There is no benefit from sending patients with hip and knee replacement to rehabilitation with a physiotherapist – as is normal practice due to a long-standing Danish tradition. Researchers from Aarhus University show that patients do just as well with home-based exercises and point out that the money should be used better.

2018.12.04 | Nanna Jespersgård

Most people have an innate idea that 'more is better' so there may therefore be an unconscious resistance to giving up on physiotherapist-supervised rehabilitation after hip or knee replacement, Inger Mechlenburg says. Photo: Private.

Patients requiring rehabilitation following hip and knee replacement surgery manage rehabilitation at home satisfactorily if they are given a leaflet with the relevant exercises. In fact, there are no measurable benefits from training with a physiotherapist – even when maximising good intentions and offering two weekly resistance-training sessions supervised by a physiotherapist for seven to twelve weeks.

This is shown by four studies from Aarhus University, wherein the latest, a newly published meta-analysis, documents that home-based exercises are competitive when measured in relation to pain, health-related quality of life and also the ability to get up from a chair, climb stairs and get into a car or out of bed.

"In other words, we have solid evidence that it is the training which makes a difference, and not whether you exercise together with a physiotherapist either alone or in a group in one of the municipal rehabilitation centres," says professor of orthopaedic rehabilitation, Inger Mechlenburg from Aarhus University and Aarhus University Hospital. She has published the research results together with Professor Kjeld Søballe, whose expertise is well-known and in demand all over the world.

Physiotherapists are certainly useful

Inger Mechlenburg has herself a background as a physiotherapist, and it is important for the research group to avoid any physiotherapist 'bashing', also bearing in mind that physiotherapists have been involved in arguing that the many patients who receive hip or knee replacements should be referred to physiotherapist-supervised rehabilitation.

"It is in no way our business to speak badly about physiotherapists as a profession, and neither do our studies rule out that patients who are at an advanced age, or have co-morbidities or few resources, may experience an effect from training with a physiotherapist. But one of our points is that we need to utilise physiotherapists precisely there – and not on a healthy and agile 65-year-old who has been given a new hip due to osteoarthritis, says Inger Mechlenburg, who following her physiotherapist degree programme, also earned a Master’s degree in health science and a PhD, before she defended her higher doctoral degree in medicine two years ago – as only the second physiotherapist to do so in Denmark.

We know, we know, but ...

Professor and co-author Kjeld Søballe has operated on thousands of hips and notes that it is ironically already well-known that the typical patient with osteoarthritis of the hip or knee does not receive any additional benefit from training with a physiotherapist. This is underlined by e.g. the new meta-analysis, which is based on six selected studies during the period 2002-2016.

"It is thought-provoking that the effect of home-based exercise compared to training with a physiotherapist was widely-known already 16 years ago and what’s more, documented several times since," says Kjeld Søballe, who in the same breath points out that Inger Mechlenburg was last year involved in drawing-up the Danish Health and Medicines Authority’s national clinical guidelines, so that home-based exercise is today recommended at the expense of training supervised by a physiotherapist.

"The thing is, it often takes ten years to change a practice, and we as researchers and clinicians are left with a feeling that the results we publish take a long time to be put into action. This is the case for both the hospitals that discharge patients to rehabilitation, and the decision-makers in the municipalities and regions. My contact with the patients ends on the operating table, but most of us still hear now and then about someone who has been to rehabilitation with a physiotherapist after receiving a hip or knee replacement," says Kjeld Søballe. He then emphasises that the collective feeling that many patients are still being referred to municipal rehabilitation following operations to insert hip or knee replacements is not supported by the university's studies – and that this is not what has been investigated.

"But also when I talk to the patients before surgery, many worry about whether they will be referred to rehabilitation with a physiotherapist after the operation. Patients clearly have great confidence in physiotherapist-supervised rehabilitation being the best," he adds.

A showdown with 'more is better'

Both Kjeld Søballe and Inger Mechlenburg suggest, however, that it has also proven difficult to ‘turn down' the level of healthcare services in other contexts, once these have first become established as a practice or established right.

"Most people have an innate idea that 'more is better' so there may therefore be an unconscious resistance to giving up on physiotherapist-supervised rehabilitation after hip or knee replacement, because its logical to think that it must be better than the almost free solution which is to exercise on your own. However, the research simply shows that training on your own following hip or knee replacement is just as effective for most patients," says Inger Mechlenburg, though she does on the other hand point out that intense resistance-training before hip and knee replacement operations appears to make a difference.

"So perhaps that’s where society should instead implement physiotherapist-supervised training, or perhaps it should be possible for the general practitioners to refer patients to free treatment by a physiotherapist when patients come with early signs of osteoarthritis in the hip or knee. New research shows that training in advance apparently makes a big difference, so here is an area that needs to be looked into more," says Inger Mechlenburg.

The research results – more information

• The article is primarily based on the study below, although three older studies from Aarhus University form the basis of the conclusions made in the article:
  

  Effects of supervised exercise compared to home-based exercise early after total hip replacement on patient-reported function, pain, heath-related quality of life and performance-based function - A Meta-Analysis of Randomised Controlled Trials is a meta-analysis based on six studies during the period 2002-2016, which were published in August 2018 in the journal Clinical Rehabilitation.
  

  The efficacy of early initiated, supervised, progressive resistance training compared to unsupervised, home-based exercise after unicompartmental knee arthroplasty: a single-blinded randomized controlled trial is a single blinded, randomised clinical trial with the participation of 55 patients published in 2017 in the journal Clinical Rehabilitation.

  Efficacy of Preoperative Progressive Resistance Training on Postoperative Outcomes in Patients Undergoing Total Knee Arthroplasty is a single blinded, randomised clinical trial with the participation of 59 patients published in 2016 in the journal Arthritis Care & Research.

  Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations. A single-blinded randomised controlled trial is a single blinded, randomised clinical trial with the participation of 73 patients published in 2014 in the journal Osteoarthritis and Cartilage

• External funding: The Danish Rheumatism Association, Association of Danish Physiotherapists’ Research Foundation, Aase and Ejnar Danielsens Foundation.

• Important partners in the trails mentioned are: Associate Professor, Physiotherapist Lone Ramer Mikkelsen, Silkeborg Regional Hospital; PhD student, Physiotherapist Peter Bo Jørgensen, Aarhus University Hospital; Physiotherapist, MSc in Physiotherapy, Sebrina Maj-Britt Hansen, University of Southern Denmark; and Physiotherapist, PhD Birgit Skoffer, Aarhus University Hospital.

Contact

Professor, PhD, DMSc Inger Mechlenburg
Department of Orthopaedic Surgery, Aarhus University Hospital
Department of Clinical Medicine, Aarhus University
Tel.: (+45) 2167 9062
Email: inger.mechlenburg@clin.au.dk

Professor, Consultant, DMSc Kjeld Søballe
Department of Orthopaedic Surgery, Aarhus University Hospital
Department of Clinical Medicine, Aarhus University Hospital
Tel.: (+45) 2062 0445
Email: Kjeld@soballe.com