A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty - short term outcome

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.

The Use of Biomarkers to Quantify Clinical Response to Total Knee Arthroplasty Interventions: A Systematic Review

The primary objective of this review was to determine whether the attenuation of the postoperative inflammatory response (PIR) after total knee arthroplasty (TKA) leads to a notable improvement in clinical outcome scores. The secondary objective of this review was to determine the optimal approach in using inflammatory biomarkers, clinical inflammatory assessments, and imaging to quantify the PIR. A systematic literature search of eight major databases was conducted using a predetermined search strategy. C-reactive protein (CRP), interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR), knee surface temperature (KST), and clinical outcome data were collected and graphically displayed. Eighty-six percent of the studies that reported a statistically significant decrease in inflammatory biomarkers in their treatment group demonstrated a concordant notable improvement in clinical outcome scores. Mean CRP, IL-6, ESR, and KST values peaked on postoperative day (POD) 2, POD1, POD7, and POD 1-3, respectively. The PIR is correlated with early pain and function recovery outcomes. Future studies comparing TKA surgical methodologies and perioperative protocols should assess PIR by incorporating inflammatory biomarkers, such as CRP and IL-6, and clinical inflammatory assessment adjuncts, to provide a more comprehensive comparison.

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications

PURPOSE

This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings.

METHODS

A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library.

RESULTS

Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism.

CONCLUSION

The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future.

LEVEL OF EVIDENCE

Level III.

Association Between Patient and Facility Characteristics and Rehabilitation Outcomes After Joint Replacement Surgery in Different Rehabilitation Settings for Older Adults: A Systematic Review

BACKGROUND AND PURPOSE

In the United States, an exponential increase in total hip arthroplasty (THA) and total knee arthroplasty (TKA) demand has occurred over the last 2 decades. Evidence suggesting patients receiving inpatient rehabilitation following a TKA or THA experience similar outcomes as those with rehabilitation in other settings led to dramatic shifts in postsurgical care settings owing to Centers for Medicare & Medicaid Services (CMS) payment reforms. A contemporary synthesis of evidence about the association between patient and facility factors and outcomes from older adults undergoing THA or TKA in the United States is needed.

METHODS

To identify eligible studies, we searched PubMed, Scopus, and CINAHL. We followed PRISMA guidelines to identify articles evaluating either patient or facility factors associated with outcomes after THA or TKA for older adults who may have been cared for in inpatient settings (ie, inpatient rehabilitation or skilled nursing facility [SNF]). Eligible articles were conducted in the United States and were published between January 1, 2000, and December 31, 2021.

RESULTS

We included 8 articles focused on patient factors and 9 focused on facility factors. Most included older adults and the majority were White (in those reporting race/ethnicity). Most studies evaluated outcomes at discharge and showed that patients admitted to inpatient rehabilitation facilities had either similar or better functional outcomes (mobility, self-care, and functional independence measure (FIM) score) and lower length of stay compared with those in SNFs. Few studies focused on home health care.

CONCLUSIONS

The systematic review focused on older adults showed that findings in these patients are consistent with previous research. Older adults undergoing THA/TKA had acceptable outcomes regardless of postsurgical, inpatient setting of care. Research conducted after CMS payment reforms, in home health care settings, and in more diverse samples is needed. Given the known racial/ethnic disparities in THA/TKA and the shifts to postsurgical home health care with little regulatory oversight of care quality, contemporary research on outcomes of postsurgical THA/TKA outcomes is warranted.

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.

The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses

BACKGROUND

Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.

METHODS AND FINDINGS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).

CONCLUSIONS

Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.

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.

Surgical prehabilitation in older and frail individuals: a scoping review

Background:

Older individuals who are scheduled for elective procedures often have co-morbidities at baseline and may be classified as frail. Both older age and frailty are associated with poor fitness and preoperative deconditioning, which can be predictors of postoperative complications. Prehabilitation aims to improve preoperative health in order to reduce complications and expedite postoperative recovery. To date, the effect of prehabilitation on improving outcomes in older and frail individuals is unclear, and the evidence in support of multi-modal treatments is evolving.

Methods:

In this scoping review, searches of PubMed and Cochrane Library between August 2012 and August 2022 were performed to identify studies investigating the efficacy of prehabilitation prior to surgical procedures.

Results:

A total of 36 articles were included in the review. Most of these examined the efficacy of unimodal (n=21) prehabilitation interventions, most commonly exercise therapy. Multimodal prehabilitation programs (n=15) included a variety of intervention components (e.g., exercise training, nutrition, psychological intervention or geriatric consultation). The most commonly studied populations were patients with gastrointestinal cancer (mostly colorectal cancer). Exercise therapy and multimodal interventions are likely to be of greatest impact on postoperative functional decline in patients awaiting total knee or hip arthroplasty, and cancer-related resection surgery (e.g., due to colorectal, gastric or lung cancer) in older and frail patients.

Conclusions:

Presurgical prehabilitation showed the potential to diminish postoperative outcomes in older and frail patients prior to surgery. However, adequately powered, randomized controlled, assessor blinded intervention trials demonstrating overall benefit of prehabilitation are needed.

Aims

This scoping review aims to summarize the current literature on the efficacy of prehabilitation in older and frail individuals who are undergoing surgical procedures in order to support clinical protocols and inform future research.

The impact of waiting time for orthopaedic consultation on pain levels in individuals with osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Time spent waiting for access to orthopaedic specialist health services has been suggested to result in increased pain in individuals with osteoarthritis (OA). We assessed whether time spent on an orthopaedic waiting list resulted in a detrimental effect on pain levels in patients with knee or hip OA.

METHODS

We searched Ovid MEDLINE, EMBASE and EBSCOhost databases from inception until September 2021. Eligible articles included individuals with OA on an orthopaedic waitlist and not receiving active treatment, and reported pain measures at two or more time points. Random-effects meta-analysis was used to estimate the pooled effect of waiting time on pain levels. Meta-regression was used to determine predictors of effect size.

RESULTS

Thirty-three articles were included (n = 2,490 participants, 67 ± 3 years and 62% female). The range of waiting time was 2 weeks to 2 years (20.8 ± 18.8 weeks). There was no significant change in pain over time (effect size = 0.082, 95% CI = -0.009, 0.172), nor was the length of time associated with longitudinal changes in pain over time (β = 0.004, 95% CI = -0.005, 0.012). Body mass index was a significant predictor of pain (β = -0.043, 95% CI = -0.079, 0.006), whereas age and sex were not.

CONCLUSIONS

Pain remained stable for up to 1 year in patients with OA on an orthopaedic waitlist. Future research is required to understand whether pain increases in patients waiting longer than 1 year.

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.

Effect of aqua walking exercise on knee joint angles, muscular strength, and visual analogue scale for patients with limited range of motion of the knee

The purpose of this study is to identify the effects of aqua walking exercise on the joint range of motion (ROM), muscular strength, and pain in patients who have limited knee ROM from surgery or joint fixation. Ten subjects were participated in this study and divided into two groups: continuous passive motion (CPM) therapy+walking exercise on dryland (CWD) and CPM+aqua walking exercise (CAW) groups. The repeated measures analysis of variance was used to verify the difference between the groups and the duration of the program. A paired t-test was used to verify the significance of the observed difference within the groups, and an independent t-test was used to verify the significance of the observed difference between different groups. In this study, ROM in the knee flexion showed interaction effect between the two groups. CAW had a significant increase of knee flexion angle compared to those in CWD. Also, strength on the knee flexors showed interaction effect between the two groups. CAW had a significant increase of knee flexion angle compared to those in CWD, while strength on the knee extensors showed no significant interaction effect between groups. Visual analogue scale (VAS) score showed interaction between the two groups. CAW had a significant increase of the VAS scores compared to those in CWD. Given these findings reported in present study, aqua walking exercise for patients with osteoarthritis is a very safe and effective therapeutic strategies that can move the joint in the optimal ROM.