Kneeling ability after total knee replacement

Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement (TKR), with 60–80% of patients reporting difficulty kneeling or an inability to kneel. Difficulty kneeling impacts on many activities and areas of life, including activities of daily living, self-care, leisure and social activities, religious activities, employment and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after TKR are a source of dissatisfaction and disappointment for many patients. Research has found that there is no association between range of motion and self-reported kneeling ability. More research is needed to understand if and how surgical factors contribute to difficulty kneeling after TKR. Discrepancies between patients’ self-reported ability to kneel and observed ability suggests that patients can kneel but elect not to. Reasons for this are multifactorial, including knee pain/discomfort, numbness, fear of harming the prosthesis, co-morbidities and recommendations from health professionals. There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation. There has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after TKR. Increased clinical awareness of this poor outcome and research to inform the provision of services is needed to improtzve patient care and allow patients to return to this important activity

A proposed anatomy syllabus for entry‐level physiotherapists in the United Kingdom: A modified Delphi methodology by physiotherapists who teach anatomy

The ever-increasing scope of physiotherapy practice is raising questions on what anatomical knowledge and skills ought to be taught within qualifying physiotherapy degree programmes in the United Kingdom (UK). The aim of the study was to create core anatomical knowledge and skills learning objectives to inform knowledge and skills for entry-level physiotherapists in the UK. A two phased modified Delphi methodology created a consensual anatomy curriculum. A Research-Team-Expert-Panel of four physiotherapists who teach anatomy proposed Anatomy Learning Objectives (Anat-LOs) and accompanying clinical rationales relevant for newly qualified entry-level physiotherapists. A Teacher-Expert-Panel of nine physiotherapists who taught anatomy to physiotherapy students in the UK reviewed Anat-LOs in two consecutive Delphi Rounds, and rated and commented on each Anat-LO. After each Delphi Round, the Research-Team-Expert-Panel reviewed the ratings and comments from the Teacher-Expert-Panel and banked Anat-LOs that passed the 85% acceptance threshold. There were 182 banked Anat-LOs that spanned all eight areas: Introductory Concepts, Principles and Basic Histology; Head and Neck; Thorax; Abdomen, Pelvis and Perineum; Upper Limb; Lower Limb; Spine; and Neuroanatomy regions/systems. The Anat-LOs develop both anatomical knowledge and key anatomical skills, such as palpation and conducting manual tests on model patients. A first ever core anatomy curriculum for entry-level physiotherapists has been created for entry-level physiotherapists, typically Band-5 NHS physiotherapists, and takes an integrated learning approach. The anatomy curriculum brings clarity to students, teachers, clinical supervisors and future employers on the expected anatomical standards for entry-level physiotherapists

Effectiveness of physiotherapy exercise following total knee replacement: Systematic review and meta-analysis

Background: Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement. Methods: We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4th 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD). Results: Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination. Conclusion: After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials

Using spectral indices to estimate water content and GPP in Sphagnum moss and other peatland vegetation

Peatlands provide important ecosystem services including carbon stroage and biodiversity conservation. Remote sensing shows potential for monitoring peatlands, but most off-the-shelf data produces are developed for unsaturated environments and it is unclear how well they can perform in peatland ecosystems. Sphagnum moss is an important peatland genus with specific characteristics which can affect spectral reflectance, and we hypothesized that the prevalence of Sphagnum in a peatland could affect the spectral signature of the area. This study combines results from both laboratory and field experiments to assess the relationship between spectral indices and the moisture content and GPP of peatland (blanket bog) vegetation species. The aim was to consider how well the selected indices perform under a range of conditions, and whether Sphagnum has a significant impact on the relationships tested. We found that both water indices tested (NDWI and fWBI) were sensitive to the water content changes in Sphagnum moss in the laboratory, and there was little difference between them. Most of the vegetation indices tested (the NDVI, EVI, SIPI and CIm) were found to have a strong relationship with GPP both in the laboratory and in the field. The NDVI and EVI are useful for large-scale estimation of GPP, but are sensitive to the proportion of Sphagnum present. The CIm is less affected by different species proportions and might therefore be the best to use in areas where species cover is unknown. The PRI is shown to be best suited to small-scale studies of single species

Comparison of Group-based Outpatient Physiotherapy With Usual Care After Total Knee Replacement: a Feasibility Study For a Randomized Controlled Trial

Objective: To evaluate the feasibility of conducting a randomized controlled trial comparing group-based outpatient physiotherapy with usual care in patients following total knee replacement. Design: A feasibility study for a randomized controlled trial. Setting: One secondary-care hospital orthopaedic centre, Bristol, UK. Participants: A total of 46 participants undergoing primary total knee replacement. Interventions: The intervention group were offered six group-based exercise sessions after surgery. The usual care group received standard postoperative care. Participants were not blinded to group allocation. Outcome measures: Feasibility was assessed by recruitment, reasons for non-participation, attendance, and completion rates of study questionnaires that included the Lower Extremity Functional Scale and Knee Injury and Osteoarthritis Outcome Score. Results: Recruitment rate was 37%. Five patients withdrew or were no longer eligible to participate. Intervention attendance was high (73%) and 84% of group participants reported they were ‘very satisfied’ with the exercises. Return of study questionnaires at six months was lower in the usual care (75%) than in the intervention group (100%). Mean (standard deviation) Lower Extremity Functional Scale scores at six months were 45.0 (20.8) in the usual care and 57.8 (15.2) in the intervention groups. Conclusion: Recruitment and retention of participants in this feasibility study was good. Group-based physiotherapy was acceptable to participants. Questionnaire return rates were lower in the usual care group, but might be enhanced by telephone follow-up. The Lower Extremity Functional Scale had high responsiveness and completion rates. Using this outcome measure, 256 participants would be required in a full-scale randomized controlled trial

Mirror Mirror on the Wall, Which Is the Most Convincing of Them All? Exploring Anti-Domestic Violence Posters.

Although domestic abuse of women by men has received significant media, police, and research attention, domestic violence directed toward men has been marginalized across the board and is still rarely treated seriously. The purpose of this research, then, is to examine and compare different anti-domestic violence messages in which the abuser's gender is not always clear. In Study 1, 200 U.K. participants (100 females and 100 males, aged 18-67, M = 28.98, SD = 9.613) evaluated posters that varied across three levels; in that the subject (male or female) was depicted as being silenced, bruised, or experiencing live abuse. The results showed that the posters featuring female victims were all rated as more effective than posters showing male victims. In Study 2, 140 different U.K. participants (95 females; 45 males) aged 18 to 59 (M = 27.27, SD = 10.662) evaluated the cartoon facial images of Disney characters who had been altered to look like victims of violence and real-life corresponding photos of human models. The results showed that the realistic posters were found to be more believable, emotional, and effective than the cartoons. The implications of such perceptions are discussed

Cost-Effectiveness of Group-Based Outpatient Physical Therapy After Total Knee Replacement: Results From the Economic Evaluation Alongside the ARENA Multicenter Randomized Controlled Trial

Objective To assess the cost-utility and cost-effectiveness of a group-based outpatient physical therapy intervention delivered six-weeks after primary total knee replacement (TKR) compared with usual care, alongside the Activity-orientated REhabilitation following kNee Arthroplasty (ARENA) multi-centre randomised controlled trial. Methods The economic analyses were performed from the perspective of the health and social care payer. We collected resource use for health and social care and productivity losses, and patient outcomes for 12 months after surgery to derive costs and quality-adjusted life-years (QALYs). Results were expressed in incremental cost-effectiveness ratios (ICERs), and incremental net monetary benefit statistics (INMBs) for a society willing-to-pay £20,000 per QALY gained, with sensitivity analyses to model specification and perspective. Results ARENA physical therapy classes cost, on average, £179 (SD=£39) per patient. Treatment in the year following surgery cost, on average, £1,739 (95%CI -£742, £4,221) per patient in the intervention group (n=89), an additional £346 (95%CI £38, £653) compared with usual care (n=91, £1,393;95%CI -£780, £3568). QALY benefits were 0.0506 higher (95%CI 0.009, 0.09) in the intervention group, corresponding to an additional 19 days in perfect health. The ICER for the intervention was £6,842 per QALY gained and the INMB was £665 (, 95%CI £139, £1,191) with a 92% probability of being cost-effective, and no less than 73% in all sensitivity analysis scenarios. Conclusion The addition of group-based outpatient physical therapy classes to usual care improves quality-of-life and is a cost-effective treatment option following TKR for a society willing-to-pay £20,000 per QALY gained

Effectiveness and Cost-effectiveness of Outpatient Physiotherapy After Knee Replacement for Osteoarthritis: Study Protocol for a Randomised Controlled Trial

Background: Primary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement. Methods/design: Two hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises. The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective. Discussion: This research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency

Effectiveness of physiotherapy exercise following total knee replacement: Systematic review and meta-analysis

© 2015 Artz et al. Background: Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement. Methods: We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4th 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD). Results: Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination. Conclusion: After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials