Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials

Abstract

ObjectivesThe clinical impact of preoperative physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement.DesignWe searched PubMed, Embase and Cochrane CENTRAL up to November 2015 for randomised controlled trials comparing prehabilitation versus no prehabilitation before joint replacement surgery. Postoperative pain and function scores were converted to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales (0–100, high scores indicate worse outcome). Random effects meta-analysis was performed to calculate weighted mean differences (WMD, 95% CI), subgrouped by hip and knee surgery.Primary and secondary outcomesPostoperative pain and function scores, time to resume activities of daily living, quality of life, length of hospital stay, total cost, patient satisfaction, postoperative complications, any adverse events and discontinuations.ResultsOf 22 studies (1492 patients), 18 had high risk of bias. Prehabilitation slightly reduced pain scores within 4 weeks postoperatively (WMD −6.1 points, 95% CI −10.6 to −1.6 points, on a scale of 0–100), but differences did not remain beyond 4 weeks. Prehabilitation slightly improved WOMAC function score at 6–8 and 12 weeks (WMD −4.0, 95% CI −7.5 to −0.5), and time to climbing stairs (WMD −1.4 days, 95% CI −1.9 to −0.8 days), toilet use (−0.9 days, 95% CI −1.3 to −0.5 days) and chair use (WMD −1.2 days, 95% CI −1.7 to −0.8 days). Effects were similar for knee and hip surgery. Differences were not found for SF-36 scores, length of stay and total cost. Other outcomes of interest were inadequately reported.ConclusionsExisting evidence suggests that prehabilitation may slightly improve early postoperative pain and function among patients undergoing joint replacement; however, effects remain too small and short-term to be considered clinically-important, and did not affect key outcomes of interest (ie, length of stay, quality of life, costs).

Selecting and optimising patients for total knee arthroplasty

“…Pre‐operative rehabilitation interventions (or “prehabilitation”) for the purposes of improving post‐operative recovery have received considerable interest. Our search identified nine systematic reviews including 14 randomised trials. Interventions included a heterogeneous group of exercise programs, including physiotherapist supervised and unsupervised exercise, coupled with co‐interventions including acupuncture, kinesiology and education .…”

“…Our search identified nine systematic reviews including 14 randomised trials. Interventions included a heterogeneous group of exercise programs, including physiotherapist supervised and unsupervised exercise, coupled with co‐interventions including acupuncture, kinesiology and education . While two reviews found marginal benefits to length of stay and knee range of motion, and one review demonstrated a dose–response benefit to several physical outcome measures, there was little benefit when a GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessment of the evidence was performed .…”

“…Interventions included a heterogeneous group of exercise programs, including physiotherapist supervised and unsupervised exercise, coupled with co‐interventions including acupuncture, kinesiology and education . While two reviews found marginal benefits to length of stay and knee range of motion, and one review demonstrated a dose–response benefit to several physical outcome measures, there was little benefit when a GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessment of the evidence was performed . Twelve of 14 trials were found to have a high risk of bias, and only small, short term benefits were found for pain (100‐point scale mean difference, − 6.1; 95% CI, − 10.6 to − 1.6) and patient‐reported function (mean difference, 4.0; 95% CI, 7.5–0.5).…”

Rehabilitation of revision total hip replacement: A multi‐centre survey of current practice

“…However, low pre-operative function is a significant risk factor for increased LOS and predictive of worse longer-term function (Biring et al, 2007;Davis et al, 2006;Yeung et al, 2010). There are no studies of rehabilitation before RTHR but there is some evidence that exercise can improve pain, muscle strength and function before primary THR (Gill & McBurney, 2013;Skoffer, Dalgas, & Mechlenburg, 2015;Wang et al, 2016) although the size and clinical importance of these changes is debated. Whether pre-operative rehabilitation focused on optimizing function before RTHR is safe, feasible and can improve outcomes seems relevant to investigate.…”

Abordaje del dolor agudo en traumatología

“…Una revisión sistemática y metaanálisis pone de manifiesto que los beneficios son modestos y clínicamente no relevantes (104).  Elevaciones periódicas de la extremidad inferior intervenida.…”