Home Rehabilitation After Knee Surgery as Effective as Hospitalization
Interviews with Justine Naylor, PhD, and Andrew Fleischman, MD
In a comparison of inpatient and home-based rehabilitation programs following total knee arthroplasty (TKA), the recovery was very similar for many key factors, including pain relief and knee functioning.1 This challenges traditional beliefs among both patients and physicians who have typically credited formal rehabilitation programs, especially extended stay, inpatient hospitalization, as the best option to achieve full recovery following TKA.
If a TKA recipient is judged well enough to go directly home after their postoperative stay—which fits for the majority of patients—they ''do not demonstrate greater benefit in their recovery if they participate in a lengthy [10-day] patient rehab program first," said Justine Naylor, PhD, a researcher at the University of New South Wales, Liverpool, Australia, lead author of the new study published in the Journal of the American Medical Association.
Information on the optimal rehabilitation programs following TKA has become especially important as the prevalence of TKA has increased 11-fold in the US from 1980 to 2010.1 While it has been accepted that formal rehabilitation programs, including extended hospitalization, optimize recovery, comparison studies have been scarce, Dr. Naylor's group found.
Seeking the Most Efficient Recovery Model
In the new study, which was conducted at 2 facilities in Sydney, Australia, a total of 165 postsurgical patients were followed: 81 patients were randomized to a 10-day hospital inpatient rehabilitation program, and 84 patients were randomized to a home-based program. An additional group of 87 patients selected the home-based program. Among the participants, 68% were women, and the mean age was 66.9 years (SD, 8.4 years).
The main outcome, mobility at 26 weeks after surgery, was assessed using a 6-minute walk test. The researchers reported no significant differences in the 6-minute walk test between the inpatient and the 2 home-based programs (mean difference -1.01, 95% CI, -25.56 to 23.55).
In addition to mobility, similar findings were reported for pain and function (knee score mean difference 2.06, 95% CI, -0.59 to 4.71) and quality of life (EQ-SD visual analog scale mean difference, 1.41, 95% CI, -6.42 to 3.60). The pain and function scores on average more than double, meaning much improvement, noted Dr. Naylor.
Complications after discharge were higher for the inpatient group versus those receiving rehabilitation at home (12 vs. 9 patients). No adverse events reported were a result of trial participation.
"I think everyone assumed that more intensive, more supervised therapy always leads to better recovery—either a quicker recovery or a greater absolute recovery—in any context," Dr. Naylor told Practical Pain Management. "We did not see either of these things." As for the finding of no differences in pain and function following the course of rehabilitation, she noted that the average level of improvement experienced by TKA recipients was ''quite astounding."
Given the unexpected similarity in outcomes between the groups, Dr. Naylor speculated that ''time is primarily dictating recovery." She added that ''it is possible that the role of rehabilitation is to guide people about what to do, provide a point of regular and personal contact with a health professional so adverse events are detected, to encourage participation in activity, and to bring people together to share in their recovery as shared experiences normalizes the process for the individual."
The study findings, have implications for how governments and individuals spend their rehab dollars, Dr. Naylor told Practical Pain Management
Living Situation, Another Factor to Consider
The study results are not surprising, said Andrew Fleischman, MD, a research fellow at the Rothman Institute, in Philadelphia, Pennsylvania who presented findings that joint replacement patients living alone can recover effectively and safely at home at the American Academy of Orthopedic Surgeons' annual meeting in March in San Diego.2 He called the JAMA study results "strong."
His study involved 769 patients who had a total hip replacement or total knee replacement. Of those, 138 lived solo, and 631 had companions. Those who lived alone were more likely to stay an additional night in the hospital and to use more home health services.2
However, those living alone had no more increase in complications or unplanned clinical events as those living with others. No differences were found in functional outcomes or pain between those living alone and those living with others.
"In our practice, 90% of patients go directly home," Dr. Fleischman told Practical Pain Management. Supervised home-based programs, he said, can include all the modalities received with inpatient programs. Part of the advantage of an at-home program, Dr. Fleischman said, is ''just a general sense that when you are at home you are healthy and doing well, and that's why you are home."
More Post-TKA Pain Management Tips
In the US, as in Australia, efforts to reduce reliance on opioids and dependence on this pain reliever are ongoing, Dr. Naylor said. "In my opinion, for optimal pain management, patients should be reviewed by their primary care physicians so that they can access appropriate medications, but also be taken off [pain meds] at the appropriate time to avoid tolerances, bowel issues, etc."
Physical rehabilitation strategies that can be recommended at home include:
- Regular cold therapy
- Compression bandaging
- Gentle massage to help with swelling
However, Dr. Naylor said, the role of these measures has not been evaluated extensively in the sub-acute period. Exercise can also help, but ''getting the right balance between doing enough and doing too much is yet to be determined," she said.