully discriminated between OA and healthy gait in all 60 cases. Of the 18 discriminatory features, only six (33%) were significantly affected by surgery, including features in all three planes of the ground reaction force (p<0.001), ankle dorsiflexion moment (p<0.001), hip adduction moment (p = 0.003), and transverse hip angle (p = 0.007). All but two (89%) of these features remained significantly different to those of the control group after surgery. CONCLUSIONS:This approach was able to discriminate gait biomechanics associated with knee OA. The ground reaction force provided the strongest discriminatory features. Despite increased gait velocity and improvements in self-reported pain and function, which would normally be clinical indicators of recovery, the majority of features were not affected by TKR surgery. This TKR cohort retained pre-operative gait patterns; reduced sagittal hip and knee moments, decreased knee flexion, increased hip flexion, and reduced hip adduction. The changes that were associated with surgery were predominantly found at the ankle and hip, rather than at the knee.

Project description:BackgroundThere is an existing perception that obesity has a negative impact on complications following total knee arthroplasty (TKA). However, data on the impact of obesity levels on patient-reported outcomes (PROMs) is sparse. We investigated the association between different obesity classes with PROMs among patients who underwent TKA.MethodsWe performed retrospective secondary analyses on data extracted from the total joint replacement data repository (Alberta, Canada) managed by the Alberta Bone and Joint Health Institute (ABJHI). Patients had WOMAC and EQ5D scores measured at baseline in addition to 3 and/or 12 months following TKA. Patients were stratified according to the World Health Organization (WHO) classification, into five body mass index (BMI) groups of normal, overweight, BMI class I, BMI class II, and BMI class III. The association between BMI and mean changes in WOMAC subscales (pain, function, and stiffness) and EQ-5D-5L index over the time intervals of baseline to 3 months and 3 to 12 months following TKA was assessed. Linear mixed-effects models were used, and the models were adjusted for age, sex, length of surgery, comorbidities, year of surgery, and geographical zone where the surgery was performed.ResultsMean age was 65.5 years (SD = 8.7). Postoperatively, there was a significant improvement (p < 0.001) in WOMAC subscales of patient-reported pain, function, and stiffness, as well as EQ-5D-5L regardless of BMI group. Although, patients in BMI class II and class III reported significantly improved pain 3 months after TKA compared to those with normal BMI, all BMI groups attained similar level of pain reduction at 12 months after TKA. The greatest improvement in all WOMAC subscales, as well as EQ5D index, occurred between baseline and 3 months (adjusted p < 0.0001).ConclusionThe findings indicate that patients reported improved pain, function, and stiffness across all BMI groups following TKA. Patients with BMI classified as obese reported similar benefits to those with BMI classified as normal weight. These results may help health care providers to discuss expectations regarding the TKA recovery in terms of pain, function, and quality of life improvements with their TKA candidates.

Project description:BackgroundElectronic health records (EHRs) have the potential to facilitate consistent clinical data capture to support excellence in patient care, quality improvement, and knowledge generation. Despite widespread EHR use, the vision to transform health care system and its data to a "learning health care system" generating knowledge from real-world data is limited by the lack of consistent, structured clinical data.ObjectiveThe purpose of this paper was to demonstrate the design of a web-based structured clinical intervention data capture system and its evaluation in practice. The use case was ambulatory physical therapy (PT) treatment after total knee replacement (TKR), one of the most common and costly procedures today.MethodsTo identify the PT intervention type and intensity (or dose) used to treat patients with knee arthritis following TKR, an iterative user-centered design process refined an initial list of PT interventions generated during preliminary chart reviews. Input from practicing physical therapists and national and international experts refined and categorized the interventions. Next, a web-based, hierarchical structured system for intervention and intensity documentation was designed and deployed.ResultsThe PT documentation system was implemented by 114 physical therapists agreeing to record all interventions at patient visits. Data for 161 patients with 2615 PT visits were entered by 83 physical therapists. No technical problems with data entry were reported, and data entry required less than 2 minutes per visit. A total of 42 (2%) interventions could not be categorized and were recorded using free text.ConclusionsThe use of user-centered design principles provides a road map for developing clinically feasible data capture systems that employ structured collection of uniform data for use by multiple practitioners across institutions to complement and augment existing EHRs. Secondarily, these data can be analyzed to define best practices and disseminate knowledge to practice.

Project description:BackgroundThe increasing demand for total knee arthroplasty (TKR) and the initiatives to reduce health care spending have put the responsibility for efficient care on hospitals and providers. Multidisciplinary care pathways have been shown to shorten length of stay and result in improved short-term outcomes. However, common problems such as post-op nausea, orthostasis, and quad weakness remain, while reliance on discharge to rehabilitation facilities may also prolong hospital stay.Questions/purposesOur aim was to document that combined modifications of our traditional clinical pathway for unilateral TKR could lead to improved short-term outcomes. We pose the following research questions. Can pathway modifications which include intra-articular infusion and saphenous nerve block (SNB) provide adequate pain relief and eliminate common side effects promoting earlier mobilization? Can planning for discharge to home avoid in-patient rehab stays? Can these combined modifications decrease length of stay even in patients with complex comorbidities indicated by higher ASA class? Will discharge to home incur an increase in complications or a failure to achieve knee range of motion?Patients and methodsA retrospective review was performed and identified two cohorts. Group A included 116 patients that underwent unilateral TKR for osteoarthritis between August 2009 and August 2010. Group B included 171 patients that underwent unilateral TKR for osteoarthritis between February 2012 to February 2013. Group A patients were treated with spinal anesthesia with patient-controlled epidural analgesia (PCEA)/femoral nerve block (FNB) for the first 48 h after surgery. Discharge planning was initiated after admission. Group B had spinal anesthesia with SNB and received a continuous intra-articular infusion of 0.2% ropivicaine for 48 h post-op. Discharge planning was initiated with a case manager prior to hospitalization and discharge to home was declared the preferred approach. An intensive home PT program was made available through a program with our local home care agency. Outcomes assessed and compared between groups included length of stay, incidence of post-op nausea, dizziness, in-hospital falls, occurrence of complications including wound infection and the recovery of range of motion at 6 weeks, 3 months, and 1 year post-op.ResultsPain control was similar between the groups but Group B had fewer side effects. With the new pathway, length of stay (LOS) was reduced from 4.32 to 3.64 days with a similar LOS reduction across all ASA classes. There was no increase in Group B wound or other complications. Return of ROM was similar between groups.ConclusionsOur findings suggest that replacing PCEA and FNB with intra-articular analgesia with a SNB allows for improved early recovery following TKR. That, combined with pre-op discharge planning and initiation of an intensive home PT program, reduced average length of stay.

Project description:Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement.We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4(th) 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD).Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination.After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials.

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Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study.

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Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study.

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