Maja Lit Review Draft 2

Knee replacement is becoming a frequently chosen option to treat joint pain as the
population ages and lives longer. Between 1997-2009, total knee replacement increased by 84%
in the American population.1 However, satisfaction rates can be very variable. Based on a study
published in the NCBI, only 22% of patients rated their satisfaction with total knee replacements
as “excellent.”2 From patient non-compliance with unnecessarily extended hospital stays, many
different factors affect patient satisfaction after total knee replacement.
Part of what increases patient satisfaction after knee replacement is how fast one can
return to prior function. The Accelerated article Rehabilitation After Total Knee Replacement
tested different ways to expand patient mobility after total knee replacement safely.Mr. David
Isaac conducted the study, Dr. and Tunde Falode, a General Manager for the Diabetes and
Cardiovascular Business Unit in the UK and Ireland at Sanofi, has found methods and made
adjustments to certain aspects of knee replacement, tested them and had published their results in
the journal The Knee in the year 2004. These titles give the researchers authority on the subject
matter on hand. 50 patients who were in the experimental group and 80 people in the control
group aged 42-88 participated in this study. There no other specific selection protocols in the
study.
The researchers wanted to test whether modifications to surgical and post-operative
procedures allowed patients to be safely discharged from the hospital earlier. The control group
did not receive accelerated rehabilitation and received the traditional surgery and post-operative
monitoring. It was predicted that more coordination between doctors and slightly modifying the
1
(n.d.). Value of Orthopaedic Treatment: Knee Replacement - A Nation in Motion. Retrieved
May 11, 2018, from https://www.anationinmotion.org/value/knee/
2
(n.d.). Patient satisfaction after total knee arthroplasty: who is satisfied and .... Retrieved May 11, 2018,
from https://www.ncbi.nlm.nih.gov/pubmed/19844772
procedure would drastically reduce the length of time spent in the hospital, increasing patient
satisfaction and financially benefiting hospitals. 3 Before operation day, patients were asked to
make sure that issues that arose, whether it was lack of aid, lack of transportation, etc. were
addressed before the operation to try to mitigate the effects of these problems as soon as
possible. When admitted to the hospital, patients were administered their required medication
and anti-embolic stockings. During surgery, each patient in both groups was given a spinal
anesthetic made of diamorphine and bupivacaine with occasional light sedation required. All
patients had one of two types of implants, and all implants were cemented. During the operation,
traditional surgical procedures were used until just before the prosthesis was cemented.
Postoperatively, the physical function of the patient’s knees was assessed on the American Knee
Society score and Oxford functional rating score. After six weeks post-op, 23 randomly selected
patients would return for revaluation and to measure a range of motion of the prosthetic knee.
Eight patients from both the experimental and control group were rated on a visual analog scale
from 1-10.
The hypothesis was generally supported 4. Patients were usually able to be safely discharged
faster from the hospital. The average length of hospital stay for people that were given
accelerated rehabilitation was 3.6 days, shortened from around the hospital average 10.5 days in
the hospital 5. Some patients in the experimental group even reported benefits to the accelerated
remission program. In most cases, pain levels were lower in the patients that underwent the
3
Issac, D., Flaode, T., & Liu, P. (2004, November 20). Accelerated Rehabilitation After Total
Knee Replacement. Retrieved April 26, 2018, from
https://pdfs.semanticscholar.org/ce91/7e1591b719d98f19e4e8028a1cfb92a37e6e.pdf
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accelerated rehabilitation, yet there was trouble following up with patients after their procedure;
therefore, the pain score data was not technically statistically significant 6. Another advantage of
this approach to knee replacement was that there was not enough blood loss to require
transfusion 7. According to the research team, it was noted that usually at least 8-11 percent of
patients need transfusions due to significant blood loss 8. The team hypothesized this is because
of the adrenaline and bupivacaine as well as the local anesthetic given to the patients to help heal
the wound faster and help patients attain some mobility surprisingly only days post op 9. Another
important thing about these improvements is that they are only slight modifications to already
existing procedures that could be readily adopted by medical professionals. The recommended
changes include the use of adrenaline before cementing the prosthesis, changing patient's
expectations, and making sure that everything such as prescriptions, home accommodations, and
care are prepared, and better communication between interdisciplinary doctors might be key to
safe and fast discharge 10. Not only do the patients have more faith in their recovery and higher
rates of satisfaction, but these alterations could be a financial benefit to the hospitals. The reason
this benefits the hospitals is that they can turn over more beds and spend less money per knee
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replacement patient and intensive care 11. The one drawback of these new methods would be
more home therapy visits which would require more outpatient physiotherapists 12. However a
positive is that there is no significant data that supports that the experimental or control group
needed more or less physiotherapy 13.
This study supports that it is possible to release patients safely and faster from the
hospital. This is key because it benefits everyone from the hospital that can save more money, to
the doctors who have more time to focus on different patients, to patients who have more faith in
themselves and their successful recovery. The more a patient believes in a return to proper and
painless function the more likely it is that they will be compliant with doing physical therapy on
their own and be motivated to get the most out of their prosthesis 14.
To understand patient noncompliance, it is vital to comprehend personal motivation and
compliance along with systematic factors such as hospital stays and surgical procedures. While
adapted surgical procedures can make a difference in patient satisfaction, to ensure long-term
patient satisfaction, the patient has to make sure that the muscles around the prosthesis are well
exercised and not weaken and atrophy as is common when patients do not use their knee
rendering the prosthesis almost useless. The results of physiotherapy are very beneficial. Quoting
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a research paper “Increased quadriceps and hamstring strength was observed following
treatment”15
Patient compliance is key to a successful recovery, and there are many reasons why
patients choose not to comply 16. Contrary to popular belief, while laziness can be a factor in
non-compliance, there are also many reasons to believe that there are other factors that can
influence non-compliers. A study titled Why don’t patients do their exercises? Understanding
non-compliance with physiotherapy in patients with osteoarthritis of the knee had researchers
Professor Rona Campbell and her research and her team interviewing patients and publishing
their data in the Journal of Epidemiol Community Health in the year 2001. Professor Campbell is
a professor of public health involved in conducting many systematic reviews for the WHO and
others giving her decent authority on this subject. The study was conducted in various University
departments in the Bristol UK area.
43 individuals were selected to do a participate in a physiotherapy program with two
phases. Initial phase and extended period that required doing kneecap taping and assigned
exercises at home. Later the physiotherapist assessed how compliant the patients were over time.
20 patients were picked at random, resulting in 14 female and 6 male patients that were to give
an interview based on either why they chose to or chose not to comply. The 43 participants were
to go through a physiotherapy program with two phases: an initial period of direct contact with
the physiotherapist and an extended period that required doing kneecap taping and assigned
15
"Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI."
https://www.ncbi.nlm.nih.gov/pubmed/10403263. Accessed 12 May. 2018.
16
Campbell, R., Evans, M., Q., & D. (2001, February 01). Why don't patients do their exercises?
Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee.
Retrieved April 26, 2018, from http://jech.bmj.com/content/55/2/132
exercises at home. Then the physiotherapist used improvement in muscle strength to assess how
compliant the patient was or not. Then the 20 interview participants were selected, and their
interviews were recorded and transcribed, each person detailing why they chose to comply or
not. After fact-checking and making sure the patient’s statements reflected the assessment rating
given by the therapist, researchers grouped comments based on commonalities between them.
There ended up being five major vital factors that determined patient compliance.
The significant factors found were general attitude towards exercise, perceived severity
of symptoms, personal ideas about the nature of the disorder, perceived effectiveness of the
treatment, and if there were perceived social norms that were not to be violated 2. While a
generally good relationship with exercise prior was helpful, the primary focus of this area is how
the patients perceived their tasks related to other aspects of their lives. Compilers saw these
exercises as an opportunity to improve their health while non-compliers saw them as obtrusive
and taking time out of their schedule. Many non-compliers cited a busy lifestyle and not enough
time to do these exercises. As one test subject puts it “So many things happening ... The boys
used to come in from school or work .....people come and see [wife] and ugh ...I’m out twice at
least a week to band practice and I have two engagements as well.”17 Perceived severity of
symptoms was also important in determining if a patient would comply. Patients who saw
themselves at risk for potentially losing mobility were more likely to continue doing their
exercises while non-compliers did not believe their symptoms impeded their lives that much as
put by a compliant patient “It got worse and worse and I started falling down ... Since I started
strengthening these muscles it seems I don’t fall over so much which is good ... it’s so
17 (n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12, 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/10403263
embarrassing.”18. Beliefs about the cause of their disease were also motivating factors 19. Patients
who believed that their arthritis was out of their control because of factors like age, weight, and
wear and tear were more likely to be resigned and unmotivated, however, patients who felt that
even though it cannot be cured, there is a change to mitigate the effects of arthritis were more
compliant 20. As explained by a non-compliant patient “[the exercise and taping] might not help
me because I’m getting old but it might help somebody else ...I just think I’m too old really to
improve.”21. Most obviously, how the effectiveness of the treatment was perceived was crucial
when determining if patients would continue the program. Logically, if someone does not see an
improvement in their condition after the program, chances are they will not continue it at home.
As a person who dropped the exercises states “ I was able to do [the exercises] pretty easily but it
didn’t appear to me to make a lot of difference . . . I carried them on during the time I was taking
part in the programme although I’ve dropped them since. .”22 Lastly, social obligations play an
interesting role in compliance 23.. If one does not want to disappoint a person in charge of their
care, they are more likely to comply. This is why compliance rates are higher during the initial
phase of treatment since people felt a certain loyalty to either the physiotherapist or to the
research 2. With one man citing his loyalty to the physiotherapist “Well I felt because
[physiotherapist] took the trouble of explaining it all to me I couldn’t turn around and say, “well
blow it, why bother sort of thing? You know? And when I first turned around and said that I
18
(n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12,
2018, from https://www.ncbi.nlm.nih.gov/pubmed/10403263
19
(n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved
May 12, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/10403263
20
(n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12,
21 (n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12, 2018, from
22 (n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/10403263
23
(n.d.). Why don't patients do their exercises? Understanding non-compliance .... Retrieved May 12,
2018, from http://jech.bmj.com/content/55/2/132
would do it, I felt well alright I wasn’t obligated to do it but I felt let’s do my bit towards it, you
know. I didn’t want her to simply think that she was wasting her time.” 24and another participant
citing his loyalty to the research:“I felt that I was contributing in some ways to research which
would probably benefit other people, and that really was why I went ahead with it ...I anticipated
some benefit for myself, but I thought well, this is great if this is going on, then I am
participating in something really worthwhile.” 25
The reason it is critical to understand patient compliance is because if simple issues in
understanding, effectiveness, and communication are corrected, that could drastically increase
motivation to do physiotherapy and increase the rate of recovery and patient satisfaction and
mobility. The suggestions placed by the non-compliant patients in these interviews can be crucial
information that can be used to help physiotherapists modify their treatment plans to keep
patients motivated.
Different types of physiotherapy can be used to adapt to varying levels of compliance.
For example, if someone is less compliant overall, then maybe regular contact with a
physiotherapist would be highly beneficial. If someone is however known to be generally
compliant, then an assigned physiotherapy regimen could be particularly helpful. It is also
essential to understand what acute care under the orthopedic surgeon and hospital was like in
order to determine how far along a patient is when it comes to performing necessary functions.
After understanding why quick recovery and patient compliance are essential, the effect
of different types of physiotherapy is also important to understand. Researchers Sara R. Piva1,
Charity G. Moore, Michael Schneider, and the team decided to test the effectiveness of different
24 (n.d.). Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI. Retrieved May 12, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/10403263
25
"Effectiveness of exercise therapy in patients with osteoarthritis ... - NCBI."
https://www.ncbi.nlm.nih.gov/pubmed/10403263. Accessed 12 May. 2018.
types of exercises and exercise environments on post-op knee replacement patients. The team
published their results in 2015. The subjects included 240 adults who underwent total knee
replacement at least two months before the experiment. The subjects were randomly assigned
into one of three treatment methods, one being clinical physiotherapy, the second being
community exercise classes, and the control group received regular medical treatment.
Quantitative data from each group were collected before the experiment, three months,
and lastly 6 months into each treatment method. The control group was randomly assigned into
one of the 2 experimental groups after 6 months of study participation and completed a 9-month
follow-up. The hypothesis stated by the researchers predicts that the experimental groups will
have better general physical capacity than their control group counterparts. The primary
dependent variable was physical function measured by the Western Ontario and McMaster
Universities Osteoarthritis Index Physical Function Subscale, and physical function was also
measured by performance-based tests. Secondary dependent variables included performance-
based tests and physical activity assessed by a patient survey and accelerometry-based physical
activity monitors. Other potentially essential outcomes included co-interventions, attrition, and
adverse events such as falls, and patient compliance 26. Data models have been fitted to compare
the changes in results across groups. Logistic regression defined patient characteristics that
predict the most functional recovery in the experimental groups. Other methods will be used to
estimate how effective each treatment method is, even in the presence of non-compliance.
Researchers Justine Naylor of Fairfield Hospital, who has participated in research in over
107 papers, Alison Harmer of the University of Marlene Fransen who is disciplined in
26 (2015, October 16). A randomized trial to compare exercise treatment methods for patients .... Retrieved May 12, 2018, from
physiotherapy, and their team set out around Australia to find evidence-based clinical guidelines
and make them available to doctors and physiotherapists during rehabilitation after total knee
replacement surgery. This was done by giving a survey Their disciplines and credentials provide
then decent authority in this area.
The survey was based upon a previous survey distributed to 4 different hospitals as well
as the researchers’ experience with total knee replacements. The final survey consisted of closed
and free-answer questions about the protocols used by physiotherapists and why the doctors
chose the “primary program” where they referred their patients. A non-probability sample was
used to select appropriate hospitals to conduct the survey. Ninety-five hospitals were randomly
selected from the 270 hospitals registered with the Australian Orthopaedic Association National
Joint Replacement Registry as performing total knee replacements. Private and public hospitals
were both equally included in this survey. The survey was distributed in November with the
proportion sent to each hospital dictated by the amount of representation in the Registry that the
researchers used. The physiotherapists primarily responsible for overseeing each primary
program were contacted. The surveys were distributed via e-mail, fax or mail. If participation
was declined, another hospital in the same area was randomly selected. In cases where the
registered hospital or contracted private practitioner predominantly referred patients elsewhere,
the listed facility or practice was also contacted when details were provided to minimize non-
compliance, reminders were sent two weeks after distribution of the survey.
170 copies were distributed in total, and 65 were returned to the researchers. Around 60 forms
were returned from acute care hospitals and 5 were sent from post-acute rehabilitation services.
In all 4 hospitals and care centers declined participation. Respondents included senior and
contracted orthopedic physiotherapists and department managers. The sample size was deemed
too small to draw statistically significant conclusions between public and private care centers 27.
The researchers still found a range of physiotherapeutic interventions found responses and
response rate similar between private and public practitioners 28. An array of types of
physiotherapy was reported for the acute postoperative period. Gait retraining exercises and
specific exercise prescriptions were the only interventions cited universally across the surveys 29.
How and when a patient was discharged from physiotherapy relied on factors in many areas of
knee function, but the requirement of independent walking was almost always required with 97
percent of participants citing it. Routine participation in outpatient or community-based

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physiotherapy was reported around 73%, to 95% percent of the time . While outpatient
rehabilitation was commonly cited, referral to inpatient rehabilitation was uncommon with only
3% of respondents citing it for regular use, and 45% of respondents referred patients to inpatient
physiotherapy on an as-needed basis only 31. 88% of providers referred patients to a primary
program with the most of the services being offered to outpatient programs 32. Individual
treatments were offered more often than supervised group class classes by 63% to 23%.
Monitored home exercise programs were cited 9% of the time as the primary program referred to
by care specialists 33. A small subset of 12% of respondents reported having ‘no primary
27
(2015, October 16). A randomized trial to compare exercise treatment methods for patients ....
Retrieved May 12, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/26474988
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program’ as only a few of their patients were referred for further physiotherapy 34.. Most
participants who cited no primary program explained this by stating that ‘further rehabilitation
was not usually necessary’ or that ‘the surgeon does not believe in rehabilitation.’
31 out of 52 centers referred patients to one-to-one treatments, 16 centers referred patients to
supervised classes or monitored exercise programs and five centers having an equal preference
for both 35. Care centers which stated that they did not provide primary programs or acute care
hospitals unable to provide information about post-discharge rehabilitation were removed from
the sample. The mean rehabilitation period reported the duration of post-acute rehabilitation was
observed to be 5.6 weeks with a range of 1 to 18 weeks. Rehabilitation commenced at 1.9 weeks
post-op 36.
This research is important because it demonstrates a large pool of physiotherapy options
people are not even aware of because their doctors rarely recommend them. If these people were
given more options, then perhaps they could choose an option that best suits their type of
motivation. For example, highly socio-competitive people may prefer to go to group
physiotherapy classes or highly self-motivated individuals may have an assigned exercise
regimen.
Nizar N.Mahomed, MD a Senior Scientist at The Krembil Research Institute, Aileen
M.Davis Ph.D. trained as a physiotherapist and clinical epidemiologist and received her
doctorate from the University of Toronto and is a Senior Scientist in the Division of Health Care
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and Outcomes Research and their team whose credentials are highly valid decided to test the
differences between inpatient and outpatient home therapy. They published their results in The
Journal Of Bone and Joint Surgery in August 2008. The study was conducted in various
hospitals in the New York and Toronto areas.
234 patients randomly selected, were either assigned home-based or inpatient
rehabilitation following total joint replacement. All patients followed standardized care pathways
and were evaluated, with the use of the Western Ontario and McMaster Universities
Osteoarthritis Index before surgery and at three and twelve months following surgery. The study
recruited patients undergoing total hip or knee replacements from two institutions. One was a
care referral center, and the other was a community hospital in the same area. Patient eligibility
for the study required that a patient is over the age of eighteen, were undergoing hip or knee
replacement for osteoarthritis, inflammatory arthritis, or osteonecrosis, were permanent residents
of the city where the two institutions were located, could speak English, and if they could give
informed consent to participate. Patients who met these requirements were identified by surgeons
in participating care facilities and were approached to participate in the trial by the study
coordinator. Eligible patients were only able to participate only after informed consent was
given. The protocol of the study and patient consent forms were reviewed and approved by the
Human Subject Review Committee. The primary dependent variable of the trial was the efficacy
of inpatient compared with home-based rehabilitation at three months after surgery when both
interventions were discontinued use of the function subscale of the Western Ontario and
McMaster Universities Osteoarthritis Index. Minor results included the measurement of health
status with use of Short Form-36 and patient satisfaction with the use of the Hip and Knee
Satisfaction Scale. All measurements were taken at baseline, three-month, and twelve-month
follow-up visits. The subjects completed each of the three questionnaires at each follow-up visit.
The Western Ontario and McMaster Universities Osteoarthritis Index, the Short Form-36, and
the Hip and Knee Satisfaction Scale were tests that assess patient satisfaction with the outcome
of total joint replacement regarding improvement in pain and function. Subjects were evaluated
approximately two weeks before surgery during a pre-operative hospital visit. This evaluation
included important information such patient demographics, valuable health information related
to their condition, socioemotional support, as well as completion of the surveys used in the study.
One week before surgery, the subjects’ methods of physiotherapy were randomly selected and
were informed of their randomization before surgery to allow sufficient time to prepare their
home settings if they were selected to do one-on-one private physiotherapy.
All subjects were admitted to an acute care hospital on operation day and were given post-op
care according to established and standardized care guidelines for total joint replacement.
Patients were excluded from the trial if any postoperative complications that delayed
participation in the rehabilitation protocol were discovered. These included heart problems,
cerebrovascular issues, fractures, wound infections, or any issues that required a return to the
operating room. The target length of inpatient stay at the hospital for both groups was five days.
All patients received the same physiotherapy protocol in the hospital before going into their
assigned outpatient care. Such exercises included active or active-assisted bed and chair
exercises, gait retraining, and assisted walking. Day 1 after surgery, goals were to be able to sit
and stand with minimal assistance or with a walker and to sit in a chair for an hour. Day 2 post-
op, goals were independent movement or walking from hospital bed to the bathroom with slight
assistance. From day 3 until discharge, goals were to regain independent walking and being able
to climb stairs. Patients assigned to home-based rehabilitation were deemed safe for discharge
from the hospital when they had achieved four critical functions: the ability to independently go
from lying down to sitting, independently being able to stand, independently walking a distance
of at least 30 meters, and if need be climbing stairs. Then they were referred to their respective
Community Care Access Centre. This center provided an early intervention program that ensured
that each subject was seen at home by a physiotherapist within forty-eight hours of discharge.
The subjects who were selected for inpatient rehabilitation were transferred to one of two
inpatient rehabilitation institutions depending on how many beds were available with a target
stay of 14 days. Subjects were discharged from the home-based program when their
physiotherapist thought that they had achieved enough functional improvement to attend an
outpatient clinic or maintain a self-directed program. All subjects returned to the operation
hospital at three and twelve months post-op for the follow-up evaluation by their operating
surgeon. Cost analysis was conducted from a health system perspective. Therefore, only direct
health-care costs were evaluated for acute care hospitals, inpatient rehabilitation hospitals, and
home-based rehabilitation services. This means physician fees, medications, indirect costs to the
patients or secondary caregivers were not included.
The average length of stay was 6.3 days for the group designated for inpatient
rehabilitation before transfer to that facility compared with 7 days for the home-based
rehabilitation group before being safely discharged home. The average length of stay in inpatient
rehabilitation was 17.7 days. The prevalence of postoperative complications up to twelve months
post-op was very similar among both groups. There was 2% rate of dislocation and a 3% rate of
deep vein thrombosis. The rate infection was 0% in the home-based care and 2% in inpatient
care. Both groups exhibited substantial improvement at both follow up visits, with no drastic
differences between the groups concerning the surveys given and there was no statistically
37
significant difference between the treatment groups in any of the measured baseline variables .
The total care costs in CAD for the inpatient rehabilitation and home-based rehabilitation was
around $14,532 and $11,082 respectively 38. 234 subjects were included in the study and 119 of
them were selected to participate in inpatient rehabilitation, and 115 subjects were assigned
home-based rehabilitation. The average age of the subjects was sixty-eight years, and around
two-thirds of the subjects were women. The mean body mass index was 28 kilograms per square
meter. Osteoarthritis was the most commonly cited diagnosis among subjects and most had two
or more other conditions. About two-thirds of subjects were white, and 20% were working
around the time of surgery. There were nearly equal proportions of hip and knee replacements.
No subject in the trial was lost to follow-up. At baseline evaluation, both treatment groups had
substantial pain and functional disability based on the surveys given, but no pre-op differences
were noted between the two groups. The statistical analysis for this study was conducted with
use of the intention-to-treat group of 115 patients who received home-based rehabilitation and
119 patients who had inpatient rehabilitation. Since researchers could not control the availability
of either type of service, the hospital stay lengths exceeded the target of five days for both
groups. The average length of stay was 6.3 days for the inpatient therapy group and 7 days for
the home-based rehabilitation group. The average length of stay in inpatient rehabilitation was
17.7 days 39. The range of postoperative home-based rehabilitation visits was four to sixteen
visits. All visits focused on physiotherapy and were approximately one hour per session. The
number of post-op complications up to twelve months after surgery was around the same in all
37
(n.d.). Inpatient compared with home-based rehabilitation following primary .... Retrieved May 12, 2018,
38
39
(n.d.). Inpatient compared with home-based rehabilitation following primary .... Retrieved
groups. There was a 2% rate of hip dislocation and a 3% rate of deep vein thrombosis in both
groups. No patients reported infections in the home-based group and only a 2% occurrence of
infection in the inpatient therapy subjects. Overall, both treatment groups had dramatic
improvements based on the survey scores at three months compared with the preoperative scores
40
. At twelve months, there was a mild continued improvement in the WOMAC results at twelve
months, yet this outcome is not statistically significant 41. A similar pattern occurred with the SF-
36 physical component scores, with both groups citing improvement in physical competency
scores at three months and continued development at twelve months after surgery compared with
preoperative scores, yet these results were also not statistically significant. With regards to
patient satisfaction, both groups generally reported similar higher scores on the Hip and Knee
Satisfaction Scale at three and twelve months post-op 42. Data was also picked apart to find
differences in improvement based on joint replacement site, and the researchers found no
differences in functional outcomes or patient satisfaction by whether patients had undergone a
hip or a knee replacement. The mean costs for the stay in the acute care hospital besides
operation day for the inpatient rehabilitation and home-based rehabilitation groups were $9411
and $10,191 respectively. This slight difference may reflect the slightly longer acute care
hospital stay for the home-based rehabilitation group compared with the inpatient rehabilitation
group as progress had to be made quickly to release patients faster. The most significant gap in
cost resulted from the post-discharge physiotherapy of the care duration. There was a nearly
sixfold difference in the mean price for inpatient rehabilitation compared with that for home-
40
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based rehabilitation with one ranging from $5120 to $7552 and the other ranging from $891 to
$1316 respectively 43.
Each source either discusses different types of physiotherapy, surgical procedures, or
both. Some examine the efficacy of different types of physiotherapy and others explained how
perceptions of physiotherapy affected compliance. Two articles talked about how shorter
inpatient care helped hospitals function better and save money. Most reports did reference patient
compliance in one way or another, and one had highlighted it as its central focus. Only a single
study however specifically talked about modifying surgical procedures as well as advanced
physiotherapy. The rest of the studies referenced either spoke about patient compliance or tested
different types of physiotherapy against each other. Each study used similar methods including
randomized trials, related subjects in similar age ranges, usually undergoing similar procedures.
Differences between methodologies include using different scales and ways of measuring
improvements in knee functioning. The topics were generally related. They were generally older
adults who have had painful joint conditions and have chosen to undergo total knee replacement.
The subjects were usually not selected via other criteria such as gender, race, or other
demographics. The sample sizes would range from small 20 items up to 234 subjects. The
studies would last anywhere from 3 to 12 months. Researchers generally wanted to try and find
more efficient types of physiotherapy, improve surgical procedures, or study and understand
patient non-compliance. The consensus among these articles is that quick and satisfactory
recovery is ideal which requires that patients comply with the physiotherapy regimens given. The
studies that compared different types of physiotherapy found no drastic differences in
performance between types of physiotherapy used. Each study is crucial and provides useful
43
(n.d.). Inpatient compared with home-based rehabilitation following primary .... Retrieved
information about contributors successful recovery after total knee arthroplasty. The first article
mentions how important it is to hasten recovery. The second analyzes patient non-compliance,
the third, fourth, and fifth compare different types of physiotherapy. These are all critical factors
which all influence the quality of recovery and thus patient satisfaction.
A reason why this research is necessary is that the human race is living longer than ever.
According to research published in 2010 “Since 1800, lifespans have doubled again, largely due
to improvements in the environment, food, and medicine that minimized mortality at earlier
ages.”44. This means that there will be older people who will probably want to be as self-
sufficient as possible before death. Therefore improvements in how total knee replacements and
physiotherapy are handled are crucial for keeping aging people in shape and self-sufficient for
longer.
Another critical reason to advocate for this research is that with this aging population,
knee implants will inevitably become more commonplace. Already sources state that “Around 7
million Americans are living with a hip or knee replacement” 45

and this number is expected to
exceed 3 million by the year 2030 46. With more people opting for this surgery, it is crucial to
analyze data on knee implants and create services that will help make the recovery process more
efficient.
44
(2010, January 26). Evolution of the human lifespan and diseases of aging: Roles ... - PNAS.
Retrieved May 12, 2018, from http://www.pnas.org/content/107/suppl_1/1718
45
(n.d.). Prevalence of Total Hip and Knee Replacement in the United States.. Retrieved May 12,
46
(n.d.). Value of Orthopaedic Treatment: Knee Replacement - A Nation in Motion. Retrieved May 12,
2018, from https://www.anationinmotion.org/value/knee/
Sources:
Campbell, R., Evans, M., Q., & D. (2001, February 01). Why don't patients do their exercises?
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Naylor, J., Harmer, A., & Fransen, M. (2006). Status of physiotherapy rehabilitation after total
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Knee replacement is becoming a frequently chosen option to treat joint pain as the

different factors affect patient satisfaction after total knee replacement.

The researchers wanted to test whether modifications to surgical and post-operative

needed more or less physiotherapy 13.

To understand patient noncompliance, it is vital to comprehend personal motivation and

departments in the Bristol UK area.

43 individuals were selected to do a participate in a physiotherapy program with two

participating in something really worthwhile.” 25

The reason it is critical to understand patient compliance is because if simple issues in

Different types of physiotherapy can be used to adapt to varying levels of compliance.

physiotherapist would be highly beneficial. If someone is however known to be generally

compliant, then an assigned physiotherapy regimen could be particularly helpful. It is also

of different types of physiotherapy is also important to understand. Researchers Sara R. Piva1,

measured by performance-based tests. Secondary dependent variables included performance-

then decent authority in this area.

registered hospital or contracted private practitioner predominantly referred patients elsewhere,

percent of participants citing it. Routine participation in outpatient or community-based

31 out of 52 centers referred patients to one-to-one treatments, 16 centers referred patients to

This research is important because it demonstrates a large pool of physiotherapy options

motivation. For example, highly socio-competitive people may prefer to go to group

physiotherapy classes or highly self-motivated individuals may have an assigned exercise

Nizar N.Mahomed, MD a Senior Scientist at The Krembil Research Institute, Aileen

hospitals in the New York and Toronto areas.

234 patients randomly selected, were either assigned home-based or inpatient

replacement for osteoarthritis, inﬂammatory arthritis, or osteonecrosis, were permanent residents

home settings if they were selected to do one-on-one private physiotherapy.

patients or secondary caregivers were not included.

differences in functional outcomes or patient satisfaction by whether patients had undergone a

$1316 respectively 43.

Each source either discusses different types of physiotherapy, surgical procedures, or

studies that compared different types of physiotherapy found no drastic differences in

million Americans are living with a hip or knee replacement” 45

Total Knee Replacement - OrthoInfo - AAOS. (n.d.). Retrieved from

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