The ability to accurately predict incidences in health care is something many providers need. When I compare this abstract to what I know about predicting outcomes, there are similarities between models. The patient factor models that include very few patient factors have poor capability to actually predict.

It seems when it comes to predictive models thoughtful consideration about the various factors that may truly affect the outcome need to be included in the model. In this particular study use of corticosteroids was a component increasing predictive capability.

For the model in this study, what is helpful for you is to keep your eye on your patients who have had a replacement due to rheumatoid arthritis – probably because of the prescribed corticosteroids for the condition. At the same time, for anyone undergoing elective joint replacement surgery that has certain comorbidities, you will need to keep your eyes open for infection.

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The abstract is included below for you to review.

Identification of high-risk groups for complication after arthroplasty: predictive value of patient’s related risk factors.

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I am sure that many of us provide care to people who have had a joint replacement. I wish that our brains could accurately recall each of our patients.

I believe that the apps have a bit more importance than just pre and post-operative education and tracking. Research is pointing to the importance of being active far sooner than when osteoarthritis is seen. And then, even when someone has osteoarthritis, it is still important to be active. It seems research is indicating that the lack of physical activity may be playing a large role in occurrence rates. It seems to me there could be a way to somehow harness that research to pull into an app to help track, motivate and increase efforts to change behaviors before the situation reaches a need for a joint replacement.

As I read the news about the current study between Apple and Zimmer Biomet, I found it interesting that surgeons may play the main role with regard to who the patient will be able to communicate. As a physical therapist, as I think about the patients who don’t quite do as well, most may not have been zealous with stretching their joint and getting themselves back to life. I am not able to see the full app design via the link, so I hope there has been thought on how to capture that the patient is actually spending time focused on gaining full range of motion. The patients who don’t begin to walk distances or go up and down stairs in a normal manner are also at risk of not regaining full use of their new knee or hip. And for some individuals, targeted education, demonstration, exercises need to be provided to help the person get rid of their limp. I’m not quite sure how an app might be able to provide the individualized feedback to help the person perform quality movement patterns. Technically it isn’t unless it merges with a video platform that can see a patient move and qualify the movement pattern.

It seems that combining this wearable technology with the app being designed by Apple and Zimmer Biomet might have a bit more value. The ability to combine the majority of the patient needs into one package seems more helpful and ties everything together for the patient. Again, the biggest question: which patients need the technology to help them be successful.

I’m not sure the surgeon will really be the professional who truly cares or even wants to spend time thinking about the patient’s day to day activity level. It seems that a physical therapist would have more stake in not only analyzing the date, but also advising on activities. I am finding it more and more interesting to learn a patient’s perspective of doing a lot of walking. Some patients think “a lot” of walking is 1,000 steps.  When I look at research to help me define activity levels based on steps: <5,000 steps is sedentary. So, yes, I can see a disconnect between “a lot of steps” and what is really necessary to have a person be considered physically active. I also think that as wearables become more commonly used with the majority of our patients, we have the opportunity to help educate on acceptable, healthy targets so the patient really is exceeding sedentary status.

Until next time,

~Selena

The post Can a Smart Watch Help with Faster Recovery after a Joint Replacement appeared first on FOTO Patient Outcomes.

It seems we are all scrambling to meet the various needs of those we interact. Our first responsibility is to the patient. Each patient is a bit different and has slightly different needs. I believe we always need to determine the best way we can fulfill the patient’s needs.

For example, with the pressure to provide value and cheaper care, we need to stay aware of new options as they become available to us. As new options become available to us, we aren’t going to have evidence be a guide for our care delivery – we will need to design our own screening processes to determine which patients a new option is appropriate. We will also have to have strategies in place to evaluate whether implementing a new option in care delivery is not only feasible but also whether it really changes anything. The biggest factor, if you place the patient in the center and forefront of care, is whether the new option was truly beneficial for the patient.

I recently came upon a company called Claris Reflex.  My attention was perked. Right now I have a “smart” treadmill that interfaces with a tablet. I am able to have all sorts of data at my fingertips about how my patient performed during the session. The patient is able to have immediate feedback on performance. I am able to provide functional goals and the patient is far more easily able to learn the movement pattern working with the devices than I have ever been able to do with verbal feedback or manual cues. There is also an opportunity to save a session and print it or add it to the patient’s medical record.

The focus of Claris Reflex is knee joint replacement care. There are already some bundled care initiatives and if joint replacement care becomes bundled across the board, everyone caring for these individuals may be looking at ways to improve outcomes. If most physical therapists are like me, then you all worry about the progression of gaining motion after the replacement. Patients are definitely able to do their home exercise program to increase their motion. The biggest problem is that some patients are a bit fearful and really aren’t willing to move their knee into a bit of discomfort for fear of damaging the knee. Another problem is that for some patients as they gain more and more motion, yet are not quite at the 120 degrees of flexion, they don’t have an accurate way to know they still have more motion that needs to be acquired. The same thing happens for some patients who have not felt their knee go straight in forever and their ability to determine their knee is straight is not accurate. I liked what Claris Reflex had to offer for those patients. 

So the question then becomes, how do we adapt our care to the opportunities that technology allows us to take? I mean, I know that every patient I treat does not need remote monitoring. How much time is acceptable to allow a patient to independently manage their care? When is the best time to introduce patient remote monitoring? What does it do to patients mentally and their pride of achieving if remote monitoring becomes a standard of care? I guess what I mean by this is that there are a lot of patients who do take pride in independently doing the work to achieve. I wonder if introducing technology for everyone without considering the individual will have negative ramifications. 

I definitely appreciate technology. It seems we will need to take some time to do some thinking before automatically bringing technology into the care.

• Which patients are the ones that need remote monitoring – which patients are at risk of failing to achieve results?
• Does the benefit outweigh the cost of the technology?
• Could there be detrimental effects using the new technology?
• How does the clinician’s role change?
• Are processes in place to help the clinician succeed as the new technology is implemented into practice?

We are going to see more and more options for remote monitoring. I think we need to have conversations in our heads and also within our organizations to help determine the best patients to incorporate this kind of intervention.

Until next time,

~Selena

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In order to share my thoughts, I read found the studies that led up to this particular study. Initially the researchers proposed a clinical trial to compare behavioral support to usual care after a total knee arthroplasty. The study was completed in August 2012, yet no results are posted for review. The proposal included the use of the WOMAC and also functional tests. I couldn’t find a final published study that put the two interventions head to head.

I can find the feasibility of using phone calls and coaching interventions to use as an option for individuals who have recently underwent surgical intervention for a total knee arthroplasty.

The group of patients in the above study that were randomized in the above study to usual care – either outpatient physical therapy services or home health services – were analyzed for the utilization of services. The study also focused on determining what kind of care was provided. The study provided pre-WOMAC scores, but did not provide any post-WOMAC scores.

This current study that includes the exact same group of patients in the usual care arm the first clinical trial focuses on the lack of detail provided in documentation to truly note the details of the exercise interventions. The study fails to provide details on the actual outcomes of care (the WOMAC, the mental and physical components of the SF-36), the actual results for the timed stair climb and the amount of knee flexion attained, in order for a clinician to analyze the final results. The researchers did not provide the minimal clinically important difference for any of the outcome measures. As I reviewed the types of exercises, I saw that biking was not included in the study. I don’t understand how it lacked sufficient detail for it to be excluded as an exercise.  The study also ignored the importance of a home exercise program. The activities performed in the clinic during a treatment session are not the only aspect that helps a patient attain outcomes after a total knee arthroplasty. 

I believe the biggest take home message is not related to outcomes of care as much as documentation of care. The exercise, dose and progression need to be easily noted by anyone reviewing records.  Without the actual raw data on the outcomes of care (both patient reported and functional), I have no way to truly know if optimal outcomes were actually achieved.

You’ll find the abstract to the recent study below.

Characteristics of Usual Physical Therapy Post‐Total Knee Replacement and their Associations with Functional Outcomes

Abstract

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I know from the upcoming report, Data Trends in U.S. Healthcare and Patient Rehabilitation – Focus Patient Characteristics, Patient Outcomes and Clinical Performance, that many patients present for services with a knee problem.

I realize that total knee replacements are costly. I also realize surgical risks are real. In all honesty, I really don’t understand the spectrum of patients I have seen who have knee osteoarthritis. To feel a knee loaded in the weightbearing position that creaks and grinds with that deep bone sound causes me to internally cringe. As much as possible I focus on the patient’s perception of their situation versus my internal cringing. There is no reason to get overly concerned when the patient only verbalizes annoyance of the sensation. On the opposite end of the spectrum are individuals who appear to have nicely aligned joints, no swelling, no crepitus. Some of these individuals report severe knee pain.

The study I recently found might be somewhat helpful in providing advice. I am a tad confused with this study because half of the subjects were surgical candidates and the other half were not.  I suppose I need to read the full article to have a better idea in my head about the results of the study.

You’ll find the abstract below.

Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials.

The post Knee Osteoarthritis: Replacement Surgery or Conservative Care? appeared first on FOTO Patient Outcomes.

A few weeks ago a funeral was held for a young man who died of a heroin overdose. He was my niece’s fiance. He had attended many family functions over the last 5-6 years. He died at the age of 27. The family worry now revolves around our niece – her feelings, how she is emotionally handling the loss, her “friends” and how they will “support” her, and our ability to be helpful while not enabling. We also have thoughts of the unknowns: we hope she isn’t using, yet we know she is in an environment in which heroin is available. From this one experience, I have met quite a few people who have lost a loved one to heroin. I never realized that once a person tries or uses heroin, the urge for more and the addiction are so strong. 

With all my patients who have had total hip or knee replacements, I always take time to discuss pain control. In all honesty, generally speaking, I am not against opioids. I do believe this medication does have a role in pain control as a short term solution. I can only hope that every physician who prescribes an opioid does a thorough screening to ensure that the use of the opioid will be helpful rather than harmful. Even then, patients can choose to lie about an addiction history, so there may not truly be a safe screening process.

I recently read an article in the Frederick, Maryland newspaper. It caught my eye because it focused on the option of no opioids post-operatively. I know from treating many individuals after knee replacements that the pain seems to be the greatest the first week after surgery. Every patient may not be a candidate for no narcotics – it seems this would be based on a case by case situation. 

The protocol that the surgeons included the injection of Exparel around the joint. The medication provides post surgical analgesia that seems to last about 72 hours. The surgeon also implanted a pain pump into the thigh. This was used for the first few days after surgery.

The other intriguing aspect within the article was the reference to “physical therapist as navigator” model. 

Physical therapists seem to be the conduit bringing everything together.  About a month prior to surgery, a physical therapist meets with the patient to perform a home safety assessment and to ensure the patient is good surgical candidate. Physical therapy services begin in the home the first week after surgery. Physical therapists are coordinating with the surgeon, the anesthesiologist and the patient on the best plan for treatment.

You may begin seeing more and more patients not prescribed a narcotic after having a joint replacement. In the mean time, do you have processes in place to educate your patients about how to decrease the use of a narcotic when it has been prescribed? Are you able to set realistic expectations so patients are able to slowly eliminate the narcotic from their daily lives? And most importantly, do you follow up to ensure your patients are no longer taking narcotics when the medication is no longer truly necessary?

Until next time,

~Selena

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