Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
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.