Dr Jon Room

Purpose
Non-weight bearing is often recommended after humeral fractures. This review aims to summarise the extent and nature of the evidence for the feasibility, acceptability, safety, and effects of early weight bearing (EWB) in people with humeral fractures, treated operatively or non-operatively.

Methods
Data sources identified published (PUBMED, EMBASE, CINAHL) and unpublished (ClinicalTrials.gov, CENTRAL, NIHR Open Research, OpenGrey) literature. Independent data extraction was conducted by two reviewers.

Results
13 901 records were retrieved. Ten studies, involving 515 post-operative patients and 351 healthcare professionals, were included. EWB was found to be feasible in nine studies. There was limited evidence regarding adherence to EWB. Trauma and orthopaedic surgeons reported that EWB was acceptable. This depended on surgery type and whether it was a post-operative polytrauma case. No acceptability data was reported from patients’ perspectives. Only one study reported two patients who developed unsatisfactory outcomes from excessive post-operative EWB. Positive effects of EWB were reported on disability level, pain, shoulder and elbow motion, and union.

Conclusion
There is some evidence for the feasibility, safety, and effectiveness of post-operative EWB after humeral fractures. There was limited data on the acceptability of EWB. Heterogeneous study designs, and variations in EWB protocols limit conclusions.

Introduction: Exercise is a widely used treatment modality for older people with musculoskeletal conditions. The effectiveness of exercise programmes is limited by adherence. The aims of this study were to examine the acceptability and feasibility of the AERO intervention in facilitating exercise adherence in older people with musculoskeletal conditions, and to inform the design of a future randomised controlled trial.

Methods: A two arm feasibility randomised controlled trial with an embedded qualitative study conducted at one orthopaedic hospital in the South of England. Older adults referred to physiotherapy with musculoskeletal conditions were randomised to receive either usual care consisting of standard physiotherapy only, or the AERO intervention, consisting of usual care with the addition of tailored exercise adherence approaches based on a brief behavioural assessment. Feasibility outcomes included recruitment, randomisation, retention, acceptability, and fidelity to trial protocol. Secondary outcomes included exercise adherence, physical activity, and behavioural regulation.

Results: 48 participants were recruited to the study with 27 randomised to usual care and 21 to AERO and usual care. On the basis of recruitment, retention, the acceptability to participants and physiotherapists and fidelity, the AERO intervention was determined to be feasible.

Conclusion: The AERO intervention in which participants received tailored adherence strategies based on a behavioural assessment plus standard physiotherapy is feasible and acceptable. It is now ready to be tested in an adequately powered randomised controlled trial.

Contribution of the paper: CLINICAL TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov REF: NCT03643432.

Keywords: Exercise adherence; Musculoskeletal conditions; Older adults.

Introduction: Physiotherapy students lack confidence when applying psychological strategies as part of interaction and assessment. Further research is required to establish consistent approaches to training in prequalifying programmes. The purpose of this study was (a) to document experiences of student physiotherapist to a Stroke-based simulation when applying the model of emotions, adaptation and hope (MEAH) tool, (b) consider if there are different experiences when the tool is applied online versus in-person and (c) provide recommendations for the use and application of the MEAH tool and training for future research and clinical practice.

Methods: An interpretative hermeneutic phenomenological study was undertaken. Two settings were selected in-person and online via zoom©. E-training focussing on the principles of the MEAH was delivered before a 10-minute simulation was undertaken by each student (online or in person). Semi-structured interview examining the experiences of the e-training were analysed using a reflexive thematic analysis. A conversation analysis was applied to 24 recorded in-person conversations.

Results:Twenty-five university final year physiotherapy students completed the in-person study and 13 second year physiotherapy student completed the online study. Thematic analysis: Four major themes across both groups were identified: (a) the content and value of the e-training, (b) the experience and perception of the simulation, (c) the application of the MEAH screening tool and (d) future training needs.

Conversational analysis: Three types of interaction were identified. Type 1 interactions (15/24, 62.5%) followed the form in a very exacting way. Type 2 interactions (3/24, 12.5%) used the tool as an aid to their conversation. Type 3 interactions (6/24, 25%) deviated from the main focus of the tool. Factors which influenced the interaction were identified.

Conclusions: The current study demonstrated that the model of emotions, adaptation and hope can be used to enhance a brief therapeutic interaction for physiotherapy students. Further research and policy recommendations are provided.

Background:
Current evidence suggests that despite being well placed to use psychological strategies to improve complex communication with patients, physiotherapists lack confidence in the application of such strategies [1]. Training to help them to navigate complex interactions with patients presenting with psychological distress is therefore recommended within prequalifying physiotherapy education [2]. A brief therapeutic interaction tool (the model of emotions, adaptation, and hope; MEAH) has been developed for this purpose [3]. The aim of this qualitative study was to explore the experiences of physiotherapy students applying the brief therapeutic interaction using the MEAH in an online setting compared to an in-person setting, within a simulated learning environment.

Methods:
An interpretive hermeneutic phenomenological study design was utilised. Two simulation learning environment settings were selected; (1) 25 final year physiotherapy students experienced the simulation-based activity in the in-person setting on a university campus, and (2) 13 second year physiotherapy students experienced the simulation-based activity in an online setting. A 50-minute pre-recorded e-training lecture was completed prior to all students participating in an individual 10-minute simulation. The simulated patient was played by the same actor in both settings. Two methods of data collection were used: (1) a single semi-structured interview, to consider the experiences of all students across both settings. This data was analysed using reflexive thematic analysis. (2) a live recording of 24 of the in-person student interactions were captured. This data was analysed using conversation analysis.

Results:
Thematic analysis: Four major themes across both groups were identified: (a) the content and value of the e-training (b) the experience and perception of the simulation, (c) the application of the MEAH screening tool, and (d) future training needs. Conversational analysis: Three types of interaction were identified. Type 1 interactions (15/24, 62.5%) followed the form in a very exacting way. Type 2 interactions (3/24, 12.5%) used the tool as an aid to their conversation. Type 3 interactions (6/24, 25%) deviated from the main focus of the tool. Factors which influenced the interaction were identified.

Conclusion:
The simulated practice learning environment provided an ideal way to enhance students’ communication skills, through safe and deliberate practice with a simulated patient. Use of the MEAH tool demonstrated that brief and focused teaching enhanced the perceived confidence of physiotherapy students to undertake difficult patient interactions. Online experiences were perceived more positively compared to in-person training, making it a useful platform to develop student confidence that should be explored further within simulation-based education.

Introduction. Vertebral fragility fractures affect at least 20% of the older population in the UK. Best practice
guidelines recommend the use of exercise to slow the rate of bone loss, to maintain muscle strength and physical function, and to prevent falls and further fractures. However, treatment effects are often small and difficult to sustain and adherence, or the extent to which patients engage in treatment, has been identified as an important issue by many studies. Our hypothesis is that integrating adherence intervention strategies with an exercise intervention will be beneficial. We will compare physiotherapy exercise rehabilitation with adherence support versus physiotherapy exercise rehabilitation alone in terms of effects on (A)
physical function, quality of life and fear of falling and (B) exercise self-efficacy and adherence.
Methods and analysis. A multicentre, two-arm, parallel group, superiority randomised controlled trial with blinded assessments at baseline (0) and 4, 8 and 12 months, with a nested qualitative study and health economic analysis. 116 participants will be allocated to either (1) outpatient
physiotherapy which will include a musculoskeletal assessment and treatment including balance, posture,
strength training and low impact weight-bearing exercises over 16 weeks or (2) OsteoPorosis Tailored exercise adherence INtervention intervention. This includes standard physiotherapy as above plus an additional, integrated assessment interview (30 min) and 60 min of adherence support spread over the subsequent 16 weeks.

Objectives. 
The paper presents insights from the Community based Rehabilitation after Knee Arthroplasty (CORKA) trial. We aimed to explore physiotherapists and physiotherapy assistants’ experiences of delivering a home-base exercise intervention following knee replacement surgery. We were particularly interested in the feasibility, potential benefits and barriers of a community-based exercise programme from the perspective of physiotherapists and physiotherapy assistants and to understand any constraints or training needs that arose. 

Design. 
Qualitative thematic analysis of semi-structured interviews. 

Setting. 
The Community based Rehabilitation after Knee Arthroplasty (CORKA) trial.

Participants. 
Five physiotherapists and six physiotherapy assistants with a range of clinical experience.

Methods. 
Interviews were digitally recorded and transcribed verbatim. We used the stages of reflexive thematic analysis suggested by Braun and Clarke. One researcher conducted the interviewers whilst three researchers with experience in qualitative research methods contributed to the coding and analysis of data.

Results. 
We developed seven themes that help to understand the benefits and challenges of delivering treatment interventions in a person’s home: seeing the person in their own world; thinking outside the cubicle;developing people skills; enjoying the above and beyond; treading a fine line between patient and friend; feeling outside my comfort zone; needing a support network.

Conclusions. 
Treating people in their own homes facilitates a holistic approach. Our findings highlight areas for clinical education: (1) how do we help clinicians to tread the fine line between friend and professional (2) how do we balance the need to provide support and structure with the freedom to work creatively and independently?

Purpose: The purpose of this study was to determine if seeing a physiotherapist affects self-rated confidence, capacity and motivation to exercise.

Methods: The sample consisted of participants from the intervention arm of the AERO feasibility study, which tested an individually tailored exercise adherence intervention for older people with musculoskeletal problems.

Participants were asked three questions prior to starting their first physiotherapy session.
•
Do you feel you have the necessary capacity (e.g. strength, flexibility, fitness, etc.) to undertake an exercise programme? Score on a scale 0–10 where 0 is ‘I definitely don’t have capacity’, to 10: ‘I definitely do have the capacity’

•
How confident do you feel that you can undertake an exercise programme? (i.e. Do you feel you have the time, any equipment that you might need etc.) Score on a scale of 0–10, where 0 is ‘not confident at all’, and 10 is ‘totally confident’

•
How motivated do you feel to undertake your exercise programme on a scale of 0–10? Where 0 is ‘completely unmotivated’ and 10 is ‘completely motivated’

Participants were then assessed and treated by a physiotherapist. After seeing the physiotherapist, the same questions were asked. The time frame between completing the questions for the first and second time was roughly 2 h.

Mean scores and standard deviation for the two timepoints were calculated. Group differences were compared using Wilcoxon signed rank test and effect sizes were calculated with Cohen's D. All data were analysed using SPSS.

Results: 21 participants were recruited to the intervention arm of the AERO feasibility RCT, with a mean age of 74.1 years (SD 6.2 years), 8 of the participants were male and 13 female. Self-reported confidence, capacity and motivation to exercise increased after seeing a physiotherapist –
•
self-rated confidence = pre-physio mean 6.63 (SD 2.59), post-physio mean 9.26 (SD 0.99) Z = −3.304, P = 0.001, d = 1.34

•
Capability pre-physio mean 6.84 (SD 2.50), post-physio mean 8.21 (SD 2.50) Z = −2.684, P = 0.007, d = 0.53

•
Motivation pre-physio mean 7.47 (SD 2.41) post physio mean 9.16 (SD 1.07) Z = −2.680, P = 0.007, d = 0.90

Conclusion(s): This study found that participants self-reported confidence, capability and motivation to exercise increased following an appointment with a physiotherapist. This is important given the challenge of adherence to exercise reported in the previous literature. If interaction with a physiotherapist has the ability to improve behavioural regulation related to exercise, it should continue to be seen as important, particularly as services emerge from COVID-19 restrictions. The results of this study need to be understood in the context of a small sample size that was recruited for a feasibility trial. However, the difference in group means and effect sizes indicate that this is an area that warrants further investigation. Future research should consider testing for this effect in an appropriately large sample size.

Impact: The importance of seeing a physiotherapist to improve behavioural regulation in regard to exercise is underlined.

Further research needs to confirm these findings in a large sample and across different populations.

Funding acknowledgements: This work was funded by the Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, UK and The Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Brookes University, Oxford, UK.

Purpose: To explore participants experiences of trying to adhere to exercise programmes prescribed for musculoskeletal conditions

Methods: This qualitative study was set within an interpretive paradigm. Participants who had taken part in the Adherence for Exercise Rehabilitation (AERO) study, a feasibility randomised controlled trial testing tailored exercise adherence strategies for older patients with musculoskeletal conditions, were invited to take part in a semi-structured interview. Participants were asked if they were interested, and if so, a study invite and participant information sheet was sent out. If still interested participants were scheduled to undertake an interview at a time and location that was convenient for them. All participants gave written informed consent prior to their interview.

All interviews were conducted using a topic guide by JR, a male physiotherapy researcher and PhD student, and all participants were aware of this. The interviews were recorded and transcribed verbatim. The data were analysed using thematic analysis. All transcripts were coded by JR, with three transcripts coded separately by FT, and meetings were held to discuss agreements and disagreements in coding, a third researcher, KB was available to resolve disputes if needed. Subthemes and themes were initially generated by JR and then refined in meetings with FT.

Results: Ten participants took part with an average age of 76 years (SD 8.51, range 66–91), five participants had been in the control group of the AERO study and five in the intervention group.

Five themes were generated from the data, 1) It's not easy, 2) Facets of the physio, 3) Facets of the person, 4) Physiotherapist patient relationship, 5) This really helped.

Conclusion(s): In the themes outlined above participants discussed their experience of trying to adhere to their exercise programmes. The first theme describes the challenge of sticking to an exercise programme, with specific factors making it difficult such as exercises being boring, pain, or not noticing any improvement. In the second theme, participants outlined the importance of who their physiotherapist was, how they made them feel, and how they communicated. Participants valued a supportive approach from someone who wanted them to succeed. Theme three describes the need to consider the individual, it was felt that everyone is different and may need different approaches with regard to sticking to an exercise programme. In the fourth theme, the relationship between physiotherapists and patients was described as crucial, the need to work together was highlighted, in order that patients can be both heard and encouraged, and physiotherapists can acknowledge the current situation but also offer hope for the future. The final theme described things that participants found useful, namely monitoring and feedback, noticing a difference and moving towards goals, exercise programmes that fitted their life, and being able to understand why they were being asked to undertake their exercise programme.

Impact: Physiotherapists may want to consider taking time to build rapport and strong therapeutic relationships, in addition to considering specific steps that may be helpful for the individual patient, in order to facilitate better adherence to exercise in older people with musculoskeletal conditions.

Objectives To evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy.

Design A prospective, single-blind, two-arm randomised controlled superiority trial.

Setting 14 National Health Service physiotherapy departments in the UK.

Participants 621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool.

Interventions A multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy.

Main outcome measures The primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance.

Results 621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4–7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2–6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI −0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months. There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions.

Conclusions The CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group.

Trial registration number ISRCTN13517704.

Objectives: The aim of this study was to explore physiotherapists' perceptions of how patients' adherence and non-adherence to recommended exercise affects their practice.

Design: A qualitative study with a focus group and semi-structured interviews. The focus group and interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

Setting: MSK physiotherapy services in the United Kingdom.

Participants: Focus group: 8 UK registered physiotherapists (age range=24-48; seven female, one male). Semi-structured interviews: 10 UK registered physiotherapists (age range=28-52; eight female, two male).

Results: Participants described how exercise adherence could be a challenging aspect of clinical practice and how they tried to improve it. Four main themes were identified: 1) A challenge but worth it; 2) It's frustrating but you can't win them all; 3) Striving to see the individual; and 4) Striving to help the patient. The importance of establishing a good working relationship with patients was emphasised. This included working collaboratively with the patient, avoiding blaming them for non-adherence and thinking about the language they used in discussing exercises.

Conclusion: Patient non-adherence to recommended exercise is a challenging aspect of clinical practice. Physiotherapists can acknowledge this difficulty, and the frustrations it may potentially bring, yet remain resilient in the face of it. Clinicians should consider potential approaches and strategies to optimise the potential for behaviour change, and to improve exercise adherence. Robust interventions to help clinicians facilitate better exercise adherence are also needed.

Keywords: Adherence; Exercise; Physiotherapy; Qualitative.

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Introduction: Historically persons with haemophilia (PWH) were not encouraged to participate in exercise due to the risk of bleeding and the lack of factor products available. This has now changed, and the availability of safe products allows PWH to be active and participate in sports. Studies have found that exercise has a positive effect on pain, joint health and movement with PWH.

Aim: To record the amount and types of physical activity undertaken by a haemophilia population at a single treatment centre.

Methods: An observational cross-sectional study to assess physical activity and quality of life of all registered patients over the age of 18 at the Oxford Haemophilia and Thrombosis Centre. Participants were posted questionnaires including the International Physical activity Questionnaire (IPAQ), Haemophilia Activity List (HAL), EQ-5D-5L and asked to list their physical activities.

Results: A total of 256 questionnaires were sent, with a 40% response rate for severe and 28% for mild patients. 85% met the UK physical activity guidelines. Sedentary behaviour for an average weekday was 6.4 hours, and weekends were 5.3 hours. Joint disease and severity type influenced the amount of activity undertaken, together with values for HAL and EQ-5D-5L. Twenty two types of activities were listed.

Conclusion: It is encouraging to see the amount of physical activity PWH participate in, however, time spent in a sedentary state needs monitoring. PWH want to be active and the challenge for caregivers is to find activities they can do and strategies to maintain participation.

Keywords: HAL; IPAQ; haemophilia; physical activity; quality of life; sedentary.

Knee osteoarthritis is a common cause of disability in older people and knee arthroplasty surgery in the UK is increasing. The CORKA trial is a randomised controlled trial of rehabilitation targeted at patients identified as being at risk of a poor outcome after knee arthroplasty. This paper describes the development and delivery of the CORKA intervention. It was informed by current evidence, relevant guidelines, expert and patient opinion, practical considerations and a pilot study. The intervention is a multicomponent rehabilitation programme with the main component being an exercise programme delivered to participants in their own home. It includes functional task practice, strategies to improve adherence and where appropriate the provision of appropriate aids and equipment.

Purpose: Small reductions in body weight can decrease osteoarthritic knee pain. Intuitively this should provide a strong incentive for weight-loss. However many people undergoing knee joint replacement (KJR) are categorised as obese. Gender theories can help us to understand differential responses to illness and therefore make an important contribution to rehabilitation. We aimed to explore barriers to weight loss in a group of older men with osteoarthritis.

Materials and methods: We conducted 12 in-depth interviews, before and 1 year after surgery, with six obese men listed for KJR. Analysis was influenced by constructivist grounded theory. We abstracted conceptual themes from the data through constant comparison.

Results: We identified the following themes: (1) I am big and healthy and don't need to lose weight; (2) being this size isn't good for me; (3) men don't have to worry about that sort of thing; (4) I am not as active as I used to be; (5) I have worked hard all my life; (6) what is the point in trying anyway?

Conclusions: Gendered narratives can make it challenging for men to lose weight. Healthcare professionals cannot ignore the influence of gender on rehabilitation and should consider gender specific strategies. Implications for rehabilitation Men may not associate being overweight with being unhealthy. Men may take pride in being in good shape and may respond better to weight loss strategies that focus on fitness not body size. Men may link weight gain with decrease in activity levels rather than overeating. Health care professionals should challenge the assumption that weight loss will follow surgery. Health care professionals cannot ignore the influence of gender on the success of rehabilitation.

Background

The number of knee arthroplasties performed each year is steadily increasing. Although the outcome is generally favourable, up to 15 % fail to achieve a satisfactory clinical outcome which may indicate that the existing model of rehabilitation after surgery may not be the most efficacious. Given the increasing number of knee arthroplasties, the relative limited physiotherapy resources available and the increasing age and frailty of patients receiving arthroplasty surgery, it is important that we concentrate our rehabilitation resources on those patients who most need help to achieve a good outcome. This pragmatic randomised controlled trial will investigate the clinical and cost-effectiveness of a community-based multidisciplinary rehabilitation intervention in comparison to usual care.

Methods/design

The trial is designed as a prospective, single-blind, two-arm randomised controlled trial (RCT). A bespoke algorithm to predict which patients are at risk of poor outcome will be developed to screen patients for inclusion into a RCT using existing datasets. Six hundred and twenty patients undergoing knee arthroplasty, and assessed as being at risk of poor outcome using this algorithm, will be recruited and randomly allocated to one of two rehabilitation strategies: usual care or an individually tailored community-based rehabilitation package. The primary outcome is the Late Life Function and Disability Instrument measured at 1 year after surgery. Secondary outcomes include the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, the Physical Activity Scale for the Elderly, the EQ-5D-5L and physical function measured by three performance-based tests: figure of eight, sit to stand and single-leg stand. A nested qualitative study will explore patient experience and perceptions and a health economic analysis will assess whether a home-based multidisciplinary individually tailored rehabilitation package represents good value for money when compared to usual care.

Discussion

There is lack of consensus about what constitutes the optimum package of rehabilitation after knee arthroplasty surgery. There is also a need to tailor rehabilitation to the needs of those predicted to do least well by focussing on interventions that target the elderly and frailer population receiving arthroplasty surgery.

Trial registration

ISRCTN 13517704, registered on 12 February 2015.