COmmunity Based Rehabilitation after Knee Arthroplasty (CORKA)

Design: A two stage study is proposed. Firstly, we will perform analysis of factors associated with poor outcome to develop a screening algorithm. Methods to identify people at high risk are uncertain, but general principles of older people with generalised frailty and significant global function / cognitive impairment prior to surgery are widely accepted using the principles of the American Geriatric Society Best Practice Guidelines for Pre-operative Assessment of Geriatric Surgical Patients (2012). We aim to identify patients at risk of poor outcome based upon these principles using 2 methods: 1. We will systematically review the literature and use expert opinion from an online survey of rehabilitation clinicians to identify factors associated with poor outcome after knee arthroplasty. 2. We will examine data from a large study cohort of patients from the COAST study - a NIHR funded study to assess outcome following lower limb joint arthroplasty. In the second stage we will conduct a prospective individually randomised single blinded two arm RCT. Patients deemed at risk of poor outcome will receive a targeted rehabilitation intervention delivered in their own homes. Setting: Recruitment from a minimum of 6 orthopaedic hubs and their surrounding physiotherapy providers, each main hub performing> 300 knee arthroplasty operations / year, geographically spread around the UK. Interventions to be delivered in the patients home for intervention arm and out-patient physiotherapy clinic for control arm. Target Population: Patients undergoing TKR assessed using screening algorithm as at risk of poor outcome Health Technology being assessed: Physiotherapy and Occupational therapy – Occupational therapy will focus on pre-operative assessment and adaptations to patients’ homes to enable a safe environment for home exercise and everyday functional tasks. Physiotherapy will include home based intervention with an emphasis on a functional activity based programme. We will test if the intervention can be delivered by generic rehabilitation therapists, rather than uni-professionally. Intervention: A multi-component rehabilitation programme. The majority component will be an exercise based exercise programme to be delivered in the patients’ own homes. Attention will also be paid to pain management, confidence building, appropriate provision of aids and appliances and suitability of the lay out of the home environment. The exercise component will include assessment of current functional level and gait re-education, progression/removal of walking aids, plus a programme of exercises to mobilise and strengthen. Repetition rate, frequency and progression of exercises will be left to the physiotherapist’s discretion. Task training will be included: getting in/out of a car. We plan to include use of rehabilitation assistants to assist with the delivery of the intervention, an approach that has been successful in other community based therapy trials Attention will be paid to the interface with other members of the primary care health team such as district nursing, health visiting and community social services, to ensure appropriate awareness and reinforcement of the rehabilitation strategy and programme. The programme will focus on both improving functional outcome but also participation levels. Control: Normal care as is currently provided, i.e. written advice and a home exercise programme on discharge from hospital and up to 6 sessions of traditional out-patient physiotherapy. A qualitative study using an interpretative phenomenological analysis approach will be incorporated to explore the experiences and views of patients about the treatment interventions. Measurement of cost and outcomes: Outcome measures will be collected at baseline, 6 months, 12 months and 24 Months (Approx only 326 participants will have 24 month data collected). Primary outcome: Late Life Function and Disability Instrument. It is an outcome in