The effects of exercise and active assisted cycle ergometry in post-operative total knee arthroplasty patients - a randomized controlled trial

P Sanzo, S Niccoli, K Droll, D Puskas, C Cullinan, S J Lees, P Sanzo, S Niccoli, K Droll, D Puskas, C Cullinan, S J Lees

Abstract

Purpose: The purpose of this study was to examine the effect of the use of an active assisted cycle ergometer as an adjunct to post-operative treatment following total knee arthroplasty.

Method: A total of 55 participants aged 50-80 years who had undergone unilateral total knee arthroplasty were randomly assigned to either the control group (standard of care) or the active assisted cycle ergometer (AACE) group. The effect on patient motivation, blood biomarkers, and knee pain, function, range of motion (ROM), strength, and swelling was examined. Qualitative feedback was also obtained post-operatively.

Results: Although there was no statistically significant difference in the standard of care compared to the AACE group, there was a trend for a greater reduction in knee pain on the visual analog scale, improved Lower Extremity Functional Scale scores, and knee extension ROM and strength. A greater percentage of the experimental group demonstrated higher motivation. There was no significant difference in swelling or blood biomarker measures. Qualitative feedback from the AACE group post-operatively was also positive.

Conclusions: The use of an AACE protocol as an adjunct to total knee arthroplasty rehabilitation may improve post-operative clinical outcomes. This study has been registered at clinicaltrials.gov (identifier NCT02265523 , Oct 16 2014).

Level of evidence: Level 1 - randomized controlled trial. Further research with a larger sample size is needed to confirm the benefits of the ergometer use.

Keywords: Exercise; Rehabilitation; Total knee replacement.

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Study Details. A) Consolidated Standards of Reporting Trials (CONSORT) flow diagram of the progress through the trial. B) Viscus© active assisted cycle ergometer (AACE)
Fig. 2
Fig. 2
Measured Knee Function. A) Goniometric range of motion (ROM) pre-op and post-op measures for knee flexion and extension in the control and active assisted cycle ergometer (AACE) groups. n = 25–26 per group. B) Resisted isometric knee flexor and extensor strength using a Lafayette Manual Muscle Tester pre-op and post-op measures for the control and active assisted cycle ergometer (AACE) groups. n = 24–26 per group
Fig. 3
Fig. 3
Self-Reported Knee Function. A) Lower extremity functional scale score for pre-op and post-op measures in the control and active assisted cycle ergometer (AACE) groups. * denotes significant difference from corresponding pre-operative measures. n = 24–26 per group. B) Visual analog pain pre-op and post-op measures in the control and active assisted cycle ergometer (AACE) groups. * denotes significant difference from corresponding pre-operative measures. n = 25–26 per group
Fig. 4
Fig. 4
Blood Biomarkers. A) Plasma IL-10 concentration pre-op and post-op measures in the control and active assisted cycle ergometer (AACE) groups. A = pre-op, B = 2 days post-op, C = 6–12 weeks post-op. * denotes significant difference from corresponding pre-operative measures (P < .001 95% CI [− 1.372, − 0.523]), # denotes significant difference from corresponding 6–12 week post-operative measures (P = .001 95% CI [0.299, 1.149]). n = 21–25 per group; only participants with all three blood draws were analyzed. B) Plasma P-selectin concentration pre-op and post-op measures in the control and active assisted cycle ergometer (AACE) groups. A = pre-op, B = 2 days post-op, C = 6–12 weeks post-op. n = 21–25 per group; only participants with all three blood draws were analyzed

References

    1. Baghbani Naghadehi F, Armijo Olivo S, Forhan M, Prado C, Gramlich L, Woodhouse L. Prevalence of obesity and the associated risk among patients with total knee arthroplasty in Alberta. Osteoarthr Cartil. 2019;27:S279. doi: 10.1016/j.joca.2019.02.661.
    1. Bliddal H, Leeds AR, Christensen R. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons - a scoping review. Obes Rev. 2014;15(7):578–586. doi: 10.1111/obr.12173.
    1. Nelson AE. Osteoarthritis year in review 2017: clinical. Osteoarthr Cartil. 2018;26(3):319–325. doi: 10.1016/j.joca.2017.11.014.
    1. Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheum Dis Clin N Am. 2013;39(1):1–19. doi: 10.1016/j.rdc.2012.10.004.
    1. Singh JA, Yu S, Chen L, Cleveland JD. Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample. J Rheumatol. 2019;46(9):1134–1140. doi: 10.3899/jrheum.170990.
    1. Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature update. Curr Opin Rheumatol. 2018;30(2):160–167. doi: 10.1097/BOR.0000000000000479.
    1. World Health Organization: Chronic rheumatic conditions. World Health Organ. ,and%20conditions%20resulting%20from%20trauma. Accessed 6 April 2021
    1. Harris WH, Sledge CB. Total hip and total knee replacement. N Engl J Med. 1990;323(11):725–731. doi: 10.1056/NEJM199009133231106.
    1. OECD . Health at a glance 2011: OECD indicators. Paris: OECD Publishing; 2011.
    1. Shin J-M, Hong S-J, Choi K-H, Shin S-I, Lee DK, Lee S-S, Lee BH. Low relative muscle volume: correlation with prevalence of venous thromboembolism following total knee arthroplasty. PLoS One. 2019;14(3):e0210800. doi: 10.1371/journal.pone.0210800.
    1. Frost H, Lamb SE, Robertson S. A randomized controlled trial of exercise to improve mobility and function after elective knee arthroplasty. Feasibility, results and methodological difficulties. Clin Rehabil. 2002;16(2):200–209. doi: 10.1191/0269215502cr483oa.
    1. Brewer BW, Van Raalte JL, Cornelius AE, Petitpas AJ, Sklar JH, Pohlman MH, Krushell RJ, Ditmar TD. Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction. Rehabil Psychol. 2000;45(1):20–37. doi: 10.1037/0090-5550.45.1.20.
    1. Sharma L, Sinacore J, Daugherty C, Kuesis DT, Stulberg SD, Lewis M, Baumann G, Chang RW. Prognostic factors for functional outcome of total knee replacement: a prospective study. J Gerontol A Biol Sci Med Sci. 1996;51(4):M152–M157. doi: 10.1093/gerona/51A.4.M152.
    1. Bedard NA, Dowdle SB, Anthony CA, DeMik DE, McHugh MA, Bozic KJ, Callaghan JJ. The AAHKS clinical research award: what are the costs of knee osteoarthritis in the year prior to total knee arthroplasty? J Arthroplast. 2017;32(9S):S8–S10. doi: 10.1016/j.arth.2017.01.011.
    1. Cram P, Landon BE, Matelski J, Ling V, Stukel TA, Paterson JM, Gandhi R, Hawker GA, Ravi B. Utilization and short-term outcomes of primary total hip and knee arthroplasty in the United States and Canada: an analysis of New York and Ontario administrative data. Arthritis Rheumatol. 2018;70(4):547–554. doi: 10.1002/art.40407.
    1. Tousignant M, Moffet H, Nadeau S, Mérette C, Boissy P, Corriveau H, Marquis F, Cabana F, Ranger P, Belzile ÉL, Dimentberg R. Cost analysis of in-home telerehabilitation for post-knee arthroplasty. J Med Internet Res. 2015;17(3):e83. doi: 10.2196/jmir.3844.
    1. Ahles TA, Ruckdeschel JC, Blanchard EB. Cancer-related pain—II. Assessment with visual analogue scales. J Psychosom Res. 1984;28(2):121–124. doi: 10.1016/0022-3999(84)90004-7.
    1. Karlsen APH, Wetterslev M, Hansen SE, Hansen MS, Mathiesen O, Dahl JB. Postoperative pain treatment after total knee arthroplasty: a systematic review. PLoS One. 2017;12(3):e0173107. doi: 10.1371/journal.pone.0173107.
    1. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2012;10(1):28–55. doi: 10.1016/j.ijsu.2011.10.001.
    1. Ferraz M, Quaresma M, Aquino L, Atra E, Tugwell P, Goldsmith C. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid-arthritis. J Rheumatol. 1990;17(8):1022–1024.
    1. Scott J, Huskisson EC. Vertical or horizontal visual analogue scales. Ann Rheum Dis. 1979;38(6):560. doi: 10.1136/ard.38.6.560.
    1. Finch E. Physical rehabilitation outcome measures: a guide to enhanced clinical decision making. Hamilton: BC Decker; 2002.
    1. Clarkson HM. Musculoskeletal assessment: joint motion and muscle testing. Philadelphia: Lippincott Williams and Wilkins; 2012.
    1. Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of goniometric measurements at the knee. Phys Ther. 1987;67(2):192–195. doi: 10.1093/ptj/67.2.192.
    1. Markland D, Tobin V. A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation. J Sport Exerc Psychol Human Kinetics. 2004;26(2):191–196. doi: 10.1123/jsep.26.2.191.
    1. (2009, 2020) Lafayette Hand-Held Dynamometer. Lafayette Instrum. Evaluation. . Accessed 6 April 2021
    1. Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79(4):371–383.
    1. Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med. 2003;10(10):1128–1130. doi: 10.1197/S1069-6563(03)00372-5.
    1. Liebs TR, Herzberg W, Rüther W, Haasters J, Russlies M, Hassenpflug J. Ergometer cycling after hip or knee replacement surgery: a randomized controlled trial. J Bone Joint Surg Am. 2010;92(4):814–822. doi: 10.2106/JBJS.H.01359.
    1. Enloe LJ, Shields RK, Smith K, Leo K, Miller B. Total hip and knee replacement treatment programs: a report using consensus. J Orthop Sports Phys Ther. 1996;23(1):3–11. doi: 10.2519/jospt.1996.23.1.3.
    1. Crawford JJ, Harenberg S, Bishop S, Hayes T, Zelada L, Fraser J. A retrospective analysis of postrehabilitation outcomes following total knee arthroplasty. Musculoskelet Care. 2018;17(1):37–43. doi: 10.1002/msc.1352.
    1. Halawi MJ, Jongbloed W, Baron S, Savoy L, Williams VJ, Cote MP. Patient dissatisfaction after primary Total joint arthroplasty: the patient perspective. J Arthroplast. 2019;34(6):1093–1096. doi: 10.1016/j.arth.2019.01.075.
    1. Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord. 2015;16(1):15. doi: 10.1186/s12891-015-0469-6.
    1. Mosevoll KA, Lindås R, Tvedt THA, Bruserud Ø, Reikvam H. Altered plasma levels of cytokines, soluble adhesion molecules and matrix metalloproteases in venous thrombosis. Thromb Res. 2015;136(1):30–39. doi: 10.1016/j.thromres.2015.04.002.
    1. Vandy FC, Stabler C, Eliassen AM, Hawley AE, Guire KE, Myers DD, Henke PK, Wakefield TW. Soluble P-selectin for the diagnosis of lower extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord. 2013;1(2):117–125. doi: 10.1016/j.jvsv.2012.09.001.
    1. van Es N, Louzada M, Carrier M, Tagalakis V, Gross PL, Shivakumar S, Rodger MA, Wells PS. Predicting the risk of recurrent venous thromboembolism in patients with cancer: a prospective cohort study. Thromb Res. 2018;163:41–46. doi: 10.1016/j.thromres.2018.01.009.
    1. Grilz E, Marosi C, Königsbrügge O, Riedl J, Posch F, Lamm W, Lang IM, Pabinger I, Ay C. Association of complete blood count parameters, d-dimer, and soluble P-selectin with risk of arterial thromboembolism in patients with cancer. J Thromb Haemost. 2019;17(8):1335–1344. doi: 10.1111/jth.14484.
    1. Ay C, Jungbauer LV, Sailer T, Tengler T, Koder S, Kaider A, Panzer S, Quehenberger P, Pabinger I, Mannhalter C. High concentrations of soluble P-selectin are associated with risk of venous thromboembolism and the P-selectin Thr715 variant. Clin Chem. 2007;53(7):1235–1243. doi: 10.1373/clinchem.2006.085068.
    1. Wei Y, Chen X, Shen H, Wu W, Cao G, Chen W, Wang Y, Shen H, Yu S, Zhang J. P-selectin level at first and third day after portal hypertensive splenectomy for early prediction of portal vein thrombosis in patients with cirrhosis. Clin Appl Thromb Hemost. 2018;24(9S):76S–83S. doi: 10.1177/1076029618788180.
    1. Marik P, Flemmer M. The immune response to surgery and trauma: implications for treatment. J Trauma Acute Care Surg. 2012;73(4):801–808. doi: 10.1097/TA.0b013e318265cf87.
    1. Reitsma PH, Rosendaal FR. Activation of innate immunity in patients with venous thrombosis: the Leiden thrombophilia study. J Thromb Haemost. 2004;2(4):619–622. doi: 10.1111/j.1538-7836.2004.00689.x.
    1. Du T, Tan Z. Relationship between deep venous thrombosis and inflammatory cytokines in postoperative patients with malignant abdominal tumors. Braz J Med Biol Res. 2014;47(11):1003–1007. doi: 10.1590/1414-431X20143695.
    1. Ahlers O, Nachtigall I, Lenze J, Goldmann A, Schulte E, Höhne C, Fritz G, Keh D. Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth. 2008;101(6):781–787. doi: 10.1093/bja/aen287.
    1. Downing LJ, Strieter RM, Kadell AM, Wilke CA, Austin JC, Dare BD, Burdick MD, Greenfield LJ, Wakefield TW. IL-10 regulates thrombus-induced vein wall inflammation and thrombosis. J Immunol. 1998;161(3):1471–1476.
    1. Henke PK, DeBrunye LA, Strieter RM, Bromberg JS, Prince M, Kadell AM, Sarkar M, Londy F, Wakefield TW. Viral IL-10 gene transfer decreases inflammation and cell adhesion molecule expression in a rat model of venous thrombosis. J Immunol. 2000;164(4):2131–2141. doi: 10.4049/jimmunol.164.4.2131.
    1. Londy FJ, Kadell AM, Wrobleski SK, Prince MR, Strieter RM, Wakefield TW. Detection of perivenous inflammation in a rat model of venous thrombosis using MRV. J Investig Surg. 1999;12(3):151–156. doi: 10.1080/089419399272557.
    1. Ben-Hadj-Khalifa S, Nguyen P, Mahjoub T, Hézard N. Anticoagulant properties of the anti-inflammatory cytokine IL-10 in a factor Xa-activated human monocyte model. Eur Cytokine Netw. 2012;23(3):87–92. doi: 10.1684/ecn.2012.0315.
    1. Khatib Y, Jenkin D, Naylor JM, Harris IA. Psychological traits in patients waiting for total knee arthroplasty. A cross-sectional study. J Arthroplast. 2016;31(8):1661–1666. doi: 10.1016/j.arth.2016.01.053.
    1. West JA, Scudday T, Anderson S, Amin NH. Clinical outcomes and patient satisfaction after total knee arthroplasty: a follow-up of the first 50 cases by a single surgeon. J Int Med Res. 2019;47(4):1667–1676. doi: 10.1177/0300060519832430.
    1. Jiang Y, Sanchez-Santos MT, Judge AD, Murray DW, Arden NK. Predictors of patient-reported pain and functional outcomes over 10 years after primary Total knee arthroplasty: a prospective cohort study. J Arthroplasty. 2017;32(1):92–100.e2. doi: 10.1016/j.arth.2016.06.009.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅