Pre-Operative Physiotherapy for Total Knee Arthroplasty

It is thought that pre-operative levels of knee pain, strength, flexibility and functional ability can influence the outcome of total knee joint replacement surgery. Therefore many hospitals offer pre-habilitation programmes with the aim of improving strength and range of movement of the knee with impacts on pain and function. So do these programmes work? The authors of a recent systematic review explored the effects of pre-operative physiotherapy on these outcomes post surgery.

Here’s what they did

The authors searched: MEDLINE, Embase, CINAHL and PEDro until June 2014 for Randomised Controlled Trials (RCTs) or quasirandomised trials published in English. Trials must have included patients with osteoarthritis undergoing TKA and compare formal physiotherapy or exercise-based programme, not simply education, nor a single physiotherapy session with control and have pain and/or functional outcomes assessments made post-operatively. Authors looked at the quality of each study.

Here’s what they found

11 studies were included, only six were of good methodological quality according to the PEDro score.
Components of programmes typically included warm-up, lower limb stretching and strengthening.
Specific focus of aerobic training (3 studies), step training (3 studies), proprioceptive and balance training (2 studies) and home exercise component where participants could carry out the exercises without physiotherapist supervision(6 studies).
The duration of the physiotherapy programmes typically lasted 6 weeks, ranging from 3 to 8 weeks.

WOMAC or SF36: No significant improvement in either the overall WOMAC (5 studies) or SF36 score (5 studies), or the individual components of pain, stiffness and function.
Quadriceps strength and/or hamstring strength: no significant differences.
Pain reduction: No significant differences (8 studies)
Knee ROM: No significant differences in active or passive range of movement (4 studies). However, one study patients in the intervention group reached 90 degrees of knee flexion at 5.8 days, 1.1 days shorter than the control group (P = 0.0016).
Hospital length of Stay: General trend in reduction of length of stay (3 studies). One study showed a significant reduction in HLOS by 0.8 days.
Discharge to rehabilitation: One study found that exercise participation prior to surgery substantially reduced the odds of discharge to a rehabilitation facility — 38% of patients in the intervention group compared to 65% in the control group.

The authors concluded

There is little evidence that pre-operative physiotherapy brings about significant improvements in patient outcome scores, lower limb strength, pain, range of movement and hospital length of stay following total knee arthroplasty.

Lack of improvement demonstrated from prehabilitation could be explained by the drastic improvement provided by the surgery itself

The Musculoskeletal Elf’s view

It is disapointing that no real improvements have been demonstrated from pre-operative physiotherapy programmes compared to control groups. However it could be postulated that any effects of pre-opertaive physiotherapy are overshadowed by the dramatic improvements that are observed by surgical interventions themselves. The studies included in this systematic review were of moderate quality and many studies had small sample sizes.

What do you think?

Do you provide pre-operative physiotherapy for total knee replacement surgery?
Will the results of this systematic review influence your service delivery?

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Do you know that there is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses? This is called the Preferred Reporting Items for Systematic Reviews and Meta-Analyses or PRISMA statement and can be accessed through the website of the EQUATOR Network. The Elves use the PRISMA statement for critical appraisal of systematic reviews, although it is not a quality assessment instrument to gauge the quality of a systematic review.