Defining Components of Physical Therapy Achieving Maximum Function after TKR

定义 TKR 后实现最大功能的物理治疗的组成部分

基本信息

批准号：
9912569
负责人：
PATRICIA D FRANKLIN
金额：
$ 22.47万
依托单位：
NORTHWESTERN UNIVERSITY AT CHICAGO
依托单位国家：
美国
项目类别：
财政年份：
2019
资助国家：
美国
起止时间：
2019-02-01 至 2021-01-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9912569
关键词：
Adult Age Aging American Physical Therapy Association Caring Clinic Clinical Clinical Trials Cohort Studies Comorbidity Consensus Data Dose Effectiveness Elderly Enrollment Exercise Future Geographic Locations Home environment Hospitals Implant Incentives Inpatients Intervention Knee Knowledge Location Measures Medical Medicare Modality Monitor Municipalities National Institute of Arthritis and Musculoskeletal and Skin Diseases Online Systems Operative Surgical Procedures Outcome Outcome Measure Outpatients Patient Participation Patient risk Patient-Focused Outcomes Patients Performance Perioperative Care Physical activity Physical therapy Physical therapy exercises Play Policy Maker Practice based research Procedures Process Protocols documentation Provider Public Health Recovery of Function Registries Rehabilitation therapy Reporting Research Resource Informatics Retrospective Studies Risk Risk Factors Role Sampling Services Site Statistical Models Supervision Surgeon System Testing Therapeutic Intervention Time Translating United States Agency for Healthcare Research and Quality United States National Institutes of Health Variant Visit Walking Work adverse outcome base bundled payment cohort compliance behavior cost design dosage electronic data capture system exercise intensity exercise program experience financial incentive follow-up functional gain functional outcomes improved informatics infrastructure knee pain knee replacement arthroplasty outcome prediction patient subsets physical therapist predictive modeling programs prospective randomized trial recruit societal costs sociodemographics strength training support tools tool web-based tool

项目摘要

ABSTRACT Functional outcomes vary following total knee replacement (TKR), the most common and costly inpatient procedure. Although post-surgical physical therapy (PT) is routinely prescribed in perioperative care, the actual PT content delivered to patients varies widely, and no consensus exists for the type, amount or intensity of PT following TKR. In 2016, Medicare will implement mandatory bundled payment for TKR in 67 municipalities across the U.S. making the surgeon and hospital responsible for all post-TKR costs, including physical therapy. These financial incentives may alter post-TKR physical therapy services without a clear understanding of the specific PT components that improve patient outcomes. Our recent retrospective study of PT care from 50 therapy sites in one geographic region documented a significant association between exercise type and progression and greater functional outcomes. Clinical trials demonstrate that muscle strengthening and functional exercises improve functional outcomes following TKR but the generalizability of these studies is limited. In contrast, practice-based research allows analysis of the variability of PT practice in a large patient sample and assessment of the association between PT care, patient participation, and functional outcomes. We propose a PT cohort study of TKR patients embedded within a national TKR cohort (FORCE-TJR) to collect specific details of all post-TKR physical therapy care from 360 patients treated by approximately 60 PTs in three geographical areas. Baseline patient attributes and outcome measures are routinely collected in the FORCE data. These data will be expanded to include the ambulatory PT intervention details as well as the patients’ participation in home exercise and physical activity. A web-based data capture system for use by physical therapists and patients will collect details of amount, type and intensity of physical therapy exercise and amount of patient participation in the rehabilitation process. The study aims are to: (1) Quantify the variation in outpatient PT components and progression in intensity, and the patient’s in home participation in prescribed rehabilitation activities following TKR in a multi-center prospective sample; (2) Identify PT components associated with optimal patient-reported functional outcomes at 6 and 12 months and knee performance measures at 6 months after TKR; and (3) Design and deploy a web-based decision support tool to predict functional outcome after TKR based on these analyses, to include patient pre-operative factors, levels of patient participation, and PT components to reinforce best practice PT and patient in-home participation. We hypothesize that a set of potentially modifiable PT practice components, such as a higher number of closed chain exercises and progressions in exercise intensity, will be positively associated with better gain in functional and performance outcomes after adjusting for patient sociodemographic and comorbidity factors and that patient adherence to daily at-home participation in physical activity will modify the effects of the PT components on knee performance and function at 6 months. Statistical modeling will examine the role PT timing, content and intensity and patient demographic and clinical factors including rehabilitation participation play in explaining the variations in functional outcomes following TKR. Predictive models of long term functional outcomes based on both PT and patient factors will identify modifiable factors of the PT intervention that contribute to optimal functional outcomes. The data and knowledge generated by this study will inform the design and content of a prospective randomized trial of best practice PT after TKR among patients at risk for poor functional gain. Moreover, the knowledge is timely and essential as policy makers and clinicians work to control the rising societal cost of total knee replacement surgery, while assuring optimal patient outcomes.

抽象的在总膝盖置换（TKR）之后，功能结果有所不同，这是最常见和昂贵的住院尽管手术后物理疗法（PT）通常在定期护理中规定送给患者的PT含量差异很大，并且PT的类型，数量或强度不存在共识遵循TKR。 2016年，Medicare将在67个市政当局实施强制性捆绑的TKR付款整个美国，使外科医生和医院负责所有TKR后的费用，包括物理疗法。这些经济激励措施可能会改变TKR后物理治疗服务，而无需清楚地了解改善患者预后的特定PT组件。我们最近对50个PT护理的回顾性研究一个地理区域的治疗部位记录了运动类型与进展和更大的功能结果。临床试验表明，肌肉增强和功能练习可改善TKR后的功能结果，但这些研究的普遍性是有限的。相反，基于实践的研究允许分析大型患者的PT练习的可变性样本和评估PT护理，患者参与和功能结果之间的关联。我们提出了一项嵌入国家TKR队列（Force-TJR）的TKR患者的PT队列研究收集360名患者的TKR后物理治疗后的所有特定细节，约60分在三个地理区域。基线患者属性和结果指标通常会在力数据。这些数据将扩展到包括门诊PT干预细节以及患者参加家庭运动和体育锻炼。一个基于Web的数据捕获系统用于使用物理治疗师和患者将收集物理疗法的数量，类型和强度的细节和患者参与康复过程的数量。该研究的目的是：（1）量化门诊PT组件的变化和强度的进展以及患者在家中的参与在多中心的前瞻性样本中，TKR之后的规定康复活动；（2）识别Pt 与最佳患者报告的功能结果相关的组件在6和12个月和膝盖 TKR后6个月的绩效指标；（3）设计和部署基于网络的决策支持工具基于这些分析来预测TKR后的功能结果，以包括患者的术前因素，患者参与水平和PT组件以增强最佳实践PT和患者在家中参与。我们假设一组潜在可修改的PT练习组件，例如更高封闭的链条练习和运动强度的进展数量将与调整患者社会人口统计学和合并症因素以及患者对每天在家进行体育锻炼的遵守将改变 PT成分对6个月时膝关节表现和功能的影响。统计建模将检查 PT时机，内容和强度以及患者人口统计和临床因素（包括康复）的角色参与参与解释TKR后功能结果的变化。长长的预测模型基于PT和患者因素的术语功能结果将确定PT的可修改因素有助于最佳功能结果的干预措施。这项研究产生的数据和知识将为潜在的设计和内容提供信息 TKR后TKR的最佳实践随机试验在功能不良的风险中。而且，当决策者和临床医生努力控制总计的社会成本上升时，知识是及时和必不可少的膝盖置换手术，同时确保最佳患者预后。