Enhanced Recovery

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  • History – fit this in with your story about being a House officer and seeing colorectal ptsAlso introduce how you got involved with reducing LOS (BUPA) and also understanding about pathways (your pts going home quickest – but due to your pathway and you operating on a Monday)
  • Kehlet schematic diagram – talk through the slideNot about changing functional ability on discharge – ER is about getting their quicker, by optimising pre-op, minimising intra-op, and promoting recover post-op
  • This is a generic (all surgical specs) from the DOH.Worth running through though
  • Spend some time on this slide talking through the details of the changes and history of the unit etc
  • Spend some time on this graphic emphasizing the gains for the elderly
  • 30 mins 10:45 -11:15
  • While I was away on holiday earlier in the summer I read Richard Moore’s book ‘Heroes, Villains, & Velodromes’ which tells the story of Chris Hoy who went on to win three gold medals in Beijing. While Chris’s achievements are not surprisingly the focus of the book, there’s some intriguing insight into the infrastructure that sits behind Chris, namely British Cycling.Britain failed to win an Olympic cycling medal during the whole on the 1980’s. At Atlanta where Britain only won one gold medal in all events (rowing), cycling contributed two medals. Thereafter, guided initially by Peter Keen and later Dave Brailsford, a steady transformation was initiated that culminated in the team winning seven out of the ten available track cycling gold medals on offer in Beijing, and with only one of the track team – Mark Cavendish who had to console himself with his four Tour De France stage wins earlier in the summer – not winning a medal.While British Cycling has undoubtedly benefited from an influx of lottery funding, so too have many sports which haven’t gone on to create similar results. What stands out with British Cycling is the quality of infrastructure that has been built up and the complete professionalism of the team. There’s a nice quote in Moore’s book from Dave Brailsford that summarises the whole ethos, attributing success to ‘performance by the aggregation of marginal gains. It means taking the 1 per cent from everything you do; finding a 1 per cent margin for improvement in everything you do’.
  • 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.
  • Abstract Background: A fast-track intervention with a short preoperative optimization period and short postoperative hospitalization has a potential for reduced convalescence and thereby a reduced need for postoperative rehabilitation. The purpose of this study was to describe patient-related outcomes, the need for additional rehabilitation after a fast-track total hip arthroplasty (THA), and the association between generic and disease specific outcomes. Methods: The study consisted of 196 consecutive patients of which none received additional rehabilitation beyond an instructional exercise plan at discharge, which was adjusted at one in-patient visit. The patients filled in 3 questionnaires to measure health-related quality-of-life (HRQOL) and hip specific function (EQ-5 D, SF36, and Harris Hip Score (HHS)) at 2 time points pre- and 2 time points postoperatively. The observed results were compared to normative population data for EQ-5 D, SF36, and HHS. Results: 3-months postoperatively patients had reached a HRQOL level of 0.84 (SD, 0.14), which was similar to the population norm (P = 0.33), whereas they exceeded the population norm at 12 months postoperatively (P < 0.01). For SF36, physical function (PF) was 67.8 (SD, 19.1) 3 months postoperatively, which was lower than the population norm (P < 0.01). PF was similar to population norm 12-months postoperatively (P = 0.35). For HHS, patients never reached the population norm within 12 months postoperatively. Generic and disease specific outcomes were strongly associated. Conclusions: If HRQOL is considered the primary outcome after THA, the need for additional postoperative rehabilitation for all THA patients following a fast-track intervention is questionable. However, a pre- or early postoperative physical intervention seems relevant if the PF of the population norm should be reached at 3 months. If disease specific outcome is considered the primary outcome after fast-track THA, clear goals for the rehabilitation must be established before patient selection, intervention type and timing of intervention can be made.
  • 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.
  • 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.
  • Background and purpose Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge cri- teria. Earlier studies have identified patient characteristics pre- dicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. Patients and methods To determine clinical and logistical fac- tors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were oper- ated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge crite- ria was assessed twice daily and specified reasons for not allowing discharge were registered. Results Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postop- eratively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. Interpretation Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, pre- vention of orthostatism, and rapid recovery of muscle function.
  • 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 RehabilitationRehabilitation 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 findingsPosted online on November 15, 2011. (doi:10.3109/09638288.2011.629019)HTMLPDF (814 KB)PDF Plus (815 KB)ReprintsPermissionsThomas Linding JakobsenMSc1, Henrik HustedMD2, Henrik KehletPhD3, Thomas BandholmPhD4Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019
  • AbstractHolm 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.ObjectiveTo examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA).DesignProspective, descriptive, hypothesis-generating study.SettingA fast-track orthopedic arthroplasty unit at a university hospital.ParticipantsPatients (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.InterventionsNot applicable.Main Outcome MeasuresWe 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.ResultsAll 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.ConclusionsOur 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.
  • Enhanced Recovery

    1. 1. @twwainwright enhancedrecoveryblog.com OSTEOARTHRITIS & HIP AND KNEE REPLACEMENT Session 3 – Enhanced Recovery
    2. 2. @twwainwright enhancedrecoveryblog.com Enhanced Recovery
    3. 3. @twwainwright enhancedrecoveryblog.com 3 History of Enhanced Recovery • In the late 1990‟s Henrik Kehlet introduced a multimodal approach to improve functional recovery after colonic surgery • Colorectal Clinical Teams from England visited the centre and started to adopt this approach in general surgery • In parallel, orthopaedic models termed “Accelerated Recovery” or “Rapid Recovery” were being developed in some UK and international units • To date, the experience in the UK has seen a piecemeal approach. The approach has not been adopted by all units and so therefore the benefits for patients and the health service have not been maximised.
    4. 4. @twwainwright enhancedrecoveryblog.com 4 What is Enhanced Recovery? “Enhanced Recovery is an evidence- based approach to care. It is designed to prepare patients for, and reduce the total impact of, surgery, helping them to recover more quickly. It is a multi-modal approach similar to that of care bundles”
    5. 5. @twwainwright enhancedrecoveryblog.com 5 Enhanced Recovery aims to minimise the effects of surgery and optimise a quicker recovery post surgery
    6. 6. @twwainwright enhancedrecoveryblog.com 6 Enhanced Recovery is a team game • Patients • Nurse specialists • Physiotherapy • Occupational therapy • Social workers • Surgeons • Anaesthesia • Pain management • Pre-assessment • Nutrition / Dietician • Team assistant • Ward nursing staff • Medical staff • Management • Primary Care • Pharmacist
    7. 7. @twwainwright enhancedrecoveryblog.com 7 The generic principles of Enhanced Recovery
    8. 8. @twwainwright enhancedrecoveryblog.com 8 Results of Implementing Enhanced Recovery
    9. 9. @twwainwright enhancedrecoveryblog.com 9 Results – Reducing length of stay Introduction of pathway in 2007 = 50% reduction in LOS
    10. 10. @twwainwright enhancedrecoveryblog.com 10 Results – Benchmarking case mix adjusted length of stay -4 -3 -2 -1 0 1 2 3 4 5 6 AVLOS greater than expected for case mix. Hospital placed in lower half of UK hospitals
    11. 11. @twwainwright enhancedrecoveryblog.com 11 Results – Benchmarking case mix adjusted length of stay -3 -2 -1 0 1 2 3 4 5 AVLOS significantly shorter than expected for case mix. Hospital placed top of all UK hospitals
    12. 12. @twwainwright enhancedrecoveryblog.com 12 Spreading the principles of enhanced recovery • Applying the principles of enhanced recovery to other orthopaedic procedures e.g. Fractured Neck of Femur • Applying the principles of enhanced recovery to all patients – not just the young and fit
    13. 13. @twwainwright enhancedrecoveryblog.com 13 National Hip Fracture Database National Report 2012 • 59,365 cases • Illustrates progress… • Mean total LOS reduced from 21.2 days to 20.2 days • Decreased in hospital mortality (9.5% to 9.1%) • Pre-op assessment by an orthogeriatrician • (increased from 37% to 43%) • and challenges… • 52% of pts admitted to an orthopaedic ward within 4hrs (Down from 56% in 2011) and 83% receive surgery within 48hrs (down from 87%)
    14. 14. @twwainwright enhancedrecoveryblog.com 14
    15. 15. @twwainwright enhancedrecoveryblog.com 15 ER in Fractured Neck of Femur - PGH
    16. 16. @twwainwright enhancedrecoveryblog.com Enhanced Recovery Pathway in the Very Elderly: Data + AnalysesDr Jenny Lewis September 2013
    17. 17. @twwainwright enhancedrecoveryblog.com 17
    18. 18. @twwainwright enhancedrecoveryblog.com 18 Demographics and metrics Bournemouth Bournemouth ESD Rest of England Dates October 2005 - July 2007 inclusive August 2007 - May 2009 inclusive August 2007 - May 2009 inclusive Patients All >=85years All >=85years All >=85years Total joint replacements 2065 134 2128 116 190506 8604 THR 966 71 883 61 86722 4390 TKR 1099 63 1245 55 103784 4214 Mean age (years) 72 87 71 86 69 87 Minimum age (years) 26 85 28 85 10 85 Maximum age (years) 98 98 93 93 100 100 Male 740 38 752 32 77176 2638 Female 1325 96 1376 84 113294 5965 % Male 36% 28% 35% 28% 41% 31% Discharged home 2028 123 2119 113 183875 7265 % discharged home 95.3% 91.8% 99.6% 97.4% 96.5% 84.4% Long length of stay 412 73 94 16 38297 4572 % Long length of stay 20.0% 54.5% 4.4% 13.8% 20.1% 53.1% (binomial confidence intervals) (18.3% - 21.7%) (46.3% - 62.7%) (3.6% - 5.3%) (7.8% - 20.7%) (19.9% - 20.3%) (52.1% - 54.2%) Emergency readmissions (30-day) 114 8 101 6 11752 808 % readmissions 5.5% 6.0% 4.7% 5.2% 6.2% 9.4% (binomial confidence intervals) (4.6% - 6.5%) (2.2% - 10.4%) (3.9% - 5.7%) (1.7% - 9.5%) (6.1% - 6.3%) (8.8% - 10.0%) 30-day mortality 2 0 0 0 317 72 % readmissions 0.1% 0.0% 0.0% 0.0% 0.2% 0.8% (binomial confidence intervals) (0.0% - 0.2%) (0.0% - 0.0%) (0.0% - 0.0%) (0.0% - 0.0%) (0.1% - 0.2%) (0.7% - 1.0%)
    19. 19. @twwainwright enhancedrecoveryblog.com 19 Length of stay – hip replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    20. 20. @twwainwright enhancedrecoveryblog.com 20 Post-operative length of stay – hip replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    21. 21. @twwainwright enhancedrecoveryblog.com 21 Length of stay – knee replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    22. 22. @twwainwright enhancedrecoveryblog.com 22 Post-operative length of stay – knee replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    23. 23. @twwainwright enhancedrecoveryblog.com 23 Post-operative length of stay – Bournemouth only Knee replacementHip replacement Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range Age: over 85 years only
    24. 24. @twwainwright enhancedrecoveryblog.com 24
    25. 25. @twwainwright enhancedrecoveryblog.com The case for physiotherapy following discharge after arthroplasty surgery 31st January 2014, Glasgow, Scotland. Tom Wainwright
    26. 26. @twwainwright enhancedrecoveryblog.com 26 The next step in enhanced recovery.
    27. 27. @twwainwright enhancedrecoveryblog.com 27 Enhanced Recovery is an ongoing process… Recovery does not stop from the patient‟s perspective when they go home “Enhanced Recovery is an evidence- based approach to care. It is designed to prepare patients for, and reduce the total impact of, surgery, helping them to recover more quickly. It is a multi-modal approach similar to that of care bundles”
    28. 28. @twwainwright enhancedrecoveryblog.com 28 Improvements are the result of the aggregation of marginal gains – what can we optimize further? „you can achieve optimal performance by the aggregation of marginal gains. It means finding a 1 per cent margin for improvement in everything you do‟ Dave Brailsford
    29. 29. @twwainwright enhancedrecoveryblog.com 29 Influencing outcome measures • Length of stay • Re-admissions • Mortality • Complications • Patient Experience • PROMs The outcomes focused on to date in ERAS Have we focused enough on these areas to date?
    30. 30. @twwainwright enhancedrecoveryblog.com 30
    31. 31. @twwainwright enhancedrecoveryblog.com 31 • 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
    32. 32. @twwainwright enhancedrecoveryblog.com 32 Improving PROMs scores
    33. 33. @twwainwright enhancedrecoveryblog.com 33 RBCH 2012-13 Oxford Hip Score
    34. 34. @twwainwright enhancedrecoveryblog.com 34 RBCH 2012-13 EQ5D Hip Score
    35. 35. @twwainwright enhancedrecoveryblog.com 35 Improvement will be when we out perform current models of recovery of physical and functional performance • Limited research evidence on the potential, and time period for improvement post THR and TKR
    36. 36. @twwainwright enhancedrecoveryblog.com 36 Why it is time for reconsideration? • 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). Bandholm T, Kehlet K (2012) Physiotherapy Exercise After Fast-Track Total Hip and Knee Arthroplasty: Time for Reconsideration? Archives of Physical Medicine and Rehabilitation Vol. 93, Issue 7, Pages 1292-1294, DOI: 10.1016/j.apmr.2012.02.014.
    37. 37. @twwainwright enhancedrecoveryblog.com 37 Physiotherapy post-discharge
    38. 38. @twwainwright enhancedrecoveryblog.com 38
    39. 39. @twwainwright enhancedrecoveryblog.com 39 What does physiotherapy include? • 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.
    40. 40. @twwainwright enhancedrecoveryblog.com 40 What could/should physiotherapy include?
    41. 41. @twwainwright enhancedrecoveryblog.com 41 Improving functional capacity with enhanced rehabilitation at both pre and post-discharge
    42. 42. @twwainwright enhancedrecoveryblog.com 42
    43. 43. @twwainwright enhancedrecoveryblog.com 43 Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. DOI 10.3109/17453674.2011.636682 Background and purpose Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge cri- teria. Earlier studies have identified patient characteristics pre- dicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. Patients and methods To determine clinical and logistical fac- tors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were oper- ated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge crite- ria was assessed twice daily and specified reasons for not allowing discharge were registered. Results Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postop- eratively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. Interpretation Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, pre- vention of orthostatism, and rapid recovery of muscle function. Total hip and total knee arthroplasty (THA and TKA) are fre- quent operations with an average length of stay (LOS) of about 6–12 days in the United Kingdom, Germany, and Denmark (Husted et al. 2006, Bundesauswertung 2009, NHS 2010). During the last decade, however, there has been increased interest in optimal multimodal perioperative care to enhance recovery (the fast-track methodology). Improvement of anal- gesia; reduction of surgical stress responses and organ dysfunc- tions including nausea, vomiting, and ileus; early mobiliza- tion; and oral nutrition have been of particular interest (Kehlet 2008, Kehlet and Wilmore 2008). These principles have also been applied to THA and TKA, resulting in improvements in pain treatment with multimodal opioid-sparing regimens including a local anesthetic infiltration technique (LIA) or peripheral nerve blocks to facilitate early mobilization (Ilfeld et al. 2006a, b, 2010a, Andersen et al. 2008, Kerr and Kohan 2008), and allowing functional rehabilitation to be initiated a few hours postoperatively (Holm et al. 2010)—ultimately leading to a reduction in LOS (Husted et al. 2008, Barbieri et al. 2009, Husted et al. 2010a, b). Using these evidence-based regimens combined with an improved logistical setup, LOS is reduced to about 2–4 days (Kerr and Kohan 2008, Husted et al. 2010 a,b,c, Lunn et al. 2011). Having well-defined functional discharge criteria is impera- tive in order to ensure a safe discharge—and it is mandatory if meaningful comparison of LOS is done following alterations in the track (Husted et al. 2008). In the same fast-track setting, an earlier study focused on patient characteristics predicting LOS (Husted et al. 2008). However, little is known about the specific reasons for why patients are hospitalized during the first 1–3 days after THA or TKA; i.e. why can patients not be discharged? We therefore analyzed clinical and organizational factors responsible for being hospitalized in a well-defined prospec- tive setup in a fast-track unit. This unit had previously docu- mented LOS of about 2–3 days (Andersen et al. 2008, Holm et al. 2010, Husted et al. 2010b, c, Lunn et al. 2011). According to Danish law, this quality-assurance study did not require approval by an ethics committee. It was registered at ClinicalTrials.gov (NTC01047371). 2008, 2010a) but the drawback is a risk of muscle weakness, a need for adjustment of infusion dose of local anesthetics, and risk of falls (Kandasami et al. 2009, Ilfeld et al. 2010b, Sharma et al. 2010). Optimization of analgesia may include a high dose of glu- cocorticoids preoperatively (Lunn et al. 2011) or use of other In other studies, short hospital stays of 1–2 days h achieved in selected patients, but no specific inf was provided on potential discharge problems (Ilfe 2006a,b, Kerr and Kohan 2008), except in one study et al. 2009). In this latter study on THA patients o charge criteria were similar to ours, but patients we ActaOrthopDownloadedfrominformahealthcare.comby82.20.71.193on02/21/12 Forpersonaluseonly. Areas for optimisation - example • Pain • Dizziness • PONV • Confusion • Sedation • Muscle Weakness • Logistical
    44. 44. @twwainwright enhancedrecoveryblog.com 44 Exercise prescription: Progressive strength training (10 RM) commenced immediately after fast-track total knee 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 112%, respectively. Linding Jakobson et al. 2012
    45. 45. @twwainwright enhancedrecoveryblog.com 45 Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme. Barker et al. (2013) Clin Rehabil published online 10 April 2013 DOI: 10.1177/0269215513478437
    46. 46. @twwainwright enhancedrecoveryblog.com 46 Loss of Knee-Extension Strength Is Related to Knee/Thigh Swelling After TKR • 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
    47. 47. @twwainwright enhancedrecoveryblog.com 47 Cryo-therapy can be effective
    48. 48. @twwainwright enhancedrecoveryblog.com 48 Cryo-compression Therapy Hip Int. 2012 Sep-Oct;22(5):527-33. doi: 10.5301/HIP.2012.9761. Cryocompression therapy after elective arthroplasty of the hip. Leegwater NC, Willems JH, Brohet R, Nolte PA.
    49. 49. @twwainwright enhancedrecoveryblog.com 49 New Modalities such as the Geko Device can also help to reduce swelling http://gekodevices.com/ Comparison of true blood volume movement per minute per device 0 50 100 150 200 Kendall Calf Flowtron Calf Flowtron Foot OnPulse device type volumeflow(ml)perminute
    50. 50. @twwainwright enhancedrecoveryblog.com 50 50 Comparison of anti-stasis mechanical compression devices (geko™ device OnPulse ™ technology) Dynamic Device Comparison* Kendall Calf Flowtron Calf Flowtron Foot OnPulseTM 0 50 100 150 200 Kendall calf Flowtron calf Flowtron foot OnPulse Volumeflow(ml)perminute Device type Comparison of True Blood Volume Movement per minute per device 0 5 10 15 20 25 30 Kendall calf Flowtron calf Flowtron foot OnPulse PeakMaxVelocity(cm/sec.) Device type Comparison of Peak Max Velocity per device *Reproduced with the kind permission of The Royal Hospital of St Bartholemew, Barts and the London NHS Trust
    51. 51. @twwainwright enhancedrecoveryblog.com 51 The Geko - How it works and mechanism of action • The gekoTM device stimulates the common peroneal nerve to activate the calf muscle pumps • Increases blood flow volume and velocity • Achieves a blood flow rate of 50-70% of walking - measured by duplex ultrasound in the femoral vein A. T. Tucker, A. Maass, D. S. Bain et al. Augmentation of venous, arterial, and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. Int. J. Angiol. 2010; 19 (1): e31-e37
    52. 52. @twwainwright enhancedrecoveryblog.com 52 • Results: A statistically significant increase in walking speed was observed in the treatment group in relation to the control group at both 6 weeks (P=0.0002) and 12 weeks (P=0.0001) postoperatively
    53. 53. @twwainwright enhancedrecoveryblog.com 53 Alter-G Anti-gravity treadmill
    54. 54. @twwainwright enhancedrecoveryblog.com 54 @twwainwright enhancedrecoveryblog.com The next step in the evolution of enhanced recovery? Illness Wellness Fitness
    55. 55. @twwainwright enhancedrecoveryblog.com 55
    56. 56. @twwainwright enhancedrecoveryblog.com 56 Summary • Rehabilitation pathways need to change if we are to improve function, activity levels and outcomes further • Changing the type, dose, timing of interventions is vital if outcomes are to be optimised
    57. 57. @twwainwright enhancedrecoveryblog.com 57 One final thought… What rehabilitation pathway would you like your mum to have?
    58. 58. @twwainwright enhancedrecoveryblog.com Thank you

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