by Mike Studer, PT, MHS, NCS, CEEAA, CWT, and Kelsi Smith, PT, DPT
Arthritis is a major health concern and the leading cause of disability among adults in the United States. The National Health Interview Survey (NHIS) reports that 22.7 million (9.8%) of all adults age 18 years and older have arthritis and arthritis-attributable activity limitation.1 In 2016, The Centers for Disease Control and Prevention (CDC) reports the annual number of hip and knee replacements totaled 1,051,000, almost double the total completed in 2010.2 Of those who underwent a total hip replacement (THR), 95% were aged 45 years and older.2 A total knee replacement (TKR) surgery in the United States will cost between $45,000 and $60,000, with a reported average of $49,500, including all imaging, surgical, presurgical, hospitalization, and rehabilitative care. For THR, the cost is $30,124 on average.3,4
While many efforts are underway to reduce the cost per joint replacement, the volume of joint replacements is projected to continue to rise. A 2007 article projected that by the year 2030, hip replacements will increase by 174% (572,000) and knee replacements by 673% (3.48 million).5 The rise can be attributed to the growing population and prevalence of obesity, incidence of youth with knee injuries, and expanding indications for joint replacements.6 Additionally, the length of stay has decreased from 5 days to just under 4,2 likely associated with medical efficiencies in presurgical care, including prehabilitation, to reduce the overall cost burden.
In 2014, more than 400,000 individuals aged 65 years and older underwent a total joint replacement with Medicare as their primary—we must be open to considering further cost reductions.7 With respect to reducing the cost, Medicare recently initiated its 5-year pilot program known as the Comprehensive Care for Joint Replacement (CJR), in 67 metropolitan statistical areas.7,8 While it is not within the scope of this article to fully detail the content and impact of the CJR, it is important to note that the anticipated cost savings for Medicare come with financial incentives in the form of percentage-based rewards; and that the gatekeeper for all postsurgical care is the admitting hospital.
One aspect of total joint replacement care that has great potential for cost-savings and—more importantly—quality of life impact is presurgical care. Authors of a 2014 study found that preoperative physical therapy was associated with a 29% decreased use in post-acute care services, $871 on average per episode of care.3 The CJR has no provision, reward, or consideration for presurgical care—therein the emphasis for the title of our article, “Easing the Impact”—a “double entendre” of the financial and physiologic aspects of postsurgical care. Brown and colleagues’ 2012 study revealed a statistically higher rating in each of eight quality-of-life measures for those who had participated in presurgical rehabilitation leading to their TKR.9
What is excellent presurgical care for the patient that needs a total joint replacement? For Northwest Rehabilitation Associates (NWRA), it means a clinical opportunity to be taken advantage of in terms of education (safety, fear-reduction, and neuromuscular facilitation), as well as measurement, goal-setting, and preconditioning.
A large body of evidence exists describing the importance of physical health prior to surgical interventions. In a recent study, authors found that individuals with lower preoperative function are less likely to achieve functional outcome.10
Education: Safety, Fear-Reduction, and Neuromuscular Facilitation
Education is one of the most effective interventions therapists can provide to patients. Knowledge provides empowerment, particularly in regard to surgery. Prehabilitation includes strengthening, but more importantly safety with transfers, mobility, and use of medical equipment. Training an individual to ambulate safely with use of an assistive device prior to surgical intervention has the potential to positively impact outcome, as many patients utilize some form of pain medication that could alter orientation, vision, balance, and judgment. Additionally, educating patients about expectations postoperative day 0-3 may prevent the prevalence of bed rest and incidence of postoperative complications. Prehabilitation exercises and education may reduce fear associated with overexertion, falls, and abiding by postsurgical precautions. Developing new patterns of movement in both compensatory (ie, bed mobility, gait pattern, negotiating curb/stair) and rehabilitative (ie, neuromuscular re-education of hip abductors for THA and quadriceps for TKA) may speed the postoperative recovery time.
Additionally, with education, we have the power to prevent secondary physiologic complications associated with bed rest. The primary response of the muscular system to bed rest is atrophy, with preferential loss of anti-gravity or postural muscles.11 A mere 3 to 5 days of bed rest can lead to a 50% loss in muscle strength, and additional 10% to 20% loss per week.12 With this loss in mind, we begin to think about fall risk as the neuromuscular system is compromised with muscle atrophy. We can reverse this process and prevent it with physical activity and specific muscle strengthening.
A final argument for presurgical care—and perhaps the most compelling—is the timing of educational efforts. Consider the capacity to attend-to and imprint new information under the influence of postsurgical pain, pain medications, sleep deprivation, and the psychological effects of even a short hospitalization. Now, compare that to how well a person can attend to information without any of those influences, when they know how relevant and important it is to learn from a focused session before surgery.
An essential part of presurgical care is measurement. At NWRA, therapists create both a baseline and a set of postsurgical expectations for patients by measuring bilateral: knee ROM, joint and limb circumferences, as well as isokinetic strength capacities. Additionally, we conduct the measures listed in Table 1, including a 2-minute walk test for both quality (descriptive) and quantity (distance); sit to stand capacities (number of repetitions), and quality (weight bearing distribution). It is important that the same PT conduct the presurgical and postsurgical care. Consistency of care affords the best patient-therapist relationship for effective use of this data both prospectively and retrospectively for the patient’s benefit.
Measurement leads directly into goal setting, for documentation, and for psychological reasons. A patient is more likely to achieve a set goal that is specific, includes a behavior, is measurable, and has an appropriate timeline. Discussion of goals in the prehabilitation interview/examination will set expectations, develop patient rapport, guide examination, reveal patient participation postoperatively, and guide the development of an appropriate plan of care. An expression such as, “You are now already walking faster after surgery than you were before,” can be a powerful psychological message expressed in terms of ROM, circumference, and sit to stand capacities (surface height or repetitions). Technological advances such as wireless body sensors and forceplate-enabled treadmills can afford therapists advantages that were not available as recently as 5 years ago.
Another importance of goal setting is accountability. A patient who identifies and sets a personalized goal is more likely to remain active, comply with precautions/home exercise program, and consistently attend physical therapy sessions.
The last point to be made about goal setting is its impact on insurance. With the new Medicare CJR pilot program, certain facilities will need to meet required benchmarks or goals to continue receiving funds. This new program may not impact everyone at the same time or equally for that matter, depending on setting. However, we must consider goal achievement as care transfers from inpatient to home or outpatient postsurgical care. In the outpatient setting, it will be important to consider therapist-based goal setting in the plan of care and appropriate functional limitation reporting (FLR) for goal impairment rating.
Presurgical conditioning recommendations can vary significantly between individuals based on function (unilateral versus bilateral involvement), comorbidities, insurance benefits, and motivation. A recent 2014 study found that as few as one to two treatment sessions are effective at reducing postoperative care of total hip/knee replacements by 29%, more than $1,000 per individual.9 Additionally, researchers found that the rate of those who required postoperative acute care decreased by 54.2% for those who underwent a small number of physical therapy services prior to surgery.13
Rehabilitation prior to surgery should include a focus on providing a pain-free opportunity for the patient to meet three primary goals:
1) Creating a functional reserve intended to counter the upcoming losses in strength due to the influences of bed rest, pain, and pain medications.
2) Functional reserve for endurance, due to the same.
3) Improve kinesthetic awareness throughout both lower extremities, before pain can influence this learning.
Therapists at this practice have the luxury of providing options for the best presurgical environment, using an underwater treadmill (UWT), or body weight supported treadmill training (BWSTT) in more severe cases. For the underwater treadmill, research has proven the benefits of buoyancy and hydrostatic pressure of water, combined with the normal biomechanics offered through this environment—as compared to other forms of unloading on land (pneumatic support).14,16
Without access to UWT or BWSTT, alternative options for conditioning must include consideration for range of motion and joint pain, as well as recovery from conditioning in a person who has not been doing so, regularly. Recumbent elliptical devices can be a more tolerable motion for the patient with osteoarthritis in the knee or hip while engaging in cardiovascular conditioning. Regardless of the machines or exercises utilized, the science of physiologic changes in strength and endurance leads us to understand that optimal presurgical care should begin at least 1 to 2 months prior to surgery. While it is beyond the scope of this article, it should be clear to therapists, surgeons, and healthcare consumers alike that an effective presurgical program will need to build a reserve of function in strength, muscular endurance, and cardiovascular capacities—three separate parameters of fitness. Programming should include both clinical and home exercise components for optimal dosage, to meet the goals stated above.
One approach to building fitness for a presurgical patient is to design exercise programs that carry over easily from the clinic to the home. A key to this strategy is to equip patients with exercise equipment for their own use that is similar to what they use in the clinic. Therapeutic elastic balls, bands, and tubing are a few examples of these types of tools. As patients work under the guidance of a therapist with an elastic band or tube performing resistance exercises aimed at building strength in upper or lower extremities, that patient likely will be more confident in performing a home program that uses similar equipment, sets, and repetitions. Therapy balls may be used in much the same way, in addition to sport cords and free weights. At home, patients may also find that foam rollers are useful for post-workout use in tissue massage, given considerations for surgical precautions and incisions.
A final consideration for presurgical conditioning includes High Intensity Interval Training (HIIT). When pain does not limit the patient’s ability to participate in HIIT, research has consistently shown the benefits of this application physiologically, requiring fewer repetitions and time to achieve similar levels over non-HIIT applications.14,16-20 Again, the reader is directed to less-impactful options such as an underwater treadmill, as stated above, for more successful HIIT participation in patients with osteoarthritis. An aquatic environment reduces the overall training load, and creates resistance and hydrostatic pressure.14,16-22
The CJR is a 5-year pilot project. Whether you are in the impacted regions the presurgical program outlined in this article is ready for the here and now, ready for the patient—and payor—alike. The opportunity to positively impact the quality of patients’ lives is ultimately what should be, and in some future models, what will be the basis for reimbursement. RM
Mike Studer, PT, MHS, NCS, CEEAA, CWT, is president and co-owner of Northwest Rehabilitation Associates. Studer is recent past chair of the Geriatric Section’s Balance and Falls Special Interest Group. He has been board-certified as a clinical specialist in neurologic physical therapy since 1995. In 2011, Studer received the Neurology Section Clinician of the Year from the APTA and received the same award from the Geriatric Section in 2014.
Kelsi Smith, PT, DPT, received her Doctorate in Physical Therapy from Washington University in St Louis in 2014. She is currently employed at Northwest Rehabilitation Associates in Salem, Ore. Her primary patient population includes multiple sclerosis (MS), Parkinson’s disease, stroke, vestibulopathy, healthy aging, and imbalance. For more information, contact [email protected].
1. Centers for Disease Control and Prevention. (2016). Disabilities and limitations. Retrieved from https://www.cdc.gov/arthritis/data_statistics/disabilities-limitations.htm.
2. Centers for Disease Control and Prevention-National Center for Health Statistics. (2015). Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000-2010. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db186.htm.
3. Snow R, Granata J, Ruhil AV, et al. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. J Bone Joint Surg Am. 2014;96(19):e165.
4. Greengard S. (2015). Understanding knee replacement costs: what’s on the bill?. Healthline. Retrieved from http://www.healthline.com/health/total-knee-replacement-surgery/understanding-costs.
5. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
6. Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am. 2012;94(3):201-207.
7. Centers for Medicare and Medicaid Services. (2015). Comprehensive care for joint replacement model. Retrieved from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-11-16.html.
8. American Physical Therapy Association. Comprehensive care joint replacement (CJR) model. Retrieved from https://www.apta.org/uploadedFiles/APTAorg/Payment/Medicare/Altnerative_Payment_Models/CJRSlides.pdf.
9. Brown B, Brosky JA, Topp R, Lajoie, AS. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study. Perceptual & Motor Skills. 2012;115(3):765-774.
10. Jones CA, Voaklander DC, Suarez-Almazor ME. Determinants of function after total knee arthroplasty. Phys Ther. 2013;83(8):696-706. Accessed July 06, 2016. Retrieved from http://ptjournal.apta.org/content/83/8/696.
11. Stuempfle K, Drury D. The physiological consequences of bed rest. J Exerc Physiol Online. 2007;10(3):32-41.
12. Campbell C. Deconditioning: the consequence of bedrest. Retrieved from University of Florida-Institute on Aging: http://aging.ufl.edu/files/2011/01/deconditioning_campbell.pdf.
13. American Physical Therapy Association-PT in Motion. 2014. Preoperative physical therapy results in ‘significant’ reduction in postoperative care use for patients undergoing hip or knee replacements. Retrieved from http://www.apta.org/PTinMotion/News/2014/10/2/PreOperativePT/.
14. Denning WM, Bressel E, Dolny DG. Underwater treadmill exercise as a potential treatment for adults with osteoarthritis. Int J Aquatic Res Ed. 2010;4:70-80.
15. Jack S, West M, Grocott MP. Perioperative exercise training in elderly subjects. Best Pract Res Clin Anaesthesiol. 201;25(3):461-72.
16. Bressel E, Wing JE, Miller AI, Dolny DG. High-intensity interval training on an aquatic treadmill in adults with osteoarthritis: effect on pain, balance, function, and mobility. J Strength Cond Res. 2014;28(8):2088-2096.
17. Weston M, Taylor G, Batterham A, Hopkins W. Effects of low-volume high-intensity interval training (HIT) on fitness in adults: a meta-analysis of controlled and non-controlled trials. Sports Med. 2014;44:1005-1017.
18. Burgomaster KA, Howarth KR, Phillips SM, et al. Similar metabolic adaptations during exercise after low volume sprint interval and traditional endurance training in humans. J Physiol. 2008;586:151-160.
19. Gibala MJ, Little JP, van Essen M, et al. Short-term sprint interval versus traditional endurance training: similar initial adaptations in human skeletal muscle and exercise performance. J Physiol. 2006;575:901-911.
20. Wertheimer V, Jukiæ I. Aquatic training – an alternative or a complement to the land-based training. Hrvat Športskomed Vjesn. 2013;28:3-66.
21. Robinson LE, Devor ST, Merrick MA, Buckworth J. The effects of land vs. aquatic plyometrics on power,torque, velocity, and muscle soreness in women. J Strength Cond Res. 2004;18(1):84-91.
22. Lambert BS, Greene AT, Carradine DP, et al. Aquatic treadmill training reduces blood pressure reactivity to physical stress. Med Sci Sports Exerc. 2014;46(4):809-816.