BACKGROUND
Osteoarthritis is a leading cause of joint disability in the United States. Approximately 54 million people (23% of adults) have osteoarthritis, and of these, 24 million are limited in their daily activities because of osteoarthritis.1 Total joint replacements—total knee arthroplasty (TKA) and total hip arthroplasty (THA)—have been some of the most successful means for treating patients with end-stage arthritis.2–5 In 2014, an estimated 680,150 patients in the United States underwent a TKA and 370,770 underwent a THA. It is expected that by 2030, 1.26 million patients will undergo a TKA annually (an 85% increase from 2014) and 635,000 will undergo a THA annually (71% increase).6
While most patients experience improvements in pain after TKA or THA, deficits in functional performance and strength commonly persist a year after surgery for many patients.7–10 Physical rehabilitation is commonly offered to patients undergoing either TKA or THA with the goal of optimizing postoperative outcomes, including strength, physical function, pain reduction, and return to normal activities of daily living (ADLs). Increasingly, “prehabilitation” (i.e., rehabilitation services provided before surgery) is considered by patients, providers, and health systems as a potential approach to maximize patients’ functional status before surgery to improve postoperative outcomes. However, the benefit of prehabilitation, and how this may vary depending on the composition or delivery of the prehabilitation program, for TKA and THA remains unclear.
We conducted a systematic review (SR)11 under the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center Program to understand the effectiveness and comparative effectiveness of prehabilitation and rehabilitation for TKA and THA (see questions for the full review in Appendix A, Supplemental Digital Content 1, https://links.lww.com/PHM/B640). In this article, we address the effects and harms of prehabilitation for patients who will undergo TKA or THA on patient-reported outcomes, performance-based outcomes, and healthcare utilization after surgery. In companion articles, we address rehabilitation after TKA12 and THA.13
METHODS
The Brown Evidence-based Practice Center used established SR methodologies as outlined in AHRQ Methods Guide.14 The SR was registered in PROSPERO (registration number CRD42020199102) and is reported in accordance with the Preferred Items for Reporting in Systematic Reviews and Meta-Analyses15 (Appendix B, Supplemental Digital Content 2, https://links.lww.com/PHM/B641). We developed the protocol with input from a broad panel of stakeholders (https://effectivehealthcare.ahrq.gov/products/major-joint-replacement/protocol). Detailed descriptions of the SR and methods can be found in the full AHRQ report11 and Appendix C (Supplemental Digital Content 1, https://links.lww.com/PHM/B640).
Data Sources and Searches
For the full SR, we conducted literature searches in MEDLINE (via PubMed), PsycINFO, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, and Scopus, restricted to January 1, 2005, through May 3, 2021. Studies published before 2005 were excluded to account for changes in TKA and THA management, particularly postoperative protocols (e.g., enhanced recovery after surgery protocol and rapid hospital discharge) more commonly employed since the 2000s.16 See Appendix C (Supplemental Digital Content 1, https://links.lww.com/PHM/B640) for search strategies.
All identified citations were independently double screened using Abstrackr (http://abstrackr.cebm.brown.edu) by a team of six researchers. Conflicts were resolved by group discussion. All potentially relevant studies were rescreened in full text in duplicate.
Study Selection
To answer our questions about prehabilitation for TKA or THA, we included studies of adults who had undergone elective nonrevision, unilateral TKA, or THA for primary osteoarthritis and who received a prehabilitation program less than or equal to 3 mos before surgery. We excluded studies of patients with nonelective (e.g., emergency), bilateral, or revision major joint replacement, or major joint replacement for conditions other than osteoarthritis. We excluded studies that involved patients on surgical waitlists who did not go on to have surgery and did not report outcomes after surgery at a minimum of 3- or 6-mo follow-up after TKA or THA, respectively. We defined prehabilitation as active, structured physical activity or activities designed to attain measurable goals of reducing impairments and improving movement-related function as defined by the International Classification of Function, Disability, and Health.17 The prehabilitation intervention had to have been delivered, supervised, and/or monitored by a healthcare professional or other trained individual (e.g., physical therapist, nurse trained in rehabilitation, health educator with training in exercise delivery or rehabilitation). Prehabilitation could be combined with adjunctive modalities, although we excluded studies designed to evaluate adjunctive modalities (ice, heat, etc.) on their own.
Prehabilitation could be compared with other prehabilitation (of different content), prehabilitation with an adjunctive modality, or prehabilitation of similar content that varied in terms of intensity or method of delivery (e.g., by different personnel or in a different setting). We did not evaluate pharmaceutical or over-the-counter interventions as cointerventions.
We included performance-based measures, patient-reported outcomes, healthcare utilization, and harms (specifically from prehabilitation). We included randomized controlled trials (RCTs) and nonrandomized comparative studies that used analytic methods to minimize selection bias (e.g., multivariable adjustment, propensity score analysis). Finally, we required at least 20 participants per intervention group.
Data Extraction and Quality Assessment
From each study, we extracted data on study design, population characteristics, outcomes, and results into the Systematic Review Data Repository (https://srdrplus.ahrq.gov/public_data?id=2965&type=project). Two independent reviewers (one with expertise in rehabilitation content, the other with expertise in complex intervention taxonomies) separately extracted intervention details. We categorized the content of the rehabilitation interventions according to a categorization scheme adapted from ongoing work by Oatis et al.18 and Franklin.19 The taxonomy comprehensively lists 147 specific rehabilitation content components that are hierarchically linked to larger rehabilitation goals. The larger component goals include: strengthening exercise, aerobic exercise, flexibility exercise, balance-motor/learning-agility exercise, task-specific training, patient education, and adjunctive modalities. We extracted information on the goals of the exercise(s) and the specific exercises used to achieve these goals; information on whether the rehabilitation was progressed (i.e., changed over time) and, if so, whether it was appropriate (i.e., according to patient-specific parameters assessed by the therapist); and who delivered the intervention (personnel), how (mode of delivery), and where (setting). We did not assess dose, intensity, and duration aside from minimal criteria needed to meet our rehabilitation definition or in cases where rehabilitation content was the same but varied only in terms of dose, intensity, or duration. More details about how we operationalized the taxonomy and our extractions of the rehabilitation interventions can be found in Appendix C (Supplemental Digital Content 1, https://links.lww.com/PHM/B640).
To assess study methodological quality, we used the Cochrane risk of bias tool for RCTs20 and, for nonrandomized comparative studies, only ROBINS-I tool21 was used. For RCTs, we also used items from the National Heart, Lung, and Blood Institute tool on the adequacy of descriptions of study eligibility criteria, interventions, and outcomes.22 Each study was extracted and assessed for methodological quality by one methodologist and reviewed and confirmed by at least one other experienced methodologist. Disagreements were resolved by discussion among the team.
Data Synthesis and Analysis
We compared interventions with their comparators for their effects, using mean differences (MD) between groups in continuous outcome data after rehabilitation. For categorical outcomes, we evaluated odds ratio.
The heterogeneity of the interventions and their comparators precluded identification of meaningful groupings of similar studies for synthesis. We, thus, summarized studies as a whole, comparing prehabilitation to no prehabilitation. We reported outcomes under the four following outcome categories: body structure and function; activity and participation; other patient reported; and healthcare utilization. Given intervention heterogeneity, we determined that meta-analysis was not warranted (i.e., average result would not have been interpretable/meaningful) and instead summarized results narratively.
For all analyses, we graded the strength of evidence (SoE) as per the AHRQ Methods Guide.23,24 For each SoE assessment, we considered the number of studies, their designs, limitations/risk of bias, the directness of the comparisons to the research question, consistency of study results, precision of estimates of effect, likelihood of reporting bias, and other limitations. Based on these assessments, we assigned a SoE rating as being either high, moderate, or low, or there being insufficient evidence to allow a conclusion.
Role of the Funding Source, Stakeholders, and Reviewers
The AHRQ Learning Health System (LHS) panel nominated this topic for SR to AHRQ. A member of the LHS panel joined stakeholder panels who contributed to discussions that helped refine the key questions and protocol. The AHRQ program officer, the LHS member, and other reviewers (both invited and public) provided comments on draft versions of the protocol and full AHRQ report.11 The LHS partner and AHRQ did not participate in the literature search, determination of study eligibility criteria, data analysis, study evaluation, or interpretation of findings.
RESULTS
The literature searches yielded 22,361 citations (for all topics addressed in the full report). We found 1016 citations to retrieve for full-text screening (Appendix D, Supplemental Digital Content 1, https://links.lww.com/PHM/B640) of which 13 RCTs reported in 15 articles addressed prehabilitation for TKA25–39 and six RCTs reported in six articles addressed prehabilitation for THA.34,40–44
Description of the Prehabilitation for TKA Evidence
Details on study designs, population characteristics, and detailed coding of prehabilitation interventions evaluated for patients undergoing TKA can be found in Appendices E and F (Supplemental Digital Content 1, https://links.lww.com/PHM/B640), respectively. The 13 studies assessed a total of 1174 patients. Studies enrolled between 45 and 243 participants each (median = 59). The average ages of participants were similar across studies, ranging from 61 to 72 yrs. Between 27% and 92% of study participants were women. Only two studies reported data on previous contralateral TKA, which ranged from 10% to 26%.32,33 Most studies were conducted in Europe (n = 9). Two trials were conducted in the United States, one in Malaysia, and one in Taiwan. Two RCTs36,38 were funded in part by companies that produce rehabilitation and orthopedic equipment. Six of the 13 studies were rated as moderate risk of bias due to lack of blinding (assessed uniquely for participants, providers, and outcomes). The remaining seven RCTs were at high risk of bias due to additional threats to the randomization process (Appendix G, Supplemental Digital Content 1, https://links.lww.com/PHM/B640). There were no nonrandomized comparative studies that addressed prehabilitation for TKA.
Only two specific prehabilitation interventions were evaluated by more than one study (two RCTs each)27,28,31,38; the remaining nine RCTs evaluated unique prehabilitation interventions composed of varying goals and exercise components (as coded by the taxonomy) in different combinations, delivered in varying settings (by different modalities) by diverse personnel (Figs. 1–3, Appendix F, Supplemental Digital Content 1, https://links.lww.com/PHM/B640).
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FIGURE 1: Overview of studies of prehabilitation to no prehabilitation for TKA. Figure presents studies (
n = 13) that evaluated prehabilitation programs for TKA versus various controls (predominately no active control with the exception of Mitchell et al.
32 which evaluated prehabilitation and postoperative rehabilitation combined vs. postoperative rehabilitation alone and did not include any active rehabilitation in the control arm during preoperative phase of the study). Study arms are described using study descriptors followed by goal components coded by the review team using the Oatis and Franklin taxonomy. The color is added for visual display and does not provide unique information. A, aerobic exercise; Adj, adjunctive; B, balance-motor/learning-agility exercise; E, patient education; F, flexibility exercise; HI, high intensity; NEMEX, neuromuscular exercise; postop, postoperative; prehab, prehabilitation; preop, preoperative; RT, resistance training; S, strengthening exercise; T, task-specific training; TENS, transcutaneous electrical nerve stimulation; TJR, total joint replacement. * Intervention included progression which was deemed appropriate.
Goal components strength, aerobic, and flexibility and their specific exercise components for prehabilitation interventions versus no prehabilitation for TKA. See
Figure 3 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities. ed, education; HI, high intensity; NEMEX-TJR, neuromuscular training program; preop, preoperative; PRT, progressive resistive training; rehab, rehabilitation; ROM, range of motion.
Goal components balance-motor-learning-agility, task-specific training, patient education, and adjunctive modalities and their specific exercise components for prehabilitation interventions versus no prehabilitation for TKA. See
Figure 2 for goal components strength, aerobic, and flexibility. ed, education; H, home; HI, high intensity; I, in-person; NA, not applicable; NEMEX-TJR, neuromuscular training program; O, outpatient physiotherapy center; prehab, prehabilitation; preop, preoperative; PreopPTEd, preoperative physical therapy education; PRT, progressive resistive training; R, remote; rehab, rehabilitation; SG, self-guided. A, Remote via telephone. B, Research personnel. C, Aquatic center.
Prehabilitation interventions were initiated between 2 and 12 wks before the scheduled TKA. The content of the specific prehabilitation programs varied across interventions. Most interventions included components to target strength (n = 11/13 prehabilitation arms) and flexibility (n = 10/13), followed by components to address task-specific training (n = 7/13), balance-motor-learning-agility (n = 5/13), and patient education (n = 5/13). Aerobic exercise was present in only two prehabilitation programs. Specific exercise components within prehabilitation goal components varied across programs. Only one study included an adjunctive modality (acupuncture) in combination with the prehabilitation program as compared with no prehabilitation.35 While one other study also assessed the effect of acupuncture, it was assessed alone and did not meet our eligibility criteria of co-occurring with a prehabilitation program; the specific acupuncture arm is therefore not discussed further.39 Six interventions reported some form of progression, of which three were assessed by clinical experts on our team as appropriate (i.e., the progression was based on patient-specific or individualized parameters as opposed to a universal, time-based progression).25,28,29,38 No study compared prehabilitation with progression versus without progression. While control groups were generally “no prehabilitation,” they were defined variably as “usual care,” “activities as usual,” or some form of minimal patient education.
Prehabilitation interventions were delivered by physical therapists in nine of the 13 studies. In other studies, at least one component of the intervention was delivered by research personnel,36 no one (i.e., unsupervised self-guided home component),27,31,36 or this information was not reported.30,37 With the exception of one study designed to be self-guided at home,31 all prehabilitation interventions had at least one part of the program delivered to patients in person: six in outpatient rehabilitation facilities, two in both outpatient and home environments (with either some remote support or a self-guided component), two exclusively at home, one at an aquatic center, and two in an unclear setting.
Description of the Prehabilitation for THA Evidence
Details on study designs, population characteristics, and detailed coding of prehabilitation interventions evaluated for THA patients can be found in Appendices H and I (Supplemental Digital Content 1, https://links.lww.com/PHM/B640), respectively. The six RCTs enrolled a total of 425 patients (between 45 and 94 participants each trial; median = 72). The average ages of participants ranged from 56 to 71 yrs. Between 25% and 80% of study participants were women. No trials reported information on the proportion of patients who had undergone previous contralateral THA. Half of the studies were conducted in the United States, the other half were conducted in Europe. Four of the 6 studies were rated as moderate risk of bias due to lack of blinding. The remaining 2 RCTs were at high risk of bias due to additional threats to the randomization process (Appendix J, Supplemental Digital Content 1, https://links.lww.com/PHM/B640). There were no nonrandomized comparative studies that addressed prehabilitation for THA.
Two studies evaluated a somewhat similar intervention involving a preoperative physical therapy program with targeting task-specific training and patient education goal.34,44 The remaining four studies evaluated unique prehabilitation interventions composed of varying goals and exercise components that were delivered in a variety of settings (Figs. 4, 5, Appendix I, Supplemental Digital Content 1, https://links.lww.com/PHM/B640). As with the TKA evidence, in the absence of meaningful groupings of interventions, we chose to summarize studies as a whole comparing prehabilitation to no prehabilitation.
FIGURE 4: Overview of studies of prehabilitation to no prehabilitation for THA. Figure presents studies (n = 6) that evaluated prehabilitation programs for THA versus nothing (defined by the study and the goal components coded by the Oatis and Franklin taxonomy). The color is added for visual display and does not provide unique information. A, aerobic exercise; Adj, adjunctive; B, balance-motor/learning-agility exercise; E, patient education; F, flexibility exercise; S, strengthening exercise; T, task-specific training. * Intervention included progression which was deemed appropriate.
FIGURE 5: Goal components and their specific exercise components for prehabilitation interventions versus no prehabilitation for THA. AI, acute in-patient; ed, education; G, gym/other community center; H, home; I, in-person; NA, not applicable; NR, not reported; O, outpatient physiotherapy center; preop, preoperative; PRT, progression resistance training; PT, physical therapy; rehab, rehabilitation.
The content varied across the specific prehabilitation programs for THA. Interventions included components to target strength (n = 3/6 prehabilitation arms), task-specific training (n = 3/6), and patient education (n = 3/6), followed by components to target flexibility (n = 1/6) and aerobic exercise (n = 1/6). No prehabilitation interventions included components of balance-motor-learning-agility or adjunctive modalities in combination with the prehabilitation components. Specific exercise components within prehabilitation goal components varied across programs.
Two studies reported some form of progression, of which one41 was assessed by clinical experts on our team as appropriate. No study compared prehabilitation for THA with versus without progression. “No prehabilitation” was defined variably across studies and was either no additional care (e.g., “no therapy,”40 “no additional care,”44 “care as usual,”41,42 or dissemination of information on surgical and postoperative expectations34,42,43).
Interventions were delivered by physical therapists in five of the six studies; Bitterli et al.40 did not define who delivered the in-person prehabilitation component of their intervention. Reported settings included home,40 an outpatient rehabilitation facility,41,42 and a community fitness center.43 Two studies did not report where prehabilitation was delivered.
Effectiveness of Prehabilitation Interventions
Compared with no prehabilitation, evidence from 13 studies suggests that prehabilitation before TKA may reduce length of stay (LOS) after surgery and increase strength postoperatively but may lead to comparable outcomes of pain, range of motion (ROM), and ADL (low SoE for all) disposition (Table 1). In addition, prehabilitation may not increase the risk of harms (low SoE). There was insufficient evidence on the impact of prehabilitation on quality of life (QoL) or need for postoperative procedures after TKA, and there was no evidence on patient satisfaction with care or posthospital disposition. For THA, evidence from six studies was insufficient or missing for all outcomes studied (Table 2). For studies assessing prehabilitation for TKA and THA, interventions and outcomes were too heterogeneous to explore whether outcomes varied by the presence of specific intervention factors (i.e., content, personnel, setting, progression). Complete data on all outcomes by outcome domain can be found in Appendix K (Supplemental Digital Content 1, https://links.lww.com/PHM/B640).
TABLE 1 -
Evidence profile: prehabilitation versus no prehabilitation for TKA
| Outcome Category |
Outcome |
No. Studies (Participants) |
RoB |
Consistency |
Precision |
Directness |
Intervention Replication |
SoE |
Conclusions |
| Body structure and function |
Pain |
9 (725) |
High |
Consistent |
Precise |
Direct |
2 studies evaluated a similar intervention; remainder unique |
Low |
Similar pain |
| ROM |
4 (448) |
Moderate |
Consistent |
Precise |
Direct |
All unique |
Low |
Similar ROM |
| Strength |
4 (257) |
Moderate |
Consistent |
Precise |
Direct |
All unique |
Low |
Increased strength |
| Activity and participation |
ADLs |
6 (636) |
Moderate |
Inconsistent |
Precise |
Direct |
All unique |
Low |
Similar ADL |
| Other outcomes |
Satisfaction with care |
0 |
NA |
NA |
NA |
NA |
NA |
Insufficient |
No evidence |
| QoL |
3 (356) |
Moderate |
Inconsistent |
Precise |
Direct |
All unique |
Insufficient |
No conclusion |
| Healthcare utilization |
LOS |
5 (485) |
Moderate |
Consistent |
Precise |
Direct |
All unique |
Low |
Reduced LOS |
| Posthospital disposition |
0 |
NA |
NA |
NA |
NA |
NA |
Insufficient |
No evidence |
| Need for postoperative procedures |
1 (122) |
Moderate |
Consistency unknown (single study) |
Precise |
Direct |
NA (single study) |
Insufficient |
No conclusion |
| Harms |
Harms from prehabilitation |
6 (474) |
Moderate |
Consistent |
Precise |
Direct |
All unique |
Low |
No increased harm |
NA, not applicable; RoB, risk of bias.
TABLE 2 -
Evidence profile: prehabilitation versus no prehabilitation for THA
| Outcome Category |
Outcome |
No. Studies (Participants) |
RoB |
Consistency |
Precision |
Directness |
Intervention Replication |
SoE |
Conclusions |
| Body structure and function |
Pain |
2 (129) |
Moderate |
Consistent |
Precise |
Direct |
Both unique |
Insufficient |
No conclusion |
| Strength |
1 (49) |
Moderate |
Consistency unknown (single study) |
Precise |
Direct |
NA (single study) |
Insufficient |
No conclusion |
| Activity and participation |
ADLs |
3 (209) |
Moderate |
Consistent |
Precise |
Direct |
All unique |
Insufficient |
No conclusion |
| Other outcomes |
Satisfaction with care |
0 |
NA |
NA |
NA |
NA |
NA |
Insufficient |
No evidence |
| QoL |
1 (80) |
Moderate |
Consistency unknown (single study) |
Precise |
Direct |
NA (single study) |
Insufficient |
No conclusion |
| Healthcare utilization |
LOS |
4 (277) |
High |
Inconsistent |
Precise |
Direct |
All unique |
Insufficient |
No conclusion |
| Posthospital disposition |
1 (94) |
High |
Consistency unknown (single study) |
NA |
Direct |
NA (single study) |
Insufficient |
No conclusion |
| Harms |
Harms from prehabilitation |
0 |
NA |
NA |
NA |
NA |
NA |
Insufficient |
No evidence |
NA, not applicable; RoB, risk of bias.
BODY STRUCTURE AND FUNCTION OUTCOMES
Prehabilitation for TKA
Ten RCTs reported on body structure and function outcomes (symptoms, pain, ROM, muscle strength, energy and vigor, and emotional functioning).25,28,29,31–33,35–39
Of the five RCTs that reported data on symptoms25,28,29,32,33,38 (using either the stiffness component of the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] or stiffness component of the Knee Injury and Osteoarthritis Outcome Score), four observed no differences between groups at 3 mos after TKA. One RCT found significantly reduced stiffness among patients randomized to high-intensity preoperative training compared with control (MD = –0.9, 95% confidence interval [CI] = –1.3 to −0.6) at 3-mo follow-up.25 Nine studies reported pain data using five different measurement instruments (the pain components of EuroQol-5D, Knee Injury and Osteoarthritis Outcome Score, 36-Item Short Form Health Survey, and WOMAC and various pain visual analog scales25,28,29,32,33,35–39). As with symptoms, most studies (n = 7) found no difference in pain between groups at 3 mos after TKA (and 1 study at 12 mos).28,29,32,33,35,36,38,39 Two studies reported statistically significant reduced pain in their respective prehabilitation programs.25,37 Calatayud et al.25 found that patients randomized to the high-intensity preoperative training had lower pain scores on the visual analog scale (MD = –1.5, 95% CI = –1.9 to −1.1) and the pain component of the WOMAC (MD = –0.9, 95% CI = –1.5 to −0.14) compared with patients who did not receive prehabilitation training, and Valtonen et al.37 found patients randomized to aquatic training reported a 58% decrease in pain (P = 0.001; MD not reported) compared with patients who continued life as usual.
Four RCTs or fewer reported data on ROM (n = 4),25,28,29,31,33 strength (n = 4),25,28,29,33,36 energy and vigor (n = 2),28,29,32 and emotional function (n = 2)28,29,32 and found mixed results. Specifically, two RCTs25,31 found their respective prehabilitation programs (high-intensity preoperative training, preoperative home exercise) led to statistically significant improvements in knee ROM compared with no prehabilitation; the other two RCTs did not.28,29,33 Two RCTs found their respective prehabilitation programs (high-intensity preoperative training, preoperative progressive resistance training) led to statistically significant improvements in strength compared with no prehabilitation and two RCTs did not. The two studies reporting on energy and vigor and emotional function found no significant differences between prehabilitation and no prehabilitation at 3 mos after surgery.28,29,32
Prehabilitation for THA
Three RCTs40,41,43 reported on body structure and function outcomes (symptoms,41 pain,41,43 ROM,41 strength,43 energy and vigor,40 and emotional functioning40) and observed no differences between groups 6–12 mos after THA for all outcomes except energy and vigor and emotional functioning. One study, Bitterli et al.,40 found an improvement in vigor and emotional functioning (measured using the vitality and emotional functioning components of the 36-Item Short Form Health Survey, respectively) among patients randomized to the preoperative home exercise sensorimotor training program compared with those who received no preoperative therapy (P < 0.05) at 12 mos after surgery.
ACTIVITY AND PARTICIPATION OUTCOMES
Prehabilitation for TKA
Nine RCTs reported on activity and participation outcomes (physical function and ADL, repeat sit-to-stand test, balance, walking speed, walking distance, stair ascent and descent, and timed up and go).25,28,29,32,33,35–39
Eight RCTs reported data on patient-reported physical function and ADLs using six different tools measured at follow-ups between 3 and 12 mos after TKA surgery.25,28,29,31–33,35,38,39 All but one study found no difference between groups. Calatayud et al.25 reported function using the physical component of the 36-Item Short Form Health Survey (0–100, higher is better) and the physical function component of the WOMAC (0–68, lower is better) and found significant improvements in function on both measures (36-Item Short Form Health Survey: MD = 2.7, 95% CI = 1.3 to 4.1; WOMAC: –3.9, 95% CI = –5.2 to −2.7) among patients randomized to high-intensity preoperative training compared with patients who did not receive prehabilitation training at 3-mo follow-up.
Five studies or fewer reported on various outcomes of mobility and balance and found mixed results. Of the four RCTs28,29,33,36,37 to report data on the sit-to-stand test, two RCTs33,37 reported statistically significant improvements due to their respective prehabilitation programs (preoperative progressive resistance training, aquatic training), and two RCTs did not. Of the five RCTs28,29,33,35,37,39 reporting walking speed, two studies found statistically significant walking improvements among patients randomized to their respective prehabilitation programs (preoperative progressive resistance training, aquatic training) and three studies did not. Two RCTs25,36 reported data on stair tests; one study reported statistically significant improvements among patients randomized to high-intensity preoperative training, and the other did not. Three RCTs25,28,29,33 reported data on the timed up and go test; two RCTs25,33 reported patients randomized to their prehabilitation programs (high-intensity preoperative training and progressive resistance training) completed the timed up and go test significantly quicker than control patients at 3 mos after surgery; one study did not.36 Two RCTs33,36 reported walking distance during the 6-min walk test and neither observed significant differences between prehabilitation and control at 3 mos after surgery. One study reported various measures of balance and found significant improvements in two of the three balance measures (anteroposterior range of center of pressure: MD = –3.2 [95% CI –4.0 to −2.4]; center of pressure area: –7.4 [95% CI −12.3 to −2.4]) among patients randomized to the high-intensity preoperative training compared with control at 3 mos after surgery.
Prehabilitation for THA
Three RCTs reported on activity and participation outcomes and observed no differences between groups a follow-up ranging from 6 to 12 mos after THA for all outcomes, except balance and mobility, which observed statistically significant results in favor of prehabilitation in one study each.40,41
OTHER PATIENT-REPORTED OUTCOMES
Prehabilitation for TKA
Seven RCTs reported on other patient-reported outcomes (health-related QoL, patient global assessments).25,28,29,32,33,35,38,39 Three RCTs reported data on QoL using two outcome measures.28,29,33,38 Two studies reported comparable QoL scores between prehabilitation and control groups at 3 mos after TKA,28,29,38 whereas one study observed improved QoL among patients randomized to prehabilitation (progressive resistance training) compared with no prehabilitation at 3 mos after surgery in one of the two QoL outcomes they measured.
Five RCTs reported data on patients’ self-reported global assessment of their health using three different measurement instruments. Only one study found significant improvements on the total WOMAC scale (score 0–96; smaller is better) among patients randomized to the high-intensity preoperative training group compared with control (MD = −5.8, 95% CI = −7.6 to −3.9) at 3 mos after surgery.25 All other studies reported comparable findings in patients’ global health assessment scores among prehabilitation and control groups at 3 mos after surgery.
Prehabilitation for THA
Only one RCT41 reported other patient-reported outcomes (health-related QoL) and observed no differences between groups at 12-mo follow-up after THA.
No studies assessing prehabilitation for TKA or THA reported on patient satisfaction with care.
HEALTHCARE UTILIZATION OUTCOMES
Prehabilitation for TKA
Five RCTs provided data on LOS.25,27,31,34,39 Three of these studies found statistically significant reductions in LOS following TKA among patients randomized to prehabilitation compared with control group (ranging from 1 to 2 hospital days). Matassi et al.31 reported on need for postoperative procedures and found comparable rates of patients reporting stiff knee who went on to receive manipulation under anesthesia between groups. Soeters et al.34 reported that patients randomized to prehabilitation were more likely to meet physical therapists discharge criteria and require fewer outpatient therapy sessions, as compared with the control group.
Prehabilitation for THA
Four RCTs34,40,42,44 studies reported on healthcare utilization outcomes. Of the four RCTs that provided data on LOS following THA, only one study reported that LOS was significantly reduced among patients who were randomized to prehabilitation compared with control (MD not reported; P = 0.001).
Three RCTs34,42,44 reported data on discharge disposition, time to postacute physical therapy discharge criteria, and the number of outpatient physical therapy sessions required. Pour et al.42 reported that patients randomized to the accelerated prehabilitation group (which comprised prehabilitation) were more likely to be discharged home (odds ratio = 3.73, 95% CI = 1.23 to 11.32) and less likely to be discharged to a skilled rehabilitation facility (odds ratio = 0.26, 95% CI = 0.08 to 0.78), as compared with patients who received no prehabilitation.
As with TKA patients above, Soeters et al.34 reported that THA patients randomized to prehabilitation were more likely to meet physical therapists discharge criteria and require fewer outpatient therapy sessions, as compared with the control group. Vukomanović et al.44 also reported that patients randomized to prehabilitation had fewer outpatient physical therapy sessions compared with those who received no prehabilitation.
HARMS FROM PREHABILITATION
Only six of the 13 RCTs evaluating prehabilitation for TKA reported on harms associated with the prehabilitation programs.28,29,31,33,35,38,39 Five studies reported no harms related to the prehabilitation intervention.28,29,33,35,38,39; one study reported minor exercise-related complaints in two patients. No RCT reported data on harms from prehabilitation for THA.
HETEROGENEITY
No studies reported subgroup analyses or more specifically, formally analyzed possible heterogeneity of treatment effects, such as statistical tests for whether the effect of prehabilitation versus its various comparators differed in one subgroup of patients versus another (e.g., patients with higher vs. lower measures of strength, flexibility, function, etc. at baseline).
DISCUSSION
The evidence base supporting prehabilitation for TKA and THA is limited. We found low SoE that prehabilitation before TKA may lead to reduced LOSs and increased strength, but comparable improvements in other patient-reported, performance-based, or healthcare utilization outcomes. No or insufficient evidence for prehabilitation before THA precluded conclusions for all other outcomes. Thus, the decision of whether for health systems and providers to provide prehabilitation (or for patients, to participate in prehabilitation) seems to be still largely hypothetical; more evidence is needed to empirically demonstrate the effectiveness of prehabilitation before major joint replacement, particularly for THA in which the evidence is most limited.
As demonstrated by our detailed coding, prehabilitation interventions are substantially diverse in their content and methods of delivery. Indeed, the interventions were so diverse that almost the only thing they had in common was that they were delivered before surgery. Such heterogeneity poses challenges to learning across studies to understanding the effectiveness of prehabilitation (or effectiveness of particular attributes of prehabilitation), particularly when interventions are not well defined using a standardized terminology and each study reports different outcomes. In the present review, almost all interventions were unique in terms of the goals of the intervention and the specific exercise components within these goals, as defined by our coding scheme and not one outcome was reported by all studies to offer a comparable measure to assess the effect of prehabilitation in general or the relative effect of different interventions or their components parts. Future trialists of novel prehabilitation interventions should consider the use of a standardized taxonomy to define intervention content (such as the taxonomy used to code content in this review),45 report intervention content using standardized reporting templates such as the Template for Intervention Description and Replication checklist,46 and report the impact of prehabilitation on core outcomes established by the field.47,48 Despite the detailed coding of interventions, timing and intensity/dosage were not well captured (in part because of the challenges of reporting, but also because of complexity) and may be considered a limitation of the review. In addition, use pharmacological agents (particularly as adjunctive to prehabilitation) may represent an important confounding variable but were considered beyond the scope of this review.
In conclusion, it remains unclear whether prehabilitation improves outcomes for adults after total joint replacement. More evidence from a coordinated and systematic plan of research is needed to ascertain whether prehabilitation would benefit patients who will undergo TKA or THA. Although there is suggestion of reduced need for acute care and increased strength among TKA patients, evidence for all other outcomes is either inconclusive or lacking. There is a compelling need for well-conducted studies that address both effectiveness (and harms) of interventions and heterogeneity of treatment effect using standardized intervention terminology and core outcome sets.
ACKNOWLEDGMENTS
The authors thank David W. Niebuhr, MD, MPH, MSc, our AHRQ Task Order Officer; members of the Key Informant and Technical Expert Panels, reviewers of our overall review (all listed in the AHRQ full report); Jennifer Racine-Avila, MBA, for early feedback and development of the protocol; Carol A. Oatis, PT, PhD, for sharing her taxonomy and providing important conceptual feedback in its application; and Shivani Mehta, BA, a research associate who played a role in conduct of the overall review.
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