The Journal of Arthroplasty Vol. 00 No. 0 2012
Differences Between Actual and Expected
Leisure Activities After Total Knee Arthroplasty
for Osteoarthritis
Dina L. Jones, PT, PhD,* Abhijeet J. Bhanegaonkar, BPharm, MPH,y
Anthony A. Billings, MS,z Andrea M. Kriska, PhD,§
James J. Irrgang, PT, PhD, ATC,‖ Lawrence S. Crossett, MD,‖
and C. Kent Kwoh, MD#
Abstract: This prospective cohort study determined the type, frequency, intensity, and duration of
actual vs expected leisure activity among a cohort undergoing total knee arthroplasty. Data on
actual and expected participation in 36 leisure activities were collected preoperatively and at 12
months in 90 patients with knee osteoarthritis. Despite high expectations, there were statistically
and clinically significant differences between actual and expected activity at 12 months suggesting
that expectations may not have been fulfilled. The differences were equivalent to walking 14 less
miles per week than expected, which is more than the amount of activity recommended in
national physical activity guidelines. Perhaps an educational intervention could be implemented to
help patients establish appropriate and realistic leisure activity expectations before surgery.
Keywords: leisure activities, total knee arthroplasty, osteoarthritis, physical activity, expectations.
© 2011 Elsevier Inc. All rights reserved.
Satisfaction after total knee arthroplasty (TKA) is
typically high [1,2]. Many factors, such as patient
expectations, can influence satisfaction. Expectations
reflect a patient's anticipation of future events because of
a medical intervention [3].
In general, positive expectations have been associated
with better functional outcomes, greater compliance
with treatment recommendations, and greater satisfaction after TKA [4,5]. Satisfaction, however, does not
From the *Department of Orthopaedics and Division of Physical Therapy,
Health Sciences Center South, West Virginia University, School of Medicine,
Morgantown, West Virginia; yDepartment of Pharmaceutical Systems and
Policy, West Virginia University, School of Pharmacy, Morgantown, West
Virginia; zDepartment of Statistics, West Virginia University, Eberly College of
Arts and Sciences, Morgantown, West Virginia; §Department of Epidemiology,
University of Pittsburgh, Graduate School of Public Health, Pittsburgh,
Pennsylvania; ‖Department of Orthopaedic Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania; and #Division of Rheumatology and Clinical
Immunology, University of Pittsburgh, VA Pittsburgh Healthcare System,
Pittsburgh, Pennsylvania.
Submitted September 20, 2010; accepted October 24, 2011.
The Conflict of Interest statement associated with this article can be
found at doi:10.1016/j.arth.2011.10.030.
Reprint requests: Dina L. Jones, PT, PhD, West Virginia University,
School of Medicine, Department of Orthopaedics, PO Box 9196, 1
Medical Center Drive, Room 3603A Health Sciences Center South,
Morgantown, West Virginia 26506.
© 2011 Elsevier Inc. All rights reserved.
0883-5403/0000-0000$36.00/0
doi:10.1016/j.arth.2011.10.030
always equate with fulfilled expectations [6]. Although
expectations for pain relief and improvements in
activities of daily living after TKA are high and generally
met, patients may have unfulfilled expectations with
more physically demanding leisure activities, if expectations are higher than postoperative capabilities [4,6].
Consequently, patients could be highly satisfied with
surgery yet have unfulfilled expectations if the activity
expectations were unrealistic.
Fulfillment of patient expectations is an important
factor affecting outcomes after TKA. To enhance
patient outcomes and satisfaction, it is important to
understand the disparity between actual and expected
leisure activities in patients after TKA. There is general
agreement among orthopedic surgeons on recommending participation in lower-intensity and no- or
low-impact activities after surgery [7,8]. These recommendations, however, may or may not be consistent
with patients' expectations for leisure activity after
surgery [9].
Previous studies of patient expectations after TKA
have focused on pain relief, functional limitations,
likelihood of complications, or the success of surgery
[4,6,10]. Although return to leisure activities is one of
the top 5 concerns voiced by patients undergoing TKA,
few studies have measured their expectations for return
to these activities [11]. In particular, there is a need to
quantify the dose (ie, volume) of activity, which includes
2 The Journal of Arthroplasty Vol. 00 No. 0 Month 2012
the activity type, frequency (number of times per week),
intensity level (low, moderate, high), and duration
(number of minutes per time) of expected participation
in these activities.
Therefore, the purpose of this prospective study was
to determine the type, frequency, intensity, and
duration of actual vs expected leisure activity in a
cohort undergoing TKA for osteoarthritis (OA). This
study provides a unique contribution to the literature
in that it (1) quantifies the dose of expected leisure
activity in patients undergoing TKA, (2) measures the
discrepancy between actual and expected leisure
activity, and (3) examines if patient expectations
were realistic after TKA.
Materials and Methods
The study included a cohort undergoing elective
primary TKA for knee OA. Consecutive patients were
recruited before surgery from 2 community hospitals
and 1 academic medical center. Approval for the study
was obtained from the institutional review board, and all
participants provided written informed consent.
Patients, 45 years and older, who were scheduled for
primary TKA were included in the study [12]. Patients
were excluded from the study if they had arthroplasty
within the previous year or had a surgical or medical
condition that currently limited their physical activity,
such as recent surgery.
Data on sociodemographic, clinical, cognitive-behavioral, ambulation, health-related quality of life, and
leisure activity characteristics were collected at baseline
from the cohort using self-administered questionnaires
and standardized, structured telephone interviews that
were conducted by trained interviewers. The sociodemographic data included age, gender, race/ethnicity,
and education.
Clinical characteristics included knee OA severity,
knee pain intensity, general arthritis severity, comorbidities, and body mass index. The reliable and valid index
of severity for knee disease was used to classify knee OA
severity from 0 to 24 with higher scores indicative of
greater disease severity [12]. Knee pain intensity was
rated on a 10-cm line ranging from 0 (“no pain”) to 10
(“worst pain ever experienced”) using a reliable and
valid visual analog scale [13]. General arthritis severity
was assessed in 10 joints bilaterally using the Rapid
Assessment of Disease Activity in Rheumatology questionnaire, which has demonstrated reliability, validity,
and sensitivity to change [14]. Higher scores on the
questionnaire represent greater self-reported joint pain
and/or tenderness because of arthritis.
The comorbidity index of the American Academy of
Orthopaedic Surgeons Outcomes Data Collection Questionnaires was used to determine the presence of
comorbid conditions (range 0 [no comorbidities] to
100 [highest level of comorbidities]) [15,16]. This
instrument is reliable and valid and has been used in
populations with arthritis [15-17]. Self-reported height
and weight were used to calculate body mass index.
Self-efficacy, an important cognitive-behavioral factor
related to physical activity, was measured using the 5item Self-Efficacy for Exercise Questionnaire, which has
high internal consistency and test-retest reliability [18].
Self-efficacy was assessed regarding a person's confidence in his/her ability to exercise under certain
circumstances (such as during illness or inclement
weather). Scores on the questionnaire range from 5 to
25, with higher scores signifying greater self-efficacy.
Finally, participants were asked if they required an
assistive device to ambulate.
Based on recommendations in the literature, healthrelated quality of life was assessed using both generic
and disease-specific measures [19]. The Medical Outcomes Study Short-Form Health Survey (SF-36 v1) was
used as the generic measure of health-related quality of
life [20]. The SF-36 produces 8 scale scores and 2
summary scores, a physical component summary score
and a mental component summary score. The SF-36 is
reliable and valid and has been used extensively in
populations with arthritis and joint arthroplasty [20-22].
The 3 subscales of the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) were used
to measure disease-specific pain, stiffness, and physical
function [23]. The WOMAC has documented responsiveness, reliability, and validity [23].
Baseline leisure activity was assessed using the
Historical Leisure Activity Questionnaire [24]. The
Historical Leisure Activity Questionnaire captures the
frequency and duration of past-month participation in
36 leisure and sporting activities. To weight each
activity by its relative intensity, the average number
of hours per week for each activity was multiplied by
the activity's metabolic equivalent (MET) and summed
across all activities to provide the average number of
MET-hours per week of total leisure activity [24,25].
The Historical Leisure Activity Questionnaire is reliable
and valid and has been used in patients with arthritis
and joint arthroplasty [17,26,27]. The season of the
year when data were collected was also documented.
Once data on baseline activities were obtained, the
participants were asked about their expected leisure
activities at 12 months (12-month expected activity)
using the same questionnaire.
After surgery, medical records were reviewed to obtain
data on the surgical procedure including the type of
hospital (community vs tertiary), number of knees
replaced, type of prosthesis used, fixation of prosthetic
components, thickness of the tibial polyethylene component, and the number of postoperative complications.
Patients were reinterviewed by telephone 12 months
after baseline to collect data on current (actual 12month activity) leisure activity.
Actual and Expected Leisure Activities After TKA for OA Jones et al
Statistical Analysis
With 90 individuals, we would have 80% power to
detect a 9-MET-hour difference in physical activity
assuming a type I error rate of 0.05, a 2-tailed alternative
hypothesis, and a standard deviation of change of 21.5
MET-hours from our previous study [17]. Nine METhours is comparable to an individual returning to brisk
walking (3.5 METs) approximately 2.5 hours (150
minutes) per week.
Descriptive statistics were calculated for all variables.
The median and interquartile range were also calculated
for the physical activity variables because of the
nonnormal distribution of the data. Three variables
were created representing the differences in total leisure
activity between (1) baseline and actual 12-month
activity, (2) baseline and 12-month expected activity,
and (3) 12-month expected and actual 12-month
activity. The Wilcoxon signed rank test was used to
compare actual with expected leisure activity, and
stepwise multiple linear regression was performed to
identify the baseline predictors of leisure activity
expectations. A significance level (P) of .10 was used as
the entry and stay criteria in the regression model. All
tests were 2-tailed and conducted with a type I error rate
of 0.05.
Results
Of the 90 patients enrolled, 83 (92%) completed the
12-month study. The cohort's baseline characteristics
are presented in Tables 1 and 2. The patients ranged in
age from 45 to 88 years with a mean ± SD of 66.5 ± 9.7
years. The cohort was predominantly white and
educated through at least high school. The prevalence
of comorbidities was low, but obesity was high. Almost
Table 1. Baseline Characteristics
Variables
Sociodemographic
Age (y), mean ± SD (range)
Gender (% female)
Race/ethnicity (% white)
Education (%) (n = 164)
Less than high school
Graduated from high school or equivalent
Some college
Graduated from college
Postgraduate school/degree
Clinical, mean ± SD
Knee pain intensity (0-10 cm) (n = 156)
Knee OA severity (0-24)
General arthritis severity (0-60) (n = 160)
Comorbidity score (0-37)
Body mass index (kg/m2) (n = 164)
Cognitive-behavioral, mean ± SD (range)
Exercise self-efficacy (5-25) (n = 159)
Ambulation
Assistive device (% yes)
TKA Cohort (n = 83)
66.5 ± 9.7 (45-88)
54 (65.1)
74 (89.2)
11 (13.3)
27 (32.5)
21 (25.3)
9 (10.8)
15 (18.1)
7.4 ± 1.8 (0-10)
13.8 ± 3.1 (7-20)
12.8 ± 8.5 (2-42)
0.9 ± 1.2 (0-6)
32.6 ± 7.2 (20.1-61.0)
11.9 ± 5.1 (1-23)
38 (45.8)
3
Table 2. Baseline Health-Related Quality of Life
Variables, Mean ± SD (range)
SF-36 (0-100) (n = 161-162)*
Scale scores
Physical function
Role limitations—physical
Bodily pain
Social functioning
Mental health
Role limitations—emotional
Vitality
General health
Summary scores
Physical composite score
Mental composite score
WOMAC (n = 162) †
Pain (0-20)
Stiffness (0-8)
Physical function (0-68)
TKA Cohort (n = 83)
27.0 ± 18.0 (0-65)
8.1 ± 18.5 (0-100)
30.9 ± 15.9 (0-74)
64.8 ± 25.7 (0-100)
77.3 ± 15.3 (28-100)
63.7 ± 44.0 (0-100)
44.8 ± 19.1 (0-86.6)
61.0 ± 21.2 (10-100)
25.0 ± 6.0 (10.8-40.3)
54.6 ± 10.5 (28.0-73.3)
10.0 ± 3.6 (0-18)
4.7 ± 1.5 (1-8)
33.4 ± 11.2 (15-58)
* SF-36: lower scores indicate worse health-related quality of life.
† WOMAC: lower scores represent better pain, stiffness, or physical
function.
46% reported ambulating with an assistive device
before surgery.
Of the 83 TKA procedures, 64 (77%) were performed at a tertiary hospital vs 19 (23%) at a
community hospital. All procedures were unilateral
with cemented components. The most frequently used
type of prosthesis in 77 of the procedures sacrificed the
posterior cruciate ligament without substitution
(58 procedures, 75%), followed by posterior-stabilized
implants (17 procedures, 22%) and then constrained
and posterior cruciate ligament-retaining prostheses
(1 procedure each, 1% each). The mean thickness of
the polyethylene component was 12.2 ± 2.4 mm (range,
9-20 mm; 95% confidence interval [CI], 11.8-12.8). The
mean number of postoperative complications was low
(0.2 ± 0.5; range, 0-3; 95% CI, 0.16-0.42). Five patients
(6%) had procedure-related complications (eg, deep
vein thrombosis, nerve palsy, wound erythema). Ten
patients (12%) had general medical complications
such as small bowel obstruction, cardiovascular events,
or hyponatremia.
The most commonly reported activities were similar at
baseline and 12 months and included walking, calisthenics/toning exercises, gardening/yardwork, and strength/
weight training (Table 3). There were several highintensity and/or high-impact activities not reported
at baseline that were expected at 12 months (Table 3).
Table 4 presents the amount of baseline, expected, and
actual 12-month total leisure activity. Moderate-intensity
exercise was the biggest contributor to total leisure
activity. Participation in high-impact activities was negligible, and therefore, the data are not reported.
At baseline, the cohort reported a median ± interquartile range of 2.2 ± 12.4 MET-hours of total leisure
activity per week, with an expectation of performing
4 The Journal of Arthroplasty Vol. 00 No. 0 Month 2012
Table 3. Types of Reported Leisure Physical Activity by
Intensity Level
Baseline
(n = 83)
Activities*
Low intensity
Bowling
Moderate intensity
Bicycling
Softball/baseball †
Volleyball †
Tai Chi
Calisthenics/
toning exercises
Walking for exercise
Horseback riding
Hunting
Fishing
Water aerobics
Dancing
Gardening/yardwork
Strength/weight training
Stair master
Golf
Canoeing/rowing/kayaking
Yoga
High intensity
Jogging †
Swimming
Basketball †
Skating
Wood chopping
Aerobic dance/step aerobics
Scuba diving
Fencing
Hiking
Tennis †
Jumping rope †
Snow skiing (downhill) †
Expected at
12 Months ‡
(n = 83)
Actual at
12 Months
(n = 83)
2 (2.4)
3 (3.6)
2 (2.4)
6 (7.2)
0 (0.0)
0 (0.0)
0 (0.0)
13 (15.7)
19 (22.9)
0 (0.0)
1 (1.2)
1 (1.2)
35 (42.2)
20 (24.1)
0 (0.0)
0 (0.0)
2 (2.4)
27 (32.5)
18 (21.7)
0 (0.0)
0 (0.0)
2 (2.4)
4 (4.8)
1 (1.2)
27 (32.5)
12 (14.5)
1 (1.2)
3 (3.6)
0 (0.0)
1 (1.2)
57 (68.7)
0 (0.0)
6 (7.2)
14 (16.9)
10 (12.0)
12 (14.5)
44 (53.0)
16 (19.3)
1 (1.2)
12 (14.5)
1 (1.2)
4 (4.8)
53 (63.9)
0 (0.0)
3 (3.6)
3 (3.6)
4 (4.8)
6 (7.2)
25 (30.1)
26 (31.3)
2 (2.4)
3 (3.6)
1 (1.2)
2 (2.4)
2 (2.4)
29 (34.9)
1 (1.2)
2 (2.4)
1 (1.2)
3 (3.6)
2 (2.4)
0 (0.0)
3 (3.6)
0 (0.0)
1 (1.2)
1 (1.2)
0 (0.0)
6 (7.2)
0 (0.0)
0 (0.0)
0 (0.0)
1 (1.2)
0 (0.0)
0 (0.0)
3 (3.6)
0 (0.0)
0 (0.0)
0 (0.0)
0
5
0
0
0
1
0
0
1
0
0
0
(0.0)
(6.0)
(0.0)
(0.0)
(0.0)
(1.2)
(0.0)
(0.0)
(1.2)
(0.0)
(0.0)
(0.0)
Note: No patients reported current, actual, or expected participation
in martial arts, football, soccer, racquetball, handball, squash, rock
climbing, water skiing, or cross-country skiing. Values are presented as
n (%).
* Intensity levels: low, 3 METs or less; moderate, 3 to 5.9 METs;
high 6 METs or more [28,29].
† High-impact activity.
‡ Italicized values indicate new expected activities that were not
previously performed.
Fig. 1. Median total leisure activity from baseline to 12 months.
significantly more activity (23.3 ± 41.1 MET-hours) by
12 months after surgery (P = .005) (Fig. 1). At 12
months, the cohort reported performing significantly
more total leisure activity than at baseline (10.8 ± 2.8 vs
2.2 ± 12.4 median MET-hours, P b .0005); however, the
actual amount of activity at 12 months was significantly
less than expected (23.3 ± 41.1 vs 10.8 ± 2.8 median
MET-hours, P = .001).
The best set of predictors of expected leisure activity at
12 months were baseline leisure activity, summer
season, and general health (Table 5). Patients who
were more recreationally active at baseline, who were
interviewed during the summer months, or who
reported better baseline general health on the SF-36
expected greater participation in leisure activities 12
months after surgery, after accounting for the other
variables in the model.
Discussion
Although studies have described the recommended
[7,30], actual [8,17,31-34], and expected [4,10,35-37]
types of leisure activities that patients engage in after
Table 4. Baseline, Expected, and Actual 12-Month Total Leisure Activity
Leisure Activity Variables
MET h/wk, Mean ± SD (range)
Median ± IQR (Q1-Q3)*
Low intensity (b3 METs)
Moderate intensity (3-5.9 METs)
High intensity (≥6 METs)
Total leisure activity
Baseline (n = 83)
Expected at 12 Months (n = 83)
Actual at 12 Months (n = 83)
0.08 ± 0.5 (0-5)
0 ± 0 (0-0)
8.1 ± 16.1 (0-96.5)
1.7 ± 11.0 (0.0-11.0)
0.7 ± 3.3 (0-26.2)
0 ± 0 (0-0)
8.9 ± 16.4 (0-96.5)
2.2 ± 12.4 (0-12.4)
0.2 ± 1.1 (0-7.5)
0 ± 0 (0-0)
28.3 ± 31.9 (0-177.5)
18.3 ± 32.7 (7-39.7)
8.4 ± 23.4 (0-157.5)
0 ± 7 (0-7)
37.0 ± 50.5 (0-335)
23.3 ± 41.1 (7.5-48.6)
0.1 ± 0.9 (0-7.5)
0 ± 0 (0-0)
19.6 ± 23.6 (0-125.6)
10.5 ± 27.5 (2.5-30)
1.5 ± 6.5 (0-52.5)
0 ± 0 (0-0)
21.4 ± 24.9 (0-125.6)
10.8 ± 2.8 (2.6-30.6)
* Interquartile range = Q3 − Q1 (Q1 = 25th percentile, Q3 = 75th percentile).
Actual and Expected Leisure Activities After TKA for OA Jones et al
Table 5. Predictors of Expected Total Leisure Activity at 12
Months
Variables in Final Model
Total baseline leisure activity
(MET h/wk)
Season (summer vs
other seasons)
Baseline general health
(SF-36)
Estimate Standard Error
P
1.0
0.3
31.3
12.6
.015
0.5
0.3
.048
R2
.005 0.28
TKA, few have quantified the frequency, intensity, and
duration of participation in these activities (ie, physical
activity dose). This prospective cohort study determined the dose of actual vs expected leisure activity
over a 12-month period in a cohort undergoing TKA
for OA.
Interpreting the Gap Between Actual and
Expected Activity
The patients undergoing TKA expected to increase
their leisure activity between baseline and 12 months,
and they did. This increase could have been caused by
any combination of factors such as the success of the joint
arthroplasty in restoring function, the impact of rehabilitation, or a desire to meet previously set expectations.
Although activity increased after surgery, there was a
statistically significant difference between actual and
expected leisure activity at 12 months suggesting that
leisure activity expectations may not have been fulfilled.
It is thus important to understand the magnitude of the
gap between actual and expected activity and determine
if the disparity was caused by unrealistic activity
expectations or an insufficient dose.
The 2008 Physical Activity Guidelines for Americans
recommend 150 minutes or more of at least moderateintensity activity per week to achieve the health benefits
associated with being physically active [38]. Under these
guidelines, walking 150 minutes at a speed of 4 mph
would translate into walking 10 miles per week.
In our cohort, the difference between actual and
expected activity at 12 months was 12.5 MET-hours per
week, which equates to 14 miles per week (walking is a
3.5-MET-hour activity). Thus, our patients reported
walking 14 less miles per week than expected at 12
months, which indicates that they intended to meet or
exceed the national guideline of 10 miles per week.
In addition to being statistically different, this 14-mile
discrepancy in a patient's expectations may be significant from a clinical and public health perspective. If
expectations had been met, patients who walked 0 miles
per week preoperatively could have moved from a
sedentary lifestyle to meeting the physical activity
guidelines postoperatively by walking at least 10 miles
per week. In those who were meeting the guidelines
preoperatively (ie, already walking 10 miles per week),
5
achieving expectations would be equivalent to walking
an additional 14 miles for a total of more than 24 miles
per week. Whether a dose of 24 miles per week is
realistic would depend on many factors, including pain
and functional status, and requires further investigation.
Patients who were somewhere between sedentary and
meeting the guidelines preoperatively would have
exceeded, but not doubled, the dose required to meet
the guidelines if their expectations had been met.
Were Patient Expectations Realistic?
Similar to other studies, patients in this study had high
expectations for leisure activity after TKA [4]. However,
their expectations for leisure activity may not have been
met. Despite high expectations after joint arthroplasty,
studies have estimated that expectations are met 55% to
89% of the time [4,36,39]. Whether the failure to meet
expectations was caused by limited functional abilities or
unrealistic expectations is less clear.
Consistent with prior published reports, most of the
reported activity in the study was of moderate intensity
and of no or low impact and was thus appropriate
[8,17,31,40]. In addition, the most commonly reported
types of leisure activities (gardening, walking, and
calisthenics) were also suitable and in accord with
previous studies [17,31,40-42].
Some of the expected leisure activities, though, may
have been unrealistic. For instance, several patients
expected to adopt a number of new high-intensity and/
or high-impact activities at 12 months, such as jogging,
basketball, or skating. This finding reinforces the results
from another study where more than 3 quarters of
patients expected to have little or no limitations in
recreational activities 12 months after TKA [37].
Although most patients in our study did not expect to
have limitations in recreational activities, few of the
newly expected activities had been adopted at 12
months. Thus, the difference between actual and
expected activity may be partially explained by the
failure of patients to adopt these new high-impact or
high-intensity leisure activities as expected.
Factors Related to Expectations
Few of the patient factors studied were related to
leisure activity expectations. In particular, demographic,
physical impairments (ie, WOMAC pain, stiffness, and
physical function), and all but 1 aspect of health-related
quality of life were not related to leisure activity
expectations. These findings were similar to those of
Mahomed et al. [4], who reported no relationship
between demographic factors or preoperative functional
health status (as measured by the SF-36 and WOMAC)
and patient expectations after TKA.
Mahomed et al [4] also suggested that self-efficacy
may influence expectations after total joint arthroplasty;
however, self-efficacy was not measured in that study.
In our study, self-efficacy for exercise was measured but
6 The Journal of Arthroplasty Vol. 00 No. 0 Month 2012
deemed unrelated to activity expectations. Although
self-efficacy has been identified as an important predictor of outcomes after TKA, past studies have focused on
the improvement in self-efficacy after a clinical or
behavioral intervention, or on different aspects of selfefficacy (eg, pain or disability), rather than specifically
on self-efficacy for exercise, as was done in our study
[43-46].
Several variables emerged as potential predictors of
expected leisure activity. The most common predictor
was the amount of leisure activity reported at baseline.
Expectations for leisure activity at 12 months were
higher in those who were more active at baseline, were
interviewed during the summer months, and reported
better general health.
Limitations
To our knowledge, this is the first study to measure the
type, intensity, frequency, and duration of expected
participation in leisure activities after TKA. The results
are clinically important and strengthened by the
prospective design of the study and the strong completion rate (N 90%).
There were several limitations to this observational
study. Although we were not able to control for factors
related to the surgeon or prosthesis, the cohort was fairly
homogenous with respect to implant characteristics and
postoperative complications. Furthermore, although
radiographic data may have provided a more comprehensive view of the patient after surgery, correlating
radiographs with the physical activity outcomes was not
the purpose of the study. This study was conducted using
reliable, valid, and well-accepted measures of disease
and symptom severity as well as both generic and
disease-specific measures of health-related quality of life
as recommended in the literature [19].
Finally, our cohort was predominantly white, and the
results may not necessarily apply to more diverse
samples. This is especially important because blacks
have been shown to have lower expectations for pain
and physical function after TKA than whites [47].
Physical activity expectations in blacks and other
minority populations have not yet been documented.
Future Implications
Fulfillment of patient expectations is a major factor
affecting health outcomes and should be routinely
discussed with patients before total joint arthroplasty
[48]. In one prospective study, expectations were the
second most important predictor of outcome, after
preoperative functional status [4]. Furthermore, results
from recent focus groups with TKA recipients indicated
that unrealistic activity expectations were an unexpected challenge they faced postoperatively. These findings
further confirm the importance of addressing expectations before surgery [49].
Many factors influence patient expectations including
whether or not a patient receives instructions regarding
the proper types of activities to engage in as well as the
appropriate frequency, duration, and intensity of participation in the activities. Patients with knee OA may
not be experts at predicting their functional abilities after
TKA; therefore, incorporating routine patient education
on expectations into the preoperative protocol may be
the optimal method for ensuring that expectations are
appropriate from the outset. Future studies could focus
on developing, testing, and implementing an educational intervention to help patients with knee OA establish
appropriate and realistic leisure activity goals for after
surgery. Combining patient education and our ability to
predict expectations based on the results of this study
could perhaps help patients with knee OA to set and
achieve their activity expectations.
Acknowledgments
This study was funded by a grant from the American
College of Rheumatology Research and Education
Foundation.
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