International Journal of Orthopaedic and Trauma Nursing 30 (2018) 14–19

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International Journal of Orthopaedic and Trauma Nursing

journal homepage: www.elsevier.com/locate/ijotn

Does physiotherapy prehabilitation improve pre-surgical outcomes and T

influence patient expectations prior to knee and hip joint arthroplasty?
Nicholas J. Clodea,∗, Meredith A. Perryb, Lauren Wulffc
a
Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington, New Zealand
b
Centre for Health Activity and Rehabilitation Research, School of Physiotherapy, University of Otago Wellington, Wellington, New Zealand
c
Hutt Valley District Health Board, Lower Hutt, New Zealand

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Evidence supporting physiotherapy prior to hip or knee replacement for decreasing pain and im-
Prehabilitation proving function pre and post-operatively is equivocal. This observational cohort study used a mixed-methods
Arthroplasty approach to investigate whether 8 weeks of physiotherapy led exercise and education (‘prehabilitation’) would
Knee replacement change pain and functional outcomes prior to surgery, and if patients' expectations and satisfaction post-surgery
Hip replacement
were influenced.
TKR
Methods: Participants awaiting THR or TKR were recruited (n = 75). Fifty two opted into the ‘prehabilitation’
THR
Physiotherapy group while twenty three opted for usual care. The prehabilitation group included a 45 min exercise and 15 min
education session twice weekly for 8 weeks. All participants completed the WOMAC, NRS, Health Thermometer,
5xSTS and TUG outcome measures. Data were collected before and after prehabilitation and 6 weeks after
surgery. Qualitative data were collected from 22 participants via telephone interviews and analysed inductively.
Results: Both groups improved post surgery. The prehabilitation group showed statistically significant im-
provements in all outcome measures after prehabilitation (pre-surgery). Participants’ felt prehabilitation pre-
pared them well for surgery and influenced expectations post-operatively. Group education talks and the ex-
perience of friends and family appeared highly valued information sources.
Conclusion: Prehabilitation improved patients’ pain and function before hip or knee replacement surgery.

Introduction Pre-operative interventions afford an opportunity to influence in-

Osteoarthritis effects approximately 1 in 5 adults in western coun-
tries (Barbour, 2013) and is a major source of disability and lost pro-
ductivity in New Zealand and internationally (Economics Access,
2010). Treatments, including joint arthroplasty, are effective in redu-
cing disability and pain in hip and knee osteoarthritis, but approxi-
mately 20% of individuals post total knee replacement (TKR) and 9%
post total hip replacement (THR) have adverse pain outcomes (Beswick
et al., 2012).
Rates of TKR and THR surgery are increasing internationally so
methods to optimise surgical outcomes are paramount (Losina et al.,
2012). Physiotherapy rehabilitation before surgery (prehabilitation)
has been proposed to optimise pre-operative function and strength, to
prepare patients for, and hasten, recovery after surgery. Improving pre-
operative capacity may assist patients in better tolerating surgical stress
(Ditmyer et al., 2002), reducing complications and expediting recovery.
In support of this Fortin et al., found pre-surgical function is a strong
predictor of function at 6 months post-surgery (Fortin et al., 1999).
dividual psychological and social variables that impact recovery.
Previous literature has found that pre-operative educational interven-
tions may improve patient's locus of control (Hartley et al., 2012). Low
locus of control has been correlated with poorer pain outcome in knee
replacement (Lopez-Olivo et al., 2011). Pre-operative education may
also mediate high patient anxiety (Fitzgerald and Elder, 2008) and fear
of movement which have been associated with negative pain outcomes
(McHugh et al., 2013), increased complications (Rasouli et al., 2016)
and reduced function at 12 months (Filardo et al., 2016).
Studies investigating the efficacy of prehabilitation in reducing post-
operative pain and improving recovery remain inconclusive with stu-
dies supporting (Santa Mina et al., 2014) and refuting the benefits of
this intervention (Cabilan et al., 2015). Recent evidence indicates pre-
habilitation may lead to improvements in function, but these im-
provements may be too small to be clinically relevant (Wang et al.,
2016).
Post-operative patient satisfaction is an important consideration in
healthcare interventions. Patient satisfaction is related to patient

∗
Corresponding author. Department of Surgery and Anaesthesia, University of Otago Wellington, 23 Mein St, Newtown, Wellington 6242, New Zealand.
E-mail address: nick.clode@otago.ac.nz (N.J. Clode).

https://doi.org/10.1016/j.ijotn.2018.05.004
Received 4 December 2017; Received in revised form 10 April 2018; Accepted 14 May 2018
1878-1241/ © 2018 Elsevier Ltd. All rights reserved.
N.J. Clode et al.
Fig. 1. Flow diagram; demonstrating time points for data collection and participant numbers across the prehabilitation and usual care groups.
expectations (McKinley et al., 2002). No previous studies have in-
vestigated the effect of prehabilitation on patient expectations and sa-
tisfaction post-operatively.
This mixed methods study prospectively follows a cohort of patients
awaiting THR and TKR. The study aimed to investigate the effect of
prehabilitation on patient outcomes. Specific objectives were to in-
vestigate the influence of prehabilitation on participants pre-operative
pain and function. Furthermore, to explore the influence of pre-
habilitaton on participants’ expectations of surgery, satisfaction and the
overall patient experience.
Methods
This observational cohort study used a mixed methods approach.
Participants were recruited from an orthopaedic waiting list at a hos-
pital in the lower North Island of New Zealand between March 2015
and May 2016. All patients awaiting elective THR and TKR due to os-
teoarthritis by two surgeons were eligible. Orthopaedic nursing staff
provided eligible participants with an information sheet on study aims,
possible risks and benefits and the components of prehabilitation.
Participants were included if they provided informed consent to take
part in the study. Participants were excluded if they were undergoing
acute surgery for fracture or failed to meet British Association of
Cardiac Rehabilitation criteria for safe participation in an exercise
programme (appendix 1). Participants self-selected into either the
‘prehabilitation' or ‘usual care' groups.
Usual care consisted of an educational booklet containing in-
formation about the surgery alongside a one-hour group multi-dis-
ciplinery education talk 2–4 weeks prior to surgery. The education talk
involved an orthopaedic nurse, pain specialist nurse, occupational
therapist and physiotherapist. Participants were presented with in-
formation on surgery, hospital stay, discharge and recovery and were
encouraged to ask questions.
The prehabilitation group underwent usual care, plus a one-hour
exercise and education session, twice weekly, for 8 weeks. The exercise
component involved a 45-min strengthening and stretching class. The
class included 13 exercise stations with 2 min spent at each station.
Participants were asked to work to muscular fatigue or failure.
Exercises were graded in terms of difficulty from 1 to 3 (easiest to
hardest). Participants started on level 1 with encouragement to increase
the level of difficulty as able. It was determined a-priori that partici-
pants should attend at least 12 out of 16 prehabilitation sessions for
their results to be included in the final analysis. This frequency and
15
International Journal of Orthopaedic and Trauma Nursing 30 (2018) 14–19
volume of exercise has previously been found to lead to improvements
in strength (Candow and Burke, 2007) and is recommended within
position statements for resistance training in untrained individuals
(Kraemer et al., 2002). The education sessions consisted of 15 min
classroom based talks and addressed concepts previously identified to
be important in prehabilitation literature (Herck et al., 2010;
Wainwright and Middleton, 2010; Yoon et al., 2010). Topics included
early mobilisation, discharge planning, pain control, benefits of ex-
ercise for arthritis, dietary education and post-operative rehabilitation.
Quantitative measures
Well validated quantitative outcome measures were used to reduce
likelihood of bias through measurement error. Pain was assessed using
a 10 point numerical rating scale (NRS) (Price et al., 1983), and func-
tional status using the Western Ontario and McMaster Universities Ar-
thritis Index (WOMAC) questionnaire (Bellamy et al., 1988). Physical
function was assessed using the Timed Up and Go (TUG) (Kennedy
et al., 2005) and Five Times Sit to Stand tests (5xSTS) (Bohannon,
2011). The 0–100 Health Thermometer from EuroQol 5D (EuroQol,
1990) 0–100 was used to quantify participants' perceived quality of life.
Data on hospital length of stay were collected post-operatively as a
secondary outcome measure. Data were collected pre and post pre-
habilitation and 6 weeks post-operatively for the intervention group,
and pre-operatively and 6 weeks post-operatively for the usual care
group. See Fig. 1.
Quantitative data analysis
Data from outcome measures pre to post prehabilitation were
compared using a paired t-test. A repeated measures ANOVA was used
for a secondary analysis investigating if changes in outcome measures
post-surgery between prehabilitation and usual care groups were sig-
nificantly different. A change of < p = 0.05 (two tailed) pre to post
intervention was accepted as a statistically significant finding. A Mann
Whitney U test was used to investigate differences between hospital
length of stay between groups.
Qualitative measures
Semi-structured phone interviews were completed between 3 and 9
months post-operatively. Interviewers were independent from the de-
sign and delivery of the prehabilitation intervention. This was deemed
N.J. Clode et al. International Journal of Orthopaedic and Trauma Nursing 30 (2018) 14–19

important to ensure participants felt able to openly expresses them- Table 2

selves and reduce hesitancy in volunteering negative opinions or ex- Mean change in STS, TUG, WOMAC, NPRS and Health Thermometer from
periences which may have occurred had the interviewer been involved baseline to post prehabilitation intervention in the Prehabilitation Group.
with running the programme. Open ended, semi-structured questions Outcome Measures Mean Change 95% Confidence Sig. Diff. 2
were developed to explore patient expectations and views of pre- Interval Tailed
habilitation (appendix 2). Interviews were recorded and transcribed
5xSTS 5.55 ± 9.00 2.67–8.42 0.000*
verbatim. Transcripts were analysed using a general inductive method
TUG 3.75 ± 5.92 2.05–5.45 0.000*
(Thomas, 2006) by 2 independent coders. Any individuals that opted WOMAC Percentage 4.56 ± 13.81 0.51–8.62 0.028*
out of prehabilitation due to aggravation of symptoms were purposively NPRS 0.68 ± 1.27 0.31–1.05 0.001*
selected to provide insight into reasons for failing to complete the Health Thermometer **-5.60 ± 16.45 **-10.54 to −0.66 0.027*
program. Following transcription of the first interview, data analysis
P = ≥0.05.
began and, where necessary, refinements to the interview schedule
Mean ± SD (Standard Deviation).
were made. Once the entire data set had been read, categories were
Note: 5xSTS Five times sit-to-stand, TUG Timed Up and Go, WOMAC Western
determined. Independent, parallel coding was undertaken with refine- Ontario and McMaster Universities Arthritis Index, NPRS Numeric Pain Rating
ments made to the categories through research group meetings. To Scale, Health Thermometer from EuroQoL 5D *Signficant difference. **Minus
improve methological rigor, participants were presented with a sum- score indicates an improvement in self rated perception of health.
mary of the qualitative findings and invited to verify the proposed
themes. and 38.60% undergoing TKR. The baseline characteristics in outcome
Ethical Approval was granted by the University of Otago Research measures were consistent across groups, apart from TUG where the
Ethics Committee and permission to undertake the study was obtained prehabilitation group scored significantly higher P = 0.01, (95% CI
from the DHB involved in the study. 0.77–5.79) indicating a lower baseline functional level.

Results Pre and post prehabilitation

Quantitative Results from 39 participants demonstrated statistically significant

improvements in all outcome measure scores after prehabilitation. Five
Data was obtained from 75 participants; 52 opted into the pre- times sit to stand time improved by a mean score of 5.55 s, SD ± 9.00
habilitation group and 23 opted into usual care (Fig. 1). Within the (2.67–8.42; P = 0.00). Full results from all outcome scores can be seen
prehabilitation group, 7 failed to complete the minimum number of in Table 2.
classes (≤12) and 6 participants declined to continue. This data was
excluded in further analysis. Only 1 of 6 participants that declined to
Pre and post-surgery
continue did so due to increasing pain levels, the remaining 5 opted out
for social reasons. Data from 39 participants was included in the final
Both groups improved in pain and function scores post-surgery
analysis after prehabilitation. Eight prehabilitation participants did not
(Table 3). A repeated measure ANOVA demonstrated significant dif-
completed their 6 week post-operative data collection so were not in-
ferences in TUG from baseline (13.81 ± 7.34) to post surgery
cluded in the analysis. The final post op comparison of prehabilitation
(9.04 ± 3.46) P = 0.01 (95% CI 0.77–5.79) in the prehabilitation
and usual care included 31 and 23 participants respectively. During the
group. No other statistically significant differences were found in other
analysis, some outcome score data were found to be missing. These data
outcome measures between groups (Table 3). The median length of
were not included in the analysis.
hospital stay was 3 days for both groups, and was not statistically dif-
Baseline statistics are demonstrated in Table 1. Mean age was 67.63
ferent.
(SD ± 8.66) years (range 49–85 years) in the prehabilitation group
and 62.48 (SD ± 12.61) (range 36–82 years) in the control group,
Thirty-eight participants (50.70%) were male and forty-five partici- Qualitative results
pants (78.90%) identified as New Zealand European. Most participants
underwent unilateral joint replacement with 54.70% undergoing THR Results were obtained from 22 participants, 15 from the pre-
habilitation group and 7 usual care participants. The one participant
Table 1
that dropped out of prehabilitation due to pain was purposively se-
Demographic and baseline characteristics. lected.
Main themes arising from interviews were around: participants'
Characteristics Prehabilitation Group n = 52 Usual Care n = 23
readiness for surgery; expectations of success and from where they
Age mean ± SD 67.63 ± 8.66 62.48 ± 12.61 obtain credible information in preparation for surgery.
Sex Male = 26 (50.0%) Male = 12 (52.2%)
Female = 26 (50.0%) Female = 11 (47.8%)
Readiness for surgery
Ethnicity New Zealand European = 31 New Zealand European = 14
(59.6%) (60.9%) Participants indicated that prehabilitation prepared them physically
New Zealand Maori = 3 New Zealand Maori = 1 and mentally for surgery: “it made a big difference”, “I think they [pre-
(5.8%) (4.3%) habilitation classes] were useful, for … Preparing me for surgery. [Be]cause
Other European = 6 (11.5%) Pacific Island = 1 (4.3%) I was stronger to start with” (P4). Participants indicated they would re-
Asian = 1 (1.9%) Not disclosed = 7 (30.4%)
Not disclosed = 11 (21.2%)
commend the classes to others undergoing joint surgery. Participants
Procedure LTKR = 13 (25.0%) LTKR = 3 (13.0%) reported prehabilitation improved their activity levels before surgery.
RTKR = 7 (13.5%) RTKR = 6 (26.1%) Many also indicated their activity levels remained higher after the
BTKR = 4 (7.7%) BTKR = 1 (4.3%) classes finished, albeit to a lesser extent.
LTHR = 14 (26.9%) LTHR = 9 (39.1%)
Participants in the usual care group talked about physical readiness
RTHR = 14 (26.9%) RTHR = 4 (17.4%)
for surgery in a different way, focusing more on their physical suit-
Key: LTKR Left total knee replacement, RTKR Right total knee replacement, ability for surgery and levels of disability: “my hip joint had crumbled”
BTKR bilateral total knee replacement, LTHR Left total hip replacement, RTHR (UC6). Most participants indicated they would have liked to attend
Right Total Hip replacement. prehabilitation but work precluded this as the sessions were in the

16
N.J. Clode et al.
Table 3
Descriptive statistics for the outcome measures of 5xSTS, TUG, WOMAC, NPRS and Health Thermometer at baseline, and post-operatively.
Outcome measures Baseline
Prehabilitation
STS N = 42
19.20 ± 9.28
TUG N = 52
13.81 ± 7.34*
WOMAC Percentage N = 49
65.20 ± 16.56
NPRS N = 51
6.42 ± 1.91
Health Thermometer N = 52
60.35 ± 21.55
STS 5 times sit-to-stand, TUG Timed Up and Go WOMAC Western Ontario and McMaster Universities Arthritis Index, NPRS Numeric Pain Rating Scale, Health
Thermometer from EuroQoL 5D. Mean ± SD (Standard Deviation) are given for each parameter.
*Statistically significant difference between groups at baseline p = 0.01, 95% CI (0.77–5.79).
daytime.
One participant in the prehabilitation group found prehabilitation
helpful as a non-pharmaceutical way of controlling their symptoms: “I
think just knowing how … when my pain was getting bad, how to deal with it
apart from taking tablets and stuff. Like what sort of exercises can strengthen
other parts you know like the muscles in the legs” (P13). However, one
participant reported that prehabilitation increased their pain and did
not tolerate the classes: "Think I'm an odd one out, because … it made the
pain a lot, lot worse, having those exercises” (P2).
Another common theme in the prehabilitation group was a benefit
gained through social interaction through meeting others going through
the same thing: “like being amongst friends” (P5). “I still see one of them as
a friend and to me the whole thing was part of that which was great” (P5).
Participants indicated that having company enhanced their motivation
to exercise and, for many, was the aspect of the class that they most
enjoyed.
Expectations of success and post-operative rehabilitation
Participants in the prehabilitation group expected to be in hospital
2–3 days after surgery. Conversely, expectations in usual care group
were less consistent and varied from “a day or two” (UC5) to “at least a
week” (UC6).
Both groups were satisfied when their expectations of arthroplasty
surgery and aftercare matched reality. The prehabilitation groups ex-
pectations and understanding of risks were more realistic yet, when
expectations did not match reality participants were less satisfied ir-
respective of group: "I had the operation … I thought I'd be right as rain.
But … I probably feel a bit cheated” (P3). This was evident in those who
experienced complications, therefore deviating from standard care.
Credible information sources
Participants gained information through multiple sources. Both
groups relied on and trusted information from friends and family who
had previous experience of joint replacements. This was particularly
evident in the usual care group: “the knowledge that I'd had through
friends and family that have had various … Joint replacements before”
(UC3). The group information talk delivered as part of usual care was
seen as beneficial by all participants: “The presentation was marvellous. It
just made you feel comfortable, well it did to me. Because up until then I'd
been a little bit scared” (UC5). Only a few participants mentioned the
information booklet which, thus, appeared to be valued less.
Discussion
These results demonstrate 8 weeks of prehabilitation before TKR
and THR led to statistically significant improvements in pain and
function prior to surgery. The improvements were clinically meaningful
International Journal of Orthopaedic and Trauma Nursing 30 (2018) 14–19
Post-Surgery
Usual Care Prehabilitation Usual Care
N = 19 N = 31 N = 10
17.66 ± 6.26 12.58 ± 3.19 14.63 ± 4.72
N = 22 N = 31 N = 13
10.53 ± 3.48* 9.04 ± 3.46 11.13 ± 3.71
N = 23 N = 31 N = 13
65.96 ± 18.05 23.39 ± 18.29 27.38 ± 18.29
N = 21 N = 31 N = 11
5.36 ± 3.04 1.42 ± 1.65 1.73 ± 1.69
N = 23 N = 31 N = 13
64.61 ± 17.16 89.26 ± 11.05 80.00 ± 12.42
in two validated objective tests of function (TUG, 5xSTS), but were not
of the magnitude to be clinically important in measures of self-reported
function, pain and quality of life. These results are consistent with re-
cent research (Wang et al., 2016). Results indicate that prehabilitation
may result in small improvements in pain and function but these im-
provements may not be substantive enough to impact important health
outcomes including quality of life, self-reported function and length of
hospital stay.
A finding of note was that patients who opted in to prehabilitation
had greater pain and physical impairment in the functional tests at
baseline than those who elected usual care. In paired comparisons, this
was only statistically significant on TUG. However, following pre-
habilitation, improvements in pain and function in the prehabilitation
group meant differences had appeared to equal out. The qualitative
interviews shed some light on potential reasons for the difference in
baseline outcome scores between the groups; most participants in the
usual care group did not opt into prehabilitation because they were still
working and unable to attend the times of the prehabilitation classes.
Participants in this group were still able to function sufficiently to work
and were therefore likely to be less physically disabled. All participants
in the usual care group reported they would have attended the classes if
this had been possible. Previous research found adherence to exercise
programs was related to time and perceived benefit (Medina-Mirapeix
et al., 2009). This study demonstrates the concept of improving pre-
surgical fitness was valued by patients and most would opt into a
prehabilitation programme if this was offered as part of routine care.
It is possible that some patients in this study benefitted more from
prehabilitation. Starks et al., (2014) found patients over the age of 85
benefit the most from multimodal enhanced recovery protocols in
hastening recovery and reducing length of hospital stay. Elderly pa-
tients’ ability to regain strength after disuse is lower than their younger
counterparts (Hvid et al., 2014), this patient group therefore may have
more to gain from prehabilitation. Furthermore, as patients with hip
and knee arthritis possess reduced activity levels compared to healthy
controls (de Groot et al., 2008); disuse atrophy may be more prevalent
in this population. This is particularly important given muscle loss of
the type 2 power generating muscle fibres is accelerated from the 6th
decade onwards (Lexell et al., 1988). Our results demonstrated pre-
habilitation is physically and symptomatically well tolerated for elderly
patients with hip and knee osteoarthritis severe enough to warrant joint
replacement. Only one participant appropriately referred into the class
dropped out due to pain. This finding aligns with other work that finds
exercise and education improves pain and function in patients with
knee and hip osteoarthritis (Bennell and Hinman, 2011). We hypothe-
sise that frail elderly patients, particularly those with comorbidity, may
have more to gain from prehabilitation. Future work should identify if
prehabilitation interventions targeted at these patients may improve
17
N.J. Clode et al.
important outcomes such as reducing hospital length of stay.
Participants in this study generally expected joint replacement
surgery to alleviate their symptoms without complications. This ex-
pectation led to dissatisfaction in patients who experienced less optimal
outcomes post-surgery. Given current rates of symptom persistence post
knee and hip joint arthroplasty, it seems prudent that patients should be
better prepared with realistic expectations of surgical complications.
Patients in our study valued group conversations where they could ask
questions, more than receiving written information. The current study
findings suggest cross-checking information individuals receive from
their family and friends may be important to verify an accurate un-
derstanding of recovery expectations, rehabilitation and length of
hospital stay.
Patients who presented with psychosocial risk factors of poor re-
covery are another sub-group who may have gained greater benefit
from prehabilitation. Specifically, those with high levels of anxiety.
Study participants reported less fear and more optimism about the
operation, discharge and recovery processes after attending the pre-
habilitation classes. This may have been attributable to enhanced
education leading to a greater sense of preparedness. Spalding et al.
(Spalding, 2003), found that education reduces anxiety by making the
future familiar. The more comprehensive education could have led
participants to perceive a greater locus of control and may have built
self-efficacy. Psychological status was not specifically measured in this
study. However, the Health Thermometer was used to capture overall
perception of wellbeing. A significant contributor to improvements in
the Health Thermometer scores after prehabilitation, could have been
attributable to improvements in mental and emotional health.
Results from the qualitative component of the study found social
support was an important component in maintaining adherence with
the exercise component of prehabilitation. It also supported continua-
tion of increased activity after completion of the classes. Previous work
found group sessions may improve exercise adherence by improving
perceived behavioural control and creating more positive attitudes
about attending exercise sessions (Duncan and McAuley, 1993). The
current study findings suggest that educational interventions that pro-
mote peer collaboration, joint learning sessions and enhance con-
nectedness may improve exercise adherence and enhance social sup-
port.
It is important to note some of the barriers with attending pre-
habilitation programmes. Lack of time and cost of exercise have pre-
viously been found to be barriers for exercise in patients with arthritis
(Veldhuijzen van Zanten et al., 2015), alongside access to transport and
parking (Dobson et al., 2016). In support of these findings, participants
in the current study who did not opt into prehabilitation cited lack of
time as the main reason for not attending. Specifically, that they were
working at the time of the classes. Current findings suggest hosting
prehabilitation classes outside of working hours may be important in
improving access to prehabilitation interventions. Human resources
requirements and associated healthcare provider costs may also chal-
lenge the establishment of prehabilitation programmes. Nevertheless,
group programmes have been demonstrated to be cost effective for
improving pain and function in patients with chronic knee pain (Hurley
et al., 2007).
This study had several limitations. Allocation into groups was not
random, therefore patients opting into prehabilitation may have been
different to those not, leading to systematic bias. Furthermore, parti-
cipants in the prehabilitation group were aware they were undergoing
an intervention to improve their pre-operative function and expecta-
tions, which may have influenced their behaviour or perceptions in
favour of the programme. Loss to follow up and missing data may have
introduced bias if the data from these participants was different.
Notably, reasons for patients opting out of the classes were recorded
and only 1 eligible participant discontinued the sessions due to pain,
indicating failure to complete the classes were not due to disease lim-
iting reasons.
18
International Journal of Orthopaedic and Trauma Nursing 30 (2018) 14–19
A strength of this project, was the mixed methods approach. The
allowed study findings to be triangulated which provided greater in-
sight into the subject area. To our knowledge, this is the first study to
use a mixed methods approach to investigate prehabilitation before hip
and knee arthroplasty. The qualitative results were useful in providing
insight into acceptability of the intervention. An intervention which is
effective to improve healthcare outcomes but is not acceptable to pa-
tients is of little use clinically, so acceptability is a key requisite. The
semi structured format of interviews allowed themes to arise not pre-
viously anticipated by the researchers. This is important, as there is
very little research investigating prehabilitation from a qualitative
perspective and therefore limited insight from previous work.
Furthermore, the interview data helped identify the components of the
intervention which were likely to be important to success. This may
help inform future trials in the area of prehabilitation in joint ar-
throplasty. Another study strength was that the exercise programming
followed principles of strength training – overload, progression, speci-
ficity – and, therefore, had good validity. Previous studies investigating
exercise training in hip and knee arthroplasty have received criticism
for sub-optimal programme design and description (Di Monaco et al.,
2009) which reduces study internal validity. The data collected from
the outcome measures was only collected by two therapists, reducing
the potential for measurement error.
Conclusion
Overall, this study suggests prehabilitation may improve patients’
pain and function before hip or knee replacement. These improvements,
however, may not be clinically meaningful when offered as part of
standard care prior to hip and knee replacement. Pre-operative edu-
cation had a positive influence on patient expectations and may result
in higher satisfaction levels. The social element of group exercise may
positively affect compliance and participation. Future research should
identify if certain subgroups, including frail elderly would benefit more
from prehabilitation.
Ethical statement
Ethical Approval was granted by the University of Otago Research
Ethics Committee and permission to undertake the study was obtained
from the DHB involved in the study prior to commencing. Written and
verbal informed consent was obtained from each patient before inclu-
sion. Confidentiality of personal information was ensured at all times.
Research funding
This study was funded by the University of Otago Wellington and
Hutt Valley District Health Board. The study sponsors had no role in
concept creation, study design, results analysis, writing up the manu-
script or any other relevant involvement in the research.
Conflicts of interest
No conflicts of interest to declare.
Acknowledgements
The authors would like to acknowledge the Otago University
Physiotherapy Students Anna Matheson, Anna Van Dissen, Judy Brown,
Ropafadzo Kadewere, Mitch Hobson, Hsuan-Yu Chang, Tanae Wills,
Hamish Fox, Nikhila Mudumbai, Ellen Bailey, Henry Emery, Shanelle
Fernandopulle, Benjamin Garratt.
Appendix 1
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