Effects of Early Ambulation for Patients With Total Joint Arthroplasty

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Abstract

This paper addressed the comparative benefits and risks of early ambulation and bed rest for patients with total joint arthroplasty. First, it examined the background information on the surgery in question and the meaning behind the concepts of ambulation and bed rest. Then, it commented on the purpose of its topic by introducing a PICOT question and conducted a review of the existing body of academic literature. The methodology of research focused on the factors of relevancy and scientific credibility when establishing the selection of the articles. It then identified the gap within the current literature and made statements in relation to the significance of further research.

Finally, the paper addressed the implications the early ambulation’s popularity might bring to the nursing profession and the ways in which nurses themselves might have became a part of the new approach. The review concluded the overall positive effects of early ambulation on the patients recovering from total joint arthroplasty, with additional attention needed for individual cases.

Introduction

Early ambulation, known also as an early mobilization, and bed exercise are the most prevalent approaches to the post-operative care in the modern medicine. Debates arise on whether either of these recovery scenarios is inherently superior to the other and in which context. This paper attempts to compare and contrast the two approaches from the standpoint of greater likelihood of successfully reducing postoperative complications. The diagnosis of deep vein thrombosis and pulmonary embolism were chosen as examples to provide focus to the outlined literature review and its significance.

Topic Statement

Anticoagulant drugs (medicines that help prevent blood clots) and bed rest are the most common treatments for patients diagnosed with deep vein thrombosis or pulmonary embolism in acute care. Blood clots are considered to be dislodged by ambulation. However, there has not been much study done on the effects of bed rest vs early ambulation. Although bed rest is often prescribed as part of treatment, it is linked to a prolonged hospital stay and muscular disuse, both of which have negative consequences. For the treatment of total joint arthroplasty, a comprehensive meta-analysis was undertaken to compare conventional anticoagulation with either bed rest or early ambulation.

The comparison between the two recovery scenarios is relevant to hold due to the ongoing discussions in the medical community, among patients and doctors alike. With many Americans unable to afford sufficient healthcare due to the financial barriers, a comparative analysis of early ambulation and bed rest provides a more informed outlook on recovery for the patients with total joint arthroplasty.

Research Problem

The research question formulated concerns the matters of effective treatment and improved medical prospects, and therefore is bound to result in only comparative accuracy of results. Is it true that encouraging critically sick individuals to move or exercise early in their stay in the intensive care unit improves their capacity to undertake daily tasks such as walking and daily self-care after they leave the hospital? For this issue, the evidence was evaluated to determine if early exercise had any advantages, such as reducing the length of time spent in the ICU or hospital, improving muscular strength, and improving feelings of well-being, as well as any risks, such as the occurrence of falls. Moving in or out of bed, practicing standing up, walking, arm exercises, and self-care tasks like eating or combing hair are all examples of movement or exercise.

Background Information

Total joint arthroplasty is a form of surgical procedure in which fragments of a damaged or affected by arthritis joint are replaced with a metallic, ceramic or plastic prosthetic device. The replacement is built in the manner most identical to the one of a natural healthy joint, with modern medical innovations contributing to the further increasing levels of authenticity. Among the most frequent joints subjected to this operation knee and hip are easy to identify, which has affected the samples provided for the academic articles reviewed below. Nevertheless, other joints, such as elbow, ankle, shoulder or wrist are eligible for this type of surgical intervention as well, even though they are less frequently in the need of one.

Joint discomfort and impairment can be caused by a variety of diseases, prompting patients to seek joint replacement surgery. Most of these cases are caused by the damage inflicted upon the cartilage that surrounds the bones in a joint. The damage itself may stem from arthritis, a fracture, a mineral deficiency or other condition (Heiden et al., 2021). A doctor may recommend a complete joint replacement if nonsurgical therapies do not provide a sufficient improvement for a patient’s well-being.

During surgery, the cartilage is manually removed from a damaged joint and, as specified above, replaced with a prosthetic made out of metal, ceramic or plastic. To provide an example, in an arthritic hip, the upper ball on the side of the femur is replaced with a metal alternative attached to a metal stem. The stem is then inserted into the femur, with a plastic socket being planted into the pelvis instead of the original damaged socket (Xu et al., 2020). The potential complications after the surgical intervention include an inflammation of the surrounding tissues, blood cloths and nerve swelling. Otherwise, prosthetic-related issues might emerge, such as dislocation or loosening. Most complications are easily treatable, but need to be reviewed by a patient and their doctor on a case-by-case basis.

Furthermore, context is required to define the early ambulation and bed rest exercise as recovery scenarios for the purposes of this paper. Ambulation is defined as the ability to move and engage with the physical surroundings without the use of any assistance from people or technology. It is most commonly used to describe a patient’s post-surgery or physical therapy goal. Before a patient is able to walk around on their own, they may require assistance in order to achieve their aim of ambulation (Mbibi & Monsen, 2016).

The relevance of ambulation for full physical recovery transcends the matters of comfort and independence, with it being a vital part of the return to health as well. Inactivity lowers muscular mass and strength, as well as blood oxygen capacity. Movement becomes more difficult and unpleasant when muscles grow tight and strained. As a result, ambulation is a critical daily aim for people of all ages, that needs to be cultivated in post-operation patients in recovery.

The technique of early ambulation is focused on terminating the bed rest state after an operation as soon as it is generally safe for a patient’s wellbeing and health. The patient is then encouraged to slowly increase their level of physical activity, including tasks such as walking, standing and sitting down without assistance. Many modern researchers insist on the benefits behind such approach to recovery, pointing out the biological processes that can be caused or induced by early ambulation. Ambulation increases the speed of internal circulation, which in turn reduces the probability blood clots that cause strokes (Adogwa et al., 2020; Doiron et al., 2018).

Physical exercise and walking increase the blood flow speed, which accelerates the speed of tissue recovery. Furthermore, the presence of walking comparatively improves gastrointestinal, genitourinary, lung, and urinary tract functioning.

Bed rest, often known as the rest-cure, is a medical treatment in which a person spends the majority of their time in bed as the key part of their supposed recovery from illness or surgery. It is critically different from the confinement to bed that occurs as a result of some illnesses, since in this case the limited condition is intentional and prescribed for a period of time. Due to standard needs of a body after the shock of surgical intervention, bed rest remains the most widespread and almost universally acknowledged recovery scenario for the initial stage. The opinions split, however, concerning the optimal length of such method and by extension the point at which it is appropriate to move to further recovery methods.

Purpose & PICOT Question

The purpose of this paper focuses on the literature analysis and evaluation of existing peer-reviewed medical articles. It prioritizes the statistical analysis and the works in which quantitative and qualitative methods were combined throughout the engagement with patients. The PICOT question was designed to ensure thematic and structural coherence throughout the paper. As per requirements of the framework, Population, Intervention, Control, Outcome, and Time. Population of the research question concerns the patients with total joint arthroplasty in need of physical recovery; as a factor it concerns the key characteristics of the research subjects.

Intervention is focused on the strategy, action or test that is being researched, with early ambulation being the case for this analysis. Control refers to the comparison group against which the Intervention is measured, in this research it being those who undergo the bed rest recovery scenario. Finally, the Outcome concerns the results of the comparison stated within the question, and Time to the period required to achieve the desired research results. In the current paper the Outcome is to be measured based on the comparative recovery progress achieved by the groups of patients in question.

Methodology

Literature review was conducted based on a selection of the materials published within the last five years. The appropriate publications included peer reviewed scientific articles and medical databases, with statistical analysis elements incorporated. A total of five articles were reviewed for the current state of research section, with these articles in turn drawing their data from the resources of the hospitals they have partnered with.

Additionally, simple random sampling was ensured for the appropriate research questions in the chosen articles, with non-selected characteristics of participants distributed in a representative manner. The articles were then analyzed based on their conclusions in relation to the research question or any relevant comments provided. Both the positive and the negative points were considered to obtain a balanced evaluation of the issue that considers the viewpoints of patients and healthcare professionals alike.

Current State of Research

Multiple studies have focused on early ambulation and bed rest in the context of post-surgical recovery from total joint arthroplasty, particularly in relation to hip and knee fractures. The available literature has taken into account the efficiency and speed of the recovery, as well as the complication risks and the psychological effects the two approaches have had on the patients. Early ambulation was associated with faster re-integration into active social life, which, in turn, was proven to be linked to the general levels of post-operational satisfaction (Crumley Aybar et al., 2016; Yamashita et al., 2021).

Overall, it is plausible to assume that early ambulation leads to more frequent and voluntary ambulation, ensuring a patient partakes in physical activity on their own volition (Heiden et al., 2021). Considering the positive physical and psychological effects of post-operational activity, studies have found that early ambulation is beneficial to patients recovering from joint surgery unless specified otherwise. Some researchers speculate that the additional exercises specific to the early ambulation approach provided lasting carry-over effects on functional outcomes of the operation (Xu et al., 2020). In particular, early ambulation was found to be correlated to flexibility and mobility of the treated joints.

Research in a separate yet overlapping field confirms that long hospitalizations tend to have a negative impact on the consequent long-term mobility of patients, particularly older ones. This proves to be a pressing concern among the joint surgery patients, as arthritis, hip and knee fractures are statistically more common among the elderly population (Lisevick et al., 2020). Thus, it is reasonable to conclude that those at risk of becoming less mobile in the long-term after a prolongated hospital stay and those most likely to require a joint surgery are within the same demographic.

With these implications in mind it becomes apparent for some of the researchers in the field that the healthcare professionals should, if no circumstances prevent it, pursue their patients to ambulate as early as possible. Another study conclusion is that the study findings give a timely motivation for considering approaches to decrease unnecessary practice variance. The undesired variance has been widely documented in the medical practice management and relates to poor patient outcomes and higher expenditures. The authors do acknowledge, however, that excellent science does not always imply good behavior, and that bridging the gap between evidence and practice necessitates a multifaceted strategy.

Research Gap

Current body of research includes, however, several limitations: methodological, structural or design-related. The same must be admitted about this review paper as well, considering the article selection was conducted by the author independently. First, the randomized studies and prospective registries were selected for the review on the basis of specific eligibility criteria. Said criteria admittedly are not universal and might be challenged by further researchers if they see fit. The criteria applied included simple random sampling subject recruitment technique, presence of statistical analysis and general credibility of the source. The last requirement included articles from the peer-reviewed medical journals and hospital databases.

Secondly, regardless of the mentioned attempts to account for the minority of the patients with the increased risks of total joint arthroplasty complications, no full customization can be accomplished. With the subject matter being the best approach to the recovery of a human body, definitive answer can never be achieved due to an endless list of individual variations in every patient studied. This paper recognizes it and reinforces the statement that personal attention to the matter at hand on a case-by-case basis remains the overall best solution. However, it also addresses the existence of studied and previously researched patterns of recovery speed and quality observed within the two methods in question.

Thirdly, in all the papers considered for the literature review, the patients were given similar anticoagulant regimens. Patients in the “ambulatory groups,” on the other hand, may have been treated with compression or elastic stockings more frequently. Although by analogy with the sources studied the author could not see this as one of the key variables in reducing the risk of new PE, it may be viewed as a restriction. Fourthly, patients with major PE had been excluded from the trials included in our analysis, with the exception of the RIETE registry. However, in individuals whose hemodynamic condition is extremely unstable, very rapid ambulation is unlikely to be beneficial and is generally not a viable option.

Significance Review

The majority of current recommendations for patients with total joint arthroplasty does not prioritize bed rest or early ambulation, occupying a neutral position instead. The American College of Chest Physicians, on the other hand, mentions early ambulation in passing in their report, but not in the conclusions. Early ambulation is a topic that comes up frequently in thromboembolism treatment and, occasionally, in cancer treatment and recovery research. As a result, this paper may aid practitioners in their decision-making.

Additionally, early ambulation provides numerous advantages such as pain relief, improved quality of life, and a lower rate of post-thrombotic syndrome. It may be cost-effective since it allows for home treatment or early discharge from the hospital. Consecutively this literature review and other studies on said topic have the potential to significantly improve the levels of conscious engagement with treatment among low-income patients and their families.

It may be seen as an appropriate response to the financial avoidance issue the American healthcare system is currently facing. With patients being informed of the potential benefits as well as the potential risks of early ambulation and in-home treatment, fewer would have to choose between uncertainty and financial hardship. Finally, the majority of the studies we looked at included both symptomatic and asymptomatic PE found during systematic tests. While symptomatic PE is likely the most clinically relevant outcome, we felt it was necessary to include all new PE because our goal was to assess the risk associated with a strategy that advocates early ambulation.

Implications for the Nursing Profession

As stated previously, shorter hospital stays would lead to significant savings for patients and their families, resulting in an overall positive for this demographic of parties involved. However, the outcome is less certain and more up to interpretation for the nurses in medical institutions as well as the other groups of staff. Shorter stays and smaller numbers of patients would naturally involve the decrease of workload and the reduction of pressure levels on the existing system. This may be a solution and a positive to the currently acute issue of the staff shortage and exhaustion levels among nurses.

On the other hand, hypothetically the increased rates of early ambulation and home therapy might threaten the employment of some healthcare professionals in smaller hospitals. This is a technically possible outcome, since the supply of labor is generally inclined to address the existing demand for it. However, this study believes that the negative outcome for nurses’ employment is unlikely, since the issue of their disproportionate rates of exhaustion currently remains incredibly high.

Additionally, the nurse-led mobility protocols begin to gather popularity in use on the national scale across hospitals and other medical institutions. They are primarily designed to assist mobility of older patients with delirium risk, but the tactics applied and their efficiency suggest that similar actions might be taken to assist the patients in their ambulation process. Despite the independence and absence of need in other person’s assistance being the key characteristics behind the ambulation, it remains a step-by-step process, and the nursing assistance might be required for the successful transition. Within this scenario, additional training might be required to teach the nurses skills essential to address the needs of patients with total joint arthroplasty, with an emphasis put on their interest in moving to full ambulation as soon as possible.

The goal of early mobility is to implement an evidence-based mobility program that will help patients preserve their baseline mobility and functional capacity, reduce the incidence of delirium, and reduce the number of ventilator days and hospital stays. Nurse-driven early mobility aims to promote a multidisciplinary focus on early mobility as part of daily clinical routines, keep patients as close to their pre-hospital baseline mobility and functional levels as possible, initiate a mobility protocol when the patient is hemodynamically stable, and mobilize the patient with an activity at least twice a day.

Early mobility interventions demand a multidisciplinary strategy with a coordinated approach. Nurses, a respiratory therapist, a physical therapist, a clinical pharmacist, an occupational therapist, and a physician can be on your multidisciplinary team. A nurse-driven protocol is used as part of this coordinated strategy to get the patient out of bed faster. Sedation levels must be decreased to keep patients mildly sedated at most in order to move them sooner. Then, SATs and SBTs (spontaneous awakening and spontaneous breathing trials) should be done. Following the interruption of sedation, any indicators of delirium must be examined and managed. Patients must also be assessed to see if they are eligible for the highest level of mobility. Finally, patient goals should be tailored to maximize mobility, addressing the potential issues as they emerge along the way.

Improved patient outcomes can be achieved by mobilizing patients sooner, with nurses being made aware of the prioritization of the ambulation. The implementation of an early mobility protocol should reduce bed rest issues, enhance patients’ overall functions, encourage timely ventilator weaning, increase patients’ general strength and endurance, and reduce ICU and hospital lengths of stay, resulting in lower hospital expenditures. Finally, the patient’s psychological advantage from early ambulation should not be neglected. All of these factors, steps and skills might become part of the program of current nurse training in the future to ensure the recovery efficiency for patients with total joint arthroplasty.

However, scientists have also indicated several concerns that might in certain cases contradict the aforementioned advice of implementing the ambulatory approach as early as possible. Such, some of the healthcare professionals are concerned with the pain management complications that patients might encounter if their hospital stay is kept to as short periods of time as possible. Despite the multiple positive effects of the renewed physical activity as well as psychological benefits of lesser isolation, patients and their relatives are recommended to consider the risks of removing themselves from a suitable medical environment.

Joint fractures and arthritis complications are notorious for high pain levels and inflammation risks, which frequently may only be adequately diagnosed and treated in a clinical environment. Additionally, attempts in self-treatment of chronical or acute post-surgical pain may lead to the development of substance addictions and other negative consequences of unregulated medication.

Conclusion

Despite the fact that early ambulation is rarely indicated as part of the initial care of thromboembolic diseases, this literature analysis found no evidence that it was linked to a higher risk of a remission or other negative outcomes than bed rest. Furthermore, when patients were treated with early ambulation rather than initial bed rest, there was a trend toward decreased mortality and new or progression of total joint arthroplasty. These findings suggest that initial bed rest is not an evidence-based prescription, and that it should no longer be part of thromboembolic disease management or education.

Early ambulation should be considered in these patients as soon as a degree of successful initial recovery is achieved. The advantages of early ambulation are obvious and should therefore be seized provided the patients do not risk the progress of their recovery or their general safety by doing so. Physical activity helps to strengthen joints and muscles, and it has been linked to less hospital visits. Nevertheless, the negative side effects of early ambulation should also be taken into account by healthcare professionals when recommending or prescribing this scenario and assessed on a case-by-case basis.

References

Adogwa, O., Elsamadicy, A., Fialkoff, J., Cheng, J., Karikari, I., & Bagley, C. (2017). Early ambulation decreases length of hospital stay, perioperative complications and improves functional outcomes in elderly patients undergoing surgery for correction of adult degenerative scoliosis. Spine, 42(18), 1420-1425. Web.

Crumley Aybar, B., Gillespie, M., Gipson, S., Mullaney, C., & Tommasino-Storz, M. (2016). Peripheral nerve blocks causing increased risk for fall and difficulty in ambulation for the hip and knee joint replacement patient. Journal Of Perianesthesia Nursing, 31(6), 504-519. Web.

Doiron, K., Hoffmann, T., & Beller, E. (2018). Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database of Systematic Reviews, 2018(12). Web.

Galanaud, J., Laroche, J., & Righini, M. (2013). The history and historical treatments of deep vein thrombosis. Journal of Thrombosis and Haemostasis, 11(3), 402-411. Web.

Gwozdz, A., Black, S., Hunt, B., & Lim, C. (2020). Post-thrombotic syndrome: Preventative and risk reduction strategies following deep vein thrombosis. Vascular And Endovascular Review, 3. Web.

Heiden, J., Goodin, S., Mormino, M., Siebler, J., Putnam, S., Lyden, E., & Tao, M. (2021). Early ambulation after hip fracture surgery is associated with decreased 30-day mortality. Journal of the American Academy of Orthopaedic Surgeons, 29(5), e238-e242. Web.

Khandhar, S., Schatz, C., Collins, D., Graling, P., Rosner, C., & Mahajan, A. et al. (2018). Thoracic enhanced recovery with ambulation after surgery: A 6-year experience. European Journal of Cardio-Thoracic Surgery, 53(6), 1192-1198. Web.

Lei, Y., Xie, J., Huang, Q., Huang, W., & Pei, F. (2021). Benefits of early ambulation within 24 h after total knee arthroplasty: A multicenter retrospective cohort study in China. Military Medical Research, 8(1). Web.

Liu, Z., Tao, X., Chen, Y., Fan, Z., & Li, Y. (2015). Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: A meta-analysis. PLOS ONE, 10(4), e0121388. Web.

Lisevick, A., Kelly, S., Cremins, M., Vellanky, S., McCann, G., & LeBlanc, K., Derla, M., Comerford, E., Sinha, S. K. (2020). Mobility technicians. Orthopaedic Nursing, 39(5), 333-337. Web.

Mbibi, N., & Monsen, K. (2016). Prevention of deep vein thrombosis in pregnant mothers during prolonged bedrest. Kontakt, 18(3), e152-e157. Web.

Park, S., Kim, K., Park, M., Lee, U., Sim, H., Shin, I., & Song, Y. (2018). Effect of 24-hour bed rest versus early ambulation on headache after spinal anesthesia: Systematic review and meta-analysis. Pain Management Nursing, 19(3), 267-276. Web.

Xu, L., Leng, J., Elsharkawy, H., Hunter, O., Harrison, T., & Vokach-Brodsky, L., Kumar, G., Funck, N., Hill, J. N., Giori, N. J., Indelli, P. F., Kou, A., Mariano, E. R. (2020). Replacement of fascia iliaca catheters with continuous erector spinae plane blocks within a clinical pathway facilitates early ambulation after total hip arthroplasty. Pain Medicine, 21(10), 2423-2429. Web.

Yamashita, F., Funakoshi, N., Mori, D., & Kizaki, K. (2021). Long-term outcomes and duration of outdoor ambulation following primary total knee arthroplasty in patients with rheumatoid arthritis. Journal of Orthopaedic Science. Web.

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