That hurts, but this was the conclusion of Arnold et al in the latest JOSPT titled “Does Physical Activity Increase After Total Hip or Knee Arthroplasty for Osteoarthritis?”
This study does not support the idea that a “new joint” is going to return the recipient to an “active life.” In pondering this disappointing conclusion, I wondered where the health care system could be failing.
In the end I came up with far more questions than answers. (One potential reason the study identified is #5 listed here.)
- Does this study have shortcomings?
Meta-analysis of the available limited number of studies, smaller sample sizes, and variable methodological qualities…
- What about the prosthesis?
I have insufficient knowledge to comment on this, but it doesn’t seem likely.
- Are there surgical shortcomings?
Complication rates increasing? Going home too soon?
- What about rehabilitation shortfalls?
What are our outcomes in ROM, strength, and function?
- Are the patients engaged enough in their rehabilitation and the idea of returning to activity?
How can we get patients to optimally do their part, to really get functionally better?
The Bigger Trends
- A recent BCBS study reported high and highly variable costs ($16-60K each) for joint replacements.
- The AAOS reports rapidly increasing trends in the prevalence of joint replacements (especially knees). The reasons in part are attributed to an aging and ever more obese population.
Why should YOU care about this study?
- Bundled payments for the procedure are becoming more common.
The AAOS report identifies a declining trend of surgical and hospital reimbursements. In the competition for a decreasing pie and pitted against the hospital corporations and medical associations, how do you think PTs will do maintaining our slice?
- Third parties are more regularly publishing outcome measures where consumers can compare.
- Pay for performance is supposed to become the norm.
Results like this study will not help justify increasing or even maintaining reimbursement rates!
What is OUR role in this?
As far as the prosthesis and surgery go, not much I think we can do there. It’s a bit like cooking seafood, if isn’t good quality and fresh, no chef or recipe can ever fix it.
But where could PT be falling short? Are we really meeting our goals?
- Are we getting the expected joint range? If not, is it muscle spasm, fascia, or incisional scarring that holds them back?
- Are we getting neuromotor recovery?
- Do we alter their longstanding muscle substitution patterns?
- Do we address concurrent spinal dysfunctions? e.g. A patient with a THA with a L3 weakness won’t recover as well.
- Do we adequately retrain proprioceptive deficits?
- Are we failing to address other biomechanical challenges in the lower quadrant? e.g. A patient with THA will not achieve normal hip extension in gait with an occult ipsilateral hallux rigidus
How well do we educate and motivate our patients?
- Is the patient involved in goal setting?
- Do they know their functional prognosis?
- Are they invested in their HEP and self care?
Joint replacements don’t need MY OMPT skills, or do they?
I have been guilty of considering patients with joint replacement as “simple.” Yet my OMPT skills have a lot to offer these patients, which they may not be otherwise receiving.
- Other means of pain control
- Better means of achieving ROM
- Improved neuromotor re-education
- A more complete biomechanical assessment of the spine and lower quadrant
OMPT skills can make a difference in this growing and perhaps underserved population. But we need to ask ourselves, are we really applying our comprehensive skill set? Equally important, are we studying our treatment and outcomes and letting the larger medical and consumer communities know what we have to offer?
W Bryant Miller, PT, DSc, OCS, FAAOMPT
Faculty Instructor, The North American Institute of Orthopaedic Manual Therapy (NAIOMT). Explore these questions and much more with Bryant Miller in upcoming courses including Lower Extremity, Lumbopelvic Spine and Cervical Spine.
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