The Community Rehabilitation after Knee Arthroplasty (CORKA) study compared standard outpatient physiotherapy with a multi-component rehabilitation program at home, but which intervention led to better results?
Knee endoprosthetics (replacement) is one of the most frequently performed orthopedic interventions worldwide with largely beneficial results. However, 10-15% of patients report little or no improvement in symptoms after surgery.
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The most common postoperative intervention is outpatient physiotherapy for 4-6 sessions with general strengthening, endurance and mobility exercises with the possibility of further follow-up if necessary. The variability in the amount and duration of post-operative service is variable, and there are concerns that this is sub-therapeutic and does not have the required intensity to be of benefit.
Therefore, a new study published in BMJ Open, called the CORKA study, aims to compare standard outpatient rehabilitation with an individualized program aimed at those who are more likely to have a poorer outcome have surgery. In addition, there is the advantage that the intensity and duration of the rehab is correct for all participants
Methods
The CORKA study was a multicenter prospective, single-blind, two-arm randomized controlled superiority study, the results of which were evaluated at the beginning of the study and after 6 and 12 months. The complete study protocol was published in Trials.
Patients were recruited by 14 different NHS trusts in the UK and were all 55 years of age or older and had knee arthroplasty. A standardized screening tool was used at prep clinic appointments to identify those eligible for eligibility and to attempt to identify those at risk of poorer outcome.
The screening tool was based on data from the data set from the knee arthroplasty study and identified those who were at risk of a worse outcome one year after the arthroplasty. Patients were not eligible to participate if preoperative complications occurred, if another operation was planned within the next 12 months and they could not take part in the training.
The randomization took place on the third day postoperatively or on discharge, if earlier. Randomization was performed using permuted blocks of 2, 6 and 6 panelists in a ratio of 1: 2: 1, which prevents any prediction of treatment allocation. After randomization into a group, patients and clinicians were aware of treatment allocation based on the nature of the interventions. However, those who carried out result measurements remained blinded.
The LLFDI function score (Late-Life Function and Disability Instrument) was used as the primary target criterion, with secondary parameters being the OKS scale, PASE, KOOS, EQ-5D-5L, 8-step walk test, 30-second chair stand test and One-legged stance. These are many measures of outcome and more than you would expect in a knee arthroscopy study that suggests a network-wide approach to measuring improvement.
What was the CORKA intervention and how does it differ from the usual care?
CORKA is a multi-component rehabilitation program at home that consists of an initial examination with up to six follow-up sessions. The interventions started up to 4 weeks postoperatively, but mostly within 2 weeks.
The aim of the intervention was to improve the function and participation in activities for people who are at risk of a worse outcome after an endoprosthesis. The main part of the intervention is an individually tailored exercise plan that is carried out within the patient's own four walls and focuses on overcoming "problematic" tasks or activities.
The program also included functional exercises, goal setting and keeping a training diary. The first and middle sessions were carried out by a physiotherapist, the rest by a rehabilitation assistant present at the beginning of the program.
Usual care was an approximation of the average of all variations of "usual care" received by patients. This included at least one physical therapy up to a maximum of six with an emphasis on movement, but could also include hydrotherapy or group sessions.
Results
A total of 621 participants took part in the CORKA study, 309 of them in the intervention group. 37 participants (6%) lost the follow-up. The average age of the participants was 70.4 years and 60% were female.
Participants in the normal care group were considered compliant if they attended a single session, while, as in the CORKA group, at least 4 sessions indicated compliance. However, the median number of sessions was 4 in the standard care group and 5 in the CORKA group
Brief summary of the CORKA study
Multi-component rehabilitation at home does not offer any advantage over conventional care
The use of support staff for post-operative knee replacement exercises offers flexibility in staffing planning
Self-directed rehabilitation is the recommended treatment option for people who have had knee arthroplasty
There was no improvement in the LLFDI between the groups with both control and intervention, with a significant improvement being noted in the first 6 months after the arthroplasty and minimal preventive care thereafter.
For all secondary endpoints there were also no significant differences between the two groups, at no time during the 1-year follow-up. There were also no differences between the groups with regard to the undesired results.
The results of this study are in agreement with a recent NICE evidence review, which revealed no difference in the clinically reported outcome measures between group or individual supervision and self-directed rehabilitation.
Therefore, for those who are well and have the circumstances that allow them, self-directed rehabilitation is the recommended treatment option for people who have had knee replacements.
