Model. This new payment model was implemented in April 2016 by the Centers for Medicare and Medicaid Services (CMS) for patients undergoing total hip and knee replacements. This model is being tested across the country for 5 years to determine its effectiveness in providing improved patient-focused care that Preoperative therapy The role of preoperative PT can be considered to be two- fold. The first impact of therapy provided at this time is that it can lead to a reduction in pain and improvement in function in the time leading up to the THA (Gill & McBurney, 2013). A systematic review and meta-analysis examining the role of therapy with exercise in reducing pain and improving physical function before hip or knee replacement surgery established that exercise-based interventions can reduce pain and improve physical function for people awaiting THA but not total knee arthroplasty. In this study a variety of interventions were assessed including but not limited to strengthening, flexibility exercises, and aerobic exercise. A key factor with an exercise program for people with hip OA is to establish opportunities where exercise does not exacerbate symptoms, and the role of pool-based exercise was emphasized for people scheduled to undergo THA (Gill & McBurney, 2013). This improvement is not limited to just healthy individuals undergoing THA; it can also positively impact frail and older individuals scheduled to undergo THA. The results of a study examining the role of a preoperative home-based PT program compared to the standard of care, which was one session of instruction, was that there was a statistically significant difference on walking ability between the groups (Oosting et al., 2012). The patients who received the home-based therapy participated in an average of seven one-on-one sessions that consisted of functional activities and walking capacity that was tailored to the patient and his/her home environment. In addition to the sessions with the physical therapist, patients were encouraged to exercise four additional times per week and kept an exercise log. Patients who underwent the home-based training reported that they thought the exercises were useful, that they were motivated to do them, and that they were better prepared for the surgery. The evidence against the positive impact of preoperative therapy is more limited and tends not to disregard the impact but rather detects low to moderate evidence in support of providing this care (Wallis & Taylor, 2011). The second role and probably the most frequently examined one is the impact of preoperative therapy on postoperative outcomes such as length of stay in the hospital, limb strength, and overall function (Oosting et al., 2012; Poortinga, van den Akker-Scheek, Bulstra, Stewart, & Stevens, 2014; Snow et al., 2014). However, there is debate on whether preoperative therapy provides a positive impact on postoperative outcomes. In a recent study examining the associations between preoperative PT and post-acute care utilization patterns and cost in THA and total knee arthroplasty (TKA), it was found that the use of preoperative PT was associated with a 29% reduction in post-acute care use. This reduction occurred due to a reduction in payments for skilled nursing facilities, home health agencies, and inpatient rehabilitation (Snow et al., 2014). Preoperative physical function, whether directly or indirectly influenced by PT, has been recognized to influence length of hospital stay. In a study where the median length of stay was 6 days, there was an 18.5% increased chance of requiring more than 6 days’ stay when a patient needed an assistive device prior to surgery or had difficulty with stairs during this time period (van Aalst, Oosterhof, Nijhuis-van der Sanden, & Schreurs, 2014). Where several studies have provided evidence to support the efficacy Postoperative therapy After THA surgery a comprehensive rehabilitation program is essential to a safe and complete recovery. The components of that rehabilitation program will vary depending on whether a patient undergoes THA in the traditional hospital setting or at a free standing surgery center where the THA is classified as an outpatient procedure (Aynardi, Post, Ong, Orozco, &
is also cost effective. Rather than reimbursing providers in each setting separately, CMS will reimburse per episode of care across all settings, requiring collaboration among all healthcare providers to provide quality care that maximizes resources (U.S. Health & Human Services, 2015). of preoperative PT prior to THA, there are also studies whose authors identified no improvements in postoperative outcomes when PT was provided preoperatively (Gawel, Brown, Collins, & McCullum, 2013; Poortinga et al., 2014). A systematic review completed in 2013 concluded that the evidence on preoperative PT was inconclusive regarding the impact of improving postsurgical outcomes. This study looked both at patients undergoing THA and also those undergoing TKA (Gawel et al., 2013). Another study that examined whether the preoperative level of activity influenced the degree of recovery 1 year after primary THA or TKA also did not identify any significant relationship (Poortinga et al., 2014). It should be noted that this article did not actually measure the impact of preoperative PT on postoperative outcomes but did imply that an individual’s preoperative level of activity did not change the long-term outcome. Despite these findings many studies support the positive impact that preoperative PT has on a patient’s preoperative functional mobility and on postoperative outcomes. Currently there are no studies indicating that harm arises from preoperative PT, and therefore participation in preoperative PT should be considered because of known preoperative impairments in those with hip OA. In addition to the role of the physical therapist in the preoperative phase providing guidance on exercise, the physical therapist can play a key role in patient education. Several studies have identified the importance of preoperative patient education on postoperative outcomes (Hansen, Bredtoft, & Larsen, 2012; Moulton, Evans, Starks, & Smith, 2015), and the physical therapist is well situated to be part of this process. Preoperative education can include but is not limited to how to prepare the home environment for the postoperative phase, the restrictions that may be in place after surgery, and the importance of early mobility after surgery (Moulton et al., 2015). The role of more intensive therapeutic exercise programs, including progressive resistive training, has gained attention recently (Oosting, Hoogeboom, Appelman, Dronkers, & van Meeteren, 2015; Skoffer, Dalgas, & Mechlenburg, 2015). A recent study examined the feasibility and efficacy of a preoperative explosive-type resistance training in patients with hip OA who were scheduled for THA (Hermann, Holsgaard-Larsen, Zerahn, Mejdahl, & Overgaard, 2016). Eight patients scheduled for THA were randomized into either a “care as usual” group or a group that performed supervised progressive explosive-type resistance training twice a week for 10 weeks. Outcomes used in this study were the Hip Osteoarthritis Outcome Score (HOOS) and leg muscle power. Adherence to the demands of each group was high (93%). After the interventions it was noted that the group that completed the resistance training scored significantly higher on the HOOS and had higher leg extension power than the group who received the “care as usual.” Additionally, in the preoperative period, physical and occupational therapists can work together to identify adaptive equipment needs and educate patients in easier, energy sparing ways to perform activities of daily living, helping the patient to get a head start on postoperative rehabilitation.
Sukin, 2014). Of the two options, surgery in the traditional hospital setting is still more common, but it is anticipated that in the future more patients will undergo THA as an outpatient procedure; therefore the rehabilitation program for both will be discussed.
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