Preoperative proprioceptive training in patients with total knee arthroplasty

Feasibility and acceptability of a telerehabilitation intervention on patients undergoing total knee arthroplasty in Iran: randomised controlled trial protocol

INTRODUCTION

Telerehabilitation is a promising avenue to enhance post-total knee arthroplasty (TKA) rehabilitation by improving accessibility, convenience and cost-effectiveness. Despite its potential benefits, its application in the context of TKA in Iran is in its early stages, lacking comprehensive studies on feasibility, acceptance and programme adherence. This article outlines a protocol for an open-label, parallel-group, randomised controlled trial investigating the impact of a 4 week telerehabilitation programme alongside usual care.

METHODS

Thirty patients (aged 50-90) undergoing TKA for severe Knee Osteoarthritis at Atiyeh Hospital in Tehran, Iran, will be recruited using block randomisation. Participants will be assigned to either the intervention group, receiving telerehabilitation or the control group without telerehabilitation. The intervention will include virtual physiotherapy sessions thrice weekly, lasting 30-45 min each, over 4 weeks. The primary objective is to assess the feasibility and acceptability of telerehabilitation, measured through recruitment and attrition rates, questionnaire completion rates, patient satisfaction using appropriate questionnaire and adherence to the intervention. Secondary outcomes encompass four Knee Injury and Osteoarthritis Outcome Score questionnaire subscales (function in Activities of Daily Living, Pain, Symptoms, Quality of Life). Patient global assessment will use a standardised question. An online survey will evaluate walking assistant device usage, exercise adherence and adverse events. The number of individuals receiving in-person rehabilitation will be documented after the first postoperative surgeon visit. Assessments occur at baseline and 4 weeks postsurgery.

ANALYSIS

Statistical analysis, including independent samples t-test, paired samples t-test, χ2 test, Fisher's exact test, analysis of covariance and multiple linear regression, will use SPSS software version 16, with significance set at p<0.05.

ETHICS AND DISSEMINATION

Approved by AJA University of Medical Sciences Ethics Committee (IR.AJAUMS.REC.1402.126), trial results will be presented to relevant groups and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

TCTR20231020004.

Mind-Body Intervention for Diabetic Neuropathy: A Pilot Study on Yoga's Effects on Muscle Strength, Proprioception, Fear of Falling, Pain, and Quality of Life

OBJECTIVE

The aim of this study was to investigate the effects of an 8-week yoga intervention on muscle strength, proprioception, pain, concerns about falling, and quality of life in individuals diagnosed with diabetic neuropathy.

METHODS

A quasi-experimental design incorporating a pretest-posttest methodology and a control group was implemented in the present study. A total of 30 patients who were diagnosed with type 2 diabetes and neuropathy were recruited and randomly assigned to intervention (n = 15) or non-exercise control (n = 15). Yoga sessions were conducted for a duration of 60 min on three occasions per week, with participants requested to practice at home on other days.

RESULTS

The results showed significant main effects of time on the muscle strength (both flexor and extensor muscles, p < .001, ηp2 = 0.652 and p < .001, ηp2 = 0.539, respectively), proprioception error (p < .001, ηp2 = 0.807), pain intensity (p < .001, ηp2 = 0.538), concerns about falling (p < .001, ηp2 = 0.700), and overall score of quality of life (p < .001, ηp2 = 0.475). Moreover, there were significant group-by-time interactions for all variables (p < .001 for all).

CONCLUSION

The study reveals that yoga intervention can be an effective alternative therapeutic approach to medication for individuals with diabetic neuropathy. Yet, future studies are needed on a larger sample size to strengthen the present understanding of the advantageous impact of yoga intervention in this population.

What are the novel rehabilitation methods in knee arthroplasty? A bibliographic review

BACKGROUND

Total knee arthroplasty (TKA) is a common procedure for treating end-stage degenerative knee osteoarthritis (OA). Despite the generally excellent outcomes, postoperative complications such as loss of muscle strength and joint limitation can occur. Therefore, postoperative physical rehabilitation is crucial for regaining strength, functionality, and managing pain. Various rehabilitation strategies employ different methods to reduce pain severity, regain muscle strength, assist patients in returning to daily activities, and increase functionality. In recent years, technological advancements have transformed rehabilitation methods. In addition to traditional applications, new methods have been incorporated into treatment plans.

OBJECTIVE

This study aimed to evaluate novel physical rehabilitation methods and options following OA.

METHODS

A literature review was conducted to identify and investigate recent and commonly used novel rehabilitation methods. The search terms "Total Knee Arthroplasty," "New Rehabilitation TKA," "Novel Rehabilitation" "Novel Rehabilitation in Arthroplasty" and "Technology Knee Rehabilitation" were searched across PubMed and Google Scholar databases, covering literature from the past 15 years. Studies on telerehabilitation, functional electric stimulation, virtual reality, yoga, and their reported outcomes were evaluated using specific keywords. The results of various studies on novel rehabilitation methods were gathered and compared to traditional treatment plans based on functionality and applicability.

RESULTS

Several studies reported that telerehabilitation was not inferior to traditional rehabilitation, with some showing positive outcomes. Telerehabilitation following TKA demonstrated positive effects on functionality and patient satisfaction. Functional electric stimulation showed significant improvements in muscle strength and pain reduction. Virtual reality demonstrated superior effects on proprioception and posture outcomes. The use of yoga in rehabilitation also resulted in improved proprioception and pain reduction.

CONCLUSION

In addition to traditional rehabilitation methods, new approaches have shown significant positive outcomes for patients who have received TKA. We are in an era of digital development, and as such, new rehabilitation techniques, particularly those involving digital advancements, will continue to emerge. With the trend toward personalized approaches in medicine, more new techniques or methods will be incorporated into rehabilitation plans, leading to better recovery outcomes from TKA.

Cost, time savings and effectiveness of wearable devices for remote monitoring of patient rehabilitation after total knee arthroplasty: study protocol for a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is a surgical procedure primarily used to treat patients with end-stage knee osteoarthritis (KOA). Postoperative physical exercise is a critical part of the overall treatment of KOA and can bring significant benefits to the patients' recovery. Wearable devices can monitor patients' exercise data and upload it to the physician's workstation. This allows the rehabilitation physician to make timely adjustments based on the patients' movement feedback, and the surgeon can be informed of the patients' functional status. Overall, this study aims to evaluate the effectiveness of using wearable monitoring devices for rehabilitation exercise after TKA, with a focus on cost, time savings, and patient outcomes.

METHOD/DESIGN

This is a single-center, single-blinded, parallel randomized controlled trial conducted at Xi'an Honghui Hospital, a regional orthopedic medical center. Eligible patients will be recruited to participate in the study, and baseline data collection and clinical assessments will be conducted at the time of admission. Using the principle of random allocation, recruited patients will be divided into either the experimental or control group. Both groups will undergo a standard, widely promoted rehabilitation program. The patients in the experimental group will wear equipment to detect and track mobility in the lower limbs. All patients will return to the outpatient clinic for follow-up assessments at 2 weeks, 12 weeks, and 24 weeks after discharge, where outcome indicators will be measured. The primary outcome will be the cost and time after discharge, while secondary outcomes will include the 6-min walk test (6MWT), range of motion (ROM), visual analog scale (VAS), American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

DISCUSSION

We should encourage the adoption of novel, easy-to-use, supervised devices if they prove to be beneficial for patients in terms of cost, time, and effectiveness after TKA. This type of device is particularly important for people in remote rural areas, those with limited financial resources, and those who are reluctant to return to hospitals for follow-up care. Trial registration Chinese Clinical Trial Registry ChiCTR2300068418. Registered on 17 February 2023.

Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis

Importance

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.

Objective

To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.

Data Sources

Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.

Study Selection

Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.

Data Extraction and Synthesis

Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Pain, function, muscle strength, and health-related quality of life (HRQOL).

Results

Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

Effects of Neuromuscular Training on Physical Performance in Older People: A Systematic Review

This systematic review aimed to assess the available evidence on the effects of neuromuscular training on physical performance in older adults. A literature search was conducted across four databases (Psychology and Behavioral (EBSCO), Scopus, Web of Science and PubMed). The PRISMA guidelines were followed. The PEDro scale and Cochrane risk of bias tool were used to assess the quality of and risk of bias in the studies, respectively. The protocol was registered in PROSPERO (code: CRD42022319239). The outcomes were muscle strength, cardiorespiratory fitness, postural balance and gait speed. From 610 records initially found, 10 were finally included in the systematic review, involving 354 older people with a mean age of 67.3 years. Nine of them reported significant changes in at least one variable related to physical performance in the intervention compared to the control groups. The neuromuscular training caused significant improvements in postural balance, flexibility, cardiorespiratory fitness, strength power of the upper and lower limbs and autonomy. The available evidence indicates that neuromuscular training has a positive effect on some variables of physical performance, especially in postural balance; however, the methodological quality and certainty of the evidence in the available literature are limited. Therefore, a greater number of high-quality studies are required to draw definitive conclusions.

Effect of Combined Kinematic Chain Exercise on Physical Function, Balance Ability, and Gait in Patients with Total Knee Arthroplasty: A Single-Blind Randomized Controlled Trial

Total knee arthroplasty (TKA) is an effective treatment for end-stage osteoarthritis. However, evidence of combined kinematic chain exercise (CCE) in early-phase rehabilitation after TKA remains lacking. This study investigated the effects of CCE training on physical function, balance ability, and gait in 40 patients who underwent TKA. Participants were randomly assigned to the CCE (n = 20) and open kinematic chain exercise (OKCE) groups (n = 20). The CCE and OKCE groups were trained five times a week (for 4 weeks) for 30 min per session. Physical function, range of motion (ROM), balance, and gait were assessed before and after the intervention. The time × group interaction effects and time effect as measured with the Western Ontario and McMaster Universities Osteoarthritis Index, ROM, Knee Outcome Survey-Activities of Daily Living, balancing ability (e.g., confidence ellipse area, path length, and average speed), and gait parameters (e.g., timed up-and-go test, gait speed, cadence, step length, and stride length) were statistically significant (p < 0.05). In the group comparison of pre- and postintervention measurements for all variables, the CCE group showed substantial improvements compared to the OKCE group (p < 0.05). Both groups showed significant within-group improvement from baseline to postintervention. Our results suggest that CCE training positively affects physical function, balance ability, and gait as an early intervention for patients undergoing TKA.

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Does preoperative physiotherapy improve outcomes in patients undergoing total knee arthroplasty? A systematic review

OBJECTIVE

To systematically review the scientific literature and to investigate the effectiveness of preoperative rehabilitation on subjective and objective outcomes after total knee arthroplasty (TKA) when compared with patients in a control group.

DATA SOURCES

A search was conducted in PubMed, PubMed Central, Embase, Cochrane Library and Physiotherapy Evidence Database databases in May 2021.

STUDY SELECTION

randomized controlled trials (RCTs) were reviewed if they compared a preoperative physiotherapy exercise intervention with no intervention group for patients undergoing TKA for severe Osteoarthritis (OA). A total of 24 RCTs were included at the end of the evaluation process. By the end of the evaluation process, a total of 24 RCTs were included.

DATA EXTRACTION

Two authors independently screened the literature, extracted data, and assessed the quality of included studies. The outcomes were knee extension, knee flexion, pain Visual Analogue Scale (VAS), overall Western Ontario and McMaster Universities OA Index, 6 min walking test, and Timed Up and Go test.

RESULTS

The majority of the studies included in this systemic review demonstrated a comparable trend of long-term postoperative improvement of knee extension strength, VAS, range of movement and functional scores, and those of quality of life between two groups. Many studies showed a significant improvement in terms of preoperative pain, length of hospital stay and functional performance shortly after the operation, but all studies failed to show a prolonged effect on knee motion or patient function between 3 and 12 months.

CONCLUSIONS

Low to moderate evidence from mostly small RCTs demonstrated that preoperative physiotherapy interventions reduce pain and improve functional performance for patients with knee OA prior shortly after the TKA.

The effects of preoperative rehabilitation on pain and functional outcome after total knee arthroplasty: a meta-analysis of randomized controlled trials

Background

There have been controversial findings for the effectiveness of rehabilitation before operation after total knee arthroplasty (TKA). This study aimed to conduct an updated, comprehensive systematic review. On that basis, the review was to be combined with meta-analysis to measure the effects of rehabilitation before operation on functions and pain after TKA.

Methods

Articles were searched by using Central Register of Controlled Trials (CENTRAL), Web of Science, EMBASE, Cochrane, Pubmed, CNKI, Wanfang, Weipu and the Chinese Biomedical Database from the beginning to December 10, 2021. The major outcomes included pain, knee flexion and extension, as well as knee range of motion (ROM). Secondary outcomes included timed-up-and-go (TUG), 6-min walk, and patient-reported functional outcome (the Knee Injury and Osteoarthritis Outcome Score (KOOS) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)). Third outcomes included the length of hospital stay.

Results

Nineteen studies recruiting 1008 patients satisfied with the inclusion criteria. Significant difference was identified in knee flexion, TUG, KOOS (knee-associated life quality and functions in sports and recreation), as well as the length of hospital stay (P < 0.05). Insignificant statistical difference was identified in pain, 6-min walk, ROM, knee extension, KOOS (pain, symptoms and function of daily living) after TKA between the two groups. No difference was found between the groups in WOMAC.

Conclusions

Preoperative rehabilitation could significantly shorten hospital stay, whereas there is not any conclusive evidence of the improvement of postoperative functions. Accordingly, in-depth high-quality studies should be conducted to confirm the effectiveness of preoperative rehabilitation in patients having received TKA.

A Systematic Review and Meta-Analysis on Randomized Control Trials for Preoperative Rehabilitation in Patients Planning for Joint Replacement Surgery for Better Outcomes

Background

The clinical influence of the preoperative and postoperative therapies for recovery after the joint replacement surgery is still questionable. This study of systematic review and meta-analysis focuses on analyzing the clinical effects of preoperative rehabilitation among the patients who are planning to opt for joint replacement surgery for enhanced results.

Objective

Randomized clinical trials were selected where preoperative therapeutic exercises were performed by adults for preoperative rehabilitation in patients who were planning for replacement surgery for better outcomes and identified through databases and screening. Two reviewers were responsible for extracting appropriate studies, relevant data, assessing the risks, therapeutic validity, etc. Material and Methods. We performed random-effects meta-analysis for calculation of risk ratios and odds ratios, for knee and hip surgery cases. Analysis of length of hospital stay, short-term-based recovery period during hospital stay, total hip replacement functional recovery during hospital stay, short-term recovery of self-reported functioning, etc. was performed.

Results

Functional scores, postoperative pain, recovery time, length of hospital stay, and quality of life were studied. Of the seven studies included, the data of 614 patients were studied. The total number of participants in both exercise and control groups was analyzed to assess the bias of the study where the risk ratio was 0.96 and (0.74–1.25) was the 95% CI. Short-term-based recovery period during hospital stay for knee replacement was analyzed where 0.87 was the risk ratio and (0.61–1.23) was the 95% CI and for hip replacement where 0.99 was the risk ratio and (0.68–1.44) was the 95% CI. The RR for total hip replacement functional recovery during hospital stay was 0.80 with 95% CI (0.54–1.19). The RR for short-term recovery of self-reported functioning was 0.98 with 95% CI (0.76–1.26). Outcome analysis for pain and functionality evaluation was performed and assessed using WOMAC, HOOS, and HHS scores where the standardized mean difference was 0.38 and (0.20–0.57) was the 95% CI in hip surgery pain analysis and in knee surgery, 0.00 was the standardized mean difference and (−0.18–0.19) was the 95% CI.

Conclusion

Long-term outcomes were not affected by the preoperative rehabilitation. Though there was a slight improvement in early postoperative pain, this is not much of clinical significance.

Do Preoperatıve IL-1beta, IL6 and TNF-Alpha Levels of Patients Who Underwent Total Knee Arthroplasty Surgery Affect The Postoperative Functional and Structural Results?

Amaç: Serum sitokinleri osteoartritin semptomalrı ve progresyonu ile ilişkilidir. Bu sitokinlerin Total Diz Artroplastisi (TDA) sonrası semptomların şiddeti üzerinde tahmin edici etkisinin olup olmadığı bilinmemektedir. Bu çalışma cerrahi öncesi serum sitokin seviyelerinin (SSS) hastanede kalış, cerrahi sonrası ağrı şiddeti, fonksiyonel durum, eklem pozisyon hissi ve X-ray deki değişim üzerine etkisini göstermek amacıyla gerçekleştirildi. Yöntem: Evre 4 osteoartriti olan yirmi dokuz hasta çalışmaya dahil edildi. Hastalar total diz artroplastisi cerrahisi için hastaneye yatırıldı. Cerrahi öncesi SSS (IL6, TNF-alfa, IL-1beta) değerlendirildi. İstirahat/aktivite ağrı şiddeti ve alt ekstremite dizilim düzgünlüğü cerrahi öncesi, cerrahi sonrası 72. saat ve 6. haftada değerlendirildi. Fonksiyonel durum ve eklem pozisyon hissi cerrahi öncesi ve cerrahi sonrası 6. haftada değerlendirildi. Hastane kalış süresi kaydedildi. Sonuçlar: Bireylerin yaş ortalaması 67,55±6,55 yıldı. Hastane kalış süresi ortalaması 6.48±3.06 gündü (en düşük:3-en yüksek:16 gün). Cerrahi öncesi IL6 ve TNF-alfa seviyeleri 6. haftada fonksiyonel durum ile negatif yönde koreleydi (r=0,46;p=0.01,r=0,39;p=0,03). Ayrıca, cerrahi öncesi TNF-alfa ve alt ekstremite dizilim düzgünlüğü arasında pozitif korelasyon vardı (r=0,39; p=0,04). Tartışma: Cerrahi öncesi daha düşük IL6 ve TNF-alfa seviyesi olan osteoartritli hastalar cerrahi sonrası dönemde daha iyi fonksiyonel durum ve alt ekstremite düzgünlüğüne sahipti. Bu nedenle TDA cerrahisi zamanlamasına karar verebilmek için öncelikle SSS'nin azaltılması, cerrahi sonrası daha iyi biyomekanik gelişime neden olabilir. Cerrahi öncesi SSS hastane kalış süresi ile direk bağlantılı değildir.

Effects of total knee arthroplasty for primary knee osteoarthritis on postural balance: A systematic review

BACKGROUND

Knee osteoarthritis is often related to physical function impairment. Although total knee arthroplasty is considered effective for advanced cases of knee osteoarthritis, its effects on postural balance is a topic of debate.

RESEARCH QUESTION

What are the effects of total knee arthroplasty for primary knee osteoarthritis on postural balance compared to preoperative status and/or to healthy controls?.

METHODS

Longitudinal studies (with more than 1-month follow-up) assessing postural balance measures (either clinical-based such as balance scales or laboratory-based such as postural sway) were considered eligible and selected in a 2-phase process. Six main electronic databases were searched, complemented by 3 grey literature sources. The risk of bias was evaluated using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

A total of 19 studies were included for qualitative synthesis, of which 14 had low and 5 had a moderate risk of bias. The follow-up period ranged from 1-24 months. Most studies (n = 11) presented comparisons to preoperative status only. From these, 7 studies reported relevant improvements in postural balance, 2 reported partial improvements, and 2 no improvements. The remaining studies (n = 8) presented comparisons to healthy controls and, although improvements following total knee arthroplasty were consistently observed, only one study reported postural balance measures comparable to that of controls.

CONCLUSIONS

The majority of studies reported relevant improvements (especially in clinical-based measures) compared to preoperative evaluations, although inconsistencies were found possibly due to variability in studies' populations, assessment tools, and follow-up times. Despite this, persistent deficits in postural balance were commonly observed when compared to healthy controls.

SIGNIFICANCE

This evidence synthesis could better inform clinicians and researchers about the therapeutic effects and limitations of total knee arthroplasty concerning postural balance. Standardization of assessment tools is recommended to strengthen the certainty of cumulative evidence.

Sensorimotor training prior total knee arthroplasty and effects on functional outcome: A systematic review and meta-analysis

BACKGROUND

Altered muscle activation patterns and proprioception, loss of strength, and weight bearing asymmetries are common limitations after total knee arthroplasty, which can also affect balance. Therefore, preoperative sensorimotor training has been proposed to enhance surgical outcome.

RESEARCH QUESTION

Is preoperative sensorimotor training effective in improving functional outcome in patients undergoing total knee arthroplasty? Does preoperative sensorimotor training affect secondary outcomes such as balance, pain, and quality of life?

METHODS

A systematic review and meta-analysis were conducted by searching PEDro, MEDLINE, Embase, Cochrane Library, and Scopus databases from inception to May 2020. Studies were eligible if participants underwent total knee arthroplasty after two or more weeks of preoperative sensorimotor training. A meta-analysis compared the effects of such interventions with standard care before and after surgery using standardized mean differences (SMD) with 95 % confidence interval (CI). Functional outcome was the primary measure. Balance, pain, and quality of life were also outcomes of interest.

RESULTS

Of the 384 items identified, 7 met the inclusion criteria, and 332 participants were assessed. There was limited evidence suggesting that preoperative sensorimotor training enhanced self-reported function (SMD, 0.89; 95 % CI, 0.16-1.62), functional performance (SMD, 0.56; 95 % CI, 0.19 to 0.93), or knee function (SMD = 0.22-1.05) compared with conventional care. Moderate quality evidence suggested that benefits were only maintained in terms of functional performance up to 3 months after surgery (SMD = 0.37; 95 % CI, 0.13 to 0.62). The outcome was similar after one year.

SIGNIFICANCE

Compared with conventional care, preoperative sensorimotor training may enhance early postoperative functional recovery, with no additional benefits on balance, knee function, or pain. The outcome is the same one year after surgery, regardless of whether such training is implemented. Further investigation is needed to determine whether sensorimotor training may be a feasible conservative treatment for severe knee osteoarthritis.

Activity Recommendations After Total Hip and Total Knee Arthroplasty

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A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).

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In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.

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For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.

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Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.

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No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.

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Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.

The Effect of Progressive Dynamic Balance Training on Physical Function, The Ability to Balance and Quality of Life Among Elderly Women Who Underwent a Total Knee Arthroplasty: A Double-Blind Randomized Control Trial

Total knee arthroplasty (TKA) is used to treat end-stage osteoarthritis. However, this surgical procedure affects the mechanical receptor function and impairs the ability to balance. Dynamic balance training has been reported to improve stability and self-confidence and safely yield increased physical activity. This study aimed to investigate the effect of dynamic balance training on physical function, the ability to balance and quality of life among patients who underwent TKA. Thirty-eight participants were assigned to either the progressive dynamic balance training (PDBT) with physical therapy group (n = 19) or the control group (n = 19). The experimental group undertook a dynamic balance program with physical therapy for 30 minutes per day, five times per week for six weeks, while the control group undertook physical therapy only. A continuous passive motion exercise was performed for 20 minutes after training by both groups. The outcomes were evaluated using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, pain pressure threshold (PPT), range of motion (ROM), Knee Outcome Survey-Activities of Daily Living (KOS-ADLS), Multifunction Force Measuring Plate, timed up and go (TUG) test and Short-Form Health Survey 36 (SF-36). Physical function (WOMAC Osteoarthritis Index, ROM and KOS-ADLS score) and the ability to balance (TUG test score, confidence ellipse area, path length and average velocity) significantly improved (p < 0.05) in the experimental group compared with the control group. In contrast, the physical component summary score for the SF-36 regarding quality of life significantly improved (p < 0.05); however, the mental component summary score for the SF-36 and PPT did not significantly differ between the groups. Therefore, we suggest that PDBT with physical therapy has positive effects on physical function, the ability to balance and quality of life among patients who underwent TKA.

A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement

PURPOSE

To investigate the effects of including balance training in a preoperative strengthening intervention on balance and functional outcomes in patients undergoing total knee replacement (TKR) and compare these effects to those induced by preoperative strengthening and no intervention.

METHODS

Eighty-two subjects scheduled for TKR were randomly allocated into the strengthening (ST, n = 28) group: a preoperative lower limb strengthening intervention; the strengthening + balance (ST + B, n = 28) group: same intervention augmented with balance training; and the control group (n = 26). The Berg Balance Scale (BBS) and the function in daily living subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-ADL) were the primary outcomes. The secondary measures included balance and mobility, self-reported status, and knee function. The outcomes were assessed at baseline, 1 week before surgery, and 2, (primary endpoint), 6 and 52 weeks after surgery.

RESULTS

Compared with the controls, the participants in the ST and ST + B groups presented significant improvements from baseline to the end of the preoperative intervention in BBS (p = 0.005) and KOOS-ADL (p < 0.001). At 6 weeks post-surgery, the knee extensor strength values were similar in the two treatment groups and significantly higher than that in the controls. Overall, the participant outcomes in all groups stabilized at 1 year after surgery.

CONCLUSION

A preoperative strengthening intervention, regardless of whether it is complemented with balance training, enhances strength but not balance or functional outcomes at 6 weeks after surgery. Patients are expected to present similar performance at 1 year postoperatively, but adequately statistically powered trials are needed to confirm the findings.

LEVEL OF EVIDENCE

II.

TRIAL REGISTRATION

NCT02995668.

Effect of prehabilitation in older adults undergoing total joint replacement: An Overview of Systematic Reviews

Purpose of Review

To review and discuss the findings of systematic reviews that synthesized the evidence on the effect of preoperative exercises (prehabilitation) on postoperative functional recovery in older adults undergoing total knee or hip joint replacement.

Recent Findings

Ten systematic reviews (8 meta-analyses) were included in this review. Findings from the systematic reviews indicated that prehabilitation decreases length of hospital stay but does not improve postoperative functional recovery in older adults undergoing joint replacement. Individual studies in the systematic reviews varied considerably in prehabilitation protocol, assessment timepoints, and outcome measures. Most importantly, systematic reviews did not assess the outcomes pre-post prehabilitation as this timepoint was not addressed in most individual studies. Therefore, it is not known whether the prehabilitation programs improved outcomes preoperatively.

Summary

There is a need to develop comprehensive prehabilitation protocols and systematically assess the preoperative and postoperative effectiveness of prehabilitation protocols on functional outcomes (i.e., self-reported and performance-based) in older adults undergoing total joint replacement.

Proprioceptive training on the recovery of total knee arthroplasty patients: A meta-analysis protocol of randomized controlled trial

BACKGROUND

Total knee arthroplasty is a common surgery for end-stage of knee osteoarthritis. Proprioceptive training has become an important part in athletes training programmes in different sports. However, the effects of proprioceptive training on the recovery of total knee arthroplasty were unknown. This meta-analysis, with its comprehensive and rigorous methodology, will provide better insight into this problem.

METHODS AND ANALYSIS

Electronic databases including PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI) database, Wanfang Database and Chinese Biomedical Literature Database (CBM) were searched from its inception to October 21, 2020. We only included proprioceptive training vs placebo in patients after total knee arthroplasty and pooled results were summarized by STATA 12.0 software. Two researchers independently selected the study and assessed the quality of the included studies. The heterogeneity was measured by I2 tests (I2 < 50 indicates little heterogeneity, I2 ≥ 50 indicates high heterogeneity). Publication bias was ruled out by funnel plot and statistically assessed by Beggs test (P > .05 as no publication bias).

RESULTS

Results will be published in relevant peer-reviewed journals.

CONCLUSION

Our study aims to systematically present the clinical effects of proprioceptive training after total knee arthroplasty patients, which will be provide clinical guidance for total knee arthroplasty patients.

Efficacy of proprioceptive training on the recovery of total joint arthroplasty patients: a meta-analysis

BACKGROUND

Optimal balance control is of paramount importance for function recovery after total joint arthroplasty (TJA). The study objective of this meta-analysis was to assess the short- and mid-term effects of proprioceptive and balance training for patients undergoing TJA.

METHODS

Electronic searches were conducted from PubMed, Cochrane library, and Embase databases to identify eligible RCTs through May 2020. Standard mean difference (SMD) with 95% confidence interval (95%CI) was applied to calculate pooled effect estimates between proprioceptive and balance training and control group. Main outcomes were self-reported functionality, balance, pain, quality of life, and function (range of motion).

RESULTS

Seven randomized controlled trials were finally included in this meta-analysis. Pooled results found that balance and proprioceptive trainings have a positive role in improving self-reported functionality at short-term after TJA. Moreover, balance and proprioceptive trainings were associated with an increase of the balance at short- and mid-term after TJA. These results were further confirmed by subgroup analysis between preoperative and postoperative administration of balance and proprioceptive trainings.

CONCLUSION

Our meta-analysis suggests that balance and proprioceptive trainings after TJA improved self-reported functionality and balance. These improvements were maintained at mid-terms. More research is needed to confirm balance and proprioceptive trainings for pain and quality of life for TJA.

Total Serum Testosterone and Western Ontario and McMaster Universities Osteoarthritis Index Pain and Function Among Older Men and Women With Severe Knee Osteoarthritis

OBJECTIVE

To investigate whether serum total testosterone level is associated with knee pain and function in men and women with severe knee osteoarthritis (OA).

METHODS

We enrolled 272 adults age ≥60 years (mean ± SD age 70.4 ± 4.4 years, 53% women) who underwent unilateral total knee replacement (TKR) due to severe knee OA. Serum testosterone levels and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function of the operated and contralateral knee were measured at 6-8 weeks after surgery. At the nonoperated knee, 56% of participants had radiographic knee OA with a Kellgren/Lawrence grade ≥2. Cross-sectional analyses were performed by sex and body mass index (BMI) subgroups, using multivariable regression adjusted for age, physical activity, and BMI.

RESULTS

At the operated knee, higher testosterone levels were associated with less WOMAC pain in men (B = -0.62, P = 0.046) and women (B = -3.79, P = 0.02), and less WOMAC disability scores in women (B = -3.62, P = 0.02) and obese men (B = -1.99, P = 0.02). At the nonoperated knee, testosterone levels were not associated with WOMAC pain in men or women, but higher testosterone levels were associated with less disability in women (B = -0.95, P = 0.02). Testosterone levels were inconsistently associated with pain and disability in BMI subgroups among men. Only among obese women, testosterone levels were inversely associated with radiographic knee OA (odds ratio = 0.10, P = 0.003).

CONCLUSION

Higher total testosterone levels were associated with less pain in the operated knee in men and women undergoing TKR and less disability in women. At the nonoperated knee, higher testosterone levels were inconsistently associated with less pain and disability.

Physical Therapist Management of Total Knee Arthroplasty

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent two of the most common procedures in orthopedic surgery. The growing need to avoid physical impairment in elderly patients undergoing this kind of surgery puts the focus on the possibility to undertake a preoperative physical activity program to improve their fit and physical health at the time of surgery. A systematic review has been carried out with online databases including PubMed-Medline, Cochrane Central and Google Scholar. The aim was to retrieve available evidence concerning preoperative physical activity and exercise, before total knee or total hip arthroplasty in patients older than 65 years, and to clarify the role of this practice in improving postoperative outcomes. Results of the present systematic analysis showed that, for TKA, most of the studies demonstrated a comparable trend of postoperative improvement of Visual Analogue Scale (VAS), range of movement (ROM) and functional scores, and those of quality of life. There is insufficient evidence in the literature to draw final conclusions on the topic. Prehabilitation for patients undergoing TKA leads to shorter length of stay but not to an enhanced postoperative recovery. Concerning THA, although currently available data showed better outcomes in patients who underwent prehabilitation programs, there is a lack of robust evidence with appropriate methodology.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.

The effects of preoperative balance training on balance and functional outcome after total knee replacement: a randomized controlled trial

Objective:

To assess the effects of preoperative balance training on the early postoperative balance and functional outcomes after total knee replacement surgery and to test whether an outpatient intervention may be as effective as a domiciliary intervention.

Design:

This is a three-arm randomized controlled trial.

Setting:

University hospital.

Subjects:

Eighty-six individuals were recruited. Seventy-seven were analysed, aged 72.1 (SD 7.6) years, of which 68% were women.

Outcome measures:

Overall state of balance, as measured with the Berg Balance Scale, and patient-perceived functionality, as measured with the Knee Injury and Osteoarthritis Outcome Score Function in Activities in Daily Living (KOOS-ADL) questionnaire, were the primary outcomes. Secondary assessments targeted knee function, balance and mobility, quality of life, and self-reported outcomes. The primary end-point was six weeks after surgery.

Intervention:

The hospital group implemented a four-week preoperative outpatient balance-oriented intervention. The home group implemented similar training, but this was domiciliary. The control group was instructed to keep performing their normal activities.

Results:

Home and hospital groups presented a moderate effect against the control group ( dhospital-control = 0.54; dhome-control = 0.63), both being similarly effective in improving the overall state of balance at six weeks after surgery ( P = 0.013). KOOS-ADL scores showed no between-group differences and a small effect size ( d < 0.5; P = 0.937). Secondary assessments suggested non-significant between-group differences.

Conclusion:

Preoperative balance training, conducted either as domiciliary or as an outpatient, is an effective approach to enhance early postoperative balance outcome but not the perceived functionality of individuals undergoing total knee replacement.

The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Existing evidence regarding the value of preoperative education and/or exercise (prehabilitation) for patients undergoing total joint replacement is conflicting. The purpose of this study was to conduct an updated, comprehensive systematic review with meta-analyses to determine the longitudinal effects and efficacy of prehabilitation on postoperative outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We searched 11 electronic databases (MEDLINE, AMED, CINAHL, Embase, Scopus, ProQuest, PEDro, SportDiscus, PsycINFO, and Cochrane) from their inception to May 2016 for randomized controlled trials that compared changes in pain, function, strength, anxiety, and hospital length of stay following THA or TKA. Two reviewers independently determined study eligibility, rated study quality, and extracted data. There were no restrictions on study dates, patient characteristics, or the follow-up time point at which postoperative outcomes were measured. We excluded trials comparing 2 interventions. Methodological quality assessments were performed using the Cochrane risk-of-bias tool. We calculated pooled estimates, with 95% confidence intervals (CIs), of standardized mean differences (SMDs).

RESULTS

Thirty-five studies with 2,956 patients were included. After a preoperative program, patients undergoing THA, but not TKA, had significantly less postoperative pain than controls (SMD = 0.15, 95% CI = 0.03 to 0.27, p = 0.017). Postoperative function was also significantly improved compared with controls, with similar improvement after THA (SMD = 0.32, 95% CI = 0.15 to 0.50, p < 0.001) and TKA (SMD = 0.32, 95% CI = 0.06 to 0.57, p = 0.015). Significantly greater quadriceps strength was observed after TKA (SMD = 0.42, 95% CI = 0.16 to 0.68, p = 0.002). No significant differences in hamstring strength were observed between groups after TKA (p = 0.132). Small-to-moderate but nonsignificant improvements in anxiety (SMD = 0.17, 95% CI = -0.05 to 0.39; p = 0.128) were observed after THA, and length of stay was significantly shorter after TKA (SMD = 0.54, 95% CI = 0.24 to 0.84, p < 0.001) and THA (p = 0.027).

CONCLUSIONS

Overall effect sizes for prehabilitation were small to moderate. In patients undergoing TKA, significant improvements were observed in function, quadriceps strength, and length of stay. In patients undergoing THA, significant improvements were observed in pain, function, and length of stay. Included studies were inconsistent with regard to the types of outcome measures reported, and the quality of the interventions varied. A more standardized approach to reporting of clinical trial interventions and patient compliance is needed to thoroughly evaluate the effects of prehabilitation on postoperative outcomes.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

How proprioception changes before and after total knee arthroplasty: A systematic review

BACKGROUND

Proprioception is one of the most significant factors in balance, joint stability, graceful movement, coordination, and injury prevention. It involves a wide set of receptors located within joints, muscles, and tendons. Given the neurophysiological processes involved in proprioception response are multiple and complex, there is not one single method to measure it. Particularly, proprioception of the knee joint, whether it is healthy, affected by osteoarthritis, or after replacement, is the most investigated by in literature.

RESEARCH QUESTION

This review addresses the analysis of proprioception in the knee joint before and after total knee arthroplasty (TKA). The aim is to obtain an overview of the proprioceptive skills in subjects who suffered from osteoarthritis and were subjected to knee replacement, evaluating changes in proprioception before and after the surgery.

METHODS

The research was conducted within four databases: Web of Science®, PubMed Central®, Cochrane®, and PEDro®, between January 2008 and February 2018. Accurate exclusion criteria and selection strategy were applied to screen the 170 articles found.

RESULTS

Ultimately, 13 papers were fully evaluated and included in this review, divided into two classes: i) works directly measuring proprioception, ii) studies indirectly evaluating proprioception. Contrasting results emerged from the analysis, and no consensus was found in the literature about the improvement or worsening in proprioception before and after TKA.

SIGNIFICANCE

Since currently there is high variability in methods, protocol and parameters used to evaluate knee proprioception, further investigations based on a consistent dataset, a well-defined protocol, measurable outcomes, timeline follow-ups, and rehabilitation programs should be performed in order to obtain reliable results on the effects of TKA on knee proprioception and balance.

Preoperative high-intensity strength training improves postural control after TKA: randomized-controlled trial

PURPOSE

This study investigates the effectiveness of preoperative high-intensity strength training (with a special emphasis on lower limb muscle strength and secondarily on balance training) on postural control after TKA.

METHODS

Forty-four subjects (7 men, 37 women, and mean age 66.7 ± 3.9 years) scheduled for unilateral TKA for osteoarthritis (OA) participated in this randomized-controlled trial. Each patient performed two postural control tests: Romberg test with eyes open and closed. These tests were assessed at 8 weeks before surgery (T1), after 8 weeks of training (T2), 1 month after TKA (T3), and finally 3 months after TKA (T4). The intervention group completed an 8-week training program 3 days per week prior to surgery, while the control group received no intervention.

RESULTS

The Center of Pressure area (COP) was lower (i.e., better score) for the intervention group at T2, T3, and T4. The anteroposterior range of COP with eyes open was lower in the intervention group at T2, T3, and T4 and with eyes closed at T2. The medial-lateral standard deviation of COP with eyes open was lower in the intervention group at T2 and T4 and with eyes closed at T2 and T3. The anteroposterior standard deviation of COP with eyes open did not change, while that with eyes closed the intervention group showed lower score at T2.

CONCLUSION

Preoperative high-intensity strength training is effective for improving postural control before and early after TKA. Recommendations should include preoperative strength training, and not only balance training, to speed-up recovery of postural control after TKA.

LEVEL OF EVIDENCE

1.

Does Rehabilitation before Total Knee Arthroplasty Benefit Postoperative Recovery? A Systematic Review

BACKGROUND

Arthritis is the most common form of joint disease. Total knee arthroplasty (TKA) is the most effective surgical intervention for end-stage knee osteoarthritis. The purpose of this study is to access whether patients who participated in preoperative rehabilitation before primary TKA received any postoperative benefit compared to patients who did not participate in preoperative rehabilitation.

MATERIALS AND METHODS

A comprehensive search of Medline, PubMed, Embase, CENTRAL, CINAHL, Ageline, and hand searching references and abstracts was performed. Inclusion criteria included patients undergoing primary and unilateral TKA. Exclusion criteria included patients who have bilateral, unicompartmental, or revision TKA. All studies compared preoperative exercise program versus no preoperative exercise. Outcomes included patients' function, acute care length of stay (LOS), pain, and stiffness. The Western Ontario and McMaster Universities Osteoarthritis Index and 36-Item Short-Form Health Survey functional scales were used to assess these outcomes. Assessment was performed within 3 months of TKA.

RESULTS

Of 1347 articles, 1308 studies were excluded during title and abstract screening. Thirty nine articles underwent full-text screening and were narrowed to five studies matching all criteria. Two studies were combined showing a significant decrease in LOS favoring preoperative exercise (-0.93, 95% confidence interval: -1.29, -0.57). There was a lack of evidence to show any difference regarding self-reported function, stiffness, pain, and physical role.

CONCLUSION

Preoperative exercise program may be beneficial and is associated with a significant decrease in length of hospital stay. No conclusive evidence can be delineated from the literature with respect to clinical outcome measures. Well-designed randomized trials would strengthen this position.

Effects of balance and proprioceptive training on total hip and knee replacement rehabilitation: A systematic review and meta-analysis

BACKGOUND

Balance and proprioceptive deficits are frequently persistent after total joint replacement, limiting functionality and involving altered movement patterns and difficulties in walking and maintaining postural control among patients.

RESEARCH QUESTION

The goal of this systematic review was to evaluate the short- and mid-term effects of proprioceptive and balance training for patients undergoing total knee and hip replacement.

METHODS

This is a systematic review of literature. MEDLINE, Embase, Cochrane Library, PEDro, and Scopus were the databases searched. The review included randomized clinical trials in which the experimental groups underwent a training aimed at improving balance and proprioception, in addition to conventional care. The studies had to assess at least one of the following outcomes: self-reported functionality or balance (primary outcomes), knee function, pain, falls, or quality of life.

RESULTS

Eight trials were included, involving 567 participants. The quantitative synthesis found a moderate to high significant effect of balance and proprioceptive trainings on self-reported functionality and balance after total knee replacement. The effects were maintained at mid-term in terms of balance alone. Conversely, preoperative training did not enhance outcomes after total hip arthroplasty.

SIGNIFICANCE

The synthesis showed that, in clinical terms, balance trainings are a convenient complement to conventional physiotherapy care to produce an impact on balance and functionality after knee replacement. If outcomes such as improvement in pain, knee range of movement, or patient quality of life are to be promoted, it would be advisable to explore alternative proposals specifically targeting these goals. Further research is needed to confirm or discard the current evidence ultimately, predominantly in terms of the effects on the hips and those yielded by preoperative interventions.

RAD, Rosa LM, Mesquita TRD, Oliveira PRD, Burigo RL, Amorim CF. POSTURAL CONTROL ANALYSIS DURING A STANDARDIZED KICK TASK IN SOCCER ATHLETES

ABSTRACT Introduction: Postural control is a determining factor for functional performance and motor skills during sports activities. Objective: The objective of this study was to investigate postural control during the controlled soccer ball kicking task through a biomechanical analysis system. Methods: The sample consisted of 11 professional male athletes recruited using convenience sampling, with a mean age of 22 years. The athletes performed twenty-five precision kicks at a target, with the ball in vertical motion released by means of a hand-held device synchronized with the computed biomechanical measurements. Marking of the lower limb segments involved in the kick and the ball were analyzed by accelerometry, while postural control measures were quantified by a force platform in three axes of movement. The support leg was investigated in single leg stance during all tests on the force platform. The main variables of postural control calculated by stabilographic analysis and computed during the 25 kicks were: center of pressure (COP) displacement area, velocity and frequency of COP oscillation in the anteroposterior and mediolateral directions. The mean was used for final analysis to determine the differences in the three phases: pre-kick, kick, and post-kick. Results: The results revealed significant differences (p <0.01) between the three phases, with the kick phase presenting higher values of postural COP oscillations than the other phases. The COP area and oscillation velocity were the variables with greatest sensitivity to changes in the kick phase, obtaining an effect size of d = 14 and d = 12, respectively. In clinical terms, the increase in COP values reached 557% between the pre-kick and kick phases; this difference was reduced to 241% when compared to post-kick (i.e., difference between kick and post-kick was 316%). Conclusion . These results have important implications for the perception of postural control responses during soccer ball kicks and consequently, for injury prevention when motor and sensory deficits are diagnosed in soccer players. Level of Evidence III; Study of nonconsecutive patients; without consistently applied reference ‘‘gold’’ standard.

The Impact of Prehabilitation on Postoperative Functional Status, Healthcare Utilization, Pain, and Quality of Life: A Systematic Review

BACKGROUND

"Preoperative rehabilitation" or prehabilitation has been increasingly studied alongside the deleterious effects of surgery and functional decline. Prehabilitation is the preoperative optimization of physical functionality to enable the individual to maintain a normal level of function during and after surgery. This systematic review evaluates the effectiveness of prehabilitation on functional status, healthcare utilization, quality of life, and pain postoperatively.

METHODS

Trials registries and databases of published and unpublished literature were extensively searched. All studies were assessed independently for relevance, eligibility, and quality. Seventeen studies were included in the review: 13 in orthopaedics (mainly knee or hip arthroplasty for osteoarthritis), 2 in abdominal surgery, and 2 in cardiac surgery.

FINDINGS

There is no evidence to show that prehabilitation has significant benefits in function, quality of life, and pain; however, it may reduce admission to rehabilitation after knee or hip arthroplasty for osteoarthritis. There is insufficient evidence to make inferences in other surgical populations, notwithstanding initial evidence does not demonstrate advantages.

High-Velocity Quadriceps Exercises Compared to Slow-Velocity Quadriceps Exercises Following Total Knee Arthroplasty: A Randomized Clinical Study

BACKGROUND AND PURPOSE

Despite improvement in pain and perceived function in older adults following total knee arthroplasty (TKA), objective outcome measures of muscular impairment and ambulatory function demonstrate significant deficits. Evidence suggests that quadriceps power may play a greater role in ambulatory function than measures of strength alone following TKA. The purpose of this study was to compare the effect of high-velocity (HV) quadriceps exercises with that of slow-velocity (SV) quadriceps exercises on functional outcomes and quadriceps power following TKA.

METHODS

This study was a randomized clinical study conducted in an outpatient physical therapy clinic. Twenty-one participants who were 4 to 6 weeks post unilateral TKA were randomly assigned to an HV or SV group. Participants performed an evidence-based standardized progressive resistance exercise program in addition to HV quadriceps exercises or SV quadriceps exercises. Participants attended 2 sessions per week for 8 weeks. Before and after the 8-week exercise intervention, participants completed a functional questionnaire, health survey, functional testing, and underwent quadriceps strength and power testing.

RESULTS

Both groups demonstrated improvements in ambulatory outcome measures, strength, speed, and power. The HV group demonstrated significantly greater improvements in distance walked and quadriceps strength than the SV group.

LIMITATIONS

These data should be considered preliminary because of a small sample size.

CONCLUSION

HV quadriceps exercises may be an effective rehabilitation strategy in conjunction with a standardized progressive resistance exercise program beginning 4 to 6 weeks after TKA.

Is it necessary to perform prehabilitation exercise for patients undergoing total knee arthroplasty: meta-analysis of randomized controlled trials

OBJECTIVES

This study was designed to test whether it is necessary to perform prehabilitation exercise for patients undergoing total knee arthroplasty (TKA).

METHODS

Literatures were identified from Pubmed, Clinicaltrials, Cochrane library, and SpringerLink. All studies that compared a prehabilitation exercise group with control group before TKA were included. The primary outcome was length of hospital stay. Secondary outcomes were quadriceps strength and functional ability in short term (1.5 to 3 months) after TKA.

RESULTS

There was significant difference in the length of hospital stay, knee range of motion (ROM) and sit-to-stand test (P＜0.05). No statistical differences were found in quadriceps strength, 6-minute walk, ROM, knee extension, knee flexion, WOMAC pain, WOMAC function, WOMAC stiffness between the two groups in short term after TKA (P＞0.05).

CONCLUSIONS

Our meta-analysis found that prehabilitation exercise was effective in reducing length of hospital stay. Importantly, it was an effective method for improving knee ROM and sit-to-stand test after TKA. However, there was no effect of prehabilitation exercise on the improvement of quadriceps strength, 6-minute walk, pain and functional recovery following TKA.

The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review

BACKGROUND

Major surgery can induce functional decline and pain, which can also have negative implications on health care utilization and quality of life. Prehabilitation is the process of optimizing physical functionality preoperatively to enable the individual to maintain a normal level of function during and after surgery. Prehabilitation training can be a combination of aerobic exercises, strength training, and functional task training to suit individual needs.

OBJECTIVES

To evaluate the impact of prehabilitation on physical functional status, health care utilization, quality of life, and pain after surgery.

INCLUSION CRITERIA

Studies of adult surgical patients, excluding day surgery patients.Any preoperative exercise interventions identified in the study as part of a prehabilitation or preoperative exercise program, versus usual care.Randomized controlled trials.Functional status, health care utilization, quality of life and pain.

SEARCH STRATEGY

Published (CINAHL, CENTRAL, EMBASE, MEDLINE, PEDro) and unpublished studies between 1996 and March 2013 were searched extensively.

METHODOLOGICAL QUALITY

All studies were assessed independently by two reviewers for relevance, eligibility and methodological quality.

DATA COLLECTION

Data from included papers were extracted using a modified data extraction tool.

DATA SYNTHESIS

Where possible, study results were pooled in statistical meta-analysis. Alternatively, results are presented in narrative and table form.

RESULTS

A total of 3167 citations were identified; after removal of duplicates, assessment for relevance and eligibility, 33 studies underwent critical appraisal. Seventeen studies met the quality criteria and were included in quantitative synthesis. Thirteen studies were conducted in orthopedics (mainly knee or hip arthroplasty for osteoarthritis), one in colorectal, two in cardiac and one in upper gastrointestinal/hepatobiliary. Function, pain and quality of life were quantified according to prehabilitation dose and postoperative months. Prehabilitation, at any dose, did not demonstrate benefits in objective and self-reported function at any of the postoperative time points. Prehabilitation did not demonstrate benefits in quality of life or pain; however, there was significant evidence that prehabilitation doses of more than 500 minutes reduced the need for postoperative rehabilitation, but no significant reduction was found in readmissions or nursing home placement.

CONCLUSIONS

Results from this review reveal that prehabilitation has no significant postoperative benefits in function, quality of life and pain in patients who have had knee or hip arthroplasty for osteoarthritis; however, there is evidence that prehabilitation may reduce admission to rehabilitation in this population. The evidence on postoperative benefits of prehabilitation in other surgical populations is limited; however, preliminary evidence does not demonstrate better outcomes.

IMPLICATIONS FOR PRACTICE

There is no evidence that prehabilitation provides benefits in function, pain or quality of life in patients who have had arthroplasty for osteoarthritis; however prehabilitation doses of more than 500 minutes might reduce acute rehabilitation admissions. The evidence is insufficient to provide recommendations on the benefits of prehabilitation in other surgical populations.

IMPLICATIONS FOR RESEARCH

Future prehabilitation studies are not recommended in patients with osteoarthritis for whom arthroplasty is planned. However, should prehabilitation be tested in other surgical populations, programs must consider patient suitability, setting, delivery of intervention and clinical effectiveness. It is also recommended that the exercises prescribed should be maintained and adhered to after surgery. Most importantly, prehabilitation studies must have adequately powered sample sizes.

In-home versus hospital preoperative balance and proprioceptive training in patients undergoing TKR; rationale, design, and method of a randomized controlled trial

Background

Severe knee osteoarthritis, as well as the surgical procedure of total knee replacement that aims to reduce its symptoms, cause great deterioration on the proprioceptive system. Taking this fact into account, and considering that balance abilities positively influence the capacity to perform basic functional tasks, this trial aims to find the short and mid-term effects of a preoperative balance and proprioceptive training when conducted by patients undergoing total knee replacement. Along with the effects, it is intended to determine whether in-home based training can be as effective as hospital training. The results will help to conclude whether the possible benefits may outweigh the health costs.

Methods

Seventy-five participants will take part. The trial will include in-home and supervised hospital experimental training compared to a non-active control group in order to estimate the actual effect of the proposal against the benefits due exclusively to the surgical procedure. Interventions last 4 weeks prior to surgery, and the follow-up will be at 2w, 6w, and 1y following the operation. The primary outcomes are in agreement with the goals: self-reported functionality in terms of KOOS and overall balance in terms of the Berg Balance Scale. The secondary outcomes will include the measurements of static and dynamic balance abilities, pain, function, and quality of life.

Discussion

It is expected for the results of this trial to provide relevant information in order to decide if a specific intervention is cost-effective to be implemented in clinical practice.

Trial registration

Clinicaltrials.gov identifier NCT03100890. Registered in April 4, 2017.

Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Importance

There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions.

Objective

To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.

Data Sources

Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016.

Study Selection

Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included.

Data Extraction and Synthesis

Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses.

Main Outcomes and Measures

Postoperative pain and consumption of opioids and analgesics.

Results

Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).

Conclusions and Relevance

In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.

Enhancing Recovery After Total Knee Arthroplasty

There have been multiple successful efforts to improve and shorten the recovery period after elective total joint arthroplasty. The development of rapid recovery protocols through a multidisciplinary approach has occurred in recent years to improve patient satisfaction as well as outcomes. Bundled care payment programs and the practice of outpatient total joint arthroplasty have provided additional pressure and incentives for surgeons to provide high-quality care with low cost and complications. In this review, the evidence for modern practices are reviewed regarding patient selection and education, anesthetic techniques, perioperative pain management, intraoperative factors, blood management, and postoperative rehabilitation.

Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of disability in older adults (≥60) in the UK. If nonsurgical management fails and if OA severity becomes too great, knee arthroplasty is a preferred treatment choice. Preoperative physiotherapy is often offered as part of rehabilitation to improve postoperative patient-based outcomes.

OBJECTIVES

Systematically review whether preoperative physiotherapy improves postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty (TKA) and compare study interventions to best-practice guidelines.

METHOD

A literature search of Randomized Controlled Trials (RCTs), published April 2004-April 2014, was performed across six databases. Individual studies were evaluated for quality using the PEDro Scale.

RESULTS

Ten RCTs met the full inclusion/exclusion criteria. RCTs compared control groups versus: preoperative exercise (n = 5); combined exercise and education (n = 2); combined exercise and acupuncture (n = 1); neuromuscular electrical stimulation (NMES; n = 1); and acupuncture versus exercise (n = 1). RCTs recorded many patient-based outcomes including knee strength, ambulation, and pain. Minimal evidence is presented that preoperative physiotherapy is more effective than no physiotherapy or usual care. PEDro Scale and critical appraisal highlighted substantial methodological quality issues within the RCTs.

CONCLUSION

There is insufficient quality evidence to support the efficacy of preoperative physiotherapy in older adults who undergo total knee arthroplasty.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Proprioception and Knee Arthroplasty: A Literature Review

Proprioceptive mechanoreceptors provide neural feedback for position in space and are critical for three-dimensional interaction. Proprioception is decreased with osteoarthritis of the knees, which leads to increased risk of falling. As the prevalence of osteoarthritis increases so does the need for total knee arthroplasty (TKA), and knowing the effect of TKA on proprioception is essential. This article reviews the literature regarding proprioception and its relationship to balance, aging, osteoarthritis, and the effect of TKA on proprioception. Knee arthroplasty involving retention of the cruciate ligaments is also reviewed, as well the evidence of proprioception in the posterior cruciate ligament after TKA.

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

OBJECTIVES

The 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.

DESIGN

We 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 OUTCOMES

Postoperative 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.

RESULTS

Of 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.

CONCLUSIONS

Existing 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).

Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? - A Systematic Review

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.

Therapeutic modalities and postural balance of patients with knee osteoarthritis: systematic review

AbstractObjective The objective of this review was to evaluate the evidence of the influence of therapeutic modalities on postural balance in patients with knee osteoarthritis (OA).Methods A search for published papers on therapeutic modalities was conducted using the Pubmed, Medline, Lilacs and SciELO databases. The keywords “knee” and “balance” in combination with “osteoarthritis” were used as the search strategy. Randomized controlled clinical trials published in the last 10 years in either English or Portuguese were selected. The PEDro scale was applied to assess the quality of the selected clinical trials.Results A total of 46 studies of patients with knee OA were found, of which seven were analyzed in full and 39 were excluded because they did not meet the inclusion criteria. Of the seven studies reviewed, six were considered to have a high methodological quality on the PEDro scale. Several therapeutic modalities were found (physical exercise, hydrotherapy, electrotherapy and manual therapy), and postural balance improved in only three studies.Conclusion The studies included in this systematic review had a high methodological quality, so it can be concluded that the therapeutic modalities used in those studies improved postural balance in patients with knee OA.