Background/Purpose:

Total knee replacement (TKR) improves pain and quality of life; however, the functional limitations that existed for years before surgery tend to persist after surgery. Progressive and intensive exercise programs could resolve these persistent limitations but they are not tolerated by many patients until later stage (>2 months) after surgery. Evidence for the effectiveness of exercise at later stage post-TKR is limited.

The purpose if this study was to compare the effectiveness of later stage exercise programs (outpatient individualized physical therapy [PT] and group classes in community centers) with an usual medical care, at improving physical function and activity, and to explore heterogeneity of treatment effects.

Methods:

The study was a 3-arm single-blind randomized clinical trial that enrolled 240 individuals at least 60 years of age, with primary TKR done at least 2 months before, who experienced moderate functional limitations, and were medically cleared to exercise. The 3 study arms were clinic-based PT exercise, community-based group exercise, or usual care (control). The control group continued their usual care whereas the exercise groups participated in supervised exercise programs during 12 weeks.

Physical function was the main outcome and was assessed primarily by the Western Ontario and McMaster Universities Osteoarthritis Index-Physical Function scale (WOMAC-PF), and secondarily by performance-based tests germane to patients with TKR, and additional patient-reported outcomes at 3 and 6 months. The trial was registered in ClinicalTrials.gov, NCT02237911.

Results:

All 3 arms demonstrated clinically important improvements. At 3 months, the PT arm showed the most improvement in WOMAC-PF (p=0.04). Compared to community arm, the PT arm had greater improvement on performance-based tests (0.1; 95%CI: 0.002, 0.2) and percentage of responders (18% to 24% more in the PT arm). PT arm also had more improvements than control in performance-based tests (0.3, 95%CI: 0.1, 0.4) and percentage of responders (19% to 34% more in PT arm). The community arm improved performance-based tests compared to control (0.2; 95%CI: 0.02, 0.3). Most differences were sustained at 6 months. Exercise was not associated with serious adverse events.

Moderator analysis showed significant interactions for obesity, anxiety/depression, and arthritis self-efficacy. Non-obese participants in both exercise arms had more improvements in physical function than the control. For obese participants, those in PT arm appear to experience more improvements than the community arm. Participants without depression/anxiety and high levels of self-efficacy in exercise arms had greater functional recovery compared to control; whereas those in the community arm with depression/anxiety symptoms and low levels of self-efficacy experienced less functional recovery.

Conclusion:

This study provides novel evidence about the safety and effectiveness of late-stage intensive rehabilitation post-TKR. Individualized PT provided greater improvements in physical function than community or control arms. Patients and clinicians could benefit from studies to test models to implement late-stage rehabilitation programs post-TKR.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/randomized-trial-on-exercise-at-late-stage-after-total-knee-replacement/