Effects of Preoperative Education on Postoperative Outcomes Following Total Hip or Total Knee Arthroplasty

Colton Ketelhut, SPT and Anna Ruppelt, SPT

DPT2019 Preoperative Education TKA Ketelhut Ruppelt

(Click on image to expand)

22 Comments on “Effects of Preoperative Education on Postoperative Outcomes Following Total Hip or Total Knee Arthroplasty

  1. Colton and Anna,
    In your written results section you indicate that there are significant results, value less than or equal to .05, for pre to post test measures of the HOOS Jr, Oxford Knee Score, KOOS Jr, STAI, and SPPB. However, when looking at the functional assessment change scores chart the values are all above the significant level (.05). Is there a difference in how the scores were calculated for the written results section versus what is displayed in the large chart? Thank you.

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  2. Courtney,
    Great question and I hope I can clarify that for you. In the written results we noted that all patients in both groups saw a significant change in their post-test score compared to pre-test score, this was as to be expected considering in those 6 weeks they had received a joint replacement and underwent physical therapy. In the chart, however, we compared the change scores (post-test minus pre-test) and compared those between the group to attended Total Joint Journey and the group who did not attend. From that, we found that there was no significant difference in the amount of change (improvement) for the group who attended TJJ vs the group who did not. In other words, the patients who did not attend the education course did just as well post-operatively did. I hope that answers your question!

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  3. Colton and Anna,

    In the background you state that the current available evidence does not support pre-operative education alone to improve post op outcomes. Your results support what the rest of the literature says. However, in your discussion/conclusion you state that research remains inconclusive on this matter. To me, it seems as though all of the evidence points toward no/minimal benefit. At what point do you feel that the research becomes conclusive on this matter?

    Thank you!
    Scott Strand

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    • That’s a great point Scott. I wonder if this study would suggest that patient’s should NOT be attending pre-operative education? If there is no benefit in pre-education, would the patients receive a greater benefit if they attended a PT session on quadriceps strengthening compared to education? I wonder if a simple brochure would be as effective to send home with the patient and less of a time commitment on the surgical staff.

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      • Hey James! Hope all is well and thanks for the question. TJJ was administered by the PT staff, with little buy-in from the orthopedic surgeons. As I discussed in my reply to Scott, our research study was not on a large enough scale to determine true effectiveness of TJJ. Our study had numerous limitations, all of which came into play when determining significance of our research. There has been some research conducted on the different mediums of delivering effective education with some varying results. Some studies report better outcomes with face-to-face interactions and others with pamphlet or brochure. Anna and I still feel there is a need and place for patient education, as it is our duty to provide the patient with the best experience possible. Perhaps the question doesn’t need to pertain to the effectiveness of a pre-op education class, but needs to address which form is the most effective both financially and beneficial to the patient. This is one area that Anna and I highlighted in which future research needs to focus on. Hope this answered all of your questions and concerns. See you soon! Thanks!

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    • Hey Scott! Hope clinical is going well for you. Thanks for your question and perhaps maybe one of the most important questions to address. Keep in mind that our research study has numerous limitations such as small sample size, poor patient compliance, lost subjects, inconsistent administration of TJJ, and inability to determine TJJ as sole determinant in patient success. With that being said, Anna and I determined that our research did not hold enough statistical power to sway the argument one way or the other. Our patient population was rural Midwest, which with our sample size cannot be compared to research conducted on the east or west coast. Though our study was very educational and we provided a service for a local rural hospital, the results were not on a large enough scale to determine conclusive vs. inconclusive evidence. Though larger scale research doesn’t support pre-op education, Anna and I still feel that there is a place and need for patient education before surgery. Research should begin to look at how to best deliver education that is both cost effective and beneficial to the patient so that our patients are undergoing surgery with appropriate expectations. I hope this answered your questions! Thanks and see you soon!

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  4. Anna & Colton,

    First off, excellent poster. It seems that the various functional outcome measures selected have not found a lot of statistically significant; nonetheless, the research itself on this topic is very interesting. My questions pertain to pre-operative anxiety. Was the STAI your primary means of assessing anxiety levels as they pertained to surgery? If so, could you outline some of the questions it contained regarding anxiety/stress related to surgery? Also, being that the research is inconclusive on this matter, is there anything that you would specifically tailor for the pre-op education for patients to better reduce anxiety?

    Thanks you!

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    • Hey Will! Hope clinicals are going well. Yes the STAI was our main outcome measure to measure patient anxiety pre and post. We decided to use the STAI because this was a valid and common test used among similar projects that we found during our literature search. The other reason we decided to use it was because it is only a 6 item assessment, making it short and easy for patients to complete. “I feel calm,…tense, upset, relaxed, content, and worried” were the 6 items that were assessed on a 1-4 point scale. The STAI was the only outcome measure that was approaching significance with the use of pre-op education. The STAI may have been significant had we had better participation rates during our study. In regards to how to reduce anxiety more effectively. I believe that individually tailored pre-operative education (greater one-on-one interaction) and participation from the orthopedic surgeons during the class would further reduce the patient’s anxiety level. Hope this helps answer your questions. Thanks!

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  5. Hi, great work on your study! I have a few questions regarding the TJJ preoperative class. How long before surgery was the class conducted? How long was the class? What were some of the specific points covered during the class? Since there hasn’t been any conclusive results in preoperative class research, do you have any ideas or have read any ideas for change in preoperative classes to improve results? Thanks!

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    • Thanks for all the questions Steven. One of the limitations to our study was consistency with the amount of time before surgery that patients participated in TJJ. Since the class was put on by PTs and PTAs, the class was only administered one time a month due to scheduling and financial considerations. There were some patients that completed the class as close as one day before surgery and as far out as one month. The study would have been better controlled had we and the hospital staff been able to standardize time before surgery. The TJJ class was approximately 1-2 hours depending on how many patients showed up and how many different joints that needed to be addressed (THA vs. TKA). The class focused on education of HEP specific to joint, what to expect day of surgery and day after surgery, prognosis of rehab, some key details of the surgery, and post-op restrictions. The class also discussed and gave a detailed outline of things to prepare for leading up to surgery and after surgery such as hydration, hygiene, and timeline of events.

      There has been conflicting results with published research on this topic. Though our study shows that pre-op education did not support the use of this education, keep in mind our study has numerous limitations (sample size, lost subjects, etc.) and was completed in rural Midwest. We looked into some research that showed that a pre-op class similar to our TJJ had the same outcome success as a pamphlet provided by the orthopedic surgeon. The research that presented on successful outcomes with pre-op education often included larger sample sizes, more one-on-one patient interaction, video presentation, and better buy in from hospital staff as a whole. Hope I have addressed all your questions. Thanks!

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  6. Anna & Colton,

    I hope the clinic is going well for both of you! Great poster. One question I had about your research was whether or not all the patients had the same surgeon? I know in rural areas, one or two orthopedic surgeons is common. Do you think the surgeon/their relationship and bedside manner with these patients would have made an impact on their level of anxiety or length of stay?

    Thanks!

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    • Hey Macie thanks for the question. Yes, there were three different orthopedic physicians that performed surgery. And to answer your second question, absolutely. As we know from a pain neuroscience concept, anxiety plays a huge role in the amount of pain a patient perceives. Patient/surgeon relationship and bedside manner of different health professions would absolutely impact anxiety level, which could in turn affect pain, function, and length of stay. Each physician is different with post-op management as to duration of restrictions and length of hospital stay. Some physicians are more conservative with length of stay and some are more aggressive. In a perfect and controlled environment, it would have been nice to have the same surgeon and nursing staff to better determine how pre/post op anxiety affects functional outcomes.

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  7. Anna & Colton

    I see that in your study design you guys included patients that had either a THA or TKA. My question is was the total joint journey class just an overall pre-operative class to any of those surgery’s, or was there specific dates and times for classes for just THA and TKA patients? Also, if it was just one pre-operative class for either THA and TKA do you think that your results would have been different if just THA or TKA patients attended a preoperative class for that specific procedure?

    Thanks,
    Emily Mensen

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    • Hey Emily! Thanks for your questions. Yes, the Total Joint Journey was open to all patients who would soon be undergoing a total joint replacement. The instructional booklet covered both TKAs and THAs. At each class, patients were asked what procedure they were having done and then the instructor tailored the class to cover the conditions of the patients in attendance. I don’t know that the results would have necessarily been different if they class was specific to just 1 joint. However, I would be interested in trialing a program that was one-on-one, so the patient could discuss their condition specifically and maybe more apt to ask personal questions as compared to in a group setting.

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  8. Anna and Colton,

    You guys did awesome on your presenting as well as on your poster! I know this was a retrospective study, but did you play a role in choosing what outcome measures were given to each patient pre and post surgery? If not, do you have any other outcome measures that you think might be more efficient at tracking the specific outcomes you were looking at? Do you think that the time frame of the administration of the outcome measures plays a role?

    Thanks!
    Nicole Sikkink

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    • Hey Nicole! Thanks for your questions. Colton and I did select the outcome measures that were administered before and after surgery. We looked through the literature to find outcome measures that had been previously validated for THA and TKA populations. We then looked at what areas they were assessing (anxiety, expectations, physical performance, etc) to come up with our final battery of assessments. We lost a few subjects to inconsistent scoring of the SPPB from the physical therapists, so maybe this was a new outcome measure for them, but we could have even used something as simple as a 6-minute walk test to determine function at PT evaluation and discharge rather than the SPPB. Lastly, the time of administration may have played a role, and we would have liked to have greater consistency with that, but after discussing with the head PT, she felt the last physician’s appointment and PT discharge were the best opportunities to have patients complete the subjective measures.

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  9. Anna and Colton,
    Hey, great job guys! I was just wondering who administered the TJJ? From my current clinical I have heard of similar preoperative education classes which have been put on by physical therapists or the orthopedic surgeons completing the course. Also did the course give the patients any sort of HEP to prepare to strengthen before the surgery, or was it all educational?
    Thanks!
    Travis Bolstad

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    • Hey Travis! Hope clinicals are going well for you! The Total Joint Journey course was presented by either a Physical Therapist or a Physical Therapist Assistant, depending on scheduling. We looked into courses that were administered by multiple disciplines such as nursing, social work, PT, and OT. It may be more beneficial for each discipline to present and answer questions on their particular topic rather than expecting the PT or PTA to cover all of those entities. To answer your next question, yes, the course did give THA and TKA patients a short and manageable home exercise program to begin some pre-hab and also just to practice the exercises as they were the same ones they would have to perform immediately after surgery.

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  10. Hey guys! Your poster looks awesome. I am wondering if you both think this type of educational program should still be explored and used for total joint patients? Your results don’t necessarily support it, and you mentioned this was a similar outcome for other studies.

    Thanks,
    Carly Uecker

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    • Thanks for the question Carly! I do still think there is a place for pre-op education for total joint patients as there is still a lot of anxiety and a lack of understanding associated with it. Our results did show that those who attended Total Joint Journey had decreased anxiety and had we measured something such as their understanding of the procedure, hospital stay, and role of therapy, I believe we would have seen significance with those who attended compared to those who did not.

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  11. Great job on your poster! My question is that with such a small percentage of patients attending the TJJ class, what do you feel is a way to motivate people to attend theses sessions? Do you feel that if you were able to get a larger percentage of patients to attend the TJJ classes it may have led to more positive results? You stated that your findings were aligned with the current literature which seems to refute the benefit of preoperative education. Have other studies you’ve found had similar issues with recruitment of patients, and do you feel as if this topic would still benefit from further research?

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    • Trevor, thank you for your questions! We felt that one of our limitations was that the push for this program was coming from the therapy department with very little buy-in from the orthopedic physicians. It is likely that patients would have felt more obliged to go if they were highly persuaded by the surgeon to attend. I can not say whether a larger sample size would have produced more “positive” results, but it definitely would have made them more accurate and able to be generalized to a greater population. A majority of the studies we looked at prior to our research did have larger sample sizes, but the sample size did not seem to correlate to whether or not their patients had significant results. Lastly, there seems to be a fair amount of research already published on this topic. However, it would be beneficial for each organization to collect data on their own program specifically to determine whether their patients are benefitting from the current program and then make alterations to the program according to the results. Thanks for the great questions!

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