therapy services following TKA and will facilitate improved data collection and research on outcomes. In addition, as younger patients seek TKA to return to high levels of activity, rehabilitation programs focused on retraining for social or competitive sports Standardized outcome measures Measuring outcomes with standardized tools will improve the ability to evaluate the effectiveness of arthroplasty surgery. For decades, the outcomes reported in the literature primarily focused on the technical aspects of prosthetic implant survivability and design. While this is an important aspect relative to patient outcome, information on how TKA impacts quality of life is just as valuable. The most common outcome tools being used after TKA include the 6MWT, TUG test, Timed Stair Climb, WOMAC, Oxford-12, and The 12-Item Short Form Survey (SF- 12), and the KSS; however, a single ideal outcome tool to assess patients after TKA does not exist (Heislein & Eisemon, 2016). The WOMAC and 6MWT are most responsive in the first 4 months after surgery. The 6MWT is predictive of functional ambulation 1+ year after surgery (Ko, Naylor, Harris, Crosbie, & Yeo, 2013), and it is preferable because the patient can perform this type of CMS bundled care initiative A major initiative that has just begun in the United States to promote best care following joint replacement surgery is the Comprehensive Care for Joint Replacement Model (CJR). The CJR is a new payment model that was implemented in April of 2016 by the Centers for Medicare and Medicaid Services (CMS) for patients undergoing total hip or knee replacements. This model is being tested in 67 metropolitan statistical areas for 5 years for episodes of care related to total knee and total hip replacements under Medicare. Hospitals will receive additional reimbursement for cost effective, quality care across the episode of care, and may have to reimburse Medicare for not meeting these benchmarks in care. This model provides an incentive for healthcare providers to work collaboratively to deliver the best Conclusion TKA is a successful means to restore quality of life and mobility to patients with end-stage arthritis, and it has a high level of patient satisfaction after the surgery. When patients are selected appropriately, prepared thoroughly, and given high- quality rehabilitation services, outcomes are optimized. Debate continues regarding whether preoperative rehabilitation is justified in patients facing TKA, but therapy that consists of flexibility, strengthening (especially of the quadriceps muscles, with and without NMES), and functional activities appears to optimize postoperative recovery in a handful of case studies. After TKA surgery, use of the CPM machine increasingly appears to be becoming obsolete, as research fails to show a benefit in recovery. Rehabilitation that helps patients focus on active goals of improving functional mobility and the return to meaningful activities seems to be the most effective approach. The most
and vigorous recreational activities need to be developed. Objective ways to measure these activities also need to be developed and researched.
test early in recovery. The Timed Stair Climb should be reserved for patient assessment later in recovery, because most patients will not be able to perform this test in the first few months after surgery. Many of these outcome assessment tools are limited in their ability to measure improvement in the higher functioning patient due to the ceiling effect of many standard outcome tools used for TKA. The High Activity Arthroplasty Score (HAAS) is one tool that has been developed to specifically assess high levels of function, including running and sport participation, in patients after TKA (Jenny, Louis, & Diesinger, 2014). Other tools aimed at evaluating high-level tasks for this patient population are in development. care to patients across all settings, rather than focusing on the care delivered in each setting separately. It will have a direct impact on physical therapists who work in these areas, and they may wish to contract with hospitals that are participating in this effort in order to provide clinical care to these patients. While this effort is in its infancy, and time will be needed to evaluate its effectiveness, this effort is a major step for CMS to create a healthcare system that provides better care that is cost effective and patient focused. With the selection of joint replacements as the first model, the role of physical therapy in contributing to coordinated quality care will be highlighted as data emerges from this effort (U.S. Department of Health and Human Services, 2015; APTA, 2016). critical period for recovery is during the first 3 postoperative months, and early mobilization with full weight-bearing status followed by progressive stretching exercises, strengthening that incorporates eccentric muscle contractions, balance and coordination activities, and functional re-education facilitates the early return to independence. More research is needed to examine the specifics of TKA rehabilitation, to define the differences between typical and more aggressive approaches to treatment, and to explore which modifiable factors can be effectively employed by physical therapists to assist patients through the recovery process. Rehabilitation programs must continue to evolve to meet the needs of patients after TKA to return them to their fullest potential and restore their function to that of age- and gender- matched controls.
CASE STUDY
Ms. C is a 61-year-old female elementary school teacher who underwent a left TKA yesterday (cruciate sparing device) for end- stage OA. She is a relatively healthy female with a past medical history significant for: ● Recent nondisplaced fracture of the right distal radius (4 months prior to surgery) which has healed well radiographically and does not limit her functionally. ● Hypertension that is well controlled with medication. ● Osteoporosis. ● Right TKA 4 years ago. Prior to surgery she was ambulating without an assistive device, but was limited in the distance she could walk due to knee pain. She also reports difficulty in her occupation, as she is unable to sit on the floor for “circle time” with her students due to limited knee motion and pain in the left knee. Prior to surgery she reports the presence of a knee flexion contracture that was present for the past 9 months. She lives alone in a two-story home, with
five steps to enter, and a half bath on the first floor. She was independent in all ADLs and IADLs prior to surgery and will have family assistance for the first 2 weeks after surgery. She works full time as an elementary school teacher, and scheduled her surgery to allow 3 months of recovery over the summer vacation. Her preoperative RAPT score was 10/12. On her initial examination she reports a 2/10 pain level on a verbal response scale and has been premedicated by nursing. Questions 1. Based on her past medical history, what issues might impede her functional training in the initial days after surgery? 2. What is her likely discharge disposition from the acute care setting? What factors will impact her discharge disposition? 3. Her initial left knee ROM on POD#1 was 70º of flexion, and –20º of extension, and her left quadriceps strength was 3/5 on manual muscle testing. As part of your patient education, you discuss the focus of the independent exercises that she
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