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No advantages in WOMAC physical function seen with late-stage exercise programs after total knee replacement vs usual care
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Patients who participated in late-stage exercise programs after total knee replacement saw no benefits in WOMAC physical function compared with patients who received the usual care, according to a published study.
“For selective patients with persistent functional limitations several months after total knee replacement, an intensive and progressive exercise program delivered by a physical therapist could help them in achieving better functional performance,” Sara R. Piva, PT, PhD, told Healio.com/Orthopedics.
Researchers from Allegheny County, Pennsylvania performed a three-arm single-blind randomized clinical trial of 240 of patients who underwent total knee replacement in which 96 patients were assigned to physical therapy, 96 patients were in a community exercise group and 48 were assigned to a control arm that received usual care. Differences in WOMAC physical function at 3 months between the treatment groups was the primary outcome. Other outcomes included performance-based tests germane to knee replacement and other physical function surveys. Linear mixed models and responder analysis were used to analyze data.
Results at 3 months showed no differences in outcomes between the groups based on the between-arm analyses for WOMAC physical function. Based on the results from performance-based tests, greater improvements were seen in patients treated with physical therapy compared with patients who were in the control group and those who were treated with community exercise. Compared with the community exercise group, the physical therapy group had 17.7% more responders and 19% more responders compared with the control group. Responder rates were not different between the community exercise group and the control group. – by Monica Jaramillo
Disclosures: Piva reports she receives grants from the Patient-Centered Outcomes Research Institute. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Lynn Snyder-Mackler, PT, ScD, FAPTA
In clinic, individualized exercise interventions result in more improvement than supervised group exercise or usual care in functional performance, but not self-report after TKR.
Piva and her colleagues at the University of Pittsburgh conducted a pragmatic trial of exercise. It involved clinic-based individualized physical therapy (n=96), community-based group exercise in supervised classes (n=96) or usual care (n=48) for 12 weeks beginning 2 to 4 months after TKR . The research underscored previous research that found a discrepancy between patient-reported outcomes and performance-based tests. At the end of the intervention period, all three groups reported clinically important improvements in the WOMAC-PF measure, with no significant differences between them.
The secondary outcome, which combined six performance tests (6-minute walk distance, 40-m gait speed, stair ascend/descend test, single-leg stance balance, chair rise, and floor sitting and rising) into a composite score, showed a significant and clinically meaningful greater improvement in the physical therapy group compared with both the community and control groups at 3 months, and that persisted at 6 months. The response rate, which the authors defined as more than 20% improvement in both the WOMAC-PF and at least three of the six performance tests, was also significantly higher in the physical therapy group compared with the community and control groups.
The authors explain that, “While patient-reported outcomes like the WOMAC-PF evaluate what individuals perceive they can do, performance-based tests evaluate what individuals can actually do.” Others have also shown that patient perception often fails to capture the acute functional declines after TKA and may overstate the long-term functional improvement with surgery.
Newark, Delaware
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Piva SR, et al. JAMA Network Open. 2019;doi:10.1001/jamanetworkopen.2019.0018.
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