Asian Journal of Surgery 44 (2021) 1245e1253

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Asian Journal of Surgery

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Review Article

Effects of progressive resistance training for early postoperative fast-

track total hip or knee arthroplasty: A systematic review and meta-
analysis
Xing Chen, Xi Li, Zhiyong Zhu, Huisheng Wang, Zhongshen Yu, Xizhuang Bai*
Department of Orthopedics and Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, Shenyang, PR China

a r t i c l e i n f o s u m m a r y

Article history: Progressive resistance training (PRT) is one of the most commonly used exercise methods after joint
Received 30 October 2020 replacement, while its effectiveness and safety are still controversial. Therefore, it's vital to investigate
Received in revised form the effect of PRT on muscle strength and functional capacity early postoperative total hip arthroplasty
17 December 2020
(THA) or total knee arthroplasty (TKA). Relevant studies were identified via a search of Medline, Web of
Accepted 22 February 2021
Available online 11 March 2021
science and Cochrane Library from 2002 to 12 May 2020. Fifteen of 704 studies which comprised 6 THAs
and 8 TKAs, involving 1021 adult patients were eligible for inclusion in the meta-analysis. There were no
significant differences between the two groups after TKA in the 6-min walk test (6-WMT) within 1
Keywords:
Exercise therapy
month (95% CI ¼ 0.41, 1.53), within 3 months (95% CI ¼ 0.27, 0.76), within 12 months (95% CI ¼ 0.29,
Functional capacity 0.66); climb performance in seconds (s) (SCP), leg extension power, timed up and go test in seconds (s)
Hip arthroplasty (TUG) within 1 month (95% CI ¼ 1.75, 0.77), within 3 months (95% CI ¼ 0.48, 0.33), within 12 months
Knee arthroplasty (95% CI ¼ 0.44, 0.35), sit to stand, number of repetitions in 30s (ST). There was no difference in the
Muscle strength incidence of adverse events (95% CI ¼ 0.01, 0.10). Similarly, two groups were also no obvious distinction
Progressive resistance training after THA in the 6-WMT, SCP, Leg extension power, ST. PRT early after THA or TKA did not differ
significantly from SR in terms of functional capacity, muscle strength recovery and incidence of adverse
events. PRT is one of the options for rapid rehabilitation after joint replacement.
© 2021 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction found that postoperative deficits in quadriceps strength (41%

Osteoarthritis (OA) of the hip and knee is associated with pain,
loss of function and impaired leg muscle function.1 An estimated
30.8 million adults in the United States and 300 million people
worldwide are suffering from osteoarthritis. On a social scale, OA
assesses that $303 billion is spent annually on medical expenses
and lost income.2 Total knee arthroplasty (TKA) and total hip
arthroplasty (THA) are recognized and demonstrated to signifi-
cantly improve function, clinical symptoms, and cost-effectiveness
in patients with arthritis, whereas postoperatively there are
quality-of-life deficits and possible increase in morbidities and
decreased utilization of health care.3e5 Bade, M. J and Walsh, M
* Corresponding author. Department of Orthopedics and Sports Medicine and
Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road,
Shenhe District, Shenyang, Liaoning Province, 110016, PR China.
E-mail address: bai_xizhuang_g3@163.com (X. Bai).
weaker), walking distance (28% less), and stair climbing speed
(105% slower) persist after TKA compared to healthy adults.6e9
According to a US study, by 2030 the demand for primary TKA
will be 673% higher than in 2005, and the demand for revision will
be 601% higher. For THA the projected estimates are 174% and 137%
for primary and revision surgery, respectively.4,10 However, the
optimal rehabilitative approach to remediating movement com-
pensations and physical function deficits has not been determined.
Progressive resistance training (PRT) is one of the most
commonly used exercise methods after joint replacement, while its
effectiveness and safety are still controversial.11 Considering the
loss of muscle strength and muscle mass post-surgery immediately,
PRT has been advocated to be initiated shortly following sur-
gery.12,13 The exercises performed were: sit to stand, block stepping,
stair climbing, walking, sitting knee extension against resistance,
lateral weight transfer exercises,1,6,12,14,15 which was performed
twice a week for 10 weeks and each session lasted 1 h within 8e12
repetition maximum.16 The standard rehabilitation (SR) usually

https://doi.org/10.1016/j.asjsur.2021.02.007
1015-9584/© 2021 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
X. Chen, X. Li, Z. Zhu et al.
includes a home-based functional non-PRT exercise designed to
allow patients to mobile safely.12,17e20 In support of this view,
preliminary results have supported the feasibility of administering
PRT within 1e2 days after TKA or THA respectively without exac-
erbating postoperative symptoms such as knee joint effusion and
pain16,21,22. However, the clinical effects have not been
researched in a larger scale using a randomized controlled study
(RCT) design with random allocation to well-described physical
rehabilitation with SR or PRT.
Nonetheless, existing reviews11,23e25 have not systematically
summarized and analyzed the literature regarding the effect of PRT
after total hip or knee arthroplasty. We hypothesized that physical
rehabilitation with PRT would be superior to that SR in remediating
movement compensations and physical function deficits early after
fast-track TKA or THA respectively.
2. Methods
The review protocol was prospectively registered on PROSPERO
(CRD42020183546).
2.1. Search strategy
The Cochrane Library, Web of Science and Medline were
searched to identify pertinent studies published in English from
2002 to 12 May 2020. The following search strategy was used to
maximize search specificity and sensitivity: arthroplasty, replace-
ment, hip [Mesh] with all entry terms, arthroplasty, replacement,
knee [Mesh] with all entry terms, exercise therapy [Mesh] with all
entry terms and resistance training [Mesh] with all entry terms. In
addition, part of the literatures was manually retrieved.
After removing duplicates, the three authors independently
screened all titles, abstracts, and full text of potentially eligible
studies. Record reasons for exclusion, and resolve inconsistencies
by discussion or corresponding author's decision.
2.2. Selection criteria
Cohort studies, case control studies, and randomized controlled
trials were eligible for inclusion if they met the following criteria:
(1) Articles are original articles written in English.
(2) Patient groups include total hip or knee arthroplasty.
(3) Comparison of the clinical outcomes of PRT and SR.
(4) Valuation of at least one of the following outcomes: 6-WMT,
KOOS/HOOS scores, SCP, ST, Leg extension power, TUG. i.6-
MWT was initially considered as a prognostic indicator for
patients with respiratory diseases. It has the advantage of
reflecting the patient's ability to carry out daily activities and
is highly repetitive in different patients26; ii. KOOS scores
refer to knee injuries and osteoarthritis scores (subscales of
symptoms, pain, daily living activities, sports/recreational
functions, and quality of life)14; iii. The TUG measures the
time to rise from a seated position in an armed chair (seat
height 46 cm), walk 3 min, turn around, and return to a
seated position in the chair; IV. The SCP is the time it takes to
ascend 14 standard steps, 20 cm high, in a normal manner
and at a comfortable pace.27 V. ST is defined as the maximum
number of times a subject can stand up from a standard chair
(43 cm) in 30 s, a test designed to reflect the ability to move
around in daily life.28
(5) If multiple studies reported results from the same patient
cohort, the study with a lower quality scores were excluded.
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Asian Journal of Surgery 44 (2021) 1245e1253
2.3. Data extraction
The data extracted from the selected literature are as follows:
study, location, journal, patient examination position, case number,
age, sex, body mass index (BMI), follow up, adverse events, out-
comes including 6-WMT, KOOS/HOOS scores, SCP, ST, Leg extension
power, and TUG (Table 1). For studies with incomplete data, we
mail original author to reach complete data.
2.4. Study quality assessment
The risk of bias and methodological quality was estimated in
duplicate using the Cochrane Collaboration recommendations, and
evaluated independently by three reviewers.29,30 The criteria
included six items as follows: (1) adequate sequence generation;
(2) allocation concealment; (3) blinding; (4) incomplete outcome
data; (5) selective reporting; and (6) other bias.
2.5. Statistical analysis
Continuous results extracted in our study were expressed as 95%
CI mean difference (MD) or standard mean difference (SMD). MD is
used when the data units are the same, and SMD is used when the
data units are different. Dichotomous outcomes extracted in our
study are expressed as the risk ratio (RR) or the odds ratio (OR).
Heterogeneity is expressed as I2. This value of I2 ranges from 0%
(complete consistency) to 100% (complete inconsistency). A fixed
effect model was applied when I2 <50%, and a random effects
model when I2 >50%. A P value < 0.05 was considered statistically
significant in the case of a trial with no event for one side or the
other. Publication bias was tested using funnel plots or Egger
method, if necessary. Forest plots are used to graphically represent
comprehensive estimates of the results of individual studies and
their respective effects. All statistical analyses were performed with
Review Manager 5.3 (Cochrane Collaboration, Oxford, UK).
3. Results
3.1. Searching results
A flowchart of the studies considered for inclusion and exclusion
in our review is shown in Fig. 1. We identified 704 potential cita-
tions (558 from Medline, 249 from Web of Science, 57 from the
Cochrane Library) comparing the functional and muscular out-
comes of PRT and SR. After reading the articles, fourteenth of the
704 citations were selected for the meta-analysis. The character-
istics and data of these 14 studies are shown in Table 1.
3.2. Meta-analysis results
The meta-analysis included 14 studies which comprised 6
THAs1,12,17,31e33 and 8 TKAs,3,6,14,18,26e28,34 involving a total of 1, 021
patients. The PRT group involved 535 patients, while the SR group
involved 486 patients. The methodological quality of all included
clinical controlled trials was high, and the possibility of bias was
low (Fig. 2). However, in order to collect large samples for larger
studies, we also included some low-quality studies, such as Hsu
20193 and Suetta 2004.32
3.2.1. 6-Min walk test (6-MWT)
Ten studies3,6,12,14,17,18,26e28,33 involving 576 patients provided
data on 6-MWT. Since THA and TKA are two types of surgical
methods, we performed subgroup analysis. Moreover, due to the
longer follow-up time in the TKA group, we also conducted a time
subgroup analysis. There was no significant difference in TKA
X. Chen, X. Li, Z. Zhu et al. Asian Journal of Surgery 44 (2021) 1245e1253

Table 1
Characteristics of included studies.

References Location Journal Group Cases Age (y) Sex BMI (kg/ Follow up Adverse Outcomes
(n) (M/F) m2) (months) events

Bade (2017)6 knee Arthritis care & research PRT 84 63(8) 39/45 31(5) 12 7 (1) (3) (4)
SR 78 64(7) 34/44 30(5) 8 (5) (9)
Heikkil€
a knee Gait & posture PRT 53 69 (8) 30/23 31 (5) 14 5 (7) (8)
(2017)34 SR 55 69 (9) 19/36 31 (6) 0
Hermann hip Osteoarthritis and cartilage PRT 40 70.0 (7.7) 13/27 28.2 (5.3) 2.5 0 (5) (10)
(2016)1 SR 40 70.8 (7.5) 15/25 27.4 (3.8) 0
Hsu (2019)3 knee the Knee PRT 14 72.0 (1.8) 0/14 29.4 (1.5) 6 NG (1) (2) (3)
SR 15 69.5 (1.5) 0/15 28.9 (1.0) NG (6) (7) (8)
Jakobsen knee Arthritis care & research PRT 35 66(4.3) 14/21 29.8 (2.1) 6.5 4 (1) (2) (5) (7) (8) (11)
(2014)14 SR 37 63 (2.8) 16/21 29.4 (1.3) 3
Jørgensen knee Clinical rehabilitation PRT 31 64.8(8.3) 16/15 29.8(4.8) 12 4 (1) (2) (5)
(2017)18 SR 24 64.4(8.7) 10/14 28.4(2.8) 0
Matheis hip Journal of bodywork and movement PRT 20 65.5 (7.4) 13/7 26.4 (3.5) 0.2 0 (1)
(2018)33 therapies SR 19 66.7(9.8) 8/11 26.3(3.5) 5
Mikkelsen hip Osteoarthritis and cartilage PRT 32 64.8 (8) 18/14 27.5 (4) 2.5 0 (1) (4) (5) (7) (8) (10)
(2014)12 SR 30 65.1 (10) 18/12 25.4 (4)
Okoro (2016)17 hip BMC musculoskeletal disorders PRT 25 65.15(9.06) 10/15 28.04(5.79) 12 NG (1) (3) (4) (6)
SR 24 66.33(11.02) 10/14 29.44(5.25) NG
Petterson knee Arthritis and rheumatism PRT 100 65.3(8.3) 53/47 29.67(4.85) 12 0 (1) (2) (3) (4)
(2009)27 SR 100 65.2(8.5) 55/45 29.99 (3.9) 0
Skoffer (2019)26 knee Clinical rehabilitation PRT 30 70.7 (7.3) 11/19 30.0 (4.98) 12 NG (1) (2) (3) (4) (5) (6)
SR 29 70.1 (6.4) 12/17 31.8 (4.48) NG (7) (8)
Suetta (2004)32 hip Journal of the American Geriatrics Society PRT 13 69 (6.5) 7/6 27.4(1.4) 3 0 (4) (6)
SR 12 68 (4) 5/7 28.2(1.7) 0
van Leeuwen knee Rehabil Res Pract PRT 10 71.8 (7.5) 7/3 27.9 (4.6) 3 0 (1) (4) (6) (12)
(2014)28 SR 8 69.5 (7.1) 4/4 27.9 (3.1) 0
Wang (2002)38 hip American journal of physical medicine & PRT 15 68.3(8.2) 6/9 NG 6 0 (1)
rehabilitation SR 13 65.7(8.4) 4/9 NG 0

Fig. 1. Flow diagram of study selection. The study flow diagram was depicted following the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA).

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X. Chen, X. Li, Z. Zhu et al.
Fig. 2. Risk of bias. Risk-of-bias graph and methodological quality of the involved
studies. This risk-of-bias tool incorporates the assessment of randomization, blinding,
completeness of outcome data, selection of outcomes reported, and other sources of
bias. The items were scored with “high risk” “low risk” or “unclear risk”.
between 6-WMT within 1 month (I2 ¼ 91%; P ¼ 0.26; 95% CI ¼ 0.41,
1.53), within 3 months (I2 ¼ 84%; P ¼ 0.34; 95% CI ¼ 0.27, 0.76),
within 12 months (I2 ¼ 82%; P ¼ 0.45; 95% CI ¼ 0.29, 0.66), but
there was a high heterogeneity among the time subgroups. Het-
erogeneity was largely due to low quality Hsu 2019.3 THA subgroup
(I2 ¼ 91%; P ¼ 0.14; 95% CI ¼ 0.38, 2.77) showed no statistical
significance and obvious heterogeneity (Fig. 3).
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Asian Journal of Surgery 44 (2021) 1245e1253
3.2.2. Timed up and go test in seconds (s) (TUG)
Five trials3,6,17,26,27 including 386 patients compared the TUG
between the PRT and SR. A random effects model was employed
sub-TKA and carried out time subgroup analysis within 1 month
(I2 ¼ 89%; P ¼ 0.45; 95% CI ¼ 1.75, 0.77), within 3 months
(I2 ¼ 66%; P ¼ 0.71; 95% CI ¼ 0.48, 0.33), within 12 months
(I2 ¼ 66%; P ¼ 0.84; 95% CI ¼ 0.44, 0.35). The results indicated that
TUG had no statistical significance and high heterogeneity origi-
nating from Hsu 20193 to a large extent (Fig. 4).
3.2.3. Climb performance in seconds (s) (SCP)
SCP involving 415 patients was assessed in six
studies.6,12,17,27,28,32 Although there was no heterogeneity in the
THA subgroup (I2 ¼ 0%; P ¼ 0.78; 95% CI ¼ 0.42, 0.32), there was
no statistical significance. The same is true for the TKA subgroup,
while it (I2 ¼ 0%; P ¼ 0.64; 95% CI ¼ 0.76, 1.24) was also no sta-
tistically significant after the removal of Petterson (2009)27(Fig. 5).
3.2.4. Leg extension power
Six studies1,6,12,14,18,26 involving 443 patients provided data on
Leg extension power. The TKA subgroup (I2 ¼ 0%; P ¼ 0.79; 95%
CI ¼ 0.20, 0.26) had no homogeneity, but no statistical signifi-
cance. The THA subgroup (I2 ¼ 70%; P ¼ 0.17; 95% CI ¼ 0.18, 1.00)
was also not statistically significant (Fig. 6).
3.2.5. Sit to stand, number of repetitions in 30 s (ST)
The outcome of ST involving 202 patients was reported in seven
studies.3,17,26,28,32,33,35 There was heterogeneity in THA subgroup
(I2 ¼ 78%; P ¼ 0.30; 95% CI ¼ 1.34, 0.41) which was no statistically
significant, but no source of heterogeneity was found. The TKA
subgroup (I2 ¼ 0%; P ¼ 0.18; 95% CI ¼ 0.13, 0.70) was statistically
significant, while the intersection of the weight and the central axis
is still not statistically significant (Fig. 7).
3.2.6. Hip/knee osteoarthritis outcome scale (KOOS/HOOS scores)
Since there is no obvious difference between the two function
scores, they are posed in Supplementary Fig. 1.
3.2.7. Other outcome indicators
Other outcome indicators were not systematically analyzed due
to incomplete data, inconsistent standards and small cardinality
including Hip/knee abduction strength (Nm/kg), Hip/knee flexion
strength (Nm/kg), WOMAC scores, OHS and r-WOMAC scores
(Table 1).
3.2.8. Adverse events
The six studies,6,12,14,18,27,34 including 617 patients and 37 events,
provided data on adverse events rates. Since most of studies re-
ported it within one year, we did not conduct a subgroup analysis of
follow-up time. The TKA subgroup (I2 ¼ 47%; P ¼ 0.11; 95%
CI ¼ 0.01, 0.10) had no statistical significance and had low het-
erogeneity (Fig. 8). In addition, some studies have reported no
adverse events, such as Hermann 20061 and Skoffer 2019.26
4. Discussion
PRT is an exercise therapy that has been gradually developed in
recent years to influence the recovery after joint replacement. It is a
hot topic all over the world, including Denmark,1,18,21,26,32,35,36 the
United States,6,27 the United Kingdom,17 Australia37,38 and other
countries,3,28,31,33,34,39 which have conducted a large number of
clinical trials on this topic. Since the major loss after joint
replacement is muscle strength and function, the goal of post-
operative exercise is to restore preoperative muscle strength and
function.12 Therefore, the outcome evaluation indicators selected in
X. Chen, X. Li, Z. Zhu et al. Asian Journal of Surgery 44 (2021) 1245e1253

Fig. 3. Randomized effects meta-analysis was performed to compare the 6-MWT weighted mean difference in PRT after total hip/knee replacement compared with SR.

Fig. 4. Randomized effects meta-analysis was performed to compare the TUG weighted mean difference in PRT after total hip/knee replacement compared with SR.

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X. Chen, X. Li, Z. Zhu et al. Asian Journal of Surgery 44 (2021) 1245e1253

Fig. 5. Randomized effects meta-analysis was performed to compare the SCP weighted mean difference in PRT after total hip/knee replacement compared with SR.

Fig. 6. Randomized effects meta-analysis was performed to compare Leg extension power weighted mean difference in PRT after total hip/knee replacement compared with SR.

our study included muscle strength (Leg extension power, Hip/knee study basically included these two parts, although the specific
abduction strength, Hip/knee flexion strength) and functional in- items were inconsistent. Through meta-analysis of outcome in-
dicators (6-MWT, KOOS scores, HOOS scores, TUG, SCP, OHS, r- dicators, we found that there was no significant difference in
WOMAC scores), and the outcome indicators for each included function and muscle strength recovery between PRT and SR in the

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X. Chen, X. Li, Z. Zhu et al.
Fig. 7. Randomized effects meta-analysis was performed to compare ST weighted mean difference in PRT after total hip/knee replacement compared with SR.
Fig. 8. Random effects meta-analysis comparing relative risk of adverse events between PRT and SR after total hip/knee replacement.
follow-up, and there was no significant difference in the incidence
of adverse events between the double. It can be inferred that PRT
has the same effect on functional capacity and muscle strength
recovery after TKA and THA as general physical training.
Two-thirds of the studies3,6,14,17,18,26,27,34,38,40 we included were
followed up for more than 6 months, and some of the studies were
followed up for 1 week after surgery, with follow-up records at
month 1, month 2, and month 3. For example, Bade (2017),6,22 the
follow-up time was 1 month, 2 months, 3 months, 6 months and 12
months. Nevertheless, there were no significant differences be-
tween groups at 3 or 12 months in SCT, TUG, 6-MWT, WOMAC
scores, knee ROM, quadriceps and hamstrings strength, quadriceps
activation, or adverse event rates. Furthermore, PRT effectiveness
may be limited by arthrogenic muscular inhibition in the early
postoperative period. Besides, a third of the studies1,28,32,33 were
followed up within six months, but the density of follow-up tests
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Asian Journal of Surgery 44 (2021) 1245e1253
was high, with the highest reaching every other week. For instance,
the follow-up of Matheis (2018) started in the first week after
surgery, but only once. They came to the conclusion that Although
there was no significant difference in functional recovery, knee
joint flexion and extension Angle was improved greatly.33 There-
fore, the length of follow-up time did not significantly change the
results, while had a vital impact on the heterogeneity of the results.
Although the current methods of PRT implementation are
generally consistent, there are differences in some aspects, which
are also a source of heterogeneity of follow-up results. Jorgensen
(2017) started PRT on the patients one week after the operation and
continued it for 8 weeks. However, Only a small number of patients
with postoperative dizziness, wound rupture, swelling and other
adverse reactions. It concluded that PRT two days/week combined
with home-based exercise five days/week was not superior to
home-based exercise seven days/week in improving leg extension
X. Chen, X. Li, Z. Zhu et al.
power of the operated leg18. Matheis (2018) started 3 days after
THA and was well tolerated compared to standard physiotherapy,
with improvements in hip range of motion and gait performance
within a week.33 In addition, scoffer (2019) designed that the
intervention group completed four weeks preoperative and four
weeks postoperative PRT, whereas the control group only
completed four weeks postoperative PRT. Surprising, this study
supports short-term, high-intensity resistance training before sur-
gery because it has long-term effects on muscle strength and may
not have significant effects on functional performance.26,32 Her-
mann (2016) reported that Progressive explosive-type RT was
feasible in the included group of hip OA patients scheduled for THA
and resulted in significant improvement in self-reported outcomes
and increased leg muscle power. The outcome indicated that
changes in HOOS ‘function’ was 10.0 points 95%CI [4.7; 15.3] higher
in PRT compared to SR (P < 0.001). For all the remaining HOOS
subscales SR scored significantly better (P < 0.03) and had higher
leg extension muscle power (P < 0.0001) compared to SR.1 There-
fore, the timing of PRT exercise preoperative or postoperative is still
a controversial topic, which is further confirmed in next study.
With the development of PRT, there are various versions in
exercise content, leading to different results in randomized
controlled trials. Okoro (2016) described the exercises they per-
formed: sitting, stair climbing, walking, block walking, sitting knee
resistance stretching and lateral weight shifting exercises. Based on
their initial physiotherapy evaluation and subsequent progress,
subjects were encouraged to exercise at least 5 times per week,
repeating the range (0e3, 4e6, 7e10).17,40 Skoffer (2019) developed
protocols for their patients, including leg pressure, hip extension,
hip abduction, hip adduction, knee extension, and knee flexion on a
resistance training machine. The training intensity progressed from
12 repetition maximum (RM) to 8 RM preoperatively and post-
operatively.19,26,41 Different versions of the training plan are mainly
determined by the initiator of the experiment, while the purpose
and principle of the scheme is unchanged.
The limitations of the present meta-analysis are as follows: 1. The
experimental group and the control group involved in the literature
did not achieve complete consistency. For example, the experimental
scheme of the intervention group may be changed due to some
research purposes of the initiator, resulting in the emergence of
heterogeneity.6,42,43 2. Most of the follow-up time was 1 year, but
some of them were within 6 months. We used the final follow-up
outcome as the target to extract data and conduct analysis, which
would also result in the emergence of heterogeneity. Secondly, the
experiment with too short follow-up time could not observe the long-
term effect of the intervention.33 3. When extracting data, some lit-
eratures were excluded due to language, lack of data and other rea-
sons, leading in the defect of fewer included literatures.5,21,35,36,42,44,45
4. When extracting outcome indicators for analysis, some outcome
indicators are not available in all the included literatures, so only 2e3
studies are used for systematic analysis of some outcome indicators,
resulting in poor reliability of the conclusions.
5. Conclusion
PRT early after THA or TKA did not differ significantly from SR in
terms of functional capacity, muscle strength recovery and inci-
dence of adverse events. PRT is one of the options for rapid reha-
bilitation after joint replacement.
Acknowledgments
We wish to thank the medical staff of the Department of Or-
thopedics and Rehabilitation medicine of Liaoning People's Hos-
pital of China for their helps.
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Asian Journal of Surgery 44 (2021) 1245e1253
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.asjsur.2021.02.007.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
This work was supported by the National Natural Science
Foundation of China, China (grant No. 81671811) and Shenyang
Science and Technology Innovation Platform Construction Plan,
China (grant No. 1800975).
References
1. Hermann A, Holsgaard-Larsen A, Zerahn B, Mejdahl S, Overgaard S. Preopera-
tive progressive explosive-type resistance training is feasible and effective in
patients with hip osteoarthritis scheduled for total hip arthroplasty–a ran-
domized controlled trial. Osteoarthritis Cartilage. 2016;24(1):91e98.
2. Abramoff B, Caldera FE. Osteoarthritis: pathology, diagnosis, and treatment
options. Med Clin. 2020;104(2):293e311.
3. Hsu WH, Hsu WB, Shen WJ, Lin ZR, Chang SH, Hsu RW. Twenty-four-week
hospital-based progressive resistance training on functional recovery in female
patients post total knee arthroplasty. Knee. 2019;26(3):729e732.
4. Patel A, Pavlou G, Mujica-Mota RE, Toms AD. The epidemiology of revision total
knee and hip arthroplasty in England and Wales: a comparative analysis with
projections for the United States. A study using the National Joint Registry
dataset. The bone & joint journal. 2015;(8):1076e1081, 97-b.
5. Judd DL, Cheuy VA, Forster JE, Christiansen CL, Stevens-Lapsley JE. Incorpo-
rating specific functional strength integration techniques to improve functional
performance for veterans after total hip arthroplasty: protocol for a random-
ized clinical trial. Phys Ther. 2019;99(11):1453e1460.
6. Bade MJ, Struessel T, Dayton M, et al. Early high-intensity versus low-intensity
rehabilitation after total knee arthroplasty: a randomized controlled trial.
Arthritis Care Res. 2017;69(9):1360e1368.
7. Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee
arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 2010;40(9):
559e567.
8. Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and
functional limitations: a comparison of individuals 1 year after total knee
arthroplasty with control subjects. Phys Ther. 1998;78(3):248e258.
9. Okoro T, Ramavath A, Howarth J, et al. What does standard rehabilitation
practice after total hip replacement in the UK entail? Results of a mixed
methods study. BMC Muscoskel Disord. 2013;14:91.
10. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision
hip and knee arthroplasty in the United States from 2005 to 2030. The Journal
of bone and joint surgery American. 2007;89(4):780e785.
11. Skoffer B, Dalgas U, Mechlenburg I. Progressive resistance training before and
after total hip and knee arthroplasty: a systematic review. Clin Rehabil.
2015;29(1):14e29.
12. Mikkelsen LR, Mechlenburg I, Søballe K, et al. Effect of early supervised pro-
gressive resistance training compared to unsupervised home-based exercise
after fast-track total hip replacement applied to patients with preoperative
functional limitations. A single-blinded randomised controlled trial. Osteoar-
thritis Cartilage. 2014;22(12):2051e2058.
13. Ardali G. A daily adjustable progressive resistance exercise protocol and
functional training to increase quadriceps muscle strength and functional
performance in an elderly homebound patient following a total knee arthro-
plasty. Physiother Theory Pract. 2014;30(4):287e297.
14. Jakobsen TL, Kehlet H, Husted H, Petersen J, Bandholm T. Early progressive
strength training to enhance recovery after fast-track total knee arthroplasty: a
randomized controlled trial. Arthritis Care Res. 2014;66(12):1856e1866.
15. Dominguez-Navarro F, Silvestre-Munoz A, Igual-Camacho C, et al. A random-
ized controlled trial assessing the effects of preoperative strengthening plus
balance training on balance and functional outcome up to 1 year following
total knee replacement. Knee Surg Sports Traumatol Arthrosc: official journal of
the ESSKA. 2021;29(3):838e848.
16. Holsgaard-Larsen A, Hermann A, Zerahn B, Mejdahl S, Overgaard S. Effects of
Progressive Resistance Training Prior to Total HIP Arthroplasty - A Secondary
Analysis of a Randomized Controlled Trial. Osteoarthritis Cartilage. 2020;28(8):
1038e1045.
17. Okoro T, Whitaker R, Gardner A, Maddison P, Andrew JG, Lemmey A. Does an
early home-based progressive resistance training program improve function
following total hip replacement? Results of a randomized controlled study.
BMC musculoskeletal disorders. 2016;17(1):173.
18. Jorgensen PB, Bogh SB, Kierkegaard S, et al. The efficacy of early initiated,
X. Chen, X. Li, Z. Zhu et al.
supervised, progressive resistance training compared to unsupervised, home-
based exercise after unicompartmental knee arthroplasty: a single-blinded
randomized controlled trial. Clin Rehabil. 2017;31(1):61e70.
19. Skoffer B, Dalgas U, Maribo T, Soballe K, Mechlenburg I. No Exacerbation of
Knee Joint Pain and Effusion Following Preoperative Progressive Resistance
Training in Patients Scheduled for Total Knee Arthroplasty: Secondary Analyses
from a Randomized Controlled Trial. PM and R. 2018;10:687e692. No
Pagination.
20. Petterson SC, Barrance P, Marmon AR, Handling T, Buchanan TS, Snyder-
Mackler L. Time course of quad strength, area, and activation after knee
arthroplasty and strength training. Med Sci Sports Exerc. 2011;43(2):225e231.
21. Kristensen MS, Jorgensen PB, Bogh SB, Kierkegaard S, Mechlenburg I, Dalgas U.
Acute and chronic effects of early progressive resistance training on knee pain
and knee joint effusion after unicompartmental knee arthroplasty. Acta Orthop
Belg. 2018;84(3):262e268.
22. Langkilde A, Jakobsen TL, Bandholm TQ, et al. Inflammation and post-operative
recovery in patients undergoing total knee arthroplasty-secondary analysis of a
randomized controlled trial. Osteoarthritis Cartilage. 2017;26(8):1265e1273.
Date of Publication: August 15, 2017.
23. Moyer R, Ikert K, Long K, Marsh J. The value of preoperative exercise and ed-
ucation for patients undergoing total hip and knee arthroplasty: a systematic
review and meta-analysis. JBJS reviews. 2017;5(12):e2.
24. Okoro T, Lemmey AB, Maddison P, Andrew JG. An appraisal of rehabilitation
regimes used for improving functional outcome after total hip replacement
surgery. Sports Med Arthrosc Rehabil Ther Technol : SMARTT. 2012;4(1):5.
25. Di Monaco M, Castiglioni C. Which type of exercise therapy is effective after hip
arthroplasty? A systematic review of randomized controlled trials. Eur J Phys
Rehabil Med. 2013;49(6):893e907.
26. Skoffer B, Maribo T, Mechlenburg I, Korsgaard CG, Soballe K, Dalgas U. Efficacy
of preoperative progressive resistance training in patients undergoing total
knee arthroplasty: 12-month follow-up data from a randomized controlled
trial. Clin Rehabil. 2020;34(1):82e90, 269215519883420.
27. Petterson SC, Mizner RL, Stevens JE, et al. Improved function from progressive
strengthening interventions after total knee arthroplasty: a randomized clin-
ical trial with an imbedded prospective cohort. Arthritis Rheum. 2009;61(2):
174e183.
28. van Leeuwen DM, de Ruiter CJ, Nolte PA, de Haan A. Preoperative strength
training for elderly patients awaiting total knee arthroplasty. Rehabil Res Pract.
2014:2014, 462750.
29. Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method
guidelines for systematic reviews in the Cochrane Back Review Group. Spine.
2009;34(18):1929e1941.
30. Higgins JPTTJ, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds. Cochrane
Handbook for Systematic Reviews of Interventions; 2020 (updated September
2020). Cochrane version 6.1.
31. Husby VS, Helgerud J, Bjorgen S, Husby OS, Benum P, Hoff J. Early postoperative
maximal strength training improves work efficiency 6-12 months after oste-
oarthritis-induced total hip arthroplasty in patients younger than 60 years. Am
1253
Asian Journal of Surgery 44 (2021) 1245e1253
J Phys Med Rehab. 2010;89(4):304e314.
32. Suetta C, Magnusson SP, Rosted A, et al. Resistance training in the early post-
operative phase reduces hospitalization and leads to muscle hypertrophy in
elderly hip surgery patients–a controlled, randomized study. J Am Geriatr Soc.
2004;52(12):2016e2022.
33. Matheis C, Stoggl T. Strength and mobilization training within the first week
following total hip arthroplasty. J Bodyw Mov Ther. 2018;22(2):519e527.
34. Heikkil€a A, Sevander-Kreus N, Ha €kkinen A, et al. Effect of total knee replace-
ment surgery and postoperative 12 month home exercise program on gait
parameters. Gait Posture. 2017;53:92e97.
35. Mikkelsen LR, Petersen AK, Mechlenburg I, Mikkelsen S, Søballe K, Bandholm T.
Description of load progression and pain response during progressive resis-
tance training early after total hip arthroplasty: secondary analyses from a
randomized controlled trial. Clin Rehabil. 2017;31(1):11e22.
36. Jakobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength training (10
RM) commenced immediately after fast-track total knee arthroplasty: is it
feasible? Disabil Rehabil. 2012;34(12):1034e1040.
37. Gilbey HJ, Ackland TR, Tapper J, Wang AW. Perioperative exercise improves
function following total hip arthroplasty: a randomized controlled trial.
J Muscoskel Res. 2011;7(2):111e123.
38. Wang AW, Gilbey HJ, Ackland TR. Perioperative exercise programs improve
early return of ambulatory function after total hip arthroplasty: a randomized,
controlled trial. Am J Phys Med Rehab. 2002;81(11):801e806.
39. Yousefian Molla R, Sadeghi H, Kahlaee AH. The effect of early progressive
resistive exercise therapy on balance control of patients with total knee
arthroplasty. Top Geriatr Rehabil. 2017;33(4):286e294.
40. Okoro T, Morrison V, Maddison P, Lemmey AB, Andrew JG. An assessment of
the impact of behavioural cognitions on function in patients partaking in a trial
of early home-based progressive resistance training after total hip replacement
surgery. Disabil Rehabil. 2013;35(23):2000e2007.
41. Skoffer B, Maribo T, Mechlenburg I, Hansen PM, Søballe K, Dalgas U. Efficacy of
preoperative progressive resistance training on postoperative outcomes in
patients undergoing total knee arthroplasty. Arthritis Care Res. 2016;68(9):
1239e1251.
42. Ciolac EG, Silva JM, Greve JM. Effects of resistance training in older women
with knee osteoarthritis and total knee arthroplasty. Clinics. 2015;70(1):7e13.
43. Rossi MD, Brown LE, Whitehurst M, Charni C, Hankins J, Taylor CL. Comparison
of knee extensor strength between limbs in individuals with bilateral total
knee replacement. Arch Phys Med Rehabil. 2002;83(4):523e526.
44. Holsgaard-Larsen A, Hermann A, Zerahn B, Mejdahl S, Overgaard S. Post-
operative effects of progressive resistance training prior to total hip arthro-
plasty e one year outcome of randomized controlled trial. Osteoarthritis
Cartilage. 2018;26:S330eS331.
45. Holm PM, Aagaard P, Schroder H, Skou ST. High-intensity strength training in
addition to standard non-surgical treatment in patients with knee osteoar-
thritis E a randomized controlled trial. Osteoarthritis Cartilage. 2017;25:
S443eS444.