Shared Decision-Making in Physiotherapy at Kauvery Hospital | Total Knee Replacement

Shared Decision-Making should be an Integral Part of Physiotherapy Practice: A Case Study on Total Knee Replacement

Hemakumar

Physiotherapist, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

Introduction

Shared decision-making (SDM) is integral to high-quality, evidence-based, patient-centered physiotherapy practice. It involves therapists and patients collaboratively making a health-related decision after discussing the options, their likely benefits and harms, and considering the patient’s values, preferences, and circumstances a decision is made. Despite being a crucial part of the final step in evidence-based practice, the skills needed to facilitate SDM are rarely taught to physiotherapists. It plays a fundamental role in improving therapist-patient communication, informed decision-making, and evidence-based care; and illustrates some of the processes involved in clinical scenarios.

By examining the experiences and outcomes of the patients, this study seeks to contribute to the growing evidence-based practice supporting the importance of SDM in physiotherapy practice.

Research Design

This study will employ a single case study design, using mixed-method approach to explore the integration of SDM in physiotherapy practice for functional outcomes in Total Knee Arthroplasty (TKA).

Intervention

The intervention will involve the integration of SDM into physiotherapy practice, using the following steps

Assessment

A 70-year-old retired electrician complained of difficulty in walking for the past 1 month and inability to ride a bicycle for more than 2 months. So, he came for further management, here it was diagnosed as OA right knee with deformity (Genu Varum). So, recommended for Total knee replacement. He underwent Right TKR with deformity correction on 06/02/2023 and he was referred for physiotherapy on the same day.

On Observation

Moderately built

Attitude of the limb – Hip -externally rotated, knee -extended, ankle -plantar flexed

On catheter

Long knee brace present on Right side

On Examination

Active ROM Left lower limb and both upper limbs normal

Active movements present in Right ankle

Muscle strength: bilateral upper limbs 5/5

Atherogenic muscle inhibition (AMI) – poor on Right quadriceps

Tone: Hip adductors right side – normal

Sensation: reduced 30%/100% (POD 0)

Functional Assessment

ICF Domains – body functions
Pain
Muscle strength
Range of motion
Proprioception

Body structures

The knee joint, muscles, bones

Activities and Participation Restriction

Mobility: TKA/TKR impact mobility, including walking, climbing stairs, and transferring.
Self-care: Daily activities such as bathing, dressing, and grooming affected by knee function.
Domestic life: Household chores.
Leisure activities: cycling

Environmental Factors

Physical environment: home and work environments can impact mobility and accessibility.
Social support: support from family influences rehabilitation outcomes.
Attitudes: societal attitudes towards disability and aging can affect the individual’s perception of their condition.

Personal Factors

Age: older adults may experience more significant declines in physical function
Comorbidities: hypertension
Coping strategies: individual coping mechanisms, can influence adaptation to the condition.

Decision Making

SDM is a collaborative process between healthcare professionals and patients, where they work together to make informed decisions about care.

In the context of immediate post-operative pain management in TKA/TKR, by considering patients values and preferences, physiotherapists can develop personalized pain management plans that meet patients’ needs better. The physiotherapist presents the patient with evidence-based treatment options for post-operative pain management, including pharmacological and non-pharmacological interventions. Few examples are,

Acute care physiotherapy interventions for post-operative pain management,

Deep Breathing exercises can help reduce stress and anxiety, promoting relaxation and pain relief.

Gentle mobilization and exercises can help reduce pain and stiffness, promoting functional ability and mobility.

Education and reassurance can help alleviate anxiety and fear, promoting a sense of control and empowerment

In Acute Care Physiotherapy Interventions for Early Mobilization

The physiotherapist assesses the patient’s values, preferences, and goals related to early mobilization. The following functions are made.

Progressive mobilization and exercise to promote functional ability and mobility (bed mobility, sit-to-stand, transfer, and ambulation)

Tailored exercise programs to encourage strength (Quadriceps), flexibility (Hamstrings, calf muscles), and range of motion (knee extension and flexion (achieving 90Degree in 4^th POD).

Mobility aids such as walkers promote safe mobilization.

Education and reassurance to alleviate anxiety and fear, promoting a sense of control and empowerment.

The patient and physiotherapist will develop a personalized treatment plan that incorporates the patient’s goals, preferences, and values.

Outcome Measures

Knee Injury Osteoarthritis outcome score for joint replacement scale (KOOS, JR)

0/28(Raw summed score) converting it into an Interval score 0-100.

Time of Assessment	Raw Summed	Interval Score
Time of Discharge	15/28	50.012
4th Week	8/28	65.994
8th Week	7/28	68.284
12th Week	3/28	79.914

Discussion

This single case study explored the application of Shared Decision Making (SDM) in acute care physiotherapy management for a patient undergoing Total Knee Replacement (TKR) surgery. The key findings of this study:

The patient demonstrated significant improvements in pain management, functional ability, and quality of life following the implementation of SDM in physiotherapy management
The patient reported high levels of satisfaction with the physiotherapy program and felt empowered to take an active role in decision-making and self-management.
The use of SDM in physiotherapy management facilitated a collaborative relationship between the patient and the physiotherapist, promoting a patient-centered approach to care. Also, it impacted on patient’s motivation by increasing their sense of autonomy and motivation to adhere to the physiotherapy plan.

Implications

The findings of this study have several implications for physiotherapy practice and research:

Patient-centred care: the use of SDM in physiotherapy management promotes a patient-centred approach to care, empowering patients to take an active role in decision-making and self-management.
Personalized care: the application of SDM ensures that physiotherapy programs are tailored to meet the individual needs and goals of patients, promoting a personalized approach to care.
Improved Health Outcomes: the use of SDM in physiotherapy management can lead to improved health outcomes, including pain management, functional ability, and quality of life.
Increased Patient Satisfaction: the application of SDM promotes high levels of patient satisfaction with physiotherapy programs, leading to improved adherence and health outcomes.

Conclusion

In conclusion, the application of SDM in physiotherapy management profoundly impacts patient motivation, trust, and adherence to physiotherapy plans. By fostering a collaborative relationship, promoting patient autonomy, and tailoring interventions to meet individual patient needs, SDM enhances patient engagement, motivation, and adherence, ultimately leading to improved health outcomes.

References

J Multidiscip Healthc. 2023 Sep 8:16:2655-2665. doi: 10.2147/JMDH.S425315. eCollection 2023. The Practice of Shared Decision-Making Among Physiotherapists and Patients with Musculoskeletal Conditions
Review Braz J Phys Ther. 2022 Jan-Feb;26(1):100382. doi: 10.1016/j.bjpt.2021.100382. Epub 2022 Jan 1. Shared decision making and physical therapy: What, when, how, and why? Tammy Hoffmann 1, Mina Bakhit 2, Zoe Michaleff 2
2019 Apr 29;191(17):E469–E475. doi: 10.1503/cmaj.180635 Enhanced recovery after surgery: implementing a new standard of surgical care. Alon D Altman 1,✉, Limor Helpman 1, Jacob McGee 1, Vanessa Samouëlian 1, Marie-Hélène Auclair 1, Harinder Brar 1, Gregg S Nelson 1, on behalf of the Society of Gynecologic Oncology of Canada’s Communities of Practice in ERAS and Venous Thromboembolism
Ingadottir, Brynja. ‘Role of Patient Education in Postoperative Pain Management’. Nursing Standard. www.academia.edu, https://www.academia.edu/59774428/Role_of_patient_education_in_postoperative_pain_management. Accessed 8 Apr. 2025.
https://www.researchgate.net/publication/356897678_Arthrogenic_Muscle_Inhibition_Best_Evidence_Mechanisms_and_Theory_for_Treating_the_Unseen_in_Clinical_Rehabilitation

Lisi, Claudio, et al. ‘Early Rehabilitation after Elective Total Knee Arthroplasty’. Acta Bio Medica : Atenei Parmensis, vol. 88, no. Suppl 4, 2017, pp. 56–61. PubMed Central. Early rehabilitation after elective total knee arthroplasty. Claudio Lisi 1,2, Patrick Caspani 2, Marco Bruggi 2, Ettore Carlisi 1,2, Donatella Scolè 1, Francesco Benazzo 3, Elena Dalla Toffola 1,2,

Shared Decision-Making should be an Integral Part of Physiotherapy Practice: A Case Study on Total Knee Replacement

Shared Decision-Making should be an Integral Part of Physiotherapy Practice: A Case Study on Total Knee Replacement

Hemakumar

Nightingale Journals