The effect of prehabilitation on the range of motion and functional outcomes in patients following the total knee or hip arthroplasty: A pilot randomized trial

The Short-Term Efficacy of Integrating the Easy-Flex Device with Inpatient Rehabilitation in Total Knee Arthroplasty Patients: Insights from a Single-Blind Randomized Controlled Trial

OBJECTIVE

To determine the effect of Easy-Flex as an adjunct to standard inpatient rehabilitation on clinical and functional outcomes.

DESIGN

Prospective randomized controlled trial SETTING: Outpatient clinic and research laboratory PARTICIPANTS: A total of 44 patients were randomized to the Easy-Flex Group (EFG) or Control Group (CG).

INTERVENTION

A rehabilitation program averaging 50-60 minutes per day was implemented for the CG patients. In the EFG, in addition to 30-40 minutes of exercise with the Easy-Flex, the rehabilitation program applied to the CG was integrated with reduced sets and repetitions, with an average duration of 20 minutes. All interventions were performed under the supervision of a physiotherapist during hospitalization. After discharge, both groups received the same home exercise program.

OUTCOME MEASUREMENTS

The primary outcome is the flexion and extension range of motion (ROM). The secondary outcomes include the Numeric Pain Rating Scale (NPRS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Five Times Sit-to-Stand Test (5TSST), 10-Meter Walking Test (10MWT), Short Form-12v2, and Global Rating of Change score (GRCS).

RESULTS

After 6 weeks, the overall group-by-time interaction for the 2 × 3 mixed-model ANOVA was found to be significant for flexion ROM (p=0.005), NPRS-rest (p=0.04), NPRS-activity (p=0.01), 10-MWT (p=0.003), WOMAC (p=0.021) and SF-12-PCS (p=0.032) in favor of EFG exercising with Easy-Flex in addition to standard rehabilitation. The between-group differences in favor of the EFG were -8.0° knee ROM, 1.35 to 1.5 points for pain intensity, and 0.12 m/sec for gait speed. Furthermore, differences favouring EFG in NPRS-rest,10-MWT speed, and SF-12 PCS were greater than the reported MCID.

CONCLUSIONS

Incorporating Easy-Flex into standard physical therapy can be a beneficial, safe, and effective approach in clinical practice, as patients undergoing TKA typically prioritize improving their quality of life by reducing pain and increasing ROM.

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 effect of rehabilitation time on functional recovery after arthroscopic rotator cuff repair: a systematic review and meta-analysis

Objective

We compared the effects of early and delayed rehabilitation on the function of patients after rotator cuff repair by meta-analysis to find effective interventions to promote the recovery of shoulder function.

Methods

This meta-analysis was registered in PROSPERO (CRD42023466122). We manually searched the randomized controlled trials (RCTs) in the Cochrane Library, Pubmed, Cochrane Library, EMBASE, the China National Knowledge Infrastructure (CNKI), the China VIP Database (VIP), and the Wanfang Database to evaluate the effect of early and delayed rehabilitation after arthroscopic shoulder cuff surgery on the recovery of shoulder joint function. Review Manager 5.3 software was used to analyze the extracted data. Then, the PEDro scale was employed to appraise the methodological quality of the included research.

Results

This research comprised nine RCTs and 830 patients with rotator cuff injuries. According to the findings of the meta-analysis, there was no discernible difference between the early rehabilitation group and the delayed rehabilitation group at six and twelve months after the surgery in terms of the VAS score, SST score, follow-up rotator cuff healing rate, and the rotator cuff retear rate at the final follow-up. There was no difference in the ASES score between the early and delayed rehabilitation groups six months after the operation. However, although the ASES score in the early rehabilitation group differed significantly from that in the delayed rehabilitation group twelve months after the operation, according to the analysis of the minimal clinically important difference (MCID), the results have no clinical significance.

Conclusions

The improvement in shoulder function following arthroscopic rotator cuff surgery does not differ clinically between early and delayed rehabilitation. When implementing rehabilitation following rotator cuff repair, it is essential to consider the paradoxes surrounding shoulder range of motion and tendon anatomic healing. A program that allows for flexible progression based on the patient's ability to meet predetermined clinical goals or criteria may be a better option.

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.

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis

BACKGROUND

Postoperative complications occur in up to 43% of patients after surgery, resulting in increased morbidity and economic burden. Prehabilitation has the potential to increase patients' preoperative health status and thereby improve postoperative outcomes. However, reported results of prehabilitation are contradictory. The objective of this systematic review is to evaluate the effects of prehabilitation on postoperative outcomes (postoperative complications, hospital length of stay, pain at postoperative day 1) in patients undergoing elective surgery.

METHODS

The authors performed a systematic review and meta-analysis of RCTs published between January 2006 and June 2023 comparing prehabilitation programmes lasting ≥14 days to 'standard of care' (SOC) and reporting postoperative complications according to the Clavien-Dindo classification. Database searches were conducted in PubMed, CINAHL, EMBASE, PsycINFO. The primary outcome examined was the effect of uni- or multimodal prehabilitation on 30-day complications. Secondary outcomes were length of ICU and hospital stay (LOS) and reported pain scores.

RESULTS

Twenty-five studies (including 2090 patients randomized in a 1:1 ratio) met the inclusion criteria. Average methodological study quality was moderate. There was no difference between prehabilitation and SOC groups in regard to occurrence of postoperative complications (OR = 1.02, 95% c.i. 0.93 to 1.13; P = 0.10; I2 = 34%), total hospital LOS (-0.13 days; 95% c.i. -0.56 to 0.28; P = 0.53; I2 = 21%) or reported postoperative pain. The ICU LOS was significantly shorter in the prehabilitation group (-0.57 days; 95% c.i. -1.10 to -0.04; P = 0.03; I2 = 46%). Separate comparison of uni- and multimodal prehabilitation showed no difference for either intervention.

CONCLUSION

Prehabilitation reduces ICU LOS compared with SOC in elective surgery patients but has no effect on overall complication rates or total LOS, regardless of modality. Prehabilitation programs need standardization and specific targeting of those patients most likely to benefit.

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.

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.

Mobile health-based home rehabilitation education improving early outcomes after anterior cruciate ligament reconstruction: A randomized controlled clinical trial

Objective

This study aimed to assess changes in joint range of motion (ROM) and knee joint function between patients who received the mobile health-based intervention and those who received regular care at 2 and 6 weeks after anterior cruciate ligament (ACL) reconstruction to provide better interventions in the future.

Methods

Patients who underwent ACL reconstruction were randomized into the experimental [Mobile health-based intervention (MHI); n = 62] and control (CON) groups (n = 63). The CON group underwent home-based rehabilitation exercise following the paper rehabilitation schedule, while the intervention group received additional mobile health-based education at weeks 1-6 after surgery. ROM, thigh circumference difference, and flexion pain were the primary outcomes. The secondary outcomes were the international knee documentation committee knee evaluation form (IKDC) scores and rehabilitation compliance scores. All the outcomes were measured 1 day before surgery as references and at 2 and 6 weeks after surgery.

Results

There was no statistical difference in the patients' ROM, thigh circumference difference, and VAS scores at the 2-week follow-up. At the 6-week follow-up, the ROM of the affected leg was (118.1 ± 20.5)° in the CON group and (126.6 ± 20.5)° in the MHI group, and the difference was statistically significant (P = 0.011). The difference in thigh circumference was 3.0 (2.0, 3.5) cm in the CON group and 2.5 (1.0, 3.0) cm in the MHI group. The difference was statistically significant (P < 0.001). The VAS score in the CON group was 3.0 (2.0, 4.0), and the MHI group was 2.5 (1.0, 3.0). The difference was statistically significant (P < 0.05). At the 6-week follow-up, the compliance score of patients in the MHI group was significantly higher than that in the CON group (P = 0.047, β = 2.243, 95%CI: 0.026-4.459). There is no statistically significant difference in IKDC scores.

Conclusion

Mobile health-based intervention positively affected patients undergoing ACL reconstruction surgery, particularly in improving the clinical outcome indicators of the knee joint.

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 Prehabilitation in Form of Exercise and/or Education in Patients Undergoing Total Hip Arthroplasty on Postoperative Outcomes—A Systematic Review

Background and Objectives: The aim of this systematic review was to determine whether prehabilitation before total hip arthroplasty, in the form of exercise therapy, education alone, or both together, improves postoperative outcomes, such as physical functioning, compared with no intervention. Materials and Methods: A systematic literature search was performed in the online databases PubMed, PEDro and Cochrane Library using the following search keywords: “prehabilitation”, “preoperative care”, and “total hip replacement”. Results: A total of 400 potentially relevant studies were identified. After title, abstract and full-text screening, 14 studies fulfilled all inclusion criteria and were included in this systematic review. Patients who completed exercise-based prehabilitation before their operation showed significant postoperative improvements compared with no intervention in the following tests: six-minute walk test, Timed Up and Go test, chair-rise test, and stair climbing. For various other assessments, such as the widely used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Hip disability and Osteoarthritis Outcome Score (HOOS), 36-item Short Form Survey (SF-36) and Barthel Index, no significant differences in outcomes regarding exercise therapy were reported in the included studies. Education alone had no effect on postoperative outcomes. Conclusions: Prehabilitation in the form of a prehabilitation exercise therapy is an effective prehabilitation measure with regard to postoperative physical functioning, while prehabilitation in the form of education has no significant effects. No negative effects of prehabilitation on the outcomes examined were reported.

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.

Introducing Virtual Prehabilitation to a UK Elective Total Hip Replacement service to improve patient outcomes: An overview of the literature and proposed implementation plan

Elective Total Hip Replacement (THR) surgery is one of the most common elective surgeries in the UK, costing the National Health Service (NHS) over £300,000,000 annually. A review of the literature identified preoperative rehabilitation, known as ‘prehabilitation’, improves patient outcomes and decreases Length Of hospital Stay (LOS). This approach follows NICE guidelines which recommend prehabilitation for all patients undergoing joint replacement surgery.

Challenges accessing prehabilitation classes at UK hospitals due to inadequate transport and COVID-19 restrictions present an opportunity to provide prehabilitation virtually. Physiotherapy services are increasingly utilising technology, in line with The NHS Long Term Plan to increase service accessibility.

A review of the literature has established virtual prehabilitation is effective, feasible, and preferable for patients. Quality Improvement methodology has been used to propose an implementation plan for a virtual prehabilitation service. Further research is required to create a standardised prehabilitation protocol, and to assess the long-term effects and sustainability of virtual prehabilitation.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

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.

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.

The James A. Rand Young Investigator's Award: Battling the Opioid Epidemic with Prospective Pain Threshold Measurement

BACKGROUND

Responsible analgesic prescribing is paramount in the opioid epidemic era, yet no standardized protocol exists. We aim to (1) quantify and correlate outpatient opioid need after total knee and hip arthroplasties (TKA and THA) with preoperative objective pain pressure thresholds (PPTs) and subjective pain measures and (2) report incidence of nonsurgical opioid prescriptions 6 weeks postoperatively.

METHODS

Prospectively, PPTs were measured using an algometer with a maximum force of 20 pounds in 160 consecutive patients (90 TKA and 70 THA). Two locations were tested: operative joint (medial epicondyle TKA and lateral iliac crest THA) and ipsilateral olecranon for systemic control. Visual Analog Score, Pain Severity Score, Pain Interference Score, and subjective pain threshold were obtained. Six-week outpatient narcotic consumption morphine equivalents recorded and prescriptions crosschecked with the state Controlled Substance Reporting System. Multivariate analysis was performed to evaluate local and/or systemic PPT and subjective measures with narcotic consumption.

RESULTS

Average operative site and systemic PPT was 6.91 and 7.72 pounds force, respectively. Subjective averages: Visual Analog Score 7.14, Pain Severity Score 5.05, Pain Interference Score 5.16, and perceived threshold 6.77. Six-week average outpatient narcotic consumption was 314.9 morphine equivalents or 125 five milligram oxycodones. Twenty percent received opioids from outside providers. Linear regression revealed a negative correlation between operative site PPT (-0.26; P = .047) and systemic PPT (-0.31; P = .021). Subjective pain metrics failed to meet significance.

CONCLUSION

This novel study demonstrated a statistically significant negative correlation between preoperative pain threshold and outpatient narcotic consumption. Twenty percent of patients received opioid prescriptions outside orthopedic providers in the 6 weeks after surgery highlighting the importance of interdisciplinary communication.

The Role of Pelvic Floor Muscle Training in the Conservative and Surgical Management of Female Stress Urinary Incontinence: Does the Strength of the Pelvic Floor Muscles Matter?

The purpose of this review is to provide an in-depth overview of the role of pelvic floor muscle (PFM) training in the management of stress urinary incontinence (SUI). The definition, epidemiology, and pathogenesis of SUI are described. We review the anatomy of the PFM and the importance of PFM strength in maintaining urinary continence and establishing normal voiding function. A brief description of the surgical options currently available for SUI and the existing data regarding the role of perioperative PFM training for SUI are included. Critical research questions to better evaluate and assess PFM training during the perioperative period are proposed. Promising novel approaches in the treatment of SUI are also presented. This review is useful for physiatrists, urogynecologists, female urologists, and nurse practitioners who specialize in the management and treatment of women with SUI. LEVEL OF EVIDENCE: IV.

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 Influence of Presurgical Factors on the Rehabilitation Outcome of Patients Following Hip Arthroplasty

PURPOSE

The aims of this study were to evaluate the relationship between sociodemographic information, anthropometric values, clinical and presurgery factors, and length of stay (LOS) in older adult patients undergoing total hip arthroplasty (THA) and to predict which factors can delay the start of the rehabilitation program and increase the corresponding LOS.

METHODS

A prospective cohort study was conducted in an orthopedic inpatient unit with 40 patients undergoing THA.

FINDINGS

The Morse Fall Scale scores and pain intensity scores delayed the commencement of the rehabilitation program. Gender and social support were important determinants of LOS and rehabilitation outcome following THA. The weight of the lower limb without osteoarthritis followed by pain intensity and overweight patients also influenced LOS.

CONCLUSIONS/CLINICAL RELEVANCE

Functional outcomes after THA are variable, and the rehabilitation process is an important factor to regain their normal level of physical functioning. This factor can have an impact in the discharge of patients, in resource allocation and in health care of older adult patients.