Enhanced Recovery – The clinical components• Post-operative                                        @officialERblog        ...
@officialERblogenhancedrecoveryblog.com
Promotion of a “wellness” model of care• Wellness not illness• Promotion of  independence• Good pain control• Early mobili...
Promotion of the wellness model Early nutrition and hydration   Effective pain control and early                          ...
Promotion of a wellness model• 2-4 Hourly Observations• Visiting hours• Get up out of bed to pass urine• Promotion of inde...
Promotion of the wellness model   No drug rounds - Patients self medicate                                         @officia...
Pathway documentation can be used toguide practice and improve quality of careVariance analysis in clinical pathways for t...
Post-op phone calls48 hour and 28 day phone calls                                    @officialERblog                      ...
Mobilisation of the operative day                                 Early Mobilisation                             The aim i...
To do this you need an MDT approach to                       reducing pain scoresWainwright T, Craig J, Swan J, Olyslaeger...
An enhanced therapy service      (OT and Physio)
7-day Physiotherapy service                             @officialERblog                    enhancedrecoveryblog.com
7-day Physiotherapy Service                              @officialERblog                     enhancedrecoveryblog.com
7-day Physiotherapy Service                             @officialERblog                    enhancedrecoveryblog.com
Frequency      DensityElective hipreplacement:LOS by day ofoperation                                     @officialERblog  ...
Frequency      DensityElective kneereplacement:LOS by day ofoperation                                     @officialERblog ...
RBH – ER pathway data 2300 cases                               @officialERblog                      enhancedrecoveryblog.com
Enhanced recovery is for all        patients                              @officialERblog                     enhancedreco...
“Trust X” – Improving outcomes for            the elderly?                                 @officialERblog                ...
“Trust X”– Improving outcomes for            the elderly?                                 @officialERblog                 ...
Improving outcomes for the                                         elderly?    Age (10-year)       Inpatients    % of all ...
Criteria-based discharge
Patients go homeData source - Dr Foster                                   @officialERblog                          enhance...
Flexion criteria for discharge• No study has shown a need for a specific  flexion at discharge• Flexion>60degrees no extra...
How did data help to question the tradition ofwaiting for 90 degrees flexion before discharge?                            ...
Physiotherapy exercise after fast-track total hipand knee arthroplasty: is it time forreconsideration?• The two latest met...
What does physiotherapyinclude?• Study suggests that during the first six postoperative weeks,  the addition of bed exerci...
• 35% of patients thought that physiotherapy  provision was inadequate.• Analysis of patient explanations about why  the p...
We need to improve our understanding of   the timeline of recovery• In all of the physical performance  measure models pat...
@officialERblogenhancedrecoveryblog.com
Cryo-therapy is very effective                                  @officialERblog                         enhancedrecoverybl...
Loss of Knee-Extension Strength Is Related toKnee Swelling After Total Knee Arthroplasty• Measures: knee-joint circumferen...
Progressive strength training (10 RM)commenced immediately after fast-track totalknee arthroplasty: is it feasible?•   The...
@officialERblogenhancedrecoveryblog.com
CPM?• Increase of sickness role• No effect on ROM or  function @1,4,6,12,52w• Literature doesn’t  support their useBruun-O...
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Enhanced Recovery Masterclass Post-op

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  • J QUAL CLIN PRACT 2000 DEC;20(4):145-9
  • plymouth
  • Major surgery, including total hip and knee arthroplasty (THA and TKA, respectively), is followed by a convalescence period, during which the loss of muscle strength and function is considerable, especially early after surgery. In recent years, a combination of unimodal evidence-based perioperative care components has been demonstrated to enhance recovery, with decreased need for hospitalization, convalescence, and risk of medical complications after major surgery – the fast-track methodology or enhanced recovery programs. It is the nature of this methodology to systematically and scientifically optimize all perioperative care components, with the overall goal of enhancing recovery. This is also the case for the care component “physiotherapy exercise” after THA and TKA. The two latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA does either not work, or is not very effective. The reason for this may be that the “pill” of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity), or is offered at the wrong time (too late after surgery). We propose changing the focus to earlier-initiated, and more intensive physiotherapy exercise after THA and TKA (fast-track physiotherapy exercise), to reduce the early loss of muscle strength and function after surgery. Ideally, the physiotherapy exercise interventions after THA and TKA should be simple, using few and well chosen exercises that are described in detail, adhering to basic exercise-physiology principles, if possible.
  • AbstractObjectives To determine whether the addition of bed exercises after primary total hip replacement (THR) improves functional outcomes and quality of life, in adult patients, during the first six postoperative weeks. Design Single-blind randomised controlled trial. Setting Inpatient and outpatient orthopaedic departments at a National Health Service hospital.Participants Sixty primary elective THR patients. Intervention Patients were assigned at random to receive either a standard gait re-education programme and bed exercises, or the standard gait re-education programme without bed exercises after THR. The bed exercises consisted of active ankle dorsiflexion/plantarflexion, active knee flexion, and static quadriceps and gluteal exercises. Main outcome measures Iowa Level of Assistance Scale (ILOA), the Short Form-12 Health Survey (SF-12), duration of hospital admission and postoperative complications were assessed at baseline, and 3 days and 6 weeks postoperatively. Results There was no statistically significant difference in ILOA scores between the two groups on the third postoperative day [gait re- education and bed exercise group median 40.5, interquartile range (IQR) 17.5 to 44.5; gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70]. Although there was a small difference between the median ILOA scores at Week 6 between the two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to 12.5; P = 0.05), this difference was not statistically or clinically significant. There was no difference between the groups in duration of hospital admission, SF-12 scores or postoperative complications at Week 6. Conclusion This study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education programme following THR does not significantly improve patient function or quality of life.
  • Table 1 Patients’ perceptions of physiotherapyCommentAdequate Inadequate Reason for physiotherapy being inadequate No physiotherapy was provided Lack of outpatient physiotherapyNot enough physiotherapy received OtherUnknown/not statedNumber of comments (%)65% (1365/2085) 35% (720/2085)11% (226/2085) 9% (179/2085)8% (166/2085) 5% (115/2085)2% (34/2085)Examples of commentsNo physiotherapy was provided No outpatient physiotherapy provided, provision was delayed and should have started sooner Physiotherapy did not last long enough, should have been more frequent Lack of advice, ineffective, lack of modalities, under-resourced, too self-motivated, too intenseWhen the inpatient physiotherapy notes of 20 patients who indicated that they had not received any physiother- apy were analysed, it was found that they had all received physiotherapy, with a physiotherapy assessment on the first postoperative day. Patients had had a minimum of three con- tacts with a physiotherapist (median 5, range 3–24). All patients had been taught bed exercises, hip/knee exercises, how to transfer to a chair, how to mobilise with a Zimmer frame and sticks, and how to climb stairs. DiscussionThis survey found that while the majority of patients thought that the physiotherapy they received in relation to their joint replacement was adequate, 35% of patients thought that it was inadequate. Analysis of patient explanations about why the physiotherapy was inadequate found that the main theme was there was not enough physiotherapy provided, par- ticularly outpatient physiotherapy. Reviewing the inpatient physiotherapy notes of 20 patients who indicated that they had not received any physiotherapy revealed that they did, in fact, have the standard hospital physiotherapy provision. Therefore, their comments most likely refer to outpatient phy- siotherapy, which is not undertaken routinely at this centre.Therefore, the largest problem identified with physiother- apy provision in this centre was a lack of outpatient physio- therapy. However, the results are limited to one orthopaedic centre, which does not refer patients for outpatient physio- therapy routinely. Further research needs to be undertaken in other centres that do refer patients for outpatient physiother- apy in order to determine other areas of patient dissatisfaction with physiotherapy, with the aim of improving physiotherapy provision for joint replacement patients. DemographicsIn total, 3260 patients had a primary joint replacement between April 2004 and April 2006. At the time of the postal survey, 135 patients were deceased; therefore, questionnaires were sent to 3125 patients. Completed questionnaires were received from 2085 patients, giving an overall response rate of 67% (2085/3125). Overall, 911 patients had a total hip replacement, 157 patients had a hip resurfacing, 866 patients had a total knee replacement, 100 patients had a unicompartmental knee replacement and 51 patients had a patellar resurfacing. The mean age of patients at the time of surgery was 67 years, and 58% (1218/2085) were female.Perceived physiotherapy provisionOf the 2085 respondents, 65% (1365/2085) indicated that their physiotherapy provision was adequate and 35% (720/2085) indicated that it was inadequate. Overall, 676 patients provided a reason why the physiotherapy was inadequate. Of these patients, 26% (179/676) commented specifically on outpatient physiotherapy provision, with the remaining comments reflecting patients’ overall expe- rience of the physiotherapy they received in relation to their joint replacement. Reasons given about why physio- therapy provision was inadequate were coded independently into the key thematic categories by two of the authors (VW and CL), and the codes were compared and discussed until agreement was reached. The results are displayed in Table 1.
  • Background: Information on early recovery after arthroplasty is needed to help benchmark progress and make appropriate decisions concerning patient rehabilitation needs. The purpose of this study was to model early recovery of physical function in patients undergoing total hip (THA) and knee (TKA) arthroplasty, using physical performance and self-report measures.Methods: A sample of convenience of 152 subjects completed testing, of which 69 (mean age: 66.77 ± 8.23 years) underwent THA and 83 (mean age: 60.25 ± 11.19 years) TKA. Postoperatively, patients were treated using standardized care pathways and rehabilitation protocols. Using a repeated measures design, patients were assessed at multiple time points over the first four postoperative months. Outcome measures included the Lower Extremity Function Scale (LEFS), the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC PF), the 6 minute walk test (6 MWT), timed up and go test (TUG) and a timed stair test (ST). Average recovery curves for each of the measures were characterized using hierarchical linear modeling. Predictors of recovery were sequentially modeled after validation of the basic developmental models.Results: Slopes of recovery were greater in the first 6 to 9 weeks with a second-degree polynomial growth term (weeks squared) providing a reasonable fit for the data over the study interval. Different patterns of recovery were observed between the self-report measures of physical function and the performance measures. In contrast to the models for the WOMAC PF and the LEFS, site of arthroplasty was a significant predictor (p = 0.001) in all of the physical performance measure models with the patients post TKA initially demonstrating higher function. Site of arthroplasty (p = 0.025) also predicted the rate of change for patients post THA and between 9 to 11 weeks after surgery, the THA group surpassed the function of the patients post TKA.Conclusion: Knowledge about the predicted growth curves will assist clinicians in referencing patient progress, and determining the critical time points for measuring change. The study has contributed further evidence to highlight the benefit of using physical performance measures to learn about the patients' actual level of disability.
  • Abstract Holm B, Kristensen MT, Bencke J, Husted H, Kehlet H, Bandholm T. Loss of knee-extension strength is related to knee swelling after total knee arthroplasty. Objective To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA). Design Prospective, descriptive, hypothesis-generating study. Setting A fast-track orthopedic arthroplasty unit at a university hospital. Participants Patients (N=24; mean age, 66y; 13 women) scheduled for primary unilateral TKA were investigated 1 week before surgery and on the day of hospital discharge 2.4 days postsurgery. Interventions Not applicable. Main Outcome Measures We assessed all patients for knee-joint circumference, knee-extension strength, and functional performance using the Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking tests, together with knee pain during all active test procedures. Results All investigated variables changed significantly from pre- to postsurgery independent of knee pain. Importantly, knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength (r=−.51; P=.01). Reduced fast-speed walking correlated significantly with decreased knee-extension strength (r=.59; P=.003) and decreased knee flexion (r=.52; P=.011). Multiple linear regression showed that knee swelling (P=.023), adjusted for age and sex, could explain 27% of the decrease in knee-extension strength. Another model showed that changes in knee-extension strength (P=.009) and knee flexion (P=.018) were associated independently with decreased performance in fast-speed walking, explaining 57% of the variation in fast-speed walking. Conclusions Our results indicate that the well-known finding of decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Future studies may look at specific interventions aimed at decreasing knee swelling postsurgery to preserve knee-extension strength and facilitate physical rehabilitation after TKA.
  • Purpose: To explore the feasibility of progressive strength training commenced immediately after total knee arthroplasty (TKA). Methods: A pilot study was conducted at an outpatient training facility. Fourteen patients with unilateral TKA were included from a fast-track orthopedic arthroplasty unit. They received rehabilitation including progressive strength training of the operated leg (leg press and knee-extension), using relative loads of 10 repetition maximum with three training sessions per week for 2 weeks. Rehabilitation was commenced 1 or 2 days after TKA. At each training session, knee pain, knee joint effusion and training load were recorded. Isometric knee-extension strength and maximal walking speed were measured before the first and last session. Results: The training load increased progressively (p < 0.0001). Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p < 0.0001) were unchanged or decreased over the six training sessions. Isometric knee-extension strength and maximal walking speed increased by 147 and 112%, respectively. Conclusion: Progressive strength training initiated immediately after TKA seems feasible, and increases knee-extension strength and functional performance without increasing knee joint effusion or knee pain. Implications for Rehabilitation Rehabilitation with progressive strength training initiated early after total knee arthroplasty (TKA) seems feasible. Rehabilitation with progressive strength training increases knee-extension strength and maximal walking speed without increasing knee joint effusion and knee pain during the first 2 weeks after TKA. During the progressive strength training exercises, patients with TKA may experience moderate knee pain, which seems to decrease over time. Resting knee pain before and after each training session is none to mild. The results of this pilot study are encouraging, but a larger randomized controlled trial, which compares rehabilitation with or without progressive strength training, is needed to confirm our findings Posted online on November 15, 2011. (doi:10.3109/09638288.2011.629019) HTML PDF (814 KB) PDF Plus (815 KB) Reprints Permissions Thomas Linding JakobsenMSc1, Henrik HustedMD2, Henrik KehletPhD3, Thomas BandholmPhD4 Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019 Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019
  • Table 2: The six-week outpatient rehabilitation protocol performed two times per week. Outpatient rehabilitation protocolWarm up (15 min) Stationary cycling Seated or supine AROM knee flexion and extension Alternating ankle dorsiflexion and plantar flexion Passive quadriceps stretching (standing or prone) Passive hamstring stretching (standing or seated)Leg strengthening exercise (30 min)5–10 min 2-3 min 1-2 min 1-2 min 1-2 min15 reps 15 reps 30 steps 15 rep 3–5 reps 30 m5 min 5 minRENEW Leg press Leg extension Leg curl Standing calf raise5–20 minutes (Table 3) 2 × 10–15 reps 70% 1 RM 2 × 10–15 reps 70% 1 RM2 × 10–15 reps 70% 1 RM2 × 10–15 reps Body weight Functional task-oriented exercise (5 min)Get up and sit down Wall sits at 60 degrees 5–10 sec holds Negotiating stairs (stepups starting at 4′′ and progressed to 8′′) Body weighted half-squatting Unilateral standing firm and/or unstable surface (build up to 30 sec holds) Walking backward, forward, marching and side step on a slope, and/or with resistanceEndurance exercise (10 min) Treadmill walkingChange of speed or on incline Stationary biking“somewhat hard” effort Utilizing RENEW as the strengthening mode of an eccentrically-biased rehabilitation program early after TKA contributed to changes in physical function to norm-based levels. This result alone suggests that the high muscle force production potential of eccentric exercise, at relatively low levels of exertion via RENEW, may contribute to an amplified level of physical function. The potential impact on best- practice rehabilitation following TKA is far reaching as greater focus on quadriceps strengthening is feasible and may be capable of optimizing outcomes.
  • Enhanced Recovery Masterclass Post-op

    1. 1. Enhanced Recovery – The clinical components• Post-operative @officialERblog enhancedrecoveryblog.com
    2. 2. @officialERblogenhancedrecoveryblog.com
    3. 3. Promotion of a “wellness” model of care• Wellness not illness• Promotion of independence• Good pain control• Early mobilisation• Home ASAP• Links with rehab in the community @officialERblog enhancedrecoveryblog.com
    4. 4. Promotion of the wellness model Early nutrition and hydration Effective pain control and early mobilisation @officialERblog enhancedrecoveryblog.com
    5. 5. Promotion of a wellness model• 2-4 Hourly Observations• Visiting hours• Get up out of bed to pass urine• Promotion of independence• Continual reinforcement of the “wellness” model from all staff• Patient goals for each day and also discharge @officialERblog enhancedrecoveryblog.com
    6. 6. Promotion of the wellness model No drug rounds - Patients self medicate @officialERblog enhancedrecoveryblog.com
    7. 7. Pathway documentation can be used toguide practice and improve quality of careVariance analysis in clinical pathways for total hip and knee joint arthroplasty is vital Clinical pathways help to incorporate evidenced-based medicine into clinical practice Variance analysis can be utilised as a process of quality control and a driver for improving patient outcomes (Variances in this study were higher than expected) Dalton et al 2000 @officialERblog enhancedrecoveryblog.com
    8. 8. Post-op phone calls48 hour and 28 day phone calls @officialERblog enhancedrecoveryblog.com
    9. 9. Mobilisation of the operative day Early Mobilisation The aim is every patient to be walking within 18 hours of surgery @officialERblog enhancedrecoveryblog.com
    10. 10. To do this you need an MDT approach to reducing pain scoresWainwright T, Craig J, Swan J, Olyslaegers C, Miles K, Fick D, Middleton R (2008) A standardised analgesic ladder can reduce pain andaccelerate rehabilitation after TKR. The Chartered Society of Physiotherapy Annual Congress, Manchester @officialERblog enhancedrecoveryblog.com
    11. 11. An enhanced therapy service (OT and Physio)
    12. 12. 7-day Physiotherapy service @officialERblog enhancedrecoveryblog.com
    13. 13. 7-day Physiotherapy Service @officialERblog enhancedrecoveryblog.com
    14. 14. 7-day Physiotherapy Service @officialERblog enhancedrecoveryblog.com
    15. 15. Frequency DensityElective hipreplacement:LOS by day ofoperation @officialERblog enhancedrecoveryblog.com
    16. 16. Frequency DensityElective kneereplacement:LOS by day ofoperation @officialERblog enhancedrecoveryblog.com
    17. 17. RBH – ER pathway data 2300 cases @officialERblog enhancedrecoveryblog.com
    18. 18. Enhanced recovery is for all patients @officialERblog enhancedrecoveryblog.com
    19. 19. “Trust X” – Improving outcomes for the elderly? @officialERblog enhancedrecoveryblog.com
    20. 20. “Trust X”– Improving outcomes for the elderly? @officialERblog enhancedrecoveryblog.com
    21. 21. Improving outcomes for the elderly? Age (10-year) Inpatients % of all Day Cases LoS Expected LoS Difference PBDS ALL 2160 100% 0 4.3 6.5 -2.3 737 25-34 4 0.2% 0 3.3 5.1 -1.9 0 35-44 8 0.4% 0 3 4.8 -1.8 0 45-54 82 3.8% 0 3.8 5.2 -1.4 30 55-64 396 18.3% 0 3.6 5.2 -1.6 49 65-74 845 39.1% 0 3.9 5.9 -2 205 75-84 713 33% 0 4.8 7.5 -2.7 368 85+ 112 5.2% 0 5.9 10.6 -4.7 86Data source - Dr Foster @officialERblog enhancedrecoveryblog.com
    22. 22. Criteria-based discharge
    23. 23. Patients go homeData source - Dr Foster @officialERblog enhancedrecoveryblog.com
    24. 24. Flexion criteria for discharge• No study has shown a need for a specific flexion at discharge• Flexion>60degrees no extra health service use• Davies, Can J Surg 2003• Mauerhan, J Arthroplasty 1998 @officialERblog enhancedrecoveryblog.com
    25. 25. How did data help to question the tradition ofwaiting for 90 degrees flexion before discharge? @officialERblog enhancedrecoveryblog.com
    26. 26. Physiotherapy exercise after fast-track total hipand knee arthroplasty: is it time forreconsideration?• The two latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA does either not work, or is not very effective.• The reason for this may be that the “pill” of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity), or is offered at the wrong time (too late after surgery). @officialERblog enhancedrecoveryblog.com
    27. 27. What does physiotherapyinclude?• Study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education following THR does not significantly improve patient function or quality of life. @officialERblog enhancedrecoveryblog.com
    28. 28. • 35% of patients thought that physiotherapy provision was inadequate.• Analysis of patient explanations about why the physiotherapy was inadequate found that the main theme was there was not enough physiotherapy provided @officialERblog enhancedrecoveryblog.com
    29. 29. We need to improve our understanding of the timeline of recovery• In all of the physical performance measure models patients post TKR initially demonstrate higher function.• The THR group surpassed the function of the patients post TKR. @officialERblog enhancedrecoveryblog.com
    30. 30. @officialERblogenhancedrecoveryblog.com
    31. 31. Cryo-therapy is very effective @officialERblog enhancedrecoveryblog.com
    32. 32. Loss of Knee-Extension Strength Is Related toKnee Swelling After Total Knee Arthroplasty• Measures: knee-joint circumference, knee-extension strength, Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking test, and knee pain• Knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength• Decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Holm et al. 2012 @officialERblog enhancedrecoveryblog.com
    33. 33. Progressive strength training (10 RM)commenced immediately after fast-track totalknee arthroplasty: is it feasible?• The training load increased progressively (p < 0.0001).• Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p < 0.0001) were unchanged or decreased over the six training sessions.• Isometric knee-extension strength and maximal walking speed increased by 147 and Linding Jakobson et al. 2012 112%, respectively. @officialERblog enhancedrecoveryblog.com
    34. 34. @officialERblogenhancedrecoveryblog.com
    35. 35. CPM?• Increase of sickness role• No effect on ROM or function @1,4,6,12,52w• Literature doesn’t support their useBruun-Olsen, Disabil Rehabil 2009Lenssen, BMC Musculoskelet Disord 2008 @officialERblog enhancedrecoveryblog.com

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