Total Knee Arthroplasty: Does preoperative physical therapy intervention reduce postoperative recovery
time?
By:
Dan McClellan
Doctoral Candidate
University of New Mexico School of Medicine
Division of Physical Therapy
Class of 2015
Advisor:
James Dexter PT, M.A.
Printed Name of Advisor:______________________
Signature:________________________ Date:______________
Approved by the Division of Physical Therapy, School of Medicine, University of New Mexico in partial
fulfillment of the requirements for the degree of Doctor of Physical Therapy.
Abstract
Background/Purpose: One of the most common chronic health problems in the United States is
Osteoarthritis (OA). Total knee joint arthroplasty (TKA) is the only effective treatment for long term relief of
the pain. As TKA procedures increase, providers are under mounting pressure to identify the most costeffective method of delivering high-quality, value-based health care. The purpose of this case study and
literature review is to investigate the effectiveness of a pre-operative physical therapy program in reducing
recovery times after a TKA.
Case Description: Mr. M, a 59-year-old male underwent total knee arthroplasty to his left knee. He had
physical therapy rehabilitation post-operatively in the hospital for 3 days before returning home with
outpatient PT. Upon his orthopedic check up 10 days later he was still using a walker and had left knee
range of 5-75 degrees.
Outcomes: Included time dependent objective knee measures, functional values, patient reported values,
length of stay in hospital, associated costs, and unexpected adverse outcomes.
Discussion: Although most evidence suggests preoperative prehabilitation for TKA is beneficial for post
operative recovery speeds, more research needs to be done to pin point the most effective interventions for
increasing rehab potential and speed. Despite the lack of concrete interventions and uniform evidence, the
PICO question was satisfactorily answered showing physical therapy intervention appears to reduce the
recovery times in patients with a TKA.
1
Table of Contents
Abstract ......................................................................................................................................................... 1
Table of Contents .......................................................................................................................................... 2
Background/Purpose: ................................................................................................................................... 3
Case Description ........................................................................................................................................... 4
Introduction: ............................................................................................................................................. 4
Examination 11/05/14 .............................................................................................................................. 4
Evaluation ................................................................................................................................................. 8
Diagnosis ............................................................................................................................................... 8
Narrative Assessment ........................................................................................................................... 8
Clinical Judgments and Problem List..................................................................................................... 9
Goals ................................................................................................................................................... 10
Prognosis ............................................................................................................................................. 10
Plan of Care ......................................................................................................................................... 11
Interventions ........................................................................................................................................... 11
Outcomes ................................................................................................................................................ 11
PICO Question and Search Strategy ............................................................................................................ 12
Articles Analyzed ......................................................................................................................................... 14
Discussion.................................................................................................................................................... 25
Conclusion/Bottom Line ............................................................................................................................. 26
References .................................................................................................................................................. 27
Appendices.................................................................................................................................................. 29
Appendix A -Table of Daily Interventions ............................................................................................... 30
Appendix B - Article analysis ................................................................................................................... 31
2
Background/Purpose:
One of the most common chronic health problems in the United States is Osteoarthritis (OA). “OA affects
13.9% of adults aged 25 and older and 33.6% (12.4 million) of those 65 and older. An estimated 26.9
million US adults were diagnosed with OA in 2005, up from 21 million in 1990. Incidence rates of OA
increase with age until leveling off at age 80” (Brown et al., 2010). “This condition is initially treated
pharmacologically but frequently progresses to where total knee joint arthroplasty (TKA) is the only
effective treatment for long term relief of the pain” (Swank et al., 2011). TKA has been an effective
treatment for those with end stage OA since 1954 (Cheatham, 2013). With total knee replacement surgery
emerging as the treatment of choice for end-stage arthritis of the knee, the estimated growth rate from 2005
to 2030 is projected to be 673%, 3.48 million patients (Snow et al., 2014). “As the volume of arthroplasties
expands within the framework of increasing health-care costs, providers are under mounting pressure to
identify the most cost-effective method of delivering high-quality, value-based health care” (Snow et al.,
2014). Delayed recovery time increases the time patients spend disabled and reliant on post acute care
services which directly increases costs associate with a TKA.
Physical therapy is considered conservative care and a good cost effective option for increasing function in
a wide variety of patient populations, especially orthopedic patients. “Preoperative range of motion (ROM)
is the most important variable to determine final flexion after total knee arthroplasty” (Matassi, Duerinckx,
Vandenneucker, & Bellemans, 2014). The ability of even severe arthritic patients to respond within 4–6
weeks to a controlled exercise program designed to increase quadriceps and hamstring strength and
endurance, reduce pain, and improve proprioception has been clearly demonstrated (Matassi et al., 2014).
The purpose of this case study and literature review is to investigate the effectiveness of a pre-operative
physical therapy program in reducing recovery times after a TKA. This report will illuminate the
effectiveness of a physical therapy program in increasing function before TKA surgery as well as reducing
3
recovery times after TKA surgery. Recovery times are assessed in many different ways throughout the
articles in this report. The primary objective in determining the most cost effective interventions to increase
function in TKA patients as soon as possible.
Case Description
Introduction:
Mr. M, a 59 year old carpenter with a well documented end stage OA in both knees with pain more severe
in the left side which was impairing lifestyle and activities of daily living (ADL). Pt had failed conservative
treatment which consisted of injections which gave no relief and had wished to proceed with a TKA.
Significant past injuries to the left knee include a fall 34 years ago, where the patient landed on a box of
nails with his knee, was treated by a local orthopedist, and underwent two separate medial open
arthrotomies with meniscal debridement. On 11/04/14, Mr. M received a left TKA and was seen by PT in
the hospitals post operative ward one day later.
He received inpatient physical therapy twice a day until he was discharged home on 11/7/14 with outpatient
physical therapy and a continuous passive movement (CPM) machine. He returned to the hospital for a
post operative checkup on 11/17/14
Examination 11/05/14

Patient History: Mr. M is a 59 year old Hispanic male carpenter who has a well documented history
of bilateral end stage OA. Immediately prior to his surgery the patient’s knee pain had been
interfering with his lifestyle and ADLs. He has tried conservative treatment with no relief in pain.
o Social situation: Mr. M live alone in Durango, CO in a house with 2 curb steps leading up
to the front door. Patient’s daughter lives nearby and is able to help with ADLs if needed.
4
o Prior Level of Function: Patient was a community ambulator, walking with a severe limp
and no assistive devices for distances greater than 150 feet. He was independent in all
aspects of his life however his severe knee pain had starting making ADLs more difficult.
o Past Medical History: (per internal medicine H&P note dated 11/04/14)

Obesity

Alcohol abuse

Depression

Bilateral osteoarthritis with pain

Hypertension

Hyperlipidemia

Diabetes (DMII)
o Past Surgical History: (per orthopedic note dated 10/8/14)

Two separate left knee arthrotomies with meniscal debridement

Both about 34 years ago
o Family History

Hypertension and OA noted in most family members past middle age, per patient
report.
o Medications

Duloxetine

Hydrocodone

Lisinopril

Rosuvastatin

Prophylactic antibiotics
o Systems Review
5

No signs of thromboembolism

No signs of infection systemically or at the incision sight

Sensation intact except for numbness in the cutaneous area near the incision sight
(anterior knee).

Distal left lower extremity appears well perfuse

Patient is alert and oriented times 3, with no significant post anesthesia delirium.

Patient has a Foley catheter and is hooked up to IV fluids with a patient controlled
analgesia (PCA) pump.
o Reason for referral: Total knee replacement/V43.65, post operative physical therapy
protocol.
o Chief Complaint: Pain in operative knee
o Patient Goals: To walk and return home
o Test and measures – Initial Evaluation 11/05/14

Pain Assessment: 4/10 in distal hamstring area, anterior knee and distal
quadriceps at rest. 6/10 pain while walking.

Bed Mobility: Independent, slow methodical movements

Supine to sit: Independent

Sit to stand/stand to sit: Modified Independent, with bed rail and/or front wheeled
walker.

Transfers: Modified Independent, requires assistance from rails, arm rests, walker,
and/or other assistive device for balance and control.

Sitting balance: Independent

Standing balance: Modified Independent
6

Gait: Modified Independent, 450’ with front wheeled walker. Requires verbal cues
to increase weight bearing, attempt full extension on initial contact with heel strike,
and increase flexion in terminal stance on the left lower extremity.

Posture: forward leaning over walker while walking.

Stairs/Curb: Not Tested

Manual Muscle Testing:

Testing and strength were both severely limited by pain.
Left
Right
Hip Flexion
3+/5
5/5
Hip Extension
Not Tested
Not Tested
Hip External Rotation
3+/5
4/5
Hip Internal Rotation
3+/5
4/5
Hip Adduction
4/5
5/5
Hip Abduction
4/5
5/5
Knee Flexion
3/5
5/5
Knee Extension
2/5 unable to move
full range against
gravity
5/5
Ankle Dorsi-flexion
5/5
5/5
Ankle Plantar flexion
5/5
5/5
7

Sensation: Within Normal Limits, with some expected superficial numbness in the
anterior left knee near the incision site.

Proprioception: Within Normal Limits

Range of Motion:


Left Knee, 10-50 degrees

Right Knee, 0-100 degrees
Palpation: painful, edema noted, slight increase in skin temperature compared to
contra-lateral side.
Evaluation
Diagnosis

Medical Diagnosis: Total Knee Arthroplasty/ V43.65

Physical Therapy Diagnosis: Impaired joint mobility, motor function, muscle performance, and
range of motion associated with joint arthroplasty.
Narrative Assessment
Mr. M is a 59 year old single male carpenter who lives in southern Colorado. He has undergone a
TKA on his left knee 11/04/14 to treat pain associated with end stage OA and now requires skilled
physical therapy to address the associated impairments. The impairments include decreased left
knee range of motion, strength, proprioception, and over all decreased exercise endurance,
balance impairments and gait deviations. These impairments arose because of the trauma, pain
and edema associated with a TKA. Patient’s prior level of function is reported as independent in all
aspects of his life although the OA pain in his left knee was making mobility more challenging and
interfering with his lifestyle. Mr. M is motivated to go home and continue the recovery process at
an outpatient rehabilitation clinic. His strengths are his relative young age for a TKA and his prior
8
level of function and his limitations include him living alone with limited family support and his
comorbidities. From the initial visit he appeared to tolerate pain well while on morphine and was
modified independent with bed mobility, transfers and ambulation with a front wheeled walker. Mr.
M has a good prognosis for a successful recovery and will benefit from skilled physical therapy to
increased range of motion, strength, balance, endurance, functional mobility and gait.
Clinical Judgments and Problem List

Severe pain in knee
o Patient can only tolerate short low intensity therapy sessions
o Patient unable to ascend/descend stairs
o Patient has an abnormal gait

Decreased endurance
o Patient becomes very fatigued when walking for short distances with a walker.

Range of motion limitation
o Patient has an abnormal gait
o Patient unable to ascend/descend into a sitting position with left leg on the ground
o Patient unable to ascend/descend stairs

Decreased Strength
o Patient unable to ascend/descend stairs
o Patient unable to transfer independently
o Patient requires assistive device for ambulation

Balance Impairments
o Patient is a fall risk

Gait Impairments
9
o Abnormal gait may lead to further impairments via compensatory movements.
The impairments and problems above prevent Mr. M from returning to his prior lifestyle and functional
capacity. While at the hospital, therapy will work to improve these deficit areas to make the return to home
more safe and manageable for the patient when he is discharged. The patient must demonstrate that he
can, at minimum, safely perform all necessary mobility tasks with modified independence before he is will
be cleared to go home. Otherwise the patient will be recommended to attend a skilled nursing facility until
he has recovered enough to safely return home. At this point the patient has demonstrated the ability to
get in and out of bed independently and transfer and ambulated with assistive devices. The patient must
overcome two curb steps at home, and likely in the community as well, so he must therefore demonstrate
the ability to perform a curb step before discharge to home. Mr. M primary concern is to correct these
impairments and return to his prior function and independent lifestyle.
Goals
1. Patient will achieve range of motion in his left knee that is equal to or greater than 0 degrees
extension and 90 degrees of flexion before discharge from hospital.
2. Patient will demonstrate the ability to ascend and descend a curb step modified independent with a
front wheeled walker before discharge from hospital.
3. Patient will demonstrate independent ambulation with a front wheeled walker for 150 feet in less
than 5 min before discharge from hospital.
4. Patient will demonstrate the ability to correctly perform his home exercise program independently
with no cues before discharge from hospital.
Prognosis
Mr. M’s physical rehabilitation prognosis was deemed good for the above stated goals. The patient may
achieve these goals within the time he is at the hospital however length of stay at the hospital is multi10
factorial and may be extended or reduced independent of the completion of the patient’s physical therapy
goals.
Plan of Care
Physical therapy will see this patient twice a day for sessions of up to 60 minutes, Monday through Friday
for the duration of his hospital stay. If the patients stay extends into the weekend He will be seen once on
Saturday for up to 60 minutes. Interventions will include skilled physical therapy for therapeutic exercise,
therapeutic activity, manual therapy, neuromuscular re-education, gait and functional mobility training.
Interventions
The PICO question was not researched until after the patient had been discharged therefore research
objectives did not impact patient treatment. Physical therapy treatment plans were adjusted every session
to fit with the patient’s level of function, willingness to participate, and pain. A detailed outline of the daily
interventions can be found in Appendix A. Interventions were focused on decreasing swelling, pain, and
increase range of motion, strength, balance and functional mobility. Exercises performed by the patient
were limited to his home exercise program to assure the patient was independent with them upon
discharge from the hospital. Gait training was catered to increase the patients exercise tolerance and
decrease compensatory gait abnormalities that may contribute to future musculoskeletal problems.
Outcomes
Mr. M was discharged from the hospital 3 days post operation based on his functional capabilities and his
stable medical condition. The patient had met only three out of four of his goals but was deemed safe to
return home and continue his rehabilitation in an outpatient physical therapy setting. The one goal that was
not accomplished before discharge was to achieve left knee range of motion of 0-90 degrees.
11
PICO Question and Search Strategy
Based on this clinical case, the following PICO question was developed to determine if patients like Mr. M
would have better outcomes if they were to enroll in some sort of preoperative physical therapy
intervention. The strategy for the search was to find articles that described physical therapy interventions
and their affect on patients before a TKA. Papers were considered if they included other non-physical
therapy specific interventions in conjunction or compared with physical therapy interventions. Papers were
also considered if they included Total Hip Arthroplasty (THA) patients as part of the study. Acceptable
outcome measures were any that were objective showing financial, functional, or incidence of adverse
affects. The papers that were finally chosen for this capstone were to represent the PICO question in its
entirety. The first logical step was to determine if preoperative PT had any effect on end stage OA patients,
the second logical step was if those affects remained after TKA surgery, and the third logical step was to
determine if the effects achieved before surgery and remained after surgery had an impact on patients
outcomes after surgery. In order to investigate this question the PubMed, CINAHL and Pedro databases
were searched with key terms shown in the table on the next page.
12
13
Articles Analyzed
1. Matassi, F., Duerinckx, J., Vandenneucker, H., & Bellemans, J. (2014). Range of motion after total knee
arthroplasty: the effect of a preoperative home exercise program. Knee Surgery, Sports Traumatology,
Arthroscopy: Official Journal of the ESSKA, 22(3), 703–709. doi:10.1007/s00167-012-2349-z
Level of Evidence: 1b
Purpose: The primary purpose of the study was to investigate whether a preoperative home exercise
program provides the patient with a better passive flexion 1 year after TKA. The secondary objective of the
study was to assess the functional performance and effectiveness of the preoperative exercise program
immediately after the exercise period on the osteoarthritic knee and after arthroplasty during immediate
postoperative recovery and at 3, 6 and 12 months postoperatively.
Methods: 122 patients with knee arthrosis were included in a prospective single blind study and randomly
allocated to either the control or treatment group. All one hundred and twenty-two patients were assessed
before and after this exercise intervention. Postoperative assessments were at 6 weeks, 6 months and 1
year. Each evaluation included knee ROM and the Knee Society Clinical Rating System. Length of hospital
stay and postoperative duration before achieving 90 degrees of knee flexion were also recorded.
Results: Exercise program improves knee motion in the presence of arthrosis of the knee. After TKA, the
patients in the exercise group achieved 90 degrees of knee flexion faster (5.8 ±2.1 days, intervention group
and 6.9 ±1.9 days, control group, p=0.0016) and had a shorter hospital stay (9.1 ±2.1 days, intervention
group and 9.9 ±2.3 days, control group, p=0.0011). There was no prolonged effect on knee motion or
patient function between 6 weeks and 1 year postoperatively.
Critique/Bottom line: It appears that preoperative home exercises provide better recovery after TKA and
may be useful in the clinical practice to reduce the time to reach 90 degrees of flexion but the effects are
not lasting. Although there were significant statistical differences between groups with days to reach 90
degrees of flexion and days spent in the hospital, these values do not appear to be clinically significant.
14
2. Snow, R., Granata, J., Ruhil, A. V. S., Vogel, K., McShane, M., & Wasielewski, R. (2014). Associations
Between Preoperative Physical Therapy and Post-Acute Care Utilization Patterns and Cost in Total
Joint Replacement. Journal of Bone & Joint Surgery, American Volume, 96(19), e165(1)–e165(8).
doi:10.2106/JBJS.M.01285
Level of Evidence: 2b
Purpose: The purpose of this study was to investigate the association between preoperative physical
therapy and post-acute care utilization and the effect that preoperative physical therapy has on the total
episode-of-care cost after total joint replacement in Ohio.
Methods: An observational cohort comparison study design was used to evaluate the associations
between preoperative physical therapy and post-acute care use of skilled nursing facility and home health
agency resources for 4733 hip and knee replacements cases. Data used for this study were supplied by the
Research Data Assistance Center (ResDAC). Data was taken from a thirty-nine-county hospital referral
cluster in central and southeast Ohio between 2008 and 2009.
Results: 77% of patients used post-acute care services after surgery. 11% of patient used preoperative
PT. Post acute care utilization decreased if preoperative PT was used. 54.2% of the preoperative PT
cohort used acute care services. 79.7% of the non-preoperative PT cohort used acute care services.
Adjusting for demographics and comorbidities, preoperative PT caused a significant 29% reduction in postacute care use (p < 0.0001). Episode of care costs were reduced by $871 between groups (p < 0.05).
Critique/Bottom Line: Preoperative PT reduced post-acute care utilization. Preoperative PT reduced the
costs associated with joint replacements. A reduction in post acute care utilization suggests that function
was restored faster. The limited amount of time spent at pre-op PT suggests sessions were geared towards
patient training on post operative assistive walking devices, planning for recovery, and managing
expectations, and not focused on developing strength and increased ROM. Only evaluated care patterns in
Medicare Fee-for-Service patients in Ohio may not be generalizable.
15
3. Desmeules, F., Hall, J., & Woodhouse, L. J. (2013). Prehabilitation improves physical function of
individuals with severe disability from hip or knee osteoarthritis. Physiotherapy Canada.
Physiothérapie Canada, 65(2), 116–124. doi:10.3138/ptc.2011-60
Level of Evidence: 2b
Purpose: designed to evaluate the effect of prehabilitation (education and exercise) on pain and function in
people with severe OA awaiting TJA who present with more compromised health and functional status. A
secondary objective was to evaluate whether the physiotherapists could triage clients with OA into those
with minimal, moderate, and severe disability, reflecting the intensity of prehabilitation required.
Method: Consecutive patients (n = 650) from January 2006 to December 2008 with advanced OA from the
Hamilton–Wentworth Region in Ontario, Canada, were referred by their orthopedic surgeon for assessment
at a specialized prehabilitation program for pre-arthroplasty patients. Patients were triaged into 3 “streams”
depending on severity of impairment to determine the intensity of the prehabilitation for the patient.
Results: It was found that physical therapist could successfully triage patients into their appropriate groups
or “streams” as there was a significant difference between all groups within the parameters that differentiate
the groups. The change in self-reported function reached statistical significance and was just below the
minimal clinically important change of 9 points. On the actual performance measures, there was a
significant mean improvement on the fast Self Paced Walk test (0.17 [SD 0.25] m/s; p = 0.011), the Stair
Test (3.8 [SD 14.6] s; p = 0.004), and the Timed Up and Go (4.2 (5.6) s; p < 0.001). The number of
participants who exceeded the minimal detectable change at 90% confidence interval on the fast SPW was
21/28 (75%); on the ST, 18/27 (67%); and on the TUG, 19/28 (68%).
Critique/Bottom Line: The allocation of participants into groups was not random but instead based on
judgment of a physical therapist and it was noted that the most important deciding factor for allocation was
BMI. The prehabilitation programs were not standardized but instead individually tailored to the patient. It
was shown that the prehabilitation program improved pain and function before surgery.
16
4. Coudeyre, E., Jardin, C., Givron, P., Ribinik, P., Revel, M., & Rannou, F. (2007). Could preoperative
rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration of
French clinical practice guidelines. Annales De Réadaptation Et De Médecine Physique: Revue
Scientifique De La Société Française De Rééducation Fonctionnelle De Réadaptation Et De
Médecine Physique, 50(3), 189–197. doi:10.1016/j.annrmp.2007.02.002
Level of Evidence: 1a
Purpose: To develop clinical practice guidelines concerning preoperative rehabilitation for hip and knee
total arthroplasty.
Method: The study combined systematic literature reviews, everyday clinical practice experiences, and
external reviews by a multidisciplinary expert panel, to develop guidelines. The main outcomes considered
in the recommendations were: Impairment, disability, medico economical factors, and postoperative
complications. The interventions included: Physiotherapy, education, and occupational therapy.
Results: From this review it was recommended a preoperative rehabilitation program, comprising at least
physical therapy and education for TJR which benefited patients with TKA by reducing length of stay in
hospital. It was also recommended occupational therapy to be combined with patient home visits and
multidisciplinary rehabilitation comprising at least occupational therapy and education is desirable for the
most fragile patients because of major disability, co-morbidity or social problems. It was not recommended
to perform isolated physical therapy before total knee arthroplasty (TKA) as it did not appear to benefit the
patient postoperatively.
Critique/Bottom Line: Rehabilitation before total hip and knee arthroplasty contributes to reduced hospital
length of and modifying discharge conditions. Preoperative patient assessment is important to predict, and
hopefully improve, outcomes.
17
5. Hansen, T. B., Bredtoft, H. K., & Larsen, K. (2012). Preoperative physical optimization in fast-track hip
and knee arthroplasty. Danish Medical Journal, 59(2), A4381.
Level of Evidence: 2b
Purpose: To investigate if screening and optimization of risk patients combined with a motivational
conversation was effective in reducing complications in patients scheduled for a fast-track hip and knee
arthroplasty.
Method: The study included 78 patients in the intervention group and 54 patients in a control group. The
intervention took place over a maximum of 4 weeks. The intervention group was assessed by a nurse
using the Preoperative Arthroplasty Screening Questionnaire (PASQ) which included the following
categories to determine areas of health optimization: Nutrition, Preexisting Health Conditions, Medications,
Physical Activity, Tobacco Use, and Alcohol Use. The primary outcome was unintended adverse patient
paths post TKA. The secondary outcomes were health-related quality-of-life (HRQOL) pre- and
postoperatively measured with the EuroQuol 5d questionnaire (EQ-5D ) and disease specific outcome
score (DSOS) measuring e.g. walking distance and ability.
Results: A total of 35 (45%) of the 78 patients in the intervention group were classified as being at risk in
one or more areas after the screening. The number of unintended patient paths was significantly less in
the intervention group: 19 (35%) in the control group; 14 (18%) in the intervention group (p = 0.025). There
was no significant difference in secondary outcomes between groups.
Critique/Bottom Line: Preoperative physical optimization of patients who are at risk of following an
unintentional path is effective in patients scheduled for fast-track hip and knee arthroplasty. This low cost,
no risk intervention should be performed on all THA, TKA and UKA. The Study limitations were a significant
difference between groups gender ratio and implant type ratio (cemented:non-cemented), the allocation to
groups was not randomized and the screening questionnaire was not validated.
18
6. Brown, K., Swank, A., Quesada, P., Nyland, J., Malkani, A., & Topp, R. (2010). Prehabilitation versus
usual care before total knee arthroplasty: a case report comparing outcomes within the same
individual. Physiotherapy Theory & Practice, 26(6), 399–407. doi:10.3109/09593980903334909
Level of Evidence: 3b
Purpose: To describe the pre- and postoperative functional ability, knee extensor strength, and perceived
pain of a patient who had a staged bilateral knee joint procedure first receiving the usual care for TKA on
her right knee (RTKA), and then returning and participating in a 4-week prehabilitation intervention exercise
program before a second TKA on her left knee (LTKA).
Method: 69-year-old female who has bilateral end stage knee OA was scheduled for a RTKA agreed to
participate in this study which would compare usual treatment pre and post operation on the right to a
prehabilitation program before her LTKA. The 2 surgeries were separated by a 3 month period. Functional
outcome measures were: (1) 6-minute walk test; (2) 30 second sit-to-stand; (3) the time to ascend; and (4)
descend two flights of 11 stairs each (22 total stairs). The prehabilitation intervention emphasized three
components: (1) resistance training; (2) flexibility; and (3) step training.
Results: The patient started her second surgery with increased strength usual care versus prehabilitation
outcomes. Analysis 3 months following the second surgery indicated that the patient maintained strength in
her right leg, but did not, however, maintain the effects of the prehabilitation in the surgical left leg after the
LTKA surgery.
Critique/Bottom Line: The study’s results may be affected by the short time between surgeries not
allowing the patient to fully recover before starting the second rehabilitation process. Also, having been
through one TKA, the expectations and educational aspects of prehabilitation that have been expected to
improve outcomes are not present in this intervention which isolated the effect of physical and functional
improvements pre-surgery. However, it appears this study confirms the hypothesis of prehabilitation
improving the speed of recovery post TKA.
19
7. Cheatham, S., W. (2013). Do Patient Factors and Prehabilitation Improve Outcomes After Total Knee
Arthroplasty? Topics in Geriatric Rehabilitation, 29(1), 17–24. doi:10.1097/TGR.0b013e318275c288
Level of Evidence: 1a
Purpose: To evaluate the influence of patient factors and prehabilitation on postoperative outcomes.
Method: The literature was reviewed from 1954 to 2012 using PubMed, CINAHL, and ProQuest. Patient
factors considered in the review were: muscle strength, age, gender, range of motion, pain, obesity, patient
expectations, and time between end stage OA symptoms and surgery. Interventions considered in the
review were exercise programs ranging from 4 – 8 week pre-operation and a 6 week cardio program. All
interventions were performed 3 times a week for the duration. Exercise interventions stressed the use of
proprioception training and neuromuscular electrical stimulation. The control groups all received “standard”
preoperative care. Outcome measures included functional and patient reported values.
Results: The study call for further investigation on the topic as the results were equivocal. Some studies
found no significant difference in function between groups and others did.
Critique/Bottom Line: The studies investigated may have been underpowered. The positive results of
some studies shows promise for the validity in the use of prehabilitation which includes strengthening and
stretching to increase recovery speed post TKA.
20
8. Swank, A. M., Kachelman, J. B., Bibeau, W., Quesada, P. M., Nyland, J., Malkani, A., & Topp, R. V.
(2011). Prehabilitation before total knee arthroplasty increases strength and function in older adults
with severe osteoarthritis. Journal of Strength and Conditioning Research / National Strength &
Conditioning Association, 25(2), 318–325. doi:10.1519/JSC.0b013e318202e431
Level of Evidence: 1b
Purpose: Physical therapy has been shown, to effectively, increased strength and function and reduce
pain in patients with knee OA. Preoperative strength and function have been correlated to better outcomes
and recovery times post TKA. This study investigates if preoperative physical therapy can increase
strength and function in patients with end stage OA awaiting a TKA with hopes to improve their recovery.
Method: A randomized controlled study comparing leg strength and performance of functional tasks among
subjects with knee OA and pain not responsive to medicine and scheduled for TKA. Subjects were
randomly assigned to usual care (control group) or usual care and a 4-8 week exercise regimen
(intervention group). Patients were tested on functional tasks at the start of the exercise regimen to get a
base line and then retested the week before surgery. The outcome measures were the 6MW test, 30
second sit to stand test, timed ascending/descending stairs, and isokinetic strength testing of quadriceps
and hamstrings for the surgical and non surgical leg. There were a total of 73 subjects, with no drop outs,
and an exercise compliance of 90% (on average) for the intervention group.
Results: There was no significant difference between groups during the baseline testing. A statistical
difference was found in all outcome measures between groups after the intervention was complete except
for in the 6MW test and the peak knee flexion torque.
Critique/Bottom Line: This study suggests that strengthening protocols at end stage OA right before TKA
can improve function and strength. This study failed to follow the patients post surgery to determine what
the post operative recovery effects were between groups and makes the assumption that with greater
preoperative function means improved outcomes after TKA surgery.
21
22
23
24
Discussion
One systematic review investigated in this report found conflicting results regarding the effectiveness of
pre-operative physical therapy (PT) on reducing recovery times post TKA. However, the other articles
analyzed in this report support the use of preoperative PT to improve recovery speed. Two of the
studies support the idea that physical therapy can improve strength and endurance and thus functional
capacity at end stage osteoarthritis (OA) just before a TKA is performed. One retrospective cohort study
looks at the economics of post surgery care between patients who were involved in PT before their TKA
surgery and found patient who were had lower associated costs. Another study looked at general
health including physical activity before a TKA and found that sedentary patients who were given
interventions to increase their daily physical activity before surgery had fewer unexpected adverse
outcomes.
It has been shown that patients who go into a TKA procedure with increased knee ROM, strength,
endurance and function have better outcomes in terms of total rehab potential and speed. The two
studies in this report that do not follow their patients help support the idea that prehabilitation before a
TKA can actually increase knee ROM, strength, endurance, and function. This allows one to more
confidently state that if improvements in recovery are seen it could likely be attributed to the
improvements obtained before surgery.
If optimizing knee ROM, strength, endurance, and function then it may be possible that optimizing
general health may improve outcomes and recovery times in patients before a major operation such as
a TKA. Post operation complications sometimes arise with a TKA including infection and thrombosis.
One Danish study by Hansen, et al. showed how optimizing health which included prescribing exercise to
sedentary patients reduces the occurrence of unexpected adverse outcomes.
The study by Snow R., et al. showing costs savings for those who received PT before the TKA procedure,
it was noted that hospital and nursing stays are shorter and length of utilization of home health and
25
outpatient PT was shortened. This study notes that PT visits were usually limited to one to two visits
implying that the visits were geared more towards education and developing a home exercise program
rather than skilled PT to increase strength and ROM. This study may be the biggest motivating factor in
influencing preoperative TKA protocol due to attention to cost savings.
Upon completion of the preliminary literature review it was suggested Mr. M could have benefited from
a prehabilitation program to reduce his recovery time. Having only received PT after the TKA, the
patient had to continue with his rehabilitation program as usual. On 11/17/14, 14 day post surgery, the
patient knee ROM of 5-75 and still ambulates with a walker. Coordinating with nursing staff and
surgeons, future TKA patients of this hospital were set up to receive an information packet with things
to expected before, during and after the surgery as well as exercises to perform before the operation.
This was a quick procedural change that was easily implemented within a short period of time until a
TKA prehabilitation clinic could be set up.
Conclusion/Bottom Line
Although most evidence suggests preoperative prehabilitation for TKA was beneficial for post operative
recovery speeds, more research needs to be done to pin point the most effective interventions for
increasing rehab potential and speed. Despite the lack of concrete interventions and uniform evidence,
the PICO question was satisfactorily answered showing physical therapy intervention appears to reduce
the recovery times in patients with a TKA.
26
References
Brown, K., Swank, A., Quesada, P., Nyland, J., Malkani, A., & Topp, R. (2010). Prehabilitation
versus usual care before total knee arthroplasty: a case report comparing outcomes within the
same individual. Physiotherapy Theory & Practice, 26(6), 399–407.
doi:10.3109/09593980903334909
Cheatham, S., W. (2013). Do Patient Factors and Prehabilitation Improve Outcomes After Total Knee
Arthroplasty? Topics in Geriatric Rehabilitation, 29(1), 17–24.
doi:10.1097/TGR.0b013e318275c288
Coudeyre, E., Jardin, C., Givron, P., Ribinik, P., Revel, M., & Rannou, F. (2007). Could preoperative
rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration
of French clinical practice guidelines. Annales De Réadaptation Et De Médecine Physique:
Revue Scientifique De La Société Française De Rééducation Fonctionnelle De Réadaptation Et
De Médecine Physique, 50(3), 189–197. doi:10.1016/j.annrmp.2007.02.002
Desmeules, F., Hall, J., & Woodhouse, L. J. (2013). Prehabilitation improves physical function of
individuals with severe disability from hip or knee osteoarthritis. Physiotherapy Canada.
Physiothérapie Canada, 65(2), 116–124. doi:10.3138/ptc.2011-60
Hansen, T. B., Bredtoft, H. K., & Larsen, K. (2012). Preoperative physical optimization in fast-track
hip and knee arthroplasty. Danish Medical Journal, 59(2), A4381.
Matassi, F., Duerinckx, J., Vandenneucker, H., & Bellemans, J. (2014). Range of motion after total
knee arthroplasty: the effect of a preoperative home exercise program. Knee Surgery, Sports
Traumatology, Arthroscopy: Official Journal of the ESSKA, 22(3), 703–709.
doi:10.1007/s00167-012-2349-z
27
Snow, R., Granata, J., Ruhil, A. V. S., Vogel, K., McShane, M., & Wasielewski, R. (2014).
Associations Between Preoperative Physical Therapy and Post-Acute Care Utilization Patterns
and Cost in Total Joint Replacement. Journal of Bone & Joint Surgery, American Volume,
96(19), e165(1)–e165(8). doi:10.2106/JBJS.M.01285
Swank, A. M., Kachelman, J. B., Bibeau, W., Quesada, P. M., Nyland, J., Malkani, A., & Topp, R. V.
(2011). Prehabilitation before total knee arthroplasty increases strength and function in older
adults with severe osteoarthritis. Journal of Strength and Conditioning Research / National
Strength & Conditioning Association, 25(2), 318–325. doi:10.1519/JSC.0b013e318202e431
28
Appendices
Appendix A -Table of Daily Interventions
Appendix B - Article analysis
29
Appendix A -Table of Daily Interventions
Date
11/05/14 am
Treatment
Time
(minutes)
30
11/05/14
– pm
30
11/06/14 am
30
Subjective
Objective
Specific interventions,
exercises, activities
Eval completed.
4/10 pain at rest and
6/10 pain while
walking. Patient
reports “the knee feels
better after walking a
while”.
Pt is tired from
morning session. But is
willing to perform
supine bed exercises
and seated exercises
and EOB.
Eval completed.
Patient came to
sitting on EOB I.
Stood from sitting
Mod I. Ambulated
450’ with FWW.
ROM 10-50 deg.
Pt performed
supine and seated
HEP exercises from
the TKA HEP
packet.
Eval Completed. Verbal
cues durning ambulation
for increased weight
bearing, extension in initial
contact, and flexion in
terminal stance on the left
knee.
HEP supine exercises
include: ankle pumps,
short arch quads, heel
slides, hip
abduction/adduction, glut
squeeze and quad sets.
HEP seated exercises
include: long arch quads
with assistance, knee
flexion stretch with
assistance.
HEP and verbal cues during
ambulation same as above.
Pt again says that
Pt ambulated 400’
walking makes his
Mod I with FWW
knee feel better
and performed
despite his increase in HEP. ROM 5-70
pain. 4/10 at rest,
deg.
6/10 during exercise.
11/06/14 - 0
Patient refused PT “I
pm
think I’m just going to
use this (CPM) right
now”
11/07/14
30
Patient expresses
Patient ambulated HEP and verbal cues during
– am
concern with his ability 400’ Mod I with
ambulation same as above.
to drive since his truck FWW and
is a standard. Patient
performed HEP.
was notified that
ROM 5-70 deg.
driving will not be
Patient performed
recommended until he a curb step Mod I
has been cleared by his with his FWW.
doctor.
Acronyms: FWW – Front wheeled walker, EOB – edge of bed, I – independent, Mod I – Modified
Independent, Amb – ambulated, Eval - Evaluation
30
Appendix B - Article analysis
1.
Intervention – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Matassi, F., Duerinckx, J., Vandenneucker, H., & Bellemans, J. (2014). Range of motion after total knee
arthroplasty: the effect of a preoperative home exercise program. Knee Surgery, Sports Traumatology,
Arthroscopy: Official Journal of the ESSKA, 22(3), 703–709. doi:10.1007/s00167-012-2349-z
Level of Evidence (Oxford scale): 2b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Yes, to investigate whether our preoperative home
Stated clearly?
exercise program provides the patient with a better
Usually stated briefly in abstract and in greater
passive flexion 1 year after TKA and at immediate
detail in introduction. May be phrased as a question postoperative recovery and at 3, 6 and 12 months
or hypothesis.
postoperatively.”
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Yes, they note gaps in the literature as “It seems
Literature
logical to preoperatively increase knee ROM in
Relevant background presented?
order to maximize flexion after TKA, but only sparse
A review of the literature should provide background information is available on the extent to which
for the study by synthesizing relevant information
preoperative exercises could be effective”
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Patients were randomly assigned to a group. No
 Discuss possible threats to internal
other threats to internal validation seem present.
validity in the research design. Include:
31
Assignment
Attrition
History
Instrumentation
Maturation
Testing
Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression







Are the results of this therapeutic trial valid?
Appraisal Criterion
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
4. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Reader’s Comments
Yes
No
Yes, they reported no significant differences in
demographics or baseline measures between
groups.
No
32
5. Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
6. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
7. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
8. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
9. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
Yes, since the control group is not receiving any
intervention it does not seem to harm the study
Yes
Yes
Yes
Yes
Reader’s Comments
“After 6 weeks of training, there was a significant
improvement (p=0.0001) of passive and active
flexion, extension and knee score for the treatment
group.” No difference in patient function scores.
“There was a significant relation between the
percentage exercise adherence and the change in
33
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
passive flexion (Spearman rho = 0.34, p = 0.009)
and the change in Knee Score (Spearman rho =
0.41, p = 0.0015).” “Patients in the treatment group
reached 90_ of knee flexion at a mean of 5.8 days
(±2.1) after the operation, whereas patients in the
control group only reached this at 6.9 days (±1.9).
This difference between both groups was significant
(p = 0.0016); Hospital stays averaged 9.1 days
(±2.1) for the treatment group and 9.9 days (±2.3)
for the control group.” See attached.
Patients did recovery ROM significantly faster but
this may not clinically significant.
11. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
This was not addressed.
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate Yes
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
14. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
15. Do the potential benefits outweigh the
Yes
potential risks using this intervention
with your patient/client?
16. Does the intervention fit within your
Yes
patient/client’s stated values or
expectations?
a. If not, what will you do now?
17. Are there any threats to external validity
in this study?
No
What is the bottom line?
34
Appraisal Criterion
PEDRO score (see scoring at end of form)
Reader’s Comments
8/10
Summarize your findings and relate this back to
clinical significance
The intervention group reached 90 degrees of
flexion sooner than the control but by 1 year there
were no differences between groups.
35
36
2.
Prognostic Study – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Snow, R., Granata, J., Ruhil, A. V. S., Vogel, K., McShane, M., & Wasielewski, R. (2014). Associations Between
Preoperative Physical Therapy and Post-Acute Care Utilization Patterns and Cost in Total Joint
Replacement. Journal of Bone & Joint Surgery, American Volume, 96(19), e165(1)–e165(8).
doi:10.2106/JBJS.M.01285
Level of Evidence (Oxford scale): 2b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Yes, “The purpose of this study was to investigate
Stated clearly?
the association between preoperative physical
Usually stated briefly in abstract and in greater
therapy and post-acute care utilization and the
detail in introduction. May be phrased as a question effect that preoperative physical therapy has on the
or hypothesis.
total episode-of-care cost after total joint
A clear statement helps you determine if topic is
replacement”.
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Yes, they clearly state a need for a study such as
this.
Does the research design have strong sampling techniques?
Appraisal Criterion
Reader’s Comments
Did the investigators provide sufficient information to Yes, very detailed demographics.
describe the sample in their study?
Does the study clearly define the group of
37
patients; is there a clear inclusion and
exclusion criterion? Is there a clear
description of the stage and timing of the
problem (illness) studied.
Are the subjects representative of the population
from which they were drawn?
Did they capture all eligible subjects?
Are the results of this prognostic study valid?
Appraisal Criterion
1. Were the subjects assembled at a
common (usually early) point in the
course of their disorder?
a. If not, what are the implications of
multiple starting points for this
study’s results?
2. Was the study time frame long enough to
capture the outcome(s) of interest? Was
patient follow-up sufficiently long and
complete?
a. If not, what are the potential
consequences of the follow-up
time for the study’s results?
3. Did all subjects originally enrolled
complete the study?
a. If not, how many subjects were
lost
b. What if anything did the authors
do about this attrition?
c. What are the implications of this
attrition and the way it was
handled with respect to the
study’s findings?
4. Were objective outcome criteria applied
to the subjects in a masked or blinded
fashion??
a. If not, what are the potential
consequences for this study’s
results
5. If subgroups with different prognoses are
identified, was there adjustment for
important prognostic or risk factors?
a. If not, what should have been
included? What are the potential
Yes
Reader’s Comments
Yes, all end stage OA receiving a TJR.
Yes
Yes
Yes
N/A
38
consequences for the lack of this
adjustment
6. Was there an independent set of patients Yes, patients who did not receive any preoperative
to validate the study?
PT.
a. If not, what are the potential
consequences for this study’s
results?
Are the valid results of this prognostic study important?
Appraisal Criterion
Reader’s Comments
7. What were the statistical findings of this
See Attached Table
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Report on correlation coefficient
and/or coefficient of
determination
c. Did they include a survival curve,
ROC, odds ratios, relative risk
ratio
d. How precise are the CIs?
e. Other stats should be included
here
8. What is the meaning of these statistical
Patients who received preoperative PT had less
findings for your patient/client’s case?
expensive episodes of care for their TJR.
What does this mean to your practice?
Can you apply this valid, important evidence about this prognostic study in caring for your
patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
9. How likely are these outcomes over time? N/A
10. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you use
this test in spite of the
differences?
11. Would sharing this information help your Yes
patient/client given their expressed
values and preferences?
What is the bottom line?
Appraisal Criterion
Reader’s Comments
39
Summarize your findings and relate this back to
clinical significance and usefulness of this study
Preoperative PT reduced post-acute care utilization.
Preoperative PT reduced the costs associated with
joint replacements. A reduction in post acute care
utilization suggests that function is restored faster.
40
3.
Prognostic Study – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Desmeules, F., Hall, J., & Woodhouse, L. J. (2013). Prehabilitation improves physical function of individuals with
severe disability from hip or knee osteoarthritis. Physiotherapy Canada. Physiothérapie Canada, 65(2),
116–124. doi:10.3138/ptc.2011-60
Level of Evidence (Oxford scale): 2b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Yes, the purpose is to “ evaluate the effect of
Stated clearly?
prehabilitation (education and exercise) on pain and
Usually stated briefly in abstract and in greater
function with more compromised health and
detail in introduction. May be phrased as a question functional status” and “to evaluate whether the
or hypothesis.
physiotherapists could triage cliants with OA into
A clear statement helps you determine if topic is
those with minimal, moderate, and severe
important, relevant and of interest to you. Consider
disability”.
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Yes.
Does the research design have strong sampling techniques?
Appraisal Criterion
Reader’s Comments
Did the investigators provide sufficient information to Yes, but no clear exclusion/inclusion criteria. It was
describe the sample in their study?
u clear how the 28 participants were chosen from
Does the study clearly define the group of
the starting 650 cohort.
41
patients; is there a clear inclusion and
exclusion criterion? Is there a clear
description of the stage and timing of the
problem (illness) studied.
Are the subjects representative of the population
from which they were drawn?
Did they capture all eligible subjects?
Are the results of this prognostic study valid?
Appraisal Criterion
1. Were the subjects assembled at a
common (usually early) point in the
course of their disorder?
a. If not, what are the implications of
multiple starting points for this
study’s results?
2. Was the study time frame long enough to
capture the outcome(s) of interest? Was
patient follow-up sufficiently long and
complete?
a. If not, what are the potential
consequences of the follow-up
time for the study’s results?
3. Did all subjects originally enrolled
complete the study?
a. If not, how many subjects were
lost
b. What if anything did the authors
do about this attrition?
c. What are the implications of this
attrition and the way it was
handled with respect to the
study’s findings?
4. Were objective outcome criteria applied
to the subjects in a masked or blinded
fashion??
a. If not, what are the potential
consequences for this study’s
results
5. If subgroups with different prognoses are
identified, was there adjustment for
important prognostic or risk factors?
a. If not, what should have been
included? What are the potential
Yes
Reader’s Comments
All patients were apparently at end stage OA
because they were receiving a TJR but the
hierarchy of end stage OA within the population was
unclear.
Yes
Yes
Not stated, if PTs were not blinded there could be
bias as to placement into a particular group.
Yes, the rehab program changed based on the
group they were in.
42
consequences for the lack of this
adjustment
6. Was there an independent set of patients No control group, there is no group to compare a
to validate the study?
baseline with.
a. If not, what are the potential
consequences for this study’s
results?
Are the valid results of this prognostic study important?
Appraisal Criterion
Reader’s Comments
7. What were the statistical findings of this
See Attached Table
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Report on correlation coefficient
and/or coefficient of
determination
c. Did they include a survival curve,
ROC, odds ratios, relative risk
ratio
d. How precise are the CIs?
e. Other stats should be included
here
8. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
This triaging tool was show to be effective. It also
seems that a patient who participates in a
preoperative PT program will increase functional
abilities before surgery that will hopefully carry over
to the postoperative recovery.
Can you apply this valid, important evidence about this prognostic study in caring for your
patient/client? What is the external validity?
Appraisal Criterion
Reader’s Comments
9. How likely are these outcomes over time? N/A
10. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you use
this test in spite of the
differences?
11. Would sharing this information help your Function can be improved before surgery and,
patient/client given their expressed
hopefully, will make recovery faster after surgery.
values and preferences?
What is the bottom line?
43
Appraisal Criterion
Summarize your findings and relate this back to
clinical significance and usefulness of this study
Reader’s Comments
This study illuminates the use of PT to effectively
increase a patient’s function before surgery at end
stage OA. This is helpful to know since the logical
step of relating prehabilitation for TKA to faster
outcomes relies on the assumption that
prehabilitation has the ability to makes changes in
patients at all.
44
45
4.
Systematic Review – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Coudeyre, E., Jardin, C., Givron, P., Ribinik, P., Revel, M., & Rannou, F. (2007). Could preoperative
rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration of French
clinical practice guidelines. Annales De Réadaptation Et De Médecine Physique: Revue Scientifique De La
Société Française De Rééducation Fonctionnelle De Réadaptation Et De Médecine Physique, 50(3), 189–
197. doi:10.1016/j.annrmp.2007.02.002
Level of Evidence (Oxford scale): 1a
Does the design follow the Cochrane method?
Appraisal Criterion
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should
specify the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Step 2 – locating studies



Should identify ALL relevant literature
Did they include multiple databases?
Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference
lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
Reader’s Comments
Yes, “Could preoperative rehabilitation modify
postoperative outcomes after total
hip and knee arthroplasty?”
They did included multiple databases and a search
strategy was defined
46
channels such as publishers)
o Sources for ‘grey literature’
Part 3:Critical Appraisal/Criteria for Inclusion
Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
Part 3 – Critically appraise for bias:
•
•
•
•
•
Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
Detection –
• Did the study selectively report
the results?
• Is there missing data?
Part 4 – Collection of the data



Was a collection data form used and is it
included?
Are the studies coded and is the data
coding easy to follow?
Were studies identified that were
excluded & did they give reasons why
Yes, two authors from two different backgrounds
assessed the literature. There was no mention of
the blinding the authors to the literature information.
It makes no consistent mention of how selection
took place, if there was blinding, attrition, or
reporting of missing data. As far as could be told
from the review, there was no missing data.
Groups in the study did receive different
interventions and this was noted briefly in the table.
The data was reported in a table that was easy to
read and leaves the reader to trust the authors
reporting of factors that may have weakened the
study.
47
(i.e., which criteria they failed).
Are the results of this SR valid?
Appraisal Criterion
18. Is this a SR of randomized trials? Did
they limit this to high quality studies at
the top of the hierarchies
a. If not, what types of studies were
included?
b. What are the potential
consequences of including these
studies for this review’s results?
19. Did this study follow the Cochrane
methods selection process and did it
identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
20. Do the methods describe the processes
and tools used to assess the quality of
individual studies?
a. If not, what are the
consequences for this review’s
results?
21. What was the quality of the individual
studies included? Were the results
consistent from study to study? Did the
investigators provide details about the
research validity or quality of the studies
included in review?
22. Did the investigators address
publication bias
Are the valid results of this SR important?
Appraisal Criterion
23. Were the results homogenous from study to
study?
a. If not, what are the
consequences for this review’s
results?
24. If the paper is a meta-analysis did they
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there
Reader’s Comments
All but one were RCTs and the one was a cohort
study. It appears they only included studies of level
1 and 2.
It did not mention the use of the Cochrane methods
selection process but it did perform searches from
the Cochrane database. The methods selection
process is not standardized and clearly defined.
No, Since the methods to assess the articles are
not clearly defined we do not know if different
reviewers assessed articles differently.
Yes, but the details were very brief and limited.
No
Reader’s Comments
No, the intervention and outcome measures were
different across the studies reviews making it
impossible for the results to be homogenous.
However clear recommendations for prehabilitation
were shown.
N/A
48
CIs?
25. From the findings, is it apparent what the Yes
cumulative weight of the evidence is?
Can you apply this valid, important evidence from this SR in caring for your patient/client? What is
the external validity?
Appraisal Criterion
Reader’s Comments
26. Is your patient different from those in
No
this SR?
27. Is the treatment feasible in your setting? Yes
Do you have the facilities, skill set, time,
3rd party coverage to provide this
treatment?
28. Does the intervention fit within your
Yes
patient/client’s stated values or
expectations?
a. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Summarize your findings and relate this back to
clinical significance
Reader’s Comments
Rehabilitation before total hip and knee arthroplasty
contributes to reduced hospital length of and
modifying discharge conditions.
49
5.
Intervention – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Hansen, T. B., Bredtoft, H. K., & Larsen, K. (2012). Preoperative physical optimization in fast-track hip and knee
arthroplasty. Danish Medical Journal, 59(2), A4381.
Level of Evidence (Oxford scale): 2b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
“To investigate if screening and optimization of risk
Stated clearly?
patients combined with a motivational conversation
Usually stated briefly in abstract and in greater
is effective in reducing complications in patients
detail in introduction. May be phrased as a question scheduled for a fast-track hip and knee
or hypothesis.
arthroplasty.”
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Yes, increasing numbers of joint replacement
surgeries and a new policy of performing total joint
replacements within 4 week of been scheduled was
in acted in the location of the study which spurred
the study to investigate if health optimizations in a 4
week (or less) time period could improve outcomes.
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Assignment was not random but part of the study.
 Discuss possible threats to internal
Patients were not intentionally separated from each
validity in the research design. Include: other but there was no reported interaction between
 Assignment
participants.
 Attrition
50
History
Instrumentation
Maturation
Testing
Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression





Are the results of this therapeutic trial valid?
Appraisal Criterion
29. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
30. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
31. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
32. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
33. Did the investigators know to which
treatment group subjects were assigned
Reader’s Comments
No, the groups were assigned to a groups based on
how they scored on the health evaluation survey.
Yes, the intervention was done at the time of
allocation.
Yes, they reported no significant differences in
demographics or baseline measures between
groups.
Yes, they were aware the intervention they were
receiving was directly related to their answers on
the health screening questionnaire.
Yes, the intervention was done at the time of
51
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
34. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
35. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
36. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
37. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
38. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
allocation.
Yes
Yes
Yes
Yes
Reader’s Comments
See attached.
The number of unintended patient paths was
significantly less in the intervention group: 19 (35%)
in the control group; 14 (18%) in the intervention
group (p = 0.025).
52
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
39. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
Optimizing health before a total joint replacement is
shown to reduce the risk for unintended adverse
outcomes.
This was not addressed.
40. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
41. Does this intervention sound appropriate Yes
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
42. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
43. Do the potential benefits outweigh the
Yes
potential risks using this intervention
with your patient/client?
44. Does the intervention fit within your
Yes
patient/client’s stated values or
expectations?
a. If not, what will you do now?
45. Are there any threats to external validity
in this study?
No
53
What is the bottom line?
Appraisal Criterion
PEDRO score (see scoring at end of form)
Summarize your findings and relate this back to
clinical significance
Reader’s Comments
6/10
Preoperative physical optimization of patients who
are at risk of following an unintentional path is
effective in patients scheduled for fast-track hip and
knee arthroplasty.
54
6.
Intervention – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Brown, K., Swank, A., Quesada, P., Nyland, J., Malkani, A., & Topp, R. (2010). Prehabilitation versus
usual care before total knee arthroplasty: a case report comparing outcomes within the same
individual. Physiotherapy Theory & Practice, 26(6), 399–407. doi:10.3109/09593980903334909
Level of Evidence (Oxford scale): 3b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
To describe the pre- and postoperative functional
Stated clearly?
ability, knee extensor strength, and perceived pain
Usually stated briefly in abstract and in greater
of a patient who had a staged bilateral knee joint
detail in introduction. May be phrased as a question procedure first receiving the usual care for TKA on
or hypothesis.
her right knee (RTKA), and then returning and
A clear statement helps you determine if topic is
participating in a 4-week prehabilitation intervention
important, relevant and of interest to you. Consider
exercise program before a second TKA on her left
how the study can be applied to PT and/or your own knee (LTKA).
situation. What is the purpose of this study?
Researchers provided ample background and
Literature
previous research examples. The justification of
Relevant background presented?
this study is that not enough research has been
A review of the literature should provide background done to show the effectiveness of preoperative PT
for the study by synthesizing relevant information
on post-operative outcomes.
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
 Discuss possible threats to internal
I believe the history of he patient In the case study
validity in the research design. Include: having already received a TKA makes the second
 Assignment
TKA a different experience since expectations are
 Attrition
changed. Also, there may not have been enough
 History
time between surgeries to allowed full recovery from
 Instrumentation
55
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
46. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
47. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
48. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
49. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
50. Did the investigators know to which
treatment group subjects were
assigned?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
the first surgery.
Reader’s Comments
N/A
N/A
N/A
N/A
N/A
56
results
51. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
52. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
53. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
54. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
55. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
Yes, besides the preoperative intervention on the
second knee, the care was equal between the
knees.
Yes
Yes
Yes
Reader’s Comments
Statistical findings are not relevant to this study
since we are comparing one knee to another, N of 1
on each side.
See Attached
57
here
56. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
Prehabilitation was shown to effectively hasten the
recovery of TKA based on all functional tests except
stair climbing. Pain from surgery was not improved
from prehabilitation.
This was not addressed.
57. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
58. Does this intervention sound appropriate Yes
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
59. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
60. Do the potential benefits outweigh the
Yes
potential risks using this intervention
with your patient/client?
61. Does the intervention fit within your
Yes
patient/client’s stated values or
expectations?
a. If not, what will you do now?
62. Are there any threats to external validity
in this study?
No
What is the bottom line?
Appraisal Criterion
PEDRO score (see scoring at end of form)
Reader’s Comments
6/10
Summarize your findings and relate this back to
Prehabilitation was shown to effectively hasten the
58
clinical significance
recovery of TKA based on all functional tests except
stair climbing. Pain from surgery was not improved
from prehabilitation.
59
60
7.
Systematic Review – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Cheatham, S., W. (2013). Do Patient Factors and Prehabilitation Improve Outcomes After Total Knee
Arthroplasty? Topics in Geriatric Rehabilitation, 29(1), 17–24. doi:10.1097/TGR.0b013e318275c288
Level of Evidence (Oxford scale): 1a
Does the design follow the Cochrane method?
Appraisal Criterion
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should
specify the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Step 2 – locating studies



Should identify ALL relevant literature
Did they include multiple databases?
Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference
lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Part 3:Critical Appraisal/Criteria for Inclusion
Reader’s Comments
Yes, “Do Patient Factors and Prehabilitation
Improve Outcomes After Total Knee
Arthroplasty?”
Interventions and outcome measure are vague in
the question.
Databases searched were not listed and search
criteria was not stated.
No.
61
Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
Part 3 – Critically appraise for bias:
•
•
•
•
•
Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
Detection –
• Did the study selectively report
the results?
• Is there missing data?
Part 4 – Collection of the data



Was a collection data form used and is it
included?
Are the studies coded and is the data
coding easy to follow?
Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
Are the results of this SR valid?
Appraisal Criterion
It makes no mention of how selection took place, if
there was blinding, attrition, or reporting of missing
data. As far as could be told from the review, there
was no missing data. Groups in the study had
similar interventions.
The data was reported in a table that was easy to
read but leave the reader with no information of the
weaknesses of the studies reviewed.
Reader’s Comments
62
63. Is this a SR of randomized trials? Did
The studies reviewed seem to be RCT’s but this is
they limit this to high quality studies at
not stated. No information of the quality of the study
the top of the hierarchies
is stated explicitly.
a. If not, what types of studies were
included?
b. What are the potential
consequences of including these
studies for this review’s results?
64. Did this study follow the Cochrane
No, It did not mention the use of the Cochrane
methods selection process and did it
methods selection process but it did perform
identify all relevant trials?
searches from the Cochrane database. The
a. If not, what are the
methods selection process is not standardized and
consequences for this review’s
clearly defined.
results?
65. Do the methods describe the processes No, Since the methods to assess the articles are not
and tools used to assess the quality of
clearly defined we do not know if different reviewers
individual studies?
assessed articles differently.
a. If not, what are the
consequences for this review’s
results?
66. What was the quality of the individual
No
studies included? Were the results
consistent from study to study? Did the
investigators provide details about the
research validity or quality of the studies
included in review?
67. Did the investigators address
No
publication bias
Are the valid results of this SR important?
Appraisal Criterion
Reader’s Comments
68. Were the results homogenous from study to No, the intervention and outcome measures were
study?
different across the studies reviewed, making it
a. If not, what are the
impossible for the results to be homogenous. And
consequences for this review’s
the results were not all in favor of preoperative PT.
results?
69. If the paper is a meta-analysis did they
N/A
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there
CIs?
70. From the findings, is it apparent what the No
cumulative weight of the evidence is?
Can you apply this valid, important evidence from this SR in caring for your patient/client? What is
the external validity?
Appraisal Criterion
Reader’s Comments
63
71. Is your patient different from those in
this SR?
72. Is the treatment feasible in your setting?
Do you have the facilities, skill set, time,
3rd party coverage to provide this
treatment?
73. Does the intervention fit within your
patient/client’s stated values or
expectations?
b. If not, what will you do now?
What is the bottom line?
Appraisal Criterion
Summarize your findings and relate this back to
clinical significance
No
Yes
Yes
Reader’s Comments
The study call for further investigation on the topic
as the results were equivocal. Some studies found
no significant difference in function between groups
and others did.
64
8.
Intervention – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Swank, A. M., Kachelman, J. B., Bibeau, W., Quesada, P. M., Nyland, J., Malkani, A., & Topp, R. V. (2011).
Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe
osteoarthritis. Journal of Strength and Conditioning Research / National Strength & Conditioning
Association, 25(2), 318–325. doi:10.1519/JSC.0b013e318202e431
Level of Evidence (Oxford scale): 1b
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Yes, “This study investigates if preoperative
Stated clearly?
physical therapy can increase strength and function
Usually stated briefly in abstract and in greater
in patients with end stage OA awaiting a TKA with
detail in introduction. May be phrased as a question hopes to improve their recovery.”
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Yes, they state that ample literature has shown
Literature
preoperative PT to improve pain and self reported
Relevant background presented?
function in TKA patients but not enough literature to
A review of the literature should provide background support objective functional gains.
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Of the original subjects, 19 were eliminated due to
 Discuss possible threats to internal
exclusion criteria. The measures used are
validity in the research design. Include: validated.
65
Assignment
Attrition
History
Instrumentation
Maturation
Testing
Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression







Are the results of this therapeutic trial valid?
Appraisal Criterion
74. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
75. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
76. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
77. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
78. Did the investigators know to which
treatment group subjects were
Reader’s Comments
yes
No
Yes, they reported no significant differences in
demographics between groups.
No
Yes, since the control group is not receiving any
66
assigned?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
79. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
80. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
81. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
82. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
83. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
intervention it does not seem to harm the study.
Yes
No, they pose the question of if this intervention
helps postoperatively but they do not follow the
patients postoperatively.
Yes
Yes
Reader’s Comments
“A significant group by time interaction was found
for the number of sit-to-stand repetitions in 30
seconds (p = 0.03), time to ascend the first (p = .02)
and second (p = 0.05) flight of stairs, and peak
extension torque in the surgical leg (p = 0.01).”
CI = 95%
See attached table.
67
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
84. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
A statistical difference was found in all outcome
measures between groups after the intervention
was complete except for in the 6MW test and the
peak knee flexion torque.
This was not addressed.
85. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
86. Does this intervention sound appropriate Yes
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
87. Are the study subjects similar to your
Yes
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
88. Do the potential benefits outweigh the
Yes
potential risks using this intervention
with your patient/client?
89. Does the intervention fit within your
Yes
patient/client’s stated values or
expectations?
a. If not, what will you do now?
90. Are there any threats to external validity No
in this study?
What is the bottom line?
Appraisal Criterion
PEDRO score (see scoring at end of form)
Summarize your findings and relate this back to
Reader’s Comments
9/10
Strengthening protocols at end stage OA right
before TKA can improve function and strength.
68
clinical significance
69
70