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 4th 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
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- 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
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