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A Comparative Study on Supervised Clinical Exercise versus Home Based Exercise in Primary Unilateral Total Knee Arthroplasty
Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS,
D.Ortho***

Abstract: Objective. This study was designed to investigate the effects of supervised clinical exercise and home Based Exercise in patient with unilateral total knee arthroplasty in sub acute phase (after 5-6 weeks of discharge). To assess the effect on function ability of patient after primary unilateral total knee arthroplasty. To assess the effect on knee integrity (it include pain, ROM, knee stability)of patient after primary unilateral total knee arthroplasty. Methods. 130 subjects were recruited from OPD physiotherapy among the patient discharge from hospital and randomly divided into supervised clinic exercise and home based exercise. Socio demographic and clinical data, pain, range of movement (ROM) and function of TKA patients were collected on day of discharge (ie day 5 to 8 post operation). A self designed data capture sheet, the goniometer, VAS (Visual Analogue Scale) and ILOA (Iowa Level of Assistance) KSKS (kne society knee score)were used to measure data. Criteria for recruitment is patient having primary unilateral total knee replacement, having a functional hip on operated side, both male and female and age between 50 to 80 years. Able to follow simple verbal commands. Patient excluded from study who are suffering from Rheumatoid Arthritis, revision TKA, bilateral knee arthroplasty. Results. The results indicate that there is significant difference between experimental group (supervised clinical exercise) and Control group (home based exercise). For knee integrity measured using the Knee Society Knee Score (p=0.017)and function measured using the ILOA Scale (p= 0.018) and goniometry (p=>0.05). The average age was 64 years in male and 66 years in females . There were 41% males and 59% females. There is statistical difference between pain, range of motion, Knee integrity, Knee functional outcomes of groups that receive post-

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discharge outpatient physiotherapy as compared to those who do not attend physiotherapy. Conclusions. After primary total knee arthroplasty, patients who completed a home based exercise program (control group) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (supervised clinic exercise ie. experimental group). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs. The overall aim of this study was to establish the early post operative status of Total knee arthroplasty patient.

Key words: Supervised clinical exercise, Home based exercise, KSKS (knee society knee score), ILOA (ILOA level of assistance)

INTRODUCTION Osteoarthritis is a leading cause of pain and disability affecting joints (Marchet al 1999). Progressive loss of the articular cartilage can result in joints that are painful and inflamed. The joint becomes stiffer and there is less stability in the joint (Parmet et al 2003). These factors affect the function of the joint which ultimately impacts on patients functional ability and their quality of life (March et al 1999). Total knee arthroplasty has been found to be effective in the management of pain (Palmer & Cross, 2004), functional status and quality of life in people suffering from OA, rheumatoid arthritis (RA) and related conditions (Zavadak et al., 1995). Physiotherapists contractures aim et to al., prevent 2006)

aims to minimize the complications following total knee replacements and to rehabilitate the patient to full functional recovery. Techniques such as cryotherapy, strengthening and stretching exercises are used (Zavadak et al 1995). Physiotherapy in hospital also includes functional

techniques such as bed mobility, transfers, ambulation and stair climbing. An

assumption can be made that if there is a relationship between knee integrity and function, physiotherapists may decide to only work on improving function, or only work on improving knee knee of integrity motion,

(improving

range

reducing swelling, reducing pain and improving muscle strength). Time could then be better utilized on one aspect of rehabilitation. Early discharge can sometimes result in transfer to an inpatient facility. A study by Bozic et al. (2006), states that clinical,

(Lenssen

decrease pain and swelling and improve knee and functional mobility in

preparation for discharge (Oldmeadow et al.,2002. Post operative physiotherapy

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Scientific Research Journal of India operation who gave

29 informed

demographic and socioeconomic factors all affect the decision to discharge a patient to an inpatient rehabilitation centre. Objective of the Study: To assess the effect on knee integrity (it include pain, ROM and knee stability) and knee function ability. To establish

constant).Able to follow simple verbal commands

Exclusion criteria: Any additional trauma to the lower limb, inability to participate in the assessment from a physical and cognitive point of view such as dementia, confusion etc. Inability of the patient to walk prior to the TKA(with suffering or from without aid). Patient Arthritis. in the

pain,ROM of the operated knee and functional level of TKA patients. To establish socio-demographic factors and clinical data of TKA patients on first follow up. To establish the relationship amongst supervised clinical exercise as well as home based exercise and

Rheumatoid to participate

Unwillingness

assessments Revision TKA, Bilateral knee arthroplasty. Inability of the patients to walk prior to the total knee replacement (with or without the aid of an assistive device).

postoperative functional status of TKA patients. To study this procedure can be clinically implemented.

MATERIAL AND METHODS Subjects: 130 subjects were recruited from OPD physiotherapy among the patient discharge from hospital and Design of study: The study employed a randomized single blind controlled experimental study design consisting of two group experimental group and control group, Subjects were randomly assigned either to experimental Inclusion criteria: Patient having primary unilateral total knee replacement having a functional hip on operated side .Both male and female who had a primary unilateral TKA able to give independent informed consent Patient between the age of 50 to 80 years of age, presented to the first follow-up session. (This was around six to eight weeks post http://www.srji.co.cc group or to control group everyday in physiotherapy OPD before discharge , each time when a patient met the criteria for inclusion a random number were picked up between 1 to 10 using sealed envelope method if it were an odd number than the subject were assigned to

randomly divided into supervised clinic exercise and home based exercise.

experimental group.

Intervention Supervised clinical exercise: These are exercise which are perfomed by patient under the observation of a qualified physiotherapist. Postoperative

assistive devices and appliance, walking pattern, safety & precaution, dos and donts.

Outcome Measures: ILOA : The patients functional ability was assessed using the Iowa Level of Assistance (ILOA) Scale, which was first described by Shields et al (1995). It was shown to be reliable and valid.The best overall result the patient is able to achieve with this scale is zero. This indicates that the patient was able to perform all five tasks independently without the use of any assistive device. The worst overall score that could be achieved is fifty which indicates that the patient was unable to perform the tasks due to medical and safety reasons and the assistive device used for standing or mobilizing was a walking frame. KSKS: This rating system was developed in 1989 by the American Knee Society to provide an evaluation form for knee integrity (Insall et al, 1989). The knee assessment has three parameters which measure pain, stability and range of motion. The knee is given a score out of a hundred. A well-aligned knee with no pain, negligible instability and range of motion of 125 degrees scores a hundred points Goniometry: It is a measuring tool used to assess the range of motion of a joint. It can be used as an initial assessment and it

rehabilitation usually consists of passive and active knee mobilisation, quadriceps strengthening and functional activities (Lenssen et al., 2006). Hip and knee flexion; hip and knee extension in neutral; hip abduction; hip adduction to neutral; ankle dorsi- and plantar flexion, static

quadriceps contraction and inner range quadriceps contraction over a rolled up towel. The physiotherapist performs antiinflammatory modalities on the patient which include ultrasound, interferential therapy, pulsed short wave diathermy, transcutaneous electrical nerve stimulation (TENS), laser, acutouch and heat or cryotherapy. Myofascial release,

continuous passive mobilisation exercises, stretching, strengthening exercises, gait re-training, massage, patient education and an exercise programme are also prescribed. Home based exercise: Home based exercise group performed the exercise which are explained and demonstrated by physiotherapist in OPD at the time of discharge to the patient for home, which included quadriceps, isometric knee exercises of for

range

motion,

strengthening exercise, effective use of

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evaluate the patients progress (Rothstein et al 1983). Rothstein et al (1983) assessed goniometric reliability and which

TKA patients, Knee integrity and Sociodemographic factors and clinical data of TKA patients, The relationship between identified factors and postoperative

goniometer size was the most reliable in a clinical setting.

functional status of TKA patients in relevance of level of assistance (ILOA) in

DATA ANALYSIS AND RESULTS All continuous variables were presented by mean. The statistical significance of P value was set at 0.05. One-way repeated measures analysis of variance (ANOVA) was made to compare ILOA score, KSKS score, Goniometry range between-groups. 130 subjects were recruited from OPD physiotherapy among the patient

control group mean (home based exercise) is11.94 and experimental group

(supervised clinical exercise) 10.01 (p= 0.018), KSKS in control group mean (home based exercise) is74.72 and

experimental group (supervised clinical exercise) 76.78 (p=0.017), goniometry in control group mean (home based exercise) is 88.06 and experimental exercise) group 95.52

(supervised

clinical

discharge from hospital and randomly divided into supervised clinic exercise and

(p=>0.05) found.

ROM Knee Flexion

ROM )in degtree) 150. 100. 50. 0. pre Home Super 30.46 28.86 post 88.06 95.52

home based exercise. 19 patients not fulfilled the inclusion criteria and four patients due to prolonged hospital stay for medical reasons, two patients for medical conditions, two patient consented to the socio demographic and clinical

questionnaire, but not to the goniometry and Iowa Level of Assistance (ILOA) testing, and therefore had to be excluded. One patient refused to be tested two patient had been discharged before the

Graph 1: Showing the mean and significance level of range of motion of two group of supervised and home based exercise.
40. 30. Level of assistence 20. 10. 0. pre Home Super 33.9 32.9 post 11.94 10.1

ILOA

researcher had been able to collect data (morning of day three). The following results are presented: Range of movement (ROM) of the operated knee and functional level of

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Graph 2: Showing the mean and significance level of IOLA(level of assistance) of two group of supervised and home based exercise.

been shown to reduce pain in patients at intervals of 24-hours, 48-hours, 72- hours and at one to eight weeks post operation (Hubbard and Denegar 2004; Jensen et al

Knee integrity & function

100. 50. 0.

KSKS

1985; Jarit et al 2003). 2: Range of motion: People normally require knee flexion of 45 to 105 during

pre Home Super 18.16 18.52

post 74.72 76.78

various activities of daily living. To demonstrate a normal gait pattern, 65 of flexion is required. To ascend and descend stairs, 90 of flexion is needed and to go from sitting to standing, 105 of flexion is required (Miner et al 2003). From the results of the range of movement shows that experimental group (mean=95.52) and control group (mean=88.06), one can assume that 51% of the patients (twenty six patients) would not be able to go from sitting to standing as they only had knee flexion of 80. However, from our sample of 50-patients, 24-patients (49%) who had 90-100 of knee flexion were able to go from sitting to standing independently without any assistance or assistive devices. Patients with less than 95 of knee flexion had worse Goniometry scores (p<.0001). Only patients with a very stiff knee will have function that is really affected by ROM. Their study identified 95 of knee flexion as a clinically meaningful cut-off point above which ROM does not limit a patients normal activities after TKR. However the long-term effects of this limitation of ROM could be detrimental to

Graph 3: Showing the mean and significance level of KSKS (knee society knee score) of two group of supervised and home based exercise. DISCUSSION KSKS: 1. Pain: Fifty percent of the patients had virtually no pain at six weeks post operation. The other fifty percent had pain that ranged from occasional to severe pain Two patients (4%) had severe pain. This indicates that the patients pain is not being managed well at home after discharge. They are perhaps not given physiotherapy modalities which are

healing in reducing pain. Cryotherapy and simultaneous exercise is more effective in reducing pain than icing alone. Icing and compression also helps to reduce pain in patients post surgery. Transcutaneous Electrical Nerve Stimulation (TENS)

causes a reduction of pain in 93% of patients who undergo surgery and the TENS group of patients consumed less pain medication. Interferential therapy has

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the normal joints, because of the patients over compensation when performing

this range of motion, the patient should manage functionally. Patients also

activities of daily living. 3. Knee Stability and alignment: The majority of the patients had normal stability and alignment. This indicates that the total score of the Knee Society Knee Score in this sample is not really affected by the components of stability and alignment, but mainly by pain and ROM. Malalignment of the prosthesis could result in stiffness which although

compensate when performing activities by using the other leg or their arms to assist with transfers. The quality of is the not

movement

being

performed

important to the patient, what is of importance is completing the movement by any means possible. The long term effect of poor ROM and poor quality of movement is that the normal joints take excess strain and over a prolonged period, there is an increased risk of developing pain and discomfort in the normal joints due to osteoarthritis. ILOA Score: Most of the patients were able to go from lying to sitting, sitting to standing and walking 4.57 meters independently, with minimal assistance. The patients scored very well in these three categories. This indicates that the ILOA Scale is not a sensitive enough functional measuring tool when used at six weeks post operation. It measures basic functional ability, not higher function. It was developed to determine whether patients who had had total hip and knee replacements were ready to be discharged from hospital (Shield et al 1995). It is the role of physiotherapists in the hospital to ensure that patients are able to perform basic transfers so that they will be independent at home, after they are discharged from http://www.srji.co.cc

uncommon is a disabling problem (Jerosh and Aldawoudy 2007). Treatment of malalignment could include manipulation or revision arthroplasty (Bong and Di Cesare 2004),which has been shown to be successful in terms of post-operative function(Miner et al 2003). 4. Knee Flexion contracture and extension lag: A percentage of the patients in this study had some degree of a flexion contracture and some degree of an extension lag at six weeks post operation. This could indicate that attaining full knee extension and flexion is not that important when it comes to functional activities such as going from sitting to standing, walking and stair climbing, as these same patients performed well when assessed using the ILOA Scale. Functional range of motion is between 45 and 105 (Miner et al 2003). As long as the extension lag and the flexion contracture do not interfere with

hospital. Five patient did not use an assistive device to perform the five functional tasks. She did however require nearby supervision for the walking, stairs and the speed test. Two patients used a walking frame at six weeks after the operation. Only one patient was unable to climb the stairs even with maximal assistance

therapist with knowledge of their acute postoperative rehabilitation status and appropriate that will

programme

influence their prognosis. integrity which was measured using the Knee Society Knee Score and function as measured using the ILOA Scale, six to eight weeks post surgery on total knee replacement. Research Recommendations: A functional tool should be developed that

CONCLUSIONS The goal of a TKA is to provide the patient with a stable and painless knee with sufficient ROM to perform ADLs (Gandhi et al., 2006). As many studies only focused on the long-term status of TKA patients (Aarons et al., 1996), this study examined the short-term status. The value of this is to furnish patients and the

assesses

the

attainment

of

higher

functional milestones, as well as the quality of the movement. If a more sensitive functional assessment tool was used, one that looked at higher functional levels, a more accurate functional

evaluation of the knee replacement could be determined.

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ACKNOWLEDGMENT: The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance throughout the study.

CORRESPONDENCE:
*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This study was not funded through a grant from the any organization.