Physical Therapist: Research Is Advancing Care, Recovery for Patients Facing Knee Replacement

More than 1 in 10 adults over age 50 experience knee pain caused by osteoarthritis, and about 1 in 25 will go on to have knee replacement surgery. As our population ages, cases of osteoarthritis are expected to climb, meaning even more patients facing the prospect of knee replacement and rehabilitation. This episode of Health Science Radio features Jennifer Stevens-Lapsley, PT, PhD, FAPTA, professor of physical therapy and executive director of the RESTORE team at the University of Colorado School of Medicine. Stevens-Lapsley talks about what’s involved in arthroplasty of the knee and how patients can best heal and recover muscle strength after surgery. She also discusses a clinical trial that will measure
the outcomes of using neuromuscular electrical stimulation as part of the
knee replacement surgery rehabilitation process in 30 clinics in Colorado
and Utah. 

Transcript

Chris Casey:

Welcome to Health Science Radio where we take to the airwaves with scientists and clinicians at the University of Colorado Anschutz Medical Campus to discuss the many ways they are innovating and advancing healthcare. My name is Chris Casey, and I'm the director of digital storytelling in our Office of Communications. It's my pleasure to again be joined by my co-host, Carie Behounek, a senior or – excuse me – a health science writer on our team.

Carie Behounek:

I can be senior if you'd like, if that means a promotion. OK. I'm here. Thank you. Glad to be here.

Chris Casey:

Today, we're going to talk about major joint repair, particularly knee repair and replacement. It's a health issue of high interest to many folks, especially those who are getting older and a bit more creaky in the knees and other joints. And I can speak for myself that I'm experiencing that at this stage. We'll discuss what's involved in knee replacement surgery and the reasons why it can be the recommended option for patients. Also, we'll talk about how a patient can best heal after a knee replacement, and we'll discuss how research is advancing care and recovery for patients suffering from osteoarthritis and other joint maladies. So there's a lot to talk about here.

And we're pleased to be joined by our guest who is Dr. Jennifer Stevens-Lapsley. Jennifer is professor and interim vice chair of research in the University of Colorado, Department of Physical Medicine and Rehabilitation, and Director of Rehabilitation Sciences PhD program. Her clinical research focuses on patients with osteoarthritis and medically complex patient populations. Her research includes the evaluation of care bundling strategies for joint arthroplasty, interventions in medically complex patient populations, and health services research to understanding how rehabilitation services impact hospitalization rates and functional performance. So welcome, Jennifer.

Jennifer Stevens-Lapsley:

Thank you for having me. Pleasure to be here.

Chris Casey:

I'm always interested to find out what drew somebody into their discipline, and this is a very integral part of the overall healthcare system: People dealing with osteoarthritis, people recovering from massive joint replacements. What drew you into physical therapy, into this field?

Jennifer Stevens-Lapsley:

Well, into physical therapy, I would say, I was very interested in the science and biology. I was a biology major as an undergraduate, and like many physical therapists, had an injury along the way that brought me into the clinic and made me wonder, "Could I combine this love of science with rehabilitation?" So that's what drew me into this profession. I work predominantly in the research of my team, I’m the director of the RESTORE team at the University of Colorado here, and predominantly, our team works on questions related to aging and older adults. So a lot of what we're trying to do is understand muscle disuse and improve muscle function in our aging population. So almost all of our work really targets questions from different angles that are designed to do exactly that: to improve mobility and physical function.

Chris Casey:

And just to look at the landscape of the issue of osteoarthritis, it seems it's becoming a growing health condition, perhaps health crisis even in America. Could you just explain what osteoarthritis is?

Jennifer Stevens-Lapsley:

Sure. Osteoarthritis is a disease where the cartilage gradually gets worn down due to high levels of physical activity or just forces that are transmitted through joints that just essentially put some additional stress on that cartilage surface, and that cartilage protects the joint. When it protects the bones, essentially, it serves as an interface, and when it gets worn down, you have pain and an uneven surface that becomes even more painful over time, and that's known as osteoarthritis. Eventually, when the wear and tear becomes enough, joints may need to be replaced, as we're going to talk about today. But there's a lot of things you can do with osteoarthritis to slow the progression of osteoarthritis, and exercise and strengthening are thought to be good avenues to try and mitigate some of the progression of osteoarthritis in many cases.

Chris Casey:

And with the general aging of our population, I imagine that cases of osteoarthritis are increasing?

Jennifer Stevens-Lapsley:

They're absolutely increasing, yes.

Carie Behounek:

And what about the health status of most Americans, is that impacting it?

Jennifer Stevens-Lapsley:

It certainly is. The poor lifestyle, sedentary activities can certainly increase obesity and obesity also then puts more weight on or more pressure on joints, which facilitates a faster wearing of that cartilage surface in many cases. There's a lot of genetics that play into osteoarthritis as well. So it's not just the physical wear and tear. There's a predisposition certainly that contributes to the development of osteoarthritis as well.

Chris Casey:

Yeah. And on the lead-in there, the introduction mentioned the term arthroplasty. And could you explain Jennifer what arthroplasty is?

Jennifer Stevens-Lapsley:

Yeah. So arthroplasty is a replacement of that cartilage surface essentially. So in the case of a knee or hip replacement, you're going to have the ends of each of the bones kind of sawed off, or removed, and a new interface placed in an interface that's not resulting in that painful osteoarthritic uneven surface. So it's basically providing a new surface for the joint to function on.

Carie Behounek:

And when you say interface, what do you mean by interface? Is that metal or …?

Jennifer Stevens-Lapsley:

Yes, usually it's a metal interface.

Carie Bohounek:

OK.

Jennifer Stevens-Lapsley:

Exactly. Cemented in place in most cases. So it's just basically replacing that surface with those metal components.

Chris Casey:

A patient facing knee replacement surgery – I imagine that fills them with a fair amount of anxiety and just the magnitude of what they're going to be facing. Could you talk a little bit about what maybe patients are at the outset, perhaps failing to understand about what would they be facing in the aftermath and the recovery period?

Jennifer Stevens-Lapsley:

Yeah. It's a fairly extensive surgery. Unlike arthroscopic surgeries, this involves a much larger incision and you're replacing the ends of bones, so there's a definite transition in terms of healing. I think people sometimes expect the pain to be gone because their osteoarthritis pain is being addressed. And so what happens is it's replaced with a different type of early post-operative pain, and that gradually goes away over time. But early after surgery, there's a fair amount of swelling as a result of the tissue trauma during the surgery, and it just takes time for that to calm down.

One of the things that patients report early after surgery is sleeping can be very challenging, because you're dealing with the pain and the swelling, and getting a good night's sleep is important to be able to exercise and do all the other things to help facilitate recovery. But it is very challenging for individuals early after surgery within the first couple weeks. I would say the other key element of the surgery is that the muscle function declines pretty precipitously right after surgery. So the quadriceps muscle is one of the biggest muscles – it’s on the front of your thigh – and that muscle shuts down after surgery due to the trauma and the swelling.

So people don't really realize how difficult it's going to be to get that muscle back up and functional. So that's one piece – it takes time to restore the quadriceps muscle activity, but it literally shuts down. It's like the body says, "Something's happened to my knee, I'm going to shut down to protect my knee and I'm going to not use this muscle because something's not right." So patients will go from normal strength, or a lot of times they're weak before surgery too, but they'll lose about 80% of their strength just within that immediate post-operative period.

And it's not like the muscle dies or disappears on them, or atrophies; it doesn't shrink by 80%. It's the ability to recruit the nerves and recruit the muscle are shut down. So that muscle appears to be immediately weakened as a result of the trauma and the surgery. It's an inhibition, the muscle becomes very inhibited. So it takes a lot of work to restore that. As well as range of motion, you're stiff after surgery and you got to get your knee bending again. So working on that range of motion is also an important part of the recovery process.

Carie Behounek:

So 80% of your muscle is lost just because of that surgery.

Jennifer Stevens-Lapsley:

Yeah. The strength is lost immediately. So when we measure strength within 24, 48 hours after the surgery compared to before surgery, the strength is lost.

Carie Behounek:

That's a big muscle to lose that much strength from. So what does that mean for recovery? I've actually had the pleasure to talk to you before about this same topic, and I remember you telling me that the surgeons themselves prioritize that range of motion, which you brought up, but as a physical therapist, you look at it a little bit differently and you're concerned about that large muscle and losing that much strength. So tell us a little bit about that.

Jennifer Stevens-Lapsley:

Yeah. The community at large, even many clinicians focus on this range of motion issue. In fact, when I give presentations in a variety of different environments, I'll often have people who've had a knee replacement come up and say, "I got 120 degrees of knee flexion,” that's the bending of the knee, after surgery. That's their metric of success. And there's a couple of reasons for that. The surgeons reinforce that that's really important. Therapists reinforce that that's really important, and it's a tangible outcome, so you actually can measure it easily. Patients tend to hang their hat on how much range of motion they get; the entire clinical community has remained very focused on that.

And as an alternative, muscle strength is a lot of what we focus on because the data suggest that, and studies suggest that, your range of motion only limits you within the first month or so after surgery. Once you get a reasonable amount of range of motion, it's not what's limiting you going up stairs or down stairs or getting up from a chair or tying your shoes. Most of the time that range of motion is normal enough that you're able to do all those activities. And what really ends up limiting people is the quadricep strength.

So we know that years after surgery, it's really that quad strength that ends up limiting physical function and activities of daily living more than the range of motion. So it's an interesting paradox, because we focus so much on the range of motion, but I think it's not the rate-limiting step to restoring normal activities in the long run. So focusing on the what is the rate-limiting step becomes more important.

Chris Casey:

Yeah. I think this nicely leads into a clinical trial that you have underway right now, if I understand correctly, a neuromuscular electrical stimulation clinical study?

Jennifer Stevens-Lapsley:

Yes.

Chris Casey:

Could you talk about that and what neuromuscular electrical stimulation is and why that's important?

Jennifer Stevens-Lapsley:

Yeah. So when I mentioned that the quadriceps muscle shuts down, one way to overcome that shutdown is to stimulate the muscle with electrical signals, essentially. So the electrical signals are stimulating the nerve that basically connects to the quadriceps muscle and allows it to contract. So even though the brain is telling those nerves, "I don't want you signaling to the muscle to contract," the electrical stimulation essentially overrides that and says, "No, I do want you to contract that muscle." So we're able to intervene and get a strong muscle contraction much earlier after surgery than would be present otherwise. So despite all the swelling and everything, using this electrical stimulation allows us to see a visible muscle contraction that otherwise wouldn't be possible.

Carie Behounek:

OK, when I hear electrical stimulation, I'm thinking, "Is that a shock? Is that a physical thing?"

Jennifer Stevens-Lapsley:

Yeah, no, it's a great question because it's a tingly sensation at the lowest intensities, and it becomes a very strong tingly sensation at the higher intensities where we're actually getting the muscle to contract. So it is not like touching an electrical fence. It's more prolonged.

Carie Behounek:

I've done that.

Jennifer Stevens-Lapsley:

But that's one of the biggest challenges with it is, the large majority of people tolerate this sensation. A handful of people do not. Some tolerate it better than others, but it is something that takes a little bit of getting used to.

Carie Behounek:

So you've demonstrated this before. You had a study in 2012 where you used this, it was a small study. And from what we understand, people were recovering about 50% quicker than they were without this neuromuscular stimulation. Can you talk a little bit about that original study and then segue into the study you're working on now?

Jennifer Stevens-Lapsley:

So yes, in that study, we did find that we almost doubled the rate of recovery, especially in terms of muscle strength and physical function. So being able to stand up from a chair, walk a certain distance, turn around and sit back down, going up and down flights of stairs, those activities became much easier for individuals who used this neuromuscular electrical stimulation. So we published that study and we kept it in the back of our minds for years that this is a highly effective strategy for restoring muscle strength and thereby improving physical performance and function.

But like many things, publishing something doesn't translate to a change in clinical practice without a more actionable plan: Let's figure out how we can build this into the healthcare system. So the purpose of the present study is to overcome some of the barriers associated with the implementation of the neuromuscular electrical stimulation. So we know it works in ideal conditions where we have one-on-one interactions with participants, and research study staff are actively involved in supervising the intervention and all of those things. But what we don't know is how to get it to work comparably in a real-world healthcare system. And that's the focus of the current study.

Chris Casey:

And one aspect of the current study that I think is interesting is aren't you looking at whether through this type of therapy, perhaps patients could minimize the amount of, say, post-op physical therapy sessions they might need? Is that a component?

Jennifer Stevens-Lapsley:

Yeah. This particular study will not constrain the number of sessions or dictate the number of sessions. So it is something that's going to be interesting to follow. The idea is as healthcare utilization keeps changing and reimbursement keeps changing and patients have higher and higher copays, the reality is that the number of visits that people are getting after a knee replacement surgery now is less than it was 20 years ago, and even 10 years ago. So trying to figure out ways in which patients can provide some of their own therapy and supplement what's happening in the PT clinic visit has been a really big emphasis or a big push. If we can get people to do something that's effective at home on their own more regularly, then that again, supplements the physical therapy and the physical therapist can focus on very targeted types of things in the clinic sessions that the patient might not be able to do themselves.

Carie Behounek:

How many times does somebody usually typically go to physical therapy after a knee replacement?

Jennifer Stevens-Lapsley:

The recommendation right now is two times a week for six weeks or so – six to eight weeks after surgery – is the ideal scenario.

Carie Behounek:

Is that enough?

Jennifer Stevens-Lapsley:

That is adequate. Most people regain good function and they're able to – not by the end of eight weeks, are they back to 100% – but they've come far enough that they can make that last jump. Usually, people around three months feel like they are closer to back to full function and certainly by six months in many cases. So that is adequate. In many places, the frequency is decreasing to be once a week or once every other week. So it depends on the healthcare provider, the healthcare system, surgeon recommendations, therapist availability, lots of things can factor into that. But ultimately, generally that two times a week for six to eight weeks is very much adequate for most people in terms of recovery.

Chris Casey:

And didn't you discover through your research that patients could also do a little type of work at home on the problem area to prep the knee for the surgery? Is there a component where they do a little pre-surgery work on their own?

Jennifer Stevens-Lapsley:

With the electrical stimulation?

Chris Casey:

Yeah.

Jennifer Stevens-Lapsley:

Yes, it is possible to do that. In most cases, the logistics of getting people a unit in time to have enough lead time to do the strengthening before surgery is challenging, but it can't hurt. It's probably more effective after surgery. So what we do know with neuromuscular electrical stimulation is if you're a healthy individual without any impairment or difficulty with your muscle function, you're better off going to the gym and doing weight training, strength training through traditional means. This particular intervention is most effective in people who have these activation deficits of their muscle where they can't recruit the muscle. And that's where it tends to be most effective.

Now, many people have some of those deficits before surgery. The osteoarthritis leads to a little bit of the shutdown of the muscle even before the surgery because of the pain and the swelling. So yes, it could be effective. We haven't emphasized that piece. We do give people neuromuscular electrical stimulation units before surgery in an ideal world, because if they can familiarize themselves with the use of it before they have surgery, they're just more comfortable. I mean, we talked about the electrical stimulation and that sensation, and now you have a major surgery and you're asking me to put these electrodes on for the first time and turn it up. It's much better received when you've done it before surgery and you know what to expect. And so most of it is familiarization, and we haven't really studied how much prehab or pre neuromuscular electrical stimulation would further benefit people through the work that we're doing.

Carie Behounek:

Tell us about this contraption that you're sending people home with. It's our understanding that you're doing this trial in 30 different clinics in Colorado and Utah, and you're sending people home with this contraption that they'll then attach to their quadriceps and shock themselves.

Jennifer Stevens-Lapsley:

Yeah. It's shocking themselves, yes. [JS1] We have electrodes that are about three by five inches that go on the part of the thigh near the knee, and then they go on the part of the thigh near the hip, and they're connected with wires to a little device. And it's a portable device. It actually has a lot of power to it, but it's probably the surface area size of those electrodes – so like three by five inches itself. So light, durable, portable. Basically, this device has the ability within it to just, you turn it on, you have instructions for how to turn it up, and it's very relatively simple to use.

What's challenging is that tolerance piece. So we know that the dose matters, and we know that there's a dose-response relationship, just like you go to the gym and you lift heavier weights, you're going to get stronger. So we know that the higher that people use this, the more effective it's going to be. And we've published data to that effect. However, getting people to tolerate it and have it be most effective is really the ultimate challenge. I tell people, “This is something that you aren't just doing while you're talking on the phone to someone.” There's an intentional element of trying to turn it up to an intensity that's actually going to be therapeutic.

Carie Behounek:

And how long do they have to have the sensors on their leg?

Jennifer Stevens-Lapsley:

Yeah. So the electrodes are just sticky electrodes. They come on and off, and so you can take them off after you're done. It's like a 15 minute session. We recommend twice a day for 15 minutes, and it's like lifting weights. You have the muscle contract for 10 seconds, and then you relax for 10 seconds and have it contract for 10 seconds and relax for 10 seconds, for a total of 15 minutes. So early after surgery, it's important to do it more frequently, because you're literally trying to keep the muscle alive, like you're trying to keep it from shrinking, and reestablish those neural connections. And later it's possible that doing it once a day, might be just as effective.

For the study, we're going to have people start out with twice a day and continue with twice a day to maximize the potential benefits of the electrical stimulation. But we know that some people will not continue to use it twice a day. So we'll learn from the people that used it once a day towards the latter end of the treatment period and see if they were able to maintain or get just as much benefit from it as the people that used it twice a day.

Chris Casey:

And we're talking about knee replacement here. Could there be applications of this type of treatment to a hip replacement?

Jennifer Stevens-Lapsley:

Hip replacement surgery doesn't impact the quadriceps muscle nearly as much. So there is an insult and there is some weakness, but it's just not as profound. And so people after hip replacement surgeries tend to do a little bit better in terms of that immediate post-operative recovery. So that's one of the big differences. Can it be used for almost any muscle group? Yes. Well, I should say, the larger muscle groups that are more accessible to putting these electrodes on them are ideal targets. If I was having hip replacement surgery, I probably would use it on my quadriceps, but it's not nearly as indicated or as effective as what we see with a knee replacement.

But NMES can be used in any patient population that has this disuse or muscle activation deficit. I have a colleague at the University of Vermont, Michael Toth, who's looking for funding to apply NMES in patients post-cardiac surgery because you can't get up and move very much and these patients are often very deconditioned. So if you could use neuromuscular electrical stimulation to strengthen both quadriceps muscles after the surgery while someone's in bed or sitting around most of the day, you might be able to preserve a lot of function. And he's also looking at patients with COPD and similarly deconditioned, they've been hospitalized and the goal is to use neuromuscular electrical stimulation to restore muscle function. So you can use it in a lot of different situations and scenarios to rebuild muscle strength.

Carie Behounek:

And when you're rebuilding that muscle strength, is that just so that they can recover cardio-vascularly? I know strength is important for everything, but is that ultimate goal – that they're able to move again and get healthy?

Jennifer Stevens-Lapsley:

I would say that it is to move and get healthy. So the cardiovascular piece comes as a byproduct of just being stronger in general and being more active and being able to engage in activities that promote more aerobic fitness – so like biking and walking where you're elevating your heart rate. Those types of activities really address cardiovascular health more. This really focuses on the strengthening of muscles that allow for functional activities – to get up and out of a chair and to walk up and down a flight of stairs and things like that. But they're all tied together because the more you engage in functional activities, the more your cardiovascular system is also benefiting. If you just take one flight of stairs instead of taking the elevator, there's evidence that suggests that small bouts of physical activity ultimately contribute to better overall cardiovascular health and function.

Carie Behounek:

Well, I imagine if you're in a lot of pain, that is probably what stops a lot of people from movement. So at what point in somebody's having knee pain due to osteoarthritis, at what point is it recommended that they actually go through with a surgery?

Jennifer Stevens-Lapsley:

Yeah. Great question. It's a question that is not as data driven as we would like. We would love to have data on a large swath of people and monitor them over 10 years and look at when they have surgery. Did they wait too long? Did they do it too early? And there's some data from other countries where there's long wait times and things that help us understand what is too long in the absence of the ideal study. The general recommendation that I give people is as soon as you start decreasing your activities because of the pain – like if you stop walking the distances that you used to walk because of the pain or you find yourself slowing down because of the pain – then it might be time to consider a knee replacement surgery. Now, age is a factor. You don't typically encourage someone who's in their 40s who is slowing down to have it as early as someone who's in their 60s or 70s, because it's harder to re-replace the knee.

So in other words, if you have one surgery and then you have to have it redone 20 years later because it's worn out, you're more cautious about encouraging people to have that knee replacement if they're younger. So there's a lot of factors that go into it – age being one of them, level of physical function and declines in physical function. But what we do know is when you wait too long, it's hard to recover your muscle strength back to where it used to be – not just before surgery, but before you started to experience the symptoms of osteoarthritis.

Carie Behounek:

Okay. Let's talk a little bit about, so you had your initial study. I think one thing or a misconception some people might have in the world of research and medicine is the idea that you can prove something in a study, but then you have to go out into the real world and implement it. So let's talk a little bit about what you've learned about the science of implementation, and how that information gets disseminated and how you were able to bring this study into a larger population.

Jennifer Stevens-Lapsley:

Yeah. It's a great question and a good topic of conversation because there's a widely cited statistic that it takes 17 years to translate published findings into clinical practice. And I think in many cases that timeline is shortening with the use of the methods and strategies that we're employing in this type of study. But ironically, the first study that I described was published in 2012, and here we are in 2025 and there has been no translation. The goal is to help facilitate and understand: What are the barriers? Why is this not being widely used? The use of neuromuscular electrical stimulation is part of our clinical practice guidelines for physical therapists for patients after knee replacement surgery. When we surveyed therapists, it was the one thing that was not being implemented amongst the recommended clinical practice guidelines.

And so what a study like this does is it looks at all the factors for what are the barriers for implementation? And one of the biggest barriers is having the devices available. So the healthcare system has to invest in a fleet of devices, or the insurance companies have to be willing to pay for the use of these electrical simulation devices. So just the access to the device is a huge barrier for translation and implementation. But there are other barriers. One is getting the units to patients before surgery. If it's ideal to give them to them before surgery and they're not getting them until after surgery, then that's another barrier to overcome. We look at all the different facets of what will allow for successful implementation and what might impair the implementation in a study like this, with the ultimate goal of figuring out what recommendations we could make to healthcare systems for a better uptake down the road. We'll learn as we go.

Chris Casey:

Yeah. Is there a dissemination plan to try to expedite the implementation? I don't know what the strategy is to try to disseminate your information to them in a timely fashion and hope that they can maybe adopt some of this?

Jennifer Stevens-Lapsley:

Well, we certainly don't want the length of time that spanned between the initial publication where we are right now to repeat itself. So we know that a publication isn't going to change anything, no matter what the results of the study, by itself. We're still in the early stages of launching. So I think we haven't given a ton of specific thought to the details of our dissemination plan, but we have been working to increase awareness to our research program more generally by developing resources and tools for outreach to wider communities. So one of the things that I think would be relatively easy to do is as we're putting these resources together, the patient-facing resources on how to use neuromuscular electro stimulation, the clinician-facing resources on how they should use it for best practice, we can share those resources, so we can make those more widely available.

And I think a lot of what we try to do increasingly is go out and present at conferences, but also engage healthcare partners, so healthcare systems and figure out from the top, how can we make a case to leadership of healthcare systems for the value of the use of NMEs? And we're going to have to look at the cost, and we're going to have to look at the time it takes and all those factors. But if we can show the patient benefit, that will help tremendously with that dissemination potential.

Carie Behounek:

Doubling the time of recovery seems pretty good, that has implications for return to work and even cost for physical therapists and all of that.

Jennifer Stevens-Lapsley:

The key is will we be able to still double the speed of recovery in a pragmatic real-world trial?

Carie Behounek:

Yes. Say more about that.

Jennifer Stevens-Lapsley:

So for the initial study, we had patients who opted into the study, they signed a consent form, they were eager to participate in research. We had high levels of oversight, we had lots of supervision, lots of touch points. And so that all optimizes the outcome that you're going to get. One of the things with this implementation trial, this more pragmatic approach, is you get to see in the real world, patients are going to clinics where the entire clinic is implementing this – that's just their standard of care. You don't select the patients, they don't select, they don't opt in. You're getting a real-world representation, and so that may diminish the magnitude of the benefit that we see.

Now, we get to collect a lot of variables to look at the characteristics of the clinicians and the clinics themselves and leadership and other things that may translate into better or worse success, as well as patient-level characteristics that may absolutely influence the success. So the ultimate goal is to try and get as meaningful an outcome as possible, but we're facing many of these real-world circumstances – what some people describe as results in a voltage drop in the likely magnitude of benefit.

Carie Behounek:

Well, yeah. And will my insurance cover this? How does that work?

Jennifer Stevens-Lapsley:

Our hope is that if we can show, and this is a trial that's going to have 3,000 patients, and it's this type of evidence that can influence reimbursement, ultimately. It does take an act of Congress to change the CMS reimbursement – what they reimburse, what they don't – so it's not a trivial consideration. But that is the goal is ultimately to show this is effective and, therefore, should be covered by insurance.

Chris Casey:

So if you could, Jennifer, on the clinical trial that's underway, you're partnering with 30 clinics. Could you just talk a little bit about that partnership?

Jennifer Stevens-Lapsley:

Absolutely. So we have 10 clinics in the UCHealth system here in Colorado, and we have 20 clinics in an Intermountain Health care system in Utah. And our local partners through UCHealth involve our surgeons and our rehabilitation teams. They have been extraordinarily willing to work with us on the implementation aspects of this. So when we talked about implementation, you can't just drop something into clinic workflows as an outsider and expect it to be successful. And so the rehabilitation leadership here and the clinical teams that are going to be helping implement the day-to-day operations have been absolutely instrumental in helping us launch, and kind of set the stage for successful translation.

Carie Behounek:

I think most people don't understand everything that goes into a study like this, and the amount of people who have to also support it and be behind it, and the amount of funds that need to go towards this as well.

Jennifer Stevens-Lapsley:

Yeah. It looks really simple. It looks like just drop this in and make it happen. But it's amazing what the behind-the-scenes efforts are just to teach therapist how to collect certain outcome measures and how to use the electrical stimulation. Most of them know how to do it, but to really most effectively use it and all the logistics from scheduling to everything. It seems simple, but it's actually very, very complex. And that's the nature of implementation science is the complexity sometimes isn't apparent at first glance, but it's definitely there.

Carie Behounek:

Well, and I'm curious, how much do these boxes cost, these neuromuscular stimulators? Is it expensive?

Jennifer Stevens-Lapsley:

Yeah. They're $300 to $400. So they're not insignificant in terms of costs, but the idea is a healthcare system would own a fleet of devices and essentially rent them out or loan them out, and that would make this intervention much more cost-effective.

Carie Behounek:

And how long is the study?

Jennifer Stevens-Lapsley:

The study is three-ish or so years, in terms of the actual intervention phase. We have about five years of funding to set up the study and then do all the analyses at the end of the study.

Carie Behounek:

OK. So what can people like Chris and I, who don't need knee surgery just yet, what could we be doing to protect our knees and saving ourselves from surgery down the line?

Jennifer Stevens-Lapsley:

One of the best things you can do is stay active and do strength training and things like that – it ultimately helps for a wide variety of health reasons, but can certainly influence joint health and physical function. So even if it's finding things that you really enjoy that you can incorporate into your normal routine from a physical activity standpoint. It's hard, sticking with it when life gets busy is challenging, but it's an important part of optimizing aging and minimizing declines in physical function.

Carie Behounek:

I was thinking about, as you were talking about shocking your muscles to keep your quads strong. I recently started working with a personal trainer, and I guess in that way I'm choosing my pain because I can barely walk after working with her. And the squats and the lunges and, yeah, it's choosing your pain there. And I guess I'll stick with the trainer, hopefully.

Jennifer Stevens-Lapsley:

You're doing the right thing. If you're sore, then that means you're improving your strength. So that's a good thing.

Carie Behounek:

OK.

Chris Casey:

Yeah. It's finding what you'll actually do and enjoy enough to keep at it seems very important.

Jennifer Stevens-Lapsley:

It's a key element is, and sometimes it's incorporating into your daily routine, going up and down the flight of stairs rather than taking the elevator, or walking farther from the parking lot, parking intentionally a little bit farther away so that you're getting-

Carie Behounek:

You do that?

Chris Casey:

I do that.

Carie Behounek:

You said you rode your bike here? I could ride my bike here, and I did not.

Jennifer Stevens-Lapsley:

It’s just trying to figure out ways that you can build it into your existing activities or day-to-day routine workflow, et cetera, means you're more likely to stick with it, for sure.

Chris Casey:

Well, this has been a great conversation and we very much appreciate your insights, Jennifer, and all the work you're doing and your team is doing. The study sounds very impressive in its scope and ambitions, so we'd certainly be interested to hear how that turns out when it's complete.

Jennifer Stevens-Lapsley:

Most definitely. I’d like to come back and tell you what the results are.

Chris Casey:

Please do. Anyway, thank you very much for joining us today.

Jennifer Stevens-Lapsley:

Thank you for having me.

Carie Behounek:

Thank you.