Five years ago, Wolfgang Fitz, MD, a knee replacement surgeon in the Department of Orthopaedic Surgery, asked his patients to bridge the two-to-three months prior to surgery with physical conditioning, tailored to their activity levels and knee osteoarthritis.
Most of these patients were in severe pain with limited mobility, but nearly all managed to participate in the prehabilitation or “Prehab” Program created by Dr. Fitz and Jean Flanagan Jay, PT, DPT, CLT, Director of Rehabilitation Services at Brigham and Women’s Faulkner Hospital.
Patients who participated in Prehab returned for their knee replacements with stronger quadriceps, improved proprioception and better standing balance. They had less pain and took less medications. Some could walk up stairs without the banister. Others no longer needed their crutches and canes. Many patients postponed their surgery. A few even canceled their replacement procedure. Patient satisfaction was higher. Overall, they were happier.
“It’s not magic. It’s the power of exercise,” said Dr. Fitz. “Most patients with arthritis think they need treatment—a drug, injection, or surgery. Most of the functional limitations are related to weakness of the hip and knee muscles. Strengthen the muscles, restore function.”
“At the time of surgery, patients say to us, ‘I could never believe that exercise could make such a big difference.’” —Wolfgang Fitz, MD
An elderly woman with severe knee osteoarthritis recently visited Dr. Fitz in a wheelchair. She was in excruciating pain, taking 120 mg of oxycodone daily, traveling from her bed to the bathroom with a walker. Ten weeks before knee arthroplasty, she enrolled in the Prehab Program.
A physical therapist assessed the woman’s balance, strength, range of motion and functional level. She then received a personalized exercise program through a cloud-based application that could be accessed through a desktop computer, tablet or phone.
The customized strengthening, stretching and proprioceptive exercises included knee extensions, seated marching, hamstring stretches, and arm and leg stretches, among many others. Short videos demonstrated each exercise. Every week, the woman recorded her pain levels and leg strength. The application also tracked her progress.
“When she returned three months later for her knee replacement, she was the happiest camper,” said Dr. Fitz. She was out of her wheelchair, walking with a cane and had weaned herself off opioids. With less pain and more mobility, she was visiting friends and family again.”
From January 2016 to October 2018, the majority of the 550 patients who have completed the entire sequence of Prehab, knee replacement surgery and follow-up rehabilitation improved their leg strength from preop to postop. Additionally, the length of hospital stay decreased by 12 hours. Most patients stayed in the hospital for 1.6 days, returning home after breakfast the day after their surgery (versus before dinner).
“The 12-hour reduction in length of hospital stay represents a tremendous cost savings. We save on nursing time. We can prepare the bed for the next patient. And we only need perhaps one PT session in the morning before the patient goes home,” said Dr. Fitz.
Following surgery, the elderly woman was placed on a multi-modal pain management regimen. After a short stay in the hospital, which included inpatient physical therapy, she returned home with just a cane. She then began a personalized, rapid recovery program.
The Prehab Program has expanded from the Faulkner to Brigham’s main campus. Antonia F. Chen, MD/MBA, a hip and knee replacement surgeon, who joined the Department of Orthopaedic Surgery in 2018, has already enrolled 55 patients in the Prehab Program. Other orthopaedic surgeons are now following her lead.
Healthcare providers from the Brigham gathered for the “Prehabilitation for Orthopaedic Surgery” Symposium. Dr. Fitz’s opening talk was titled, “Why bother, I just want surgery.” Jean Flanagan Jay discussed the use of Prehab’s cloud-based application for PT preassessment, exercise and follow-up. Jay will present data to a national physical therapy meeting in Washington D.C. in 2019.
“Physical conditioning prior to surgery actively involves the patient in their care. Prehab gives the patient autonomy and motivates them to get through their knee surgery much smoother,” said Dr. Fitz.
Read more information about Wolfgang Fitz’s orthopaedic procedures, including patient reported outcome measures (PROMs).