Prehabilitation May Not Improve Knee Replacement Results
Laird Harrison
March 09, 2022
Exercises and education prescribed as prehabilitation before total knee
replacements (TKR) may not significantly improve the outcomes of the surgery,
researchers say.
"This randomized clinical trial found no evidence that multidisciplinary
prehabilitation before TKR for
osteoarthritis improves short-term functional independence or reduces midterm activity
limitations after surgery," write Christelle Nguyen, MD, PhD, Cochin
Hospital, University Center, Paris, and colleagues in
JAMA Network Open .
The finding contradicts previous research and the approach followed by
many surgeons who assign weeks of regimens to improve their patients'
health before operating on them.
But the limitations of the study make its significance hard to interpret,
said Bert Mandelbaum, MD, in an interview with
Medscape Medical News. Mandelbaum is professor of orthopedics at Cedars-Sinai Kerlan-Jobe Institute
in Los Angeles, California, and team physician for the Los Angeles Galaxy
professional soccer club, and was not involved in the study.
Previous research has shown that people fare better after
total knee replacement if they start out in good health. And a few studies have suggested that
physical therapy, exercise therapy, occupational therapy, and education,
either alone or in combination, can improve outcomes and shorten hospital
stay. But most of these studies have had small sample sizes.
In search of more definitive evidence, Nguyen et al. recruited —
from three French tertiary care centers — 178 women and 84 men,
with a mean age of 68.6 years, whose osteoarthritis made them candidates
for total knee replacement.
The researchers randomly assigned the patients to two groups of 131 each.
One group received standard advice at the discretion of their surgeons
and an information booklet.
The other group received the same information, advice, and rehabilitation.
In addition, they experienced four supervised sessions of education and
exercises for 2 weeks starting 2 months before their knee replacement.
The sessions consisted of 30 minutes of education and 60 minutes of exercises.
In the educational sessions, they learned about the positive effects of
exercise therapy, work rehabilitation, social support, weight management,
stress and anxiety, and returning home.
The exercise program consisted of muscle strengthening, lower-limb stretching,
endurance training, proprioception exercises, walking and balance exercises,
training to perform four functional tests (transfer from lying to sitting,
transfer from sitting to standing, walking 30 meters, and going up and
down a flight of stairs), and a home-based program.
The regimen didn't seem to make much difference. Tested a mean of four
days after the surgery, only 34% of the patients who underwent prehabilitation
had achieved functional independence, defined as their ability to perform
the four functional tests without help. That was scarcely better than
the 27% of the control group who attained that outcome; the difference
was not statistically significant (P = .15).
At 6 months, the mean area under the curve of the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) function subscale was 38.10 mm2 in the group that underwent the experimental program, versus 40.7 mm2 in the control group, a difference that was also not statistically significant (P = .31).
The researchers found no evidence of reduced pain or activity limitations,
improved health-related quality of life, or increased number of steps
in the previous week in the experimental group compared with the control
group at 6 and 12 months after surgery.
The researchers also found that the mean costs of the two groups were equivalent:
€15,573 ($20,516) in the experimental group versus €15 987 ($21,061)
in the control group.
One possible explanation for the small difference between the two groups
could be low participation: 33% of the patients assigned to the prehabilitation
group didn't participate, perhaps because they had such severe arthritis
that they found the regimen burdensome. "Prehabilitation should probably
include more targeted modalities than the ones delivered in the current
study," the researchers write. "For example, a preoperative,
simplified, home-based rehabilitation education program could represent
a more acceptable solution in this population."
The researchers also noted that the effectiveness of total knee replacement
itself could have obscured benefits from the prehabilitation. And they
noted that the information booklet and standard advice given to the control
group could have improved the outcomes for those patients.
That's an important consideration, Mandelbaum said. "As far as
I can see, there's no way to determine what the people were doing
or not doing in the control group."
Another limitation to the study is that WOMAC scores don't measure
activity levels above a basic level, Mandelbaum said. If some patients
improved their ability to do more demanding activities, such as hiking,
this study would not have captured that improvement, he said.
Clinicians should recommend exercise regimens to their patients before
surgery, he said. "It's just common sense."
JAMA Network Open. 2022;5(3):e221462. doi:10.1001/jamanetworkopen.2022.1462. Published online
March 9, 2022.
Full text
Authors reported relationships with Medacata, Grunenthal, Zimmer, Adler,
the French Ministry of Health, and Programme Hospitalier de Recherche
Clinique. The study was funded by the French Ministry of Health. Mandelbaum
reported no relevant financial relationships.
Laird Harrison writes about science, health, and culture. His work has
appeared in national magazines, in newspapers, on public radio, and on
websites. He is at work on a novel about alternate realities in physics.
Harrison teaches writing at the Writers Grotto. Visit him at www.lairdharrison.com or follow him on
Twitter: @LairdH.
For more news, follow Medscape on
Facebook,
Twitter,
Instagram,
YouTube, and
LinkedIn.
Medscape Medical News © 2022
Cite this: Prehabilitation May Not Improve Knee Replacement Results -
Medscape - Mar 09, 2022.