Rehabilitation after knee replacement is an essential part of the recovery process. But what's the best way to prepare patients before the procedure? Researchers at Hospital for Special Surgery (HSS) in New York City launched a pilot study to find out if a "pre-habilitation" program - counseling by a peer coach who has already had a knee replacement - could empower and inform patients scheduled for the surgery, leading to better outcomes.
The study found that such a program could be helpful to patients scheduled for a knee replacement, according to Iris Navarro-Millan, MD, MSPH, a rheumatologist at HSS who served as principal investigator. She presented the study at the American College of Rheumatology/Association of Rheumatology Professionals annual meeting on November 12 in Atlanta.
"On a national level, up to 30% of patients may have persistent pain after knee replacement surgery for osteoarthritis," Dr. Navarro said. "One possible approach to improve outcomes is to optimize muscle strength, physical condition and mental preparation before surgery. Social cognitive theory posits that self-efficacy, peer or social support, sociocultural factors and expectations influence goals and outcomes."
"There are successful programs in other areas of medicine, such as diabetes care, in which patient navigators share their experience and knowledge with their peers to help them better manage the disease," said Lisa Mandl, MD, MPH, senior study author and a rheumatologist at HSS. "The thinking is that having the right mindset could optimize outcomes."
The HSS researchers established focus groups of people who had a knee replacement at HSS to obtain information about their thoughts and experiences. The researchers sought to determine if a "pre-hab" program with trained peer coaches could be helpful and of interest to future patients scheduled for knee replacement surgery.
The investigators defined a peer coach as a patient who has already undergone knee replacement surgery and has been trained to provide personalized pre- and post-knee replacement support.
The 31 patients in the focus groups ranged in age from 65 to 89 and had had a knee replacement at HSS at least 12 months earlier with a good outcome. For almost half the patients, it was their second knee replacement, as they had undergone a previous surgery on their other leg.
"We asked patients about their challenges before and after knee replacement, potential barriers to accessing a pre-habilitation program and perspectives on what it might be like working with a peer coach to encourage exercise prior to knee replacement," Dr. Navarro said.
The following themes emerged from the focus groups:
- Many patients with osteoarthritis delayed knee replacement for many years, often until the pain became very bad.
- Many weren't sure of the best way to prepare for knee replacement surgery.
- They appreciated advice from other patients about preparation and recovery, and learning about the positive experiences of others often motivated them to have the surgery.
- The concept of peer coaches was well received.
- A few participants were already informally helping others scheduled for surgery and found it very rewarding.
- The researchers concluded that preparation and expectations for surgery were influenced by patients' own prior experience with a knee replacement, as well as by the experience of other patients who had already had the surgery.
"Patients with high outcome expectations who had undergone a previous knee replacement learned from their first experience and reported feeling motivated to engage in physical activity for muscle strengthening before their second knee replacement," Dr. Navarro explained. "They expressed that their own experiences made them more informed, self-efficacious and physically active to prepare for their surgery."
Patients for whom it was their first knee replacement reported that informally connecting with another individual who had already had the surgery was important in their decision to go ahead with the procedure, and also in preparing for it. They indicated that working with a peer coach would be beneficial for both preparation and recovery.
"Our findings suggest that formal peer-to-peer counseling that prepares patients for their first knee replacement surgery may hold promise to improve outcomes," Dr. Navarro said. "Future studies could focus on the best way to establish such a program."
Other study authors include Sarah R. Young, PhD (Binghamton University); Geyanne Lui, BS (Weill Cornell Medicine); Mariana B. Frey, BA (HSS); Janey C. Peterson, RN, MS, EdD (Weill Cornell Medicine); Susan M. Goodman, MD (HSS); and Monika M. Safford, MD (Weill Cornell Medicine).
HSS is the world's leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report "Best Children's Hospitals" list (2019-2020). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In addition, HSS will be opening a new facility in Florida in early 2020. In 2018, HSS provided care to 139,000 patients and performed more than 32,000 surgical procedures, and people from all 50 U.S. states and 80 countries travelled to receive care at HSS. There were more than 37,000 pediatric visits to the HSS Lerner Children's Pavilion for treatment by a team of interdisciplinary experts. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is the world's leading provider of education on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. http://www.hss.edu.