1. Provide a brief summary of the main research study aims/ objectives, methods and findings.
2. Provide a critical appraisal of the article, justifying your rationale for the main strengths and limitations of the study.
Note that marks will be awarded for highlighting strengths and limitations of the study other than those stated by the authors throughout the article.
3. 250 – 300 words
This study compared the effects of preopera- tive physical therapy or general cardiovascular conditioning exercises with the routine proce- dure of no preoperative physical therapy on pa- tients undergoing primary total knee replace- ment. Thirty patients were randomly assigned to 1 of 3 groups. Group 1 was the control
group. Group 2 participated in a physical ther- apy program designed to strengthen the upper and lower limbs and improve knee range of motion. Group 3 participated in a cardiovascu- lar conditioning program, consisting of arm er- gometry, cycle ergometry, aquatic exercises, and aerobic activity. All patients were evalu-
ated preoperatively and postoperatively using the Hospital for Special Surgery Knee Rating, the Arthritis Impact Measurement Scale, and the Quality of Well Being instrument. Both ex- perimental groups tolerated their respective exercise protocols extremely well. All 3 groups showed significant improvement postopera- tively as measured by the Hospital for Special Surgery Knee Rating, the Arthritis Impact
Measurement Scale and the Quality of Well Be- ing measurement scales. However, neither type From the Division of Orthopaedics, Scripps Clinic and Research Foundation, La Jolla, CA. Reprint requests to Clifford W. Colwell, Jr.. MD, Head, Division of Orthopaedics, Scripps Clinic and Research Foundation, 10666 North Torrey Pines Rd, MSI 16, La Jolla, CA92037.
Most studies evaluating total joint replace- ment emphasize design, material characteris- tics, fixation techniques, and wear phenome- non. Few evaluate the effects of conditioning and exercise programs.lg Approximately 35% of the population between the ages of 65 and 75 years experience limitation in ac- tivity.’ Although chronic diseases account for a portion of this inactivity, simple decon- ditioning causes a progressive decline of physical fitness in the elderly, even in the ab- sence of disease. As a consequence of dimin- ished exercise, an increasing number of theelderly will be living close to the threshold of physical inactivity, needing only a minor intercurrent illness to render them depen- dent.’,’ This study compared the effects of preoperative physical therapy or general car- diovascular conditioning exercises with the routine procedure of no preoperative physi- cal therapy on patients over 55 years of age undergoing primary total knee replacement. MATERIALS AND METHODSConsecutive patients scheduled for elective pri- mary unilateral total knee replacement were 174
Number 326 May, 1996 Preoperative Exercise and Total Knee Replacement 175 screened for participation in this study following informed consent. The program was reviewed and approved by the institution’s InvestigationalReview Board. Eligibility requirements were age greater than 55 years, a primary diagnosis of osteoarthritis or rheumatoid arthritis, and residence within conve- nient distance of the facility. Only patients needing unilateral knee replacements were included. Ex- clusion criteria included cognitive, psychological, or language impairment. Patients had to be able to read and sign a consent form developed for sev- enth to ninth grade reading comprehension level. This was reviewed and approved by the Investiga- tional Review Board. Patients with major cardio- vascular impairment such as labile hypertension and unstable angina were excluded. Further screening by means of stress electrocardiogram was carried out if patients had borderline symp- toms. Patients were also excluded if they had his- tory of cerebral ischemia such as stroke or transient ischemic attacks.
All surgeries were performed by the senior au-thor (C.W.C.) using the Press-Fit Condylar total knee system (Johnson & Johnson Orthopaedics, New Brunswick, NJ). A computer generated randomization list was used to assign patients to 1 of the following treat- ment groups: Group 1 (Control): 10 Patients These patients met with a physical therapist pre- operatively for 45 minutes. Printed material that included the postoperative exercise regimen was provided. No recommendations for preoperative physical therapy or exercise were made. The ex- isting routine postoperative protocol for total knee replacements included quadriceps and ham- string setting, straight leg raises, hamstring and heel cord stretching, knee strengthening, sitting and prone knee range of motion exercises, and routine precautions. Group 2 (Experimental Physical Therapy): 10 Patients
Patients participated in a I-on-1 physical therapy training program to strengthen the upper and lower extremities and improve knee range of motion. This program included initial stretching of calf, hamstring, and quadriceps muscles, followed by isometric and isotonic strengthening exercises of the triceps surae, quadriceps, hamstrings, hip flex- ors, hip extensors, hip abductors, shoulder flexors, shoulder abductors, and triceps brachii. Weights were used as tolerated by the patient. Each session lasted for 45 minutes and was administered 3 times a week for a total of 18 exercise sessions. Patients were taught to use a graphed exercise program to meet a goal determined by the patient and therapist based on the patient’s capabilities. The graph was used to record the number of repetitions. At each visit, the exercises were reviewed with the physi- cal therapist to ascertain that they were performed properly. The graphed records were also reviewed with the patient. The number of repetitions was in- creased by 1 repetition every third day until the goal was reached. Group 3 (Experimental Cardiovascular Conditioning): 10 Patients The patients initially were tested by an exercise physiologist on the Monark 88 1 E Arm Ergometer and the Monark 818 Cycle Ergometer (Quinton, Seattle, WA). This included timed tests with mea-surement of resting, peak, and ending heart rate and blood pressure to establish endurance and pre- dictable workload. A cardiovascular conditioning program was designed for each patient to improve fitness within their physical limitations and to maintain heart rate in the training range by the for- mula: Training Heart Rate Range = Resting Heart Rate + 0.4 to 0.7 Heart Rate Reserve9 (where Heart Rate Reserve = Maximum Heart Rate – Resting Heart Rate). This consisted of 3 exercise sessions per week for a total of 18 sessions, each lasting 45 minutes. Twelve of these sessions emphasized arm ergometry and cycle ergometry on the Cybex Aer- obic Ergometer and the Cybex Upper Body Er- gometer (Cybex, Ronkonkoma, NY), and included light stretching, muscle toning, and aerobic activ- ity. The remaining 6 sessions consisted of aquatic exercises. Heart rate was monitored throughout all the sessions, and blood pressure was monitored throughout each ergometry session. Measurement Instruments All patients were evaluated at 6 weeks preopera- tive, 1 week preoperative, 3 weeks postoperative, 12 weeks postoperative, 24 weeks postoperative, and 48 weeks postoperative. Three tools were used for this evaluation, 1 of which was the Hospital for Special Surgery Knee Rating. This rating scale is a functional assess- ment developed by Insall et als (Hospital for Spe-
