Study Shows Prehabilitation Before Total Knee Replacement Doesn't Improve Outcome

Christelle Nguyen, MD, PhD

The results of a recent study question the value of prehabilitation before a total knee replacement (TKR). No evidence was found that idicated improvements in short-term functional independence after surgery. According to investigators, osteoarthritis (OA) is the most common osteoarticular disease and a leading cause of disability worldwide.

Initial approaches when treating an individual with knee osteoarthritis include targeting symtoms like pain, stiffness and activity limitations. However, when those therapies don't help to alleviate symptoms, total knee replacement is considered.

While there's some evidence that suggested prehabilitation before the surgery may slightly improve physical and functional outcomes and reduce the length of hospital stay, many trials were found to be low or moderate quality. Additionally, large clinical trials that assess short-term and midterm effects of this practice are lacking.

The Intervention

Investigators, led by Christelle Nguyen, MD, PhD, Université de Paris, Faculté de Santé, Unités de Formation et de Recherche de Médecine, performed a prospective, open-label randomized clinical trial to compare how multidisciplinary prehabilitation and the usual care routine before the procedure would impact functional outcomes following a total knee replacement.

Rectuitment of patients 50-85 years of age began in October 2012 with the follow-up completed in November 2017 and statisal analyses took place between March 2018-March 2019. Patients met the American College of Rheumatology (ACR) criteria for knee osteroarthritis and were scheduled for total knee replacement at 3 French tertiary care centers.

Patients either received an informational booklet and standard advice from their orthopedic surgeon (control group) or they participated in 4 supervised sessions of prehabilitation and education. The multidisciplinary approach consisted of 2 sessions per week, at least 2 months before surgery, delivered to groups of 4-6 patients at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy.

The Statistical Analyses

"This randomized clinical trial found no evidence that a multidisciplinary rehabilitation education program before TKR improves functional independence or reduces activity limitations in people with knee osteoarthritis after surgery," investigators wrote. "However, the interpretation of the results of this trial is limited by the low uptake of the experimental intervention."

A total of 262 patients were randomized with 131 in each group. When assessing the short-term primary outcome, investigators found that after an average of 4 post-surgery, 34% of patients in the experimental group acheived functional independence, compared with 27% from the control group (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P=.15).

As for the midterm primary endpoint at 6 months, the mean area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group compared with 40.6 (17.8) mm2 in the control group (absolute difference, −2.8 mm2; 97.5% CI, −7.8 to 2.3; P = .31 after multiple imputation).

"We found no evidence that our intervention improved any of the secondary end points (ie, pain, quality of life, level of physical activity, and costs)," investigators wrote. "Even though these outcomes belong to the core outcome set for knee osteoarthritis, our intervention may not have been specifically designed to target these dimensions."

The study "Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes" was published in JAMA Network Open.