Effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement for osteoarthritis: study protocol for a randomised controlled trial

Abstract

BackgroundPrimary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement.Methods/designTwo hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises.The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective.DiscussionThis research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency.Trial registrationISRCTN32087234, registered on 11 February 2015.

Assessment of Outcomes of Inpatient or Clinic-Based vs Home-Based Rehabilitation After Total Knee Arthroplasty

“…One, identified via a search in ClinicalTrials.gov, 45 plans to evaluate unsupervised home exercise with and without a web-based recovery platform compared with traditional outpatient physiotherapy after TKA. Another, with a published protocol 46 and feasibility study, 47 will compare clinic-based group physiotherapy with usual (home-based) care. However, the method proposed suggests possible crossover between settings in the latter arm because some patients were referred to physiotherapy services on an individual basis at the discretion of the hospital physiotherapist, orthopedic team, or general physician, with no indication of how many such referrals were made.…”

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

“…One of these, the ARENA randomised trial of physiotherapy exercise after TKR commenced in March 2015. 633 Ultimately, we aim to develop consensus statements and the conclusions of the RESTORE programme will be a cornerstone of these along with new studies based on these research findings and information from the National Joint Registry.…”

Prehabilitation and Rehabilitation for Major Joint Replacement

“…Additionally, for KQs 1 and 3 related to prehabilitation, we included: length of stay (postoperative) and posthospital disposition (e.g., to home, outpatient, skilled nursing facility, "subacute" rehabilitation, "acute" inpatient rehabilitation). The prioritized outcome domains are consistent with the "core outcome sets" recommended by Osteoarthritis Research Society International (OARSI) 59 and the Total Joint Arthroplasty and Outcome Measures (TJAOM) 60 toolkits, published in 2013 and 2014, respectively. Core outcome sets are agreed minimum sets of outcomes that should be reported in research in a given topic area.…”