According to statistics from the Ministry of the Interior, the population aging index in Taiwan is 96.34% (Ministry of the Interior, Department of Household Registration, Taiwan, ROC, 2016), which is higher than the world population aging index of 30.77% and the aging index of developing countries of 20.69%. The most common degenerative diseases faced by the elderly population are musculoskeletal system diseases (Ministry of Health and Welfare, Taiwan, ROC, 2015). Degenerative arthritis is a common musculoskeletal disease. Each year, approximately 410,000 people seek medical treatment for joint diseases in Taiwan (Ministry of Health and Welfare, Taiwan, ROC, 2015), with the incidence of degenerative arthritis ranking at the top. According to 2015 statistics from the Ministry of Health and Welfare, 56%–72% of adults aged older than 55 years have degenerative arthritis, with estimates revealing that, by 2030, up to 85% of patients with degenerative arthritis will require knee arthroplasty surgery (Ministry of Health and Welfare, Taiwan, ROC, 2015).
Degenerative arthritis is the most prevalent type of degenerative musculoskeletal system disease in the elderly population. Degenerative arthritis can lead to arthralgia, physical disabilities, and major disruption of daily life functions, especially the ability to walk, perform household chores, and daily activities (Usiskin et al., 2016). Moreover, degenerative arthritis may gradually deteriorate until the patient is unable to conduct daily life functions. The clinical treatment includes total knee arthroplasty surgery. After undergoing total knee arthroplasty surgery, patients must undergo continuous passive motion knee rehabilitation exercise interventions to increase the joint bending angle and muscle strength of the lower limbs (Kuntze, von Tscharner, Hutchison, & Ronsky, 2015). However, after discharge, lack of appropriate home rehabilitation exercise activities in continuing knee rehabilitation affects joint movement and leads to health problems such as chronic pain and disability in the lower limbs, thus severely affecting the quality of life of patients. Chen, Tseng, Huang, and Li (2013) designed a senior elastic band exercise program for elderly adults aimed at improving body flexibility and lower limb muscle endurance. As such, the use of appropriate rehabilitation exercise interventions in knee rehabilitation to ensure optimal knee joint and lower limb function is prioritized in home health care for patients undergoing total knee arthroplasty. However, no studies have been conducted to elicit the effects of elastic band exercise on the lower limb rehabilitation of elderly patients with total knee arthroplasty. Therefore, the purpose of the current study was to evaluate the effects of elastic band exercise on the lower limb rehabilitation of elderly patients with total knee arthroplasty.
The American Academy of Orthopedic Surgeons (2016) indicated that patients with total knee arthroplasty must undergo rehabilitation exercise activities to maintain maximum muscle power of the quadriceps femoris and the mobility of the knee joint. Research has indicated that patients who persist in their rehabilitation exercise activities after total knee arthroplasty may experience reduced postoperative pain and complications and earlier recovery of motor functions (Amano et al., 2016 ; Yoshioka et al., 2016). Patients with total knee arthroplasty perform closed and open kinetic chain exercise activities, such as knee joint flexors and extensors, to increase muscle strength (Liang, Chao, Lin, Shih, & Lin, 2007). Elderly people who have undergone total knee arthroplasty should continue to perform active and passive knee joint exercise activities to avoid knee stiffness, increase knee activity and stability, and enhance the muscle strength of the lower limbs (Pozzi, Marmon, Snyder-Macker, & Zeni, 2016). Research has shown that engaging in “stretching exercises” and “straight leg raise exercise,” constituting the critical nursing care for patients with total knee arthroplasty, increases knee joint flexion and extension angles, reduces postoperative knee contracture, and increases the muscle strength of the knee joints and lower limbs (Lin, 2009 ; Tuner et al., 1999). If elderly patients with total knee arthroplasty fail to engage in rehabilitation exercise activities, the knee joint may not reach its maximum activity range, resulting in health problems such as chronic pain and disability in the lower limbs (Valtonen, Röyhönen, Heinonen, & Sipilä, 2009). On the basis of the aforementioned literature, performing knee rehabilitation exercise activities is a necessity for patients with total knee arthroplasty.
This study applied a quasiexperimental design. A convenience sampling method was used to recruit participants who (a) were over 65 years old, (b) were diagnosed with degenerative arthritis and received a single total knee arthroplasty procedure, (c) did not have knee arthroplasty history, and (d) able to understand Mandarin or Taiwanese. Individuals with severe or acute cardiovascular or lung diseases were excluded from participating.
Before the intervention was conducted, the study was approved by the institutional review board of a medical center (Approval No. 99-3520A). Interested and eligible participants were informed of the study and notified that the collected data would be used only in academic research. The participants indicated their consent to the study by signing or giving a thumbprint on the written consent form. During the study period, the participants maintained the rights to withdraw from the study at any time without affecting their care quality.
To estimate the sample size, this study analyzed the angle of the knee joint. After total knee arthroplasty surgery, the knee joints of patients could be flexed to angles of 100°–120° (American Academy of Orthopedic Surgeons, 2016), which falls within normal physiological degeneration, considering that the research participants are elderly people. The mean knee flexion angle of the control group was set as 100°, whereas that of the experimental group could reach up to 125°, with the standard deviation being 20°; moreover, α = 0.05 and power (1 − β) = 0.8. G*Power statistical software (Heinrich Heine University, Düsseldorf, Germany) revealed that each group had a sample size of 17 participants. Considering the sample loss in the process of the study, both groups were set to be composed of 25 participants each, thus yielding a total of 50 participants.
The participants were divided into a control group and an experimental group, with each group comprising 25 participants. The patients in the control group performed continuous passive motion knee rehabilitation exercise activities after surgery. In addition to the aforementioned rehabilitation exercise activities, researchers instructed and demonstrated to the participants in the experimental group how to use elastic bands for performing rehabilitation exercise activities at home. After discharge, through home visits, the researchers were able to confirm that the participants in the experimental group correctly performed the elastic band exercise activities at home. When the control and experimental groups returned to hospital at the 2- and 4-week marks, the knee joint activity, lower limb muscle strength, knee joint pain, and physical function of the two groups were compared. The physical therapist instructed the researchers to operate the measuring instruments till the researchers could operate the instruments precisely. To control the accuracy of interventional measures, the researchers examined the consistency of elastic band use for flexion, extension, and lower limb muscle strength exercise activities in seven patients.
The rehabilitation equipment is an elastic band 200 cm long and 30 cm wide. The elastic band exercise activities involved two phases: (a) knee flexion and extension movement and (b) leg raise exercise; these activities were aimed at strengthening the muscle of the knee joints, quadriceps, and hamstrings. Image-based elastic band exercise instructions were designed to attract the attention of the elderly participants. To prevent injuries, the participants were instructed in each elastic band exercise and monitored by a research assistant, who was a licensed physical therapist. The participants were asked to exercise four times per day with at least a 2-hour interval between sessions. Participants were asked to refrain from performing the elastic band exercise an hour before or after meals to avoid physical discomfort and instructed to take a moderately progressive approach to prevent lower limb pain after exercise and to increase the sense of achievement and confidence.
The outcome measurements were conducted using a (a) Demographic Questionnaire, (b) Joint Electronic Measuring Instrument, (c) Strength Measuring Device, (d) WOMAC Osteoarthritis Index, Knee Joints Assessment, and (e) Visual Analogue Scale.
Demographic Questionnaire: This tool was used to gather information on age, gender, education level, and marital status.
Joint Electronic Measuring Instrument: This tool measured the active and passive flexion and extension angles of joints.
Strength Measuring Device: This tool measured the strength of the quadriceps and hamstrings.
WOMAC Osteoarthritis Index, Knee Joints Assessment: The original tool (WOMAC) was developed by Bellamy and Buchanan (1986) to evaluate pain, stiffness, physical function, social function, and emotional function of patients with osteoarthritis in the hip or knee. The self-report tool (WOMAC Osteoarthritis Index, Knee Joints Assessment) was modified by the Taipei Society of Physical Therapists in Taiwan to assess physical function of patients undergoing total knee arthroplasty. Six activities was performed to evaluate physical function, which included walking, standing, squatting, getting up from a chair, lying down, and squatting or sitting on the toilet. Each activity was rated on a 5-point scale: not difficult (5), slightly difficult (4), moderately difficult (3), difficult (2), and very difficult (1). The higher score indicated the greater physical function.
Visual Analogue Scale: This scale is a self-completed instrument for assessing variations in the intensity of pain (McCormack, Home, & Sheather, 1988), with a higher score indicating greater pain intensity. In clinical practice, the pain relief assessed by the Visual Analogue Scale is often considered to be a measure of the efficacy of treatment. Therefore, this study applied the Visual Analogue Scale to assess the participants’ perception of knee joint pain after total knee arthroplasty surgery.
Statistical Methods and Analysis
SPSS Statistics 20.0 software (SPSS, Inc., Chicago, IL) was used for statistical analysis. Descriptive statistics (frequency distributions and percentages) were used to describe the participant demographic characteristics. The chi-square test, the t test, and a general linear model were used to determine the effects of the elastic band exercise activities on lower limb rehabilitation.
The study participants were predominantly women, 15 of whom were in the control group (60%) and 16 in the experimental group (64%). The majority of the participants were aged older than 70 years, 17 of whom were in the control group (68%) and 16 in the experimental group (64%). In terms of education level, most of the participants were illiterate, 19 of whom were in the control group (76.0%) and 15 in the experimental group (60%). Moreover, most of the participants were married, 20 of whom were in the control group (80%) and 21 in the experimental group (84%). Most of the participants had good perceived health, accounting for 19 in the control group (76%) and 20 in the experimental group (80%).
Two weeks after surgery, the mean active knee flexion angles of the experimental group had reached 85.50°, compared with 78.50° for the control group; in addition, the mean passive knee flexion angles of the experimental group had reached 115.20°, compared with 104.50° for the control group. These results indicate a significant difference (p < .001) between the groups. For mean active knee extension angles, the experimental group reached 14.20°, compared with 16.30° for the control group; moreover, for mean passive knee extension angles, the experimental group reached 4.20°, compared with 8.80° for the control group. These results also show a significant difference (p < .001) between the groups. In the experimental group, the muscle strength of the quadriceps was recorded at 5.63 lb and that of the hamstrings at 5.21lb, whereas in the control group, the muscle strength of the quadriceps was recorded at 3.97 lb and that of the hamstrings at 3.76 lb, showing a significant difference (p < .001) between the groups. The knee joint pain felt by the experimental group was recorded at 2.65, compared with 1.95 for the control group, showing a significant difference (p < .001; Table 1). The experimental group (mean score of 3.91) exhibited significantly higher performance in executing physical activities including walking, standing, squatting, getting up from a chair, lying down, and squatting or sitting on the toilet, compared with the control group (mean score of 3.28; p < .001; Table 2).
As shown in Table 3, in terms of the range of the knee flexion angle 1 month after surgery, the experimental group achieved a mean active flexion angle of 90.80° and a mean passive flexion angle of 124.20°, whereas the control group achieved a mean active flexion angle of 80.60° and a mean passive flexion angle of 105.50°, showing a significant difference (p < .001). Regarding the knee joint extension angle, the experimental group achieved a mean active extension angle of 7.50° and a mean passive extension angle of 1.80°, whereas the control group achieved a mean active extension angle of 14.30° and a mean passive extension angle of 7.20°, signifying a significant difference (p < .001). In terms of lower limb muscle strength 1 month after surgery, the muscle strength of the quadriceps in the experimental group was recorded at 6.57 lb and that of the hamstrings at 6.79 lb; in comparison, the muscle strength of the quadriceps in the control group was recorded at 4.55 lb and that of the hamstrings at 4.43 lb. These results indicate a significant difference in lower limb muscle strength between the two groups (p < .001). Regarding knee joint pain, the knee joint pain experienced by the experimental group was recorded at 0.45, whereas that of the control group was at 1.75 (p < .001). In terms of performing lower limb activities, the experimental group (mean score of 5.00) showed better performance than did the control group (mean score of 3.95). Regarding the activities of walking, standing, squatting, getting up from a chair, lying down, and squatting or sitting on the toilet, the experimental group exhibited a significantly higher performance in the mean score of the six items than did the control group (p < .001; Table 4).
Lin (2009) indicated that straight leg raise exercises enhanced the knee flexion angle of patients with total knee arthroplasty and should reach 100°–105° approximately 4–6 weeks after surgery. The results of the present study show that, approximately 2 weeks after surgery, the passive joint flexion angle of the experimental group reached 115.20°, whereas that of the control group reached 104.50°. One month after surgery, the passive joint flexion angle of the experimental group reached 124.20°, whereas that of the control group reached 105.50°, demonstrating that the participants in the experimental group showed greater knee flexion angle recovery 2 and 4 weeks after surgery than did the patients in the study of Lin (2009).
The findings indicate that participants who performed elastic band exercise activities experienced a significant improvement in knee movement and lower limb muscle power and endurance, which is consistent with the findings of Chan et al. (2016). The stretch training involved in elastic band exercise activities helped the participants stretch their knee joints and lower limb muscles, which promoted joint mobility and flexibility and enhanced muscle power and endurance.
Two weeks after surgery, the perceived knee joint pain experienced by the experimental group was higher than that of the control group, and this is attributable to pain, joint swelling, and other immediate postoperative factors. These factors may have contributed to the experimental group participants being more susceptible to knee joint pain when performing knee joint rehabilitation exercise activities. However, 1 month after surgery, when the immediate postoperative factors begin to subside, continued rehabilitation exercise activities increase knee joint and lower limb activity and alleviate the pain (Crosbie, Naylor, Harmer, & Russell, 2010), allowing the degree of perceived pain felt by the experimental group to be lower than that felt by the control group.
The results have shown that participants who performed elastic band exercise activities experienced a significant improvement in knee extension range of motion, strength of lower limbs, and physical function. Strength of knee extensor and lower limb muscle may be important factors in improving physical function in patients undergo total knee arthroplasty, which is consistent with the findings of Chen, Li, and Lin (2016) and Pua et al. (2013). Patients with total knee arthroplasty received home rehabilitation exercises to improve the knee extension range of motion and strength of lower limbs, which may be useful in improving the overall physical function and quality of life.
Participants of this study stated that the safe and easy exercise tool allowed them to execute rehabilitation exercise activities at home correctly and improved their body endurance, functional mobility, and quality of life, which is consistent with the findings of Shin (2016). Moreover, participants expressed that the personalized instructions and caring offered by nursing personnel during home visits were the main driving force in supporting them to persevere through the rehabilitation exercise activities and help their knee joints and lower limb function to recover to optimal conditions. A study indicated that conducting one-on-one rehabilitation guidance for patients with total knee arthroplasty is effective in improving the efficacy of rehabilitation exercise interventions, enhancing knee joint functions, and alleviating knee joint pain (Chen, Chen, & Lin, 2014).
Furthermore, because the participants of this study were mostly illiterate, designing image-based elastic band exercise instructions may facilitate understanding in the participants and allow them to execute rehabilitation exercise activities at home correctly. Using images to replace words and using multimedia materials to offer instruction for rehabilitation exercise activities to elderly people with total knee arthroplasty should enhance the motivation and effectiveness of the rehabilitation exercise (McDonall et al., 2016).
This study has limitations in terms of sample selection and size. This study was conducted using only participants living in southern Taiwan. Therefore, the outcomes of the study do not represent participants outside southern Taiwan. A long-term, regular intervention is expected to result in better treatment effectiveness. We recommend that future research be conducted using a long-term elastic exercise program in a larger population to obtain representative and valuable results.
This study confirmed the positive effects of elastic band exercise activities in improving lower limb rehabilitation in elderly patients with total knee arthroplasty. Moreover, the participants reported experiencing enhancing self-efficacy while performing these exercise activities. Therefore, health professionals who work with elderly patients undergoing total knee arthroplasty may consider recommending or implementing the elastic band exercise program as a rehabilitation modality for such patients. Future studies should work to assess and validate the effects of elastic band exercise activities in a larger population.
Key Practice Points
- Patients with total knee arthroplasty require rehabilitation exercise to avoid physical function weakness.
- Elastic band exercise activities facilitate significant improvement knee extension range of motion, strength of lower limbs, and physical motion function.
- Proper rehabilitation tools inspire the will of patients to engage in home rehabilitation exercise after total knee arthroplasty.
- Health professionals may consider implementing the elastic band exercise as a rehabilitation modality for patients undergoing total knee arthroplasty.
This work was supported by a grant from National Tainan Junior College of Nursing. The authors wish to acknowledge appreciation for this grant and the participants in this study.
The conception, design, data collection, analysis and interpretation of data, writing, and revising the manuscript critically were undertaken by Li-Na Chou and Min-Li Chen.
Conflicts of Interest
The authors declare no conflict of interest.
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Keywords:© 2019 Association of Rehabilitation Nurses.
Elastic Band Exercise; Elderly Adult; Physical Function; Rehabilitation; Total Knee Arthroplasty