Background/Purpose: Arthrofibrosis is a complication following knee joint replacement due to excessive scar tissue formation. It leads to knee stiffness,  restricted range of movement (ROM) and poor function. Dysregulated inflammation underlies this complication and aggressive rehabilitation may perpetuate this. Physiotherapy is the first-line treatment but there are no guidelines as to what this should include or how it should be delivered.   

The purpose of this study was to develop an optimal evidence- and theory- based intervention to improve outcomes for people with arthrofibrosis.

Methods: Four work-packages (WP), guided by the Medical Research Council framework for intervention development, were undertaken.  A ‘Patient and Public Involvement’ group made up of people with experience of arthrofibrosis were involved throughout.

WP1.  A systematic review of non-surgical interventions for arthrofibrosis following TKR.  

WP2. Qualitative interviews with patients and health care professionals (HCPs) to explore their experiences and perceptions of needs and care receive and the context of managing arthrofibrosis. 

WP3.  A modified Delphi survey with HCPs and patients to agree the content of an optimal intervention. 

WP4.  Workshops to refine the content and delivery of the intervention.

Results: WP1. 15 primary studies reported on a variety of interventions. Therese were often poorly described and the evidence was of low quality. Most studies reported improvements in ROM but data did not enable a meta-analysis. There was limited reporting on other patient relevant outcomes.

WP2. The rehabilitation experience was characterised by inconsistencies in approach and guidance. Patients expressed feelings of frustration but remained motivated and were proactive in thier approach. HCPs including surgeons, occupational and physiotherapists reported several barriers to  management including (1) issues identifying arthrofibrosis, (2) perceived patient factors such as attitudes and approaches, (3) shortcomings of current interventions, and (4) system issues such as resources, poor communication between HCPs, and variation in access to care.

WP3. 104 individual statements around the delivery and content of an optimal intervention were generated from the systematic review and Delphi. After 3 rounds these were reduced to 63 items that were categorised into Advice and information, Exercise, Manual therapy, Mechanical devices and splints, and aspects of delivery.  

WP4. The final intervention is a personalised physiotherapy programme that integrates behaviour change techniques, and a traffic light system to monitor patient symptoms to tailor the programme according to clinical indicators of inflammation.   

Conclusion: This study collected a wide range of data and perspectives from patients and healthcare professionals about managing arthrofibrosis following knee replacement. The final intervention supports early identification of patients at risk, a non-aggressive approach to exercise and monitoring symptoms to tailor the intervention.  We will now conduct a feasibility trial to determine the acceptability of the intervention and feasibility of powered RCT.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/development-of-an-optimal-physiotherapy-intervention-to-reduce-stiffness-following-knee-joint-replacement/