The online version of this article (doi:10.1186/s12891-015-0469-6) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
Conception and design: NA, ADB, CML, CS. Analysis and interpretation of the data: NA, KTE, CML, CS, PJ, ADB. Drafting of the article: NA, KTE, ADB. Critical revision of the article for important intellectual content: CML, CS, PJ. Final approval of the article: NA, KTE, CML, CS, PJ, ADB. Provision of study materials or patients: NA, KTE, ADB. Statistical expertise: CML, CS, ADB. Obtaining of funding: CS, ADB. Administrative, technical, or logistic support: NA, KTE, ADB. Collection and assembly of data: NA, KTE, ADB.
Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement.
We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4th 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement.
Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD).
Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling.
Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3–4 months, SMD −0.37 (95% CI −0.62, −0.12), and pain, SMD −0.45 (95% CI −0.85, −0.06). Benefit up to 6 months was apparent when considering only higher quality studies.
There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion.
There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination.
After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials.
National Joint Registry. 10th Annual Report 2013. Hemel Hempstead: NJR Centre.
National Hospital Discharge Survey. Public data file documentation. Atlanta, US: U.S Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics; 2010.
Spiers NA, Matthews RJ, Jagger C, Matthews FE, Boult C, Robinson TG, et al. Diseases and impairments as risk factors for onset of disability in the older population in England and Wales: Findings from the Medical Research Council Cognitive Function and Ageing Study. J Gerontol A Biol Sci Med Sci. 2005;60(2):248–54. PubMed
Song J, Chang RW, Dunlop DD. Population impact of arthritis on disability in older adults. Arthritis Care Res. 2006;55(2):248–55.
National Institute for Health and Care Excellence. Osteoarthritis: Care and management in adults. London: NICE; 2014.
BOA, BASK. Knee replacement: a guide to good practice. London: British Orthopaedic Association; 1999.
Artz N, Dixon S, Wylde V, Beswick A, Blom A, Gooberman-Hill R. Physiotherapy provision following discharge after total hip and total knee replacement: a survey of current practice at high-volume NHS hospitals in England and Wales. Musculoskeletal Care. 2013;11(1):31–8. PubMed
Oatis CA, Li W, DiRusso JM, Hoover MJ, Johnston KK, Butz MK, et al. Variations in delivery and exercise content of physical therapy rehabilitation following total knee replacement surgery: a cross-sectional observation study. Int J Phys Med Rehabil. 2014;S5:002. doi:10.4172/2329-9096.S5-002.
Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. Bmj. 2007;335(7624):812. PubMed
Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. ᅟ: The Cochrane Collaboration; 2011. Available from www.cochrane-handbook.org.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12. PubMed
Muller E, Mittag O, Gulich M, Uhlmann A, Jackel WH. Systematic literature analysis on therapies applied in rehabilitation of hip and knee arthroplasty: methods, results and challenges. Die Rehabilitation. 2009;48(2):62–72. PubMed
DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled Clinical Trials. 1986;7(3):177–88. PubMed
Kauppila AM, Kyllonen E, Ohtonen P, Hamalainen M, Mikkonen P, Laine V, et al. Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized controlled study of its effects on functional capacity and quality of life. Clin Rehabil. 2010;24(5):398–411. PubMed
Mockford BJ, Thompson NW, Humphreys P, Beverland DE. Does a standard outpatient physiotherapy regime improve the range of knee motion after primary total knee arthroplasty? J Arthroplasty. 2008;23(8):1110–4. PubMed
Rajan RA, Pack Y, Jackson H, Gillies C, Asirvatham R. No need for outpatient physiotherapy following total knee arthroplasty: a randomized trial of 120 patients. Acta Orthop Scand. 2004;75(1):71–3. PubMed
Monticone M, Ferrante S, Rocca B, Salvaderi S, Fiorentini R, Restelli M, et al. Home-based functional exercises aimed at managing kinesiophobia contribute to improving disability and quality of life of patients undergoing total knee arthroplasty: a randomized controlled trial. Arch Phys Med Rehab. 2013;94(2):231–9.
Frost H, Lamb SE, Robertson S. A randomized controlled trial of exercise to improve mobility and function after elective knee arthroplasty. Feasibility, results and methodological difficulties. Clin Rehabil. 2002;16(2):200–9. PubMed
Moffet H, Collet J-P, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial. Arch Phys Med Rehab. 2004;85(4):546–56.
Evgeniadis G, Beneka A, Malliou P, Mavromoustakos S, Godolias G. Effects of pre- or postoperative therapeutic exercise on the quality of life, before and after total knee arthroplasty for osteoarthritis. J Back Musculoskelet. 2008;21(3):161–9.
Minns Lowe CJ, Barker KL, Holder R, Sackley CM. Comparison of postdischarge physiotherapy versus usual care following primary total knee arthroplasty for osteoarthritis: an exploratory pilot randomized clinical trial. Clin Rehabil. 2012;26(7):629–41. PubMed
Mitchell C, Walker J, Walters S, Morgan AB, Binns T, Mathers N. Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial. J Eval Clin Pract. 2005;11(3):283–92. PubMed
Piqueras M, Marco E, Coll M, Escalada F, Ballester A, Cinca C, et al. Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: a randomized controlled trial. J Rehabil Med. 2013;45(4):392–6. PubMed
Tousignant M, Moffet H, Boissy P, Corriveau H, Cabana F, Marquis F. A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare. 2011;17(4):195–8. PubMed
Madsen M, Larsen K, Kirkegard Madsen I, Soe H, Hansen TB. Late group-based rehabilitation has no advantages compared with supervised home-exercises after total knee arthroplasty. Dan Med J. 2013;60(4):A4607. PubMed
Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop Relat Res. 2003;410:225–34. PubMed
Fung V, Ho A, Shaffer J, Chung E, Gomez M. Use of Nintendo Wii FitTM in the rehabilitation of outpatients following total knee replacement: a preliminary randomised controlled trial. Physiotherapy. 2012;98(3):183–8. PubMed
Liebs TR, Herzberg W, Ruther W, Haasters J, Russlies M, Hassenpflug J. Ergometer cycling after hip or knee replacement surgery: a randomized controlled trial. J Bone Joint Surg Am. 2010;92(4):814–22. PubMed
Bruun-Olsen V, Heiberg KE, Wahl AK, Mengshoel AM. The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial. Disabil Rehabil. 2013;35(23):2008–15. PubMed
Harmer AR, Naylor JM, Crosbie J, Russell T. Land-based versus water-based rehabilitation following total knee replacement: a randomized, single-blind trial. Arthritis Rheum. 2009;61(2):184–91. PubMed
Moffet H. Acupuncture trial with indistinguishable exposures is moot . Clin Rehabil. 2008;22(1):71. PubMed
Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988.
Barron CJ, Klaber Moffett JA, Potter M. Patient expectations of physiotherapy: Definitions, concepts, and theories. Physiotherapy Theory Pract. 2007;23(1):37–46.
Scott CEH, Bugler KE, Clement ND, MacDonald D, Howie CR, Biant LC. Patient expectations of arthroplasty of the hip and knee. J Bone Joint Surg Br. 2012;94 B(7):974–81.
Gonzalez Saenz de Tejada M, Escobar A, Herrera C, Garcia L, Aizpuru F, Sarasqueta C. Patient expectations and health-related quality of life outcomes following total joint replacement. Value Health. 2010;13(4):447–54. PubMed
Muniesa JM, Marco E, Tejero M, Boza R, Duarte E, Escalada F, et al. Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Geriontol Geriatr. 2010;51(3):e83–7.
Mancuso CA, Sculco TP, Wickiewicz TL, Jones EC, Robbins L, Warren RF, et al. Patients’ expectations of knee surgery. J Bone Joint Surg Am. 2001;83(7):1005–12. PubMed
Judge A, Cooper C, Williams S, Dreinhoefer K, Dieppe P. Patient-reported outcomes one year after primary hip replacement in a European Collaborative Cohort. Arthritis Care Res. 2010;62(4):480–8.
Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, et al. Which Patients Are Most Likely to Benefit From Total Joint Arthroplasty? Arthritis Rheum. 2013;65(5):1243–52. PubMed
Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e00043543.
Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–4. PubMed
Tew M, Forster IW, Wallace WA. Effect of total knee arthroplasty on maximal flexion. Clin Orthop Relat Res. 1989;247:168–74. PubMed
Park KK, Chang CB, Kang YG, Seong SC, Kim TK. Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients. J Bone Joint Surg Br. 2007;89-B(5):604–8.
Miner AL, Lingard EA, Wright EA, Sledge CB, Katz JN, Kinemax Outcomes G. Knee range of motion after total knee arthroplasty: how important is this as an outcome measure? J Arthroplasty. 2003;18(3):286–94. PubMed
Parent E, Moffet H. Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch Phys Med Rehab. 2002;83(1):70–80.
Lindemann U, Becker C, Unnewehr I, Muche R, Aminin K, Dejnabadi H, et al. Gait analysis and WOMAC are complementary in assessing functional outcome in total hip replacement. Clin Rehabil. 2006;20(5):413–20. PubMed
The difference between rehabilitation with or without strength training after total knee replacement. [ http://www.clinicaltrials.gov/ct2/show/NCT01351831?cond=osteoarthritis&intr=exercise+or+physiotherapy&rank=21]
Effective rehabilitation of patients operated with total knee arthroplasty. [ http://clinicaltrials.gov/show/NCT01877733]
Independent exercise compared with formal rehabilitation following primary total knee replacement. [ http://clinicaltrials.gov/show/NCT01826305]
Progressive rehabilitation following total knee arthroplasty (PROG). [ http://clinicaltrials.gov/show/NCT01537328]
Targeted rehabilitation to improve outcome after knee replacement- A physiotherapy study (TRIO-Physio). [ http://www.clinicaltrials.gov/ct2/show/NCT01849445?cond=osteoarthritis&intr=exercise+or+physiotherapy&rank=1]
McLean SM, Burton M, Bradley L, Littlewood C. Interventions for enhancing adherence with physiotherapy: a systematic review. Man Ther. 2010;15(6):514–21. PubMed
Beswick A, Rees K, West R, Taylor F, Burke M, Griebsch I, et al. Improving uptake and adherence in cardiac rehabilitation: Literature review. J Adv Nurs. 2005;49(5):538–55. PubMed
- Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis
Karen T Elvers
Catherine Minns Lowe
Andrew D Beswick
- BioMed Central
Neu im Fachgebiet Orthopädie und Unfallchirurgie
Mail Icon II