PREHABILITATION IMPROVES KNEE FUNCTIONING BEFORE AND WITHIN THE FIRST YEAR AFTER TOTAL KNEE ARTHROPLASTY: A SYSTEMATIC REVIEW WITH META-ANALYSIS

P. Gränicher^1,2, L. Mulder^1,3, T. Lenssen^1,3, J. Scherr², J. Swanenburg^4,5, R.A. de Bie¹

¹Maastricht University, Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht, Netherlands, ²Balgrist University Hospital, University Center for Prevention and Sports Medicine, Zurich, Switzerland, ³Maastricht University Medical Center+, Department of Physiotherapy, Maastricht, Netherlands, ⁴Balgrist University Hospital, Integrated Spinal Research ISR, Department of Chiropractic Medicine, Zurich, Switzerland, ⁵University of Zurich, Zurich, Switzerland

Background: Total knee arthroplasty (TKA) is the treatment for patients with end-stage knee osteoarthritis (KOA), when pain and/or functional disability persist after conservative treatments. Primary KOA is the main reason for performing TKA. Preoperative pain, physical fitness and impairments predict knee functioning after TKA. After being scheduled for surgery, patients often have to wait weeks to months before TKA can be performed. During this time, knee functioning may decline, while painsymptoms increase. Better preoperative knee functioning and physical fitness would promote postoperative recovery. Preoperative exercise therapy may improve patients' physical status preceding orthopaedic surgeries. However, it is unclear whether a significant correlation exists between preparation for surgery and enhanced outcomes after major joint replacements, particularly regarding functioning in activities of daily living (ADL). No systematic review has yet analysed the effect of prehabilitation at recovery-relevant pre- and postoperative measurement points. It remains unclear whether time-bound effects impact pre- and/or postoperative knee functioning.

Purpose: To assess whether prehabilitation influenced knee functioning before and within the first year after total knee arthroplasty (TKA) surgery.

Methods: A database search of MEDLINE/PubMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, Web of Science and Scopus was performed until March 2022. The study selection criteria were peer-reviewed articles comparing preoperative, short-, mid- or long-term effects of exercise-based physical therapy before primary unilateral TKA with TKA without prehabilitation. For data sysnthesis, bias was assessed using the Cochrane Risk of Bias tool (ROB 2.0) and therapeutic validity using the i-CONTENT tool. Standardised mean differences (Hedges’g) and 95% confidence intervals (CIs) were calculated for knee functioning. Certainty of evidence was assessed using the GRADE approach.

Results: Sixteen trials (968 participants) were included; 14 qualified for meta-analysis. Low- to very low-certainty evidence favoured prehabilitation over no intervention for improving knee functioning before (g=1.23; 95%CI: 0.49-1.97) and up to 3 months after TKA (short-term: 1 day to 1 month, g=0.90; 95%CI: 0.18-1.61; mid-term: 6 weeks to 3 months, g=0.45; 95%CI: 0.06-0.84). There were no significant between-group differences at long-term follow-up (6–12 months,g=0.07; 95%CI: −0.17-0.30).

Conclusions: There was low- to very low-certainty evidence that prehabilitation promotes superior knee functioning before and up to 3 months after TKA, compared to TKA alone. The long-term postoperative effects were inconclusive.

Implications: The results show a positive impact of prehabilitation on knee functioning in patients undergoing TKA. The SMD was largest immediately after the programme and gradually decreased to non-significance at long-term follow-up. Nevertheless, preoperatively assessing knee functioning and enhancing general fitness before surgery may be recommended to support faster recovery after TKA. Confounding factors (such as lack of standardised rehabilitation procedures, variable physical therapy interventions and different surgical procedures) and the influence of other health issues, may reduce the effect of prehabilitation over time. It therefore remains debatable whether short preoperative intervention periods can influence knee functioning up to 1 year after surgery. High-quality trials with large sample sizes should provide transparent data on exercise programmes, including intensity and progression protocols, to obtain high-quality evidence on efficacy of content, dosage and settings of prehabilitation.

Funding acknowledgements: This systematic review did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Keywords:
Preoperative Exercise
Physiotherapy
Total Knee Arthroplasty

Topics:
Orthopaedics
Disability & rehabilitation
Musculoskeletal: lower limb

Did this work require ethics approval? No

Reason: Ethics approval was nog required because this is a systematic review.