As a homecare physical therapist, most of my caseload consists of patients who have had knee or hip replacements. I am regularly evaluating, treating, and discharging these patients, usually over the course of about two weeks, to prepare them for outpatient therapy. We work on home safety, walking, range-of-motion, lower extremity strength, all the things you would expect. And over the course of five years of doing this, I would like to think I have learned a thing or two about managing these patients.
But sometimes I get surprised. Sometimes I get to observe a natural experiment, where the patient’s circumstances change the course of their rehab. On a few occasions, and for varying reasons, I have had patients who miss their rehab appointments with me and they get fewer sessions that I would instinctually recommend. What happens to these patients?
Anecdotally, nothing. They do about just as well as everyone else. But anecdotal evidence, of course, is just anecdotal. Maybe it approximates the truth, or maybe there is something else going on. However, some of the latest research on total knee replacements has bolstered my intuitions and cast doubt on the utility of a physical therapist to manage a patient’s care.
Despite my intuitions, I was honestly shocked to see the results of two meta-analyses that sought to compare traditional rehabilitation with unsupervised or remote care. According to Chaudhry et.al. and Bravi et.al., supervised and unsupervised programs fare equally well for patients who have had their knee replaced (Chaudhry 2023, Bravi 2023). Each analysis included eleven articles total, seven of them shared.
Physical therapy after a knee replacement seems like a no-brainer. A slam dunk. A perfect use-case for the value and expertise of a physical therapist. But is my presence really necessary for a patient to get better? What am I actually doing for my patients? What is the point of all this if it doesn’t matter if I am there or not?
Am I administering a treatment that only a therapist can? Am I stretching a patient’s knee with that super sexy secret knee stretching technique that we learned? Or is it just a stretch that anyone can be trained to do? Does constant, aggressive stretching really improve a patient’s knee flexion? Physical therapists have known for a long time that continuous passive motion machines don’t make any differences in outcomes (Yang, 2019), so why would my manual stretching for a few times a week make a difference? Would a patient’s ROM, pain, or strength get better on its own, without any intervention? Maybe. I might just be feeling pessimistic, but I have certainly been grappling with my own pointlessness here. The best answer I have come up with is that I can guide a patient through progressive exercise. That’s really it. I could probably do it over the phone or through a telerehab session.
So what does this mean for me? What does it mean for me as a physical therapist? As a person with a job that, at the very least, has debatable utility?
It means that I have to pivot.
Over the past six months, I have been preparing to pivot to a new career as a biostatistician. I am eternally grateful that I have been able to help so many people and get paid well doing it, but I knew for a long time that something has been “off,” and I haven’t truly felt fulfilled in my career. I knew from writing this blog that my interest in science, philosophy, and mathematics would lead me somewhere else, and I think I found the path forward. It has taken more time than I thought, and been more stressful than I had ever imagined. But in meeting with career counselors, academic advisors, and biostatisticians, I am confident I am finally on the right path. I was accepted into the University of Nebraska Medical Center’s online Master Of Biostatistics program, and I start in about two months.
Bravi, M., Longo, U. G., Laurito, A., Greco, A., Marino, M., Maselli, M., Sterzi, S., & Santacaterina, F. (2023). Supervised versus unsupervised rehabilitation following total knee arthroplasty: A systematic review and meta-analysis. The Knee, 40, 71–89. https://doi.org/10.1016/j.knee.2022.11.013
Chaudhry, Y. P., Hayes, H., Wells, Z., Papadelis, E., Khanuja, H. S., & Deirmengian, C. (2023). Not all patients need supervised physical therapy after primary total knee arthroplasty: A systematic review and meta-analysis. Cureus. https://doi.org/10.7759/cureus.35232
Yang, X., Li, G., Wang, H., & Wang, C. (2019). Continuous passive motion after total Knee Arthroplasty: A systematic review and meta-analysis of associated effects on clinical outcomes. Archives of Physical Medicine and Rehabilitation, 100(9), 1763–1778. https://doi.org/10.1016/j.apmr.2019.02.001
Physical Therapy Evidence 