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10 Articles in Volume 10, Issue #1
An Overview of CRPS
Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care
Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
Dextrose Prolotherapy Injections for Chronic Ankle Pain
Genetic Influences on Pain Perception and Treatment
Headache in Children and Adolescents
Hormone Replacements and Treatments in Chronic Pain: Update 2010
Opioid Treatment 10-year Longevity Survey Final Report
Therapeutic Laser in the Treatment of Herpes Zoster
Use and Effectiveness of Spinal Cord Stimulation

Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients

Preoperative biopsychosocial screening processes can identify patients at risk for poor post-surgical outcomes and help decide whether the patient would benefit from additional pre- or post-surgical treatment aimed at increasing physical function or reducing psychosocial distress.

Osteoarthritis, a debilitating condition often resulting from the degradation of the joint, affects millions of individuals worldwide. An elective surgical procedure, Total Joint Arthroplasty (TJA), has increased in popularity due to its ability to restore function and decrease pain and disability in patients needing knee or hip replacement surgery. Table 1 presents data on the number of TJAs performed in the United States between the years 2000-2004.1,2

To evaluate the effectiveness of the surgical procedure, objective measures of the joint—along with self-reported measures of pain, function and quality of life—are typically assessed prior to surgery and at designated follow-up intervals post-surgery. Although in recent years there has been a significant increase in the rates of both total knee and total hip arthroplasty,1-3 disparity of outcomes following TJA has also become very evident. Because of these disparities in outcomes, many studies have focused on how various factors, including physiological, psychosocial and socioeconomic factors inhibit post-surgical success.

While a surplus of research is available on the disparities in outcomes following TJA, the only interventions that have been designed, studied and implemented have focused on increasing physical functioning and mobility prior to, and immediately following, TJA through the use of physiotherapy. There is no doubt that physical functioning plays a role in the success of knee and hip replacement surgery. However, it is also evident that there is a need for evaluation and interventions aimed at non-physical factors too. By utilizing the biopsychosocial approach, patients undergoing TJA can be evaluated on multiple domains. In doing so, interventions implemented for these patients at risk of poor surgical outcome can be tailored to meet the unique needs of each individual.

Preoperative function and mobility is thought to be a major factor in predicting postoperative functional status following TJA.4,5 Therefore, encouraging exercise for patients with end-stage osteoarthritis is a strategy with the intention to improve post-surgical function.6 Several studies have focused on “pre-habilitation,” yet, because of the types of interventions and the outcomes being evaluated, the overall findings are somewhat inconsistent.

Preoperative Physiotherapy Effects: Null Findings

Various prognostic studies and randomized-controlled trials have focused on preoperative physical therapy and exercise programs afforded to patients undergoing TJA with end-stage osteo-arthritis of the knee or hip. Contrary to the original hypotheses, though, several of these studies have identified no significant benefits from pre-habilitation. For example, in a randomized-controlled trial involving a six-week intervention of either prescribed exercise (intervention group) or education (control group), Rooks et al7 evaluated Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) post-surgical functional status. Patients undergoing THA showed short-term improvement in functional scores immediately following surgery. However, their findings revealed no significant differences in functional status between the intervention and control groups at the follow-up evaluations at both 8 weeks and 26 weeks postoperative. In another study on outcomes of primary knee replacement, measures of function, quality of life and health utilization were used to evaluate the effect of preoperative exercise and education programs.8 The results of this randomized-controlled trial again found no significant differences in outcomes between the comparison groups for any of the identified outcome measures. There was a trend for the exercise group to require a shorter hospital stay but this was not statistically significant.

A recent study on patients undergoing hip replacement surgery evaluated the post-surgical effects of preoperative physiotherapy on measures of function, pain ratings, and quality of life.9 Individuals in the intervention group participated in both individual and group exercise sessions prior to scheduled surgery—five days per week for four weeks. The exercise protocol consisted of strength and flexion training and cardiovascular conditioning through use of a stationary bicycle. The analyses performed showed no significant differences in the outcome measures of functional impairment and overall quality of life between the intervention (exercise) and control group. Another randomized-controlled trial aimed at improving surgical outcomes for patients undergoing total hip replacement utilized an eight-week preoperative physiotherapy program.10 Those individuals in the intervention program worked on stretching hamstrings and hip flexor muscles, along with upper-extremity strengthening exercises. Following the surgery, those in the intervention group exhibited better transfer abilities attributed to the upper-extremity exercises. However, no differences were found between the two groups on measures of pain and functional status. Similarly, a preoperative exercise intervention for patients undergoing knee replacement surgery was conducted to see if there is a difference in outcomes between exercises aimed at limb-strengthening and those focused on cardiovascular conditioning.11 The outcome measures included changes in functional status and quality of life indicators. The results showed that not only was there no difference in outcomes between the two exercise protocols, but also that the control (no-exercise) group fared as well as the intervention groups.

Finally, several reviews of the literature have been conducted to evaluate the efficacy of preoperative rehabilitation for patients undergoing TJA. In a review of literature on outcomes of TJA, Dauty et al12 reported no evidence of benefits of physical training rehabilitation before knee or hip replacement surgery. Another review that evaluated preoperative exercise-only interventions found a lack of studies meeting criteria for consideration; and, those considered were only able to recommend preoperative physiotherapy from a pragmatic, not a research-based stance13 due to the inconclusiveness of research evidence. Ackerman and Bennell14 conducted a systematic review of preoperative physiotherapy and concluded that of the five studies that met criteria for the review, four did not show significant post-surgical changes in functional outcomes following TJA.

Yet many of the studies conducted evaluated interventions that averaged 4-8 weeks of physical therapy prior to surgery. Most patients who need TJA have developed their degenerative disease over many years. For these chronic pain patients, short durations of exercise may not be substantial enough to produce significant outcome differences following surgery. Further research on extended durations of preoperative exercise would be needed to fully evaluate the effects of physiotherapy on end-stage osteoarthritis.

Preoperative Physiotherapy Effects: Significant Findings

While the previously reviewed studies failed to provide sufficient findings linking TJA functional outcomes to preoperative physiotherapy, other research has provided some evidence of actual improved outcome measures based on exercise programs initiated prior to surgery. For example, Topp et al15 used a randomized-controlled trial to determine the effects of preoperative exercise on post-surgical measures of strength and functioning of individuals undergoing total knee replacement. The intervention group in this study used prehabilitation techniques that centered on resistance training, step training, and exercises aimed at increasing flexibility. While both the control and intervention groups observed decreased pain and improved function following, the patients in the intervention group experienced these positive results more quickly than did those in the control group. In an evaluation of change of flexion of the knee prior to and following total knee replacement, Shi et al16 identified that individuals with greater preoperative range of motion had better functional outcomes following surgery.

Aside from the standard outcomes of pain reduction and functional improvement, other outcome measures have been identified as benefits to preoperative physiotherapy for patients undergoing TJA. Whitney and Parkman17 used mobility (walking distances) as an outcome measure for patients with hip osteoarthritis. Patients who participated in routine physical activities prior to surgery were found to have better postoperative walking distances compared to patients reporting no preoperative physical activities. These authors also suggest that, in addition to focusing exercises on the specified joint, building upper-body strength is as important in increasing mobility following surgery.

The reduction of time for in-hospital stay is another positive outcome measure that can be used to evaluate intervention efficacy in studies involving individuals undergoing either knee or hip replacement. Rooks et al7 identified that a six-week prehabilitation program was effective in reducing the odds of needing inpatient rehabilitation following TJA. For patients awaiting knee replacement surgery, those who were assigned to a six-week preoperative intervention using physiotherapy exhibited a trend for which the in-hospital stay time following surgery was shorter as compared to the control group.18

The purpose of the studies presented in this present review is to identify if preoperative physiotherapy for patients undergoing TJA improves function and reduces pain over and above that of the surgery itself. The findings thus far do not unequivocally show that there is a significant difference in functional status outcomes between those who participated in the exercise protocols compared to those who did not. There are several reasons possible to explain these null findings. First, Total Joint Arthroplasty is designed to decrease pain and improve function in patients with severe osteoarthritis of the knee and hip. The procedure itself is so effective that it may “shadow” any secondary attempts to improve outcomes, such as the implementation of physiotherapy prior to surgery. Secondly, the effort put forth by the patients in these interventions may not equate to that of individuals not experiencing chronic pain. Pain catastrophization and fear of injury may, in fact, inhibit the motivation of these patients. And lastly, most of the studies reviewed used a short timeframe to implement the exercise intervention. Considering that the individuals in these studies may have been inactive for years due to the progression of their degenerative disease, mild exercise for a short duration may not be an effective intervention to produce statistically and clinically significant results when all patients considered have been treated with surgery. Perhaps a better method of assessing the effects of physiotherapy for patients with end-stage osteoarthritis would be to study changes in functional status and pain thresholds for those either on waiting lists for surgery or for whom surgery is not a viable option.

Post-Surgical TJA Rehabilitation Options

In order for the patient to regain function and mobility following knee and hip replacement surgery, rehabilitation is necessary. The degree to which the individual improves often depends on motivation, initiative and goals set by the patient and the physician. While some patients are hesitant to begin rehabilitation following surgery to allow for adequate healing to occur, others are advised to begin physiotherapy promptly in an attempt to quickly regain function. Both the duration of time between surgery and rehabilitation, as well as the type of exercise protocols recommended, have been shown to affect patient outcomes following TJA. In the following sections, we will review studies that have focused on postoperative physiotherapy and also discuss the various exercise strategies that have been shown to be successful for individuals recovering from knee or hip replacement surgeries.

Post-Surgical Physiotherapy

Evaluating the efficacy of post-surgical physiotherapy programs has been the focus of several studies. Short-term effects have been identified for patients who undergo physiotherapy immediately following TJA. An intensive 3-week exercise regime was utilized for patients recovering from knee or hip arthroplasty and, compared to those with usual care, this intervention group was found to show improvement on measures evaluating function, range-of-motion and pain for up to 26 weeks post-surgery. At 52 weeks, however, both the intervention group and the control group fared the same.19 Similar findings were identified in a review of randomized-controlled trials of physiotherapy following total knee arthroplasty. While immediate effects were noted between the intervention and control groups, these differences were not evident at one-year post-surgery.20

Beginning rehabilitation immediately following surgery has been shown to benefit patients in several ways. Dejong et al21 identified that when earlier and more intense rehabilitation regimes follow TJA, the patients show improvement in functional status for both knee and hip replacement surgeries. Early rehabilitation has also been shown to decrease the length of hospital stay. Iyengar et al22 reported that targeted early rehabilitation for both knee and hip replacements resulted in an average decrease in hospital stay of six days for hip patients, and four days for knee patients. Furthermore, complication rates were not seen to increase with an earlier hospital discharge. In a review on multidisciplinary rehabilitation programs following TJA, Khan et al23 identified that improvement in outcomes and increase in activity is observed more frequently in those who participated in early multidisciplinary rehabilitation. The benefit of early rehabilitation goes beyond that of regaining functional status following TJA, such that early discharge from the hospital is a cost-effective option that benefits the patient and the insurance carriers.

Several studies have evaluated the efficacy of home-bound treatment as compared to inpatient and outpatient rehabilitation programs following TJA. For patients recovering from total knee arthroplasty, those who received subacute care (inpatient or outpatient), compared to those who discharged directly home, showed no significant differences in functional outcome measures.24 In a randomized-controlled trial comparing home-bound to inpatient rehabilitation following hip or knee replacement, Mahomed et al25 detected no significant differences in outcomes based on the type of therapy received. A similar randomized trial was conducted on patients who received total knee arthroplasty which compared outpatient rehabilitation to a home-bound regime. This study determined that, as long as the patient received adequate inpatient rehabilitation following surgery along with a well-designed home exercise protocol, there was no need for outpatient rehabilitation.26 A systematic review of research on rehabilitation following knee replacement surgery revealed that home therapy is as effective as inpatient or outpatient rehab-ilitation for younger individuals with fewer comorbid conditions.27

“Given that functional status before and immediately after surgery predicts postoperative outcomes, it is important for the patient and physician to develop a plan in advance aimed at pre- and postoperative reconditioning.”

The costs associated with rehabilitation following surgery can hinder the patient’s motivation to progress with physical therapy. The utilization of home-bound rehabilitation therapies following TJA is beneficial not only in physical improvement outcomes, but is also a more cost-effective option as compared to inpatient or outpatient programs. For patients requiring a physical therapist to assist with rehabilitation, individualized homebound therapy can be more costly than group therapy. Coulter et al28 determined that group physiotherapy is not only cost-effective but also provides the same outcomes as private physical therapy sessions.

Physiotherapy Programs Following TJA

Finding the right exercise program for patients recovering from joint arthroplasty is important not only for therapeutic outcomes, but also to allow for increased patient compliance. Individuals with osteoarthritis often experience a significant amount of pain prior to, and also following, surgery. For these patients, the pain associated with the joint impacts the individual’s ability to walk, exercise, sleep and perform daily activities.29 When developing appropriate exercise regimes, it is critical to minimize pain and to create therapies that are not aversive to the patients. Thus, progressive strengthening has been shown to be effective in functional outcomes following knee replacement surgery.30 As compared to the control group that received usual care, the intervention group participated in six weeks of outpatient physical therapy that focused on progressively strengthening the quadriceps. The post-treatment analyses showed that the intervention group reported greater functional improvement up to one year following treatment.

In addition to general stretching and strengthening work outs, other types of exercises have been recommended for patients recovering from TJA. Cycling has been proposed as an exercise that provides aerobic activity without the increased load on the hip or knee joint.31 Pilates is another type of exercise that has been recommended as a post-surgical form of rehabilitation for patients with knee or hip replacements.32 Another low-impact exercise regime used for patients recovering from TJA is aquatic physiotherapy. Rahmann et al33 conducted a randomized-controlled trial comparing three different types of physiotherapy: aquatic therapy, non-water therapy, and inpatient ward therapy. The immediate findings showed that those in the aquatic group displayed more strength, greater gait speed, and better functional ability two weeks following treatment.

Given that functional status before and immediately after surgery predicts postoperative outcomes, it is important for the patient and physician to develop a plan in advance aimed at pre- and postoperative reconditioning. Exercises —including squats, heel raises, hamstring pulls, and overhead, tricep and cardio pulls—help to strengthen muscles needed for mobility following knee and hip replacement surgery. Furthermore, improving cardiovascular endurance prior to surgery will help reduce fatigue during post-surgical rehabilitation.34

Further, in a recent systematic review of the literature, Kuijer and colleagues35 have concluded that there is a lack of studies evaluating either the beneficial or limiting factors of TJA on one important function outcome: return-to-work. Future studies are needed to assess whether preoperative or perioperative management techniques will have an impact on this important functional outcome.

Disparities in Outcomes and the Biopsychosocial Approach

While in recent years there has been a significant increase in the rates of both total knee and total hip arthroplasty,1-3 disparity of outcomes following TJA has also become very evident. Many studies have focused on how various factors, including physiological, psychosocial and socioeconomic factors, may inhibit post-surgical success. In addition to highlighting the evidences of disparity in post-surgical TJA outcomes, we will discuss how using the biopsychosocial approach for the assessment and treatment of patients undergoing TJA will create an opportunity to identify and control for the socioeconomic, physiological, and psychosocial factors that may hinder treatment success.

There are many ways to characterize successful outcomes following TJA. Not only are outcomes classified by complications, infections and revision rates, but also considered is improvement in stiffness, function and pain levels. The typical evaluation of surgical outcomes following TJA often consists of both an objective assessment of the joint by the surgeon and a subjective rating of pain and function by the patient. While the physician’s post-operative appraisal of the knee or hip may indicate improvement, oftentimes, some patients fail to report the same progress in perceived levels of pain and function.36 Regardless of the condition of the joint itself, these poor patient-perceived treatment outcomes can lead to deconditioning of the joint, dependency on pain medications, psychosocial distress, an increase in disability, and even unnecessary medical treatments such as surgical revision. However, for an adequate assessment of the outcomes of TJA, both the physician’s assessment of the joint and the patient’s perception of pain and function following surgery are necessary.37 Hence, these discrepancies in post-surgical outcomes following TJA have been a primary focus in orthopaedic research—particularly in the areas related to demographic, socioeconomic, physiological and psychosocial factors.

Various demographic and physiological factors have been examined as indicators that may hinder progress following TJA. Several studies focused on outcomes for patients undergoing TKA have shown that there are no significant gender differences in overall outcomes.4,38-40 A general predictor of post-operative complications following TJA is age. With older patients, the complications that arise are often attributed to comorbid factors.4,40,41 Obesity has been repeatedly shown to be a risk factor for poor post-surgical outcomes following TJA. Not only is obesity linked to lower levels of patient-perceived quality of life,40,42 it is also a significant factor in post-operative complications, increased length of stay and prosthetic failure.41,43

A primary focus in research on osteoarthritis has also centered on the accessibility and utilization of various treatment options. In fact, differences in racial and socioeconomic factors have been shown to be relevant determinants of having surgical procedures such as TJA. More recently, studies have identified that lower education levels44 and lower income levels45 negatively affect post-surgical outcomes. The type of insurance has also been predictive of TJA outcomes, with individuals having private/commercial insurance more likely to report more function and less pain46 and fewer complications47 following TJA. Along the same lines, individuals who undergo TJA at specialty or high-volume hospitals often report fewer complications and more positive outcomes compared to those at general or low-volume hospitals.48,49

From a socioeconomic perspective, factors such as education level, income level and insurance, have been shown to contribute to the disparity of outcomes for individuals undergoing TJA. Psychosocial factors have also been shown to affect outcomes following TJA. In fact, research on psychosocial distress has chronicled how depression and anxiety can exacerbate symptoms and hinder progress in chronic pain populations. Multiple studies have found direct associations with psychosocial distress and poor outcomes following TJA.50-52

“From a socioeconomic perspective, factors such as education level, income level and insurance, have been shown to contribute to the disparity of outcomes for individuals undergoing TJA. Psychosocial factors have also been shown to affect outcomes following TJA.”

Several studies have highlighted the negative relationship between depressive symptoms and post-surgical outcomes of TJA. In an investigation of how depression affects outcomes of total knee arthroplasty, Brander et al51 discovered that there was a significant correlation between symptoms of depression identified prior to the surgical procedure with high levels of physical dysfunction up to five years following surgery. Elevated levels of anxiety and uncertainty were also shown to have a negative effect on post-operative physical and mental outcomes.53 Fisher et al54 theorized that poor post-surgical outcomes following TJA may be due to the depressed individual’s lack of motivation to exercise and follow-through with the prescribed rehabilitation regime. Other components of psychosocial distress—such as pain catastrophizing55-57 and low levels of self-efficacy56,58-61—were found to directly inhibit patient-perceived measures of improvement in pain and function following TJA.

While many studies have drawn attention to the strong association between socioeconomic factors and psychosocial distress with poor surgical outcomes following TJA, little has been shown regarding interventions aimed at diagnosing and treating these psychosocial disorders preoperatively. However, studies conducted on individuals with chronic pain in tertiary rehabilitation programs have repeatedly shown that the assessment for, and in conjunction with, treatment of psychosocial distress is linked to positive post-treatment outcomes.62,63 Therefore, it is necessary to consider methods of implementing assessment and treatment regimes aimed at reducing psychosocial distress in these patients who are high-risk for poor surgical outcomes following TJA.

Indeed, such pre-surgical screening methods have already been developed for spine surgery candidates,64 as well as initial development for implantable devices such as spinal cord stimulators and intrathecal drug pumps.65 In both instances, an array of biopsychosocial variables has been isolated and, together, have shown to be good predictors of surgical outcomes. A similar pre-surgical algorithm is now greatly needed for TJA surgical candidates.

Conclusions

The patient-perceived post-surgical outcomes can often vary from the physician’s assessment for those undergoing total knee or hip replacement surgery. Oftentimes, poor outcomes associated with a lack of improvement in levels of pain, function and quality of life are correlated not only with lower preoperative functional condition, but are also linked to socioeconomic status and psychosocial distress. While ample research has been provided identifying disparity in outcomes following TJA from physiological, socioeconomic and psychosocial attributes, little has been put forth regarding a solution.

The biopsychosocial approach offers a method for accurate assessment as well as guidelines for appropriate treatment of the intervening factors that interfere with outcome success. Through the use of preoperative screening processes, patients can be identified a priori to be at risk for poor post-surgical outcomes. Decisions can then be made at that time whether the patient would benefit from additional pre- or post-surgical treatment aimed at increasing physical function or reducing psychosocial distress. This prescreening process would also help to identify patients who might be considered poor candidates for surgery. If a patient with osteoarthritis is considered to be high risk for encountering poor surgical outcomes, then other cost-effective, non-surgical treatment options can be considered.

Last updated on: March 28, 2017
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