REHABILITATION AFTER TOTAL HIP AND KNEE REPLACEMENT: PROBLEMS AND PERSPECTIVES Ratmanov M.A., Benyan A.S., Kuznetsova T.V., Borkovskiy A.Yu., Barbasheva S.S.
Samara Regional Clinical Hospital named after V.D. Seredavin,
Samara State Medical University, Samara, Russia
One of the objectives of WHO global disability action plan is initiation and development of rehabilitation services. Currently, some countries have called for support for development (extension) of rehabilitation services. The importance and attention to problems of rehabilitation are determined by general understanding of disability issues, role and place of restorative treatment in healthcare system. To achieve the objective of initiation of rehabilitation system, the important initial step is clarification of degree of participation and involvement of governing boards in this mission, determination of precise elements of management, and use of systematic approaches in estimation, analysis and synthesis of organizational solutions [1, 2]. It is considered that the modern concept of rehabilitation will be evenly distributed in facilities of federal and private financing and management [3].
Methodological aspects of initiation of rehabilitation system for patients after replacement of big joints of the lower extremities are currently presented by some precise and concrete directions within the plane of solution of organizational, regulatory, medicodiagnostic and quality-control issues. The key aspects are: 1) initiation of rehabilitation sites; 2) implementation of fast rehabilitation approaches; 3) improvement in the pre-rehabilitation stage; 4) estimation of rehabilitation efficiency; 5) rehabilitation digitalisation. The conducted literature review has the aim of objective estimation of the modern status of rehabilitation system after joint arthroplasty, as well as assessment of problems and perspectives of improvement.
Initiation of rehabilitation platforms
The basic issue in initiation or improvement of the present rehabilitation systems is foundation of a platform for realization of programs for postsurgical rehabilitation management. A solution on selection of a place, time and a type of rehabilitation is based on variety of external and internal factors, which often are beyond the borders of healthcare system jurisdiction and require for inter-institutional interaction. For estimation of possibilities of implementation of rehabilitation system, Gutenbrunner C. et al. developed a check-list and a questionnaire with examination and monitoring of such aspects as a country profile, healthcare system, disability and rehabilitation, national politics, laws and responsibilities, non-governmental concerned parties [4].
Currently, rehabilitation is more often conducted with beds in orthopedic units and centers, and very rare − in outpatient clinical conditions. Some rehabilitation modules have appeared, which are based on telemedicine consultations and virtual management of the patient. According to a statistical study in USA in 2016, which was oriented to rehabilitation routing of patient after knee and hip replacement, about 18-21 % of patients are discharged to home immediately after surgery, 34-38 % of patients are cared and observed at home, 31-35 % visit facilities of extensive care, and only 10-13 % receive inhospital rehabilitation [5]. Jansen E. et al. consider the following indications for inhospital rehabilitation: realization of two single-step arthroplasty procedures, revision surgeries after previous hip or knee arthroplasty, presence of postsurgical complications, older age, concurrent diseases influencing on the rehabilitation process, social difficulties, need for adaptation to environment, insufficient level of outpatient management of such patients [6]. The importance of inhospital rehabilitation procedures is accentuated in a study by Larsen J.B. et al. They performed 3-week hospital course of multimodal personalized rehabilitation for patients after knee joint replacement and showed significant improvement in results and a decrease in recovery time in patients with normal postsurgical course and with various surgical complications [7].
At the same time, the staged rehabilitation presents the most balanced approach, which considers all possible clinical, organizational and socioeconomic factors influencing on final results [8]. Continuity and stage-by-stage approach for rehabilitation should include maximal objectification of results of each stage and monitoring of movement. Therefore, the classical three-stage rehabilitation model can be modified to some degree, but with obligatory preservation of the inhospital rehabilitation stage in a special department or center [9].
Formation of the multidisciplinary team (MDT) is one of the key moments in creation of rehabilitation system. The requirements to MDT specialists should be clearly described and realized. Despite of the fact that the platform for MDT activity is the coordination center in outpatient polyclinical conditions, all specialists should have constant inhospital practice. This requirement is especially important for operating trauma surgeons and anesthesiologist-intensivists. The main ideological direction for MDT activity is consideration of the problem of surgical replacement through the rehabilitation prism since pre-rehabilitation (the complex of procedures for health improvement and for further rehabilitation prognosis) is to be initiated long before future surgery, and the rehabilitation medicine methods are used for the final stage of treatment program [10].
Development of the system for rehabilitation of patients after joint arthroplasty is closely related to revision of approaches for selection and formation of registry of patients for surgical treatment. The rehabilitation aspect, as well as indications for surgery and estimation of tolerance of an intervention is the key factor in redesigning of the present registries and for provision of processes of regular revision and continuous monitoring. Estimation of each candidate for arthroplasty from the perspective of a rehabilitation specialist will promote the improvement in management of the whole program, including the techniques of surgical and conservative management, psychological and social preparation.
Implementation of Enhanced Recovery After Surgery
The importance of development of national programs for implementation of Enhanced Recovery After Surgery (ERAS) in medical facilities is supported by the data from countries with different level of healthcare [11]. The opinions on need for rehabilitation are quite similar and do not require for further discussion. Also the appropriateness of use of fast recovery techniques is not doubtful. Currently, there is a reliable basis of evidence of efficiency of fast rehabilitation from both medical and socioeconomic points of view [12]. Most authors note that it promotes the ideology of rehabilitation, as well as minimizes the negative effects of surgical management such as thromboembolic and infectious complications [13].
The change in the common hospital model of treatment with Fast Track Surgery is characterized by higher level of medical techniques with lower time intervals. Moreover, by the moment of discharge, all recourse-consuming surgical and anesthesiological procedures must be completed [14]. It determines the decrease in hospital period, and, for the first sight, provides the positive economic balance for facilities in relation to ratio of real costs and issued invoice for an insurance event. However, some known difficulties can appear during interaction with territorial organs of obligatory medical insurance. Reduction of hospital stay can cause some specific requirements for decrease in costs for arthroplasty owing to small amount of bed-days and incompleteness of an insurance case. A cause of preservation of charges is strict and complete realization of standards according to the actual clinical recommendations, and structuring of charges with clear distribution of costs into treatment and hospital stay. Although of the economic side of the issue should not be decisive for determination of a type, terms and a rehabilitation platform, the foundation for realization of clinicoeconomic conjunction is different resource intensity of hospital, outpatient clinical and telerehabilitation, resulting in combination of systemic and personalized approaches [15].
It is obviously that ERAS presents the continuous process, which begins from the moment of the first consultation by orthopedist and with estimation of a patient for realization of Fast Track. The check-lists allow statistical estimation of the use/realization of components of the program, but do not show the time course of the patient's condition, and a relationship with the rehabilitation routing scale. Distribution of Fast Track concept to all stages of consulting, diagnosis and treatment provides fast rehabilitation and, at the same time, standardization of management with use of the personalized approach.
Improvement in pre-rehabilitation stage
ERAS concept is closely related to the stage of presurgical testing and planning of the treatment program. The important moment is correct selection of patients for ERAS. To prevent complications of planning of ERAS for single patients, it is preferred to conduct the testing and estimation of compliance at the initial stage of curation. According to A.M. Ageenko et al., arterial hypertonia was the single presurgical predictor of prolonged hospital stay after arthroplasty with Fast Track. Also the common causes of delayed discharge are pain, dizziness and general weakness. To prevent these complications and to realize the possibilities for early mobilization, the authors recommend preliminary preparation and positive mindset in the presurgical period [16].
Pre-rehabilitation for patients with planned Fast Track is more critical since early mobilization can be provided with good presurgical preparation and mindset of the patient. The modern trends show a decrease in postsurgical period. According to this reason, preparation and training for most components of rehabilitation must be realized in the presurgical period. The main components of the pre-rehabilitation program include correction of somatic pathology, particularly, arterial hypertension and excessive body mass, sanitation of chronic foci of infection, mental preparation for correction of anxiety and neurotic disorders which often appear at the background of feeling of uncertainty, helplessness and fear of narcosis and surgery [17]. However, despite of understanding of multiple causes and consequences of insufficient pre-rehabilitation, there are not any full-volume and efficient forms of pre-rehabilitation [18].
Participation of patients and their relatives in the rehabilitation process is one of the primary components of Fast Track. Along with estimation of patient's compliance, it is necessary to arrange continuous bilateral connection for optimization and improvement of forthcoming and subsequent rehabilitation courses. Jansson M.M. et al. offers estimation of 8 criteria: selection of patients, provision of warrant of medical services, routing, care after hospital discharge, consulting, understanding of processes, quality of communications, presence of feedback [19]. The attention should also be given to the project of clinical protocol for pre-rehabilitation offered by Svinoy O.E. et al. Its aim is confirmation of significance of the role of pre-rehabilitation for achievement of the final result [20]. A study by Tanzer D. et al. shows the influence of presurgical training and correction of patients' expectations on outcomes of arthroplasty, as well as importance of planning of early discharge before surgery and in the hospital [21]. Obviously, patients' fear of fast discharge also slows down his/her movement activity. It is especially common for older patients with problems of self-care before surgery. Owing to concurrent diseases, which worsen the general well-being, they initiate activity only on the days 3-5 after surgery. The long term bed rest significantly increases the rehabilitation period and worsens subsequent prognosis. It can be accompanied by such effects as myopathy, respiratory disorders, oxygenation tissue decrease, increasing risk of thromboembolic complications [22].
Estimation of efficiency of rehabilitation
International classification of functioning (ICF) is used for uniform estimation of criteria when describing the structures, functions, vital activity and medium factors. All-sided description of functioning allows making the rehabilitation diagnosis, resulting in possibility of determination of the objective, tasks and individual program of medical rehabilitation, and its efficiency. The basic notion of ICF is deviation, which is used for designation of statistically significant variance from statistical norms. The description of the problem with use of ICF codes allows precise description of actual problems of the patient, but ICF is not a scale, and it does not measure disorders [23].
Monitoring and estimation of efficiency of rehabilitation are based on the use of high amount of scales and tests. The most common ones are stair climbing test (SCT), 6-minute walk test (6MWT), Timed Up and Go test (TUG), WOMAC (Western Ontario McMaster Universities Osteoarthritis Index). Unification of assessment criteria, and combination of results in the uniform information system will promote formation of the universal rehabilitation program, which provides availability and quality of medical care for all patients [9].
In the domestic studies, and in the pilot project "Development of system for medical rehabilitation in the Russian Federation" (2015), the most common scales were Modified Renkin Scale (estimation by traumatologist), Harris and Leken score (estimation by remedial gymnastics specialist), hospital score of anxiety and depression (estimation by psychologist). Additionally, hip circumference data, goniometry, 6-point strength scale, 6-minute walking test, visual analogue scale of pain, EQ-5D. Mental status is estimated with Spilberg, Z-SDS and Glosman scores [24, 25, 26]. Generally, the use of the scales allows integral estimation, assessment of efficiency of rehabilitation and can be used for making of individual program of rehabilitation [27].
Estimation of rehabilitation efficiency also supposes the indication and validation of criteria influencing on the disease course and treatment results. According to a Danish study (2008), some features were found, which influenced on postsurgical period duration: age, gender, transfusion need, first mobilization time, patient's satisfaction[28]. Guler T. et al. consider patient's age and basic values of functional tests as the main positive predictors of improvement in functioning of the operated extremity [29].
The important moment is not only estimation of rehabilitation quality, but also assessment of quality of rehabilitation organization. Monitoring and analysis of feedback are used for this purpose. The rehabilitation monitoring is directed to identification of and fixation of physical activity volume in pre- and postsurgical period, as well as to logistics and routing of patients. Implementation and wide use of movement activity transducers provides the possibility for continuous monitoring and time course of patient's recovery, and promotes the clinical estimation of rehabilitation effects [30].
Rehabilitation digitalisation
The modern methods of communication and information exchange make the important contribution to development of telerehabilitation system. Lebleu J. et al. studied recovery of physical activity with use of fitness bands in patients after arthroplasty. The program included daily instructions for exercises in tablet computers, and monitoring of feedback through fitness bands. The use of telerehabilitation allowed achievement of presurgical physical activity after 7 weeks from surgery [31].
The efficiency of telerehabilitation is reported by Chughtai M. et al. They performed virtual consulting and monitoring of 157 patients in home conditions and showed a decrease in need for physician visits, positive time trends of decreasing intensity of pain and increasing functional activity. The authors accentuate the role of various modules and scores, and patients' data analysis [32]. Russell T.G. et al. accentuate the need for adherence to modern technologies as the important factor of equivalent results of on-site or virtual rehabilitation [33]. The authors declare the increase in availability of rehabilitation, especially for patients living in remote areas.
Jiang S. et al. conducted a systematic review and meta-analysis of efficiency of traditional rehabilitation in conditions of modern facilities, and telerehabilitation in home or outpatient conditions after total knee joint replacement. The authors found that pain correction and achievement of targeted values of WOMAC show comparable clinical results in relation to extension of range of physical activity and quadriceps strength increase. The telerehabilitation results showed a statistically significant improvement [34]. Shukla H. et al. received similar results after analysis of four prospective randomized studies [35]. High satisfaction of patients with rehabilitation techniques was observed. The advantage of telemedicine is mentioned by Fisher C. et al. They perform sessions of video connection with patients 3 times per week during 3 weeks after hospital discharge. During sessions, they carry out navigation of remedial exercises and record results over time [36].
The domestic experience with telemedicine and rehabilitation of patients after arthroplasty is described by Lyadov K.V. et al. They found that the use of remote rehabilitation in home conditions presents the alternative to common rehabilitation techniques and gives similar therapeutic effects and costs [37].
Despite of positive and promising results of telerehabilitation, it is necessary to consider subsequence and a place of this approach in the whole system of telerehabilitation. It is efficient to include this technique into the program already after realization of inhospital rehabilitation − as the stage of end results and continuation of medical control and monitoring of patients. Eichler S. et al. presented a similar model of 3-month telerehabilitation after previous 3-week course of inhospital rehabilitation. A program with 38 exercises with various strength and balance was developed. The program presents logical continuation of inhospital rehabilitation. Estimation of results was conducted with analysis of 6-minute walking test, stair walking test and 5-time squatting and standing up test, SF-36 and others [38].
CONCLUSION
The modern concept of rehabilitation of patients after arthroplasty of big joints of the lower extremities is based on recourse-consuming organizational decisions, practical realization of which require for strict adherence to standards and implementation of new technologies. The important factor is a degree of participation of medical staff and patients in creation and maintenance of the system. The obligatory condition of efficiency of the fast recovery program is required level of interaction between the operating trauma surgeon, patient and MDT specialists of medical rehabilitation (attending physician of rehabilitation department, physiatrist, remedial gymnastics physician and remedial exercise instructor).
The appropriate availability of the above-mentioned specialists should be the basis of organization of regional coordination rehabilitation centers including high qualified MDT specialists. The tasks of the coordination center are estimation of somatic and mental status of patients, preparation at the outpatient stage, control of realization of pre-rehabilitation program, separation of a group of patients with indication of the rehabilitation method (standard, fast, individual). Moreover, the functions of the coordination center include postsurgical follow-up, estimation of rehabilitation potential at each stage of treatment, estimation of need for 24-hour stay in hospital (the stage 2 of rehabilitation) or in a health center (the stage 3 of rehabilitation).
The very important aspect is development of a new information system, which monitors patient's movements at all stages of rehabilitation from primary visit of a clinic. The improvement in interaction between a clinic and a hospital, and information exchange between all participants of the rehabilitation process allow decreasing the amount of patients, reducing the time of waiting for surgical treatment, improving the selection of patients at the prehospital stage and increasing the quality of care.
Therefore, creation of the coordination center along with the medical information system "Rehabilitation" will solve the problem of monitoring of patients, will improve the quality and rapidness of medical care for patients who need for arthroplasty and rehabilitation. Participation of MDT at the final stage of rehabilitation will favor timely response to possible long term complications.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.