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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”

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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%

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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