Defining Components of Physical Therapy Achieving Maximum Function after TKR

摘要 全膝关节置换术(TKR)是最常见和最昂贵的住院患者，术后功能结果各不相同 程序。虽然手术后物理治疗(PT)是围手术期护理的常规处方，但实际情况是 提供给患者的PT内容差异很大，对于PT的类型、数量或强度还没有达成共识 跟随TKR。2016年，联邦医疗保险将在67个城市实施强制性捆绑支付TKR 在全美范围内，要求外科医生和医院负责TKR后的所有费用，包括物理治疗。 这些经济激励措施可能会改变TKR术后的物理治疗服务，而不是清楚地了解 改善患者预后的特定PT组件。我们最近对50名PT患者进行的回顾研究 在一个地理区域的治疗地点记录了运动类型和 进展和更大的功能结果。临床试验表明，肌肉强化和 功能锻炼改善了TKR后的功能结果，但这些研究的概括性是 有限的。相反，基于实践的研究允许分析大患者PT实践的可变性 对PT护理、患者参与和功能结果之间的关联进行抽样和评估。 我们建议对嵌入国家TKR队列(FORCE-TJR)的TKR患者进行PT队列研究，以 收集360名接受TKR治疗的患者的所有物理治疗后护理的具体细节，这些患者接受了大约60例 在三个地理区域。基线患者属性和结果测量通常收集在 强制数据。这些数据将扩大到包括动态PT干预细节以及 患者参与家庭锻炼和体力活动的情况。一个基于Web的数据捕获系统，供 物理治疗师和患者将收集物理治疗运动量、类型和强度的详细信息 以及患者在康复过程中的参与度。本研究的目的是：(1)量化 门诊PT成分的变化和强度的进展，以及患者在家中参与的 多中心前瞻性样本的TKR后规定的康复活动；(2)确定PT 与患者在6个月和12个月以及膝关节报告的最佳功能结果相关的组件 在TKR后6个月进行绩效评估；以及(3)设计和部署基于Web的决策支持工具 根据这些分析来预测TKR术后的功能结果，包括患者的术前因素， 患者参与度和PT组件，以加强最佳PT实践和患者在家 参与。我们假设一组潜在的可修改的PT练习组件，如更高的 闭链运动的次数和运动强度的进步将与 在根据患者的社会人口学和性别因素进行调整后，功能和表现结果得到更好的改善 合并症因素和患者坚持每天在家参加体力活动将改变 PT假体对6个月后膝关节性能和功能的影响。统计建模将检验 PT的时机、内容和强度以及包括康复在内的患者人口统计学和临床因素的作用 参与解释TKR术后功能结果的变化。多头的预测模型 基于PT和患者因素的长期功能结果将确定PT的可修改因素 有助于获得最佳功能结果的干预。 这项研究产生的数据和知识将为预期的设计和内容提供参考 在有功能获得不良风险的患者中进行TKR后最佳操作PT的随机试验。此外， 随着政策制定者和临床医生努力控制不断上升的社会总成本，知识是及时和必要的 膝关节置换手术，同时确保最佳的患者结果。

ABSTRACT Functional outcomes vary following total knee replacement (TKR), the most common and costly inpatient procedure. Although post-surgical physical therapy (PT) is routinely prescribed in perioperative care, the actual PT content delivered to patients varies widely, and no consensus exists for the type, amount or intensity of PT following TKR. In 2016, Medicare will implement mandatory bundled payment for TKR in 67 municipalities across the U.S. making the surgeon and hospital responsible for all post-TKR costs, including physical therapy. These financial incentives may alter post-TKR physical therapy services without a clear understanding of the specific PT components that improve patient outcomes. Our recent retrospective study of PT care from 50 therapy sites in one geographic region documented a significant association between exercise type and progression and greater functional outcomes. Clinical trials demonstrate that muscle strengthening and functional exercises improve functional outcomes following TKR but the generalizability of these studies is limited. In contrast, practice-based research allows analysis of the variability of PT practice in a large patient sample and assessment of the association between PT care, patient participation, and functional outcomes. We propose a PT cohort study of TKR patients embedded within a national TKR cohort (FORCE-TJR) to collect specific details of all post-TKR physical therapy care from 360 patients treated by approximately 60 PTs in three geographical areas. Baseline patient attributes and outcome measures are routinely collected in the FORCE data. These data will be expanded to include the ambulatory PT intervention details as well as the patients’ participation in home exercise and physical activity. A web-based data capture system for use by physical therapists and patients will collect details of amount, type and intensity of physical therapy exercise and amount of patient participation in the rehabilitation process. The study aims are to: (1) Quantify the variation in outpatient PT components and progression in intensity, and the patient’s in home participation in prescribed rehabilitation activities following TKR in a multi-center prospective sample; (2) Identify PT components associated with optimal patient-reported functional outcomes at 6 and 12 months and knee performance measures at 6 months after TKR; and (3) Design and deploy a web-based decision support tool to predict functional outcome after TKR based on these analyses, to include patient pre-operative factors, levels of patient participation, and PT components to reinforce best practice PT and patient in-home participation. We hypothesize that a set of potentially modifiable PT practice components, such as a higher number of closed chain exercises and progressions in exercise intensity, will be positively associated with better gain in functional and performance outcomes after adjusting for patient sociodemographic and comorbidity factors and that patient adherence to daily at-home participation in physical activity will modify the effects of the PT components on knee performance and function at 6 months. Statistical modeling will examine the role PT timing, content and intensity and patient demographic and clinical factors including rehabilitation participation play in explaining the variations in functional outcomes following TKR. Predictive models of long term functional outcomes based on both PT and patient factors will identify modifiable factors of the PT intervention that contribute to optimal functional outcomes. The data and knowledge generated by this study will inform the design and content of a prospective randomized trial of best practice PT after TKR among patients at risk for poor functional gain. Moreover, the knowledge is timely and essential as policy makers and clinicians work to control the rising societal cost of total knee replacement surgery, while assuring optimal patient outcomes.