Challenging the Status Quo on Physical Therapy after TKA
A study from The Rothman Institute questions whether every patient who undergoes primary total knee arthroplasty really needs to participate in a formal outpatient physical therapy program.
A supervised physical therapy program, either at a rehabilitation facility or at an outpatient facility, may be unnecessary for many patients undergoing primary total knee arthroplasty (TKA), according to a prospective, randomized controlled trial from The Rothman Institute.
The study findings, presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans, are consistent with the findings of a previous study from The Rothman Institute demonstrating that patients do not need to participate in a formal physical therapy program during recovery from primary total hip arthroplasty. 
For the study on TKA patients, the researchers evaluated outcomes of 200 patients who had undergone primary TKA between March 2016 and April 2017. The procedures were performed by 8 surgeons from The Rothman Institute.
After surgery, patients participated in outpatient physical therapy, unsupervised home exercise using an interactive web-based platform, or unsupervised home exercise using a paper manual. Patients in the 2 home therapy groups who were struggling to achieve knee flexion goals at 2 or 4 weeks – 70 or more flexion in the operated knee at 2 weeks or 90 or more at 4 weeks – were required to cross over to the outpatient therapy group.
Knee flexion was the primary outcome, with secondary outcomes of:
- Knee injury and Osteoarthritis Outcome Score (KOOS)
- Resumption of activities of daily living (ADLs), such as work, driving, and walking without an assistive device
- Discontinuation of opioid pain medications
- Satisfaction with visual analog scale (VAS) score
Antonia F. Chen, MD, MBA, one of the study authors, said she and her colleagues had “hypothesized that patients who received formal physical therapy after a total knee arthroplasty would have better range of motion postoperatively.” But that was not the case. “Our study demonstrated no difference in flexion among the patients who received paper physical therapy, web-based physical therapy, or formal physical therapy,” Dr. Chen said.
That was also true of the secondary outcomes, with no statistically significant differences found in KOOS improvement from baseline to follow-up, time from surgery to resumption of ADLs, time from surgery to discontinuation of pain medications, or satisfaction with VAS score.
The study findings challenge current practice with regard to participation in a formal physical therapy program after primary TKA, demonstrating that, “formal outpatient PT does not need to be prescribed to every single patient after primary TKA,” Dr. Chen said. “This is a change in patient, nursing, PT and surgeon thinking, which changes clinical practice. We want surgeons to try and guide patient expectations after primary TKA and to change the way they practice to allow for good postoperative outcomes while reducing postoperative costs.”
It’s not surprising that some patients are on board with this change, while others are uncomfortable with it.
“Some patients are excited that they don’t have to find a ride to every PT session, and they are also happy that they don’t have pay a copay for each outpatient physical therapy session,” Dr. Chen said.
“On the other hand, other patients have friends or relatives who received physical therapy and expect it postoperatively. Some patients can request outpatient PT, but from this study, we may recommend limiting the number of postoperative PT sessions until the patient feels comfortable doing exercises on their own.”
Due to the relatively small patient population in this study, the researchers could not determine which patients would benefit from a formal outpatient physical therapy program and which would do well with an unsupervised home-based program, Dr. Chen said. But given that some patients crossed over from the home-based groups to the outpatient group – 9.1% in the web-based group and 14.9% in the paper-based group – there clearly are some patient who will need to participate in a formal outpatient program.
“We would recommend assessing patients first to understand their postoperative expectations with regard to therapy, and potentially utilizing outpatient supervised physical therapy in patients with decreased preoperative range of motion,” Dr. Chen said.
Surgeons at The Rothman Institute are practicing what they preach: They have “decreased the amount of physical therapy prescribed to primary total joint arthroplasty patients postoperatively without compromising outcomes,” Dr. Chen said, which has reduced patient costs and overall costs of an episode of care – an important consideration in the era of bundled payments for total joint arthroplasty.
Fleischman A, Crizer MP, Tarabichi M, Rothman RH, Lonner JH, Chen AF. Unsupervised Home Exercise Provides Equivalent Outcomes to Traditional Outpatient Physiotherapy after Primary Total Knee Arthroplasty: A Randomized Controlled Trial (Paper 793). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.
Dr. Fleischman, Ms. Crizer, and Dr. Tarabichi have no disclosures. Dr. Rothman has disclosed that he is a paid consultant for Stryker. Dr. Lonner has disclosed that he receives royalties from, is a paid consultant for, is a paid presenter for, and receives research support from Zimmer Biomet and Smith & Nephew; that he receives research support from and has stock or stock options in Force Therapeutics; and that he has stock or stock options in Proteonova. Dr. Chen has disclosed that she is a paid consultant for 3M, ACI, bOne, ConvaTec, DJO Surgical, Heraeus, Pfizer, Recro, Stryker, and Zimmer Biomet; that she has stock or stock options in Graftworx, Joint Purification System, and Sonoran; that she is a paid consultant for and receives research support from Halyard and Irrimax; and that she receives research support from Smith & Nephew.
Note: Dr. Chen was with The Rothman Institute at the time of the study and is now at Brigham & Women’s Hospital in Boston.
- Austin MS, Urbani BT, Fleischman AN, et al. Formal physical therapy after total hip arthroplasty is not required: a randomized controlled trial. J Bone Joint Surg Am. 2017 Apr 19;99(8):648-655. doi: 10.2106/JBJS.16.00674.