Advertisement

Rheumatology International

, Volume 37, Issue 2, pp 219–227 | Cite as

Patients who underwent total hip or knee arthroplasty are more physically active than the general Dutch population

  • J. M. T. A. MeessenEmail author
  • W. F. Peter
  • R. Wolterbeek
  • S. C. Cannegieter
  • C. Tilbury
  • M. R. Bénard
  • H. M. J. van der Linden
  • R. Onstenk
  • R. Tordoir
  • S. B. Vehmeijer
  • S. H. M. Verdegaal
  • H. M. Vermeulen
  • R. G. H. H. Nelissen
  • T. P. M. Vliet Vlieland
Open Access
Public Health

Abstract

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) bring relief of pain and functional disability to patients with end-stage osteoarthritis, and however, the literature on their impact on patients’ level of physical activity (PA) is scarce. Cross-sectional study in patients who underwent THA/TKA surgery in the preceding 6–22 months and a random sample of persons aged >40 years from the Dutch general population, participating in a national survey. PA in minutes per week (min/week) and adherence to the Dutch recommendation for PA (NNGB yes/no) were measured by the short questionnaire to assess health-enhancing PA. Multivariable linear (total min/week) and logistic regression analyses (meeting recommendations PA), adjusting for confounders, were performed for THA and TKA separately. In total, 258 THA [62.3% female, aged 69.4 (9.1)] and 221 TKA [65.7% female, aged 69.5 (8.9)] patients and 4373 persons from the Dutch general population [51.4% female, aged 58.9 (11.6)] were included. The presence of THA was associated after adjusting for age, sex, BMI education and musculoskeletal comorbidities, with more total min/week spent on PA (THA 13.8% increase, 95% CI 1.6–27.6%), whilst both TJA groups were associated with adhering to NNGB (THA: OR 1.79, 95% CI 1.26–2.56; TKA: OR 1.73, 95% CI 1.20–2.51). As this study used questionnaires to compare the PA of THA/TKA patients to the general population, some recall and selection bias might have been induced. After surgery, overall, TJA patients are more likely to adhere NNGB than a representative sample of persons >40 years from the Dutch general population.

Keywords

Osteoarthritis Physical activity Arthroplasty THA TKA 

Introduction

Worldwide, the numbers of patients undergoing total hip or total knee arthroplasty (THA or TKA) for hip or knee osteoarthritis (OA) are rapidly increasing. Overall, the outcomes are favourable, with a large majority of patients having less pain and improved physical functioning after surgery [1, 2, 3, 4].

Although the benefits of THA and TKA are well documented for pain and function, relatively little is known on their impact on one specific aspect of physical functioning, i.e. physical activity (PA). Just like for any other individual, achieving and maintaining a sufficient level of PA is important for patients with hip and knee OA with respect to their potential general health benefits. Moreover, in patients who undergo THA or TKA, PA may have an additional beneficial effect on the quality of the bone, which in turn may prevent complications such as early loosening [5, 6, 7, 8]. In addition, PA may have a positive effect on muscle strength and range of motion of the affected leg [9].

With respect to the literature on PA after THA or TKA, de Groot et al. demonstrated in 84 THA and TKA patients that 6 months post-operatively PA levels as measured with an activity monitor did not significantly differ from the preoperative activity levels [10]. Harding et al. [11] found similar results when measuring PA by means of an accelerometer in 63 American THA and TKA patients before surgery and 6 months post-operatively. Kahn and Schwartzkopf [12] found no difference in PA as measured with an accelerometer between those on the waiting list for TKA and those who had TKA 2 years earlier.

By using the patient-reported University of California at Los Angeles (UCLA) activity questionnaire, Baumann et al. [13] found that both THA and TKA patients were regularly active on moderate to high levels after on average 6–12 months after surgery. This finding is supported by Dahm et al. [14], who reported that 5.7 years after surgery TKA patients had an average physical activity score of 7.1 out of 10, with 10 being highly active. In contrast to these findings, Kahn and Schwartzkopf [12] observed, using an accelerometer, that adherence to health-enhancing PA guidelines was only 5% in persons with TKA. In all of these studies, a comparison with the general population was lacking.

Two Dutch studies compared patient-reported physical activity in THA [15] and TKA [16] patients at 1–5 years post-operatively to that of age and gender-matched controls. It was found that in THA the proportion of persons reaching the Dutch Public Health Physical Activity guideline (the “Nederlandse Norm Gezond Bewegen”, NNGB) was similar to that of matched controls [51.2% (THA) vs 48.8% (controls)] [15], whereas in TKA patients the proportion of patients adhering to the guideline (54.5%) was significantly lower than that of the matched control population (63.7%) [16]. However, these studies did not take BMI into account, whilst BMI is one of the determinants of physical activity [17].

Given the lack of knowledge on post-operative PA levels after total joint arthroplasty (TJA) compared to the general population, the aim of the present study was to compare the minutes of PA and proportion meeting the public health guidelines of THA and TKA patients to those of the general Dutch population. Moreover, factors other than TJA, possibly contributing to levels of physical activity, were also evaluated.

Patients and methods

Design and recruitment of subjects

This cross-sectional, multicentre study concerned a comparison of PA levels of THA and TKA patients approximately one year after surgery with those of the general Dutch population. The data from the population of patients with THA and TKA were obtained from a study primarily aiming to make an inventory of the use of physical therapy and the presence of comorbidity [18], whereas the data from the general population were obtained from the Dutch National Bureau of Statistics (in Dutch: Centraal Bureau voor de Statistiek, CBS).

Since the survey had to be filled in only once by patients, it was judged to fall outside the remit of the law for Medical Research Involving Human Subjects Act; MO [in Dutch; Wet medisch wetenschappelijk onderzoek met mensen (WMO)]. An exemption for medical ethical review was therefore given by the Medical Ethical Committee of the Leiden University Medical Center. The health monitoring conducted by the CBS commissioned by the Dutch Government also falls outside the remit of the WMO. The study was conducted in accordance with the Handbook for Good Clinical Research Practice of the World Health Organization [19] and the Declaration of Helsinki principles [20].

Patients with THA or TKA

The patient data were obtained from a cross-sectional study performed in 2012, including patients who underwent THA or TKA for hip or knee OA in 2011 in four different hospitals in the Leiden region (Leiden University Medical Center in Leiden, Rijnland Hospital in Leiderdorp, Groene Hart Hospital in Gouda and Reinier de Graaf Hospital in Delft, the Netherlands). Patients receiving THA or TKA for reasons other than end-stage OA (such as fracture or rheumatoid arthritis) were excluded from the study, as well as patients undergoing revision surgery.

Between July 2012 and October 2012, all patients operated in 2011 were approached by mail by their orthopaedic surgeon, resulting in a range of post-surgery time of 7–22 months. The orthopaedic surgeon sent all eligible persons an invitation letter, information leaflet, informed consent form, survey and pre-stamped return envelope. Patients who returned the envelope with a completed survey and signed informed consent were included in the study.

Data general population

Data from the Dutch general population were provided by the CBS and were derived from a nationwide survey on general health (Gezondheids-enquête) [21]. This questionnaire is annually administered to a representative sample of ±8.000 Dutch inhabitants and is the prime health monitor tool of the Dutch government [22].

The selection of participants is drawn from municipality registers. Persons living in institutionalized homes (e.g. nursing homes) are excluded. For the present study on physical activity, only data were selected from 2011, i.e. the same year as the data from patients with THA or TKA, and from respondents who were over 40 years of age, as none of the persons with arthroplasty was aged below 40.

Assessments

Included in both surveys were the following variables or questionnaires.

Socio-demographic and basic health characteristics

Demographic variables included: age, gender and marital status (split into either married or not married). The height and weight of the patient were asked in order to calculate the body mass index (BMI). Smoking status (non-smoker, ex-smoker and smoker) and educational level (low (elementary school, lower secondary education), medium (secondary school or college) or high (higher secondary education or university)) were recorded.

Physical activity

PA was assessed using the validated Dutch version of the short questionnaire to assess health (SQUASH) [23, 24]. The SQUASH records the total amount of minutes per week (min/week) spent on PA in an average week in the past 12 months regarding eight different domains of active life: commuting, work activities, walking, cycling, gardening, odd jobs, household and sports. With the aid of the compendium of Ainsworth [25], PA can subsequently be categorized into light, moderate or vigorous intensity. Using this information, it is possible to define whether an individual adhered to the Dutch Public Health recommendation (NNGB) for PA (30 min of moderate intensity PA on at least 5 days per week) [26].

Quality of life (QoL)

QoL of the persons with a THA/TKA was assessed with the Short Form 36 (SF36) questionnaire, whilst the QoL of the general Dutch population was assessed with the Short Form 12 (SF12) [27, 28]. The SF36 outcomes of the THA/TKA patients were transformed to SF12 outcomes. From the SF12, two summary scales were derived: the physical component scale (PCS) and the mental component scale (MCS). The higher the score on these scales, the better the physical or mental functioning.

Comorbidity

The presence of comorbidity was assessed by means of a self-reported questionnaire of the CBS which comprised 19 different comorbidities [29]. For every comorbidity, the participants of the survey were asked to respond with either yes or no to the question “Have you received any treatment for [condition] in the past year”. The included diseases were then clustered into three groups:

Musculoskeletal comorbidities

Severe back pain (including slipped disc), severe neck or shoulder pain, severe elbow wrist or hand pain, inflammatory arthritis or other joint conditions.

Non-musculoskeletal comorbidities

Asthma or COPD (chronic obstructive pulmonary disease), (severe) cardiac disorder or coronary disease, arteriosclerosis (abdomen or legs), hypertension, (consequences of) stroke, severe bowel disorder, diabetes mellitus, migraine, psoriasis, chronic eczema, cancer and urine incontinence.

Sensory comorbidities

Hearing impairments (group and face-to-face conversation), vision impairments (short and long distance) and dizziness in combination with falling.

Statistical analyses

The demographic and health characteristics of patients undergoing THA or TKA were each compared with those of the general Dutch population by means of two sample t tests or Chi-square tests, where appropriate.

Mann–Whitney tests were conducted to compare the min/week spent on PA for each of four different age groups (aged under 65, 65–69, 70–74 and 75+).

The min/week of PA was log-transformed to reach a normal distribution. Multivariable linear regression models were used to assess whether having had a joint replacement was associated with min/week spent on PA. Each analysis was done separately for THA versus the general Dutch population and TKA versus the general Dutch population. The antilog of the effect sizes (beta’s) is reported for both the analyses with the 95% confidence interval (CI).

Multivariable logistic regression was used to assess the association between the presence of a joint replacement and adherence to the Dutch public health physical activity guideline. These results are presented as odds ratio (OR) with the 95% CI. The analyses were done separately for THA versus the general Dutch population and TKA and the general Dutch population.

All models (multivariable linear and multivariable logistic regression analyses) were constructed using a stepwise method. Potential confounders for the level of physical activity, i.e. sex, BMI, age and education level, were included in the models.

The determinants of minutes per week spent on activities categorized according to the three different levels of intensity of physical activity were determined for the arthroplasty groups and the Dutch population separately, by means of linear regression models including the variable of interest and correcting for age and sex. These analyses were performed including the variables age, sex, BMI, education, non-musculoskeletal comorbidities, musculoskeletal comorbidities, sensory comorbidities, MCS, PCS and time since surgery.

The level of statistical significance was set at P < 0.05, and analyses were performed using the SPSS statistical package (version 20.0, SPSS, Chicago, IL).

Results

Study population

Of the 545 THA and 465 TKA patients of the 4 hospitals who were invited to participate, 258 THA patients (response rate 47.3%) and 221 TKA patients (response rate 47.5%) completed the questionnaires.

The selection of data from the general Dutch population from the year 2011 yielded 4373 surveys completed by people aged 40 years or older. Of those, 568 persons (13%) replied positively to the question “Have you received any treatment for osteo- or rheumatic arthritis in the past year?”.

The arthroplasty groups comprised statistically significantly more females, and the patients had a higher mean age and higher BMI than the general Dutch population. The PCS and MCS were statistically significantly lower in both the THA and the TKA groups than in the general population. There was no difference in the presence of sensory comorbidities between the arthroplasty groups and the general population. However, both musculoskeletal and non-musculoskeletal comorbidity were more present in the arthroplasty patients as compared to the general population (see also Table 1).
Table 1

Characteristics of patients with total joint arthroplasty and a sample from the general Dutch population

 

General Dutch population

Total hip arthroplasty

Total knee arthroplasty

 

P value α

 

P value α

Total

#

4373

  

258

  

221

  

Female

# (%)

2248

(51.4%)

 

159

(62.3%)

 

0.01

144

(65.7%)

 

<0.01

Age (years)

Mean (SD)

59

(11.6)

 

69

(9.1)

 

<0.01

70

(8.9)

 

<0.01

BMI

Mean (SD)

26

(5.0)

 

27

(4.1)

 

<0.01

29

(5.0)

 

<0.01

Education level

  

<0.01

 

<0.01

 Low education

# (%)

653

(15.6%)

 

75

(37.3%)

  

72

(41.1%)

  

 Medium education

# (%)

2391

(57.0%)

 

86

(42.8%)

  

81

(46.3%)

  

 High education

# (%)

1150

(27.4%)

 

40

(19.9%)

  

23

(12.6%)

  

SF12

 PCS

mean (SD)

53.9

(9.4)

 

47.6

(11.2)

 

<0.01

46.6

(10.8)

 

<0.01

 MCS

mean (SD)

44.1

(5.0)

 

39.8

(5.2)

 

<0.01

40.6

(5.1)

 

<0.01

Comorbidities

 ≥1 Non-M.Sa

# (%)

2465

(57.4%)

(N = 4292)

142

(72.8%)

(N = 195)

<0.01

138

(84.1%)

(N = 164)

<0.01

 ≥1 M.S.b

# (%)

1224

(27.9%)

 

93

(39.7%)

(N = 238)

<0.01

84

(40.7%)

(N = 206)

<0.01

 ≥1 Sensory

# (%)

400

(9.3%)

(N = 4319)

21

(8.4%)

(N = 249)

0.736

21

(9.9%)

(N = 212)

0.717

Education levels: low (elementary school, lower secondary education); medium (secondary school or college); and high (higher secondary education or university)

BMI body mass index, SF12 Short Form 12, PCS physical component subscale of the SF12, MCS mental component subscale of the SF12

α P value is given for a two sample t test or Chi-square between the hip or knee replacement group and the general Dutch population

aNon-musculoskeletal comorbidities

bMusculoskeletal comorbidities

Table 2 shows the crude number of minutes spent per week on PA, stratified for age and gender. It can be seen that the male arthroplasty patients spend more minutes per week physically active in the higher age groups as compared to the general Dutch population. The proportion of persons adhering to the NNGB guideline is in the arthroplasty groups higher than in the general Dutch population (THA 76%, TKA 73% and general Dutch population 68%) (Fig. 1).
Table 2

Total minutes per week spent on physical activity per gender, age group for total hip arthroplasty, total knee arthroplasty or general Dutch population

 

General Dutch population

Total hip arthroplasty

Total knee arthroplasty

Mean

SD

N

Mean

SD

N

P valueα

Mean

SD

N

P valueβ

Men

 Aged <65

2846

1543

2521

2722

1252

32

0.692

2924

1468

21

0.959

 Aged 65–69

1976

1474

414

2315

1336

23

0.052

2079

1316

20

0.34

 Aged 70–74

1784

1330

313

2130

843

20

0.003

1968

1667

12

0.912

 Aged ≥75

1461

1209

372

1443

1065

21

0.840

2193

1477

22

0.018

Women

 Aged <65

2845

1530

2761

2745

1148

38

0.857

2883

1695

46

0.956

 Aged 65–69

2075

1412

401

2480

1908

34

0.364

2048

1539

25

0.764

 Aged 70–74

1967

1273

286

1867

1071

33

0.888

1944

2122

28

0.239

 Aged ≥75

1449

1173

525

1703

1453

53

0.350

1284

912

45

0.577

 

Count

%

N

Count

%

N

P value δ

Count

%

N

P value ε

Adherence to NNGB

2954

67.6

4373

195

75.6

258

0.007

161

72.9

221

0.105

NNGB Nederlandse Norm Gezond Bewegen, Dutch public guideline for physical activity

α P value for Mann–Whitely test between the hip arthroplasty group and the general Dutch population

β P value for Mann–Whitely test between the knee arthroplasty group and the general Dutch population

δ P value for Chi-square test between hip arthroplasty group and the general Dutch population

ε P value for Chi-square test between knee arthroplasty group and the general Dutch population

Fig. 1

Stratified representation of total minutes per week physical per week per age group and gender

Association between TJA and minutes per week spent on total physical activity

Univariately, both THA and TKA were significantly associated with more minutes per week physical activity when compared to the general population. As there were major differences between the groups, it was needed to correct for potential confounders. When correcting for age, gender, BMI, education and musculoskeletal comorbidities a statistically significant association was for THA, not TKA. With the adjustments, persons with a THA spend 13.8% more minutes per week on physical activity compared to the general population (see Table 3).
Table 3

Regression analyses of min/week and adherence to NNGB

 

Total hip arthroplasty

Total knee arthroplasty

B

95% CI

P value

B

95% CI

P value

Total min/week PA

 Univariatea

1.229

1.099

1.352

<0.001

1.324

1.186

1.483

<0.001

 Multivariate 1b

1.14

1.023

1.274

0.018

1.122

0.998

1.262

0.055

 Multivariate 2c

1.138

1.016

1.276

0.024

1.112

0.986

1.256

0.084

Adherence to NNGB

 Univariated

1.487

1.111

1.989

0.008

1.289

0.952

1.745

0.101

 Multivariate 1e

1.75

1.243

2.465

0.001

1.75

1.219

2.512

0.002

 Multivariate 2f

1.789

1.253

2.556

0.001

1.731

1.195

2.507

0.004

aUnivariate analysis of total min/week PA ~ arthroplasty

bMultivariate analysis of total min/week PA ~ arthroplasty + age + sex + BMI + education

cMultivariate analysis of total min/week PA ~ arthroplasty + age + sex + BMI + education + musculoskeletal comorbidities

dUnivariate analysis of adherence to NNGB ~ arthroplasty

eMultivariate analysis of adherence to NNGB ~ arthroplasty + age + sex + BMI + education

fMultivariate analysis of adherence to NNGB ~ arthroplasty + age + sex + BMI + education + musculoskeletal comorbidities

Association between TJA and meeting public health recommendation

The multivariable logistic regression models showed that, adjusted for age, gender, BMI, education and muscular comorbidities, both THA and TKA patients had a significantly higher likelihood of meeting public health recommendations for healthy PA as compared to the general population [THA: OR 1.79 (95% CI 1.25–2.55); TKA: OR 1.73 (95% CI 1.20–2.51)]. See also Table 3.

Determinants of physical activity

Regarding the determinants of physical activity in the general population, age, sex, PCS and education were found to be statistically significantly associated with total minutes per week spent on PA and per category of intensity (see Table 4). In the general population, BMI was associated with the number of min/week of moderate and vigorous intensity PA, but not with light intensity PA. Within both the arthroplasty groups, it was found that age was a significant determinant of total min/week of PA and the min/week of light intensity PA. Within the THA group, age was also a determinant for the min/week of moderately intensive PA. Sex was associated with the min/week of moderate and vigorous intensity PA in both arthroplasty groups and also with the min/week of light intensity PA in the THA group.
Table 4

Variables statistically significantly associated with min/week physical activity after correcting for age and sex

General Dutch population

THA

TKA

 

Beta

P

 

Beta

P

 

Beta

P

Total physical activity

 Age

0.973

<0.001

Age

0.966

<0.001

Age

0.966

<0.001

 Sexa

0.953

0.037

      

 BMI

0.995

0.022

BMI

0.960

0.005

   

 PCS

1.016

<0.001

      

 Low educationb

0.774

<0.001

      

 Non-M.S. comorbiditiesc

1.076

0.002

      

 M.S. comorbiditiesd

1.052

0.046

      

 Sensory comorbiditiese

1.202

<0.001

Sensory comorbiditiese

1.517

0.028

   

Light physical activity

 Age

0.966

<0.001

Age

0.604

<0.001

Age

0.973

<0.001

 Sexa

0.748

<0.001

Sexa

0.604

<0.001

   
      

BMI

0.759

0.044

 PCS

1.007

<0.001

      

 Low educationb

0.809

<0.001

      

 Medium education

0.834

<0.001

      

Moderate physical activity

 Age

0.991

<0.001

Age

0.984

0.031

   

 Sexa

1.084

0.02

Sexa

1.596

0.001

Sexa

1.538

0.009

 BMI

0.912

0.022

   

BMI

0.964

0.027

 PCS

1.016

<0.001

      

 MCS

0.989

0.001

      

 Low educationb

1.180

0.006

      

 Medium education

1.384

<0.001

      

Vigorous physical activity

 Age

1.026

<0.001

      

 Sexa

1.189

<0.001

Sexa

1.489

0.005

Sexa

1.432

0.022

 BMI

0.986

0.003

      

 PCS

1.014

<0.001

   

PCS

1.021

0.027

      

MCS

0.957

0.008

 Medium educationb

1.151

0.002

      

aFemales were reference

bHigh education as reference

cAffected with non-musculoskeletal comorbidities persons as reference

dAffected with musculoskeletal comorbidities persons as reference

eAffected with sensory comorbidities persons as reference

In the general population, comorbidities were only found to be a determinant of total minutes per week of PA, but not of the min/week in the three categories of PA intensity. In THA patients only the presence of sensory comorbidities was associated with the total min/week of PA, whereas in TKA the presence of comorbidities was not associated with PA.

Although the association of a number of potential determinants with PA in the TKA and TJA groups did not reach statistical significance, overall the directions of the associations were similar to those within the general population (results not shown).

Discussion

This study demonstrated that the presence of a THA was associated with more min/week spent on PA as well as better adherence to public health recommendations for PA (NNGB) when compared to the general population. TKA was found to only be associated with adhering to the NNGB when compared to the general Dutch population.

Overall, it seems the Dutch population spends more minutes per week on physical activity, but since the patient group differs from the general population the comparison between these groups should be adjusted. When adjusting for age, sex, BMI and education it is found that persons with THA do spend more minutes per week on physical activity and that persons with a THA and TKA are more likely to adhere to the Dutch guideline on physical activity, NNGB. That TKA is associated with the NNGB but not to the minutes per week activity can be explained by the level of intensity of the physical activity performed.

In the general population, more associations between potential determinants of physical activity and the actual numbers of PA reached statistical significance than in the arthroplasty groups. The lack of significance is probably due to the relatively small sample sizes in the arthroplasty groups, limiting the statistical power.

Our groups spent more min/week on PA than reported by two other Dutch studies (for THA in this study 2183 min/week PA, THA in Wagenmakers et al. 1601 min/week, for TKA in this study 2153 min/week PA, TKA in Kersten et al. 1347 min/week PA) [15, 16]. In parallel, regarding the proportion of patients adhering to the Dutch recommendation for physical activity, the outcomes were more favourable in the present study (THA in this study 75.6% and THA in Wagenmakers et al. 51.2%; TKA in this study 72.8% and TKA in Kersten et al. 55%).

Both these latter two studies were done at 1–5 years post-surgery, and our study included patients within the first 22 months after surgery. As reported earlier by our group (Peter et al.), 43.5% of the THA patients and 50.5% of the TKA patients had post-operative physiotherapy for more than 3 months [30]. This implies that a vast amount of our patients might still have intense training with aid of physiotherapists, motivating patients to adhere to the PA. As for the other two studies (Kersten, Wagenmakers), no data on prolonged post-operative physiotherapy are present, and thus, these patients might resume easier into their old, less active activity level.

A recent systematic review on physical activity after THA or TKA measured with accelerometers showed that the post-operative PA levels were lower in the arthroplasty groups as compared to healthy control participants [31]. The differences in outcome could be because our sample of the general population might not be totally healthy and be less active than selected healthy persons. Also, as this study used a questionnaire whilst the systematic review concerned objective measures, participants might have caused some recall bias.

The general population in our study had an adherence rate to the Dutch PA of 67.5% which is comparable to reports from CBS published (Dutch adult population, 66% adhered to the Dutch public health physical activity guideline in 2012) [32]. The minutes per week spent on PA in our study was also consistent with the numbers reported by CBS (2589 min per week in 2012 and 2525 min per week in our study for overall physical activity for the Dutch population) [33].

Factors we identified as influencing the level of PA of persons with hip or knee arthroplasty (BMI, increased age, physical component score) are in line with the findings in a systematic review by Stubbs et al. [34] regarding PA in patients with hip or knee OA. The inverse association of BMI on the level of PA shows that it is an important factor, as well as age and gender, to include in any case–control study [17].

Low-impact activities like walking or cycling seem to protect against function loss and experienced pain from OA [35, 36], in contrast heavy load activities might be a risk factor for the development of osteoarthritis, but also early implant failure although debate exists on the latter [37, 38]. Since contradictory evidence exists on this topic, research into this field is necessary.

Current post-operative rehabilitation after a hip or knee arthroplasty is focussed at independent ambulation and regaining a normal walking pattern, which was deteriorated in the years before surgery due to the slowly progressing osteoarthritis. Secondary to this it aims at getting physically active patient. As mentioned before, about half of our patients reported to receive physiotherapy for more than 3 months after surgery [30]. This might imply that these patients are more motivated to be active than the general population.

Another reason for the higher levels of PA in the arthroplasty groups might be the fact that PA is a risk factor for TJA [39]. As shown by de Groot et al. [10], the post-operative levels of PA did not significantly differ from preoperative levels, suggesting that PA levels of TJA were probably higher than those of the general population before surgery as well.

Finally, the patients filling in the questionnaire knew that the subject of the study was PA, whilst the Dutch general population had to fill in an elaborate list of questions including all aspects of life, with only a subset on PA. Thus, the patients in our study might have overestimated their PA.

The limitations of this study are potential overestimation of outcome measures and recall bias, due to using the SQUASH questionnaire, more objective measures like accelerometers should be used in future studies. Furthermore, the preoperative levels of PA should be taken into account as an important confounder for outcome as well. Thus, more valid comparisons with the general population are possible. Also, patients in our study who refused to fill in the questionnaires were not asked about their reasons as to why they declined to participate, and therefore, we have no information about any possible self-selection bias. In addition, the comorbidities of participants were all self-reported and we were unable to confirm the presence of comorbidities both in the general Dutch population and the arthroplasty groups.

The findings of this study give insights into the movement patterns of arthroplasty patients compared to the general Dutch population. Findings show that although a part of the arthroplasty patients adhere to the Dutch public health guideline, there is still a considerable group who should increase their PA levels.

Summary conclusion

Overall OA patients with a hip prosthesis have a higher level of activity compared to the general Dutch population when adjusted for age, sex, education and BMI.

Notes

Acknowledgements

The authors would like to thank all the participants of the original physiotherapy study and the Gezondheids-Enquete. A special thanks to the onsite CBS data assistants (Martin Broxterman, Michael Vermaessen, Alfred Baven, Ivo Gorissen and Jan-Willem Bruggink) for their support and assistance.

Compliance with ethical standards

Conflict of interest

There are no conflicts of interest by any of the authors.

References

  1. 1.
    Meftah M, Ranawat AS, Ranawat CS (2012) Ten-year follow-up of a rotating-platform, posterior-stabilized total knee arthroplasty. J Bone Joint Surg Am 94(5):426–432CrossRefPubMedGoogle Scholar
  2. 2.
    Meding JB et al (2012) Pain relief and functional improvement remain 20 years after knee arthroplasty. Clin Orthop Relat Res 470(1):144–149CrossRefPubMedGoogle Scholar
  3. 3.
    Kurtz S et al (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Jt Surg Am 89(4):780–785Google Scholar
  4. 4.
    Wolf BR et al (2012) Adverse outcomes in hip arthroplasty: long-term trends. J Bone Jt Surg Am 94(14):e103CrossRefGoogle Scholar
  5. 5.
    Kuster MS (2002) Exercise recommendations after total joint replacement: a review of the current literature and proposal of scientifically based guidelines. Sports Med 32(7):433–445CrossRefPubMedGoogle Scholar
  6. 6.
    Trudelle-Jackson E, Smith SS (2004) Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial. Arch Phys Med Rehabil 85(7):1056–1062CrossRefPubMedGoogle Scholar
  7. 7.
    Cushnaghan J et al (2009) Long-term outcome following total knee arthroplasty: a controlled longitudinal study. Ann Rheum Dis 68(5):642–647CrossRefPubMedGoogle Scholar
  8. 8.
    Sharma L et al (2003) Physical functioning over three years in knee osteoarthritis: role of psychosocial, local mechanical, and neuromuscular factors. Arthritis Rheum 48(12):3359–3570CrossRefPubMedGoogle Scholar
  9. 9.
    Reeuwijk KG et al (2010) Osteoarthritis of the hip or knee: which coexisting disorders are disabling? Clin Rheumatol 29(7):739–747CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    de Groot IB et al (2008) Small increase of actual physical activity 6 months after total hip or knee arthroplasty. Clin Orthop Relat Res 466(9):2201–2208CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Harding P et al (2014) Do activity levels increase after total hip and knee arthroplasty? Clin Orthop Relat Res 472(5):1502–1511CrossRefPubMedGoogle Scholar
  12. 12.
    Kahn TL, Schwarzkopf R (2015) Does total knee arthroplasty affect physical activity levels? Data from the osteoarthritis initiative. J Arthroplasty 30(9):1521–1525CrossRefPubMedGoogle Scholar
  13. 13.
    Bauman S et al (2007) Physical activity after total joint replacement: a cross-sectional survey. Clin J Sport Med 17(2):104–108CrossRefPubMedGoogle Scholar
  14. 14.
    Dahm DL et al (2008) Patient-reported activity level after total knee arthroplasty. J Arthroplasty 23(3):401–407CrossRefPubMedGoogle Scholar
  15. 15.
    Wagenmakers R et al (2008) Habitual physical activity behavior of patients after primary total hip arthroplasty. Phys Ther 88(9):1039–1048CrossRefPubMedGoogle Scholar
  16. 16.
    Kersten RF et al (2012) Habitual physical activity after total knee replacement. Phys Ther 92(9):1109–1116CrossRefPubMedGoogle Scholar
  17. 17.
    Okeyo OD, Ayado OL, Mbagaya GM (2009) Physical activity and dietary fat as determinants of body mass index in a cross-sectional corelational design. East Afr J Public Health 6(1):32–36PubMedGoogle Scholar
  18. 18.
    Peter WF et al (2015) The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty. Rheumatol Int 35(7):1233–1241CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    WHO, Library W (ed) (2005) Handbook for good clinical research practise (GCP): guidance for implementation. GenevaGoogle Scholar
  20. 20.
    W.M.A. (2013) Declaration of Helsinki—ethical principles for medical research involving human subjects. JAMA 310(20):3Google Scholar
  21. 21.
    van den Berg J, van der Wulp C (2003) Rapport van de Werkgroep Revisie POLSGezondheidsenquête. Centraal Bureau voor de Statistiek. Retrieved from: http://www.cbs.nl/NR/rdonlyres/C3A60CA3-2FAC-4F2E-8A19-39088CFEF552/0/revisiepols1999.pdf
  22. 22.
    Rijksinstituut voor Volksgezondheid en Milieu (RIVM) (2016) Gezondheidsenquete. Ref Type: Online Source, link; https://bronnen.zorggegevens.nl/Bron?naam=Gezondheidsenqu%C3%AAte
  23. 23.
    Wagenmakers R et al (2008) Reliability and validity of the short questionnaire to assess health-enhancing physical activity (SQUASH) in patients after total hip arthroplasty. BMC Musculoskelet Disord 9:141CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Wendel-Vos GC et al (2003) Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity. J Clin Epidemiol 56(12):1163–1169CrossRefPubMedGoogle Scholar
  25. 25.
    Ainsworth BE et al (2011) 2011 Compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exerc 43(8):1575–1581CrossRefPubMedGoogle Scholar
  26. 26.
    Volksgezondheid NK (2015) Nationaal Kompas Volksgezondheid: normen van lichamelijke (in)activiteit. http://www.nationaalkompas.nl/gezondheidsdeterminanten/leefstijl/lichamelijke-activiteit/normen-van-lichamelijke-in-activiteit/#definition_1347. Accessed 11-11-2015
  27. 27.
    Aaronson NK et al (1998) Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 51(11):1055–1068CrossRefPubMedGoogle Scholar
  28. 28.
    Gandek B et al (1998) Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International quality of life assessment. J Clin Epidemiol 51(11):1171–1178CrossRefPubMedGoogle Scholar
  29. 29.
    Planbureau, S.C. Onderzoek naar zorggebruik 2014–2017. https://www.scp.nl/Onderzoek/Lopend_onderzoek/Enqu_tes_in_uitvoering/Onderzoek_naar_zorggebruik_2014_2017. Accessed 10-11-2015 03-08-2016
  30. 30.
    Peter WF, Tilbury C, Verdegaal SHM, Onstenk R, Vehmeijer SB, Vermeulen EM, van der Linden-van der Zwaag HMJ, Nelissen RGHH, Vliet Vlieland TPM (2016) The provision of preoperative and postoperative physical therapy in elderly people with hip and knee osteoarthritis undergoing primary joint replacement surgery. Curr Orthop Pract 27(2):10CrossRefGoogle Scholar
  31. 31.
    Arnold JB, Walters JL, Ferrar KE (2016) Does physical activity increase after total hip or knee arthroplasty for osteoarthritis? A systematic review. J Orthop Sports Phys Ther 46(6):431–442CrossRefPubMedGoogle Scholar
  32. 32.
  33. 33.
  34. 34.
    Stubbs B, Hurley M, Smith T (2015) What are the factors that influence physical activity participation in adults with knee and hip osteoarthritis? A systematic review of physical activity correlates. Clin Rehabil 29(1):80–94CrossRefPubMedGoogle Scholar
  35. 35.
    Fransen M, McConnell S, Bell M (2002) Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. J Rheumatol 29(8):1737–1745PubMedGoogle Scholar
  36. 36.
    van Baar ME et al (1999) Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. Arthritis Rheum 42(7):1361–1369CrossRefPubMedGoogle Scholar
  37. 37.
    Vogel LA et al (2011) Physical activity after total joint arthroplasty. Sports Health 3(5):441–450CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Golant A et al (2010) Athletic participation after hip and knee arthroplasty. Bull NYU Hosp Jt Dis 68(2):76–83PubMedGoogle Scholar
  39. 39.
    Wang Y et al (2011) Is physical activity a risk factor for primary knee or hip replacement due to osteoarthritis? A prospective cohort study. J Rheumatol 38(2):350–357CrossRefPubMedGoogle Scholar

Copyright information

© The Author(s) 2016

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • J. M. T. A. Meessen
    • 1
    Email author
  • W. F. Peter
    • 1
  • R. Wolterbeek
    • 2
  • S. C. Cannegieter
    • 3
  • C. Tilbury
    • 1
  • M. R. Bénard
    • 4
  • H. M. J. van der Linden
    • 1
  • R. Onstenk
    • 5
  • R. Tordoir
    • 6
  • S. B. Vehmeijer
    • 5
  • S. H. M. Verdegaal
    • 6
  • H. M. Vermeulen
    • 7
  • R. G. H. H. Nelissen
    • 1
  • T. P. M. Vliet Vlieland
    • 1
    • 8
    • 9
  1. 1.Department of OrthopaedicsLeiden University Medical CenterLeidenThe Netherlands
  2. 2.Department of Medical StatisticsLUMCLeidenThe Netherlands
  3. 3.Department of Clinical EpidemiologyLUMCLeidenThe Netherlands
  4. 4.Department of OrthopaedicsReinier de Graaf GroepDelftThe Netherlands
  5. 5.Department of OrthopaedicsGroene Hart ZiekenhuisGoudaThe Netherlands
  6. 6.Department of OrthopaedicsRijnland ZiekenhuisLeiderdorpThe Netherlands
  7. 7.Department of PhysiologyLUMCLeidenThe Netherlands
  8. 8.Rijnlands Rehabilitation CentreLeidenThe Netherlands
  9. 9.Sophia RehabilitationThe HagueThe Netherlands

Personalised recommendations