Preoperative physiotherapy and short-term functional outcomes of primary total knee arthroplasty

Optimizing the Preoperative Preparation of Sarcopenic Older People: The Role of Prehabilitation and Nutritional Supplementation before Knee Arthroplasty

BACKGROUND

Age-related loss of skeletal muscle strength and mass is linked to adverse postoperative outcomes in older individuals with sarcopenia. Half of patients suffer from severe associated osteoarthritis requiring orthopedic interventions. Mitigating the onset and progression of sarcopenia before surgery is essential to improve the prognosis and reduce surgical complications. The aim of this research was to innovatively explore whether the preoperative period could be the appropriate timeframe to empower surgical resilience, through prehabilitation and dietary supplementation, in older sarcopenic patients undergoing knee arthroplasty.

METHODS

The current literature concerning the effectiveness of prehabilitation and dietary supplementation before knee arthroplasty in sarcopenic older individuals was reviewed, following the SANRA criteria, between December 2023 and February 2024. The study inclusion criteria were as follows: (1) prehabilitation and/or dietary supplementation interventions; (2) human participants aged 65 years and older; (3) relevant outcome reporting (functional status, postoperative complications, and patient-reported outcomes); and (4) articles written in English The extracted information included study characteristics, demographics, intervention details, outcomes, and the main findings.

RESULTS

Merged prehabilitation and dietary supplementation strategies extrapolated from the current literature and involving strength, resistance, balance, and flexibility training, as well as essential amino acids, iron, vitamin D, adenosine triphosphate, and glucosamine sulphate supplementation, could improve the functional capacity, ability to withstand the upcoming surgical stressors, and postoperative outcomes in older people undergoing knee arthroplasty.

CONCLUSIONS

Addressing complex links between knee osteoarthritis and sarcopenia in older individuals undergoing knee arthroplasty requires a multidimensional approach. Prehabilitation emerges as a crucial preliminary step, allowing the optimization of surgical outcomes. Nutraceutical integration, included in a comprehensive care plan, could have a synergic effect in achieving prehabilitation goals. Those interventions are essential for surgical resilience, in terms of muscle function preservation, recovery acceleration, and overall quality of life enhancement. Intensive collaboration among specialists could advance knowledge and the sharable consensus concerning the critical and evolutive field of perioperative care.

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

Impact of end-stage knee osteoarthritis on perceived physical function and quality of life: A descriptive study from Jordan

OBJECTIVE

Of the present study was to evaluate the impact of end-stage knee OA on patient's perception of their functional abilities and quality of life (QoL) using the self-reported questionnaire; the Knee Injury and Osteoarthritis Outcome Score (KOOS), and to determine the contribution of knee pain on patient's perceived outcomes.

METHODS

Patients with end-stage knee OA who are on the waiting list for total knee arthroplasty were recruited in this cross-sectional study. Patients were asked to fill out the KOOS questionnaire. Knee pain for both sides was quantified on a continuous scale from 0-10. Age, and anthropometric data were recorded. Descriptive statistics were calculated for patients' characteristics, and for the scores of each KOOS subscale. Hierarchical linear regression models were created to determine the contributions of knee pain on two KOOS subscales; the function in daily living (KOOS-ADL), and the knee-related quality of life (KOOS-QoL).

RESULTS

Patients in this study scored low across KOOS subscales (27.7% - 54.2%) with the QoL subscale being the lowest. After accounting for age and BMI, hierarchical linear regressions revealed that knee pain in both sides were determinants of self-perceived KOOS-ADLs, while only knee pain in the most-affected side significantly contributed to lower KOOS-QOL scores.

CONCLUSION

End-stage knee OA negatively impact the patients' perceived function and quality of life. Patients' KOOS scores were similar to those reported in other countries, with QoL being the domain most affected. Our findings demonstrate that the level of knee pain has a determinant effect on our patients' perceptions of functional abilities and QoL. As waiting-list patients, addressing knee pain with a targeted regimen prior to TKA, as well as increasing patient's awareness about knee pain management, may improve/ or minimize deterioration in perceived functional ability and QoL while awaiting TKA.

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.

Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review

ABSTRACT

We sought to systematically review the evidence on the benefits and harms of prehabilitation interventions for patients who are scheduled to undergo elective, unilateral total knee arthroplasty or total hip arthroplasty surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We selected for inclusion randomized controlled trials and adequately adjusted nonrandomized comparative studies of prehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. While large heterogeneity across evaluated prehabilitation programs limited strong conclusions, evidence from 13 total knee arthroplasty randomized controlled trials suggest that prehabilitation may result in increased strength and reduced length of stay and may not lead to increased harms but may be comparable in terms of pain, range of motion, and activities of daily living (all low strength of evidence). There was no evidence or insufficient evidence for all other outcomes after total knee arthroplasty. Although there were six total hip arthroplasty randomized controlled trials, there was no evidence or insufficient evidence for all total hip arthroplasty outcomes.

Prehabilitation Improves Knee Functioning Before and Within the First Year After Total Knee Arthroplasty: A Systematic Review With Meta-analysis

OBJECTIVE: To assess whether prehabilitation influenced knee functioning before and within the first year after total knee arthroplasty (TKA) surgery. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: The authors searched the MEDLINE/PubMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, Web of Science, and Scopus databases from their inception until March 2022. STUDY SELECTION CITERIA: The authors included peer-reviewed articles comparing preoperative, short-, mid- or long-term effects of exercise-based physical therapy before primary unilateral TKA with TKA without prehabilitation. DATA SYNTHESIS: We assessed bias using the Cochrane Risk-of-Bias tool (ROB 2.0) and therapeutic validity using the i-CONTENT tool. Standardized mean differences (Hedges' g) and 95% confidence intervals (CIs) were calculated for knee functioning. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Sixteen trials (968 participants) were included; 14 qualified for meta-analysis. Low to very low certainty of evidence favored prehabilitation over no intervention for improving knee functioning before (g = 1.23; 95% CI: 0.49, 1.97) and up to 3 months after TKA (short-term: 1 day to 1 month, g = 0.90; 95% CI: 0.18, 1.61; mid-term: 6 weeks to 3 months, g = 0.45; 95% CI: 0.06, 0.84). There were no significant between-group differences at long-term follow-up (6-12 months, g = 0.07; 95% CI: -0.17, 0.30). CONCLUSION: There was low to very low certainty of evidence that prehabilitation promotes superior knee functioning before and up to 3 months after TKA, compared to TKA alone. The long-term postoperative effects were inconclusive. J Orthop Sports Phys Ther 2022;52(11):709-725 Epub: 20 September 2022. doi:10.2519/jospt.2022.11160.

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.

Preoperative Factors Affecting Patient-reported Outcome Measures for Total Knee Arthroplasty

Objectives:

The aim of this study was to investigate the preoperative factors affecting health-related quality of life (HRQOL) at 3 and 12 months after total knee arthroplasty (TKA).

Methods:

In total, 156 patients who underwent unilateral TKA for knee osteoarthritis were included in the study. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used as a measure of HRQOL before surgery and 3 and 12 months post-TKA. The Modified Gait Efficacy Scale (mGES) score, tibiofemoral angle, rest pain, walking pain, knee joint range of motion, knee joint extensor strength, and walking speed were recorded preoperatively. Pearson’s correlation coefficient and the correlation ratio were used to calculate the correlation between KOOS and preoperative factors at 3 and 12 months post-TKA. Multiple regression analysis was performed using the stepwise method with the five postoperative KOOS subscales as dependent variables and the other preoperative factors as independent variables.

Results:

Preoperative mGES scores were significantly correlated with KOOS Activities of Daily Living, Sport/Rec, and QOL subscores at 3 months post-TKA and with all five KOOS subscales at 12 months post-TKA. Multiple regression analysis identified mGES as an influencing factor for all KOOS subscales except Pain at 3 months post-TKA and all KOOS subscales except Symptoms at 12 months post-TKA.

Conclusions:

Preoperative walking self-efficacy influenced HRQOL at 3 and 12 months post-TKA. Psychological factors such as self-efficacy should be considered when predicting postoperative outcomes.

Insight Into the Effect of Hospital-Based Prehabilitation on Postoperative Outcomes in Patients With Total Knee Arthroplasty: A Retrospective Comparative Study

BACKGROUND

Osteoarthritis (OA) has become one of the most prevalent joint diseases worldwide, leading to a growing burden of pain and disability as populations age. Although there is consistent evidence to support postoperative rehabilitation and high-intensity prehabilitation for total knee arthroplasty (TKA), the clinical outcomes of hospital-based prehabilitation remain unclear. We aimed to evaluate the effect of a hospital-based prehabilitation program on knee score (KS), function score (FS), and length of stay (LOS) among patients with knee OA after TKA.

METHODS

A retrospective comparative study was conducted at Renmin Hospital of Wuhan University among patients with primary knee OA. Seventy-two postopearative patients who did not undergo the prehabilitation program were included as the control group, while 68 postoperative patients who underwent the prehabilitation program were assigned to the intervention group. All patients went through the same care after TKA. The KS, FS, and pain levels were measured 5 days before surgery, immediately preceding surgery, immediately after the surgery, and at 1 week and 1 month postoperatively. LOS for each patient was recorded.

RESULTS

The new prehabilitation training program significantly improved the KS over time in the intervention group. However, no significant between-group difference was identified in the change of FS. The prehabilitation program also provided shorter LOS.

CONCLUSIONS

The hospital-based prehabilitation program leads to improved recovery, as indicated by higher KS postoperatively, which may result in improved clinical outcomes of TKA.

Effects of Preoperative Telerehabilitation on Muscle Strength, Range of Motion, and Functional Outcomes in Candidates for Total Knee Arthroplasty: A Single-Blind Randomized Controlled Trial

This study aims to investigate the effect of a preoperative telerehabilitation (PT) program on muscle strength, knee range of motion (ROM), and functional outcomes in candidates for total knee arthroplasty (TKA). Sixty patients (all women, mean age 70.53 ± 2.7 years) scheduled for bilateral TKA participated in this study. The PT and preoperative patient education (PE) groups participated in a 3-week intensive exercise program (30 min/session, 2 times/day, 5 days/week), whereas the control group received the usual care before TKA. Quadriceps muscle strength, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), ROM of knee flexion, pain, and time up-and-go (TUG) test time were evaluated at 4 weeks preoperatively, post-interventionally, and 6 weeks after TKA. Significant differences were found in the time-by-group interaction for 60°/s extension peak torque [F(4, 100) = 2.499, p = 0.047, η²_p = 0.91], 180°/s extension peak torque [F(4, 100) = 3.583, p = 0.009, η²_p = 0.125], ROM [F(4, 100) = 4.689, p = 0.002, η²_p = 0.158], TUG time [F(4, 100) = 7.252, p < 0.001, η²_p = 0.225], WOMAC pain [F(4, 100) = 9.113, p < 0.001, η²_p = 0.267], WOMAC functional outcome [F(4, 100) = 6.579, p < 0.001, η²_p = 0.208], and WOMAC total score [F(4, 100) = 10.410, p < 0.001, η²_p = 0.294]. The results of this study demonstrate the early benefits of a PT program in elderly female patients with end-stage osteoarthritis. The PT program improved muscle strength, ROM, and functional outcomes before TKA, which contributed to better functional recovery after TKA.

Effects of electromyography biofeedback for patients after knee surgery: A systematic review and meta-analysis

There has been no systematic review evaluating the efficacy of electromyography (EMG) biofeedback after knee surgery recently. This meta-analysis aimed to determine whether EMG-biofeedback is effective for improving the range of motion (ROM), physical function, and pain relief in patients after knee. Randomized controlled trials (RCTs) assessing the effect of EMG-biofeedback after any knee surgery were retrieved from EMBASE, PubMed, Cochrane Library, Physiotherapy Evidence Database, ClinicalTrials.gov, ProQuest. This review identified 773 unique studies, and six RCTs were in the final meta-analysis. EMG-Biofeedback treatment has a significant difference compared to other rehabilitation therapy in knee ROM improving (SMD = -0.48, 95% CI = -0.82 to -0.14, p = 0.006, I² = 37%). Moreover, there was no significant difference in pain (SMD = -0.33, 95% CI = -0.67 to0.02, p = 0.07, I² = 41%) and physical function scores (MD = 1.83, 95% CI = -3.48 to7.14, p = 0.50, I² = 0%). The results illustrate that EMG-biofeedback can improve knee ROM in patients after knee surgery. However, it is not superior to other rehabilitation methods for pain relief and physical function improvement.

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.

Physical therapy prehabilitation on a reverse total shoulder replacement candidate: a case study

[Purpose] The purpose of this report is to describe the PT evaluation, prehab interventions, and outcomes of a patient pursuing reverse total shoulder replacement (rTSR) for pain reduction and functional gains. [Participant and Methods] A 62-year-old male self-referred to PT two months before his right rTSR. His chief complaints were right shoulder pain, stiffness, and functional impairment due to rotator cuff tendon tears and shoulder arthritis. He demonstrated poor posture, limited ROM, decreased strength, and diminished function. The PT prehab program consisted of an initial encounter followed by six treatment sessions across approximately one month. [Results] On the last visit, the patient's pain had meaningfully decreased along with improved posture, AROM, and muscle strength producing a clinically significant improvement in function resulting in the postponing of his rTSR. On a three months follow-up, the patient had maintained or improved in his test and measures and functional outcomes. He expressed satisfaction with the prehab outcomes and that he had indefinitely postponed his rTSR. [Conclusion] PT prehab program improved pre-operative measures on pain, posture, joint mobility, muscle strength, and function on a patient who had been scheduled for rTSR surgery. PT prehab program may delay the need for rTSR surgery.

The role of prehabilitation with a telerehabilitation system prior to total knee arthroplasty

Background

The purpose of the current study was to evaluate the usage of prehabilitation on a telehealth platform prior to total knee arthroplasty (TKA) and its impact on short-term outcomes. Specifically, the study examined whether patients participating in a prehabilitation program impacted length of stay (LOS) and discharge disposition.

Methods

A total of 476 consecutive patients who underwent TKA at three institutions were included. The average age of the 476 patients was 65.1 years (range, 35 and 93 years). There was a total of 114 patients who utilized the novel prehabilitation program that provided exercises, nutritional advice, education regarding home safety and reducing medical risks, and pain management skills prior to surgery. A group of 362 patients who did not utilize the program formed the control cohort. The outcomes evaluated were LOS and discharge disposition to home, home with health aide (HHA), or skilled nursing facility (SNF).

Results

The average LOS in the prehabilitation group was significantly shorter than in the control group (2.0 vs. 2.7 days, P<0.001). Additionally, prehabilitation patients had more favorable discharge disposition status in comparison to the control group. In the prehabilitation patients, 77.2% went home without assistance, compared to 42.8% in the control group (P<0.001). Also, significantly fewer patients in the prehabilitation group were discharged to a SNF when compared to the control group (1.8% vs. 21.8%, P<0.0001).

Conclusions

Prehabilitation preceding TKA in the current study showed early benefits in LOS and discharge disposition. This study will help expand the current literature and educate orthopaedic surgeons on a novel technology. To truly appreciate the role of telerehabilitation in the setting of TKA, further investigation is needed to investigate long-term outcomes, cost analysis, and patient and clinician satisfaction.

The effect of a 12 week prehabilitation program on pain and function for patients undergoing total knee arthroplasty: A prospective controlled study

BACKGROUND

The concept of preparing the body before a stressful event, such as surgery, has been termed "prehabilitation" (preoperative physiotherapy and exercise programs). Prehabilitation programs for people awaiting total knee arthroplasty (TKA) have positive effects on patients health status and may also lead to better postoperative outcomes.

AIM

The purpose of this study was to examine effect of a prehabilitation program on knee pain, functional ability among patients with knee osteoarthritis after TKA surgery.

STUDY DESIGN

A Prospective Controlled Study.

PATIENTS AND METHODS

Subjects enrolled in this prospective controlled study who referred to our Orthopedics and Traumatology outpatient clinic between 2014 April-2015 May, had severe OA with pain not responsive to conservative treatment and scheduled for unilateral TKA. Subjects were assigned to a control or prehabilitation group. Patients of prehabilitation group were recruited from the orthopaedic waiting lists for primary unilateral TKA. Partipicants in the prehabilitation group were prescribed a training program that consisted of education and home-based exercise 12 weeks before the operation. After the TKA, all subjects partipicated in the same postoperative rehabilitation protocol. Evaluations were made before the surgery, with follow-up assessments at 3 and 6 months after surgery. Knee pain was assessed by the use of a 10-cm Visual Analog Scale (VAS) and function assesed by Knee injury and Osteoarthritis Outcome Score (KOOS) scale.

RESULTS

A statistically significant improvement was observed in the values of VAS and all subsclaes of KOOS in both groups at third and sixth month compared to baseline. The intergroup comparison of the improvement (pre-post scores at sixth month) did not show any statistically significant diffeferences in VAS and KOOS scores.

CONCLUSION

Our results show that prehabilitation before TKA is not superior to surgical treatment alone but about 20% of the patients changed their operation decision. So it is important to be able to postpone this process especially in the early period.

Influence of early mobilization program on pain, self-reported and performance based functional measures following total knee replacement

BACKGROUND

Total knee replacement (TKR) is an optimal treatment for persons with severe knee joint pain and disability, who were unsuccessful with conservative management. Early mobilization can be defined as moving out of bed and/or walking quickly after the surgery for reducing the risks allied with bed rest. There is a paucity of studies on effects of early mobilization on a performance-based measure of timed up and go test (TUG), six-minute walk test (SMWT) and a self-reported disease-specific measure of a knee injury and Osteoarthritis outcome score (KOOS) following TKR.

METHODS

A prospective pre-post-trial was conducted at Manipal Hospital, Bangalore, India. Participants underwent early (POD '0') mobilization on the same postoperative day within 7 h post-TKR surgery. Outcome measures were recorded by an independent blinded observer. The statistical significance level was set at 'p' value < 0.05. The difference between pre-operative and post-operative outcome measure at 1 month and 3 months post-intervention were analyzed using repeated measures of ANOVA.

RESULTS

The study included a total of 78 participants (59 Females; 19 Males) and the mean age of the included participants was 64.1 ± 7 years. Amongst, 78 participants, 53 underwent unilateral TKR, 25 underwent bilateral TKR. There were three dropouts in the study due to post-operative complications. Significant improvements from pre-operative to one month were observed following POD '0' mobilization on NPRS (7.35 ± 1.2 to 4.3 ± 1.7), SMWT (169 ± 70 to 236.7 ± 80.7). KOOS subscales of pain, symptom, and quality of life showed significant changes at one month and 3 months. TUG, Knee strength, Knee ROM and KOOS ADL subscale shown improvements only at 3 months post-intervention.

CONCLUSION

Our study findings suggest that POD '0' (early) mobilization can result in reduced pain and an increase in walking speed at 1 month. Significant changes were observed in pain, Knee strength, Knee ROM, TUG, SMWT and KOOS subscales at 3 months following total knee replacement.

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

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.