The Journal of Arthroplasty xxx (2015) xxx–xxx

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The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org

Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review Iris H.Y. Kwok, BMedSci (Hons), MRCS, MSc , Bruce Paton, Bach Appl Sc (Physiotherapy), Fares S. Haddad, MCh (Ortho), FRCS, Dip Sports Med FFSEM University College London Hospital, London, UK

a r t i c l e

i n f o

Article history: Received 10 February 2015 Accepted 3 April 2015 Available online xxxx Keywords: knee arthroplasty osteoarthritis physiotherapy exercise knee replacement

a b s t r a c t We undertook a systematic review of 11 randomised controlled trials comparing patient outcomes in total knee arthroplasty in those who had undergone pre-operative physiotherapy-based interventions against control groups. Results show that 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. The overall quality of the studies was moderate to poor, mostly due to the small sample sizes. © 2015 Elsevier Inc. All rights reserved.

In the UK, the prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, a quarter of whom are severely disabled [1]. In patients with intractable pain and functional impairment failing conservative management, total knee arthroplasty (TKA) is a successful treatment for reducing pain as well as improving function and quality of life [2–6]. According the National Joint Registry, over 84,000 primary TKAs were performed in the UK in 2012, 58,500 of which were performed in National Health Service (NHS) hospitals. Short-term to medium-term survivorship is excellent across almost all common types of total knee arthroplasties and mortality of the procedure is low, at 0.4% at 90 days after surgery [7]. Despite the success of surgery, functional deficits do remain post-operatively when these patients are compared to age-matched and gender-matched peers with no history of knee pathology. This is particularly noticeable when performing activities of increasing demand requiring quadriceps strength, flexibility and control [8,9]. Several factors have been shown to influence outcomes following TKA. These include pre-operative levels of knee pain, strength, flexibility and functional ability [10–12]. It is therefore hypothesised that preoperative physiotherapy, often known as prehabilitation should improve post-operative outcomes. Prehabilitation is the process of enhancing functional capacity in a patient in order to allow him or her to withstand the stressor of inactivity

associated with an orthopaedic procedure. Fig. 1 illustrates the theory of prehabilitation [13]. A generic prehabilitation programme incorporates the components of warm-up, aerobic exercise, resistance training, flexibility training, proprioceptive training and practising of functional tasks [13]. ‘Physiotherapy’ is a broad term which is often difficult to define. It can refer to and include different treatment modalities such as exercise therapy, manual therapy, soft tissue therapy, electrotherapy and hydrotherapy. In this review, ‘physiotherapy’ refers to exercise therapy alone. The evidence on the efficacy of pre-operative physiotherapy on the post-operative outcomes in TKA has so far been weak or inconclusive. Patients undergoing TKA do not seem to benefit from pre-operative exercise training to the same degree as those undergoing total hip arthroplasty [14]. Several systematic reviews have been carried out looking at prehabilitation on outcomes of hip and knee arthroplasty surgery but few have looked at its effect on TKA in isolation [15–17]. A mini-review was carried out in 2004 for TKA alone but only two RCTs were compared [18]; since then several trials have been published on this topic. The aim of this systematic review was to evaluate the evidence on whether pre-operative physiotherapy improves patient outcomes following TKA. Methods Data Acquisition: Search Strategy

No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.04.013. Reprint requests: Iris HY Kwok, BMBS, BMedSci (Hons), MRCS, MSc, C62 Herbal Hill Gardens, 9 Herbal Hill, London EC1R 5XB, UK.

In June 2014, four computer databases were searched: MEDLINE (1946 to June Week 3 2014), Embase (1980 to 2014 Week 26), CINAHL (1982–2014) and PEDro (Physiotherapy Evidence Database)

http://dx.doi.org/10.1016/j.arth.2015.04.013 0883-5403/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013

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I.HY. Kwok et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

(until June 2014). Searches were limited to human and English studies published in peer-reviewed journals. In order to be included in the review, each trial had to: (1) Be a randomised controlled trial (RCT) or have a quasirandomised design; (2) Be conducted in patients with osteoarthritis undergoing TKA; (3) Compare the pre-operative effects of a physiotherapy-based intervention to a control group; (4) Have an intervention involving a formal physiotherapy or exercise-based programme, not simply education, nor a single physiotherapy session; (5) Have pain and/or functional outcomes assessments made postoperatively. Exclusion criteria for trials included: (1) studies looking at unicompartmental knee arthroplasty and (2) publications where full text was unavailable. Comprehensive search strategies were constructed using subject heading mapping. Combinations of search terms were used in all the databases: ‘knee,’ ‘osteoarthritis,’ ‘replacement,’ ‘arthroplasty,’ ‘knee prosthesis,’ ‘physical therapy,’ ‘physiotherapy,’ ‘preoperative’ and ‘exercise.’ An example of the search on MEDLINE and Embase is shown in Appendix 1. Cross-referencing and hand searches of the reference lists of shortlisted studies were carried out to retrieve additional results. A total of 689 results were retrieved from the initial search. 668 studies were excluded on the basis of the title of abstract, the study content, language or if there were duplications. Of the remaining 21 studies, 10 were excluded as they were of the wrong study type, did not include postoperative outcome measures or were not available in full text. 11 studies met the pre-defined criteria and were used in this systematic review. Fig. 2 illustrates the decision making process in the selection of studies.

could be blinded from the study. Therefore this limits the maximum possible PEDro score to 8. The study by Rodgers et al (1998) used a quasi-randomised allocation for the intervention and control groups, based on geographical feasibility for participation in the physiotherapy programme. Study Characteristics Means and standard deviations (SD) for the outcomes of interest were obtained from each of the studies. The study subject characteristics are summarised in Table 2. The age means between the studies and the male to female ratios were comparable. Interventions The contents of each physiotherapy exercise programme are outlined in Table 3. Components of programmes typically included warm-up, lower limb stretching and strengthening. Three studies included aerobic training [22–24] and three studies included step training [25–27]. Proprioceptive and balance training were used in two studies [28,29]. Six of the programmes had a home exercise component, where the study subjects could carry out the exercises without physiotherapist supervision [25–30]. The duration of the physiotherapy programmes typically lasted 6 weeks but varied between studies, ranging from 3 to 8 weeks. Results Due to the wide variation in the outcome measures used in different trials, it was difficult to aggregate the results from the RCTs for statistical analyses. Some studies did not provide adequate numerical data for results to be combined. The outcomes from each study are summarised in Table 4.

Assessment of Methodological Quality

Summary of Evidence

The criteria used in the PEDro scale were used to assess the methodological quality of the studies [19], based on the original Delphi list developed in 1998 [20,21]. The PEDro scale determines which randomised clinical trials are internally valid and could have sufficient statistical information for their results to be interpretable. Criterion 1 (specification of eligibility criteria) relates to external validity but is not used to calculate the total PEDro score. RCTs scoring 6 or above are considered methodologically to be of moderate to high quality. PEDro scores ranged from 3 to 8, with six studies considered to have good methodological quality (score ≥6/10) (Table 1). The nature of the RCTs reviewed is such that neither the participant nor the therapist

Does Pre-Operative Physiotherapy Improve WOMAC or SF-36 Outcome Scores After TKA? Of the eleven studies that were included in this review, five of them included WOMAC as a self-reported clinical outcome score. None of the five studies showed significant improvement in either the overall WOMAC score, or the individual components of pain, stiffness and function when comparing the treatment and control groups [22,24,28,29,31]. The SF-36 was used in five studies, none of which showed significant improvement between the intervention and control groups. In one study, the intervention group scored significantly higher in the Physical Functioning component of the SF-36 three months post-operatively

Fig. 1. Theoretical model of prehabilitation in patients undergoing TKA [13].

Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013

I.HY. Kwok et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

Score (VAS)). No significant differences were found in pain reduction between intervention and control groups after TKA surgery in all of these studies. Topp et al (2009) reported a significant reduction in pain in both the intervention and control groups, but did not mention whether the difference between the two groups reached statistical significance.

Searched: MEDLINE, Embase, CINAHL, PEDro

689 results Excluded 668 • Based on title or abstract • Study content • Duplications • Not in English 21 studies selected Excluded 10 • Based on study type • Outcome measures • No full text Accepted 11 studies

Fig. 2. Flow diagram illustrating the decision making process in the selection of studies.

(P = 0.04), but none of the other components nor the overall score showed significant difference [25]. Does Pre-Operative Physiotherapy Improve Lower Limb Strength After TKA? Lower limb strength was reported in five studies, expressed either as peak flexion/extension torque or force generated [22–24,27,31]. Quadriceps strength and/or hamstring strength did not show any significance between intervention and control groups post-operatively. One study showed that peak knee flexion strength showed modest gains in the treatment group but not extension strength. However, the strength gains in this intervention group were not seen in the immediate postoperative period but only from 6 weeks to 3 months after surgery. Topp et al (2009) reported that post-operative quadriceps strength was increased in the intervention group compared to their preoperative baseline. They also had a significant improvement in performance in all of the functional tasks apart from the 6-minute walk. Does Pre-Operative Physiotherapy Improve Pain After TKA? Pain was reported in eight studies, either as a component of one of the outcome scores (e.g. WOMAC, SF-36, or as a pain Visual Analogue

Table 1 Methodological Quality of Included RCTs. Study

D’Lima et al (1995) Rodgers et al (1998) Beaupre et al (2004) Rooks et al (2006) Williamson et al (2007) Evgeniadis et al (2008) Topp et al (2009) Gstoettner et al (2011) Brown et al (2012) McKay et al (2012) Matassi et al (2014) Number of Studies Fulfilling Criteria

3

PEDro Scores 1

2

3

4

5

6

7

8

9

10

11

Total

1 1 1 1 1 1 1 1 0 1 1 10

1 0 1 1 1 1 1 1 1 1 1 10

0 0 1 0 1 1 0 1 1 1 0 6

1 0 1 1 1 1 1 1 0 1 1 9

0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0

0 0 1 0 1 0 0 0 0 0 1 3

0 1 0 0 1 0 1 1 0 0 1 5

0 0 1 1 1 1 0 0 0 1 0 5

0 1 1 1 1 1 0 1 1 1 1 9

1 1 1 1 1 1 1 1 1 1 1 11

3 3 7 5 8 6 4 6 4 6 6 –

PEDro criteria: 1. Specification of eligibility criteria. 2. Random allocation. 3. Concealed allocation. 4. Baseline similarity between groups. 5. Subject blinding. 6. Therapist blinding. 7. Assessor blinding. 8. N85% follow-up. 9. Intention-to-treat analysis. 10. Between-group statistical comparison. 11. Point measures and measures of variability reported.

Does Pre-Operative Physiotherapy Improve Knee ROM After TKA? Range of movement was reported in four studies [22,23,30,31]. None of these demonstrated any significant differences in active or passive range of movement between the intervention and control groups post-operatively. However, in the study by Matassi et al (2014), 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). Does Pre-Operative Physiotherapy Affect Hospital length of Stay After TKA? Hospital length of stay (HLOS) was reported in four studies [26,29,31,32]. Of these, only the study by Matassi et al (2014) showed a significant reduction in HLOS by 0.8 days. The other three studies showed a reduction in HLOS in the intervention group that did not reach statistical significance, ranging from 0.1 to 1.5 days [29,31,32]. Interestingly, Rooks et al (2006) 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. Discussion The overall quality of evidence for pre-operative physiotherapy on outcomes following TKA was moderate to poor. Only six out of the 11 studies reviewed were of good methodological quality according to the PEDro score. In terms of study design, one of the major limitations of the RCTs reviewed was the very small sample sizes used. The numbers of subjects in some studies were as low as 10 patients per treatment arm [22,23,32]. The results from these studies were therefore not adequately powered. Even with studies adequately powered for clinical outcomes, the sample sizes were still inadequate for health service costing measures. Geographical constraints are an important consideration when a single-site intervention is used. Five studies in this review did not use a home exercise programme and involved patients travelling to the physiotherapy-providing facility on a frequent and regular basis. This can introduce selection bias to study participants and can lead to a low overall recruitment rate for trials. Non-participation is often seen in elderly, rural-dwelling patients with restricted transportation options [22]. Although very few studies reported their participant dropout rates, geographical constraints may have contributed to non-completion of prehabilitation programmes. For future trials, convenience of the location of intervention and outcome testing ought to be an important consideration [24]. Most interventions involved multi-modal physiotherapy, encompassing a combination of different types of exercises – warm-up, aerobic exercise, resistance training, flexibility training, proprioceptive training and practising of functional tasks – with or without patient education. However, the components of exercise programmes were very variable in different studies, with one utilising proprioceptive training only [28] and another four which did not include aerobic exercise training [29–32]. As there is little evidence as to which types of exercise are most effective in bringing about improvements in post-operative outcomes, a combination approach may dilute out the impact of more effective elements. In the studies reviewed, little information had been given on exercise intensity and dosage. Percentage of VO2 peak in aerobic training or torque per body weight in strength training is a useful measure of exercise dosage. However these measurements require specialist equipment and may be costly to carry out. Rate of perceived exertion (RPE) is

Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013

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I.HY. Kwok et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

Table 2 Study Subject Characteristics. Surgery Type D’Lima et al (1995) USA

Primary unilateral TKR

Rodgers et al (1998) USA Beaupre et al (2004) Canada Rooks et al (2006) USA

Primary unilateral TKR Primary TKR Primary unilateral TKR Primary unilateral THR

Williamson et al (2007) UK

Primary KR (unicondylar or total)

Evgeniadis et al (2008) Greece

Primary TKR

Topp et al (2009) USA Gstoettner et al (2011) Austria Brown et al (2012) USA McKay et al (2012) Canada Matassi et al (2014) Italy

Unilateral TKR

a

Unilateral TKR TKR Unilateral TKR Primary unilateral TKR

Group Intervention A Intervention B Control Intervention Control Intervention Control Intervention Control Interventiona Controla Intervention A Intervention Ba Control Intervention A Intervention Ba Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control

n

Age Mean (SD)

Sex % Female

10 10 10 10 10 65 66 22 23 32 31 60 60 61 18 15 20 26 28 18 20 17 15 10 12 61 61

68.5 (4.6) 71.6 (6.6) 69.5 (6.5) 70 (range 63–78) 65 (range 50–83) 67 (7) 67 (6) 65 (8) 69 (8) 65 (11) 59 (7) 70 (8.8) 72.4 (7.7) 69.6 (10) 67.1 (4.4) 68.6 (5.9) 69.4 (1.9) 64.1 (7.1) 63.5 (6.7) 72.8 (range 65–78) 66.9 (range 61–75) – – 63.5 (4.9) 60.6 (8.1) 66 (7.2) 67 (7.7)

70 20 50 60 50 60 50 50 57 63 52 52 55 54 83 87 70 68 68 89 70 – – 50 67 54 43

Had additional experimental groups which were not included in the current review.

a simple and effective means of measuring exercise intensity and should be measured in future studies. Pain, swelling and joint stiffness from osteoarthritis limit the exercise intensity attained by patients. Therefore patients may be unable to work at sufficient levels of intensity to bring out strength improvements and tissue change. In the RCTs reviewed, there was no mention of the types and quantity of analgesia consumed prior to physiotherapy sessions and when clinical measurements were made; analgesic heterogeneity may lead to variability and inconsistency in results. In future studies, this could be taken into account by standardising or recording the amount of analgesia received by the participants in the previous 24 hours. Physiotherapy exercises tend to use closed-chain isotonic exercises whereas strength testing in these studies often utilised open-chain isokinetic measurements using the Cybex isokinetic testing device. The principle of specificity of training is key when choosing appropriate

outcome measurement tools. Functional task performance varies depending on the muscle group utilised and the movement patterns performed [33,34]. Inconsistencies between prehabilitation and strength measurement procedures mean that significant differences in strength may have been present but not detected or measured [22,23,27]. Lower limb strength is often measured by different methods; a leg press replicates a more functional movement than leg extension alone. The former incorporates hip and knee movement, and does not isolate quadriceps muscle strength like leg extension does. It is therefore more accurate a reflection of the ability to carry out daily functional activities. Often exercise programmes do not work to reach evidence-based levels of intensity and duration to bring about fitness change in the elderly. The American College of Sports Medicine guidelines currently recommend resistance training three times a week, with each session approximately 30 minutes in duration in order to bring about

Table 3 Content and Design of Interventions. Programme Used D’Lima et al (1995) Rodgers et al (1998) Beaupre et al (2004) Rooks et al (2006) Williamson et al (2007) Evgeniadis et al (2008) Topp et al (2009) Gstoettner et al (2011) Brown et al (2012) McKay et al (2012) Matassi et al (2014)

Lower limb stretching Lower limb isometric and isotonic strengthening Lower limb stretching, warm-up, strengthening, aerobic — customised Lower limb mobility, warm-up, strengthening Water and land-based exercise Aerobic, strengthening and stretching — customised Lower limb strengthening, balance training, functional exercises — group session Trunk and upper extremity strengthening Lower limb strengthening, stretching and step training Proprioceptive training Warm-up, strengthening, stretching and step training — individualised if unable to progress Warm-up, aerobic, quadriceps strengthening Lower extremity strengthening, stretching and step training

Duration of Programme

No. of Sessions

6 weeks

18

6 weeks

18

4 weeks 6 weeks

12 18

6 weeks

6

Session Duration 45 mins

Frequency

Supervised?

3×/wk

Yes

3×/wk

Yes

b30 mins 30–60 mins

3×/wk 3×/wk

Yes Yes

60 mins

1×/wk

No

?

3 weeks Variable 6 weeks 8 weeks

9 Variable 6 24

? ? 45 mins 50 mins

3×/wk 3×/wk 1×/wk 3×/wk

No No No No

6 weeks 6 weeks

18 30

30 mins ?

3×/wk 5×/week

Yes Yes

Mins = minutes, ×/wk = times per week,? = unspecified.

Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013

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Table 4 Summary of Study Results. Assessment Points D’Lima et al (1995)

6 weeks, 1 week pre-op Post-op: 3 weeks, 12 weeks, 24 weeks, 48 weeks

Rodgers et al (1998)

Baseline for intervention group only Both groups: pre-op, 6 weeks post-op and 3 months post-op

Outcome Measures

Beaupre et al 6 weeks pre-op (2004) Post-op: 3 months, 6 months, 12 months

Rooks et al (2006)

Pre-intervention (within 7 days), pre-op Post-op: 8 weeks, 26 weeks

Williamson et al (2007)

Pre-op Post-op: 7 weeks, 12 weeks, 3 months

Evgeniadis et al (2008) Topp et al (2009)

4 weeks pre-op, 1 day pre-op Post-op: 1 day, day of discharge, 6 weeks, 10 weeks, 14 weeks Baseline: at least 4 weeks pre-op, 1 week pre-op Post-op: 1 month, 3 months

Gstoettner et al (2011)

6 weeks pre-op, 1 day pre-op (intervention group only) Post-op: 6 weeks

Brown et al (2012)

Post-op: 3 months

McKay et al (2012)

Pre-op Post-op: 6 weeks, 12 weeks

Matassi et al (2014)

6 weeks pre-op, 1 day pre-op Post-op: 6 weeks, 6 months, 1 year

HSSKR AIMS QWBS HLOS HSSKR Knee ROM Isokinetic knee strength Thigh circumference Walking speed Thigh muscle area on CT WOMAC SF-36 Knee ROM Quadriceps and hamstring strength HLOS WOMAC SF-36 1-rep max Functional reach Timed up and go Discharge location OKS WOMAC Pain VAS HAD 50-m timed walk HLOS SF-36 ILAS Active ROM 6-minute walk Sit-to-stand repetitions in 30 secs Ascending and descending stairs (22 steps) Quadriceps strength Pain VAS for each functional task Balance test Gait speed WOMAC KSS SF-36

Isometric quadriceps strength WOMAC SF-36 Arthritis self-efficacy Knee ROM Knee Society Clinical Rating System HLOS

Results: Difference in Group Means [Intervention − Control] (95% CI) HSSKR: 3 (−7 to 13.1) AIMS % improvement: 6% (no CI) QWBS % improvement: −9% HLOS: 0.21 days longer (−0.7 to −1.2) HSSKR: 2 (no CI) Knee ROM: −2 in degrees extension, −4 degrees flexion (no CI) Peak knee strength at 60 degrees: 1 ft-lb in flexion, −3 ft-lb in extension (no CI) Thigh circumference: 1 cm (no CI) Walking speed: 1 sec longer (no CI) Thigh muscle area: 3.9 cm3 (no CI) WOMAC pain: 2 (−3.6 to −7.6), stiffness: −4 (−11.5 to −3.5), function 0 (−5.8 to −5.8) SF-36 physical component score −3 (−6.5 to −0.5), mental component score −2 (−5.0 to −1.0) Knee ROM −4 (−10.1 to −2.1) Quadriceps strength 9 (−2.4 to −4.4) Hamstring strength 0 (−2.7 to −2.7) HLOS −1.5 WOMAC function: 8.5 (1.4–16.6), pain 0.1 (−1.7 to −1.9) SF-36 physical function: 1.9 (−16.1 to −19.9), pain 3.1 (−14.1 to −20.3), role limitation physical 12.8 (−19.4 to −45.0) 1-rep max: 18 kg (−16.8 to −52.9), exercise group 20% increase in muscle strength Functional reach: 1.3 cm (−4.5 to −7.1) Timed up and go: −1.6 secs (−4.3 to −1.1) Discharge to rehabilitation: 38% in intervention group compared to 65% in control group OKS: 1.61 (−3.9 to −7.1) WOMAC: 1.33 (−9.5 to −12.2) Pain VAS: −0.09 (−1.7 to −1.5) HAD: anxiety, depression 50-m timed walk: 2.51 secs (−3.5 to −8.5) HLOS: −0.12 (−1.1 to −1.8) SF-36: no significant differences in all eight health domains. ILAS: total score −0.07 (−0.4 to −0.3) AROM: no significant differences in hip, knee or ankle 6-minute walk −28 m (−58.6 to −2.6) Sit-to-stand 1.6 repetitions (1.2–2.1)

Ascending stairs: 0.99 secs (0.6–1.4) Descending stairs: 0.54 secs (−0.1 to −1.1) Maximum quadriceps extension strength: 1.5 torque/body wt (−1.2 to −4.2) Pain VAS: both intervention and control groups showed reduction in all measures of pain Balance test: OSI −0.7 (−1.2 to −0.2), APSI −0.6 (−0.9 to −0.3), MLSI −0.3 (−0.7 to 0.1) Gait speed: 60 m 5.0 secs (−4.3 to −14.3), stairs up 3.8 secs (−3.6 to 11.2), stairs down 4.2 secs (−5.1 to −13.5) WOMAC: pain 0.32 (−0.4 to −1.0), stiffness 0.4 (−0.6 to −1.4), function −0.7 (−1.4 to −0.0) KSS: 1.9 (−10.2 to −14.0), KSS function: 0.4 (−9.7 to −10.5) SF-36: Physical functioning t = 2.3 (P = 0.04), Role-physical t = 1.0 (P = 0.33), Bodily pain t = 1.2 (P = 0.23), General health t = 1.0 (0.33), Vitality t = 0.04 (P = 0.97), Social functioning t = 1.4 (P = 0.18), Role-emotional t = 1.6 (P = 0.13), Mental health t = 0.01 (P = 0.99) Quadriceps strength: 0.03 NM/kg (−0.4 to −0.4) Mobility: 50-ft walk −0.02 secs (−3.9 to −3.9), stair test 4.8 secs (−12.8 to −22.4) WOMAC: pain 0.82 (−2.7 to −4.3), function −1.2 (−13.5 to −11.1) SF-36: PCS 6.4 (−2.4 to −15.7), MCS −3.4 (−18.5 to −11.62) Arthritis self-efficacy: 11.5 (−9.3 to −32.4) Knee ROM: days to achieve 90 degrees −1.1 (−1.8 to −0.38) Passive knee flexion insignificant (no figures) Active knee flexion insignificant (no figures) Evolution of knee extension significant (P = 0.032) Knee Society Clinical Rating System insignificant (no figures) HLOS: −0.8 (−1.6 to −0.01)

HSSKR: Hospital for Special Surgery Knee Rating (0–100 scale, 100 = perfect score). AIMS: Arthritis Impact Measurement Scale (0–30 scale, 0 = perfect score). QWBS: Quality of Wellbeing Scale (0.00–1.00 scale, 1.00 = perfect score). HLOS: hospital length of stay. WOMAC: Western Ontario and McMaster Universities Arthritis Index (0 = best, 100 = worst). SF-36: Short form-36 Health Survey. OKS: Oxford Knee Score. Pain VAS: Pain Visual Analogue Scale (0 = best, 100 = worst). HAD: Hospital Anxiety and Depression score. ILAS: Iowa Level of Assistance Scale (0–50, demerit system). KSS: Knee Society Score (0 = worst, 100 = best). Arthritis Self-Efficacy Scale. Knee Society Clinical Rating System (0 = worst, 100 = best).

Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013

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improvements in overall health and fitness capacity in the older adult. For aerobic training, the ACSM recommends an exercise intensity of 60–90% of maximum heart rate, 20 to 60 minutes at 3 to 5 days a week [35]. The duration and intensity of exercise programmes were highly variable between the studies reviewed. Funding constraints tended to limit the duration of physiotherapy programmes to 6 weeks or less. The study by Evgenias et al (2008) and Beaupre et al (2004) only lasted three weeks and four weeks respectively, which is below the recommended duration to bring about any improvements in lower limb strength [36]. Many patients requiring TKA are chronically deconditioned and suffer from other medical comorbidities. As they are ‘undertrained,’ a few weeks of exercise training may be insufficient for the patient to reap the benefits of prehabilitation [29]. However, longer prehabilitation programmes require more commitment and patience, and may incur an increased cost (e.g. travel expenses) on the elderly patient. This could lead to non-participation as well as increased dropout rates. Compliance and adherence to physiotherapy sessions were variable and generally poorly reported in the studies reviewed. Some patients may have decided to drop out of the intervention programme as soon as they experienced a small amount of improvement. The number of exercise sessions attended by participants should ideally be standardised as there might be a dose-response effect depending on the quantity and intensity of intervention received. Pre-operative patient expectations are an important predictor of post-surgical functional outcome and satisfaction [37]. As the patients have voluntarily agreed to participate in the RCTs, the studies reviewed lend themselves to an inherently self-selected population where a degree of motivational bias may exist, with participants having a positive expectation in prehabilitation. It can also alter their perception of the degree of control and self-efficacy they have over their care during the peri-operative period [25]. Similarly, patients randomised to the control group may have covertly taken up more physical activity outside the study protocol than they otherwise would have [27]. These are often difficult to control or account for in the trials. HLOS has cost implications to the health service, and was one of the outcomes measured in several studies. However, a previous study showed that predictors of LOS in patients following TKA included age, gender, marital status, the use of walking aids, day of the week of surgery, blood transfusion requirements and medical co-morbidities by ASA grade [38]. Apart from the use of walking aids, it is unlikely that any of the other predictors can be modified by pre-operative physiotherapy programmes. The lack of improvement demonstrated from prehabilitation in TKA patients could be explained by the drastic improvement provided by the surgery itself, such that it overshadows the relatively minor benefit of pre-operative physiotherapy. An alternative possibility is that patients are deconditioned so significantly from the surgery such that any benefits gained from prehabilitation are lost [32]. Overall, patients undergoing TKA do not benefit from pre-operative exercise training in the same way as those undergoing total hip arthroplasty, in terms of post-operative functional outcome, pain, and hospital LOS, all of which is in keeping with the current literature [14,16,17]. There are currently few good quality studies on this topic, but the current review has shown that there is little evidence to indicate that pre-operative physiotherapy brings about significant improvements following TKA. A structured physiotherapy programme in a monitored environment should improve compliance to be compared to home exercise regimes [31]. However, as the evidence in the current literature in supporting prehabilitation before TKA is limited future programmes may have to consider more cost-effective and less resource-intensive approaches to prepare patients for TKA surgery. For example, patient instructional leaflets or videos for home exercise programmes, combined with a single exercise training session can be considered. Future research should

also focus on the optimal components of a pre-operative physiotherapy programme, including exercise types, duration, frequency and intensity of sessions. Appendix 1. Example of search on MEDLINE and Embase 1. Osteoarthritis 2. Osteoarthritis, Knee 3. Osteoarthritis.mp. 4. Knee Prosthesis/ or Knee/ or Knee Joint 5. Knee.mp. 6. 1 or 2 or 3 or 4 or 5 = 328,894 studies

7. preop*.mp. 8. periop*.mp. 9.presurgery.mp. 10. 7 or 8 or 9 = 639,946 studies

11. arthroplasty.mp. or Arthroplasty, Replacement, Knee/ or Arthroplasty, Replacement/ or Arthroplasty/ 12. “total knee”.mp. 13. 11 or 12 = 112,572 studies

14. Physical Therapy Modalities/ or physical therapy.mp. 15. Physical Therapy Specialty/ 16. physiotherapy.mp. 17. exercise therapy.mp. or Exercise Therapy/ 18. physiotherap*.mp. 19. 14 or 15 or 16 or 17 or 18 = 157,000 studies

20. 6 and 10 and 13 and 19 = 544 studies

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Please cite this article as: Kwok IHY, et al, Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? — A Systematic Review, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.04.013