The effects of prehabilitation with advanced technologies in patients with musculoskeletal diseases waiting for surgery: a systematic review and meta-analysis

This systematic review with meta-analysis aimed to assess the impact of PrAT on clinically relevant outcomes in patients affected by musculoskeletal diseases awaiting surgery.

A comprehensive search of PubMed, EMBASE, Cochrane Library, PEDro and Cinhal databases was conducted up to February 2023. ClinicalTrials.gov was searched for registered protocols. Randomized and non-randomized controlled trials comparing PrAT to standard (usual care or no intervention) were included. Participants were adults affected by any musculoskeletal disease awaiting surgery. Two independent reviewers conducted study selection, data extraction and critical appraisal. Meta-analyses were performed using random-effects models, and certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation system. The primary outcome was function, while secondary outcomes included pain, strength, risk of fall, autonomy in daytime activities, patient’s satisfaction, health-related quality of life, adverse events and treatment adherence. The study protocol was registered on PROSPERO (CRD42022345811).

Seven studies were included, focusing on patients undergoing knee or hip arthroplasty, primary meniscal tear and spine surgery. PrAT programs showed relevant variability in terms of modality (synchronous or asynchronous) and focus (mindfulness, exercise, education or combinations). For candidates to knee or hip replacement, compared to control, PrAT showed significant better function (pre-surgery: MD -7.59, CIs 95% from -10.85 to -4.33 I²=0%; post-surgery: MD -7.84, 95% CIs from -11.80 to -3.88, I²=75.3%), preoperative pain (MD -1.67, 95% CIs from -2.50 to -0.48, I²=0%) and risk of fall (MD -2.54, 95% CIs from -3.62 to -1.46, I²=0%) and postoperative stiffness (MD -2.00, 95% CIs from -2.01 to -1.99, I²=87%), with low or very low certainty of evidence. No significant differences in pain were observed one-month post-surgery. Meta-analysis was not possible for the other secondary outcomes and for data from studies on meniscal tear and spinal surgery.

PrAT may be better than standard in improving pre- and postoperative function in patients undergoing knee or hip arthroplasty. No quantitative results have been achieved on other musculoskeletal conditions. Effective prehabilitation programs could include mobility, strengthening, proprioceptive exercises and education or less structured interventions as exercises suggestions, mindfulness, walking and yoga practicing.

PrAT is a valid intervention for patients with poor preoperative outcomes, with high compliance supporting its clinical feasibility. Further primary studies are needed to provide strong evidence on the effects dimension provided by prehabilitation, extending investigation to a wider range of musculoskeletal diseases. Guidelines defining programs characteristics and the use of technology in prehabilitation should be developed to standardize care.