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 ]