RTS Hüft- und Knie-TEP

Transcription

RTS Hüft- und Knie-TEP
1. Literaturrecherche
2. Studienübersicht
3. Literaturverzeichnis
1.1 Methodik
Bei der Literaturrecherche zu den Reha-Therapiestandards „Hüft- und Knie-TEP“ wurden
sämtliche seit 2007 veröffentlichte Studien miteinbezogen, um nahtlos an die letzte
inhaltliche Evidenzüberprüfung der Reha-Therapiestandards anzuknüpfen. Die Literaturrecherche erfolgte schrittweise: Zunächst wurden relevante und aktuelle Leitlinien gesucht,
daraufhin Metaanalysen und systematische Reviews und schließlich Originalarbeiten. Die
Suche nach relevanten Leitlinien und HTAs erfolgte in den Datenbanken leitlinien.de, AWMF
online, g-i-n.net, NGC, NICE und HTA database (University of York, Centre for Reviews and
Dissemination). Für systematische Reviews und Metaanalysen wurden die Datenbanken
Cochrane Library, Scopus, MEDLINE, PSYNDEX, CINAHL und PsycINFO durchsucht,
ebenso für Originalarbeiten (hierbei mit Ausnahme der Cochrane Library). Suchbegriffe
waren Kombinationen aus der Indikation (hip, joint, knee, arthroplast$, replac$, prosthe$,
endoprosthe$), der Intervention (rehabilitation, activities of daily living, adl, multidisciplinary,
interdisciplinary, multiprofessional, multimodal, patient care team) und den gewünschten
Artikelmerkmalen (systematic review, meta-analysis, randomized controlled trial, rct, cohort
study). Der Methodenbericht zu den RTS Hüft- und Knie-TEP (vgl. „Therapiestandards für
die Rehabilitation nach Hüft- oder Knietotalendoprothese: Methodenbericht“, S. 236 ff)
dokumentierte zudem Suchalgorithmen für ausgewählte Datenbanken, welche ebenfalls
genutzt wurden. Eine Handsuche erfolgte in den einschlägigen Fachzeitschriften mit den
höchsten Impact-Faktoren: Journal of Bone and Joint Surgery (Impact Faktor: 3.23), Knee
Surgery, Sports Traumatology, Arthroscopy, (Impact Faktor: 2.68), Journal of Orthopaedic &
Sports Physical Therapy (Impact Faktor: 2.95), Clinical Orthopaedics and related research
(Impact Faktor: 2.79) und Journal of Arthroplasty (Impact Faktor: 2.11). Berücksichtigt
wurden ebenfalls Veröffentlichungen in den Tagungsbänden der Reha-Kolloquien der Jahre
2007 bis 2014. In Anlehnung an die vergangene Literaturrecherche wurden alle
Grunderkrankungen für Hüft- und Knie-TEP berücksichtigt (u. a. Arthrose, Nekrose, Rheuma,
Fraktur), alle Formen der Implantatverankerung, auch Teilprothesen (Hemiarthroplastik,
unikondyläre oder unikompartimentelle Prothesen, Patellofemoralprothesen) und bilaterale
Totalendoprothesen. Einbezogen wurden alle Interventionsstudien zu Therapienformen bei
Hüft- und Knie-TEP im Anschluss zur Primärtherapie sowie Studien mit Angaben zur
Mindestdauer der Therapiemodule oder der Mindestanzahl von zu behandelnden Patienten.
Narrative oder qualitative Studien wurden ausgeschlossen, ebenso Studien zu
medikamentösen, allopathischen oder pflegerischen Therapien. Andere Evidenzen als die
wissenschaftliche Evidenz (z.B. Evidenz aus der good clinical practice, Empirie aus der
Versorgungspraxis (praxisnahe Evidenz), konsensbasierte Evidenz, Evidenz aus rechtlichen,
ethischen oder systemimmanenten Vorgaben) wurden hier nicht verfolgt.
1.2 Ergebnisse
Identifikation
Die nachfolgende Abbildung 1 zeigt den Verlauf der Studienauswahl. Bei der Datenbanksuche wurden anfangs 1447 relevante Dokumente identifiziert, bei der Handsuche weitere
1723 Dokumente (darunter 1177 aus Fachzeitschriften und Tagungsbänden der RehaKolloquien von 2007 bis 2014). Nach dem Ausstreichen von Duplikaten wurden 2943
Dokumente in die Vorauswahl aufgenommen, nach Ausschluss anhand von Titel und
Abstract verblieben 147 Dokumente. Nach der Eignungsbeurteilung der 147 Volltexte
verblieben 125 Dokumente, welche für die Aktualisierung der Reha-Therapiestandards Hüftund Knie-TEP von Relevanz sind und in die folgende Auswertung miteinbezogen werden.
Gefunden durch Datenbanksuche
(n =1447)
Zusätzlich gefunden in anderen
Quellen
(n =1723)
Eingeschlossen
Eignung
Vorauswahl
Verbleiben nach Entfernung von Duplikaten
(n =2943)
In Vorauswahl
aufgenommen
(n =2943)
Ausgeschlossen
(n =2796)
Volltext auf Eignung
beurteilt
(n =147)
Volltext ausgeschlossen,
mit Begründung
(n =22)
Studien eingeschlossen
in die Zusammenfassung
(n =125)
Abbildung 1: Ergebnisse der Literaturrecherche zur Indikation Brustkrebs (PRISMA-Flussdiagramm)
Tabelle 1 zeigt die Aufteilung dieser verwendeten Dokumente zu den einzelnen Therapiemodulen. Insgesamt konnten 1 Leitlinie, 30 Metaanalysen bzw. systematische Reviews und
94 Originalarbeiten gefunden werden. Das Literaturverzeichnis befindet sich unter Punkt 3.
Tabelle 1
: Aufteilung der gefundenen Dokumente für die Reha-Therapiestandards Hüft- und Knie-TEP zu den
einzelnen Therapiemodulen
Leitlinien
Metaanalysen / Reviews
4
Originalarbeiten
16
1
2
3
Hüft-TEP
7
16
Knie-TEP
13
23
ETM-übergreifend
ETM 01 Bewegungstherapie
ETM 02 Alltagstraining
Hüft-TEP
3
Knie-TEP
1
ETM 03 Physikalische
Therapie
Hüft-TEP
1
1
3
Knie-TEP
3
ETM 04 Patientenschulung
TEP
Hüft-TEP
1
16
Knie-TEP
ETM 05 Gesundheitsbildung
1
Hüft-TEP
Knie-TEP
ETM 06 Ernährungsschulung
2
1
Hüft-TEP
Knie-TEP
ETM 07 Psychologische
Beratung und Therapie
1
1
1
Hüft-TEP
1
2
Knie-TEP
ETM 08 Entspannungstraining
1
2
Hüft-TEP
1
Knie-TEP
ETM 09 Sozial- und
sozialrechtliche Beratung
Hüft-TEP
Knie-TEP
ETM 10 Unterstützung der
beruflichen Integration
Hüft-TEP
Knie-TEP
ETM 11 Nachsorge und
soziale Integration
Hüft-TEP
Knie-TEP
1
1
1
1
Summe Ergebnisse:
1
30
94
1.3. Darstellung der Ergebnisse der Literaturrecherche für die einzelnen
Therapiemodule
Im Folgenden werden die gefundenen wissenschaftlichen Evidenzen der Literaturrecherche
getrennt nach den jeweiligen Therapiemodulen der RTS dargestellt. Gefundene Leitlinien
und Metaanalysen bzw. Reviews werden kurz mit den wichtigsten Ergebnissen vorgestellt.
ETM-übergreifend
Ein Cochrane-Review von Khan und Kollegen ((2008) belegt die Wirksamkeit früher,
multidisziplinärer Rehabilitation nach Hüft- und Knie-TEP. Die Behandlung nach Leitlinien
erweist sich hierbei als effektiver als die Routinebehandlung (Barbieri et al., 2009; Van
Herck et al., 2010). Zudem wurden Originalarbeiten zur Effektivität spezieller
Rehabilitationsprogramme gefunden (Raphael et al., 2011, Van den Akker-Scheek et al.,
2007). Rehabilitation als Gruppenangebot erwies sich als ebenso effektiv wie EinzelRehabilitation (Aprile et al., 2011). Weitere 3 Originalarbeiten zeigen durch Vergleiche die
Vor- und Nachteile spezifischer Pflegeeinrichtungen sowie ambulanter und stationärer
Therapien auf (Mahomed et al., 2008; Mallinson et al., 2011; Tian et al., 2011).
Hüft-TEP
Der Ansatz zu multimodaler Schmerzbehandlung bei Hüft-TEP-Patienten wird durch ein
systematisches Review unterstützt (Sharma et al., 2009). Spencer-Gardner et al., (2014)
zeigen in ihrer Studie die Effektivität eines 5-Phasen-Rehabilitationsprotokolls um den
steigenden Aktivitätslevel nach der Operation zu dokumentieren.
Knie-TEP
Die 9 ETM-übergreifenden Originalarbeiten zur Rehabilitation nach Knie-TEP beschreiben
die Vorteile verschiedener Rehabilitationskonzepte (den Hertog et al., 2012; Kauppila et al.,
2010), traditioneller chinesischer Medizin im Vergleich zu standardisierten stationären
Rehabilitationsprogrammen (Yang et al., 2013), früherer im Vergleich zu späterem
Rehabilitationsbeginn (Bade et al., 2011; Labraca et al., 2011) sowie der virtuellen
Telerehabilitation, welche die Patienten von Zuhause aus nutzen (Piqueras et al., 2013;
Tousignant et al., 2011a,b; Russell et al., 2011). Die Ergebnisse zur Telerehabilitation zeigen
sich vielversprechend und die Autoren gehen davon aus, dass das neuartige
Therapieprogramm mindestens so effektiv ist wie konventionelle Therapiepläne.
Zum Therapiemodul „Bewegungstherapie“ wurde eine große Fülle wissenschaftlicher Studien gefunden: Eine kanadische Leitlinie des „Ontario Health Technology Advisory
Committee (OHTAC, 2014) empfiehlt in ihrer aktuellen Version den Übergang zu
kommunalen Physiotherapienageboten nach der Akutbehandlung für Hüft- oder Knie-TEP
bzw. selbstorganisiertes Training von zu Hause aus mithilfe telefonischer Kontrolle eines
Physiotherapeuten. 2 systematische Reviews beschreiben die Wirkung von Physiotherapie
übergreifend bei Knie- und Hüft-TEP. Mak et al. (2013) empfehlen frühe Mobilisation, jedoch
nicht die Anwendung der elektrischen Bewegungsschiene (Continuous Passive Motion).
Villlalta et al. (2013) empfehlen Physiotherapie im Wasser (Hydrotherapie) als ebenso wirksam wie „trockene“ Therapien im Hinblick auf Verbesserungen bezüglich Schmerzen,
Ödeme, Stärke und Bewegungsradius. Das Risiko für langsamere Wundheilung steigt durch
die Hydrotherapie nicht. 3 weitere Originalstudien beleuchten die Vorteile von Gruppengegenüber Einzeltherapie (Coulter et al., 2009), sowie intensivierter Bewegungstherapie,
welche ohne die Gefahr unerwünschter Nebenwirkungen signifikante Effekte zeigt. Welche
Intensitäten konkret zu höheren Therapieeffekten führen, bleibt noch offen (Hendrich et al.,
2011, 2012).
Hüft-TEP
Weitere 7 systematische Reviews wurden zur Bewegungstherapie speziell bei Hüft-TEPPatienten gefunden. Müller et al. (2009) fanden 4 Gruppenvergleiche zur Effektivität von
Sport- und Bewegungstherapie (Laufbandtraining, Armergometertraining, Kraftraining) und
bewerten den Evidenzgrad gerätegestützter Trainingstherapie nach Hüft-TEP mit Ib.
Laufbandtraining, unilaterales Widerstandstraining des Quadrizepsmuskels und
Armergometer wurden ebenfalls von Di Monaco et al. (2009) als effektive Interventionen
nach Hüft-TEP bewertet, auch eine Vollbelastung der operierten Hüfte („unrestricted weight
bearing“) wird bereits direkt nach der Operation als effektiv empfohlen und führt zu keinerlei
unerwünschten Nebenwirkungen (Hol et al., 2010). Intensives Aufbautraining mit Gewichten
(Progressive Resistance Training, PRT) induziert effektiv Muskel-Hypertrophie und
Muskelstärke (Okoro et al. 2012). Zur Wirksamkeit der Physiotherapie fanden Minns Lowe et
al. (2009) keine ausreichende Evidenz, Coulter et al. (2013) bestätigten jedoch
Verbesserungen der Stärke des Hüft-Abduktorenmuskels, der Schrittgeschwindigkeit und der
Trittfrequenz durch die Einsetzung von physiotherapeutischen Übungen. Zum zeitlichen
Verlauf der Bewegungstherapie empfehlen Di Monaco et al. (2013) Ergometertraining und
Maximalkrafttraining in der frühen postoperativen Phase, Belastungsübungen in der späten
Phase (> 8 Wochen postoperativ). 16 weitere Originalstudien zu der Wirksamkeit von
Physiotherapie, Ergometer Training, Bewegungstherapie im Wasser, frühe Auslastung der
Muskelkraft und Gehtraining bei Hüft-TEP-Patienten wurden gefunden. Für die
Bewegungstherapie im Wasser wurden gegenläufige Empfehlungen hinsichtlich des idealen
Anfangszeitpunkts gefunden: Während Liebs et al. (2012) von einem frühen Beginn nach der
Hüft-Operation ausdrücklich abraten, empfehlen Rahmann und Kollegen (2009) die
Physiotherapie im Wasser bereits ab dem 4. Tag nach der Operation.
Eine detaillierte Beschreibung der Originalstudien findet sich in der Übersichtstabelle.
Knie-TEP
Zur Bewegungstherapie bei Knie-TEP-Patienten wurden 13 systematische Reviews und
Meta-Analysen gefunden. Hiervon beziehen sich 4 Studien auf die Effektivität von
Physiotherapie. Im Vergleich zu traditionellen Übungsprogrammen zeigen
physiotherapeutische Übungen einen höheren kurzfristigen Effekt (Minns et al., 2007; Minns
Lowe et al., 2007). Dieses Ergebnis wird auch von Müller et al. (2009) bestätigt und die
Wirksamkeit von Physiotherapie nach Knie-TEP mit einem Evidenzgrad von Ia bewertet.
Eine frühzeitige Verlegung zur ambulanten Physiotherapie wird unterstützt (Genêt et al.,
2007). Die Anwendung der elektrischen Bewegungsschiene (Continuous Passive Motion)
führt lediglich zu kurzzeitigen Verbesserungen der Kniebeweglichkeit, allgemein besteht für
die Anwendung keine dauerhafte bzw. nur eingeschränkte Evidenz (Harvey et al., 2010;
Postel et al., 2007; Van Dijk et al., 2007; Viswanathan et al., 2010). Die Übersichtsarbeiten
von Meier et al. (2008) und Schache et al. (2014) verweisen auf die Notwendigkeit von
Muskelaufbautraining zur Stärkung der Quadrizeps-Muskeln und der hinteren
Oberschenkelmuskulatur, welche bei Knie-TEP-Patienten besonders geschwächt sind. Nach
Pozzi et al. (2013) sollte die optimale Bewegungstherapie intensive funktionsstärkende
Übungen im Wasser oder auf dem Trockenen beinhalten, welche sich in ihrer Intensität mit
dem Fortschritt der Patienten steigern. Direkte Vollbelastungen und Aktivität zeigen keine
Verschlechterungen nach Knie-Operationen (Smith et al., 2007). Die Wundheilung bei
Beugung anstelle von Streckung des Knies kann im weiteren Verlauf zu einem größeren
Bewegungsradius des Gelenks führen (Smith et al., 2010). Weitere 23 Originalarbeiten
behandeln die Wirksamkeit von allgemeinen Bewegungsprogrammen, Physiotherapie,
Bewegungstherapie im Wasser, Balance- und Stärkungsübungen, der Bewegungsschiene
und kardiovaskulärer Fitness und stützen die Aussagen der beschriebenen
Übersichtsarbeiten. So konnten zur Effektivität der Bewegungsschiene auch hier keine oder
nur kurzfristige positive Ergebnisse gefunden werden (Alkire et al., 2010; Bruun-Olsen et al.,
2009; Chen et al., 2013; Herbold et al., 2012; Lenssen et al., 2008; Maniar et al., 2012).
Trainingsübungen im Wasser zeigen hingegen positive Auswirkungen, unter anderem auf die
Muskelstärke und die Mobilitätsgrenzen (Harmer et al., 2009; Valtonen et al., 2010, 2011).
Auch Balanceübungen haben positive Auswirkungen auf den Funktionsstatus der unteren
Extremitäten und die Mobilität (Liao et al., 2013; Piva et al., 2010).
Eine detaillierte Beschreibung der Originalstudien findet sich in der Übersichtstabelle.
Fazit: Das Modul Bewegungstherapie ist ausführlich wissenschaftlich belegt (Evidenzlevel
Ia). Empfohlen wird die Anwendung früher Physiotherapie („trocken“ oder im Wasser), sowie
bei Hüft-TEP- und Knie-TEP-Patienten getrennt eine Vielzahl unterschiedlicher Sport- und
Bewegungstherapien. Während die Anwendung der Bewegungsschiene im vorangehenden
Methodenreport noch wissenschaftlich unbelegt war, wird nun in mehreren Publikationen die
mangelhafte Wirksamkeit der Anwendung belegt.
Zum Therapiemodul Alltagstraining wurden drei Originalstudien zu Hüft-TEP sowie eine
Studie zu Knie-TEP gefunden.
Hüft-TEP
Eine randomisiert kontrollierte Studie von Smith und Kollegen (2008) zeigte keine positiven
Effekte der zusätzlichen Durchführung von Bewegungsübungen im Bett (vgl. KTL H113).
Postler und Kollegen (2011) fanden in einer prospektiven Kohortenstudie eine eher geringe
Auftretenswahrscheinlichkeit postoperativer kognitiver Dysfunktionen bei Hüft-TEP-Patienten
im Alter von 65 Jahren oder älter. Kognitives Training anhand von Videospielen mit
Gedächtnisübungen kann die Gedächtnisfunktionen bei Hüft-TEP-Patienten verbessern
(Brem et al., 2010).
Knie-TEP
Jenkins et al. (2008) fanden positive Langzeiteffekte nach Anleitungen und Übungen zum
Knien 6 Wochen nach der Knie-Operation (vgl. KTL E152, E160, H101).
Fazit: Das Modul „Alltagstraining“ entstammt dem Modul „Ergotherapie und Pflege“, welches
zum Zeitpunkt der Ersterstellung der RTS nicht wissenschaftlich belegt war. Im Vergleich
dazu hat sich die Evidenzlage verbessert, es liegt Evidenz aus randomisiert kontrollierten
Studien vor (Evidenzlevel Ib). Konkrete Hinweise auf die Ausgestaltung des Moduls
hinsichtlich Dauer und Umfang der Maßnahmen lassen sich jedoch nicht ableiten. Da die
zugehörigen Therapien bereits in der aktuellen Fassung der Reha-Therapiestandards einen
hohen Stellenwert aufweisen (Mindestanteil 90%) besteht aufgrund der Literaturrecherche
kein Aktualisierungsbedarf.
ETM 03 Physikalische Therapie
Müller et al. (2009) untersuchten in ihrem systematischen Review die Effektivität der
Anwendung von Kältetherapie (Kryotherapie) und Elektrotherapie bei Hüft- und Knie-TEPPatienten. Kältetherapie zeigte nur vereinzelt positive Auswirkungen in den ersten Tagen
nach der Operation, eine Überlegenheit gegenüber anderen postoperativen
Schmerztherapien konnte nicht berichtet werden (Evidenzgrad Ib). Zur Anwendung der
Elektrotherapie wurden Hinweise gefunden, dass diese in sehr hoher Dosis bei Hüft- als
auch Knie-TEP-Patienten zu verbesserter Gehfunktion führen kann (Evidenzgrad Ib), einem
Krafttraining bei Hüft-TEP-Patienten jedoch nicht überlegen ist. Auch müssen mögliche
Nebenwirkungen berücksichtigt werden. Eine prospektive Kohortenstudie zeigt zudem die
allgemeinen positiven Auswirkungen von physikalischer Therapie bei frühestmöglicher
Anwendung (Chen et al., 2012).
Hüft-TEP
2 Studien zu Hydrotherapie bei Hüft-TEP-Patienten zeigen positive Auswirkungen der
Therapie und empfehlen ihre Anwendung (Giaquinto et al., 2007; 2010). Eine randomisiert
kontrollierte Studie von Gremeaux und Kollegen (2008) untersuchte die Kombination von
Physiotherapie und elektrischer Muskelstimulation und fand größere Effekte hinsichtlich
Muskelstärke und Balance im Vergleich zu Physiotherapie alleine.
Knie-TEP
Mak et al. (2013) berichten in ihrer Übersichtsarbeit von geringen kurzzeitigen
Verbesserungen nach Kälteanwendungen bei Knie-TEP-Patienten, die jedoch keine
Routineanwendung rechtfertigen. Eine weitere Literaturübersicht (Markert, 2011) fasst
zusammen, dass Kältetherapie zwar keine statistisch gesehen effektive Anwendung ist, sie
jedoch einige Vorteile für die Patienten mit sich bringt, etwa Verbesserungen in den
Bereichen Bewegungsradius, Schwellungen und Blutverlust. Zudem wurden drei
Originalarbeiten zu Kälteanwendungen bei Knie-TEP-Patienten gefunden: Im Vergleich zu
herkömmlichen Eiskompressionen zeigen kryopneumatische Anwendungen leichte Vorteile
(Su et al., 2012), gasförmige Kälteanwendungen jedoch nicht (Demoulin et al., 2012).
Die Anwendung von Elektrotherapie (neuromuskuläre elektrische Stimulation) im betroffenen
Quadrizeps-Muskel während der ersten 6 Wochen post-operativ führt nach dem Review von
Bade et al. (2012) zu schnellerer Erholung und langfristigen Verbesserungen bezüglich
Stärke und Leistungskapazität. Acht randomisiert kontrollierte Studien zur Effektivität
neuromuskulärer elektrischer Stimulation wurden zudem gefunden. Die Kombination von
Mikrostromtherapie und physiotherapeutischen Übungen führt zu besseren Effekten als die
Durchführung von Physiotherapie alleine oder die Kombination mit Scheinbehandlungen
(Avramidis et al., 2010; Levine et al., 2013; Rockstroh et al., 2010). Vor allem bei höheren
Intensitäten werden Hamstring- und Quadrizeps-Muskel gestärkt (Stevens-Lapsley et al.,
2012a,b). Nichtinvasive interaktive Neurostimulation (NIN) verbesserte bereits nach 3 Tagen
signifikant Schmerzen und Bewegungsradius des Knies (Nigam et al., 2011),
elektromagnetische Navigation zeigte hingegen keine signifikanten Effekte (Smith et al.,
2013).
Bezüglich der Anwendung von Dehnungsübungen erwiesen sich alle drei getesteten
Variationen (aktiv, passiv, mit neuromuskulärer Förderung) als gleich wirksam (Chow et al.,
2010). Zur Effektivität von Akupunktur sind die Ergebnisse widersprüchlich: Positive
Auswirkungen auf Schmerzen und Bewegungsgrad wurden in einer randomisiert kontrollierte
Studie gefunden (Mikashima et al., 2012), in einer weiteren nicht (Tsang et al., 2007). Auch
manuelle Lymphdrainage verbesserte die Dehnung des Knies (Ebert et al., 2013).
Fazit: Zu dem Therapiemodul Physikalische Therapie (Evidenzlevel Ia) wurde eine Vielzahl
an wissenschaftlichen Belegen gefunden. Diese beziehen sich auf die Anwendung von
Kryotherapie und Elektrotherapie sowie physikalische Therapie im Allgemeinen. Bei HüftTEP-Patienten zudem auf Hydrotherapie und elektrische Muskelstimulation, bei Knie-TEPPatienten auf Kryotherapie, Elektrotherapie, Dehnungsübungen, Akupunktur und manuelle
Lymphdrainage. Die wissenschaftliche Evidenzlage hat sich somit im Vergleich zur
vorangehenden Literaturrecherche deutliche verbessert.
ETM 04 Patientenschulung TEP
Hüft-TEP
Müller et al. (2009) beschreiben in ihrem systematischen Review Hinweise auf die positiven
Auswirkungen intensiver Patientenschulungen bei Hüft-TEP-Patienten (Evidenzgrad Ib).
Einschränkend ist anzumerken, dass sich dieses Ergebnis auf nur eine Studie stützt, deren
Praxis nicht dem in Deutschland üblichen Vorgehen entspricht.
Fazit: Das Therapiemodul Patientenschulung TEP ist wissenschaftlich evidenzbasiert. Dies
stütz sich auf eine Studie bei Hüft-TEP-Patienten (Evidenzgrad Ib). Wie auch bei der
vorangehenden Literaturrecherche konnten zur Patientenschulung bei Knie-TEP keine
geeigneten Publikationen gefunden werden.
Für die zum Modul „Gesundheitsbildung“ zugehörigen Therapieformen wurden keine
Interventionsstudien gefunden. Ein Review von Westby (2012) weist darauf hin, dass man
Hüft- und Knie-TEP-Patienten über die Vorteile körperlicher Bewegung nach der Operation
aufklären und zu einem regelmäßigen, moderaten Bewegungsprogramm motivieren sollte.
Knie-TEP
Eine deskriptive Langzeitstudie von Su und Kollegen (2010) zeigt, dass Patienten nach der
Entlassung aus dem Krankenhaus vor allem das Bedürfnis nach Aufklärung über mögliche
weitere Krankenhausaufenthalte haben. Der Bedarf an gesundheitsbezogenen Leistungen
ist unter anderem abhängig von Stresssymptomen, Alter und Geschlecht.
Eine weitere, quasi-experimentelle Studie (Chen et al., 2014) zeigt, dass eine Intervention
zur Gesundheitsbildung (kognitiv-behaviorale Gesundheitsbildungs-Intervention mit
schriftlichen Unterlagen und CD) bei Knie-TEP-Patienten zu geringeren Schmerzen und
verbesserten Körperfunktionen führt.
Fazit: Für das Therapiemodul Gesundheitsbildung besteht mäßige wissenschaftliche
Evidenz (Evidenzlevel IIb), worin bereits eine Verbesserung zum Zeitpunkt der Ersterstellung
der RTS besteht. Die gefundene Literatur gibt Hinweise darauf, dass gesundheitsbildende
Informationen, vor allem bei Knie-TEP-Patienten, positive Auswirkungen auf den
Gesundheitsstatus der Patienten haben können. Das Modul trägt zudem zur good clinical
practice bei.
Für das Modul „Ernährungsschulung“ wurden keine zugehörigen Interventionsstudien
gefunden. Ein systematisches Review von Inacio et al. (2013) zu der Frage „Verlieren
Patienten nach Hüft- oder Knie-TEP Gewicht?“ fand lediglich Studien geringer Qualität,
welche bei 14% bis 49% der Patienten Gewichtsverluste beschrieben. Nach den Autoren
besteht demnach keine Evidenz für Gewichtsveränderungen nach Hüft- oder Knie-TEP.
Knie-TEP
Eine retrospektive Kohortenstudie (Baker et al., 2013) zeigt, dass auch übergewichtige und
stark übergewichtige Knie-TEP-Patienten funktionellen Gewinn aus der Operation ziehen.
Fazit: Der Gewinn von Ernährungsschulungen nach Hüft- und Knie-TEP ist nach
wissenschaftlichen Erkenntnissen nicht gesichert (Evidenzlevel IIa). Auch zur Ersterstellung
wurden keine geeigneten Publikationen zum Therapiemodul gefunden, zur Wirksamkeit
können demnach keine gesicherten Aussagen getroffen werden.
ETM 07 Psychologische Beratung und Therapie
Mak et al. (2013) berichten in einem systematischen Review von kurzzeitigen
Tabakentwöhnungsprogrammen bei Hüft- und Knie-TEP-Patienten mit einem Evidenzlevel
von I bis II: Vor der Operation und während der Akutphase durchgeführt, wird ein
Tabakentwöhnungsprogramm mit geringeren Komplikationen nach der Operation assoziiert.
Eine deskriptive Studie von Nickinson et al. (2009) zeigt, dass 50% der Patienten
postoperativ depressive Symptome entwickeln, was die Notwendigkeit psychologischer
Diagnostik und Beratung anerkennt.
Hüft-TEP
Badura-Brzoza und Kollegen (2009) berichten ebenfalls allgemein von den Auswirkungen
psychischer Faktoren auf den Gesundheitsstatus von Hüft-TEP-Patienten nach der
Operation und weisen auf die Notwendigkeit der Berücksichtigung dieser Faktoren hin,
ebenso in einer Langzeitstudie von Montin et al. (2007).
Müller et al, (2009) berichten in ihrem systematischen Review von einer randomisierten
Studie zu mentalem Gehtraining bei Hüft-TEP-Patienten. Im Vergleich zur Kontrollgruppe
zeigten diese Patienten eine größere Verbesserung der Schrittlänge und eine tendenziell
verbesserte Gehgeschwindigkeit.
Knie-TEP
In einer ebenfalls bei Müller et al. (2009) aufgeführten Studie zu kognitiv-behavioraler
Therapie bei Knie-TEP-Patienten führt eine Kurzintervention in der Akutphase zu
Verbesserungen hinsichtlich der Selbstwirksamkeitserwartung, der Ergebniserwartung
bezüglich körperlicher Aktivität sowie der Funktion (Gehgeschwindigkeit, Aufstehen aus dem
Sitzen).
Fazit: Für einige der im Therapiemodul zusammengefassten Therapieformen besteht
wissenschaftliche Evidenz (Evidenzlevel Ib): Für Tabakentwöhnungsprogramme, für
mentales Gehtraining bei Hüft-TEP-Patienten sowie für kognitiv-behaviorale Therapie bei
Knie-TEP-Patienten, obgleich der Durchführungszeitraum der Therapien in den Studien nicht
immer dem Zeitraum der Rehabilitation entspricht. Allgemein zeigen mehrere Studien den
Bedarf an psychologischer Diagnostik und Therapie. Die Aussagen der gefundenen
Publikationen sind vergleichbar mit der Evidenzlage zum Zeitpunkt der letzten Überprüfung
der RTS.
Zum Therapiemodul Entspannungstraining wurden 3 Originalarbeiten gefunden, darunter
eine Studie speziell zu Knie-TEP-Patienten. Eine randomisiert-kontrollierte Studie
(Büyükyılmaz et al., 2013) fand Hinweise, dass Entspannungstechniken und
Rückenmassage bei Hüft- und Knie-TEP-Patienten positive Auswirkungen auf Schmerzen
und Angst haben. Ebenso fand Lin (2012), dass Entspannungstherapie (Atemtechniken,
geführte Visualisierungstechniken) zu besserem Angst- und Schmerzmanagement führen
kann. Der Zeitraum beider Studien bezog sich jedoch auf 1 bis 3 Tage postoperativ.
Knie-TEP
Eine Fallstudie über eine Knie-TEP-Patientin (McClelland et al., 2012) beschreibt die positive
Wirkung von Biofeedback zum Wiedererlernen symmetrischer Bewegungsabläufe (vgl. KTL
F070 „Biofeedback“).
Fazit: Das Therapiemodul Entspannungstraining ist wissenschaftlich gut belegt (Evidenzlevel
Ib). Es liegen Studien zur Wirksamkeit von Rückenmassagen, Entspannungstechniken,
Atemtechniken, geführte Visualisierungen sowie Biofeedback bei Knie-TEP-Patienten vor.
Unklar bleibt, ob die Umstände der gefundenen Publikationen direkt auf den Alltag einer
Rehabilitationseinrichtung übertragbar sind.
ETM 09 Sozial- und sozialrechtliche Beratung
Zu diesem Therapiemodul wurde weder zu Hüft- noch zu Knie-TEP geeignete
wissenschaftliche Evidenz gefunden. Auch bei der Ersterstellung der RTS wurden keine
entsprechenden Publikationen gefunden, das Modul basiert demnach auf good clinical
practice.
ETM 10 Unterstützung der beruflichen Integration
Es wurden keine Interventionsstudien zu den Therapieangeboten im Modul „Unterstützung
der beruflichen Integration“ gefunden. Ein systematisches Review von Kuijer et al. (2009)
untersuchte die Frage nach förderlichen und hindernden Faktoren beim Wiedereinstieg in
den Beruf nach Hüft- oder Knie-TEP: Die vorhandene Evidenz war sehr gering, die Autoren
fanden jedoch Hinweise darauf, dass Bewegungseinschränkungen der Patienten nach der
Operation hinderlich auf dem Weg zur beruflichen Reintegration sind.
Hüft-TEP
Nunley et al. (2010) fanden anhand von Telefoninterviews mit 943 Hüft-TEP-Patienten unter
60 Jahren heraus, dass die meisten Patienten nach einem Jahr wieder arbeiteten (90.4%),
davon die Mehrheit im vorherigen Arbeitsgebiet. Nur sehr wenige Patienten (2.3%) waren zu
dieser Zeit noch arbeitsunfähig.
Fazit: Für die dem Modul „Unterstützung der beruflichen Integration“ zugehörigen
Therapieformen liegen derzeit keine geeigneten Publikationen vor. Gefunden wurden
lediglich Studien mit allgemeinen Aussagen zum Zeitpunkt des beruflichen Wiedereinstiegs
sowie zu förderlichen und hinderlichen Faktoren (Evidenzlevel IIa), welche einen eher
geringen Bedarf an Unterstützung bei der Berufsaufnahme vermitteln und somit mit dem
geringen Mindestanteil (20% der Rehabilitanden) im Einklang stehen.
ETM 11 Nachsorge und soziale Integration
Zum Therapiemodule Nachsorge und soziale Integration wurden 2 Studien gefunden:
Mazaleski (2011) legte in ihrer Studie an Patienten mit Gelenkprothesen keine endgültigen
Ergebnisse vor, verwies jedoch anhand ihrer Literaturrecherche auf die Wichtigkeit der
Unterstützung und Einbeziehung der Patientenangehörigen (vgl. KTL D060, D071, D072).
Hüft-TEP
Eine Studie mit Hüft-TEP-Patienten über 65 Jahren (Hordam et al., 2010) fand Hinweise,
dass unterstützende telefonische Interviews in der Nachsorgephase den Gesundheitsstatus
der Patienten verbessern.
Fazit: Zum Therapiemodul Nachsorge und soziale Integration wurden nur wenige
wissenschaftliche Belege gefunden (Evidenzlevel Ib), die einzige Interventionsstudie bezieht
sich auf die Wirksamkeit unterstützender Telefoninterviews bei älteren Hüft-TEP-Patienten.
Somit ist das Modul besser belegt als zur Ersterstellung der RTS, konkrete Hinweise zur
Ausgestaltung des Moduls lassen sich jedoch nicht ableiten
2. Studienübersicht für die Indikation Hüft- und Knie-TEP
ETM-übergreifend
Reviews
Autor/en und Publikationsjahr
Barbieri et al., 2009
Anzahl Studien
22 studies
Khan et al., 2008
5, 619 patients
Van Herck et al., 2010
34 studies
Kernergebnis
Aus Ergebnis abgeleitete
Empfehlung
Significantly fewer patients suffering
postoperative complications in clinical
pathways group compared with standard
care. Additional they have a shorter length
of stay and lower costs during the hospital
stay
Silver level evidence, that following hip or
knee joint replacement, early
multidisciplinary rehabilitation can improve
outcomes at the level of activity and
participation
Clinical pathways can improve the quality
of care. None of the included studies
analyze the cost of development and
implementation of the pathways, therefore
it’s not possible to conclude that the
implementation is a cost-effective process
The evidence presented in this review
provides modest support for the
recommendation that people following hip
or knee joint replacement should be
assessed for their need for appropriate
rehabilitation intervention
Clinical pathways for joint arthroplasty
could improve process and financial
outcomes. The effects on clinical outcome
are mixed. Evidence on team and service
outcome is lacking
Clinical pathways are a useful tool for
improving the care process in this setting.
Recommendations for clinical practice
include the implementation of EBP in
pathway development.
Originalartikel
Autor/en und
Publikationsjahr
Aprile et al., 2011
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
27 patients undergoing
a physical therapy
program after knee or
2 Intervention
programs, G1: 15 days
group rehab, followed
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
-
Endpunkt(e),
Outcome
Clinical disability
evaluation (JOASH,
IKS, DI) and patient-
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
His pilot trial suggests
that the group
rehabilitation program
A potential benefit of
group-based therapy is
the reduction of
hip replacement
by individual rehab for
15 days. G2: Individual
rehab (15 days)
followed by 15 days
group rehabilitation
Either home-based or
inpatient rehabilitation.
All patients followed
standardized care
pathways.
Mahomed et al., 2008
234 Patients following
total joint replacement
Mallinson et al., 2011
Patients with total knee
(n=146) or total hip
replacement (n=84) not
related to traumatic
injury.
Skilled nursing
facilities (SNFs; n_5),
inpatient
rehabilitation facilities
(IRFs; n_4), and home
health agencies
(HHAs; n_6) from 11
states. No
interventions.
Raphael et al., 2011
100 patients
The fast-track
program emphasizes
preoperative patient
education,
postoperative
multimodal analgesia
with periarticular
-
100 patients treated
before the introduction
of the program,
standard program.
oriented assessment
(SF-36, WOMAC and
VAS)
is just as efficient as
the individual
rehabilitation
rehabilitation costs.
Differences between
the groups with
respect to WOMAC,
Short Form-36, or
patient satisfaction
scores (p > 0.05)
Despite concerns
about early hospital
discharge, there was
no difference in pain,
functional outcomes,
or patient satisfaction
between the group
that received homebased rehabilitation
and the group that had
inpatient
rehabilitation
On the basis of our
findings, we
recommend the use of
a home-based
rehabilitation protocol
following
elective primary total
hip or knee
replacement as it is the
more cost-effective
strategy
Self-care and mobility
status at
PAC discharge
measured by using the
Inpatient Rehabilitation
Facility Patient
Assessment
Instrument.
HHA patients were
significantly less
dependent than SNF
and IRF patients at
admission and
discharge in self-care
and mobility. IRF and
SNF patients had
similar mobility levels
at admission and
discharge and similar
self-care at admission,
but SNF patients
were more
independent in selfcare at discharge.
For the patients in our
U.S.-based study,
direct discharge to
home with home care
was the optimal
strategy for patients
after total joint
replacement surgery
who were healthy
and had social support.
For sicker patients,
availability of
24-hour medical and
nursing care may be
needed
Length of hospital stay
adjusted for age, sex,
smoking,comorbidities,
American Society of
Anesthesiologists’
physical status
classification, body
Our multimodal
multidisciplinary fasttrack
protocol reduced
hospital stay and
opioid consumption
while maintaining a
Program
implementation is
feasible both in tertiary
care and in
community hospitals.
injections, early
physiotherapy and
rehabilitation, and
discharge home with
an outpatient
rehabilitation program.
Tian et al., 2011
948 knee
replacement patients
and 618 hip
from 11 IRFs and 7
SNFs
This study aims to
determine the
efficiency of
rehabilitation care
provided by SNF and
IRF to joint
with respect to both
payment and length of
stay (LOS).
Van den Akker-Scheek
et al., 2007
103 patients (50
GOES, 53 controls
Validation of the
program theory of the
Groningen orthopaedic
exit strategy (GOES).
ETM-übergreifend: Hüft-TEP
Reviews
53 controls
mass index,
surgical procedure,
morphine utilization,
pain scores
both at rest and with
activity, than in
patients, rate of ED
visits or readmissions
in the first 30 days.
Output was measured
by motor functional
independence
measure (FIM) score
at discharge.
Efficiency was
measured in 3 ways:
payment efficiency,
LOS efficiency,
and stochastic frontier
analysis efficiency.
high level of patient
safety.
IRF patients incurred
higher expenditures
per case but also
achieved larger motor
FIM gains in shorter
LOS than did SNF
patients. Setting of
care was not a strong
predictor of overall
efficiency of
rehabilitation care.
Early rehabilitation
was consistently
predictive of efficient
treatment.
The
advantage of either
setting is not clear-cut.
Definition of
efficiency depends in
part on preference
between cost and
time. SNFs are more
payment efficient; IRFs
are more LOS
efficient.
Questionnaires were
used to assess
mediating and
outcome variables preoperatively, and 6 and
26 weeks postoperatively
No difference was
seen between the two
groups in terms of
changes between preoperative and postoperative mediating
variables
(action theory).
The conceptual theory
is supported; however,
as the treatment did
not influence the
mediating variables
(action theory), it has
no added value in its
current form.
Sharma et al., 2009
Anzahl Studien
16 level I and II studies
Kernergebnis
Empfehlung
Literature supports the use of a
multimodal pain control to improve patient
compliance in accelerated
rehabilitation. Multimodal pain control with
revised anesthesia protocols and
accelerated rehabilitation speeds recovery
after minimally invasive THA compared to
the standard approach THA, but a smaller
incision length or minimally invasive
approach does not demonstrably improve
the short-term outcome.
Preoperative physiotherapy may facilitate
faster postoperative
functional recovery but multicenter and
welldesigned prospective randomized
studies with outcome measures are
necessary to confirm its efficacy
Originalartikel
Autor/en und
Publikationsjahr
Spencer-Gardner et
al., 2014
Patientengruppe,
die untersucht
wurde
Fifty-two patients (19
male and 33 female)
with a median age of
42 (range
16–59) years
Intervention (Art,
Intensität, Dauer)
5-phase rehabilitation
protocol
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Mean MHHS, HOSADL, and HOS-sport
scores at a mean 12.5
(range 12–15) months
Patients following this
rehabilitation
protocol after hip
arthroscopy
demonstrated
satisfactory
clinical and functional
outcomes
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
This five-phase
provides a framework
where progression
from surgery to
increasing postoperative activity level
can take place in a
predictable manner
ETM-übergreifend: Knie-TEP
Originalartikel
Autor/en und
Publikationsjahr
Bade et al., 2011
den Hertog et al.,
2012
Patientengruppe, die
untersucht wurde
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Eight patients, who
participated in the HI
program, were compared
to 8 age-matched and
sex-matched patients
who participated in a
lower intensity
(control group).
Patients were assessed
preoperatively, and at
3.5, 6.5, 12, 26, and 52
weeks postoperatively
to assess the clinical
outcomes of a highintensity rehabilitation
program (HI)
A group of agematched and sexmatched controls who
underwent a lower
intensity rehabilitation
program.
Assessment of
patients included
measures of pain,
range of motion
(ROM), functional
performance, and
quadriceps strength
and activation.
The implementation of
more intense and longduration interventions
after TKA should be
considered, as the
results of this study
suggest the potential
for better functional
short-and long-term
outcomes.
147 patients with TKA (N
= 74 fast-track
rehabilitation,
N = 73 standard
rehabilitation).
Investigation of a fasttrack rehabilitation
concept
in terms of a
measurable effect on
the early recovery after
total knee arthroplasty
(TKA).
The standard
rehabilitation
group received
individual
postoperative care
according to the
existing protocol, with
1:1 physiotherapy
(1 h/day).
The cumulative
American Knee
Society Score
(AKSS) was the
primary evaluation
variable. The
secondary
evaluation variables
were WOMAC index
score,
analgesic drug
consumption, length
of stay (LOS), and
safety
A HI program leads to
better short- and longterm strength and
functional performance
outcomes compared to a
lower intensity
rehabilitation program.
The HI program did not
impair knee ROM and
did not result in any
musculoskeletal injuries
in this small group of
patients.
After TKA, patients in the
fast-track rehabilitation
group showed enhanced
recovery compared with
the standard
rehabilitation group, as
based on the differences
between the groups for
the cumulative
AKSS,WOMAC index
score, reduced intake
of concomitant analgesic
drugs, reduced LOS, and
lower number of adverse
events.
For TKA,
implementation of
pathway-controlled
fast-track rehabilitation
is achievable and
beneficial
as based on the AKSS
and WOMAC score,
reduced intake
of analgesic drugs,
and reduced LOS.
86 patients who were
scheduled for primary
total knee
arthroplasty due to
osteoarthritis of the knee.
A ten-day
multidisciplinary
rehabilitation
programme, which was
focused on enhancing
functional capacity, was
organized 2–4 months
after surgery.
In both groups, a
standard amount of
physiotherapy was
included in conventional
care.
Conventional care.
The Western
Ontario and
McMaster
Universities
Osteoarthritis
Index (WOMAC),
the 15D, 15-m walk
test, stair test,
isometric strength
measurement
of the knee. Use of
rehabilitation
services was asked
about with a
questionnaire.
Patients undergoing
primary total knee
arthroplasty for
osteoarthritis were
randomly assigned
to experimental (n=153)
and control (n=153)
groups
To compare the benefits
of initiating rehabilitation
treatment within 24
hours versus 48–72
hours after total knee
arthroplasty for
osteoarthritis:
Rehabilitation was
started within 24 hours
post surgery in the
experimental group.
Between 48 hours and
72 hours post surgery
was the start in the
control group.
Primary outcome
measures were
range of motion,
muscle strength and
pain; secondary
measures were
autonomy, gait and
balance.
142 total knee
arthroplasty patients
Interactive virtual
telerehabilitation
system.
Conventional outpatient physical
therapy
The main outcome
was function
assessed with active
range of knee
movement.
Other variables,
such as muscle
strength, walk
speed,
pain and the
Western Ontario
and McMaster
Kauppila et al.,
2010
Labraca et al., 2011
Piqueras et al.,
2013
In both groups,
functional capacity and
quality of life improved
significantly.
The mean absolute
change in the WOMAC
function score was –
32.4mm in the
rehabilitation group and
–32.8mm in the control
group. No difference was
found between groups in
any outcome measure or
in the use of
rehabilitation services
during the study period.
In comparison with the
controls, the
experimental group
showed significantly
shorter hospital stay,
fewer rehabilitation
sessions until medical
discharge, lesser pain,
greater joint range of
motion in flexion and
extension, improved
strength in quadriceps
and hamstring muscles,
and higher scores for
gait and balance.
Baseline characteristics
between groups were
comparable.
All participants improved
after the 2-week
intervention
on all outcome variables
(p < 0.05). Patients in
the
interactive virtual
telerehabilitation group
achieved improvements
This study indicates
that a 10-day
multidisciplinary
outpatient
rehabilitation
programme 2–4
months after surgery
does not yield faster
attainment of
functional recovery or
improvement in quality
of life than can be
achieved with
conventional
care.
Initiation of
rehabilitation within 24
hours after total knee
arthroplasty reduces
the mean
hospital stay and
number of sessions
required to achieve
autonomy and normal
gait and balance.
A 2-week interactive
virtual telerehabilitation
programme is at least
as effective as
conventional therapy.
Telerehabilitation is a
promising alternative
to traditional
face-to-face therapies
after discharge from
total knee arthroplasty,
especially for those
in the functional
variables similar to those
achieved in the
conventional therapy
group.
patients who have
difficulty
with transportation to
rehabilitation centres.
65 TKA patients
6-week intervention :
Internet-based
telerehabilitation
program
Conventional
outpatient physical
therapy
(WOMAC)
measured at
baseline and six
weeks by a blinded
independent
assessor.
Secondary
outcomes included
the Patient-Specific
Functional Scale,
the timed up-andgo test,
pain intensity, knee
flexion and
extension,
quadriceps muscle
strength, limb girth
measurements,
and an assessment
of
gait
Baseline characteristics
between groups were
similar, and all
participants had
significant improvement
on all outcome
measures with the
intervention. After the
six-week intervention,
participants in the
telerehabilitation
group achieved
outcomes comparable
to those of the
conventional
rehabilitation group with
regard to flexion
and extension range of
motion, muscle
strength, limb girth,
pain, timed up-and-go
test, quality of life, and
clinical gait and
WOMAC scores.
The outcomes
achieved via
telerehabilitation at
six weeks following
total knee
arthroplasty were
comparable
with those after
conventional
rehabilitation.
48 community-living older
adults who received total
knee
arthroplasty
24 in-home
telerehabilitation, The
tele-treatments were
delivered to the
participants at a rate of
two sessions per week
for 8 weeks (total of 16
24 control group
patients, the home
visit/outpatient clinic
treatments were
delivered
as usual over a period
of 2 months on
Healthcare
Satisfaction
Questionnaire, the
patients’
perception of inhome telehealth, the
satisfaction of the
Both groups of patients
(Tele and Comparison)
were satisfied
with the services
received and no
significant difference was
observed between them.
As patient satisfaction
is important in
maintaining motivation
and treatment
compliance
and the satisfaction of
healthcare
Russell et al., 2011
Tousignant et al.,
2011a
Universities
Osteoarthritis Index,
were also collected.
sessions).
average, and the
number of
sessions was not
controlled by research
procedures but took
place as
usual
healthcare
professionals with
the technology
(technical quality
subjective
appreciation
questionnaire)
48 patients after knee
replacement surgery
(TKA)
Home telerehabilitation:
Telerehabilitation
sessions (16 per
participant over two
months) were
conducted by trained
physiotherapists using
videoconferencing to the
patient’s home via an
Internet connection (512
kbit/s upload speed).
Conventional
rehabilitation
41 patients in 3 groups,
undergoing primary
unilateral TKA
EXP I: Given
concomitant physical
therapy (PT), TCM,
continuous
passive motion (CPM),
and oral non-steroid
anti-inflammatory drugs
(NSAIDs); (2) EXP II:
Given concomitant
TCM, CPM, and oral
NSAIDs
Control subjects, given
concomitant PT, CPM,
and oral
NSAIDs.
Disability and
function were
measured using
standardized
outcome measures
in face-to-face
evaluations at three
times ( prior to and
at the end of
treatment, and
four months after
the end of
treatment).
Levels of pain were
then monitored
using a Visual
Analogue Scale
(VAS).
Tousignant et al.,
2011b
Yang et al., 2013
Leitlinien
Autor/en
Jahr der
Empfehlung
Moreover, the
physiotherapists’
satisfaction
with regard to goal
achievement, patient–
therapist relationship,
overall session
satisfaction, and quality
and performance of the
technological platform
was high.
Clinical outcomes
improved significantly for
all subjects in both
groups between
endpoints. Some
variables showed larger
improvements in the
usual care group two
months post-discharge
from therapy
than in the
telerehabilitation group.
professionals must be
high in order for new
treatments to become
mainstream in clinics,
the results show that
in-home
telerehabilitation
seems to be a
promising alternative
to traditional face-toface treatments
Home telerehabilitation
is at least as effective
as usual care, and has
the potential to
increase access to
therapy in areas with
high speed Internet
services.
Significant alleviation of
pain and
diminution of flexion
contractures were
achieved using TCM,
with and without
standard rehabilitation.
These outcomes
support the use of
TCM immediately
post-TKA to facilitate
patient recovery
Veröffentlichung
OHTAC
2014
OHTAC recommends community-based physiotherapy after primary total knee or hip
replacement. In regards to location of physiotherapy within the community, the health
system should allow for flexibility, depending on the local care context and the patients’
needs. Current initiatives that are underway in the province to improve allocation of
physiotherapy services for primary hip and knee replacement patients should be
supported by the health care system. For patients who could attend an outpatient
physiotherapy clinic, consideration may be given to a self-managed home exercise
program with a physiotherapist monitoring through phone calls. The full benefit of a
preoperative exercise program is not as yet realized.
Reviews
Autor/en und
Publikationsjahr
Mak et al., 2013
Villalta et al., 2013
Originalartikel
Anzahl
Studien
Kernergebnis
Well-designed RCTs with adequate power were lacking
in some areas and heterogeneity of outcome measures
across trials limited generalizability to clinical practice in
other areas.
There was a deficiency in the quality of the evidence supporting key aspects of
the continuum of care for primary THR/TKR surgery. Consequently,
recommendations were limited. For example:
- Wait times in the short to intermediate period (up to 6 months) do not
significantly result in increased pain or HRQoL, but cases will be required to be
assessed individually.
- Multidisciplinary teams are necessary to optimize preparation for surgery.
- Exercise to maintain or improve function and pain in the preoperative period
is advised.
- A short-term smoking cessation programme is implemented prior to surgery
and in the acute care period.
- Use of a structured care pathway can reduce length of stay and may improve
clinical outcomes.
When compared with land-based physical therapy, early
aquatic physical therapy does not increase the risk of
wound-related adverse. There
were no significant differences in pain .
After orthopedic surgery, aquatic physical therapy improves function and does
not increase the risk of wound-related adverse events and is as effective as
land-based therapy in terms of pain, edema, strength, and range of motion in
the early postoperative period.
75
8
Aus Ergebnis abgeleitete Empfehlung
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
Intervention
(Art, Intensität,
Dauer)
Consecutive patients
(N=51) having hip or
knee replacement
surgery
Quasiexperimental
sequential cohort
trial with 12week follow-up to
compare
effectiveness and
time efficiency of
physiotherapy
rehabilitation
provided within a
group with an
individualized
program provided
at home.
132 Hüft-und Knie
TEP-Patienten
Standard‐
Bewegungstherapie
mit intensiviertem
Krafttraining
Coulter et al., 2009
Hendrich et al.,
2011
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren aus dem
Ergebnis abgeleitete
Empfehlung
Home physiotherapy
group
Primary outcome
measures included
the WOMAC, SF-36,
Timed Up & Go (TUG)
test, and knee range of
motion (ROM).
Secondary measures
included the 6-m walk
test and a patient
evaluation
questionnaire.
.
There was no
difference between
the 2 groups for
either the WOMAC or
SF-36 scores, 6-m
walk test, TUG test,
or ROM measures at
12 weeks (P_.05),
although both groups
of patients improved
between hospital
discharge and 12
weeks.
This trial suggests that the
class-based exercise
rehabilitation was the most
efficient method of delivery of
the physiotherapy service,
without cost to patient
outcomes.
Standard‐
Bewegungstherapie
Gelenkfunktion
(WOMAC),
Gesundheitsbezogene
Lebensqualität (SF36),
Gelenkbeweglichkeit
(Neutral-Null-Methode),
Gehgeschwindigkeit,
Belastungsnormative,
Intensität (Borg-Skala
6-20),
Schmerzempfinden (PIIndex; visuelle
Analogskala 0-10)
Signifikante, klinisch
relevante
Verbesserungen der
Gelenkfunktion über
die Zeit. Keine
signifikanten
Gruppenunterschiede
durch die Intervention.
Verstärkte Analyse
existierender
Bewegungstherapieprogramme
nach Knie- oder Hüft-TEP.
124
Rehabilitanden/innen
nach
Erstimplantierung
einer Knie- oder
Hüft-TEP
Randomisierte,
kontrollierte
Intervention
(StandardBewegungstherapie
vs. intensivierte
MTT)
Hauptzielparameter war
die Gelenkfunktion
(WOMAC-Score),
Nebenzielparameter die
Gelenkbeweglichkeit
(Physiotherapeutischer
Befund), die
gesundheitsbezogene
Lebensqualität (SF 36)
sowie die Gehfähigkeit
(Ganggeschwindigkeit
über 10m) untersucht.
Die Therapie-Intensität
wurde mit der BorgSkala (6-20)erfasst, die
wahrgenommen
Schmerzen mit dem PI
Schmerzindex (0-10).
Hendrich et al.,
2012
Die auf der BorgSkala erreichten
Therapie-Intensitäten
unterschieden sich
signifikant (p < 0.05),
nicht allerdings die
während
der MTT
wahrgenommenen.
Im WOMAC-Score
zeigten sich für beide
Indikationen z.T.
signifikante (p <
0.01) Unterschiede
über die Zeit, jedoch
weder zu t1
noch zu t2
signifikante
Gruppenunterschiede.
Trotz einer deutlich höheren
Therapie-Intensität in den IGs
wurden auch hier nur geringe
wahrgenommene Schmerzen
angegeben. Eine
Intensivierung der
Bewegungstherapie erscheint
ohne die Gefahr von
unerwünschten
Nebenwirkungen möglich.
Offen bleibt, welche
Intensitäten konkret zu
höheren Therapieeffekten
führen.
ETM 01 Bewegungstherapie – Hüft-TEP
Reviews
Anzahl Studien
Coulter et al., 2013
5
Di Monaco et al., 2009
9
Kernergebnis
Empfehlung
Most outcomes were similar between
outpatient and home-based exercise
programs
Physiotherapy rehabilitation improves hip
abductor strength, gait speed and
cadence. Physiotherapist-directed
rehabilitation exercises appear to be
similar effective whether they are
performed unsupervised at home or
supervised by a physiotherapist in an
outpatient setting.
Convincing evidence for the effectiveness
Early postoperative protocols should
Di Monaco et al., 2013
Hol et al., 2010
Minns Lowe et al., 2009
Müller et al., 2009
11
of single interventions in addition to usual
exercise programs exists for each of the
tree following options: treadmill training
with partial bodyweight support, unilateral
resistance training of the quadriceps
muscle (operated side), and arm- interval
exercise with an ergometer.
Each of the nine RCTs addressed a
specific issue and overall the results were
sparse. In the early postoperative phase
favorable outcomes were due to
ergometer cycling and maximal strength
training. Inconclusive results were
reported for aquatic exercises, bed
exercises without external resistance or
without its progressive increase according
to the overload principle, and timing. In the
late postoperative phase (>8 weeks
postoperatively) advantages were due to
weight-bearing exercises.
We found moderate to strong evidence
that no adverse effects on subsidence and
osseous integration of the femoral stem
after uncemented THA occur after
immediate UWB.
include additive interventions whose
effectiveness has been shown. Late
postoperative programs are useful and
should comprise weight-bearing exercises
with hip-abductor eccentric strengthening.
Results indicate that physiotherapy
exercise after discharge following total
hip replacement has the potential to
benefit patients.
Insufficient evidence exists to establish
the effectiveness of physiotherapy
exercise following primary hip
replacement for osteoarthritis. Further
well designed trials are required to
determine the value of post discharge
exercise following this increasingly
common surgical procedure.
Es besteht nur für wenige in der
Rehabilitation bei Hüft- und
Kniegelenks-Total-Endoprothesen
angewendete Therapien Evidenz
Die Ableitung von konkreten
Empfehlungen für die notwendige Dauer
und Häufigkeit einzelner Therapien aus
der Literatur ist
13
8
21
Insufficient evidence exists to build up a
detailed evidence-based exercise protocol
after THA. Sparse results from few RCTs
support specific exercise types which
should be added to usual mobility training
in THA.
We recommend early rehabilitation after
uncemented THA with a reciprocally gait
pattern using crutches, one cane for
independency in ADL in case patients
walk limp-free and walking without
crutches as soon as possible. During the
first weeks after surgery only stair climbing
should be performed with protected weight
bearing because of high
torsion loads on the hip.
Okoro et al., 2012
15
für ihre Wirksamkeit aus
wissenschaftlichen Studien.
The use of a progressive resistance
training (PRT) programme led to
significant improvement in muscle strength
and function if the intervention was carried
out early in a centre or late in a home
based setting. In direct comparison, there
was no difference in functional measures
between home and centre based
programmes (2 studies), with PRT not
included in the regimes prescribed.
nicht möglich.
Centre based program delivery is
expensive as high costs are associated
with supervision, facility provision, and
transport of patients. Early interventions
are important to counteract the deficit in
muscle strength in the affected limb, as
well as persistent atrophy that exists
around the affected hip at 2 years postoperatively.
Originalartikel
Autor/en und
Publikationsjahr
Barker et al., 2013
Galea et al., 2008
Patientengruppe, die
untersucht wurde
Intervention (Art,
Intensität, Dauer)
Comparisons were made by
dividing the cohort (1367
patients) into 4
groups based on body
mass index (BMI) 18.5–25.0
kg/m2 (n = 253);.25.0–30.0
kg/m2 (n = 559);.30.0235.0
kg/m2
(n = 373);.35.0 kg/m2 (n =
182).
Retrospective
comparative cohort
study using
prospectively
collected data from
an institutional
arthroplasty
register
23 patients with unilateral
THR
The center-based
group completed an
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Unsupervised homebased exercise group
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
(WOMAC)
and Medical Outcomes
Trust Short Form-36 (SF36) scores supplemented
by a validated measure
of satisfaction
preoperatively
and subsequently at 1,2
and 3 year postoperatively.
Despite lower preoperative, 1 and 3
year WOMAC and
SF-36 scores patients
with the highest BMIs
.35.0 kg/m2
experienced similar
improvements to
patients with a
‘normal‘ BMI at 1 year
and this improvement
was sustained at up
to 3 years. This effect
was also observed for
the SF-36 mental and
physical component
scores.
No significant
interaction (group by
Obese and morbidly
obese patients gain
as much functional
benefit from total
knee replacement as
patients
with lesser body mass
indexes. This benefit
is maintained for up to
3 years following
surgery. However,
these patients are
less satisfied with
their knee
replacement.
Quality of life, physical
function,
The targeted
strengthening
8-week targeted
exercise program
while under the direct
supervision of a
physiotherapist. After
initial instruction, the
home-based group
completed the 8-week
targeted exercise
program at home
without further
supervision.
(n=12).
and spatiotemporal
measures of gait.
time) or main
effects of grouping
were found. Within
each group, quality of
life, and stair climbing
improved significantly
as did Timed Up & Go
test and 6-minute
walk test
performances.
program was effective
for both the homeand center-based
groups. This finding is
important because it
shows that THR
patients can achieve
significant
improvements
through a targeted
strengthening
program delivered at
a center or at home.
68 patients with primary
unilateral THA, 35 women
and 33 men
Training group. Each
patient had 12
sessions, twice a
week for 70minutes.
The control group did
not attend any
supervised
physiotherapy
programs during the
same time period, but
were encouraged to
continue with the
exercises they had
learned in the hospital
or during their
rehabilitation stay,
and to keep generally
active.
The training group
had larger
improvements than
the control group at
posttest 1 on the
6MWT. There were
also improvements on
the figure-of-eight
test, IMF, active hip
ROM in extension
HHS and self-efficacy.
The walking skill
training program was
effective, especially in
improving walking
both immediately after
the intervention and 1
year after THA
surgery.
Patients (N=24) with
osteoarthritis as the main
reason for THA were
randomly assigned to
perform maximal
strength training (n=12) or
conventional rehabilitation
(n=12).
The maximal strength
training group (STG)
performed maximal
strength training in
leg press and
abduction
with the operated leg
only 5 times a week
for 4 weeks in
addition to the
conventional
rehabilitation
The conventional
rehabilitation group
(CRG) received
supervised
physical therapy 3 to
5 times a week for 4
weeks..
The primary outcome
was the 6-minute walk
test (6MWT). The
secondary outcomes
were the
stair climbing test (ST);
figure-of-eight test; Index
of Muscle Function (IMF);
active hip range of
motion (ROM) in flexion,
extension, and
abduction; Harris Hip
Score (HHS); selfefficacy; and Hip
Dysfunction and
Osteoarthritis Outcome
Score.
1-repetition maximum
(1RM)
leg press strength, 1RM
abduction strength, rate
of force development
(RFD), work efficiency,
gait patterns, and quality
of life.
1RM increased in the
bilateral leg press and
in the operated leg
separately in the STG
compared
with the CRG. 1RM
abduction strength in
the operated
leg and the healthy
leg increased in the
STG compared with
the CRG. RFD
Early maximal
strength training 1
week postoperatively
is feasible and an
efficient treatment to
regain muscular
strength for patients
who have undergone
THA, demonstrated
by a significantly
larger increase in
muscular strength
Heiberg et al., 2012
Husby et al., 2009
program.
and a trend towards a
better work efficiency
in the STG
compared with the
CRG.
24 (22) total hip arthroplasty
patients
4 weeks of maximal
strength training and
conventional
rehabilitation
compared to
conventional
rehabilitation only.
After the intervention
period, all patients
attended conventional
rehabilitation.
Conventional
rehabilitation
Outcome measures were
hip abduction and leg
press strength, gait
patterns,work efficiency,
maximal oxygen
consumption, and healthrelated quality of life.
Work efficiency was
significantly higher in
the strength training
and conventional
compared with the
conventional
rehabilitation.
Leg press for the
healthy leg and rate of
force development for
the operated leg were
significantly higher in
the strength training
and conventional
compared with the
conventional
rehabilitation.
The study indicates
that a prolonged
maximal
strength training
program and aerobic
endurance training
are required to
fully recover total hip
arthroplasty patients.
362 patients two weeks
after total hip or knee
replacement
Ergometer cycling, 2
weeks after
replacement.
No cycling.
The primary outcome
was self-reported
physical function
as measured with the
Western Ontario and
McMaster Universities
Osteoarthritis Index
(WOMAC) at three, six,
twelve, and
twenty-four months
postoperatively.
The primary
outcome, physical
function as
measured with the
WOMAC, was
significantly better at
three months
and twenty-four .
Ergometer cycling
after total hip
arthroplasty is an
effective means of
improvement in
patients’ quality of
life and satisfaction.
However, this study
does not support the
use of ergometer
cycling after knee
arthroplasty.
Patients (N=465)
undergoing primary THA
(n=280) or TKA (n=185):
Patients were
randomly assigned to
receive
WOMAC, Medical
Outcomes
Study 36-Item Short-
After TKA all WOMAC
subscales were
superior in the early
Early start of aquatic
therapy had contrary
effects after TKA
Husby et al., 2010
Liebs et al., 2010
Liebs et al., 2012
increased in the STG
compared with the
CRG followed by a
trend towards
increased peak force
in the STG.
156 men, 309 women.
aquatic therapy (pool
exercises aimed at
training of
proprioception,
coordination, and
strengthening) after 6
versus 14 days
after THA or TKA.
Form Health Survey,
LequesneHip/Knee-Score,
WOMAC-pain and
stiffness scores, and
patient satisfaction.
aquatic therapy
group. After THA,
however, all
outcomes were
superior in the late
aquatic therapy
group. However, the
differences
between treatment
groups of these
subanalyses were not
statistically
significant.
Merle et al., 2009
8 men and 6 women,
ranging in age from 57 to 85
years
in the course of these
tests they were
required to minimize
their body sway
as much as possible
by keeping their eyes
open. Three
successive 32-s trials
(sampled at 64 Hz)
with intermediate
recovery periods of
equivalent duration
were performed
allowing period of rest
between each trial.
The balance strategies
were evaluated through a
frequency analysis of the
resultant and plantar
centers of pressure
(CPRes) of each foot and
of the estimated
trajectories of the
vertical projection of the
center of gravity (CG),
and from the difference
CPRes—CG
No difference was
found for the plantar
CP trajectories in the
situation where
body weight is
spontaneously
distributed, whereas
loading the implanted
extremity induced
increased CPRes,
CG, and CPRes—CG
trajectory amplitudes
along the mediolateral
axis.
Mikkelsen et al.,
2012
primary THR surgery
Intervention group
Control group (n =
(n= 23) receiving 12
weeks of intensified
exercises (e.g.
rubber band
resistance)
21) receiving
standard
rehabilitation
exercises without
external resistance.
Maximal gait speed,
isometric hip abductor
muscle strength, onelegged stance, healthrelated quality of life
(EuroQol-5
Dimensions), patient
satisfaction, and
There were
significant increases
in both groups in all
the measurements
during the 12 weeks
of exercises. In the
IG, four participants
(17.4%) had
when compared with
THA and it influenced
clinical outcomes
after TKA. However,
the results of this
study do not support
the use of early
aquatic therapy after
THA. The timing of
physiotherapeutic
interventions has to
be clearly defined
when conducting
studies to evaluate
the effect of
physiotherapeutic
interventions after
TKA and THA.
here we deliberately
attempted to favor
balance
control with visual
information. The
reproducibility of the
results in nonvision
conditions also
remain to be
demonstrated.
This pilot study
indicates that the
majority of THR
patients tolerated
early-initiated
intensified exercises
without additional
pain and with high
primary hip or
knee arthroplasty
Supplementary
inpatient
physiotherapy,
beginning on day
4: aquatic
physiotherapy,
nonspecific water
exercise, or additional
ward physiotherapy.
Groups: Aquatic
intervention
physiotherapy, ward
control, exercise
group.
20 women (57 ± 6 years)
with THR
Standardized
gait training including
an
intervention based on
real-time visual
feedback (IG).
Patients were
admitted to either
skilled nursing or
inpatient rehabilitation
facilities; a subset (N
=84) with telephone
follow-up outcomes 8
months after
rehabilitation
discharge
Gait training including
an intervention based
on verbal information
from a physiotherapist
(CG)
The treatment group
received twice-daily
physiotherapy from
day 1 after surgery to
discharge
Control group = usual
care
Rahmann et al.,
2009
Schega et al., 2014
224 Patients with hip
fractures treated with hip
arthroplasty
Siebens et al.,
2012
Stockton et al.,
2009
Patients (N_57) with
primary total hip
replacement
patient-evaluated
function, stiffness and
pain (WOMAC).
difficulties when
performing the
intensified exercises
at home.
patient satisfaction.
Strength, gait speed, and
functional
ability at day 14.
At day 14, hip
abductor strength was
significantlygreater
after aquatic
physiotherapy
intervention than
additional ward
treatment or water
exercise .
No adverse events
occurred
with early aquatic
intervention.
A specific inpatient
aquatic physiotherapy
program has a
positive effect on
early recovery of hip
strength after joint
replacement surgery.
Further studies are
required to
confirm these
findings.
Pre- and post-tests have
been performed. Tests
and interventions were
undertaken in a clinical
setting at an orthopedic
rehabilitation clinic.
Cognitive, motor, and
total Functional
Independence
Measure scores at
rehabilitation discharge
and at 8-month follow-up;
living location
at discharge and followup.
Results
indicate significant
improvements in
mental representation
of gait in the post-test
only in IG.
WBAT was
associated with less
osteoarthritis and
lower admission
medical severity
(ACSI). Significant
predictors for home
discharge included
lower maximum,
younger age, higher
cognition, and WBAT.
Beneficial
effects were provoked
by visual feedback.
The Iowa Level of
Assistance at
postoperative days 3 and
6 and LOS.
This study
demonstrates that
patients who received
twice-daily land-based
physiotherapy after
primary total hip
WBAT is associated
with a greater
likelihood of home
discharge and had
similar functional
outcomes compared
with restricted weight
bearing. These
findings add support
for allowing WBAT
after arthroplasty for
hip fracture.
Patients who received
twice-daily
physiotherapy
showed a trend
toward earlier
achievement of
42 Patients with total hip
arthroplasty
Early unrestricted
weight bearing
combined with
intensive
physiotherapy or
partial weight bearing
combined with selftraining.
Micromigration,
determined with high
accuracy using
radiostereometric
analysis (RSA)
24 female patients with THA
Walking exercise
groups with either
decreased pushoff or
increased pushoff.
Patients in the
decreased pushoff
group and increased
pushoff group were
given the instructions
"push less with your
foot when you walk"
and "push more with
your foot when you
walk"
Group 1 (2 exercises
2x per day, 6 weeks):
Home exercise
program, Group 2:
same exercise
procedure as group 1,
but with direct
physiotherapist
supervision in a
hospital
Body kinematic
measurements:
Reflective markers were
attached to the body
according to the Vicon
Plug-in-Gait marker
placement protocol,
Three measuring
sessions were included
in this study.
Ström et al., 2007
Tateuchi et al.,
2011
26 THA patients
Unlu et al., 2007
Group 3 served as
the control group, with
no specific
intervention
Maximum isometric
abduction torque of
operated hip muscle, gait
speed and cadence were
measured before and
after the study.
replacement attained
earlier achievement of
functional milestones
than patients that
received once-daily
physiotherapy.
Radiostereometric
analysis showed 1.2
mm subsidence of the
stem at 24 months in
both groups. There
was no significant
difference in the
migration pattern
between the
unrestricted and
partial weight bearing
groups
In the decreased
ankle pushoff group,
hip flexor power
absorption and
hip/ankle power ratio
were higher during
post-exercise than
during pre-exercise. in
the hip power by the
decreasing ankle
pushoff was higher in
the patients with
greater ankle pushoff
in their natural gaits.
When the three
groups
were compared,
group 2 showed the
best improvement
only in maximum
isometric abduction
torque.
functional milestones;
however, this finding
did not translate to
decreased
LOS.
Early full
weight bearing and
active rehabilitation
can be used for the
uncemented CLS
stem without
increased risk of early
loosening.
Walking exercise with
decreased ankle
pushoff may help
improve the
distribution of muscle
power between hip
flexors and ankle
plantarflexors during
walking in patients
with THA
Both home and
supervised exercise
programmes are
effective one year
after total hip
arthroplasty. Home
exercise
programmes with
close follow-up could
be recommended
ETM 01 Bewegungstherapie – Knie-TEP
Reviews
Anzahl Studien
Genêt et al., 2007
16
Harvey et al., 2010
20
Meier et al., 2008
Minns et al., 2007
Minns Lowe et al., 2007
Kernergebnis
Empfehlung
The literature review results showed some
advantage for programs of ambulatory
physiotherapy for patients able to return
home just after total hip replacement. The
main outcomes ameliorated are muscle
strength and function. However, studies
were methodologically limited.
There is high-quality evidence that
continuous passive motion increases
passive knee flexion range of motion and
active knee flexion range of motion. These
effects are too small to be clinically
worthwhile.
Quadriceps muscle impairments and how
these impairments can contribute to the
related functional limitations following TKA
When the patient can return home directly
from the surgery department, we
recommend ambulatory physiotherapy as
suggested by French clinical practice. The
program and number and objectives of the
ambulatory rehabilitation must be defined
in future trials with good methodology.
The effects of continuous passive motion
on knee range of motion are too small to
justify its use. There is weak evidence that
continuous passive motion reduces the
subsequent need for manipulation under
anaesthesia.
Muscle impairments that exist following a
TKA may persist for years. Improving
quadriceps strength may mitigate these
impairments and result in improved
functional outcomes. An emphasis on
muscle weakness countermeasures, like
resistance exercises and NMES, is
needed.
Interventions including physiotherapy
functional exercises after discharge result
in short term benefit after elective primary
total knee arthroplasty. Effect sizes are
small to moderate, with no long term
benefit.
Clinical Commentary
6
5
There was a small to moderate
standardised effect size in favour of
functional exercise for function three to
four months postoperatively.
There were also small to moderate
weighted mean differences for range of
joint motion and for quality of life in favour
of functional exercise three to four months
postoperatively
A small to moderate standardised effect
size, in favour of functional exercise, was
seen for function at 3–4 months post
operatively. Small to moderate weighted
mean differences, in favour of functional
Functional exercises should be
considered for inclusion in post-discharge
physiotherapy programmesfollowing knee
arthroplasty.
exercise, were seen for range of joint
motion and quality of life at 3–4 months
post operatively
57 Studien zu Physiotherapie und/oder
Sport- und Bewegungstherapie
Postel et al., 2007
21
Pozzi et al., 2013
19
Schache et al., 2014
Smith et al., 2007
15
8
Ein telefonisch angeleitetes
physiotherapeutisches Heimtraining bei
Knie-TEP sowie computerbasierte
Anleitung in der stationären Rehabilitation
bei Hüft- und Knie-TEP können zumindest
bei Patienten mit regelhaftem
Genesungsverlauf gleichwertig zu durch
den Therapeuten angeleiteten Übungen
sein
The literature contains no evidence of the
advantages of CPM over other techniques
of mobilization, although CPM could be
adjuvant therapy used to accelerate shortterm recovery.
Strengthening Interventions: Aquatic
Therapy, Balance Training, Clinical
settings
The meta-analyses showed that TKA
patients had weaker quadriceps than the
controls at every postoperative time. The
meta-analyses of hamstring strength for
patients 1–3 years post-operatively also
showed patient weakness and no
significant difference at N3 years postoperatively
The review reported that there appeared
to be little differences in radiological or
clinical outcomes between patients who
are full weight bearing, began immediate
active exercises, and were not
immobilized in a knee brace, compared to
those who were initially non-weight
bearing, instructed not to exercise their
knee, and were immobilized in a knee
brace during the initial postoperative
weeks.
Es besteht Evidenz für kurzfristige Effekte
von Physiotherapie nach Knie-TEP
(Evidenzgrad Ia)
Good methodological quality studies are
needed to assess different CPM
modalities and compare them to
alternative intermittent
mobilization techniques
In conclusion, progressive exercise is
critical to recovery after TKA. There is a
large decrease in quadriceps strength
immeridately aftr TKA, which is attributed
to activation deficits and atrophy
There was low quality evidence of
quadriceps and hamstring weakness
following TKA. Further research
is required to determine if other lower limb
muscles also display similar muscle
weakness.
There was insufficient evidence to draw
firm conclusions about the optimal postoperative rehabilitation regimen for
patients who had undergone medial
patellofemoral ligament reconstruction for
patellar instability, and further good-quality
research was required.
Smith et al., 2010
3
Van Dijk et al., 2007
45
Viswanathan et al., 2010
9
On analysis, patients with TKA wounds
closed in flexion had greater flexion range
of motion and required less domiciliary
physiotherapy compared to those with
wounds closed in full extension.
Three studies showed positive effects of
CPM for short term ROM and two studies
for incidence of needed manipulations and
pain intensity. Positive effects for knee
ccircumference, ‘functional status’ and
muscle strength were found by one study
each. One pragmatic study showed a
relatively progressive CPM treatment to
be more effective than a relatively
conservative form.
These studies show that there may be
short term benefits with using continuous
passive motion particularly for range of
motion, but these effects are generally not
long term.
The specific degree of knee flexion used
when closing total knee replacement
wounds may be an important
variable to clinical outcome.
There is morderate evidence for CPM
after TKA being effective for (short term)
ROM. There is limited evidence for CPM
being effective for incidence of
manipulations, pain intensity, knee
circumference, ‘functional status’ and
muscle strength. Evidence is limited for a
relatively progressive form of CPM being
the most effective.
There is limited evidence on the beneficial
effect of continuous passive motion on
knee function.
Originalartikel
Autor/en und
Publikationsjahr
Alkire et al., 2010
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
TKA
The experimental
group received CPM
thrice daily and
physical therapy (PT)
twice daily during their
hospitalization
The control group
received PT twice daily
and no
CPM during the
hospital stay
Knee Society scores,
Western Ontario
McMaster
values, range of
motion, knee
circumference, and
HemoVac drainage.
Data were collected at
various intervals from
preoperatively
There was no
statistically
significant difference in
flexion, edema or
drainage, function,
or pain between
groups through the 3month study period
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
The findings of this
study saw no benefit
of in-hospital
use of CPM for
postoperative
computer-navigated
TKAs
through 3 months
Goniometer, visual
analogue scale (VAS),
timed ‘Up and Go’ test
(TUG), timed 40 m
walking distance and
timed stair climbing
Bruun-Olsen et al.,
2009
primary TKA
Continuous passive
motion
(CPM) as an adjunct
to active exercises
Control group: Active
exercises only
Chen et al., 2013
107 patients after TKA
Control group: Basic
rehabilitation protocols
Range of motion,
modified Short Form36 (SF-36) and semiquantitative visual
analogue scale
Fung et al., 2012
50 patients with TKA
Basic rehabilitation
protocols and
additional daily use of
continuous passive
motion for more than
six hours per
day
Patients received a
physiotherapy session
followed by 15 minutes
of Wii Fit gaming
activities. The games
encouraged lateral
and multidirectional
weight shifting, and
provided visual
feedback regarding
postural balance
Control group:
Physiotherapy session
followed by 15 minutes
of lower extremity
strengthening and
balance training
exercises
Length of outpatient
rehabilitation, 2-minute
walk test, knee range
of motion, timed
standing, Activityspecific
Balance Confidence
Scale, Lower Extremity
Functional Scale and
Numeric Pain Rating
Scale
Harmer et al., 2009
102 patients after total
knee replacement
(TKR)
Randomized
participation in either
land-based (n = 49)
or water-based (n =
53) exercise classes
Herbold et al., 2012
61 patient pairs after
TKA
Use of CPM for 2
hours per day as an
The 6-Minute Walk
test, stair climbing
power (SCP), the
Western Ontario and
(WOMAC)
visual analog scale for
joint pain, passive
knee range of motion,
and knee edema
Control group: 61
patients did not receive
Primary outcomes
were discharge, active
There were no
statistical differences
between the treatment
groups for any
outcome measures
either at one week or
after three months
There was no
significant difference in
range of motion, visual
analogue scale and
SF-36 between groups
at each visit
There were no
significant differences
in pain, knee flexion,
knee extension,
walking speed,
timed standing tasks,
Lower Extremity
Functional Scale,
Activity-specific
Balance Confidence
Scale or patient
satisfaction with
therapy services
between the groups.
Significant
improvements were
observed across time
in all outcomes at 8
weeks, minor
between-group
differences were
evident for 4
outcomes: SCP,
WIMAC stiffness,
WOMAC function, and
edema
No statistically
CPM was not found to
have an additional
short-time effect
compared with active
physiotherapy
With the advances in
surgical technique,
aggressive continuous
passive motion does
not provide obvious
benefits
Wii Fit is potentially
acceptable as an
adjunct to
physiotherapy
intervention for
outpatients following
total knee
replacement,
provided the games
chosen challenge
balance and postural
control, and use the
lower extremities
Land-based or waterbased rehabilitation
delivered in the early
phase after TKR was
associated with
comparable outcomes
at the end of the
program and up to 26
weeks post-surgery
Using a matched
cohort design, we
adjunct to the 3 hours
of physical and
occupational therapy
customary in an IRF
Jakobsen et al., 2012
14 patients with
unilateral TKA
Johnson et al., 2010
Kim et al., 2009
50 patients after
bilateral TKA
Rehabilitation
including progressive
strength training of the
operated leg (leg
press and kneeextension), using
relative loads of 10
repetition maximum
with three training
sessions per week for
2 weeks.
Rehabilitation was
commenced 1 or 2
days after TKA
Whole-body vibration
(WBV) as an
alternative
strengthening regimen
for 4 weeks
Patients received
regular passive ROM
exercise (PROME) for
one knee and not for
the other
the adjunct therapy
knee flexion, ROM and
flexion gain
At each training
session, knee pain,
knee joint effusion and
training load were
recorded. Isometric
knee-extension
strength and maximal
walking speed were
measured before the
first and last session
Control group:
Traditional progressive
resistance exercise
(TPRE)
Knee extensor
strength, quadriceps
muscle activation,
mobility, pain and
range of motion (ROM)
The pain level,
patient’s preference,
maximum flexion and
American Knee
Society and WOMAC
scores were
determined in the
knees with and without
PROME and
were found in any of
the outcome variables
that were compared in
this matched case
design, including
AROM knee, flexion
gain, discharge to the
community, need for
home care services
after discharge, and
discharge with cane/no
device
The training load
increased
progressively (p <
0.0001). Patients
experienced only
moderate knee pain
during the strength
training exercises, but
knee pain at rest and
knee joint effusion
were unchanged or
decreased over the six
training sessions
compared CPM use
with non-CPM use and
determined that the
application of CPM
may not
significantly influence
ROM gain
The WBV knee
extensor strength
improved 84.3%,
TPRE increased
77.3%. TUG scores
improved 31% in the
WBV group and 32%
for the TPRE group
There were no
in the maximum
flexion, pain level,
patient’s preference,
AKS scores and
WOMAC scores
Influence of WBV on
muscle activation
remains unclear, as
muscle activation
levels were normal for
both groups
Progressive strength
training initiated
immediately after TKA
seems feasible, and
increases kneeextension strength and
functional performance
without increasing
knee joint effusion or
knee pain
The incorporation of
PROME does not
offer additional clinical
benefits to the patients
after TKA
Lenssen et al., 2008
TKA
The experimental
group received CPM +
PT for 17 consecutive
days after surgery
The usual care group
received the same
treatment during the inhospital phase (i.e.
about four days),
followed by PT alone
(usual care) in the first
two weeks after
hospital discharge
Liao et al., 2013
The experimental
group not only
received the same
conventional training
as the control group,
but also received
additional balance
exercises in each
admission
The control group
received conventional
function training for
eight weeks
Liu et al., 2009
115 patients after
bilateral TKA
The alternate protocol
group performed the
same exercises, but
alternated between
legs with each
individual repetition
The traditional-protocol
group performed a
series of exercises on
one leg and then
repeated the same
sequence on the other
leg
compared
Efficacy was assessed
in terms of faster
improvements in range
of motion (RoM) and
functional recovery,
measured at the end
of the active treatment
period, 17 days after
surgery
Measurements before
and after training:
distance of functional
forward reach;
duration of single leg
stance; timed sit-tostand test; timed upand-down stair test;
timed 10-m walk;
timed up-and-go test;
and the Western
Ontario and McMaster
Universities
score
Symptoms and
function were
assessed preoperatively and at 1, 3,
6 and 12 months postoperatively
Prolonged use of CPM
slightly improved
short-term RoM in
patients with limited
RoM at the time of
discharge after total
knee arthroplasty
when added to a semistandard PT
programme
The experimental
group demonstrated
significant changes in
10-m walk and in
timed up-and-go tests.
Significant changes of
all other measures and
Western Ontario and
score were also
observed
The alternate protocol
group had lower visual
analogue pain scale
scores in the early
postoperative period,
as well as higher Knee
Society Scores and
SF-12 physical and
mental health
summary scores after
1 and 3 months
compared with the
Although results
indicate that prolonged
CPM use might have a
small short-term effect
on RoM, routine use of
prolonged CPM in
patients with limited
RoM at hospital
discharge should be
reconsidered, since
neither long-term
effects nor transfer to
better functional
performance was
detected
Additional balance
training exerted a
significant beneficial
effect on the function
recovery and mobility
outcome in patients
with knee
osteoarthritis after total
knee replacement
The alternate-protocol
for rehabilitation
resulted in an early
return to function and
decreased pain levels
following simultaneous
bilateral TKA and was
associated with the
potential to produce
more positive
emotional states and
earlier functional
Madsen et al., 2013
primary unilateral TKA
Individual, supervised
home-training
Maniar et al., 2012
84 patients with TKA
3 standard
rehabilitation regimes:
no-CPM, 1-day-CPM,
and 3-day-CPM
Mockford et al., 2008
One group received
outpatient
physiotherapy for 6
weeks (group A).
Another received no
outpatient
physiotherapy (group
B)
Monticone et al., 2013
110 patients after
undergoing primary
TKA
In the experimental
group, before returning
home, the patients
were asked to
continue the functional
exercises learned
during hospitalization
in twice-weekly 60minute sessions for 6
months, and were
Control group: Groupbased rehabilitation: 12
outpatient visits during
six weeks including
strength and
endurance exercises,
education and selfmanagement
combined with home
exercises
In the control group,
the patients were
advised to stay active
and gradually recover
their usual activities
Oxford Knee Score;
EuroQoL-5
Dimensions Qol and
Physical Function of
the Medical Outcomes
Short Form 36, pain,
knee range of motion,
tandem test, Leg
Extensor Power, 10-m
walking test, 30-sec.
and five-times sit-tostand
“Timed up and go”
test, pain, Western
Universities
(WOMAC), short form12 (SF-12), range of
motion, knee and calf
swelling, and wound
healing parameters
Range of knee motion
was measured
preoperatively and at
1-year review.
Validated knee scores
and an SF-12 health
questionnaire were
also recorded
The effect of treatment
on disability, fearavoidance beliefs, pain
intensity, and quality of
life
traditional-protocol
group
There were no
difference in gain of
function or quality of
life between the two
groups at three and six
months follow-up
independence
The study found no
statistically significant
difference among the 3
groups in each
parameter
The authors concluded
that CPM gives no
benefit in immediate
functional recovery
post-TKA, and in fact,
the postoperative knee
swelling persisted
longer
Although patients in
group A achieved a
greater range of knee
motion than those in
group B, this was not
statistically significant.
No difference either
was noted in any of
the outcome measures
used
The analysis revealed
a significant time by
group interaction in all
the variables in favor
of the experimental
group. The treatment
effect was clinically
tangible in terms of
disability and quality of
life, and persisted for 6
Outpatient
physiotherapy does
not improve the range
of knee motion after
primary total knee
arthroplasty
Individual, supervised
home-training and
group-based
rehabilitation
programmes improved
patients’ quality of life
and physical function
equally six months
after TKA
A home-based
program based on
functional exercises
and the management
of kinesiophobia was
useful in changing the
course of disability,
fear-avoidance beliefs,
pain, and the quality of
life in patients with
given a book
containing theoretical
information about the
management of
kinesiophobia
Patients in the
experimental group
were instructed to use
I-ONE stimulator
4hours/day for 60days.
Postoperatively, all
patients received the
same rehabilitation
program
Moretti et al., 2012
TKA
Naylor et al., 2012
TKR
A 6-week group-based
(GRP) or monitored
home-based
programme (MHP) 2
weeks post surgery
Petterson et al., 2009
200 patients with
primary, unilateral TKA
1 of 2 intervention
protocols: an exercise
group (volitional
strength training) or an
exercise-NMES group
(volitional strength
training and NMES)
Control group: No
treatment
The Knee Society
Score, SF-36 HealthSurvey and VAS.
Patients were
evaluated preoperatively and one,
two, six and 12 months
after TKA
HR and participant
perceived exertion
(PE, 0–10 point scale)
captured exercise
intensity. Qualitative
description using
triangulation of
informant sources
identified factors
influencing exercise
performance
Control group:
Standard of care
A burst superimposition test to
assess quadriceps
strength and volitional
activation 3 and 12
months
postoperatively. The
Medical Outcomes
Study Short Form 36
months after the
intervention ended
TKA
The Knee-Score, SF36 and VAS
demonstrated
significantly positive
outcomes in the I-ONE
stimulated group
compared with the
controls at follow-ups.
In the I-ONE group,
NSAID use was
reduced and joint
swelling resolution was
more rapid than in
controls
For both programmes,
attainment of training
HR was almost
universal, average
time spent above the
training HR exceeded
30 minutes, and PE
indicated moderate
exertion. Individual
inconsistency in time
spent above the
training HR was
evident between
testing weeks in GRP
participants
Strength, activation,
and function were
similar between the
exercise and exerciseNMES groups at 3 and
12 months. The
standard of care group
was weaker and
exhibited worse
The results of the
study show early
functional recovery in
the I-ONE group. IONE therapy should
be considered after
TKA to prevent the
inflammatory reaction
elicited by surgery, for
pain relief and to
speed functional
recovery
TKR recipients
participating in
exercise programmes
can exercise
moderately hard
indicating a potential
for rehabilitation to
improve
cardiovascular fitness.
Whether individual
fitness actually
improves likely
depends in part on
therapist recognition of
key modifiable factors
Progressive
quadriceps
strengthening with or
without NMES
enhances clinical
improvement after
TKA, achieving similar
short- and long-term
functional recovery
Piva et al., 2010
43 TKA patients
The interventions were
6 weeks (12 sessions)
of a supervised FT or
FT-B program,
followed by a 4-month
home exercise
program
Piva et al., 2011
31 TKA patients
The purpose of the
study was to
determine whether hip
abductor strength
(force-generating
capacity) contributes
to physical function
beyond what can be
explained by
quadriceps muscle
strength in patients
after a TKA
Valtonen et al., 2010
50 patients after
unitaleral TKR
Twelve-week
progressive aquatic
resistance training
(n=26)
and Knee Outcome
Survey were
completed. Knee
range of motion,
Timed Up and Go,
Stair-Climbing Test,
and 6-Minute Walk
were also measured
Feasibility measures
included pain,
stiffness, adherence,
and attrition. The
primary outcome
measure was a battery
of physical
performance tests:
Self-selected gait
speed, chair rise test,
and single-leg stance
time
Control group: No
intervention (n=24)
Strength of quadriceps
muscles and hip
abductors was
measured using an
isokinetic
dynamometer.
Performance-based
physical function was
assessed with 4
measures: selfselected walking
speed, the Figure-of-8
Walk Test, the Stair
Ascend/Descend Test,
and the 5-Chair Rise
Test
Mobility limitation
assessed by walking
speed and stair
ascending time, and
self-reported physical
functional difficulty,
function at 12 months
compared with both
treatment groups
and approaching the
functional level of
healthy older adults.
Conventional
rehabilitation does not
yield similar outcomes
Feasibility of the
balance training in
people with TKA was
supported by high
exercise adherence, a
relatively low dropout
rate, and no adverse
events. Both groups
demonstrated clinically
important
improvements in
lower-extremity
functional status
Quadriceps muscle
strength was
associated with
performance on the
Stair Ascend/Descend
Test. Hip abductor
strength was
associated with
performance on the
Stair Ascend/Descend
Test, the Figure-of-8
Walk Test, and the
5-Chair Rise Test
There is a need for
conducting a larger
randomized controlled
trial to test the
effectiveness of an
FT_B program after
TKA
Compared with the
change in the control
group, habitual walking
speed increased by
9% and stair
ascending time
Progressive aquatic
resistance training had
favorable effects on
mobility limitation by
increasing walking
speed and decreasing
After TKA, hip
abductor strength
influenced physical
function in participants
more than did
demographic or
anthropometric
measures or
quadriceps strength
Valtonen et al., 2011
50 patients after
unitaleral TKR
Twelve-month followup of 12-week
progressive aquatic
resistance training
Control group: no
intervention
pain, and stiffness
assessed by Western
University
(WOMAC)
questionnaire
Isokinetic knee
extensor and flexor
power, thigh muscle
cross-sectional area
(CSA), habitual
walking speed, stair
ascending time, and
sit-to-stand test
decreased by 15% in
the aquatic training
group. There was no
significant difference
between the groups in
the WOMAC scores
stair ascending time.
In addition, training
increased lower limb
muscle power and
muscle CSA
After the 12-month
follow-up, the 12-week
aquatic traininginduced benefits in
knee extensor and
flexor power were
maintained, whereas
the mobility benefits
had disappeared
Aquatic resistance
training should be
continued at least on
some level to maintain
the training-induced
benefits in mobility
ETM 02 Alltagstraining – Hüft-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
32 patients after THA
Brem et al., 2010
Intervention (Art,
Intensität, Dauer)
A 10-day longitudinal
study of patients
who played Dr.
Kawashima’s Brain
Training: How Old Is Your
Brain? (Nintendo;
Redmond, Washington)
on a Nintendo DS
handheld
console
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Control group: No
treatment
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Cognitive
performance 1 day
preoperation, as
well as on days 2 and
9 postoperation
With the daily
exercise
of a specific VG by
the play group, the
patients’ fluid
intelligence, working
memory capacity, and
rate of information
processing
significantly improved
over the course of 7
Exercise with video
games (VGs) can
prevent the loss of
cognitive performance
during prolonged
hospitalization
60 patients older than
65 years after THR
Cognitive dysfunction and
other adverse events
(AEs) were measured in
this prospective cohort
study
60 primary elective
THR patients.
Standard gait reeducation programme
and bed exercises, which
consisted of active ankle
dorsiflexion/plantarflexion,
active knee flexion, and
static quadriceps and
gluteal exercises
The cognitive function
was measured
preoperatively, one
week and six months
postoperatively by the
mini-mental state test
(MMSE)
Postler et al., 2011
Smith et al., 2008
ETM 02 Alltagstraining – Knie-TEP
Control group:
Standard gait reeducation programme
without bed exercises
Iowa Level of
Assistance Scale
(ILOA), the Short
Form-12 Health
Survey (SF-12),
duration of hospital
admission and
postoperative
complications were
assessed at baseline,
and 3 days and 6
postoperative days.
The cognitive
performance of the
control group did not
increase. However,
the memory spans of
both groups did not
systematically
change.
Shortly after surgery 4
patients (6.7%)
developed
postoperative
cognitive dysfunction,
which has recovered
at six-months-followup. In 41 patients
(68.3%) AEs were
recorded.
Postoperative anemia
occurred as the most
common AE (n = 32;
53.3%)
There was no
difference in ILOA
scores between the
two groups on the
third postoperative
day. There was no
difference between
the groups in duration
of hospital admission,
SF-12 scores or
postoperative
complications at
Week 6
With use of a simple
and quickly performed
test like the MMSE
patients can be
effectively screened
for impaired cognitive
function. Secure
identification of those
patients is mandatory
to avoid complications
with harmful longterm effects
This study suggests
that during the first six
postoperative weeks,
the addition of bed
exercises to a
standard gait reeducation programme
following THR does
not significantly
improve patient
function or quality of
life
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
60 adults with medial
compartment
osteoarthritis, suitable
for a PKR
Jenkins et al., 2008
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Six weeks after PKR,
participants randomly
received either
kneeling advice and
education or routine
care where no specific
kneeling advice was
given
Control group: Routine
care
The primary outcome
measure was patientreported kneeling
ability, as assessed by
question 7 of the
Oxford Knee Score.
Other factors
associated with
kneeling ability were
recorded
A significant
improvement in
patient-reported
kneeling ability was
found at 1 year
postoperatively in
those participants who
received the kneeling
intervention
The single factor that
predicted patientreported kneeling
ability at 1 year
postoperatively was
the physical therapy
kneeling intervention
given at 6 weeks after
PKR. The results of
this study suggest that
advice and instruction
in kneeling should
form part of a
postoperative
after PKR
ETM 03 Physikalische Therapie
Reviews
Anzahl Studien
Kernergebnis
Empfehlung
10 Studien zu Kryotherapie, 10 Studien zu
Elektrotherapie
Zur Kryotherapie konnten nur vereinzelt
positive Auswirkungen in den ersten
Tagen nach der Operation im Vergleich
mit den Kontrollbehandlungen beobachtet
werden, so dass eine Überlegenheit der
Kälteanwendungen gegenüber anderen
postoperativen Schmerztherapien nicht
Kryotherapie: Da jedoch einzelne Studien
Effekte gezeigt haben, liegt dennoch für
beide Indikationen der Evidenzgrad Ib vor.
Studien zur Elektrotherapie bieten
Hinweise, dass bei einer sehr hohen
Therapiedosis der Elektrotherapie eine
verbesserte Gehfunktion sowohl bei Hüft-
eindeutig abgeleitet werden kann.
als auch bei Knie-TEP-Patienten erreicht
werden kann (jeweils Evidenzgrad Ib),
jedoch einem Krafttraining bei Hüft-TEPPatienten nicht überlegen ist.
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
136 primary total
joint arthroplasties
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
The isolated effect of
physical therapy (PT)
on total joint
arthroplasty hospital
length of stay (LOS) in
a prospective cohort
study
Chen et al., 2012
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
The LOS was
determined by the
operative start time
until the time of
discharge. On
postoperative day
(POD) 0, 60 joints
remained in bed, 51
moved to a chair, and
25 received PT (22
ambulated, 3 moved to
a chair). Length of stay
differed for patients
receiving PT on POD 0
(2.8 ± 0.8 days)
compared with POD 1
There was no
difference in PT
treatment based on
nausea/vomiting, pain
levels, or discharge
location. Isolated PT
intervention on POD 0
shortened hospital
LOS, regardless of the
intervention performed
This emphasizes
the need for faster and
earlier patient recovery
so that they may
receive immediate
postoperative PT to
facilitate earlier
discharges. Future
longitudinal studies
are needed to assess
if limited PT affect
patients' longterm
outcomes and
functionality
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
ETM 03 Physikalische Therapie – Hüft-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Empfehlung
16 patients who
underwent primary
total hip arthroplasty
(THA)
A hydrotherapy (HAT)
16 age-matched
healthy volunteers
were the control
subjects
Mean speed, mean
stance duration, mean
swing duration, step
duration, balance,
mean stride length
70 elderly inpatients
with recent THA
The subjective
functional outcome of
total hip arthroplasty
(THA) in patients who
underwent
hydrotherapy (HT) 6
months after
discharge: A
prospective
randomized study
The intervention group
(n_16; 78_8y)
received simultaneous
low-frequency electric
muscle stimulation
of bilateral quadriceps
and calf muscles
(highest tolerated
intensity, 1h session, 5
d/wk, for 5 weeks)
associated with
33 of them were
treated in conventional
gyms (no-hydrotherapy
group = NHTG
Interviews with the
Western-Ontario
MacMasters
Universities
(WOMACTM) were
performed at
admission, at
discharge and 6
months later
Maximal isometric
strength of knee
extensors, FIM
instrument, before and
after; a six-minute walk
test and a 200m fast
walk test, after; length
of stay (LOS)
Giaquinto et al., 2007
Giaquinto et al., 2010
Subjects (N=29)
referred to the
rehabilitation
department after THA
for hip OA
Gremeaux et al., 2008
The control group
(n_13; 76_10y)
received conventional
physical therapy alone
(25 sessions)
The patients presented
with a mean speed of
749 meters per hour at
the baseline. At the
last session the mean
speed was 1175
meters per hour. The
mean stance duration
was 1.59 s on the
operated side and 1.67
on the non-operated
side. By contrast, the
mean swing duration
was 1.02 s on the
operated side and 0.95
s on the non-operated
side. The differences
in balance were
Both groups improved.
Pain, stiffness and
function were all
positively affected.
Statistical analysis
indicated that WOMAC
sub-scales were
significantly lower for
all patients treated with
HT
Low-frequency electric
muscle stimulation
was well tolerated. It
resulted in a greater
improvement in
strength of knee
extensors on the
operated side. This
group also showed a
greater improvement
in FIM scores, though
The study design
permits accurate
definition of stride
parameters during
rehabilitation which
allows optimization of
the programme.
Increase in speed and
regain of balance are
monitored on a daily
basis and they appear
as the targets of a HT
programme
The benefits at
discharge still
remained after 6
months. We conclude
that HT is
recommended after
THA in a geriatric
population
Low-frequency electric
muscle stimulation is
a safe, well-tolerated
therapy after THA for
hip OA. It improves
knee extensor
strength, which is one
of the factors leading
to greater functional
independence after
THA
conventional physical
therapy including
resistance training
improvements in the
walk tests were similar
for the 2 groups, as
was LOS
ETM 03 Physikalische Therapie - Knie-TEP
Reviews
Anzahl Studien
Bade et al., 2012
Unbekannt – literature review
Mak et al., 2013
One SR with meta-analysis assessing the
efficacy of ice after TKR was included
Markert et al., 2011
11 articles
Kernergebnis
Empfehlung
There is emerging evidence that strength
and functional gains can be made after the
acute postoperative recovery period with
programs focusing on the use of
progressive aquatic exercise or eccentric
exercise
. Cryotherapy increases knee flexion at the
time of discharge (6 degrees), and
reduces blood loss but does not reduce
the rate of donor blood transfusion
Functional recovery following TKA can be
enhanced by the use of NMES and
utilization of a comprehensive, higher
intensity strength training program in
conjunction with traditional rehabilitation
approaches
Recommendation: Small and temporary
benefits gained from cryotherapy do not
support its routine use after TKR
Six of the studies showed significantly
lower pain scores in the cold compression
group than in a control group. Overall,
most of the studies showed no difference
in ROM of the operated knee , a decrease
in swelling, and a decrease in blood loss
with the cold compression
Even though current evidence does not
point to the Cryo/Cuff as being more
effective, it appears to provide better
patient outcomes – patient comfort and
being kept informed are two major facors
in patient care
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
(Intervention,
Patientengruppe)
70 patients who
underwent TKR
Patients in group A
received electric muscle
stimulation and standard
physiotherapy for 6
weeks
100 patients with TKR
3 groups of: active
stretching (group 1,
n=32), passive stretching
(group 2, n=35) and
proprioceptive
neuromuscular facilitation
stretching (group 3,
n=33)
primary unilateral TKA
Patients were
randomized into three
groups and received
‘‘gaseous cryotherapy
(GC)’’, ‘‘cold pack’’ and
‘‘cryocuff’’ applications
Patients in group B
received physiotherapy
only
All patients were
assessed with both
subjective and
objective clinical
scales preoperatively
and at 6, 12, and 52
Avramidis et al., 2011
Chow et al., 2010
Demoulin et al., 2012
The immediate
change in both active
and passive knee
flexion range after the
first treatment session
and the pattern of
change in these
ranges throughout the
2-week study period
were compared
among
the three groups
Primary outcomes
(knee pain intensity,
mobility and girth
measurements) were
recorded on
preoperative day 1 as
well as on
postoperative day
(POD) 7
Patients in group A
demonstrated a
increase in walking
speed, Oxford Knee
Score, and American
Knee Society function
score compared to
those in group B at 6
weeks. A statistically
significant increase in
the SF-36 physical
component summary
score was observed
at 6, 12, and 52
weeks
For between group
comparisons, no
was found in both
active and passive
knee range
immediately after
stretching
Although skin
temperature dropped
to 14 8C following GC
versus 22 to 24 8C for
the other two
applications (P <
0,05), the three
groups did not differ
at POD7 regarding
the three primary
outcomes
Electrical stimulation
of the vastus medialis
muscle in addition to
conventional
physiotherapy
improves functional
recovery and early
rehabilitation after
TKR
This study revealed
that all three modes of
stretching were
associated with an
increase in the knee
flexion range of
patients after total
knee replacement,
with no statistically
between the changes
seen
Gaseous cryotherapy
was not more
beneficial than
routinely used
strategies for applying
cold therapy. Further
studies with larger
sample size and with
a more frequent and
closer gaseous
cryotherapy
applications are
needed to confirm our
43 patients scheduled
for TKA
MLD (vs no MLD) on
days 2, 3, and 4
postoperatively. Both
groups underwent
conventional,
concomitant physical
therapy
20 patients scheduled
for unilateral primary
TKA
The patients were treated
on two days (day 7 and
day 10) postoperatively.
On one day they
received 30 minutes of
knee icing (active
treatment) and on the
other day they received
30 minutes of elbow icing
(control treatment)
A program of NMES and
range of motion
exercises performed at
home without therapist
supervision
Control group:
Conventional physical
therapy
Ebert et al., 2013
Holm et al., 2012
Levine et al., 2013
Control group: A
postoperative protocol
of conventional
physical therapy with a
licensed therapist,
including range of
motion exercises and
strengthening
exercises
Clinical assessment
was undertaken preand postoperatively
prior to and after the
designated
postoperative MLD
sessions (days 2, 3,
and 4) and at 6 weeks
postsurgery
Maximal knee
extension strength
(primary outcome),
knee pain at rest and
knee pain during the
maximal knee
extensions were
measured 2–5
minutes before and 2–
5 minutes after both
treatments by an
assessor blinded for
active or control
treatment
Noninferiority of the
NMES program was
obtained 6 weeks
postoperatively (Knee
Society pain/function
scores, Western
Universities
flexion
A significant group
effect was observed
for active knee
flexion, with post hoc
tests demonstrating a
significantly greater
active knee flexion in
the MLD group when
compared with the
control (no MLD)
group at the final
measure prior to
hospital discharge
(day 4 postsurgery)
and at 6 weeks
postsurgery
The change in knee
extension strength
associated with knee
icing was not
significantly different
from that of elbow
icing. The changes in
knee pain at rest or
knee pain during the
knee extension
strength
measurements were
not different between
treatments
Noninferiority was
shown 6 months
postoperatively for all
parameters. The
results suggest that
rehabilitation
managed by a
physical therapist
results in no functional advantage or
difference in patient
satisfaction when
results
MLD in the early
postoperative stages
after TKA appears to
improve active knee
flexion up to 6 weeks
postsurgery, in
addition to
conventional care.
In contrast to
observations in
experimental knee
effusion models and
inflamed knee joints,
knee joint icing for 30
minutes shortly after
had no acute effect on
knee extension
strength or knee pain
Neuromuscular
electrical stimulation
and unsupervised athome range of motion
exercises may provide
an option for reducing
the cost of the
postoperative TKA
recovery process
without compromising
quadriceps strength or
patient satisfaction
80 patients following
TKA
The complementary
treatment of acupuncture
was performed three
times/
week from postoperative
day 7 until postoperative
day 21
A 65-year-old female
underwent a right,
cemented TKA
A traditional TKA
augmented by NMES,
which was initiated 48
hours after surgery and
continued twice a day for
the first 3 weeks, and
once daily for 3 additional
weeks
59 patients after TKR
Neurostimulation (NIN)
therapy using the InterX
device: 8 sessions of NIN
therapy over 3 post-op
days in addition to the
standard course received
by the Control group
The control group
received the standard
hospital course of pain
medication and
rehabilitation twice
daily for 3 post-op
days
78 stationäre KTEPPatienten
Alle Patienten erhielten
eine standardisierte
stationäre
Anschlussheilbehandlung
(AHB). Die
Kontrollgruppe:
Scheintherapie mit
einem baugleichen
Gerät im gleichen
Prozedere
Mikashima et al., 2012
Mintken et al., 2007
Nigam et al., 2011
Rockstroh et al., 2010
Control group: No
treatment
Outcome measures
were: i) pain as
assessed by a visual
analog scale; ii)
reduction of swelling
around the knee as
indicated by its
circumference at the
center of the patella;
and iii) ROM of the
affected knee
Isometric quadriceps
and hamstrings
muscle torque were
measured
preoperatively and at
3, 6, and 12 weeks
after TKA. Quadriceps
muscle activation was
measured using a
doublet interpolation
technique at the same
time points
Pain and range of
motion were collected
as the primary study
measures
Als primärer klinischer
Endpunkt der
Untersuchung wurde
die dreimonatige
Änderung eines auf
compared with NMES
and an unsupervised
at-home range of
motion program
Group A patients had
significantly reduced
pain and swelling
around the knees and
earlier recovery of
ROM than did those
in Group C
At 3, 6, and 12 weeks
after TKA, quadriceps
torque was greater
than the preoperative
values of the involved
side by 16%, 29%,
and 56%,
respectively. Similarly,
activation improved to
93.4%, 94.6%, and
93.5% at 3, 6, and 12
weeks after TKA
Within a relatively
short 3-day period of
time, patients in the
experimental group
obtained the
necessary ROM for
discharge and did it
experiencing lower
levels of pain than
those in the control
group
Die Stichproben
unterschieden sich
statistisch signifikant
im dreimonatigen
Anstieg (p < 0,001),
Acupuncture provides
effective treatment
during the post-acute
phase of rehabilitation
after TKA with respect
to pain relief,
reduction
of swelling around the
knee, and early
recovery of ROM
Mitigating quadriceps
muscle weakness
immediately after TKA
using early NMES
may improve
functional outcomes,
because quadriceps
weakness has been
associated with
numerous functional
limitations and an
increased risk for falls
The results clearly
demonstrated the
clinical benefit of NIN
therapy as a
supplement to the
standard rehabilitation
protocol. The subjects
receiving InterX fared
significantly better
clinically
Die Kombination der
Mikrostromtherapie
mit einer
konservativen
Physiotherapie nach
Interventionsgruppe
erhielt zusätzlich zehn
Anwendungen der
Mikrostromtherapie (MT)
nicht jedoch im
Nutzenwert vor AHB
(p = 0,841)
Knie-TEP hat einen
quantifizierbaren früh
zeitigen und
mittelfristig nachhaltig
höheren funktionellen
Nutzen als die
Physiotherapie mit
Scheinbehandlung
No significant
difference was found
in terms of the
maximum, minimum
and excursion knee
joint angle during any
of the functional
activities
At 3.5 weeks, there
was a significant
association between
NMES training
intensity and a
change in quadriceps
muscle strength and
activation. At 6.5
weeks, NMES training
intensity was related
to a change in
strength but not to a
change in activation
At 3.5 weeks after
TKA, significant
improvements with
NMES were found for
quadriceps and
hamstring muscle
strength, functional
performance, and
There were minimal
functional
improvements in the
navigated total knee
arthroplasty group 12
months after surgery.
However, these are
unlikely to have a
significant effect on
daily activity for the
navigated group
Higher NMES training
intensities were
associated with
greater quadriceps
muscle strength and
activation after TKA
The patients were
randomised into 2
surgical groups (n=102
navigated group, n=98
conventional group;
mean age navigated=67,
conventional=67)
30 people who were
50 to 85 years of age
and who received
NMES after TKA
Standard rehabilitation
plus NMES to the
quadriceps muscle to
mitigate strength loss.
NMES was applied 2
times per day at the
maximal tolerable
intensity for 15
contractions beginning
48 hours after surgery
over the first 6 weeks
after TKA
Control group:
Neuromuscular
electrical stimulation
training intensity and
quadriceps muscle
strength and activation
were assessed before
surgery and 3.5 and
6.5 weeks after TKA
66 patients, aged 50 to
85 years and planning
a primary unilateral
TKA
plus NMES applied to the
quadriceps muscle
(initiated 48 hours after
surgery). The NMES was
applied twice per day at
the maximum tolerable
intensity for 15
Control group:
Data for muscle
strength, functional
performance, and selfreport measures were
obtained before
surgery and 3.5, 6.5,
13, 26, and 52 weeks
after TKA
Smith et al., 2013
Stevens-Lapsley et al.,
2012a
Stevens-Lapsley et al.,
2012b
dem OSWESTRYFragebogen basierten
Nutzenwerts ( %)
festgelegt. Sekundäre
Zielgrößen waren der
WOMAC-ArthroseIndex sowie das
subjektive
Schmerzempfinden
laut Visueller
Analogskala (VAS)
Flexible
electrogoniometry was
used to measure
patient's knee
kinematics with
respect to time during
12 functional activities
The early addition of
NMES effectively
attenuated loss of
quadriceps muscle
strength and improved
functional
performance following
TKA. The effects were
contractions
Patients were
randomised to treatment
with a cryopneumatic
device or ice with static
compression
Patients were
evaluated by physical
therapists blinded to
the treatment arm.
Range of motion
(ROM), knee girth, six
minute walk test
(6MWT) and timed up
and go test (TUG)
were measured preoperatively, two- and
six-weeks postoperatively
30 patients (24 women
and 6 men)
undergoing bilateral
Standard postoperative
physiotherapy
programme, each patient
was also given either 10
sessions of acupuncture
or sham acupuncture
within two weeks
Control group:
Standard
postoperative
physiotherapy
programme
TKA
Millimetre wave therapy
(MWT) consisted of six
sessions, each session
Control group: Sham
procedure
Su et al., 2012
Tsang et al., 2007
Usichenko et al., 2008
The primary outcome
measures were the
levels of pain at rest
and at maximum after
exercise measured by
the numeric pain
rating scale. Other
outcome measures
included active and
passive ranges of
knee motion
measured by standard
goniometer, and
ambulation measured
by the timed up-andgo test
The primary outcome
measure was
postoperative
knee extension active
range of motion. At 52
weeks, the
differences between
groups were
attenuated, but
improvements with
NMES were still
significant
At two weeks postoperatively, both the
treatment and control
groups had
diminished ROM and
function compared to
pre-operatively. Both
groups had increased
knee girth compared
to preoperatively.
There was no
in ROM, 6MWT, TUG,
or knee girth between
the 2 groups
The mean differences
in overall averages of
postoperative mean
pain levels were 0.4
(–0.6 to 1.3) and –0.8
(–2.0 to 0.4) at rest
and at maximum
respectively. There
were no significant
differences in the
active and passive
ranges of knee motion
and the time for the
timed up-and-go test
between the two
groups
Piritramide
requirement was
similar in both groups
most pronounced and
clinically meaningful
within the first month
after surgery, but
persisted through 1
year after surgery
There was a trend
toward a greater
distance walked in the
6MWT. Patient
satisfaction with the
cryopneumatic cooling
regimen was
significantly higher
than with the control
treatment
There is no difference
between the acute
effects of acupuncture
and sham
acupuncture in
addition to standard
postoperative
physiotherapy
programme in patients
with knee
osteoarthritis
undergoing bilateral
The majority of
patients in both
groups believed they
of 30 min duration.
During each session the
knee wound was
exposed to
electromagnetic waves
with frequency 50–75
GHz and power density
4.2 mW/cm2
piritramide
requirement for three
days after surgery
whereby all patients
reported adequate
pain relief measured
on a VAS. Secondary
outcome measures
were also comparable
in both groups
had received true
MWT and wanted to
repeat it in future.
Millimetre waves
applied to surfaces of
surgical wounds did
not reduce opioid
requirement
compared to the sham
procedure after TKA
ETM 04 Patientenschulung
ETM 04 Patientenschulung – Hüft-TEP
Reviews
Anzahl Studien
Eine randomisierte Studie mit Hüft-TEPPatienten von Wong et al.
ETM 04 Patientenschulung – Knie-TEP
Reviews
Kernergebnis
Empfehlung
Bei den Patienten mit Patientenschulung
zeigte sich eine deutlich höhere
Compliance bezüglich des postoperativen
Heimtrainings, und die Patienten fühlten
sich am Ende der Akutphase besser auf
die Entlassung vorbereitet. Keine
Gruppenunterschiede zeigten sich in
Bezug auf die Funktionsfähigkeit und in
einem Wissenstest zu Komplikationen
Die Studie liefert Hinweise auf positive
Auswirkungen intensiver
Patientenschulung bei Patienten mit HüftTEP, allerdings schlagen sich diese
Vorteile eher in den „ weichen “ OutcomeKriterien nieder (Evidenzgrad Ib)
Westby et al., 2012
Anzahl Studien
6 studies
Kernergebnis
Empfehlung
There is evidence to suggest that
evaluation and management of
perioperative psychosocial and other
patient factors are important in enhancing
outcomes after TJA. Further, there is a
growing body of research that points to the
importance of progressive resistance
training after TJA to address the muscle
weakness associated with aging and endstage hip and knee OA, and secondary to
the surgery itself, and to optimize
functional outcomes
With the projected increases in number of
individuals undergoing TJA over the next
two decades, it becomes even more
critical to develop cost-effective
rehabilitation strategies and identify
individuals who would most benefit from
such interventions
ETM 05 Gesundheitsbildung – Hüft-TEP
ETM 05 Gesundheitsbildung – Knie-TEP
Originalartikel
Autor/en und
Publikationsjahr
Su et al., 2010
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
total knee-replacement
surgery
Patients were
interviewed before and
1–2 weeks after
hospital discharge
about their health care
needs
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Data were collected on
participants’
demographic
characteristics,
disease
characteristics,
symptom distress and
health care needs
Before hospital
discharge, the most
important need was
medical personnel to
help relieve
postoperative pain,
and health care needs
were predicted by
symptom distress and
age. After hospital
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Given today’s shorter
hospital stays,
clinicians need to
prioritise health care
needs indicated by
predictive variables.
This strategy would
help optimise
assessment and care
management by
92 total kneereplacement patients
Chen et al., 2014
The experimental
group (n = 42)
received a healtheducational
intervention
The control group (n =
50) received routine
care
Pain scores, stair
climbing ability
discharge, the most
important need was
medical personnel to
help understand the
conditions requiring a
return visit to hospital,
and health care needs
were predicted by
symptom distress,
health care needs
before discharge, age
and gender
The experimental
group reported lower
levels of postoperative
pain than the control
group. The stairclimbing ability of the
experimental group
was superior to that of
the control group
focusing on patients’
greater health care
needs and by tailoring
care information and
skills to patients’
individual needs
The health-educational
model can be included
in regular clinical
management and care
of total kneereplacement patients
Reviews
Inacio et al., 2013
Anzahl Studien
Twelve studies were identified, one casecohort study and 11 case series
ETM 06 Ernährungsschulung – Hüft-TEP
Kernergebnis
Owing to the observational nature of the
studies and the serious limitations
identified, all were considered very low
quality according to GRADE criteria.
Studies reported 14% to 49% of patients
had some weight loss at least 1 year
postoperatively
Empfehlung
We found no conclusive evidence that
weight or body composition increases,
decreases, or remains the same after TJA
ETM 06 Ernährungsschulung – Knie-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
1367 patients after
TKR
Baker et al., 2013
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Questionnaires to
assess the influence
pre-operative body
mass index has upon
knee specific function,
general health status
and patient
satisfaction at 3 years
following total knee
replacement
Endpunkt(e),
Outcome
Western Ontario and
McMaster University
(WOMAC) and
Medical Outcomes
Trust Short Form-36
(SF-36) scores
supplemented by a
validated measure of
satisfaction
preoperatively and
subsequently at 1,2
and 3 year postoperatively
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Patients with the
highest BMIs
experienced similar
improvements to
patients with a ‘normal‘
BMI at 1 year and up
to 3 years. Despite
equivalent functional
improvements levels of
satisfaction in the .35.0
kg/m2 group were
lower than for any
other BMI group
Obese and morbidly
obese patients gain as
much functional
benefit from total knee
replacement as
patients with lesser
body mass indexes.
This benefit is
maintained for up to 3
years following
surgery. However,
these patients are less
satisfied with their
knee replacement
ETM 07 Psychologische Beratung und Therapie
Reviews
Mak et al., 2013
Anzahl Studien
This review identified NHMRC level I
and/or II evidence to support aspects of
clinical care in more than half the areas
reviewed (16 out of 25)
Kernergebnis
Empfehlung
Level I or II evidence is only available for
smoking cessation programmes. Smoking
cessation, through a short-term
programme, is associated with fewer
complications after surgery
Recommendation: A short-term smoking
cessation programme is implemented prior
to surgery and in the acute care period
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
17 patients after
THA/TKA
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Questionnaires to
investigate the
presence and rates of
anxiety and
depression in
postsurgical patients
Nickinson et al., 2009
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
The Hospital Anxiety
and Depression Scale
was used to measure
anxiety and
depression levels.
Patients completed the
questionnaire on the
day prior to surgery,
then on each postoperative day up to
and including their day
of discharge
Post-operatively 17
patients became
anxious prior to
discharge. No
variables were
significant predictors of
anxiety. Postoperatively 28 subjects
(50%) became
depressed at some
point prior to
discharge. Females
were more likely to
become depressed
than males Those who
had had a previous
lower limb arthroplasty
were more likely to
develop post-operative
depression
The results suggest
that post-operative
depression does occur
in orthopaedic surgery.
The prevalence may
be higher than that
reported in other
surgical specialities.
These findings
emphasize the need
for evaluation of
patients’ psychiatric
state postoperatively
ETM 07 Psychologische Beratung und Therapie – Hüft-TEP
Reviews
Anzahl Studien
Kernergebnis
Empfehlung
4 Studien
Die Ergebnisse bieten Evidenz für die
Wirksamkeit
kognitiv-behavioraler Therapie bei Hüftund Knie-TEP-Patienten
(jeweils Evidenzgrad Ib)
Beide Ansätze werden bereits
erfolgreich in einzelnen
Rehabilitationskliniken in Deutschland
angewandt, jedoch (soweit uns bekannt
ist) im Falle der kognitiv-behavioralen
Therapie nicht spezifisch bei Patienten
mit Total-Endoprothesen
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
The postoperative
values of the PCS and
the MCS for the whole
group of patients
correlated negatively
with the SOC values.
Neuroticism (EPI) and
anxiety as a trait
(STAI) were also
associated with
postoperative
performance, both
in mental and physical
terms
After surgery, state
anxiety remained at a
moderate level,
although a
few minor peaks were
observed, but no
relationship between
state anxiety and
HRQoL was found
Total hip replacement
improves significantly
the patient’s healthrelated quality of life at
6 months after
surgery, what is
influenced by sense of
coherence,
neuroticism and
anxiety as a trait
102 subjects
undergoing total hip
replacement (59
female, 43 male)
Investigating he
relation between some
psychological and
psychiatric factors and
their influence on
health-related quality
of life in patients after
total hip replacement
Beck Depression
Inventory e BDI, State
and Trait Anxiety
Inventory e STAI,
sense of coherence
(SOC-29),
personality traits
(Eysenck Personality
Inventory e EPI) and
health related quality
of life (SF-36)
100 patients
Evaluation of patients’
anxiety and its
possible relationship
with HRQoL
before and after
surgery
The State Trait Anxiety
Inventory was used to
measure patients’
level of anxiety before
surgery and at 1
month, 3 months and 6
months postoperatively. The
Sickness
Impact Profile was
used to measure
Badura-Brzoza et al.,
2009
Montin et al., 2007
Intervention (Art,
Intensität, Dauer)
Patients’ needs and
characteristics should
be carefully assessed
when planning postoperative care and
support. Nurses
should be aware of
factors that may relate
to anxiety and also
consider different
methods of
patients’ total HRQoL
before surgery and
post-operatively at 3
and 6 months
supporting patients’
recovery
ETM 07 Psychologische Beratung und Therapie – Knie-TEP
Reviews
Anzahl Studien
4 Studien
Kernergebnis
Empfehlung
Die Ergebnisse bieten Evidenz für die
Wirksamkeit
kognitiv-behavioraler Therapie bei Hüftund Knie-TEP-Patienten
(jeweils Evidenzgrad Ib)
Beide Ansätze werden bereits
erfolgreich in einzelnen
Rehabilitationskliniken in Deutschland
angewandt, jedoch (soweit uns bekannt
ist) im Falle der kognitiv-behavioralen
Therapie nicht spezifisch bei Patienten
mit Total-Endoprothesen
Originalartikel
Autor/en und
Publikationsjahr
Büyükyılmaz et al.,
2013
Patientengruppe,
die untersucht
wurde
Intervention (Art,
Intensität, Dauer)
60 THA / TKA patients
Relaxation
techniques and back
massage on
postoperative pain,
anxiety, and vital
signs on postoperative
days 1-3
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Control group: No
treatment
Endpunkt(e),
Outcome
The McGill Pain
Questionnaire Short
Form (MPQ-SF)
and State Anxiety
Inventory (SAI),
vital signs, including
blood pressure
Kernergebnis
Results of this
research provide
evidence to support
the use of relaxation
techniques and back
massage
at bed rest times of
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Use of these
interventions should
be implemented by
nurses into routine
plans of care for
patients
Subjects (n = 93)
recruited from a
medical centre in
Taipei,
Lin et al., 2010
Relaxation
therapy from the day
before surgery to the
third postoperative
day. Researchers
helped participants
listen to a breath
relaxation
and guided imagery
tape for 20 minutes
daily
Control group: No
treatment
(systolic
and diastolic), pulse,
and respiratory rate
A pain and anxiety
scale questionnaire,
the State-Trait Anxiety
Inventory
questionnaire, blood
pressure and heart
rate were monitored
before and after
intervention
patients to decrease
pain and anxiety
The two groups
differed significantly in
systolic blood pressure
but not in mean blood
pressure, heart rate, or
State-Trait Anxiety
Inventory scores.
Patients reported that
relaxation therapy
helped them relax and
promoted sleep.
Clinical practice
should include
complementary
relaxation therapy to
alleviate pain and
anxiety
in patients with joint
replacement
ETM 08 Entspannungstraining – Hüft-TEP
ETM 08 Entspannungstraining – Knie-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
A 57-year-old female
with unilateral knee
osteoarthritis (case
report)
McClelland et al., 2012
Intervention (Art,
Intensität, Dauer)
A novel rehabilitation
protocol intended to
improve walking
biomechanics and
functional outcomes
after TKA: Evaluation
prior to TKA and at 3
and 10 weeks after
surgery
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Outcomes of the
rehabilitation were
compared to a
historical cohort of
patients with TKA.
Kernergebnis
Progressive
quadriceps
strengthening and
movement retraining
to promote
symmetrical weight
bearing during
strengthening
exercises and
functional activities
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Restoration of
symmetrical
movement patterns
could improve longterm outcomes of TKA
ETM 09 Sozial- und sozialrechtliche Beratung
ETM 10 Unterstützung der beruflichen Integration
Reviews
Anzahl Studien
3 studies
Kernergebnis
Empfehlung
Patient discharge based on guidelines
compared to discharge without guidelines
The results suggests
that patient discharge guidelines
have no effect on the time patients take to
RTW
Kuijer et al., 2009
ETM 10 Unterstützung der beruflichen Integration – Hüft-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
943 patients younger
than
60 years
Nunley et al., 2010
Intervention (Art,
Intensität, Dauer)
A multicenter
telephone survey
about the returning to
work
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Endpunkt(e),
Outcome
Factors associated
with return to work
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Most young, active hip
arthroplasty
patients can expect to
return to their
preoperative
occupation, and very
few will be limited in
their ability
to return to their prior
job due to concerns or
problems
with their operative hip
Return to employment
is an important goal for
many
patients undergoing
hip arthroplasty
surgery, especially
younger, more active
patients with high
levels of
preoperative function
ETM 10 Unterstützung der beruflichen Integration – Knie-TEP
ETM 11 Nachsorge und soziale Integration
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
Support persons of
patients who have
undergone total joint
replacement surgery
Mazaleski et al., 2011
Intervention (Art,
Intensität, Dauer)
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
The Plan, Do, Study,
Act quality
improvement model
utilized to organize
and evaluate a
weekly postoperative
class for support
persons
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Results gathered from
post-class surveys
thus far indicate that
the knowledge gained
from the postoperative
class has increased
perception of caregiver
preparedness for the
recovery phase of the
patients
An innovating
opportunity to educate
not only patients but
also their loved ones
to ensure
positive outcomes
after discharge
Endpunkt(e),
Outcome
Kernergebnis
Von den Autoren
aus dem Ergebnis
abgeleitete
Empfehlung
Health status: Eight
main dimensions
The intervention
reduced the time
patients needed to
reach their habitual
levels in 3 of 8
Intervention by
telephone support and
counselling seems to
benefit patients’
improvement in health
Enhancing patientand family-centered
care
ETM 11 Nachsorge und soziale Integration – Hüft-TEP
Originalartikel
Autor/en und
Publikationsjahr
Patientengruppe,
die untersucht
wurde
180 patients aged 65
years and over
Hordam et al., 2010
Intervention (Art,
Intensität, Dauer)
Telephone interviews
2 and 10 weeks after
surgery, patients were
given counselling with
reference to their
Falls
Kontrollgruppe:
Beschreibung der
Kontrollgruppe
(Intervention,
Patientengruppe)
Control group: No
treatment
postoperative situation
ETM 11 Nachsorge und soziale Integration – Knie-TEP
dimensions of health
status
status
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RTS Hüft- und Knie-TEP

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