Home based rehabilitation after a knee replacement is as effective as physiotherapy

Why was the study needed?

More than 100 000 people had a knee replacement in the UK in 2017, and the numbers are rising. Surveys of patients have found that up to one in three (15-30%) experience little or no improvement after surgery. People undergoing knee replacement are increasingly likely to be older and to have more than one long term health condition.

At present, rehabilitation treatment varies widely around the UK. Some people are seen for regular appointments in clinics, others are sent home with a list of exercises to do on their own.

This study was set up to see how a targeted rehabilitation programme, delivered by rehabilitation assistants in people’s homes, compared with standard physiotherapy in the clinic.

What did the study do?

Researchers designed a programme of rehabilitation exercises to be delivered at home by a rehabilitation assistant, and known as Community-based Rehabilitation after Knee Arthroplasty (CORKA). They compared CORKA with standard care (up to six sessions with a physiotherapist). They looked at patients’ outcomes, costs, and acceptability to both patients and clinicians.

Patients thought to be at risk of a poor outcome after knee replacement were selected from 14 NHS hospitals across the UK. The 621 people who agreed to take part were randomly assigned to have standard rehabilitation care or the CORKA intervention.

The CORKA intervention included personalised rehabilitation exercises aimed at helping people carry out tasks. People in this group also received help with adaptations to their home to ensure it was safe for exercises and everyday living. Rehabilitation assistants visited them in their homes for a first assessment and up to six follow-up sessions.

The group receiving usual care had between one and six rehabilitation sessions with a physiotherapist.

What did it find?

One year later, people in both groups said they were able to do more everyday tasks and activities than at the start of the trial. No difference was seen in average scores between the groups.

There was similarly little difference in other outcomes such as knee pain and function, quality of life, how quickly people could stand from a chair, whether they could walk in a figure of eight, or stand on one leg.

Overall, when all costs were considered, CORKA was cheaper to deliver than standard care. The study found that:

– The CORKA programme was cheaper to provide than standard care (£65 per person)

– People in the CORKA group had more primary care and hospital appointments after treatment, making their NHS costs slightly higher (£77 per person)

– When all costs to society were taken into account, including time off work for people attending appointments and unpaid care from friends and relatives, total costs were lower for CORKA than for standard care (£316 per person).

Interviews with 10 patients showed they appreciated the CORKA intervention. They were glad not to have to travel to appointments, and said they got more done in appointments at home than in hospital. They enjoyed the company of the visitor and thought it was helpful for the clinician to adapt their home environment.

The physiotherapists and rehabilitation assistants also said they gained from the experience, although some assistants reported feeling out of their comfort zone.

Why is this important?

Current NICE guidelines for rehabilitation after knee replacement state that a member of the physiotherapy team should give advice on self-directed rehabilitation exercises before the patient leaves hospital. They recommend supported group or individual rehabilitation for certain groups of people, including people who find that self-directed rehabilitation is not working.

The CORKA programme is a feasible alternative to standard knee replacement rehabilitation, and is less expensive on some measures. It was popular with patients, who felt that their treatment was adapted to their individual needs. In addition, it removed the need for them to travel to hospital, which can be difficult for many reasons including caring responsibilities, or other long term conditions.

This model of delivering rehabilitation has implications for the workforce: fewer physiotherapists but more rehabilitation assistants would be needed to implement it more widely. It could be considered when NHS trusts are reconfiguring services

What’s next?

The covid-19 pandemic meant that hospitals involved in the trial had to halt in-person rehabilitation such as CORKA, although some may choose to reintroduce it as services open up again.

The researchers will provide details of the CORKA intervention to any NHS trust interested in taking it up. They say that good communication between the trust carrying out the surgery and the trust carrying out the rehabilitation helps identify the patients likely to benefit from the intervention.