Is routine outpatient physiotherapy required post discharge after arthroplasty surgery?

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Presentation from the Current Controversies in Orthopaedic Enhanced Recovery. 31st January 2014, Beardmore Hotel and Conference Centre, Glasgow, Scotland. …

Presentation from the Current Controversies in Orthopaedic Enhanced Recovery. 31st January 2014, Beardmore Hotel and Conference Centre, Glasgow, Scotland.

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  • 12% hip replacements are sent on for outpatient therapy

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  • 1. Is routine outpatient physiotherapy required post discharge after arthroplasty surgery?......I say NO Mr David A McDonald Service Improvement Manager Whole System Patient Flow Improvement Programme QuEST Team Scottish Government
  • 2. Disclaimer Personal view point I am a physiotherapist Developed the CALEDonian Programme at the GJNH
  • 3. Total Hip Arthroplasty
  • 4. Total Hip Arthroplasty Two good systematic reviews Both of high quality and synthesise the available evidence 13 studies in total However when you remove duplicated studies = 9
  • 5. Minns Lowe et al 2009
  • 6. Minns Lowe et al 2009 Only searched studies up to 2007 One study seems to have been excluded Very difficult to compare across trials – interventions/timing/ duration Tried where possible to pool data where possible Summary Not yet possible to establish the extent to which post d/c physio is effective in terms of function/ Quality of life/Mobility/ RoM/ muscle strength Poor study designs.
  • 7. Coulter et al 2013
  • 8. Coulter et al 2013 Searched up to 2012 Only two additional studies included Does support that post d/c exercise does improve strength and gait speed compared to no input However no difference if this was home based or outpatient based
  • 9. Total Hip Arthroplasty -ERAS All papers in both reviews from before 2008 Pre-op education Multimodal analgesia Accelerated rehabilitation Enhanced Recovery
  • 10. Artaban Study
  • 11. National Picture • 12% Pts in Scotland are referred for OP physiotherapy on d/c • Artz et al (2013) survey of England and Wales – no routine referral for OP
  • 12. Total Knee Arthroplasty
  • 13. Blinded RCT – Comparing 6/52 OP physio vs Internet telerehab Conclusions: The outcomes achieved via telerehabilitation at six weeks following total knee arthroplasty were comparable with those after conventional rehabilitation. J Bone Joint Surg Am, 2011 Jan 19;93(2
  • 14. Only 5 trials included All pre-date 2005 Short term benefit No difference at one year
  • 15. Patient-controlled lumbar epidural versus wound infiltration for total knee arthroplasty within an ERPa randomised clinical trial. D McDonald1, AWG Kinninmonth1, A H Deakin1, B Ellis2, T Howe2, Y Robb2, NB Scott1 1Golden Jubilee National Hospital, Clydebank, Scotland 2Glasgow Caledonian University, Glasgow, Scotland 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 16. Methods • All patients received a standardised programme of: – Pre-operative education – Multimodal analgesia (McDonald et al, 2012) – – – Premed including Gabapentin and Dexamethasone Spinal Anaesthesia (no opiods) Oxycodone/ Paracetamol/ NSAID – Accelerated Rehabilitation 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 17. Methods - Groups • Group PCEA • Group LIA • Side-directed lumbar epidural sited in theatre • Patient-controlled system 2ml 0.125% bupivacaine epidural. • NO BACKGROUND RATE • Discontinued on the morning of POD 1 • Standard infiltration of 200ml 0.2% Ropivacaine • 3 post op boluses of 40ml at • 4-6 hrs post surgery • 11.00pm • 8.00am on POD 1 • Catheter removed following final bolus 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 18. Outcome Measures • Statistical significance was set at p<0.01 • Primary outcome measure was the proportion of patients discharged by day 4 from rehabilitation. • Secondary Outcome Measures • • • • • • • • • Length of hospital stay Pain Scores Use of PRN Analgesia Mobilisation rates % Post-operative urinary catheterisation PONV Range of Movement Oxford Knee Scores Following randomisation 20 patients were excluded due to failed spinal anaesthesia. 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 19. Results - Demographics PCEA LIA P value N 109 113 Age (SD,) 67 (8.1) 68 (7.3) 0.601 BMI (SD) 32 (5.2) 32 (6.1) 0.622 Gender (% Males) 46% 41% 0.466 Operative side (%Left) 50% 58% 0.171 13 (10.8) 21 (17.8) 81 (67.5) 78 (66.1) 26 (21.6) 18 (15.3) 0 1 (0.01) 43(6.6) 43(6.8) ASA 1(%) ASA 2(%) ASA 3(%) ASA 4(%) Pre Operative Oxford Score 0.946 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 20. Primary Outcome Measure • No differences was observed between the proportion of patients discharged from rehabilitation by post-operative day four • PC-LEA = 77% vs. LIA = 82% (p=0.33) • Median hospital stay was four days for both groups (p=0.54) 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 21. Mobilisation • No statistical difference was observed in the proportion of patients mobilised on the day of theatre (p= 0.013) • 35% vs. 51% • or within 24 hours (p=0.04) almost all patients in both groups were independently mobile (PC-LEA 96% vs. LIA 100%). 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 22. Secondary Outcomes PCEA LIA P value Post Operative Urinary Catheterisation (%) 10 (9.2) 5 (4.4) 0.159 Total PRN usage of 10mg Oxynorm (range) 4 (0-15) 4 (0-15) 0.554 Post Operative Nausea and Vomiting (% vomiting) 16 14 D/C RoM (Range) 80 (60-100) 80 (65-105) % Outpatient Physiotherapy referral on discharge 18% 19% Follow up RoM (Range) 95 (50-120) 100 (20-120) 0.316 Follow up Oxford Score (range) 28 (13-53) 26 (13-48) 0.204 Change in Oxford Score (SD) 14 (9.3) 16 (9.9) 0.301 0.795 6 Week Follow up Data 2nd ERAS-UK Society Annual Meeting, 2nd November 2012, Cheltenham
  • 23. Sub data analysis NO OP PHYSIO ON D/C OP PHYSIO ON D/C Age 68 64 Sex (% Male) 44% 62% BMI 32 33 ASA Score 2 2 Pre-op Oxford 42 42 D/C RoM 84 78 Post-op LoS (median) 3 5 RoM 97 90 Oxford Score 27 29 RoM 105 100 Oxford Score 19 19.5 Six week Follow Up One Year
  • 24. Patients who need OP Physio Young Male Poor Pain control day 0 Should only be ~ 20% of patients
  • 25. So why the disparity?
  • 26. Here ends the lesson Mr Wainwright ….If only I had a cigar david.mcdonald@nhs.net