The Journal of Arthroplasty 30 (2015) 1657–1663

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total

Knee Arthroplasty? — A Systematic Review
Iris H.Y. Kwok, BMedSci (Hons), MRCS, MSc ,
Bruce Paton, Bach Appl Sc (Physiotherapy), Fares S. Haddad, MCh (Ortho), FRCS, Dip Sports Med FFSEM
University College London Hospital, London, UK

a r t i c l e i n f o a b s t r a c t

Article history: We undertook a systematic review of 11 randomised controlled trials comparing patient outcomes in total knee
Received 10 February 2015 arthroplasty in those who had undergone pre-operative physiotherapy-based interventions against control
Accepted 3 April 2015 groups. Results show that there is little evidence that pre-operative physiotherapy brings about significant
improvements in patient outcome scores, lower limb strength, pain, range of movement and hospital length of
Keywords:
stay following total knee arthroplasty. The overall quality of the studies was moderate to poor, mostly due to
knee arthroplasty
osteoarthritis
the small sample sizes.
physiotherapy © 2015 Elsevier Inc. All rights reserved.
exercise
knee replacement

In the UK, the prevalence of painful disabling knee osteoarthritis in
people over 55 years is 10%, a quarter of whom are severely disabled
[1]. In patients with intractable pain and functional impairment failing
conservative management, total knee arthroplasty (TKA) is a successful
treatment for reducing pain as well as improving function and quality of
life [2–6]. According the National Joint Registry, over 84,000 primary
TKAs were performed in the UK in 2012, 58,500 of which were performed
in National Health Service (NHS) hospitals. Short-term to medium-term
survivorship is excellent across almost all common types of total knee
arthroplasties and mortality of the procedure is low, at 0.4% at 90 days
after surgery [7]. Despite the success of surgery, functional deficits do re-
main post-operatively when these patients are compared to age-matched
and gender-matched peers with no history of knee pathology. This is par-
ticularly noticeable when performing activities of increasing demand
requiring quadriceps strength, flexibility and control [8,9].
Several factors have been shown to influence outcomes following
TKA. These include pre-operative levels of knee pain, strength, flexibility
and functional ability [10–12]. It is therefore hypothesised that pre-
operative physiotherapy, often known as prehabilitation should im-
prove post-operative outcomes.
Prehabilitation is the process of enhancing functional capacity in a pa-
tient in order to allow him or her to withstand the stressor of inactivity
associated with an orthopaedic procedure. Fig. 1 illustrates the theory of
prehabilitation [13]. A generic prehabilitation programme incorporates
the components of warm-up, aerobic exercise, resistance training, flexibi-
lity training, proprioceptive training and practising of functional tasks [13].
‘Physiotherapy’ is a broad term which is often difficult to define. It
can refer to and include different treatment modalities such as exercise
therapy, manual therapy, soft tissue therapy, electrotherapy and hydro-
therapy. In this review, ‘physiotherapy’ refers to exercise therapy alone.
The evidence on the efficacy of pre-operative physiotherapy on the
post-operative outcomes in TKA has so far been weak or inconclusive.
Patients undergoing TKA do not seem to benefit from pre-operative ex-
ercise training to the same degree as those undergoing total hip
arthroplasty [14]. Several systematic reviews have been carried out
looking at prehabilitation on outcomes of hip and knee arthroplasty sur-
gery but few have looked at its effect on TKA in isolation [15–17]. A
mini-review was carried out in 2004 for TKA alone but only two RCTs
were compared [18]; since then several trials have been published on
this topic.
The aim of this systematic review was to evaluate the evidence on
whether pre-operative physiotherapy improves patient outcomes
following TKA.
Methods

Data Acquisition: Search Strategy

No author associated with this paper has disclosed any potential or pertinent conflicts
which may be perceived to have impending conflict with this work. For full disclosure
statements refer to http://dx.doi.org/10.1016/j.arth.2015.04.013.
In June 2014, four computer databases were searched: MEDLINE
Reprint requests: Iris HY Kwok, BMBS, BMedSci (Hons), MRCS, MSc, C62 Herbal Hill (1946 to June Week 3 2014), Embase (1980 to 2014 Week 26),
Gardens, 9 Herbal Hill, London EC1R 5XB, UK. CINAHL (1982–2014) and PEDro (Physiotherapy Evidence Database)

http://dx.doi.org/10.1016/j.arth.2015.04.013
0883-5403/© 2015 Elsevier Inc. All rights reserved.
1658 I.HY. Kwok et al. / The Journal of Arthroplasty 30 (2015) 1657–1663

(until June 2014). Searches were limited to human and English studies could be blinded from the study. Therefore this limits the maximum
published in peer-reviewed journals. possible PEDro score to 8.
In order to be included in the review, each trial had to: The study by Rodgers et al (1998) used a quasi-randomised alloca-
tion for the intervention and control groups, based on geographical
(1) Be a randomised controlled trial (RCT) or have a quasi-
feasibility for participation in the physiotherapy programme.
randomised design;
(2) Be conducted in patients with osteoarthritis undergoing TKA;
Study Characteristics
(3) Compare the pre-operative effects of a physiotherapy-based
intervention to a control group;
Means and standard deviations (SD) for the outcomes of interest
(4) Have an intervention involving a formal physiotherapy or
were obtained from each of the studies. The study subject characteris-
exercise-based programme, not simply education, nor a single
tics are summarised in Table 2. The age means between the studies
physiotherapy session;
and the male to female ratios were comparable.
(5) Have pain and/or functional outcomes assessments made post-
operatively.
Interventions
Exclusion criteria for trials included: (1) studies looking at
The contents of each physiotherapy exercise programme are
unicompartmental knee arthroplasty and (2) publications where full
outlined in Table 3. Components of programmes typically included
text was unavailable.
warm-up, lower limb stretching and strengthening. Three studies in-
Comprehensive search strategies were constructed using subject
cluded aerobic training [22–24] and three studies included step training
heading mapping. Combinations of search terms were used in all the
[25–27]. Proprioceptive and balance training were used in two studies
databases: ‘knee,’ ‘osteoarthritis,’ ‘replacement,’ ‘arthroplasty,’ ‘knee pros-
[28,29]. Six of the programmes had a home exercise component,
thesis,’ ‘physical therapy,’ ‘physiotherapy,’ ‘preoperative’ and ‘exercise.’ An
where the study subjects could carry out the exercises without physio-
example of the search on MEDLINE and Embase is shown in Appendix 1.
therapist supervision [25–30]. The duration of the physiotherapy
Cross-referencing and hand searches of the reference lists of
programmes typically lasted 6 weeks but varied between studies, ranging
shortlisted studies were carried out to retrieve additional results. A
from 3 to 8 weeks.
total of 689 results were retrieved from the initial search. 668 studies
were excluded on the basis of the title of abstract, the study content, lan-
Results
guage or if there were duplications. Of the remaining 21 studies, 10 were
excluded as they were of the wrong study type, did not include post-
Due to the wide variation in the outcome measures used in different
operative outcome measures or were not available in full text. 11 studies
trials, it was difficult to aggregate the results from the RCTs for statistical
met the pre-defined criteria and were used in this systematic review.
analyses. Some studies did not provide adequate numerical data for results
Fig. 2 illustrates the decision making process in the selection of studies.
to be combined. The outcomes from each study are summarised in Table 4.

Assessment of Methodological Quality Summary of Evidence

The criteria used in the PEDro scale were used to assess the metho-
dological quality of the studies [19], based on the original Delphi list de-
veloped in 1998 [20,21]. The PEDro scale determines which randomised
clinical trials are internally valid and could have sufficient statistical in-
formation for their results to be interpretable. Criterion 1 (specification
of eligibility criteria) relates to external validity but is not used to calcu-
late the total PEDro score. RCTs scoring 6 or above are considered metho-
dologically to be of moderate to high quality.
PEDro scores ranged from 3 to 8, with six studies considered to have
good methodological quality (score ≥6/10) (Table 1). The nature of the
RCTs reviewed is such that neither the participant nor the therapist
Does Pre-Operative Physiotherapy Improve WOMAC or SF-36 Outcome
Scores After TKA?
Of the eleven studies that were included in this review, five of them
included WOMAC as a self-reported clinical outcome score. None of the
five studies showed significant improvement in either the overall
WOMAC score, or the individual components of pain, stiffness and func-
tion when comparing the treatment and control groups [22,24,28,29,31].
The SF-36 was used in five studies, none of which showed significant
improvement between the intervention and control groups. In one
study, the intervention group scored significantly higher in the Physical
Functioning component of the SF-36 three months post-operatively

Fig. 1. Theoretical model of prehabilitation in patients undergoing TKA [13].

 I.HY. Kwok et al. / The Journal of Arthroplasty 30 (2015) 1657–1663 1659

Searched:
Score (VAS)). No significant differences were found in pain reduction
MEDLINE, Embase, CINAHL, PEDro between intervention and control groups after TKA surgery in all of
these studies. Topp et al (2009) reported a significant reduction in pain
in both the intervention and control groups, but did not mention whether
the difference between the two groups reached statistical significance.

Does Pre-Operative Physiotherapy Improve Knee ROM After TKA?

689 results Range of movement was reported in four studies [22,23,30,31]. None
of these demonstrated any significant differences in active or passive
Excluded 668 range of movement between the intervention and control groups
• Based on title or abstract post-operatively. However, in the study by Matassi et al (2014), patients
• Study content in the intervention group reached 90 degrees of knee flexion at 5.8 days,
• Duplications 1.1 days shorter than the control group (P = 0.0016).
• Not in English
21 studies selected
Does Pre-Operative Physiotherapy Affect Hospital length of Stay After TKA?
Hospital length of stay (HLOS) was reported in four studies
Excluded 10
[26,29,31,32]. Of these, only the study by Matassi et al (2014) showed
• Based on study type
• Outcome measures a significant reduction in HLOS by 0.8 days. The other three studies
• No full text showed a reduction in HLOS in the intervention group that did not
reach statistical significance, ranging from 0.1 to 1.5 days [29,31,32].
Accepted 11 studies Interestingly, Rooks et al (2006) found that exercise participation
prior to surgery substantially reduced the odds of discharge to a rehabili-
Fig. 2. Flow diagram illustrating the decision making process in the selection of studies.
tation facility — 38% of patients in the intervention group compared to
65% in the control group.
(P = 0.04), but none of the other components nor the overall score
showed significant difference [25]. Discussion

Does Pre-Operative Physiotherapy Improve Lower Limb Strength After TKA? The overall quality of evidence for pre-operative physiotherapy on
Lower limb strength was reported in five studies, expressed either as outcomes following TKA was moderate to poor. Only six out of the 11
peak flexion/extension torque or force generated [22–24,27,31]. Quad- studies reviewed were of good methodological quality according to
riceps strength and/or hamstring strength did not show any significance the PEDro score.
between intervention and control groups post-operatively. One study In terms of study design, one of the major limitations of the RCTs
showed that peak knee flexion strength showed modest gains in the reviewed was the very small sample sizes used. The numbers of subjects
treatment group but not extension strength. However, the strength in some studies were as low as 10 patients per treatment arm [22,23,32].
gains in this intervention group were not seen in the immediate post- The results from these studies were therefore not adequately powered.
operative period but only from 6 weeks to 3 months after surgery. Even with studies adequately powered for clinical outcomes, the sample
Topp et al (2009) reported that post-operative quadriceps strength sizes were still inadequate for health service costing measures.
was increased in the intervention group compared to their pre- Geographical constraints are an important consideration when a
operative baseline. They also had a significant improvement in perfor- single-site intervention is used. Five studies in this review did not use
mance in all of the functional tasks apart from the 6-minute walk. a home exercise programme and involved patients travelling to the
physiotherapy-providing facility on a frequent and regular basis. This
Does Pre-Operative Physiotherapy Improve Pain After TKA? can introduce selection bias to study participants and can lead to a
Pain was reported in eight studies, either as a component of one of low overall recruitment rate for trials. Non-participation is often seen
the outcome scores (e.g. WOMAC, SF-36, or as a pain Visual Analogue in elderly, rural-dwelling patients with restricted transportation options
[22]. Although very few studies reported their participant dropout rates,
geographical constraints may have contributed to non-completion of
Table 1 prehabilitation programmes. For future trials, convenience of the loca-
Methodological Quality of Included RCTs.
tion of intervention and outcome testing ought to be an important
Study PEDro Scores consideration [24].
1 2 3 4 5 6 7 8 9 10 11 Total Most interventions involved multi-modal physiotherapy, encompassing
a combination of different types of exercises – warm-up, aerobic exer-
D’Lima et al (1995) 1 1 0 1 0 0 0 0 0 0 1 3
Rodgers et al (1998) 1 0 0 0 0 0 0 1 0 1 1 3 cise, resistance training, flexibility training, proprioceptive training
Beaupre et al (2004) 1 1 1 1 0 0 1 0 1 1 1 7 and practising of functional tasks – with or without patient education.
Rooks et al (2006) 1 1 0 1 0 0 0 0 1 1 1 5 However, the components of exercise programmes were very variable
Williamson et al (2007) 1 1 1 1 0 0 1 1 1 1 1 8 in different studies, with one utilising proprioceptive training only
Evgeniadis et al (2008) 1 1 1 1 0 0 0 0 1 1 1 6
[28] and another four which did not include aerobic exercise training
Topp et al (2009) 1 1 0 1 0 0 0 1 0 0 1 4
Gstoettner et al (2011) 1 1 1 1 0 0 0 1 0 1 1 6 [29–32]. As there is little evidence as to which types of exercise are
Brown et al (2012) 0 1 1 0 0 0 0 0 0 1 1 4 most effective in bringing about improvements in post-operative
McKay et al (2012) 1 1 1 1 0 0 0 0 1 1 1 6 outcomes, a combination approach may dilute out the impact of more
Matassi et al (2014) 1 1 0 1 0 0 1 1 0 1 1 6
effective elements.
Number of Studies 10 10 6 9 0 0 3 5 5 9 11 –
Fulfilling Criteria In the studies reviewed, little information had been given on exer-
cise intensity and dosage. Percentage of VO2 peak in aerobic training
PEDro criteria: 1. Specification of eligibility criteria. 2. Random allocation. 3. Concealed
allocation. 4. Baseline similarity between groups. 5. Subject blinding. 6. Therapist blinding.
or torque per body weight in strength training is a useful measure of
7. Assessor blinding. 8. N85% follow-up. 9. Intention-to-treat analysis. 10. Between-group exercise dosage. However these measurements require specialist equip-
statistical comparison. 11. Point measures and measures of variability reported. ment and may be costly to carry out. Rate of perceived exertion (RPE) is
1660 I.HY. Kwok et al. / The Journal of Arthroplasty 30 (2015) 1657–1663

Table 2
Study Subject Characteristics.

Surgery Type Group n Age Mean (SD) Sex % Female

D’Lima et al (1995) Primary unilateral TKR Intervention A 10 68.5 (4.6) 70

USA Intervention B 10 71.6 (6.6) 20
Control 10 69.5 (6.5) 50
Rodgers et al (1998) Primary unilateral TKR Intervention 10 70 (range 63–78) 60
USA Control 10 65 (range 50–83) 50
Beaupre et al (2004) Primary TKR Intervention 65 67 (7) 60
Canada Control 66 67 (6) 50
Rooks et al (2006) Primary unilateral TKR Intervention 22 65 (8) 50
USA Control 23 69 (8) 57
Primary unilateral THR Interventiona 32 65 (11) 63
Controla 31 59 (7) 52
Williamson et al (2007) Primary KR (unicondylar or total) Intervention A 60 70 (8.8) 52
UK Intervention Ba 60 72.4 (7.7) 55
Control 61 69.6 (10) 54
Evgeniadis et al (2008) Primary TKR Intervention A 18 67.1 (4.4) 83
Greece Intervention Ba 15 68.6 (5.9) 87
Control 20 69.4 (1.9) 70
Topp et al (2009) Unilateral TKR Intervention 26 64.1 (7.1) 68
USA Control 28 63.5 (6.7) 68
Gstoettner et al (2011) Unilateral TKR Intervention 18 72.8 (range 65–78) 89
Austria Control 20 66.9 (range 61–75) 70
Brown et al (2012) TKR Intervention 17 – –
USA Control 15 – –
McKay et al (2012) Unilateral TKR Intervention 10 63.5 (4.9) 50
Canada Control 12 60.6 (8.1) 67
Matassi et al (2014) Primary unilateral TKR Intervention 61 66 (7.2) 54
Italy Control 61 67 (7.7) 43
a
Had additional experimental groups which were not included in the current review.

a simple and effective means of measuring exercise intensity and should
be measured in future studies.
Pain, swelling and joint stiffness from osteoarthritis limit the exercise
intensity attained by patients. Therefore patients may be unable to work
at sufficient levels of intensity to bring out strength improvements and
tissue change. In the RCTs reviewed, there was no mention of the types
and quantity of analgesia consumed prior to physiotherapy sessions and
when clinical measurements were made; analgesic heterogeneity may
lead to variability and inconsistency in results. In future studies, this
could be taken into account by standardising or recording the amount
of analgesia received by the participants in the previous 24 hours.
Physiotherapy exercises tend to use closed-chain isotonic exercises
whereas strength testing in these studies often utilised open-chain
isokinetic measurements using the Cybex isokinetic testing device.
The principle of specificity of training is key when choosing appropriate
outcome measurement tools. Functional task performance varies de-
pending on the muscle group utilised and the movement patterns per-
formed [33,34]. Inconsistencies between prehabilitation and strength
measurement procedures mean that significant differences in strength
may have been present but not detected or measured [22,23,27].
Lower limb strength is often measured by different methods; a leg
press replicates a more functional movement than leg extension alone.
The former incorporates hip and knee movement, and does not isolate
quadriceps muscle strength like leg extension does. It is therefore more
accurate a reflection of the ability to carry out daily functional activities.
Often exercise programmes do not work to reach evidence-based
levels of intensity and duration to bring about fitness change in the
elderly. The American College of Sports Medicine guidelines currently
recommend resistance training three times a week, with each session
approximately 30 minutes in duration in order to bring about

Table 3
Content and Design of Interventions.

Programme Used Duration of No. of Session Duration Frequency Supervised?

Programme Sessions

D’Lima et al (1995) Lower limb stretching 6 weeks 18 45 mins 3×/wk Yes

Lower limb isometric and isotonic strengthening
Rodgers et al (1998) Lower limb stretching, warm-up, strengthening, 6 weeks 18 ? 3×/wk Yes
aerobic — customised
Beaupre et al (2004) Lower limb mobility, warm-up, strengthening 4 weeks 12 b30 mins 3×/wk Yes
Rooks et al (2006) Water and land-based exercise 6 weeks 18 30–60 mins 3×/wk Yes
Aerobic, strengthening and stretching — customised
Williamson et al (2007) Lower limb strengthening, balance training, functional 6 weeks 6 60 mins 1×/wk No
exercises — group session
Evgeniadis et al (2008) Trunk and upper extremity strengthening 3 weeks 9 ? 3×/wk No
Topp et al (2009) Lower limb strengthening, stretching and step training Variable Variable ? 3×/wk No
Gstoettner et al (2011) Proprioceptive training 6 weeks 6 45 mins 1×/wk No
Brown et al (2012) Warm-up, strengthening, stretching and step training — 8 weeks 24 50 mins 3×/wk No
individualised if unable to progress
McKay et al (2012) Warm-up, aerobic, quadriceps strengthening 6 weeks 18 30 mins 3×/wk Yes
Matassi et al (2014) Lower extremity strengthening, stretching and step training 6 weeks 30 ? 5×/week Yes

Mins = minutes, ×/wk = times per week,? = unspecified.

 I.HY. Kwok et al. / The Journal of Arthroplasty 30 (2015) 1657–1663 1661

Table 4
Summary of Study Results.

Assessment Points Outcome Measures Results:

Difference in Group Means [Intervention − Control] (95% CI)

D’Lima et al 6 weeks, 1 week pre-op HSSKR HSSKR: 3 (−7 to 13.1)

(1995) Post-op: 3 weeks, 12 weeks, AIMS AIMS % improvement: 6% (no CI)
24 weeks, 48 weeks QWBS QWBS % improvement: −9%
HLOS HLOS: 0.21 days longer (−0.7 to −1.2)
Rodgers et al Baseline for intervention HSSKR HSSKR: 2 (no CI)
(1998) group only Knee ROM Knee ROM: −2 in degrees extension, −4 degrees flexion (no CI)
Both groups: Isokinetic knee Peak knee strength at 60 degrees: 1 ft-lb in flexion, −3 ft-lb in extension (no CI)
pre-op, 6 weeks post-op and strength
3 months post-op Thigh Thigh circumference: 1 cm (no CI)
circumference
Walking speed Walking speed: 1 sec longer (no CI)
Thigh muscle Thigh muscle area: 3.9 cm3 (no CI)
area on CT
Beaupre et al 6 weeks pre-op WOMAC WOMAC pain: 2 (−3.6 to −7.6), stiffness: −4
(2004) Post-op: 3 months, 6 months, (−11.5 to −3.5), function 0 (−5.8 to −5.8)
12 months SF-36 SF-36 physical component score −3 (−6.5 to −0.5),
mental component score −2 (−5.0 to −1.0)
Knee ROM Knee ROM −4 (−10.1 to −2.1)
Quadriceps and Quadriceps strength 9 (−2.4 to −4.4)
hamstring strength Hamstring strength 0 (−2.7 to −2.7)
HLOS HLOS −1.5
Rooks et al Pre-intervention WOMAC WOMAC function: 8.5 (1.4–16.6), pain 0.1 (−1.7 to −1.9)
(2006) (within 7 days), pre-op SF-36 SF-36 physical function: 1.9 (−16.1 to −19.9), pain 3.1
Post-op: 8 weeks, 26 weeks (−14.1 to −20.3), role limitation physical 12.8 (−19.4 to −45.0)
1-rep max 1-rep max: 18 kg (−16.8 to −52.9), exercise group 20% increase in muscle strength
Functional reach Functional reach: 1.3 cm (−4.5 to −7.1)
Timed up and go Timed up and go: −1.6 secs (−4.3 to −1.1)
Discharge location Discharge to rehabilitation: 38% in intervention group compared to 65% in control group
Williamson Pre-op OKS OKS: 1.61 (−3.9 to −7.1)
et al Post-op: 7 weeks, 12 weeks, WOMAC WOMAC: 1.33 (−9.5 to −12.2)
(2007) 3 months Pain VAS Pain VAS: −0.09 (−1.7 to −1.5)
HAD HAD: anxiety, depression
50-m timed walk 50-m timed walk: 2.51 secs (−3.5 to −8.5)
HLOS HLOS: −0.12 (−1.1 to −1.8)
Evgeniadis 4 weeks pre-op, 1 day pre-op SF-36 SF-36: no significant differences in all eight health domains.
et al Post-op: 1 day, day of discharge, ILAS ILAS: total score −0.07 (−0.4 to −0.3)
(2008) 6 weeks, 10 weeks, 14 weeks Active ROM AROM: no significant differences in hip, knee or ankle
Topp et al Baseline: at least 4 weeks pre-op, 6-minute walk 6-minute walk −28 m (−58.6 to −2.6)
(2009) 1 week pre-op Sit-to-stand Sit-to-stand 1.6 repetitions (1.2–2.1)
Post-op: 1 month, 3 months repetitions in
30 secs
Ascending and Ascending stairs: 0.99 secs (0.6–1.4)
descending stairs Descending stairs: 0.54 secs (−0.1 to −1.1)
(22 steps)
Quadriceps Maximum quadriceps extension strength: 1.5 torque/body wt (−1.2 to −4.2)
strength
Pain VAS for each Pain VAS: both intervention and control groups showed reduction in all measures of pain
functional task
Gstoettner 6 weeks pre-op, 1 day pre-op Balance test Balance test: OSI −0.7 (−1.2 to −0.2), APSI −0.6 (−0.9 to −0.3), MLSI −0.3 (−0.7 to 0.1)
et al (intervention group only) Gait speed Gait speed: 60 m 5.0 secs (−4.3 to −14.3), stairs up 3.8 secs (−3.6 to 11.2),
(2011) Post-op: 6 weeks stairs down 4.2 secs (−5.1 to −13.5)
WOMAC WOMAC: pain 0.32 (−0.4 to −1.0), stiffness 0.4 (−0.6 to −1.4), function −0.7 (−1.4 to −0.0)
KSS KSS: 1.9 (−10.2 to −14.0), KSS function: 0.4 (−9.7 to −10.5)
Brown et al Post-op: 3 months SF-36 SF-36: Physical functioning t = 2.3 (P = 0.04), Role-physical t = 1.0 (P = 0.33), Bodily pain
(2012) t = 1.2 (P = 0.23), General health t = 1.0 (0.33), Vitality t = 0.04 (P = 0.97), Social functioning
t = 1.4 (P = 0.18), Role-emotional t = 1.6 (P = 0.13), Mental health t = 0.01 (P = 0.99)
McKay et al Pre-op Isometric Quadriceps strength: 0.03 NM/kg (−0.4 to −0.4)
(2012) Post-op: 6 weeks, 12 weeks quadriceps Mobility: 50-ft walk −0.02 secs (−3.9 to −3.9), stair test 4.8 secs (−12.8 to −22.4)
strength
WOMAC WOMAC: pain 0.82 (−2.7 to −4.3), function −1.2 (−13.5 to −11.1)
SF-36 SF-36: PCS 6.4 (−2.4 to −15.7), MCS −3.4 (−18.5 to −11.62)
Arthritis Arthritis self-efficacy: 11.5 (−9.3 to −32.4)
self-efficacy
Matassi et al 6 weeks pre-op, 1 day pre-op Knee ROM Knee ROM: days to achieve 90 degrees −1.1 (−1.8 to −0.38)
(2014) Post-op: 6 weeks, 6 months, Knee Society Passive knee flexion insignificant (no figures)
1 year Clinical Rating Active knee flexion insignificant (no figures)
System Evolution of knee extension significant (P = 0.032)
Knee Society Clinical Rating System insignificant (no figures)
HLOS HLOS: −0.8 (−1.6 to −0.01)

HSSKR: Hospital for Special Surgery Knee Rating (0–100 scale, 100 = perfect score). AIMS: Arthritis Impact Measurement Scale (0–30 scale, 0 = perfect score). QWBS: Quality of Wellbeing
Scale (0.00–1.00 scale, 1.00 = perfect score). HLOS: hospital length of stay. WOMAC: Western Ontario and McMaster Universities Arthritis Index (0 = best, 100 = worst). SF-36: Short
form-36 Health Survey. OKS: Oxford Knee Score. Pain VAS: Pain Visual Analogue Scale (0 = best, 100 = worst). HAD: Hospital Anxiety and Depression score. ILAS: Iowa Level of Assistance
Scale (0–50, demerit system). KSS: Knee Society Score (0 = worst, 100 = best). Arthritis Self-Efficacy Scale. Knee Society Clinical Rating System (0 = worst, 100 = best).
1662 I.HY. Kwok et al. / The Journal of Arthroplasty 30 (2015) 1657–1663

improvements in overall health and fitness capacity in the older adult. also focus on the optimal components of a pre-operative physiotherapy
For aerobic training, the ACSM recommends an exercise intensity of programme, including exercise types, duration, frequency and intensity
60–90% of maximum heart rate, 20 to 60 minutes at 3 to 5 days a of sessions.
week [35]. The duration and intensity of exercise programmes
were highly variable between the studies reviewed. Funding con-
Appendix 1. Example of search on MEDLINE and Embase
straints tended to limit the duration of physiotherapy programmes
to 6 weeks or less. The study by Evgenias et al (2008) and Beaupre
1. Osteoarthritis 7. preop*.mp. 11. arthroplasty.mp. 14. Physical
et al (2004) only lasted three weeks and four weeks respectively, 2. Osteoarthritis, 8. periop*.mp. or Arthroplasty, Therapy
which is below the recommended duration to bring about any im- Knee 9.presurgery.mp. Replacement, Knee/ Modalities/ or
provements in lower limb strength [36]. Many patients requiring TKA 3. 10. 7 or 8 or or Arthroplasty, physical
are chronically deconditioned and suffer from other medical co- Osteoarthritis.mp. 9 = 639,946 Replacement/ or therapy.mp.
4. Knee studies Arthroplasty/ 15. Physical
morbidities. As they are ‘undertrained,’ a few weeks of exercise training
Prosthesis/ or 12. “total knee”.mp. Therapy Specialty/
may be insufficient for the patient to reap the benefits of prehabilitation Knee/ or Knee 13. 11 or 16.
[29]. However, longer prehabilitation programmes require more com- Joint 12 = 112,572 physiotherapy.mp.
mitment and patience, and may incur an increased cost (e.g. travel ex- 5. Knee.mp. studies 17. exercise
6. 1 or 2 or 3 or 4 therapy.mp. or
penses) on the elderly patient. This could lead to non-participation as
or 5 = 328,894 Exercise Therapy/
well as increased dropout rates. studies 18.
Compliance and adherence to physiotherapy sessions were variable physiotherap*.mp.
and generally poorly reported in the studies reviewed. Some patients 19. 14 or 15 or 16
may have decided to drop out of the intervention programme as soon as or 17 or
18 = 157,000
they experienced a small amount of improvement. The number of exercise
studies
sessions attended by participants should ideally be standardised as there 20. 6 and 10 and 13 and 19 = 544 studies
might be a dose-response effect depending on the quantity and intensity
of intervention received.
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