ON Chiropractic Winter 2014 - Page 10

ON Chiropractic COVER STORY / PREHABILITATION review of recent research has identified that chiropractors can potentially play an enhanced role in the prehabilitation and rehabilitation of surgical patients. Much of the data has focussed on total joint arthroplasty, but there is data to support similar interventions for other surgeries, such as spinal disc replacement surgery. Current research suggests that arthroplasty patients are well served by a pre-operative regimen focussing on diet, education, exercise and range of motion therapies in addition to post-operative rehabilitation. Review of Relevant Research Findings: n 2013, an article appeared in Physiotherapy Canada that outlined preliminary evidence that prehabilitation improves physical function in “even the most severely compromised patients” who are waiting to undergo total joint arthroplasty.s The study reported the experience of 16 women and 12 men who were scheduled to undergo either total hip (10 patients) or total knee (18 patients) arthroplasty. The total sample was divided among three treatment streams based on I patient symptoms and clinical histories. For example, while stream one patients were relatively self-sufficient, stream three included practitioner-dependent cases. These particular patients could not walk safely without assistance, had suffered two or more falls in the previous six months and, needed repeated support to learn and perform regular exercise. Prehabilitation regimens were “ stretching and exercises designed to improve strength of the supporting joint musculature”s were prescribed along with more passive approaches. Aerobic exercise using a cycle ergometer was also incorporated if patient pain and ROM allowed. Special attention was also paid to joint surface compression, balance, proprioception, gait practice and gait-aid adjustment to be certain that patient safety Prehabilitation improves physical function in “even the most severely compromised patients” who are waiting to undergo total joint arthroplasty.” developed for each of the three streams and then modified to suit the needs of each patient. In all cases, the goal was to reach an exercise skill level that would allow long-term independence and maximize functional levels in advance of surgery. Specific exercise programs were designed to improve the relevant joints. “Active range of motion (ROM), active was maximized. Patients were encouraged to exercise daily in the home within a comfortable ROM and to continue taking prescribed medications. Nine weeks was the mean duration of the prehabilitation programs. Overall, a mean change of 7.6 on the 80 point Lower Extremity Functional Scale was achieved. A 9.0 point change is Statistics 93,446 95.4% 82.1% Number of hospitalizations for all hip and knee replacements in Canada in 2010/2011 Percentage of primary knee replacements resulting from degenerative osteoarthritis in 2010/2011 Percentage of primary hip replacements resulting from degenerative osteoarthritis in 2010/2011 considered “clinically important” in this test. Significant mean improvement was also observed in the fast Self-Paced Walk test and Timed Up-and-Go test. Similarly encouraging results were reported in a 2012 article in the Journal of the American Academy of Physical Medicine and Rehabilitation.l This randomized controlled pilot study sought to determine the efficacy of a six-week prehabilitation exercise training program on presurgical quadriceps strength among patients undergoing total knee arthroplasty. As in the study above, this sample included osteoarthritis patients only. Patients in the intervention group exercised three times per week for six weeks prior to their surgery. The exercise consisted of a 10-minute aerobic warm-up followed by a circuit of bilateral lower body exercises. Two sets of eight repetitions of standing calf raises, seated leg presses, leg curls and knee extensions were performed. Researchers observed a significant increase in quadriceps strength, the primary outcome measure, as well as improvements in walking speed and mental health in advance of surgery. In this pilot study, these improvements did not impart lasting benefits to patients in the 12 weeks following surgery. This indicated to researchers that quadriceps strength may not drive functional improvement following surgery, but that additional study was warranted. In other studies, however, there were significant post-operative benefits observed. In 2007, the French journal the Annales de Réadaption et de Médicine Physique published a literature review that looked at the benefits of prehabilitation on total hip and knee arthroplasty surgeries.n This article determined that prehabilitation regimens, including a minimum of some physical therapy and patient education, are recommended in advance of all total hip and knee arthroplasty. Physical therapy is not recommended in the case of total knee arthroplasty in absence of patient education. Thus, collaboration among multiple health care practitioners is considered beneficial. Another study published in Arthritis Care & Research reported similar findings in 2006.W This clinical research study of 108 patients scheduled for total hip or knee arthroplasty tested the outcome of a six week exercise regimen versus an education regimen of the same duration. Among those awaiting hip surgery, significant positive results were measured using the Western Ontario and McMaster University Osteoarthritis Index and the Short Form 36 physical function score. There were no significant improvements with respect to the knee patients in these Exercise Facilities in your Clinic: Chiropractors are not new to exercise. Many practicing chiropractors were introduced to the profession when they themselves were act ]