Catherine J Minns Lowe

Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis. Design Systematic review. Data sources Database searches: AMED, CINAHL, Embase, Kings Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis. Outcome measures Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity. Results Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to four months postoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (−1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year. Conclusions Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit.

Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials

AbstractBackgroundPhysiotherapy has long been a routine component of patient rehabilitation following hip joint replacement. The purpose of this systematic review was to evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for osteoarthritic patients following elective primary total hip arthroplasty.MethodsDesign: Systematic review, using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Quorom Statement. Database searches: AMED, CINAHL, EMBASE, KingsFund, MEDLINE, Cochrane library (Cochrane reviews, Cochrane Central Register of Controlled Trials, DARE), PEDro, The Department of Health National Research Register. Handsearches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. No language restrictions were applied. Selection: Trials comparing physiotherapy exercise versus usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. Outcomes: Functional activities of daily living, walking, quality of life, muscle strength and range of hip joint motion. Trial quality was extensively evaluated. Narrative synthesis plus meta-analytic summaries were performed to summarise the data.Results8 trials were identified. Trial quality was mixed. Generally poor trial quality, quantity and diversity prevented explanatory meta-analyses. The results were synthesised and meta-analytic summaries were used where possible to provide a formal summary of results. Results indicate that physiotherapy exercise after discharge following total hip replacement has the potential to benefit patients.ConclusionInsufficient evidence exists to establish the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. Further well designed trials are required to determine the value of post discharge exercise following this increasingly common surgical procedure.

Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review

BACKGROUND Existing review required updating. OBJECTIVE To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis. DESIGN Systematic review from January 2007 to November 2013. DATA SOURCES AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied. ELIGIBILITY CRITERIA Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. OUTCOMES Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion. STUDY APPRAISAL Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered. RESULTS 11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening. LIMITATIONS The overall quality and quantity of trials, and their diversity, prevented meta-analyses. CONCLUSIONS Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.

Supported community exercise in people with long-term neurological conditions: a phase II randomized controlled trial

Objective: Adults with long-term neurological conditions have low levels of participation in physical activities and report many barriers to participation in exercise. This study examines the feasibility and safety of supporting community exercise for people with long-term neurological conditions using a physical activity support system. Design: A phase II randomized controlled trial using computer-generated block randomization, allocation concealment and single blind outcome assessment. Setting: Oxfordshire and Birmingham community Inclusive Fitness Initiative gyms. Subjects: Patients with a long-term neurological condition. Interventions: The intervention group (n = 51) received a 12-week, supported exercise programme. The control group (n = 48) participants received standard care for 12 weeks and were then offered the intervention. Main measures: Physical activity, adherence to exercise, measures of mobility, health and well-being. Results: Forty-eight patients (n = 51) completed the intervention, achieving 14 gym attendances (range 0–39) over the 12 weeks. Overall activity did not increase as measured by the Physical Activity Scale for the Elderly (change score mean 14.31; 95% confidence interval (CI) −8.27 to 36.89) and there were no statistically significant changes in body function and health and well-being measures. Conclusions: People with long-term neurological conditions can safely exercise in community gyms when supported and achieve similar attendance to standard exercise referral schemes, but may reduce other life activities in order to participate at a gym.

Living with a symptomatic rotator cuff tear 'bad days, bad nights': a qualitative study.

BackgroundRotator cuff tears are a common cause of shoulder pain. There is an absence of information about symptomatic rotator cuffs from the patients’ perspective; this limits the information clinicians can share with patients and the information that patients can access via sources such as the internet. This study describes the experiences of people with a symptomatic rotator cuff, their symptoms, the impact upon their daily lives and the coping strategies utilised by study participants.MethodsAn interpretive phenomenological analysis approach was used. 20 participants of the UKUFF trial (The United Kingdom Rotator Cuff Surgery Trial) agreed to participate in in-depth semi-structured interviews about their experiences about living with a symptomatic rotator cuff tear. Interviews were digitally recorded and fully transcribed. Field notes, memos and a reflexive diary were used. Data was coded in accordance with interpretive phenomenological analysis. Peer review, code-recode audits and constant comparison of data, codes and categories occurred throughout.ResultsThe majority of patients described intense pain and severely disturbed sleep. Limited movement and reduced muscle strength were described by some participants. The predominantly adverse impact that a symptomatic rotator cuff tear had upon activities of daily living, leisure activities and occupation was described. The emotional and financial impact and impact upon caring roles were detailed. Coping strategies included attempting to carry on as normally as possible, accepting their condition, using their other arm, using analgesics, aids and adaptions.ConclusionsClinicians need to appreciate and understand the intensity and shocking nature of pain that may be experienced by participants with known rotator cuff tears and understand the detrimental impact tears can have upon all areas of patient’s lives. Clinicians also need to be aware of the potential emotional impact caused by cuff tears and to ensure that patients needing help for conditions such as depression are speedily identified and provided with support, explanation and appropriate treatment.

Musculoskeletal Physiotherapy in Primary Care Sites: Survey of English NHS trusts

Summary Objective To determine the extent of GP/health centre-based musculoskeletal physiotherapy services provided by NHS trusts in England; to ascertain the value of relocation to primary care settings as perceived by physiotherapy service managers; to discuss implications; and to identify issues for further research. Methodology A postal survey, using a questionnaire with closed and open questions, was carried out. Questionnaires were sent to physiotherapy service managers in all 325 NHS trusts in England who supplied a musculoskeletal physiotherapy service. Questionnaires were piloted before the main study. Results A response rate of 76.3% (n = 248) was obtained. Of trusts responding to the survey, 80% provided musculoskeletal physiotherapy services located in GP/health centres. Rapid expansion in services was perceived to be demand-led with 47.8% of managers planning future expansion. Of physiotherapy service managers 60.6% considered that the provision of this service increased physiotherapy membership of the primary healthcare team which was advantageous for the physiotherapy profession; 49.8% believed the service offered increased benefits to patients. The risk of isolation from peers was raised by 48.8% of managers. Professional isolation, the risk of professional fragmentation, the impact of restricted on-site resources on the quality of patient care, and staffing issues were identified as issues that needed to be addressed. Conclusions The issues raised by this study require consideration during the development of primary care trusts. Managers perceived that a shift in location of physiotherapy services will have implications for equitable service provision. The rapid expansion of these services will require manpower planning and, in the shorter term, may threaten quality in other core areas of physiotherapy practice.

Letter to the Editor:Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society

To the Editor: We are writing in response to the recent publications in this Journal [2, 3] regarding The Knee Society’s standardized list and definitions associated with TKA. The importance of identifying, recording, and evaluating complications following TKA cannot be overstated. We support the importance of this list in assisting “surgeons, researchers, health plans, and government officials” to evaluate the “surgical results and patient outcomes after knee arthroplasties” [2]. However, we are concerned that this list cannot currently meet this purpose due to the absence of important complications affecting outcomes. The most obvious example of a missing complication is pain. The reported proportion of people with unfavorable postoperative long-term pain in studies ranges from about 10% to 34% after knee arthroplasty [1]. Even in the best quality studies, approximately 20% of patients report long-term pain following knee arthroplasty [1]. Yet, this complication is not currently included in the list. Healy and colleagues’ decision to exclude conditions considered not clearly defined as complications directly related to surgery, such as poor functional outcome, limit The Knee Society’s list of complications and outcome following surgery. We would like to raise the question, should complications such as pain should be included in the list, for discussion. The Knee Society list was developed via a literature review and survey of Knee Society members. Recent preliminary research indicates that patients report a wider variety of complications following arthroplasty, perceive the importance of complications differently than healthcare professionals, and report different complications from the Knee Society’s list [4]. It is our view that any standardized list designed to improve collection and evaluation of complications following TKA must reflect all important complications affecting outcomes — not just those associated with the surgical procedure. The Knee Society’s list currently contains important and highly relevant complications related to surgery, but does not, in our opinion, currently achieve these aims. Could this initial list be expanded to incorporate patients’ views and thus achieve a more comprehensive list of complications affecting patient outcomes? We would then be in a position to use one list to obtain a much clearer picture of complications following TKA than obtained by concentrating upon the surgical procedure alone.