Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review

Abstract

We sought to systematically review the evidence on the benefits and harms of prehabilitation interventions for patients who are scheduled to undergo elective, unilateral total knee arthroplasty or total hip arthroplasty surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We selected for inclusion randomized controlled trials and adequately adjusted nonrandomized comparative studies of prehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. While large heterogeneity across evaluated prehabilitation programs limited strong conclusions, evidence from 13 total knee arthroplasty randomized controlled trials suggest that prehabilitation may result in increased strength and reduced length of stay and may not lead to increased harms but may be comparable in terms of pain, range of motion, and activities of daily living (all low strength of evidence). There was no evidence or insufficient evidence for all other outcomes after total knee arthroplasty. Although there were six total hip arthroplasty randomized controlled trials, there was no evidence or insufficient evidence for all total hip arthroplasty outcomes.

Figure 1.. Overview of studies of prehabilitation to no prehabilitation for total knee arthroplasty

Figure presents studies (n=13) that evaluated prehabilitation programs for total knee arthroplasty versus various controls (predominately no active control with the exception of Mitchell 2005 which evaluated prehabilitation and postoperative rehabilitation combined vs. postoperative rehabilitation alone and did not include any active rehabilitation in the control arm during preoperative phase of the study). Study arms are described using study descriptors followed by goal components coded by the review team using the Oatis and Franklin taxonomy. The color is added for visual display and does not provide unique information. Abbreviations: Adj = adjunctive, A = aerobic exercise, B= Balance-motor/learning-agility exercise, E = patient education, F = flexibility exercise, HI = high intensity, NEMEX = neuromuscular exercise, prehab = prehabilitation, preop = preoperative, postop = postoperative, RT = resistance training, S = strengthening exercise, T = task-specific training, TENS = transcutaneous electrical nerve stimulation, TJR = total joint replacement * Intervention included progression which was deemed appropriate.

Figure 2.. Goal components strength, aerobic, and flexibility and their specific exercise components for prehabilitation interventions versus no prehabilitation for total knee arthroplasty

See Figure 3 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities. Abbreviations: ed = education, HI = high intensity, NEMEX-TJR = neuromuscular training program, PRT = progressive resistive training; preop = preoperative; rehab = rehabilitation, ROM = range of motion

Figure 3.. Goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities and their specific exercise components for prehabilitation interventions versus no prehabilitation for total knee arthroplasty

See Figure 2 for goal components strength, aerobic, and flexibility. Abbreviations: ed = education, H = home, HI = high intensity, I = in-person; NA = not applicable, NEMEX-TJR = neuromuscular training program, O = outpatient physiotherapy center, PreopPTEd = Preoperative physical therapy education, PRT = progressive resistive training; preop = preoperative, prehab = prehabilitation, R = remote, rehab = rehabilitation, SG = self-guided. A Remote via telephone B Research personnel C Aquatic center

Figure 4.. Overview of studies of prehabilitation to no prehabilitation for total hip arthroplasty

Figure presents studies (n=6) that evaluated prehabilitation programs for total hip arthroplasty versus nothing (defined by the study and the goal components coded by the Oatis and Franklin taxonomy). The color is added for visual display and does not provide unique information. Abbreviations: Adj = adjunctive, A = aerobic exercise, B= Balance-motor/Learning-agility exercise, E = patient education, F = flexibility exercise, S = strengthening exercise, T = task-specific training. * Intervention included progression which was deemed appropriate.

Figure 5.. Goal components and their specific exercise components for prehabilitation interventions versus no prehabilitation for total hip arthroplasty

Abbreviations: AI = acute in-patient; ed = education, I = in-person, G = gym/other community center, H = home, NA = not applicable, NR = not reported, O = outpatient physiotherapy center, PT = physical therapy, preop = preoperative; PRT = progression resistance training, rehab = rehabilitation