Knee arthroplasty: a window of opportunity to improve physical activity in daily life, sports and work.

Knee arthroplasty is an issue for many and societal participation after surgery is important

Unicompartmental and total knee arthroplasty are well established treatment options, primarily aimed at reducing pain and improving joint function for patients with end-stage knee osteoarthritis.1 Although most patients receiving knee arthroplasty have good clinical outcomes, core outcome definitions suggest that societal participation after surgery is not a primary treatment goal.2 This is unfortunate as the number of patients receiving arthroplasty is rapidly increasing. In the Netherlands, a 297% growth in knee arthroplasties is expected between 2005 and 2030,3 with half of the patients of working age due the rising pension age and increasing trends in osteoarthritis among younger people. In particular for these ‘younger’ patients, societal participation including activities of daily life, sport and work is essential.4

Knee arthroplasty may improve physical activity and sports participation

In BMJ Open Sport & Exercise Medicine, Konings and colleagues5 reported on a systematic review on 19 studies (n=4074 participants) on physical activity and sports participation before and after knee arthroplasty. The authors found that knee arthroplasty, in general, has positive effects on physical activity and sports participation. Physical activity and sports participation return to levels similar to those before the osteoarthritis symptoms and is fortunately much higher compared with presurgery. Only high-impact sports were less frequently resumed after surgery. Furthermore, patients who remained active until the surgery were also most active after surgery, while patients who stopped participating in physical activities and sports prior to surgery were less likely to restart postsurgery.

The importance of physical activity and other forms of societal participation

Physical activity is a well-established contributor to longevity and good health. In various initiatives, including national and international guidelines, regular engagement in physical activity has been advocated for all, including for people with disabilities.6 In this light, the results of Konings and colleagues5 are encouraging, as they show that knee arthroplasty provides patients with a renewed possibility to engage in more physical activity and sports than they did presurgery.

Apart from engaging in physical activity and sports, also other forms of societal participation are of great importance for knee arthroplasty patients. Participation in daily activities such as work, but also other social and family activities, is highly relevant for many knee arthroplasty patients, as inability to participate in society has a significant negative impact on their quality of life.7

A window of opportunity to improve more than only physical activity

Konings and colleagues5 concluded that ‘to achieve the full benefits out of knee arthroplasty, clinical guidelines and strategies aimed to keep patients capable and motivated to participate in sport activities until close before and after surgery are warranted’. In other words, with adequate guidance, knee arthroplasty provides a window of opportunity to improve physical activity in sports, daily life and work. Such guidance is in line with the Exercise is Medicine principle8 that advocates better integration of physical activity advice in clinical practices. Despite the window of opportunity provided, however, better implementation of Exercise is Medicine is needed. Hence, more knowledge is required regarding when, how much and in what way we can best guide knee arthroplasty patients to increase their physical activity.

Towards a more active life after knee arthroplasty

An important limiting factor may be reluctance of clinicians to advise knee arthroplasty patients to be highly physically active due to a fear of an increased risk of revision surgery. This fear seems unnecessary, as a recent study showed that this risk of revision surgery is even reduced in patients with high levels of physical activity after knee arthroplasty.9 Nonetheless, more data on the long-term effect of physical activity on implant survival are needed.

Second, no consensus exists about how much physical activity should and can be prescribed to knee arthroplasty patients. Dutch healthcare professionals provide no or highly variable advice regarding recovery for daily activities after knee arthroplasty.10 For example, recommendations when to resume walking without crutches varied, if given at all, from 4 to 12 weeks postsurgery. Well-defined multidisciplinary recovery recommendations for resumption of physical activities are therefore needed to set realistic recovery expectations. These guidelines can, among others, be based on evidence provided by Konings and colleagues.5 Unfortunately, evidence in this review was based on self-reports of physical activity and sports, while more information from device-based measurements of those activities is needed.

Finally, it is unclear what the best way of providing guidance regarding physical activity for sports, daily life and work would be. A systematic review published in 2018 showed that, at that time, there were zero interventions regarding activity-based rehabilitation for return to work or sports after knee arthroplasty.11 A more recently published study showed that an intervention in which patients worked towards self-chosen activity goals together with a physical therapist lead to statistically significant more physical activity than with usual care, although only 9 min/day.12 These interventions may be promising. However, a limiting factor in the implementation of these interventions may be the finite amount of time a healthcare professional can spend on each patient. eHealth programmes could effectively replace healthcare professionals’ tasks and provide daily patient-specific guidance regarding physical activity in daily life, sports and work, as we can learn from other types of surgery.13 Given the pressing demands on healthcare systems, such eHealth tools can be promising to be able to provide sustainable participation-based care in the future (figure 1).

Figure 1

An example of a dashboard of an eHealth portal, providing knee arthroplasty patients tailored guidance on resumption of physical activity after surgery. Guidance on the resumption of activities and the recovery status of these activities (upper two panels) can be provided, while wearable devices can be used to provide patients with feedback on their physical activities, helping them to work towards self-chosen goals. This example is based on the IkHerstel app that has been evaluated for other patient populations13 and is currently being adapted for knee arthroplasty patients.

Conclusion

An mounting amount of evidence, including the review by Konings and colleagues,5 suggests that knee arthroplasty provides a window of opportunity to improve physical activity. As the number of ‘younger’ knee arthroplasty patients will likely rise in coming years, this opportunity should be taken to provide better participation-based care. Promising interventions should be multidisciplinary in nature and evidence-based. Examples include the Exercise is Medicine recovery recommendations, patient-specific activity-based goal setting and eHealth initiatives providing knee arthroplasty patients with tailored advice to support more physical activity for sport and in daily life and work.