Original research| Volume 102, ISSUE 5, P881-887, May 2021

Association of Therapy Time Per Day With Functional Outcomes and Rate of Recovery in Older Adults After Elective Joint Replacement Surgery

Published:November 16, 2020DOI:



      To explore the association between therapy minutes per length of stay (LOS) day (TMLD), functional outcomes, and rate of functional recovery among older adults after elective hip or knee replacement surgery across postacute (PAC) settings.


      Secondary analysis of data collected for an observational cohort study from 2005 to 2010.


      Four inpatient rehabilitation facilities (IRF) and 7 skilled nursing facilities (SNF).


      Adults aged 65 years or older (N=162) with Medicare fee-for-service insurance and a primary diagnosis of elective hip or knee replacement.


      Not applicable.

      Main Outcome Measures

      FIM mobility and self-care measures at discharge.


      The TMLD was divided into high, medium, and low categories. Participants were grouped into low, medium, and high gain rate groups based on their average change in mobility and self-care FIM measures per LOS day. Gain rate and TMLD groups were crossmapped to create 9 gain-TMLD groups separately for mobility and self-care. There were no significant differences in admission mobility or self-care measures by gain rate and TMLD trajectory or by facility type (IRF or SNF). TMLD was not significantly associated with discharge mobility measures. Participants in high gain trajectories attained independence with mobility and self-care tasks at discharge regardless of TMLD. Those in low gain trajectories needed supervision or assistance on all mobility tasks. Older age and greater pain at discharge were significantly associated with lower odds of being in the medium or high gain rate groups.


      For clinicians and facility managers who must care for patients with constrained resources, the shift to value-based reimbursement for rehabilitation services in PAC settings has reinvigorated the question of whether the duration of therapy provided influences patient outcomes. Three hours of daily therapy after joint replacement surgery may exceed what is necessary for recovery. Postsurgical pain management remains a significant challenge in older adults.


      List of abbreviations:

      IQR (interquartile range), IRF (inpatient rehabilitation facility), LOS (length of stay), PAC (postacute care), SNF (skilled nursing facility), TMLD (therapy minutes per length of stay day)
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        • Etkin C.D.
        • Springer B.D.
        The American Joint Replacement Registry—the first 5 years.
        Arthroplast Today. 2017; 3: 67-69
        • Kremers H.M.
        • Larson D.R.
        • Crowson C.S.
        • et al.
        Prevalence of total hip and knee replacement in the United States.
        J Bone Joint Surg Am. 2015; 97: 1386-1397
        • Jubelt L.E.
        • Goldfeld K.S.
        • Chung W.
        • Blecker S.B.
        • Horwitz L.I.
        Changes in discharge location and readmission rates under Medicare bundled payment.
        JAMA Intern Med. 2016; 176: 115-117
        • Fleischman A.N.
        • Austin M.S.
        • Purtill J.J.
        • Parvizi J.
        • Hozack W.J.
        Patients living alone can be safely discharged directly home after total joint arthroplasty: a prospective cohort study.
        J Bone Joint Surg Am. 2018; 100: 99-106
        • Centers for Medicare and Medicaid Services
        Inpatient rehabilitation therapy services: complying with documentation requirements.
        (Available at:)
        • Medicare Payment Advisory Council
        Medicare Payment Policy: Report to Congress. Medicare Payment Advisory Commission.
        (Available at:)
        • Medicare Payment Advisory Council
        Skilled nursing facility services payment system. Published online 2016.
        (Available at:)
        • Khan F.
        • Ng L.
        • Gonzalez S.
        • Hale T.
        • Turner-Stokes L.
        Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy.
        Cochrane Database Syst Rev. 2008; : CD004957
        • DeJong G.
        • Hsieh C.-H.
        • Gassaway J.
        • et al.
        Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities.
        Arch Phys Med Rehabil. 2009; 90: 1269-1283
        • World Health Organization
        International Classification of Functioning, Disability and Health (ICF).
        (Available at:)
        • DeJong G.
        • Horn S.D.
        • Smout R.J.
        • Tian W.
        • Putman K.
        • Gassaway J.
        Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities.
        Arch Phys Med Rehabil. 2009; 90: 1284-1296
        • Herbold J.A.
        • Bonistall K.
        • Walsh M.B.
        Rehabilitation following total knee replacement, total hip replacement, and hip fracture: a case-controlled comparison.
        J Geriatr Phys Ther. 2011; 34: 155-160
        • Mallinson T.
        • Deutsch A.
        • Bateman J.
        • et al.
        Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.
        Arch Phys Med Rehabil. 2014; 95: 209-217
        • Mallinson T.R.
        • Bateman J.
        • Tseng H.-Y.
        • et al.
        A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.
        Arch Phys Med Rehabil. 2011; 92: 712-720
        • Inouye S.K.
        • Studenski S.
        • Tinetti M.E.
        • Kuchel G.A.
        Geriatric syndromes: clinical, research and policy implications of a core geriatric concept.
        J Am Geriatr Soc. 2007; 55: 780-791
        • van der Steen J.T.
        • Volicer L.
        • Gerritsen D.L.
        • Kruse R.L.
        • Ribbe M.W.
        • Mehr D.R.
        Defining severe dementia with the Minimum Data Set.
        Int J Geriatr Psychiatry. 2006; 21: 1099-1106
        • Said C.M.
        • Morris M.E.
        • McGinley J.L.
        • et al.
        Additional structured physical activity does not improve walking in older people (>60years) undergoing inpatient rehabilitation: a randomised trial.
        J Physiother. 2018; 64: 237-244
        • Taylor N.F.
        • Lawler K.
        • Brusco N.K.
        • et al.
        Saturday allied health services for geriatric evaluation and management: a controlled before-and-after trial.
        Australas J Ageing. 2020; 39: 64-72
        • Braun T.
        • Grüneberg C.
        • Süßmilch K.
        • et al.
        An augmented prescribed exercise program (APEP) to improve mobility of older acute medical patients – a randomized, controlled pilot and feasibility trial.
        BMC Geriatr. 2019; 19: 240
        • McCartney C.J.L.
        • Nelligan K.
        Postoperative pain management after total knee arthroplasty in elderly patients: treatment options.
        Drugs Aging. 2014; 31: 83-91
        • Tracy B.
        • Morrison R.S.
        Pain management in older adults.
        Clin Ther. 2013; 35: 1659-1668
        • Lamplot J.
        • Wagner E.
        • Manning D.
        Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial.
        J Arthroplasty. 2014; 29: 329-334
        • Garland E.L.
        • Brintz C.E.
        • Hanley A.W.
        • et al.
        Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis.
        JAMA Intern Med. 2019; 180: 91-105
        • Lim Y.C.
        • Yobas P.
        • Chen H.-C.
        Efficacy of relaxation intervention on pain, self-efficacy, and stress-related variables in patients following total knee replacement surgery.
        Pain Manag Nurs. 2014; 15: 888-896
        • Carpenter J.J.
        • Hines S.H.
        • Lan V.M.
        Guided imagery for pain management in postoperative orthopedic patients: an integrative literature review.
        J Holist Nurs. 2017; 35: 342-351
        • Moukarzel M.
        • Rienzo F.D.
        • Lahoud J.-C.
        • et al.
        The therapeutic role of motor imagery during the acute phase after total knee arthroplasty: a pilot study.
        Disabil Rehabil. 2019; 41: 926-933
        • Antall G.F.
        • Kresevic D.
        The use of guided imagery to manage pain in an elderly orthopaedic population.
        Orthopaedic Nurs. 2004; 23: 335-340
        • Tedesco D.
        • Gori D.
        • Desai K.R.
        • et al.
        Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty: a systematic review and meta-analysis.
        JAMA Surg. 2017; 152e172872
        • Hart T.
        • Dijkers M.P.
        • Whyte J.
        • et al.
        A theory-driven system for the specification of rehabilitation treatments.
        Arch Phys Med Rehabil. 2019; 100: 172-180
        • Webster F.
        • Perruccio A.V.
        • Jenkinson R.
        • et al.
        Understanding why people do or do not engage in activities following total joint replacement: a longitudinal qualitative study.
        Osteoarthritis Cartilage. 2015; 23: 860-867
        • Span P.
        A change in Medicare has therapists alarmed.
        (Available at:)