ANALYSIS ON PHYSIOTHERAPY REHABILITATION FOR POST OPERATIVE TOTAL KNEE REPLACEMENT FOR THIGH MUSCLES STRENGTHENING
JV'n Reshu Jain1, Prof. Triveni Khurana2, Prof. Ashok Jain3
1,2,3Jayoti Vidyapeeth Women’s University, Jaipur
Abstract-
Background: Shably Hospital caterers to a large volume of patients daily. Many of those patients need surgical procedures and a high turnover rate in relation to postoperative length of stay in hospital is the norm. However, some elective surgical procedures, such as total knee replacement, have a prolonged hospital stay possibly due to the physiotherapy rehabilitation protocol being practiced.
Aim: The aim of this study is to determine whether electrical muscle stimulation on the quadriceps muscle in addition to the normal physiotherapy rehabilitation protocol will influence the short-term functional outcomes at six weeks post total knee replacement when compared with the normal physiotherapy rehabilitation protocol at Hospital.
Method: A single blinded randomized controlled trial was conducted at shalby Hospital. Participants were selected from the patients, between 45 and 80 years of age, requiring total knee replacement due to osteoarthritis during the period of dec 2019 to September 2020. The study sample consisted of 50 participants who were randomly allocated into two groups to which the researcher was blinded. Both groups received the normal physiotherapy rehabilitation protocol.
Conclusion: The addition of electrical muscle stimulation on the quadriceps muscle to the practiced protocol does not significantly influence the short-term functional outcomes post total knee replacement and did not significantly reduce the length of stay in hospital. The introduction of physiotherapy rehabilitation over the weekend did however, see a significant reduction in length of stay compared to previous statistics.
Although there were some significant findings in this study, for now, electrical muscle stimulation should not be incorporated into the protocol currently being used a Shalby Hospital, but with further research it could be re-looked.
1 PHYSIOTHERAPY INTERVENTIONS FOR POST-OPERATIVE KNEE STIFFNESS: RELEVANT STUDIES AND LITERATURE ANALYSIS
There are several popular methods for rehabilitation of post-operative knee stiffness and the rehabilitation paradigms are often physiotherapist specific, but none of the method is universally accepted. None of the following studies discusses the parameters of specific rehabilitation techniques, but the common goal is to suggest whether physiotherapy is significant or not in post-operative stiffness.
A literature reviewed by Bistolfi et al. explored some relevant clinical studies that include randomized blinded study, a sequential cohort study, a pilot randomized clinical trial that shows that physiotherapy is useful before and after total knee replacement. The study also reviewed that neuromuscular electrical stimulation (NMES) may be applied both pre and postoperatively to improve strength in quadriceps muscle after total
knee replacement, but parameters must be considered before the application. A longitudinal randomized control trial (RCT) revealed that NMES when applied to quadriceps muscle 2 times a day with 15 contractions had significantly improved quadriceps muscle, hamstring muscle strengths, and knee extension ROM when assessed after 3.5 weeks after surgery.[7] The other specific rehabilitation technique showed by RCT and clinical trial is whole body vibration that is used to improve muscular strength, increase in countermovement and to gain postural control in patients having low extremity weakness. The other technique explored in literature is continuous passive motion (CPM), in which an external motorized device passively moves the knee joint through a preset desired arc of motion. Authors of RCT suggested that patients who received CPM immediately in the recovery room after TKR had significantly gained in the active and passive flexion ROM as compared to patients who received CPM
1st day after surgery. However, systematic review indicated that CPM had small, short-term effects on active and passive knee flexion ROM and no evidence support the presence of long-term effects of CPM on active or passive knee extension ROM, pain, swelling, and quadriceps strength.[8]
1.1 Knee Osteoarthritis
Knee osteoarthritis (OA) results in continued pain and clinically significant functional limitations that reduce quality of life (QoL) and impair the ability to perform activities of daily living (ADLs) . Total knee replacement (TKR) surgery has considerably changed the method of care of patients suffering from degenerative or inflammatory arthritis of the knee and is becoming one of the most commonly performed orthopaedic procedures .
1.2 Problem Statement
Shalby Hospital, being the largest hospital in India, sees a large number of patients on a daily basis for surgical procedures.
Although a high turnover rate in relation to post-operative LoS in hospital is normal. Some types of elective surgical procedures, such as TKR, have a longer hospital stay. This could possibly be due to the physiotherapy rehabilitation protocol (PRP).
1.3 AIM
The aim of this study is to determine whether EMS on the QM in addition to the normally PRP will influence the short- term functional outcomes at six weeks and LoS in hospital post TKR when compared with the normal PRP at SHALBY.
2 REVIEW OF LITERATURE
Kentaro et. al. [1] presented Background:
Postoperative impediments in the scope of movement (ROM) after TKR might happen sporadically and limit a patient's ADL.
Despite the fact that ROM practice is a method for expanding the ROM after TKR, the ideal season of starting ROM practice is as yet hazy. The reason for this study is to analyze different commencement timings of postoperative ROM practices after TKR and to think about the outcomes regarding postoperative agony,
decide the ideal season of starting ROM practices following TKR.
Fred et. al. [2] revealed in this paper showed A solitary physically planned knee framework was embedded working together with an interconnected tibial stem expansion containing 3D accelerometers, 3D spinners, a power source, and a telemetry transmission capacity in 3 cadaveric pelvises to toe examples. The legs were moved by hand to preset tibial situations at full knee expansion, midflexion, flexion, and back to midflexion and expansion for a sum of 16 preliminaries across 6 knees. The outcomes affirm signals created from an implanted TKR sensor can send through bone and concrete, giving precise scope of movement information and might be fit for distinguishing changes in prosthesis obsession from a distance.
3 THE OSTEOARTHRITIC KNEE 3.1 Biomechanics of Gait
The reliability of the sensorimotor systems is important to perform a seamless and stable gait pattern. Proprioceptive perception warrants precise timing and placement of the lower limb at heel strike, and eccentric quadriceps activity after heel strike decrease the effect of joint loading. Changes in sensory input from articular mechanoreceptors can decrease proprioceptive perception and QMS, weakening the neuromuscular protective mechanisms that can possibly lead to destructive impact overloading after heel strike, thereby speeding up articular damage.
3.2 Quadriceps Muscles in Relation to Function and Strength
The quadriceps muscle is important for functional knee stability and an impairment of the quadriceps sensorimotor function will cause the feeling of weakness, postural instability and poor confidence in performing functional activities and ADLs (Hurley et al 1997). Hurley et al (1997) used 128 participants of which 25 had no OA of the knee, to determine QS, voluntary activation, proprioceptive acuity and functional outcomes. Hurley et al (1997) is as it looked at the effect knee OA had on QMS and the performance of ADLs, who used outcome measures similar to
4 STUDY DESIGN
A single blinded random sampling is using.
A randomised controlled trial is the most rigid method of determining whether a cause effect relation exists between an intervention and the outcome.
This involved a random allocation to intervention groups. Both groups were treated identically except for the intervention that was tried. The researcher was screened to which group an individual is assigned, making the researcher blinded. The two groups were followed up to see if there were any differences in outcomes.
4.1 Study Setting
This study was conducted at the shalby Hospital Jabalpur, since Dec 2019
4.2 VARIABLES
4.2.1 Dependent Variables:
Short term functional outcomes
ROM
QS
Days to achieve 0˚ QL
5 DATA ANALYSIS AND
INTERPRETATION FOR
PHYSIOTHERAPY OF PATIENT Day 1 post operative total knee
Replacement patient Table 5.1
Age details of respondents S.
No. Age No. of
Respondents Percentage 1 45 to 50
years 2 4
2 55 to 60
years 21 42
3 65 to 70
years 22 44
4 75 to 80
years 5 10
Total 50 100
The above table shows that 8 percent of the respondents are in the age group of 45-50 years, 18 percent of the respondents are in the age group of 55- 60, 44 percent of the respondents are in the age group of 65-70 years and 30 percent of the respondents are in the age group of 75-80 years.
Figure 5.1
Age details of respondents
Table 5.2
Gender participants of the respondents S.
No.
Gender No. of Respondents
Percentage
1 male 20 40
2 female 30 60
Total 50 100
Information reported in Table indicates that out of 50 respondents 90 percent patients are married and 10 per cent are unmarried. It is concluded that majority of selected patients are married.
Figure 5.2
Table 5.3
Family Type of the respondents S.
No. Family Type No. of
Respondents Percentage
1 Nuclear Family 37 74
2 Joint Family 13 26
Total 50 100
Table shows the type of family. Out of 50 respondents 74 percent of respondents are in the nuclear family system. The rest 26 percent are in the joint family system.
It can be inferred that nuclear family types are more in the study area.
Figure 5.3
Family Type of the respondents
Table 5.4
Occupation of respondents S.
No. Occupation No. of
Respondents Percent age
1 Agriculture 12 24
2 Business/
Professionals 21 42
3 Industry 06 12
4 Government
Service 04 8
5 Labour and
other 07 14
Total 50 100
It is seen from Table that 24 percent are from agricultural based family background, 42 percent are from Business/Professionals based family background, 12 percent are froSm industry based family background, 08 percent are from Government service based family background and 14 percent are from labour and other based family background. It can be inferred that respondents having business/professional family background are more in the study area.
Figure 5.4
Occupation of respondents
Outcomes post operation TKR (Day 1) Table 5.5
Do you have Blood Pressure?
S.
No. Description No. of
Respondents Percentage
1 Yes 30 60
2 No 20 40
Total 50 100
From the analysis of the data given in the above table, it is found that out of the total respondents, 60 percent respondents said yes I have blood pressure and 40 percent of the respondents said that no I don't have blood pressure.
Figure 5.5
Do you have Blood Pressure?
Table 5.6
Do you have Diabetes?
S.
No. Description No. of
Respondents Percentage
1 Yes 15 30
2 No 35 70
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 30 percent respondents said I don't have Diabetes and 70 percent of the respondents said that I have Diabetes.
Figure 5.6 Do you have Diabetes?
Table 5.7
Are you Osteoporotic?
S.
No. Description No. of
Respondents Percentage
1 Yes 5 10
2 No 45 90
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 10 percent respondents said I am Osteoporotic and 90 percent of the respondents said that I am not Osteoporotic.
Figure 5.7 Are you Osteoporotic?
Table 5.8
Are you able to perform acquired daily living activity?
S.
No. Description No. of
Respondents Percentage
1 Yes 1 2
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 2 percent respondents said I am able to perform acquired daily living activities and 98 percent of the respondents said that I am not able to perform acquired daily living activities.
Figure 5.8
Are you able to perform acquired daily living activity?
Table 5.9
Are you using any assistive device?
S.
No. Description No. of
Respondents Percentage
1 Yes 48 96
2 No 2 4
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 96 percent respondents said I am using any assistive device and 4 percent of the respondents said that I am not using any assistive device.
Figure 5.9
Are you using any assistive device?
Table 5.10
Do you have swelling?
S.
No. Description No. of
Respondents Percentage
1 Yes 47 94
2 No 3 6
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 94 percent respondents said I have swelling and 3 percent of the respondents said that I have no swelling.
Figure 5.10 Do you have swelling?
Table 5.11
Do you have any neuromuscular condition?
S.
No. Description No. of
Respondents Percentage
1 Yes 46 92
2 No 4 8
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 92 percent respondents said I have any neuromuscular condition and 4 percent of the respondents said that I have no any neuromuscular condition.
Figure 5.11
Do you have any neuromuscular condition?
Table 5.12
Do you have morning stiffness?
S.
No. Description No. of
Respondents Percentage
1 Yes 49 98
2 No 1 2
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 92 percent respondents said I have morning stiffness and 4 percent of the respondents said that I have no morning stiffness.
Figure 5.12
Do you have morning stiffness?
Table 5.13
Do you have problem in stair climbing?
S.
No. Description No. of
Respondents Percentage
1 Yes 50 100
2 No 00 00
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 100 percent respondents said I have problem in stair climbing and Details of 0 percent respondents were blank.
Figure 5.13
Do you have problem in stair climbing?
Table 5.14 Do you have Oozing?
S.
No. Description No. of
Respondents Percentage
1 Yes 5 10
2 No 45 90
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 10 percent respondents said yes I have oozing and 90 percent respondents said No, I have no Oozing.
Figure 5.14 Do you have Oozing?
Table 5.15
Do you have pain full active movement at knee joint?
S.
No. Description No. of
Respondents Percentage
1 Yes 49 98
2 No 1 2
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 98 percent respondents said yes I have pain full active movement at knee joint and 02 percent respondents said No, I have no pain full active movement at knee joint.
Figure 5.15
Do you have pain full active movement at knee joint?
Table 5.16
Can you lift your lower limb in supine lying position?
S.
No. Description No. of
Respondents Percentage
1 Yes 2 4
2 No 48 96
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said yes I am lift my lower limb in supine lying position and 96 percent respondents said No, I am not lift my lower limb in supine lying position.
Figure 5.16
Can you lift your lower limb in supine lying position?
Table 5.17
Can you sit on chair painfree?
S.
No. Description No. of
Respondents Percentage
1 Yes 00 00
2 No 50 100
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 0 percent respondents were blank and 100 percent respondents said No, I am not sit on chair painfree.
Figure 5.17
Can you sit on chair painfree?
Table 5.18
Can you change your position by yourself?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 2
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said yes, I am change my position by myself and 98 percent respondents said No, I am not change my position by myself.
Figure 5.18
Can you change your position by yourself?
Outcomes post operation TKR (After 6 week)
Table 5.19
Do you have Blood Pressure?
S.
No.
Description No. of Respondents
Percentage
1 Yes 30 60
2 No 20 40
Total 50 100
From the analysis of the data given in the above table, it is found that out of the total respondents, 60 percent respondents said yes I have blood pressure and 40 percent of the respondents said that no I don't have blood pressure.
Figure 5.19
Do you have Blood Pressure?
Table 5.20
Do you have Diabetes?
S.
No. Description No. of
Respondents Percentage
1 Yes 15 30
2 No 35 70
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 30 percent respondents said I don't have Diabetes and 70 percent of the respondents said that I have Diabetes.
Figure 5.20 Do you have Diabetes?
Table 5.21
Are you severe Oesteoporotic?
S.
No. Description No. of
Respondents Percentage
1 Yes 5 10
2 No 45 90
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 10 percent respondents said I am Oesteoporotic and 90 percent of the respondents said that I am not Oesteoporotic.
Figure 5.21 Are you Oesteoporotic?
Table 5.22
Are you able to perform acquired daily living activity?
S.
No. Description No. of
Respondents Percentage
1 Yes 50 100
2 No 00 00
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 100 percent respondents said I am able to perform acquired daily living activities and 00 percent respondents were blank.
Figure 5.22
Are you able to perform acquired daily living activity?
Table 5.23
Are you using any assistive device?
S.
No. Description No. of
Respondents Percentage
1 Yes 1 2
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 01 percent respondents said I am using any assistive device and 98 percent of the respondents said that I am not using any assistive device.
Figure 5.23
Are you using any assistive device?
Table 5.24
Do you have swelling?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 02
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said I have swelling and 98 percent of the respondents said that I have no swelling.
Figure 5.24 Do you have swelling?
Table 5.25
Do you have any neuromuscular condition?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 02
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said I have any neuromuscular condition and 98 percent of the respondents said that I have no any neuromuscular condition.
Figure 5.25
Do you have any neuromuscular condition?
Table 5.26
Do you have morning stiffness?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 02
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said I have morning stiffness and 02 percent of the respondents said that I have no morning stiffness.
Figure 5.26
Do you have morning stiffness?
Table 5.27
Do you have problem in stair climbing?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 02
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said Yes, I have problem in stair climbing and, 98 percent respondents said No, I have not problem in stair climbing and
Figure 5.27
Do you have problem in stair climbing?
Table 5.28 Do you have Oozing?
S.
No. Description No. of
Respondents Percentage
1 Yes 00 00
2 No 50 100
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 00 percent respondents said yes I have oozing and 00 percent respondents were blank.
Figure 5.28 Do you have Oozing?
Table 5.29
Do you have painfull active movement at knee joint?
S.
No. Description No. of
Respondents Percentage
1 Yes 01 02
2 No 49 98
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 02 percent respondents said yes I have painfull active movement at knee joint and 98 percent respondents said No, I have no painfull active movement at knee joint.
Figure 5.29
Do you have painfull active movement at knee joint?
Table 5.30
Can you lift your lower limb in supine lying position?
S.
No. Description No. of
Respondents Percentage
1 Yes 50 100
2 No 00 00
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 100 percent respondents said yes I am lift my lower limb in supine lying position and 00 percent respondents were blank.
Figure 5.30
Can you lift your lower limb in supine lying position?
Table 5.31
Can you sit on chair painfree?
S.
No. Description No. of
Respondents Percentage
1 Yes 50 100
2 No 00 00
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 100 percent respondents said Yes, I am sit on chair painfree and 00 percent respondents were blank.
Figure 5.31
Can you sit on chair painfree?
Table 5.32
Can you change your position by yourself?
S.
No. Description No. of
Respondents Percentage
1 Yes 50 100
2 No 00 00
Total 50 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 100 percent respondents said yes, I am change my position by myself and 00 percent respondents were blank.
Figure 5.32
Can you change your position by yourself?
5.1 Introduction
Participants who met the inclusion and exclusion criteria consented to participate in this study. The demise of a participant in the control group, due to medical complications whilst in hospital, was excluded from this study as no measurements were obtained on discharge. The loss to follow up in both groups were particularly high at 25 each group
5.2 Demographic Data Of Participants The demographics of the study sample are summarized in Table 5.33.
Table 5.33 Demographics of study sample (n=52)
Group1 (EMS)
n=25
Group 2 (PRP) n=25 Age
median
(p25-p75) 45-60 60-80 Gender n
(%) Female
Male
28
17 2
3
Table 5.33 shows no significant difference between the two groups with regard to the demographics of the participants at base line.
5.3 Clinical Profile of Participants The clinical profiles of the study sample are summarized in Table 5.34.
5.4 Outcomes
All pre-operative, post-operative day 1 and six- week follow-up data for the study sample are summarized in Tables 5.34 and 5.35.
The pre-operative outcome measures of the study sample are summarized in Table 5.34.
Table 5.34 shows that there was no significant difference in pre-operative outcome measures between the two groups.
Table 5.34 Outcome measures pre- operatively of study sample n=52
Outcome measures
Group 1 (EMS)
n=25
Group 2 (PRP) n=25 ROM active
flexion
in degrees 68 (50°-90°) 58° (55°- 65°) ROM passive
flexion in degrees 70 51 Quadriceps lag in 0 (0-0) 0 (0-3)
degrees Muscle strength
in
kilogram force 3.7 (5-6.2) 4.70 (3.8-6.2)
Table 5.35 Outcome measures at six weeks of study sample (n=52) Outcome measures Group 1
(EMS) n=25
Group 2 (PRP) n=25 ROM active flexion
in degrees 100° (97-103) 118° ( 118°-120°) ROM passive
flexion in degrees 120 (119-
120) 119 (118- 120) Quadriceps lag in
Degrees** 0 (0-0) 0 (0-0) Muscle strength in
kilogram force 5.95 (4.3-8.1) 5.90 (4.7- 8.2) OKS 25.5 (22-28) 25.5 (21-
29) The only parameter that was significantly different between the groups at six weeks, in table 5.35,
5.4.1 Short Term Functional Outcomes The Oxford Knee Score was used to determine the functional ability of the participants pre-operatively and at six weeks. Both groups showed vast improvement in the OKS at 6 weeks post- surgery. As shown in table 5.35, there was no significant difference between the groups at six weeks post-surgery.
5.4.2 Range of Motion of Knee Flexion Table 5.33 revealed no significant difference in active ROM between the two groups pre-operatively with a median of 68 (50°-90°) in theEMS group and 58°
(55°-65°) in the control group . At six weeks, with a median of 100° (97-103) in the EMS group and 118° ( 118°-120°) in the PRP group as seen in table 4.5, showed no significant difference, either.
5.4.3 Quadriceps Lag
The data in table 5.33 revealed no significant difference in QL between the two groups pre-operatively with a median of 0° (0°-0°) in the experimental group and 0° (0°- 3°) in the PRP group. However, table 4.4 showed the EMS group, who had a median of 0° (0°-0°) QL, yielded a better outcome on discharge, than the PRP group
There was also a significant difference in QL at six weeks, with a median of 0° (0°- 0°) in the EMS group and 0° (0°-0°) in the PRP group.
5.4.4 Muscle Strength
The data revealed no significant clinical difference in QMS between the two groups preoperatively with a median of 3.7 kgf (5 kgf-6.2 kgf) in the EMS group and 4.05kgf (3.8 kgf-6.2 kgf) in the PRP group .and at six weeks with a median of 5.95kgf (4.3 kgf-8.1 kgf) in the EMS group and 5.90kgf (4.7 kgf-8.2 kgf) in the PRP group.
5.5 Conclusion
There was, however, a difference in QL in patients who received EMS on the QM in addition to the standard practiced PRP post TKR, to that in patients who received the PRP only, is particularly evident at six weeks. From the results, it can also be noted the control group reached their post-operative ROM milestones sooner than the experimental group, who EMS and the standard practiced PRP post TKR.
5.5.1 Hypothesis Test
Hypothesis0: post exercise Physiotherapy does not provide successful functionality to TKR patient compare EMS.
Hypothesis 1: Post Physiotherapy provide successful functionality to TKR patient compare EMS.
Table 5.36
How many patients have recovered after EMS physiotherapy? Group 1 S.
No. Description No. of
Respondents Percentage
1 Yes 01 90
2 No 24 10
Total 25 100
How many patients have recovered after exercise physiotherapy? Group 2
S.
No. Description No. of
Respondents Percentage
1 Yes 23 90
2 No 02 10
Total 25 100
From the analysis of the data given in the above table, it is known that out of the total respondents, 90 percent respondents said yes, patients are recovered after PRP physiotherapy and 10 percent respondents said No, patients are not recovered after physiotherapy.
5.6 Research Analysis 5.6.1 Introduction
This study aimed to identify to the practiced protocol at Shalby Hospital,
with exercise therapy. a high volume institution, would significantly influence the short term functional outcomes post TKR at six weeks and significantly reduce the LoS in hospital. In this study, the addition of EMS on the QM to the normal PRP post TKR appears to have no clinically significant influence on shortterm functional outcomes and hospital stay. However, the control group who received the PRP only had a greater QL on discharge and at six weeks compared to patients in the experimental group who received EMS on the QM in addition to the standard practiced PRP post TKR.
5.7 Short Term Functional Outcomes Osteoarthritis is a chronic gradually progressing degenerative disorder resulting in a debilitating condition that leads to pain, joint failure, disability.
These studies, however, do not describe the severity of the knee OA prior to surgery or how long patients waited for surgery. In keeping with Stevens- Lapsley’s et al (2012) study, sixweek post- operative progressive strength training of the lower limb, with increases in resistance, and ROM exercise programme, was given to patients in the current study, as well as using NMES, but only for the duration of admission.
5.7.1 The Oxford Knee Score
In the current study, there was no significant difference between the two groups at six weeks following surgery. In keeping with the study conducted by Boniforti et al (2014), the current study showed that six weeks after surgery, the OKS had decreased below 30 points as compared to the pre-operative score of above 40 points, which is evident in table 5.33. However, being an observational study, Boniforti et al (2014), had no added interventions, but merely looked at patients’ satisfaction and functional outcomes following TKR at six weeks.
Although showing vast improvements, it is in the opinion of Boniforti et al (2014) that recovery begins six weeks after surgery, and is therefore too soon to evaluate the outcomes of joint replacement surgery. This is why studies with NMES using the OKS may be limited.
5.8 Range of Motion of Knee Flexion Similar to the study by Stevens-Lapsley et al in 2012, the introduction of EMS started 48 hours post-surgery but was only performed twice a day for ten minutes until discharge, opposed to twice a day over a period of six weeks. The insignificant results from this study could be owed to the assumption that the NMES works to strengthen the QM and not influence knee flexion ROM and hamstring activation or strength.
Electrically stimulated muscle contractions allow for more the significant activation of the larger type II muscle fibres magnifying the production of force as compared to the smaller type I muscle fibres (Stevens-Lapsley et al 2012) which could be over stimulating the QM, explaining the outcome of this result.
5.9 Quadriceps Lag
There was a significant difference in QL on discharge and at six weeks (tables 5.34 and 5.35). The experimental group fared better and yielded similar results to the study by Stevens et al (2004) and Stevens-Lapsley et al, 2012. Similar to the study by Stevens-Lapsley et al in 2012, the introduction of EMS started 48 hours post-surgery but was conducted for a shorter period in the current study.
Stevens et al (2004), looked at QMS in patients with bilateral TKRs, and concluded that when NMES is added to a voluntary exercise programme, shortfalls in QMS and activation recovered rapidly after TKR. Intervention in that study only commenced after the surgical staples were removed between three to four weeks after surgery. Therapy sessions continued for six weeks including three sessions a week for a total of 18 sessions.
5.10 Muscle Strength
When looking at the results of QMS in this study in tables 5.33 and 5.35, it is noted there is no significant difference between the two groups but there is a difference between the pre-operative and six weeks follow up results, which was expected. The usual practice at shalby is, that on discharge, all patients received a home exercise programme, during which they are expected to perform ten repetitions of each exercise thrice daily for six weeks until their follow up appointments. This programme comprised
knee extension and flexion range, circulatory and MS exercises.
5.11 Days to Reach Milestones
Literature on how soon patients receiving exercise physio reached their post- operative milestones is extremely limited and it is therefore difficult to explain these results. The current study showed the control group reached their post- operative milestones far sooner and had a more progressive recovery. Than the experimental group, which showed to be very significant in the current study. This could be owed to the assumption that the NMES works to strengthen the QM and not influence knee flexion ROM and hamstring activation or strength.
6 CONCLUSION
The number of replacement cases in India is following the global trend and is seeing a steady annual increase. Having a standardised, cost effective and sustainable protocol to reduce the LoS in hospital is a desirable goal.
The introduction of EMS during the time of admission did not significantly reduce the LoS in hospital or influence functional outcomes. However, the introduction of physiotherapy rehabilitation over the weekend did however, see a significant reduction in LoS compared to previous statistics.
6.1 Recommendations
The addition of EMS, as practiced in the current study, is not recommended, but in conjunction with a more extended programme, possibly extending into the post discharge phase, could warrant further research.
If extended protocols are implemented, follow ups at three and six months, should be performed to determine the long term effects of EMS in this population and to determine if the results of this study is maintained or rendered unchanged.
Further research looking at the effects of physiotherapy rehabilitation over the weekend should be conducted to determine if there is a significant reduction in LoS in hospital following replacement procedures at SHALBY.
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