Returning to work after knee replacement

Research: Realistically 9 to 30% of patients do not return to work after knee replacement

Before I begin, let me state that some people get great benefits from total or partial knee replacement. But not everyone is convinced it will be of great benefit to them or realizes the expectation they had going into knee replacement that they would come out with a pain-free knee with increased mobility. Some people are willing to wait months for their knee replacement, some people try to avoid the knee replacement because they have a lot of concerns about lengthy rehabilitation, down time, ability to return to work or some type of sport and the possibility that something can go wrong. Some people get the knee replacement because they think everything will go right.

New and concerning research is out about how quickly someone getting a total knee replacement is able to return to work.

The research (1) says that an increasing number of patients in the working population are undergoing total knee replacement for end-stage osteoarthritis. The timing and success of their return to work is becoming increasingly important for this group of patients, with social and economic implications for patients and their employers.

The concern is that patients have a limited understanding of the realistic variables that determine the ability to return to work. In other words – they think they can get back to work sooner than they will actually be able to.

In speaking with knee-replacement patients, the researchers found that the patients had a great deal of concern, primarily involving these three factors:

1. The time delay in getting the surgery (i.e., being on a long waiting list)
2. Limited and often inconsistent advice from health care professionals regarding when they would be able to return to work
3. The absence of rehabilitation that would optimize recovery and facilitate the return to work

The patients felt that all of these factors contributed to potential delays in a successful return to work

70-80% of total knee replacement patients return to work within three to six months

Recently, a 2021 study (2) indicated that 70-80% of total knee replacement patients return to work within three to six months. In this study “according to participants, factors within the following four themes can contribute to a successful return to work: occupational, patient, rehabilitation and medical care. Incorporating these factors into the integrated care pathway for the “young” total knee replacement patients may increase the chances of a successful return to work.

“Not what I expected”

In January 2020,(3) doctors in Sweden produced an ambitious study to try to understand why a patient was not happy with their knee replacement when there were no obvious reasons that they should be. Especially when the surgery went without complication and was considered successful.

Here are some of the problems the patient reported and how it hindered them in their daily routine or trying to get back to work.

• Participants experienced “Pain and stiffness.” For some, problems did not improve during the first year as expected. The longer the time the participants continued with these complaints the more they felt frustration and wondering about the success of surgery.
• In the beginning, disappointment was expressed over insufficient pain relief, the fact that medication could not soothe the postoperative pain, and that it did not subside in the first few months. The participants described how disturbed they were with the continual pain, and said that the pain was sometimes so intense that they were unable to do their knee exercises.
• Despite the preoperative information that pointed out the likely extent and duration of the postoperative pain, which could be expected to last up to 1 year from the index surgery, some were discontented due to having experienced continued pain for a long time. Pain at night and at rest was described as uncomfortable and worrisome. The participants described discomfort that encompassed the whole knee. The onset of new pain when performing their usual activities and movements created frustration.
• Discontentment with annoying and long-lasting stiffness was another experience often mentioned by the participants. They expressed their disappointment over not being able to bend and straighten the knee as expected, and said that their knee joint did not feel the same as before.
• Difficulties performing normal daily activities included standing to wash dishes, vacuum cleaning, cutting the grass, working in the garden, driving a car, or performing their jobs; symptoms that were mentioned as obstacles in performing these activities were pain, stiffness, swelling, weakness in the leg, and not being able to trust the knee.
• Patients also expressed disappointment with their inability or difficulty in performing their favorite recreational activities, such as biking, dancing, hunting, fishing, playing golf, skiing, hiking, swimming, and playing with their grandchildren.

Examining patients who were of “working age,” and needed a knee replacement. What happened?

In this January 2019 study (4) examining patients who were of “working age,” that were being recommended to knee replacement surgery, doctors assessed when knee replacement patients returned to work and if they return to normal hours and duties. They also wanted to identify which factors influence postoperative return to work. These researchers were looking to answer their own hypothesis that there is no difference in time of return to work between the different types of surgery (partial or total), and no difference in time of return to work based on the physical demands of the job the patient wanted to return to.

• Patients examined were less than 65 years who had undergone unilateral primary total hip replacement, total knee replacement, or medial unicompartmental knee replacement. We will look at the results here of the knee replacement patients.
• 31 patients had total knee replacement, and 27 had undergone partial knee replacement.
• Of all patients 91% patients returned to work.
• 8.6% patients did not:
  • 4.3% retired,
  • 2.6% reported physical health reasons.
  • 1.7% had been made redundant or replaced at their job.
• Patients returned to work after (average) 7.7 weeks (total knee replacement), and 5.9 weeks (partial knee replacement).
• Time of return to work was not significantly influenced by type of surgery.
• Rehabilitation, desire, and necessity promoted return to work. Pain, fatigue and medical restrictions impeded return to work.

“15 to 30% of patients do not return to work”

In an earlier study from 2017, (5) researchers made this assessment: 15 to 30% of patients do not return to work

“Total knee arthroplasty (replacement) is an effective intervention for people with osteoarthritis. However, 15 to 30% of patients do not return to work, and studies frequently fail to provide an explanation of what may lead to work disability. . . “

Study 3: Why 46 patients did not return to work and 121 did

In a study of 167 patients who were employed at the time of their total knee replacement surgery, researchers wanted to know why 46 patients did not return to work and 121 did. (6)

• The average age of the 167 patients was 60 at the time of the surgery
• More than half of these patients had significant weight problems, 58% being obese
• Thirty-one percent of the patients believed that their type of work is what caused them to need a knee replacement

46 patients did not return to work because:

• Eight patients had problems related to the knee replacement.
• Seven patients reported other medical issues that prevented them from working.
• Thirty-one simply opted for retirement.

The average time back for those who did return to work?

• 8 returned to work within 1 month
• 50 between 1 and 3 months
• 43 within 3–6 months
• and 20 after 6 months.

So what are my options?

Physical therapy?

A February 2022 survey of patients and physical therapists (7) offered a possible explanation as to post-surgical “failure” of follow up care. In this case why patients may have not had successful physical therapy. The summary points of this research are:

Unrealistic expectations of recovery

• Physical therapists reported patients often do not receive adequate information about the recovery process after surgery which can lead to unrealistic expectations. Some physical therapists felt these unrealistic expectations can demotivate patients resulting in less patient effort and engagement in rehabilitation.

Physical therapists believed that they were trying to help patients who should have not have the knee replacement in the first place

• In some cases, physical therapists believed certain patients should not have had surgery due to their health condition or physical limitations, as this sets the patient up for failure during recovery.

The patient was not prepared for the amount of work needed to recover

• Physical therapists reported that they believed some patients were not prepared for the length of the recovery process or its demands. That some patients had no idea how extensive recovery may be when going into surgery and that their surgical team does not inform them of this.

In this paper one physical therapist wrote: “I think with the chronic pain piece and my background, the words that you use are really very important. If a provider says something like—if a doctor says something like, “We’re going to do this surgery and you’re going to be just fine,” then they might not realize the amount of work they have got to put into the rehab after the fact.”

The summary of this study suggested that to improve post-recovery 

• Physical therapists should consider using a “flexibility within fidelity” approach to treatment protocols, treatments and patient goals which emphasize the patient’s home environment and function in daily life, and preoperative consultations to reduce patients’ postoperative uncertainty and facilitate improved communication and continuity during care transitions.

Does Neuromuscular electrical stimulation help?

A January 2022 study (8) examined Neuromuscular electrical stimulation (NMES) which has been reported as an effective treatment method for quadriceps strengthening and which could attenuate muscle loss in the early total knee replacement  postoperative recovery period. The purpose of this randomized controlled trial, according to its authors, was to test whether postoperative use of Neuromuscular electrical stimulation on total knee replacement  patients results in increased quadriceps strength and ultimately improved functional outcomes.

• Patients were randomized 2:1 into treatment (Neuromuscular electrical stimulation (NMES), 44 patients) or control (No Neuromuscular electrical stimulation (NMES), 22 patients).
• Patients who used the device for an average of 200 minutes/week or more (starting 1 week postoperative and continuing through week 12) were considered compliant.
• Baseline measurements and outcomes were recorded at 3, 6, and 12 weeks postoperatively, and included quadriceps strength, range of motion (ROM), resting pain, functional timed up and go (TUG), stair climb test, and knee injury and osteoarthritis outcome score (KOOS) and veterans rand 12-item health survey (VR-12) scores.
• Patients in the treatment arm (NMES use) experienced quadriceps strength gains over baseline at 3, 6, and 12 weeks following surgery, which were statistically significant compared with controls with quadriceps strength losses at 3 and 6 weeks .  Use of a home-based application-controlled NMES therapy system added to standard of care treatment showed statistically significant improvements in quadriceps strength and TUG following TKA, supporting a quicker return to function.

In our office we like to present non-surgical options. We have been very fortunate over the years to have helped many people avoid a knee replacement. Can we help everyone? No. Can we help you? We would need to explore your candidacy for treatment. You can use the form below to contact me.

References:

1 Bardgett M, Lally J, Malviya A, Deehan D. Return to work after knee replacement: a qualitative study of patient experiences. BMJ Open.2016;6:e007912. doi:10.1136/bmjopen-2015-007912.
2 Pahlplatz TM, Schafroth MU, Krijger C, Hylkema TH, van Dijk CN, Frings-Dresen MH, Kuijer PP. Beneficial and limiting factors in return to work after primary total knee replacement: Patients’ perspective. Work. 2021 Jan 1;69(3):895-902.
3 Mahdi A, Svantesson M, Wretenberg P, Hälleberg-Nyman M. Patients’ experiences of discontentment one year after total knee arthroplasty- a qualitative study. BMC Musculoskelet Disord. 2020 Jan 14;21(1):29. doi: 10.1186/s12891-020-3041-y. PMID: 31937282; PMCID: PMC6961288.
4 McGonagle L, Convery-Chan L, DeCruz P, Haebich S, Fick DP, Khan RJ. Factors influencing return to work after hip and knee arthroplasty. Journal of Orthopaedics and Traumatology. 2019 Dec 1;20(1):9.
5 Maillette P, Coutu MF, Gaudreault N. Workers’ perspectives on return to work after total knee arthroplasty. Annals of physical and rehabilitation medicine. 2017 Sep 1;60(5):299-305.
6 Kuijer PP, Kievit AJ, Pahlplatz TM, Hooiveld T, Hoozemans MJ, Blankevoort L, Schafroth MU, van Geenen RC, Frings-Dresen MH. Which patients do not return to work after total knee arthroplasty?. Rheumatology international. 2016 Sep 1;36(9):1249-54.
7 Graber J, Lockhart S, Matlock DD, Stevens‐Lapsley J, Kittelson AJ. “This is not negotiable. You need to do this…”: A directed content analysis of decision making in rehabilitation after knee arthroplasty. Journal of Evaluation in Clinical Practice. 2022 Feb;28(1):99-107.
8 Klika AK, Yakubek G, Piuzzi N, Calabrese G, Barsoum WK, Higuera CA. Neuromuscular electrical stimulation use after total knee arthroplasty improves early return to function: a randomized trial. The Journal of Knee Surgery. 2022 Jan;35(01):104-11.