Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy following total knee arthroplasty: Design of a randomised controlled trial [ISRCTN85759656]

BACKGROUND: Adequate and intensive rehabilitation is an important requirement for successful Total Knee Arthroplasty. The primary focus of early rehabilitation is ambulation of patients and regaining range of motion in the knee. Although research suggests that Continuous Passive Motion should be implemented in the first rehabilitation phase following surgery, there is substantial debate about the duration of each session and the total period of CPM application and. A Cochrane review on this topic concluded that short-term use of CPM leads to greater short-term range of motion. It also suggested, however, that future research should concentrate on the treatment period during which CPM should be administered. METHODS: In a randomised controlled trial we intend to investigate the efficacy of prolonged use of a continuous passive motion (CPM) device in the home situation as an adjunct to standardised physical therapy. The experimental treatment is compared to standardised physical therapy, in patients with osteoarthritis of the knee undergoing Total Knee Arthroplasty (TKA). Efficacy will be assessed in terms of faster improvements in range of motion and functional recovery. Seventy patients with knee osteoarthritis undergoing TKA and experiencing early postoperative flexion impairment (less than 80° of knee flexion at the time of discharge) will be randomised over two treatment groups, a usual care group and an experimental group The experimental group will receive CPM + physiotherapy for 17 consecutive days after surgery, whereas the usual care group will receive the same treatment during the in-hospital phase (i.e. about four days), followed by physical therapy alone (usual care) in the first two weeks after hospital discharge. From 18 days to three months after discharge, both groups will receive standardised PT. The primary focus of rehabilitation will be functional recovery (e.g. ambulation) and regaining range of motion (ROM) in the knee. DISCUSSION: Because restricted knee ROM affects functional activities, knee ROM and knee function are regarded as the primary indicators of successful TKA. Potential effects of the intervention under study include rapid return of knee flexion accompanied by earlier return to functional activities of daily life. If patients benefit significantly from prolonged CPM use, this treatment should be added to the standard PT treatment at home. We expect the additional home CPM programme to be more effective than the usual physiotherapy programme, resulting in a difference in ROM of at least 5°, 17 days after surgery. This clinically important difference, with a possible flexion ROM of about 100°, is expected to lead to better functioning in activities of daily life, like walking, and earlier ability to cycle. These advantages should result in earlier and increasing independence

Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT

BACKGROUND: The main goal of physical therapy treatment (PT) in the clinical stage following total knee arthroplasty (TKA) is to prepare patients for discharge from the hospital as soon as possible after their operation. Although aggressive rehabilitation is believed to be important, evidence of effects of different exercise programmes following TKA is limited. This led to the question whether the intensity of PT (once versus twice daily) following TKA affects short-term recovery, measured as range of motion. METHODS: A randomised controlled trial compared an exercise regimen of two sessions per day with a similar programme administered once daily. Primary outcome measure was ROM. RESULTS: At the time of hospital discharge, there was no difference between the experimental and control groups in range of motion. CONCLUSION: This study shows that in our setting twice daily PT sessions do not produce different results as daily PT sessions. It may be questioned whether multiple daily therapy sessions are needed as an in-hospital PT regimen in OA total knee patients

Reproducibility of goniometric measurement of the knee in the in-hospital phase following total knee arthroplasty

<p>Abstract</p> <p>Background</p> <p>The objective of the present study was to assess interobserver reproducibility (in terms of reliability and agreement) of active and passive measurements of knee RoM using a long arm goniometer, performed by trained physical therapists in a clinical setting in total knee arthroplasty patients, within the first four days after surgery.</p> <p>Methods</p> <p>Test-retest analysis</p> <p>Setting: University hospital departments of orthopaedics and physical therapy</p> <p>Participants: Two experienced physical therapists assessed 30 patients, three days after total knee arthroplasty.</p> <p>Main outcome measure: RoM measurement using a long-arm (50 cm) goniometer</p> <p>Agreement was calculated as the mean difference between observers ± 95% CI of this mean difference. The intraclass correlation coefficient (ICC) was calculated as a measure of reliability, based on two-way random effects analysis of variance.</p> <p>Results</p> <p>The lowest level of agreement was that for measurement of passive flexion with the patient in supine position (mean difference 1.4°; limits of agreement 16.2° to 19° for the difference between the two observers. The highest levels of agreement were found for measurement of passive flexion with the patient in sitting position and for measurement of passive extension (mean difference 2.7°; limits of agreement -6.7 to 12.1 and mean difference 2.2°; limits of agreement -6.2 to 10.6 degrees, respectively). The ability to differentiate between subjects ranged from 0.62 for measurement of passive extension to 0.89 for measurements of active flexion (ICC values).</p> <p>Conclusion</p> <p>Interobserver agreement for flexion as well as extension was only fair. When two different observers assess the same patients in the acute phase after total knee arthroplasty using a long arm goniometer, differences in RoM of less than eight degrees cannot be distinguished from measurement error. Reliability was found to be acceptable for comparison on group level, but poor for individual comparisons over time.</p

Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review

This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1-7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited

Impact of quality items on study outcome: Treatments in acute lateral ankle sprains

Objective: This study investigates the influence of different aspects of methodologic quality on the conclusions of a systematic review concerning treatments of acute lateral ankle sprain Method: A data set of a systematic review of 44 trials was used, of which 22 trials could be included in this study Quality assessment of the individual studies was performed using the Delphi list. We calculated effect sizes of the main outcome measure in each study in order to evaluate the relationship between overall quality scores and outcome. Next, we investigated the impact of design attributes on pooled effect sizes by subgroup analysis Results: The quality of most studies (82%) was low, only 4 of 22 trials were of high quality. Studies with proper randomization and blinding procedure produce a slightly higher (not statistically significant) effect estimate compared to the other studies Conclusion: Previous research has suggested that methodologically poorly designed studies tend to over-estimate the effect estimate. Our study does not confirm these conclusions

Efficacy of 904 nm laser therapy in the management of musculoskeletal disorders: a systematic review

This systematic review was undertaken to assess the effectiveness of 904nm low level laser therapy (LT) in musculoskeletal disorders. In order to retrieve randomized trials, computer-aided searches of databases and of bibliographic indexes were performed. Furthermore, congress reports, reviews and handbooks were all checked for relevant citations. Subsequently, all retrieved studies were scored on methodological quality. This review found 25 studies that investigated the effects of 904nm LT versus placebo or any other intervention, in subjects with a condition for which LT was thought a feasible intervention. Of these, 21 fulfilled the entry criteria for this review, and were assessed in a blinded manner on methodological criteria. Overall, study quality ranged from ‘poor’ to ‘reasonable’. In a classification of the material into diseases studied, no clear evidence was found for the effectiveness of LT, except perhaps for knee problems and myofascial pain. It is concluded that 904nm LTdoes not seem to be effective in the treatment of musculoskeletal disorders, but that further and improved research is needed to shed more light on its effectiveness

Quality Assessment of Trials: A Comparison of Three Criteria Lists

Objective. The conclusion of a systematic review depends on the quality of the individual studies included. This article presents the results of a qualitative comparison using three different methods of quality assessment. Method. A data set of 21 randomised clinical trials (RCTs) from a systematic review concerning the efficacy of laser therapy in patients with musculoskeletal disorders is used. The criteria lists to assess the methodological quality were the 'Maastricht' list, the 'Jadad' list and the 'Delphi' list. Results. The three criteria lists show moderate to good correlation. Major differences between the lists are the number of items, and differences in wording of the items seem to affect the ranking of the studies. Conclusion. Based on our results, we conclude that the Delphi list seems the most practical and satisfactory instrument for quality assessment of RCTs

Differences between observers, plotted against the mean values of both observers for each patient for passive extension

<p><b>Copyright information:</b></p><p>Taken from "Reproducibility of goniometric measurement of the knee in the in-hospital phase following total knee arthroplasty"</p><p>http://www.biomedcentral.com/1471-2474/8/83</p><p>BMC Musculoskeletal Disorders 2007;8():83-83.</p><p>Published online 17 Aug 2007</p><p>PMCID:PMC2040146.</p><p></p> The figure shows the mean difference between observers (solid line at centre) and the limits of agreement (dashed outer lines corresponding to ±1.96 SD of the mean difference between the first and second observers)

Scatter plot of interobserver reliability of measurement of passive flexion whilst sitting, as indicated by the ICCs

<p><b>Copyright information:</b></p><p>Taken from "Reproducibility of goniometric measurement of the knee in the in-hospital phase following total knee arthroplasty"</p><p>http://www.biomedcentral.com/1471-2474/8/83</p><p>BMC Musculoskeletal Disorders 2007;8():83-83.</p><p>Published online 17 Aug 2007</p><p>PMCID:PMC2040146.</p><p></p