First steps in developing clinical practice guidelines for post-acute rehabilitation after primary total hip and knee arthroplasty

Total hip (THA) and total knee arthroplasty (TKA) are cost-effective interventions for advanced osteoarthritis (OA) of the knee and hip. With the rapidly growing number of these procedures performed annually in Canada and the United States, greater attention needs to be directed to identify rehabilitation practices that optimize outcomes and minimize cost. Currently, there is no consensus on rehabilitation best practice and no evidence-based clinical practice guidelines to inform clinical decision-making on post-acute rehabilitation following THA and TKA. A multi-phase, mixed-method project integrated stakeholder perspectives, research evidence and expert opinion to develop best practice recommendations for THA and TKA rehabilitation. Chapter 2 involved 11 focus groups and eight interviews to identify key themes related from North American patients and health care professionals on rehabilitation practices and outcomes. Chapters 3-4 are Cochrane systematic reviews examining the strength of the evidence for post-acute physiotherapy after THA and TKA. Chapter 5-6 involved two parallel Delphi surveys with consumers, clinicians and researchers to develop consensus on a range of rehabilitation topics to inform best practice for THA and TKA rehabilitation. Chapter 2: Six key themes emerged relating to communication, patient expectations, patient attitude, forms of support, barriers to recovery, and diversity of outcomes. Chapters 3-4: Systematic reviews of THA (n=8) and TKA (n=7) trials revealed limited, low to high quality evidence with mixed findings for various forms of post-acute physiotherapy on pain, function and health-related quality of life. Trial heterogeneity prevented meta-analysis. Chapters 5-6: Consensus (80% agreement) was reached on the need for post-acute rehabilitation, types of interventions, rehabilitation providers, treatment settings, outcomes and outcome measurement. Consensus was not reached regarding timing and dosage of rehabilitation. Sub-group analysis revealed few differences comparing responses by profession, primary role and country. This thesis has taken important first steps in identifying appropriate rehabilitation interventions and health care resources to optimize individuals’ activity, participation and health-related quality of life after THA and TKA. Further, it highlights the need for more high quality research to address the knowledge gaps and inform policy on this important and understudied aspect of arthroplasty surgery.Medicine, Faculty ofGraduat