Considering a total knee replacement?

 

Considering a total knee replacement?

 

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed).   From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

 

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

 

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

 

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

 

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

 

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

 

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

 

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

 

PURPOSE:

1. To determine the feasibility of applying a balance exercise program in patients with TKA
2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
3. To test the method and calculate a sample size for a future RCT with a larger sample size

 

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

 

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

 

See the appendix for the protocol (6 weeks).

 

Testing measures:

1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
2. Timed chair rise test (5 repetitions): easily added to our testing.
3. single leg stance time: easily added in
4. LEFS
5. WOMAC

 

RESULTS:

1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

 

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

 

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

1. SLS
2. Chair rise test
3. Gait speed: important indicator of function/independence/death
4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).