Orthopedics

Feature Article 

Preoperative Exercise Participation Reflects Patient Engagement and Predicts Earlier Patient Discharge and Less Gait Aid Dependence After Total Joint Arthroplasty

Sahitya K. Denduluri, MD; James I. Huddleston III, MD; Derek F. Amanatullah, MD, PhD

Abstract

Whether preoperative physical therapy actually leads to improved clinical outcomes after total joint arthroplasty (TJA) remains unclear. The authors sought to use participation in a preoperative online exercise and education program as a marker for patient engagement. They hypothesized that increased preoperative participation with the program would predict shorter length of stay (LOS) and gait independence. Forty consecutive patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) by a single surgeon were given access to the PrimePrehab Prehabilitation Exercise Program (NextPT, Boulder, Colorado). Patients were guided through questionnaires, and the program generated educational readings and exercise modules directed toward initial ability. Preoperative completion of readings, completion of exercise modules, and improvement in exercise difficulty were tracked. Patients received a standardized postoperative protocol, including physical therapy on the day of surgery and subsequent hospital days. Length of stay and gait aid use at 90 days postoperatively were recorded. Analyses were simple or multiple regression with a significance of P≤.05. Patients completed a mean of 7 exercise modules with 30% improvement in difficulty. Controlling for demographic variables, the frequency of program completion correlated with shorter LOS (P=.037). This finding was not different between THA and TKA (P=.387). No association was found between the frequency of program completion and gait aid use at 90 days (P=.213), although there was a decrease in gait aid use at 90 days with improvement in exercise difficulty (P=.034). A preoperative education and exercise program can predict patient engagement, which correlates with a shorter LOS and suggests that increasing exercise difficulty is associated with gait independence after TJA. [Orthopedics. 2020;43(5):e364–e368.]

Abstract

Whether preoperative physical therapy actually leads to improved clinical outcomes after total joint arthroplasty (TJA) remains unclear. The authors sought to use participation in a preoperative online exercise and education program as a marker for patient engagement. They hypothesized that increased preoperative participation with the program would predict shorter length of stay (LOS) and gait independence. Forty consecutive patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) by a single surgeon were given access to the PrimePrehab Prehabilitation Exercise Program (NextPT, Boulder, Colorado). Patients were guided through questionnaires, and the program generated educational readings and exercise modules directed toward initial ability. Preoperative completion of readings, completion of exercise modules, and improvement in exercise difficulty were tracked. Patients received a standardized postoperative protocol, including physical therapy on the day of surgery and subsequent hospital days. Length of stay and gait aid use at 90 days postoperatively were recorded. Analyses were simple or multiple regression with a significance of P≤.05. Patients completed a mean of 7 exercise modules with 30% improvement in difficulty. Controlling for demographic variables, the frequency of program completion correlated with shorter LOS (P=.037). This finding was not different between THA and TKA (P=.387). No association was found between the frequency of program completion and gait aid use at 90 days (P=.213), although there was a decrease in gait aid use at 90 days with improvement in exercise difficulty (P=.034). A preoperative education and exercise program can predict patient engagement, which correlates with a shorter LOS and suggests that increasing exercise difficulty is associated with gait independence after TJA. [Orthopedics. 2020;43(5):e364–e368.]

Patient discharge after total joint arthroplasty (TJA) is dependent on a variety of factors, including pain control, status of the surgical wound, management of medical comorbidities, disposition planning, and progress with physical therapy.1–4 In-patient length of stay (LOS) following TJA has a tremendous impact on total cost of care, both to the patient and to the health care system.5,6 Among patients undergoing total hip arthroplasty (THA), Regenbogan et al6 reported that a shorter LOS was associated with nearly $3000 in decreased total surgical episode cost and no significant change in post-discharge spending. Regarding outcomes, patient satisfaction has been correlated with return to normal daily activities without pain.7,8 Singh et al9 reported that patients who had some or complete dependence on walking aids after total knee arthroplasty (TKA) had significantly higher odds of moderate-severe pain and activity limitation when compared with those who did not require walking aids.

Various studies evaluated whether preoperative functional status correlates with outcomes after TJA, and the conclusions are mixed.10–12 Kennedy et al13 found that higher preoperative scores with regard to the Western Ontario and McMaster Universities Osteoarthritis Index, the 6-minute walk test, and the timed up and go test all predicted better functional status at 1 week after THA or TKA. Petis et al14 showed that with every 5-second interval increase in the timed up and go test time, patients were twice as likely to stay in the hospital beyond 48 hours after THA.

Whether these short-term outcomes are clinically significant during a longer follow-up period remains unclear. In fact, a recent study found that patient-reported physical activity prior to TKA did not predict return to work postoperatively.12 Kwok et al15 performed a systematic review of 11 randomized trials and concluded that preoperative physical therapy did not lead to significant improvements in patient outcome scores, pain, range of motion, or LOS after TKA.

Recently, several investigators suggested that patient engagement with the recovery process may correlate with outcomes after TJA. One study concluded that preoperative beliefs and expectations were more predictive of returning to work after TJA when compared with preoperative physical activity.12 Andrawis et al16 examined patient activation, a measure of the propensity to engage in adaptive health behavior by taking into account beliefs such as optimism, hope, self-efficacy, and locus of control. They determined that higher preoperative patient activation correlated with improved patient-reported pain, symptoms, and satisfaction after TJA.16 Given these studies, the current authors sought to develop a screening tool that could be used to identify patients who are more likely to succeed after TJA.

The PrimePrehab Prehabilitation Exercise Program (NextPT, Boulder, Colorado) guides patients through a series of personalized modules preoperatively, with the goals of fostering more patient engagement and improving exercise tolerance in preparation for surgery. The current authors hypothesized that more preoperative engagement in rehabilitation prior to TJA would decrease LOS and hasten patients to return to function with decreased use of an assistive gait device.

Materials and Methods

This retrospective cohort study received institutional review board approval. All patients were excluded if their etiology of disease was not osteoarthritis or they received an aseptic revision surgery or surgery for an infection. Forty consecutive patients with osteoarthritis undergoing a posterior approach THA or medial parapatellar TKA performed by a single surgeon (J.I.H.) were given the PrimePrehab Exercise Program free of charge. The program guided patients through a series of modules on surgical expectations and rehabilitation prior to surgery, with a goal of fostering patient engagement in preparation for joint replacement. Participants were given an access code and directions for how to access the PrimePrehab Prehabilitation Exercise Program creation portal at the time of indication for joint replacement.

Following program registration, participants used a unique user ID and password to log in to the PrimePrehab website ( http://www.nextpt.me/primeprehab) and create a personalized preoperative education and exercise program. This was achieved by guiding the patient through a series of online questionnaires regarding the type of upcoming surgery, date of operation, current level of physical function, postoperative goals, presence of potential high fall risk factors. Using participant-specified information, the PrimePrehab website compiled a series of 8 educational readings and 5 exercise modules drawn from well-established, evidence-based physical therapy programs that were adjusted to the participant's initial ability level (Table 1).17,18

PrimePrehab Prehabilitation Exercise Programa Educational Readings and Exercise Modules

Table 1:

PrimePrehab Prehabilitation Exercise Program Educational Readings and Exercise Modules

At any time, participants were able to increase or decrease the level of difficulty of an exercise module (range, 1–5), fast forward or rewind the exercise, or move to the next or prior category of exercises. Points were awarded each time the participant viewed all 5 daily exercise videos and completed each educational reading. The number of points achieved by the patient preoperatively was considered as the “frequency” of program participation. Improvement was measured by change in difficulty level from program initiation to the maximum level reached preoperatively. Participants were instructed to exercise 5 times per week leading up to surgery and to complete all 8 educational lessons before the day of surgery.

Postoperatively, all patients received a standardized rehabilitation protocol that involved mobilization with physical therapy on the day of surgery. Inpatient physical therapy was then continued at least once daily while the patient was admitted to the hospital. Patients were deemed appropriate for discharge either to home or a skilled nursing facility based on their progress with therapy (eg, distance ambulated, number of stairs ascended) and home safety considerations (eg, help of another person, stairs, durable medical equipment). Postoperative LOS in the hospital and gait independence at 90 days postoperative (GI90; eg, none, cane, walker, or wheelchair [score range, 0–3, respectively]) were recorded.

Results were described as medians and ranges for demographics, means and standard deviations for continuous variables, and numbers and percentages for all categorical variables. Statistical analyses were conducted as either simple or multiple regression using SPSS version 26 software (IBM, Armonk, New York). The authors added an interaction term to the regressions to determine whether the effects of the exercise program were moderated by surgery type (either THA or TKA).

Results

Median age of the cohort was 65 years (range, 49–86 years). Twenty-three (57.5%) participants were women and 17 (42.5%) were men. Median body mass index was 27.6 kg/m2 (range, 20.4–39.6 kg/m2). Twenty-five (62.5%) patients had a right-sided operation, 14 (35.0%) had a left-sided operation, and 1 (2.5%) had a simultaneous bilateral procedure. Median American Society of Anesthesiologists (ASA) classification score was 2 (range, 1–3). Twenty-three (57.5%) patients underwent TKA, whereas 17 (42.5%) underwent THA. Data on LOS were available for all 40 patients (100%), but gait aid data were documented for only 33 (82.5%) at 90-day clinic follow-up (Table 2).

Cohort Characteristics

Table 2:

Cohort Characteristics

Preoperatively, participants completed a mean of 6.9±13 exercise modules (1 outlier completed 65 modules) and showed a mean improvement of 31%±27.0% in exercise difficulty. No significant associations were found between sex and frequency of program completion (P=.286) or improvement in difficulty (P=.683).

Postoperatively, participants spent a mean of 62.3±16 hours in the hospital prior to discharge (1 outlier spent 178 hours). Four (10.0%) patients were discharged to a skilled nursing facility and 36 (90.0%) were discharged to home. Based on simple regression, no correlation was found between LOS and age (P=.146), sex (P=.207), weight (P=.483), or ASA classification (P=.476).

Controlling for age, sex, weight, and ASA classification, the number of preoperative exercise modules completed was significantly associated with shorter LOS (P=.037; Figure 1). This finding was not different between THA and TKA (P=.387). When controlling for the above demographic variables, improvement in exercise difficulty was not significantly correlated with LOS (P=.938).

A scatter plot of modules completed correlated with decreased length of stay. Preoperative exercise modules completed correlated significantly with decreased length of stay in hospital (P=.037) (A), but improvement in preoperative exercise difficulty did not (P=.938) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.

Figure 1:

A scatter plot of modules completed correlated with decreased length of stay. Preoperative exercise modules completed correlated significantly with decreased length of stay in hospital (P=.037) (A), but improvement in preoperative exercise difficulty did not (P=.938) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.

At 90-day follow-up, patients scored a mean of 0.76±1.3 for gait aid dependence (GI90 score ranged from 0 to 3 for no aid, cane, walker, and wheelchair). Paradoxically, there was a trend toward increased gait independence at 90 days (lower GI90 score) with higher patient weight (P=.051). No correlation was found between gait independence at 90 days and age (P=.119), sex (P=.071), or ASA classification (P=.959). Controlling for all demographic variables, no significant association was found between the number of modules completed and gait independence at 90 days (P=.213). However, a significant correlation was found between gait independence and preoperative improvement in exercise difficulty (P=.034; Figure 2). Again, this association was not significantly different between patients who underwent THA and TKA (P=.854).

A scatter plot showing improvement in exercise difficulty correlated with decreased gait aid use at 90 days. Preoperative exercise difficulty improvement correlated significantly with decreased gait aid use at 90 days postoperatively (P=.034) (A), but the number of preoperative exercise modules completed did not (P=.213) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.

Figure 2:

A scatter plot showing improvement in exercise difficulty correlated with decreased gait aid use at 90 days. Preoperative exercise difficulty improvement correlated significantly with decreased gait aid use at 90 days postoperatively (P=.034) (A), but the number of preoperative exercise modules completed did not (P=.213) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.

Discussion

Accelerating recovery after TJA is important to patients and providers. Recently, several investigators have demonstrated that patient engagement may play a role in the recovery process, but none have looked specifically at ways to identify which patients will have favorable outcomes postoperatively. In this novel study, the current authors sought to use participation in a preoperative education and exercise program to demonstrate patient engagement with the recovery process, thereby correlating with improved outcomes after TJA. The findings indicate that increased participation with a preoperative exercise program correlates with a decreased hospital LOS and increased gait independence.

Several other studies examined the impact of preoperative physical therapy on postoperative outcomes, but those therapy protocols were not clearly defined or the results were mixed.19,20 Rodgers et al19 examined the effect of preoperative physical therapy for 6 weeks on postoperative muscle strength after TKA, concluding that there were no significant differences between groups regarding strength testing. However, their study only included 10 patients in each treatment arm and did not specifically evaluate clinically relevant outcomes such as distance walked, use of a gait aid, or LOS.19 A 2017 study in Denmark examined patients undergoing preoperative neuromuscular group exercise supervised by a physical therapist for 8 weeks before THA or TKA.21 Those authors concluded that patients in the intervention group had moderate improvement in quality of life measures only at 1 year postoperatively, but they did not study any functional outcomes.21 A systematic review by Kwok et al15 examined 11 randomized controlled trials evaluating preoperative physical therapy in primary TKA. The quality of studies was deemed to be poor due to small sample sizes, and furthermore, there were no significant differences in pooled outcome scores, strength, pain, range of motion, and hospital LOS.15

By comparison, the current study is distinct in that the authors used a standardized training program that was individualized to the patient's preoperative functional status and progress. They were also able to specifically track patient use of the program, allowing them to correlate preoperative engagement to postoperative clinical outcomes. The authors believe their data will guide larger comparative case-control studies and randomized controlled trials in the future, with the goal of ultimately incorporating personalized, interactive rehabilitation programs into a standard preoperative care pathway that will be used to identify patients who are engaged and portend favorable outcomes, as well as preemptively targeting more intensive and proactive resources toward the patients who are less engaged in this portion of the care pathway.

Several limitations exist for this study. First, this pilot study combined patients undergoing both THA and TKA. However, the authors believe that future studies focusing specifically on each operation should yield similar results, particularly given that they added an interaction term to their analyses to determine whether effects were moderated by surgery type. In addition, it is possible that some of the variations in use of the program could be attributed to differences in patients' familiarity and comfort with using technology needed to access the education material and exercises. Next, although statistically significant, it is difficult to determine whether the decrease in hospital LOS is clinically meaningful. That is, it is challenging to discern whether shorter LOS, often less than 1 day, has any impact on cost or satisfaction. Furthermore, the authors recognize that a variety of nonmedical factors may contribute to the exact time of discharge and, as such, individual data points should be interpreted with caution. That given, the authors believe that the general trend likely holds true.

Finally, this study does not specifically measure whether these outcomes of shorter LOS and gait aid independence are correlated with long-term clinical outcomes or increased satisfaction. Previous studies demonstrated that both of these variables affect a patient's perception of care,9,22,23 but the current work does not specifically evaluate this.

Conclusion

The authors have demonstrate that patient engagement with a preoperative education and exercise program correlates with decreased LOS and improved gait independence following TJA.

References

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PrimePrehab Prehabilitation Exercise Programa Educational Readings and Exercise Modules

Educational ReadingsExercise Modules
Information on the upcoming surgical procedureStatic balance training
Recommended home safety modificationsDynamic balance training
What to expect on surgery dayQuadriceps strengthening
What to bring to the hospitalGluteus medius strengthening
Potential postoperative discharge destinationsHamstrings strengthening
Details of each discharge destination
Correct icing techniques at home
Therapist recommendations for an efficient recovery

Cohort Characteristics

CharacteristicValue (N=40)
Age, median (range), y65 (49–86)
Male/female, No. (%)17 (42.5)/23 (57.5)
BMI, median (range), kg/m227.6 (20.4–39.6)
ASA class, median (range)2 (1–3)
TKA/THA, No. (%)23 (57.5)/17 (42.5)
Preoperative gait aid, No. (%)
  None25 (62.5)
  Cane10 (25.0)
  Walker5 (12.5)
Length of stay, median±SD, h62.3±16
Discharge disposition, No. (%)
  Home36 (90.0)
  Skilled nursing facility4 (10.0)
90-day gait aid,a No. (%)
  None (GI90 score 0)22 (66.7)
  Cane (GI90 score 1)8 (24.2)
  Walker (GI90 score 2)2 (6.1)
  Wheelchair (GI90 score 3)1 (3.0)
Authors

The authors are from the Department of Orthopaedic Surgery, Stanford Medicine, Redwood City, California.

Dr Denduluri has no relevant financial relationships to disclose. Dr Huddleston is a paid consultant for Exactech and Corin and holds stock in NextPT. Dr Amanatullah is a paid consultant for Stryker, Exactech, and Ethicon and has received grants from Stryker, Zimmer Biomet, and Roam Robotics.

The authors thank Roselinde Kaiser, PhD, for assisting with statistical analysis and figure preparation for this study.

Correspondence should be addressed to: Derek F. Amanatullah, MD, PhD, 450 Broadway St, M/C 6342, Pavilion C, 4th Fl, Rm 402, Redwood City, CA 94063 ( dfa@stanford.edu).

Received: January 22, 2019
Accepted: May 21, 2019
Posted Online: July 07, 2020

10.3928/01477447-20200619-04

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