The effects of a six-week, pre-operative, physiotherapy-led exercise and education intervention on post-operative recovery, in terms of pain and function, in patients with osteoarthritis undergoing total knee arthroplasty in the Western Cape

Master Thesis


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University of Cape Town

Background: Osteoarthritis (OA) is one of the most common musculoskeletal conditions (MSCs) worldwide, most commonly affecting those over 60 years of age. OA is associated with pain and disability, and also has negative social and emotional effects on the individual. End stage management for OA of the knee, when the individual is no longer receiving adequate relief from conservative measures, is total knee arthroplasty (TKA). Long waiting lists are a challenge globally and in South Africa (SA) where patients often have to wait years to receive their surgery. Evidence suggests that the longer an individual is in pain, the more likely they are to stay in pain and thus long waiting lists may result in poor post-operative outcomes. It has been found that 10-34% of patients undergoing TKA do not gain adequate relief from surgery. Literature suggests that self-management interventions using exercise and education are effective in reducing pain and improving function in patients who are on a waiting list, in a South African context. The current literature on selfmanagement programmes does not include post-operative follow-up and thus the current study was warranted to determine the effects of a six-week pre-operative physiotherapist-led exercise and education intervention on post-operative recovery in patients with OA undergoing total knee replacement. Methods: A single-blind randomized controlled trial was conducted at Tygerberg Hospital (TBH) in the Western Cape, SA. Pain was the primary outcome measure, with disability (WOMAC), healthrelated quality of life (EQ-5D-5L), fear of movement (TSK) and function (ALF) as secondary outcomes. Participants were randomly placed into the experimental or control group. The experimental group took part in a six-week, group programme, which they attended at TBH. Classes were two hours long and consisted of education, exercise and relaxation training. The control group’s management remained unchanged and they received their usual care. Measurements were taken at recruitment, post-intervention, pre-operatively, post-operatively, and at six weeks and three-months postoperatively by a blinded research assistant. Analysis was by intention to treat. Due to the small sample size, non-parametric analysis was conducted and results are presented as median and range throughout. Effect sizes were calculated with a 95% confidence interval. Results: There were no significant changes between groups on the primary outcome measure of pain. The only outcome revealing any significant change between groups was the TSK, with a large effect size of 1.39 (0.41 – 2.26 95% CI), indicating that the experimental group performed better than the control group at three months post-operative follow-up. Conclusion: Participation in the intervention provided no significant benefit to the experimental group over the control group and did not change post-operative outcomes. There were challenges with regard to participation and completion of the measurement tools used, raising questions regarding issues of pain and fear, self-efficacy, social learning, social cohesion and behavior change. The suitability of this intervention for use in a pre-operative population for post-operative benefits, needs to be reviewed; it would appear that what is suitable for those on a waiting list, with no clarity on when surgery will occur, may not necessarily apply to those who are actually due to undergo surgery. Future research should consider modifying the intervention, including information appropriate to pre and post-operative needs of the population. The roles of self-efficacy, social cohesion and social learning in behavior change should be considered and, levels of self-efficacy and fear of movement beliefs assessed prior to randomization, in order to adequately establish the effect of the intervention on these factors.