Self-Care and Total Knee Replacement

Self-Care and Total Knee Replacement

DeAnn E. Kiefer, MS, OTR/LLynnda J. Emery, EdD, OTR/L, FAOTA

ABSTRACT. The purpose of this study was to examine the gains inself-care and transfer skills of persons after total knee replacement(TKR) and measure the effectiveness and efficiency of treatment. In thisretrospective chart review, 47 patients met the selection criteria during atwo-year period. Baseline and discharge Functional Independence Mea-sure (FIM) subscales of self-care and transfers were compared usingpaired t-tests with post hoc analysis. Effectiveness and efficiency mea-sures were calculated. FIM subscale scores improved 2.29 points onaverage. Statistically significant improvement was made in all eightsubscales where baseline was less than independent level. Improvementin functional performance was made in self-care and transfers with dis-charge ratings at modified independent to independent. [Article copiesavailable for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Functional performance, transfers, older persons, mobi-lity, occupational therapy, physical therapy

DeAnn E. Kiefer is Regional Manager, Therapy Alliance, Cincinnati, OH.Lynnda J. Emery is Professor, Eastern Kentucky University, Lancaster, KY.Address correspondence to: Lynnda Emery, Eastern Kentucky University, Depart-

ment of Occupational Therapy, Lancaster 521/Dizney 103, Richmond, KY 40475(Email: [email protected]).

The authors thank Susan Hart and Jill Blandford Greenwell for their assistance withword processing.

Physical & Occupational Therapy in Geriatrics, Vol. 24(4) 2006Available online at http://www.haworthpress.com/web/POTG

© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J148v24n04_04 51

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With 300,000 total knee replacements (TKR) performed each year inthe United States for end-stage arthritis, many advances in technologyhave occurred in the past 10 years (National Institute of Health, 2003).Rehabilitation therapies typically are initiated by a referring orthopedicsurgeon who performs the procedure on a regular basis in a supportiveenvironment (Katz et al., 2004). Although specific recommendationsfor lower extremity exercises, walking, home modifications, and adap-tive equipment are reinforced by physicians, patients are typicallyreferred for physical and occupational therapy in a rehabilitation center(American Academy of Orthopedic Surgeons, 2004). Today’s practiceenvironment requires researchers and clinicians to examine evidenceassociated with clinical outcomes (Holm, 2000). Specifically, effective-ness and efficiency of inpatient postoperative rehabilitation for kneereplacement is needed (Shepperd, Harwood, Gray, Vessey, & Morgan,1998).

Therapy After Total Knee Replacement

The need for evidence-based practice (Turner et al., 1999) demandsthe continued study of physical and occupational therapy followingTKR. For example, recent reports of research suggest that postoperativecare can be enhanced equally well by cryo-pad technology or lessexpensive compression bandaging (Smith, Stevens, Taylor, & Tibbey,2002). Additionally, physical therapists are advised that early mobiliza-tion and exercise alone following TKR are cost-effective and conti-nuous passive motion (CPM) and slider board (SB) therapy should bereserved for as-needed use (Beaupre, Davies, Jones, & Cinats, 2001).Also, for patients who do not improve with a typical regimen of high-intensity strengthening, electrical stimulation can help the patientimprove (Lewek, Stevens, & Snyder-Mackler, 2001).

Using consensus, a panel of experts attained 70% agreement on totalknee replacement physical therapy protocols (Enloe, Shields, Smith,Leo, & Miller, 1996). Protocols range from only walking patients tocomplete instruction in specific exercises and functional activities.These programs include gait training, transfer training, exercises, homeprograms, and functional training activities. Continued rehabilitationfor endurance should be performed several times a week using low-loadactivities like swimming, cycling, and possibly power walking (Kuster,2002). For the more disabled or frail elderly, measuring progress afterTKR is enhanced using a Timed Up and Go test in addition to gait time(Freter & Fruchter, 2000).

52 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

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Understanding improved quality of life after knee replacement re-quires researchers and clinicians to consider the total functional andsocial burden for patients (Paterniti & Price, 2002). Based on resultsfrom interviews, patients’ diaries, and standardized measures of qualityof life, researchers suggest that problems with self-care and mobilityundermine perceived quality of life. A qualitative method to examinecircumstances around rehabilitation is recommended. Likewise, therewas a statistically significant direct relationship between having pur-pose in life and better mental health after TKR (Smith & Zautra, 1999).Additionally, active coping contributed to better physical health afterTKR. Given this, occupational therapists should emphasize purposefulactivities. In early stages of intervention, this includes self-care skillslike dressing, grooming, bathing and sufficient mobility to performthem. Similarly, self-efficacy was the sole predictor of outcomes, ac-counting for 8% to 33% of the variance in performance indicators(Moon & Backer, 2000). For example, higher levels of self-efficacywere correlated with longer distances in ambulation and more repeti-tions of leg exercises. Consequently, the researchers suggest thatpatients’ self-efficacy beliefs need to be considered more strongly whenplanning treatment.

PURPOSE OF THE STUDY

Establishing the difference that therapy can make on functionalimprovement following TKR is needed to justify service in a cost-con-scious health care environment (Colburn & Robertson, 1997; Freeman& Chambers, 1997; Rogers & Holm, 1994). The purpose of this retro-spective chart review was to examine the gains in self-care and transferskills of patients after TKR using baseline and discharge FunctionalIndependence Measure (FIM) subscales. Additionally, effectivenessand efficiency indicators were explored.

METHOD

Participants

The participants considered for inclusion in this study were patientsadmitted to the rehabilitation unit of a large metropolitan hospital inthe Midwest for a two-year period following TKR surgery. First, a

DeAnn E. Kiefer and Lynnda J. Emery 53

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computer search applied inclusion criteria and identified participantswith TKR diagnostic codes who were over age 60. These charts in-cluded unilateral TKR, including re-operative patients. There were nobilateral TKR, manipulations, or multijoint involvement patients iden-tified in the computer search. Following this initial computer screen,participant charts were manually screened using additional criteria. Ex-clusion criteria produced a cohort of participants without other condi-tions that might influence performance. These exclusion criteriaincluded (1) any neurological condition, (2) present or past physical in-jury causing disability of either upper extremity, (3) upper extremityfracture within two years, and (4) upper extremity sensory deficits. Thisselection process produced 47 participants for this study.

Instrumentation

This study used a retrospective chart review of data. Data collectionincluded measures of function in self-care and transfers (admission anddischarge FIM subscale scores). A widely used functional assessment,FIM was developed in the United States by the Uniform Data Systemfor Medical Rehabilitation (UDSMSR; 1995). Using Rasch rating scaleanalysis to quantify measurement error, clinicians can be confident inthe accuracy of the FIM (Heineman, Linacre, Wright, Hamilton, &Granger, 1994). The FIM has been tested extensively for reliability andvalidity. The interrater reliability of the FIM is high. The total FIMintraclass correlation coefficient was .96 with subtest correlations of self-care .94, transfers .92, and social cognition .89 (Uniform Data System forMedical Rehabilitation, 1995).

Specifically, this study included all six subscales of self-care andthree subscales of mobility (transfers). Additionally, the baseline anddischarge means of the three subscales of social cognition were reportedto screen for cognitive ability. These included social interaction, prob-lem solving, and memory. All FIM raters in this study participated intraining to accurately assess patient status. Interrater reliability of evalu-ators was high.

Intervention

Intervention emphasized methods expected to improve performancein FIM subscales of self-care and transfers. To promote patient care andmeasurement for evidence-based practice, critical pathways are used atthe hospital. Following the acute hospital stay where the surgery was


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performed, patients are transferred to the inpatient rehabilitation unit.Within the inpatient rehabilitation unit, both physical and occupationaltherapy are emphasized to complement rehabilitative nursing.

In this study, intervention for physical and occupational therapy was90-120 minute sessions per day for each therapy. This was for five toseven days per week. Intervention directed toward the FIM subscalesused in this study emphasized: self-care training, adaptive equipmenttraining, caregiver training, functional mobility training, compensatorytechniques for self-care, and lower extremity range of motion. In thesession prior to discharge, guidance was provided on home and workmodification and community and work reintegration training. Physicaltherapy for locomotion was outside the scope of this study.

Data Collection and Analysis Procedures

A data collection form was developed to assist with efficient and ef-fective data extraction from medical records and to facilitate use of soft-ware. The Institutional Review Boards at the collaborating universityand the hospital reviewed and approved the study. Computer screeningfor a two-year period produced 120 client records. These patient recordswere then reviewed using the inclusion and exclusion criteria; thisproduced 47 charts for this study. Data were collected from each partici-pant’s medical record onto the form. No participant or provider identi-fying information was collected. The information entered into the SPSSsoftware was subjected to random checks to ensure accuracy of dataentry and storage.

Database and SPSS statistical software were used to analyze data.Analysis included inspection of distributions, calculation of means,standard deviations, and paired t-tests. Given use of multiple pairedt-tests, post hoc analysis for correction of type I error was performedand statistical consultation was obtained. Rejecting a true hypothesis isknown as a type I error and to reduce this, a more stringent significancelevel can be considered. Statistical significance was established at p � .05with p � .01 also reported. Examination of findings included the Dunnmethod of multiple comparisons using Bonferroni inequality for deter-mining the critical value of t (Glass & Hopkins, 1984).

Baseline and discharge data were also examined in terms of effec-tiveness and efficiency. Effectiveness is the extent to which desiredresults are attained (Abramson, 1988). On each FIM subscale effective-ness was examined (discharge score minus baseline score) divided bypotential improvement (maximum score on the scale minus baseline


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score), multiplied by 100 to give percent (%) effectiveness. Effective-ness is expressed as a percentage. This is the percentage of actual im-provement that occurred; 100% indicates that a maximal score (7) wasattained on a FIM subscale.

Efficiency is the balance between the results and the resource expen-diture to achieve them (Abramson, 1988). Efficiency is calculated bychange in FIM subscale score (discharge score minus baseline score)divided by length of stay (LOS) in days. The efficiency rate measuresthe average actual improvement that occurred on a FIM subscale perday. A relative efficiency score is the percentage of resources used dur-ing rehabilitation, on average that is directed toward improvement on anFIM subscale. These percentages provide a method to compare the rela-tive magnitudes of the rates that were calculated.

RESULTS

Participants

The average age of the participants was 71.2 years. A descriptionof participants is in Table 1. The cognitive composite score from FIM


TABLE 1. Description of Participants

Variable Percentage

Gender

Male 26

Female 74

Handedness

Right 92

Left 6

Ambidextrous 2

Work status

Retired 96

Not retired 4

Discharge status

Caregiver at home 68

Home alone 30

To assisted living 2

Note: N = 47.

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indicated that all participants were independent, on average, when thestudy began (M = 6.87; SD = .65). In this study, patients were admittedto the inpatient rehabilitation unit on average of 3.3 days after surgeryand they remained on the unit an average of 6.4 days.

Differences Between Initial and Discharge Scores

The mean baseline and discharge FIM subscale scores are presentedin Table 2. At baseline, participants scored highest in and were inde-pendent in eating and in cognition. No additional statistical contrastswere made on these two FIM subscales. Grooming (M = 5.02) and up-per body dressing (M = 4.91) scored similarly at baseline and requiredonly supervision for task completion. The lowest performance at base-line was in tub transfers (M = 1.80) at the maximal to total assist level.The greatest variability in baseline scores was in tub transfers (SD =1.34).

In addition to baseline, Table 2 presents discharge scores and pairedt-tests measuring significant improvement. Improvement on FIM


TABLE 2. Baseline to Discharge Improvement in Self-Care and Transfers

FIM subscale Baseline Discharge Paired t Significance

Mean SD Mean SD

Self-care

Eating 6.91 .41 6.95 .29 NC NC

Grooming 5.02 .90 6.78 .69 –14.88** .001

Bathing 3.87 .54 5.93 1.11 –13.20* .031

Upper body dressing 4.91 .69 6.72 .83 –14.15* .019

Lower body dressing 3.65 .87 5.91 1.17 –14.69** .001

Toileting 4.12 1.17 6.51 .95 –13.73** .007

Mobility

Bed, chair, W/C transfer 3.72 .93 6.55 .95 –20.15** .001

Toilet transfer 3.82 .96 5.97 .71 –16.21** .002

Tub, shower transfer 1.80 1.34 4.87 1.66 –11.23* .012

Cognition composite 6.87 .65 6.91 58 NC NC

Note: N = 47. *Denotes significance at p < .05. **Denotes significance at p < .01.NC = Not Calculated. Significance includes post hoc analysis.FIM Scale: 1 - total assist, 2 - maximal assist, 3 - moderate assist, 4 - minimal assist,5 - supervision, 6 - modified independent (device), 7 - complete independent.

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subscale scores was 2.29 points, on average, with significant improve-ment in all categories. The greatest improvement was in tub (3.07) andbed (2.83) transfers. Statistically significant improvement provided fordischarge ratings at modified independent (6) to independent (7) in self-care subscales. Variability among patients at discharge was at one-levelon the eight subscales, on average. Specifically, the greatest variabilitywas in tub, shower transfers (SD = 1.66) and the smallest in grooming(SD = .69).

Effectiveness and Efficiency Indicators

Effectiveness of treatment was 75.6%, on average, with tub transfersthe lowest (59.0%) and grooming the highest (88.9%) (Table 3). Effi-ciency rates, the actual improvement that occurred in one day, are high-est with lower extremity and mobility skills. The relative efficiencyscores reflect the average percentage of resources used with tub trans-fers highest at 16.8% resource utilization. Grooming and upper bodydressing had the lowest relative efficiency scores at 9.8% each.


TABLE 3. Effectiveness and Efficiency Indicators

FIM Subscale % Effectiveness Efficiency Rate Relative Efficiency

Self-care

Eating NC NC NC

Grooming 88.9 .28 9.8

Bathing 65.8 .32 11.2

Upper body dressing 86.6 .28 9.8

Lower body dressing 67.5 .35 12.2

Toileting 83.0 .37 12.9

Mobility

Bed, chair, W/C transfer 86.3 .44 15.4

Toilet Transfer 67.6 .34 11.9

Tub, shower transfer 59.0 .48 16.8

Cognition - composite NC NC NC

Note: N = 47. NC. Denotes “Not Calculated” due to non significant difference. Percent Effective-ness = actual improvement; percent of total improvement if maximal scores had been attained.Efficiency Rate = average actual improvement that occurred in one day. Relative Efficiency Score =percent of resources used on average; column total = 100%.

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DISCUSSION

Outcomes in this study suggest that therapy improved performancein self-care and transfer skills. FIM subscale scores improved 2.29points on average. The discharge mean of all subscales (M = 6.49) sug-gests modified independence or independence, on average. These pa-tients were discharged home alone or with a caregiver with only oneexception. The attained performance levels were compatible with theirdischarge plans. Patients in this study were of better health and demon-strated achievement consistent with the results of Paterniti and Price(2002) and Smith and Zautra (1999).

Indicators of effectiveness and efficiency reflect positive outcomesof treatment. The six and one-half day average length of stay in the reha-bilitation unit was productive. These findings are similar to a recentrandomized controlled trial in their support of inpatient hospital care(Shepperd et al., 1998). In that study, home health care and inpatientcosts were similar following knee replacement.

Statistical consultation suggests that percent effectiveness in thisstudy reinforces that improvement to independent level is not attainedin every subscale prior to discharge. Caregiver education and assistancemay be targeted to these areas. Efficiency indicators provide a place tostart when considering resource allocation. The efficiency indicatorsassume that resources were equally divided across subscale areas in thesame proportions as the improvement. While this may or may not beprecise for a given patient, the measure provides a starting point toexamine where intervention effort was expended.

The literature suggests that there is a need for future research oneffectiveness and efficiency indicators (Turner et al., 1999). There is aneed for future research to compare effectiveness and efficiency indica-tors with actual treatment emphasis as billed. This may guide therapistson what areas require greater emphasis following TKR and guide themto identify needed outcomes for independent discharge placement.Measurement of improvement from initial to discharge evaluations isneeded. While use of a control group may not be ethically justified, spe-cific treatment options should be compared for their efficacy. Evalua-tion methods should be considered carefully to determine if they shouldbe routinely used or only to meet specific patient needs.

This study describes the initial self-care and transfer status of patientsafter TKR as minimal assist (M = 4.20) on average with scores rangingfrom 1.80 to 6.91. The low score in tub transfers may be due to the scor-ing procedures for FIM. For example, if a patient is not able to get in the


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shower because of staples in the knee the score is a “1” because this taskwas not attempted. The score does not reflect that the patient physicallyrequired a great amount of assistance. The score reflects compliancewith postoperative instructions in addition to physical performanceability.

Limitations of the study need to be considered. There was no controlgroup to provide a comparison group concerning treatment outcomes.Participant selection criteria were used to address this. The study wasconfined to participants whose rehabilitation efforts only addressedTKR and no other factors that might affect FIM subscale scores. Cogni-tive performance on FIM subscales, review of past medical history, andruling out past neurological and upper extremity disorders provided auniform study cohort.

Without a control group, statistical contrasts were limited to pairedt-tests. Post hoc analysis using Bonferroni inequality was used (Glass &Hopkins, 1984). Post-test scores may be influenced by the regressioneffect. Even so, the findings suggest that something other than chanceinfluenced the scores. A significance test does not give reason for thecause of difference; it only indicates that the difference is greater thancan be attributed to chance. Glass and Hopkins (1984) emphasize that itis the design of the study that allows the researcher to specify causes.This reinforces the need for future research.

In summary, positive outcomes in self-care and transfers were at-tained by patients after TKR. Of clinical significance to physical andoccupational therapists, patients who received intervention improvedacross all FIM subscales. While there is need for future research, thisstudy suggests that physical and occupational therapy provide therapeu-tic benefits to patients.

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Received: 03/01/05Revised: 11/15/05

Accepted: 11/30/05


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Documents

Self-Care and Total Knee Replacement