July 2011

Prehabilitation for TJA: More than just exercise

New England Baptist Hospital’s multi­disciplinary prehabilitation program is grounded in research suggesting that outcomes after total joint replacement can be positively influenced by preoperative care that includes management of patient expectations as well as exercise.

By Claire E. Robbins, PT, DPT, MS, GCS, James V. Bono, MD, and Carl T. Talmo, MD

Prehabilitation is a word that appears to have become en vogue in the healthcare and the fitness communities during the past decade. The literature is peppered with articles describing the effectiveness of prehabilitation for improving function in surgical patients, patients in the intensive care unit (ICU) and athletes.1-6

However, the reader will be hard pressed to find a universal definition of the word prehabilitation in a standard, medical, or electronic dictionary. Prehabilitation has been described as: the process of enhancing the functional capacity of an individual to enable him or her to withstand the stressor of inactivity associated with an orthopedic procedure; a form of strength training that aims to prevent injury before the actual occurrence; and the concept of doing physical therapy to prevent injuries.7 Athletes prehabilitate through strength and conditioning programs which help reduce the risk of injury associated with competition.

At New England Baptist Hospital (NEBH) in Boston, we have developed and implemented a comprehensive prehabilitation model for patients undergoing total hip and total knee arthroplasty. A multidisciplinary team of physical and occupational therapists, orthopedic surgeons, medical consultants, and nursing, pain management, anesthesia, and case management personnel actively participate in a preoperative/prehabilitative process to ensure a successful surgery and optimal postoperative results. The process consists of multiple elements and is designed to achieve a multifaceted outcome, in contrast with some other prehabilitation models that feature a single element to achieve a single result. At NEBH, prehabilitation can be defined as a multidisciplinary, preoperative process of evaluation, education, and therapeutic exercise designed to meet the functional, psychological, and social needs of patients undergoing joint replacement surgery.

Discussion

Total joint replacement surgery can provide pain relief and restore function in individuals with osteoarthritis of the hip and knee. The demand for hip and knee surgeries in the U.S. has been increasing due to the aging population. However, advances in technology, surgical technique, and perioperative care over the past few decades also have made total hip arthroplasty (THA) and total knee arthroplasty (TKA) more suitable for a wider age group of patients, including aging baby boomers.8-11

Volumes of primary THA and TKA procedures increased steadily between 1990 and 2002, and the rate is projected to increase substantially over the next two decades.11 It is expected that the demand for THA will have increased 174% by 2030, and by then the number of TKA procedures could be as high as 3.48 million.12,13 Given these statistics and the ever-changing health care environment, hospitals and outpatient surgical facilities compete endlessly to attract patients and provide superior service.

Comprehensive preoperative preparation and care can contribute to the success of total joint replacement surgery. The importance of assessing preoperative patient expectations and providing multidisciplinary education to patients undergoing joint replacement surgery is documented in the literature.14-22 One prospective cohort study17 of THA and TKA patients found that expectations of complete pain relief after surgery predicted improved functional outcomes and expectations of low complication rates predicted satisfaction with the procedure six months after surgery. Another paper encompassing two prospective, randomized controlled trials demonstrated that patients’ preoperative expectations of recovery from THA and TKA can be modified by preoperative educational classes.18 Thomas and Sethares analyzed the effect of interdisciplinary  preoperative education intervention on patients undergoing total joint replacement surgery by comparing a control group who received standard preoperative education with an experimental group who attended an additional preoperative interdisciplinary session. The experimental group was able to better verbalize and demonstrate postoperative skills.15

The positive effects of prehabilitation programs or preoperative exercise are also documented for patients undergoing total joint replacement surgery, spinal surgery, colorectal surgery, cardiac catheterization, and ICU admission.1-6,23-24 Rooks et al examined the effect of a six-week presurgical exercise program on persons undergoing THA or TKA and found improvements in preoperative functional status and muscle strength.23 Another retrospective review24 examined early postoperative functional mobility and discharge disposition in a small cohort of patients with a body mass index (BMI) greater than or equal to 30kg/m2 who performed self-reported preoperative exercise prior to THA or TKA. Preoperative exercise improved immediate postoperative functional mobility and increased the likelihood of discharge to home in this population of obese total joint replacement patients.

NEBH is an acute, orthopedic specialty hospital that performs more than 4500 TKA and THA procedures a year. The majority of the total joint surgeries are elective procedures. Patients travel from all parts of the U.S. and the world to undergo surgery at NEBH. They expect the hospital, surgeons, and staff to be knowledgeable of and offer “cutting edge” techniques, treatments, and rehabilitation options. Most expect to return to work, sport, or pain-free activities of daily living within weeks of their operative procedure. Therefore, the importance of a comprehensive preoperative program at this institution cannot be overstated.

The prehabilitation model

At NEBH, a referral for total joint replacement surgery is the catalyst for the prehabilitation process. The preadmission screening unit (PASU) becomes the primary site for execution of the model. Each segment of the multidisciplinary team has defined roles.

Physical and occupational therapy. Together, the disciplines of physical and occupational therapy play a crucial role in the prehabilitation team. Physical therapists perform a thorough preoperative assessment during the preadmission screening process. Information from this assessment is then shared with other team members to determine both preoperative and postoperative functional and equipment needs of the patient. At this time, therapists address any patient special needs, such as bariatric equipment, caregiver issues, or home therapy concerns.

During this same preoperative meeting time, therapists instruct patients on a preoperative therapeutic exercise program to target key lower extremity muscle groups that will be important in the immediate postoperative phase. The preoperative THA and TKA programs, which are very similar, focus on isometric and concentric strengthening and active and passive range of motion of the hip, knee, and ankle. Muscles targeted include hip flexors and extensors, hip abductors and adductors, knee flexors and extensors, and ankle dorsiflexors and plantar flexors. Exercises are performed in supine, sitting, and standing positions. One difference between programs is that the TKA preoperative program includes prone lying knee flexion exercises and the THA program does not.

Figure 1: This chart illustrates length of stay (y-axis=number of days) for total joint replacement patients at NEBH for the last three years.

The preoperative exercise program is modified accordingly for any pre-existing medical conditions. For example, if a patient is unable to lie supine as a result of recent spine surgery or cardiopulmonary pathology, a wedge or pillows may be used to allow the patient to perform the exercises in a modified supine position. Alternately, a patient may be unable to stand because of weightbearing restrictions or body habitus. The program would then focus on the sitting and supine aspects of the program. The patient is also issued a joint-specific DVD and exercise booklet for home use with the same preoperative program.

Therapists also review with each patient the fall prevention program and policy at NEBH. Following the review, the patient and therapist sign a preoperative safety contract, which remains in the patient record during their hospital stay.

Orthopedic surgeons. The orthopedic surgeon starts the prehabilitation process by making the referral for a patient to undergo TKA or THA surgery. In this respect, the surgeon and

Figure 2 : Fall rate for NEBH for the past five years. NEBH is compared against the data on the Massachusetts Hospital Association’s Patient First website.

surgeon’s office staff are essential to alerting the PASU of any pre-existing medical or psychological issues that may need special attention during the preadmission screening process. This enables the PASU to contact appropriate personnel prior to the patient’s preoperative visit. Preoperatively, the surgeon also discusses the relevant total joint protocol and offers the patient the opportunity to attend a hip or knee class.

Any patient undergoing total hip replacement or total knee replacement surgery at NEBH has the opportunity to attend a preoperative hip or knee class. The classes are offered during the week and on the weekends to accommodate the varied schedules of our joint replacement population. The class is a comprehensive, multidisciplinary session in which the surgical process and hospital stay is reviewed from start to finish. Patients are encouraged to bring family members and to ask questions. We consider this session to be a valuable asset to the prehabilitation model.

Nursing. The nurse practitioner undertakes many roles on the PASU, including the roles of coordinator, educator, and medical assessor.

Our nurse practitioners perform a medical assessment of the preoperative patient, paying particular attention to cardiovascular, respiratory, and other comorbidities that may affect preparation for anesthesia or the outcomes of surgery. Nursing personnel alert other team members if special medical assessments are necessary.

Figure 3: Percentages of patients who would recommend New England Baptist Hospital for TKA and THA surgery.The percentages are taken from Hospital Compare, which is Medicare’s public website. The percentages for the U.S. and Massachusetts are based upon survey findings from all vendors reporting information to the Centers for Medicare & Medicaid Services.

Nursing coordinates the methicillin-resistant staph aureus (MRSA) and methicillin-sensitive staph aureus (MSSA) screening program. They provide preoperative education on these infections and oversee the medical technician who obtains the nasal screens and conducts the follow-up process.

The nurse practitioner educates the patient on the overall perioperative process and is the preoperative contact person should the patient have any questions or concerns. He or she provides the patient with details about the preoperative hip and knee classes and how to access and register for the hospital-based support e-mail program/website for patients undergoing total joint replacement surgery.

Pain management/anesthesia. “Cohesive yet separate” best describes these two groups and their roles in the prehabilitation model. Preoperatively, the primary role of the anesthesiology team is determining the proper anesthesia protocol based on the cardiovascular and respiratory health of the patient. However, as members of the broader pain management team, they are also vital in helping to develop a perioperative pain management program for each patient and educating those patients who may be receiving an indwelling femoral nerve catheter. Patients who will receive an indwelling nerve catheter are given an educational DVD in the preoperative period. Anesthesia specialists are available to counsel and educate the patient on this pain management protocol during the entire perioperative period.

Medical consultants. This group consists of members from internal medicine, pulmonology, cardiology, oncology, infectious disease, rheumatology, radiology, and psychiatry. They are consulted based on the individual and specific needs of our joint replacement patients.

Case management. A prehabilitation goal of case man­agement is to ensure that all patient discharge needs are identified and planned for. Insurance needs, home care, or rehabilitation placement, transportation and caregiver needs should be resolved to enable the patient to experience a successful surgery and postoperative recovery.

Outcomes

One method of assuring the quality and effectiveness of any model or program is to periodically assess the goals and results. Several components of our NEBH prehabilitation model were assessed over the past year:

1) The departments of rehabilitation services (physical and occupational therapy) and orthopedic surgery published an article24 highlighting the positive effects of preoperative exercise on postoperative functional mobility and discharge disposition in patients who are obese and undergo total joint replacement surgery. The study found that self-reported preoperative exercise can improve early postoperative mobility and increase the likelihood of discharge to home in this patient cohort.

2) Since implementation of the multidisciplinary prehabilitation model, case management reports an average length of stay for TKA and THA patients combined (in 2010) to be 3.5 days, with 63% discharged to home and 37% to short-term or long-term acute care (L-TAC) level or acute level rehab. Figure 1 shows a decrease in length of stay over the past three years.

3) The infection control component of the model has demonstrated a decrease in postoperative total joint infections between 2009 and 2010. The rate for total hip procedures decreased from a rate of .49 to .41, and the rate for total knee procedures decreased from .39 to .35.

4) The nursing and health care quality sectors report a significant decrease in falls (figure 2) and patient satisfaction scores (figure 3) since implementation of the comprehensive model.

Summary

As the demand for TKA and THA surgeries continues to rise over the next two decades, so will the needs of total joint replacement patients. Our responsibility as health care providers is to meet these needs and prepare the patient for the physical, psychological, and social changes that may accompany this surgical procedure.  Based on our results at NEBH, we believe we have implemented and presented a prehabilitation model that meets this responsibility.

Claire E. Robbins, PT, DPT, MS, GCS, is a research assistant in the department of orthopedic surgery and per diem physical therapist at New England Baptist Hospital in Boston. James V. Bono, MD, is vice chairman of orthopedic surgery and director of education at NEBH and a clinical professor of orthopedic surgery at Tufts University Medical School in Boston. Carl T. Talmo, MD, is an orthopedic surgeon at NEBH specializing in joint replacement surgery of the hip and knee, and an assistant clinical professor of orthopedic surgery at Tufts.

References

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