Get the Most Out of Joint Replacement

In a systematic review of English language articles published prior to August 2003, Ackerman and Bennel found a limited number of randomized controlled trials (RCTs) examining the effectiveness of preoperative exercise programs (physical therapy) on THR and TKR outcomes.⁴ Of the five studies meeting the review’s inclusion criteria, two pertained to THR and three to TKR, with a combined total of 146 subjects. In the two THR studies reporting outcomes for the same patient cohort, significant improvements were reported for self-reported function (Western Ontario and McMaster Universities Osteoarthritis Index or WOMAC), hip flexion range of motion (ROM), isokinetic hip strength, and various gait-related parameters at one week pre-op and three, 12, and 24 weeks post-op. The small-to-moderate treatment-effect sizes suggested potentially clinically important differences between the groups. Confounding the results, however, was the fact that the intervention group also received intensive postoperative exercise therapy. The preoperative exercise component consisted of a twice-weekly eight-week customized exercise program comprising stationary cycling, hydrotherapy, and resistive strength training.

Small, statistically nonsignificant treatment effects for self-reported function (Hospital for Special Surgery Knee Rating, Arthritis Impact Measurement Scale), knee ROM, isokinetic knee strength, and walking speed were found for the three TKR trials. However, the trials failed to show clinically important differences between groups in both the pre-op and post-op phases. These preoperative interventions ranged from a five-week group exercise program offered three times per week to six weeks of individualized exercise therapy, also three times per week.

A more recent review conducted as part of the French Physical Medicine and Rehabilitation Society’s guideline development process included English and French language papers on preoperative PT, published up to January 2006.⁵ These authors reported that the heterogeneous nature of the preoperative interventions (differing health care providers, duration, and modes of exercise therapy) prevented the pooling of results. No trials of isolated preoperative exercise therapy were found for THR and only one (included in the previous review) was found for TKR. Nonetheless, the authors recommended a preoperative rehabilitation program comprising PT and education following preoperative assessment to identify those patients most likely to benefit.

A trial published subsequent to these two reviews reported statistically significant improvements in pain and self-reported and performance-based function following a six-week land- and pool-based preoperative exercise program.⁶ Patients undergoing THR surgery responded better than TKR patients; however, both groups were more likely to be discharged home if they had participated in the exercise intervention.