Changing the narrative for exercise-based prehabilitation: evidence-informed and shared decision making when discussing the need for a total knee arthroplasty with patients

“The better you go into surgery – the better you leave surgery”. That is the narrative often used to argue the importance of prehabilitation exercise in total knee arthroplasty (TKA) to enhance postoperative recovery. Although the narrative makes sense intuitively, it has been very difficult to show clinically relevant superiority of prehabilitation exercise on postoperative muscle strength and function outcomes after TKA compared to no prehabilitation. In this narrative review, we present a clinical use case for prehabilitation exercise in severe knee osteoarthritis where the focus is more on enhancing surgical decision making and guideline adherence than on enhancing post-operative recovery. We call this “pre-evaluation exercise”. A simple pre-evaluation exercise program performed at home twice a week (after initial instruction)—seems to provide a basis for enhanced surgical decision making in severe knee OA. If combined with education about the importance of being physically active daily, using a type of activity that makes sense for the individual patient, metabolic fitness and cardiovascular health could also be targeted

[Numismatique monnaies de collection]

[Vente. Numismatique. 1983-12-09 - 1983-12-10. Paris]Avec mode text

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial.

AimClinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.MethodsThis qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis.ResultsFrom the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care.ConclusionWe found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment.Trial registrationClinicalTrials.gov, ID: NCT02931058

RAPID KNEE-EXTENSIONS TO INCREASE QUADRICEPS MUSCLE ACTIVITY IN PATIENTS WITH TOTAL KNEE ARTHROPLASTY:A RANDOMIZED CROSS-OVER STUDY

BACKGROUND: Inhibition of the quadriceps muscle and reduced knee-extension strength is common shortly following total knee arthroplasty (weeks to months), due to reduced voluntary activation of the quadriceps muscle. In healthy subjects, strength training with heavy loads is known to increase agonist muscle activity, especially if the exercise is conducted using rapid muscle contractions. PURPOSE: The purpose of this study was to examine if patients with total knee arthroplasty could perform rapid knee-extensions using a 10 RM load four to eight weeks after surgery, and the degree to which rapid knee-extensions were associated with greater voluntary quadriceps muscle activity during an experimental strength training session, compared to that elicited using slow knee-extensions. STUDY DESIGN: A randomized cross-over study. METHODS: Twenty-four patients (age 66.5) 4-8 weeks post total knee arthroplasty randomly performed one set of five rapid, and one set of five slow knee-extensions with the operated leg, using a load of their 10 repetition maximum, while surface electromyography recordings were obtained from the vastus medialis and lateralis of the quadriceps muscle. RESULTS: Data from 23 of the 24 included patients were analyzed. Muscle activity was significantly higher during rapid knee-extensions (120.2% [10(th)-90(th) percentile: 98.3-149.1]) compared to slow knee-extensions (106.0% [88.8-140.8]) for the vastus lateralis (p<0.01), but not for the vastus medialis (120.8% [90.4-134.0]) and (121.8% [93.0-133.0]) (p = 0.17), respectively. Slow and rapid knee-extensions were performed at a median angular velocity of 19.7 degrees/sec (13.7-24.4) and 51.4 degrees/sec (28.9-63.1), respectively CONCLUSION: Four to eight weeks after their total knee arthroplasty, the patients in the present study were able to conduct rapid knee-extensions according to the experimental protocol with an approximately doubled angular velocity compared to slow knee-extensions. This was associated with increased muscle activity in the vastus lateralis when compared to slow knee-extensions, but not in the vastus medialis. Whether this significant, although relatively small, difference in vastus lateralis muscle activity has any clinical relevance needs further study. LEVEL OF EVIDENCE: