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Does Exercise Reduce Pain and Improve Physical Function Before Hip or Knee Replacement Surgery? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Published:September 06, 2012DOI:https://doi.org/10.1016/j.apmr.2012.08.211

      Abstract

      Objective

      To investigate the preoperative effects of exercise-based interventions on pain and physical function for people awaiting joint replacement surgery of the hip or knee.

      Data Sources

      Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Reference lists of retrieved articles were also screened.

      Study Selection

      Randomized or quasi-randomized studies comparing an exercise-based intervention with a no-intervention group for people awaiting hip or knee joint replacement surgery were included. Outcomes were pain and physical function including self-reported function, walking speed, and muscle strength. One of 2 reviewers determined that 18 studies met the inclusion criteria.

      Data Extraction

      The methodologic quality of each study was independently assessed by 2 reviewers using the PEDro scale, and a final PEDro score was determined by discussion and consensus between the reviewers. Participants’ characteristics, content and design of the interventions, and data for quantitative synthesis were extracted by 1 reviewer.

      Data Synthesis

      For participants awaiting knee replacement surgery, quantitative data synthesis found no significant differences between the exercise and no-intervention groups for pain, self-reported function, walking speed, or muscle strength. For participants awaiting hip replacement surgery, quantitative data synthesis found a significant difference between the groups, with standardized mean differences (SMDs) indicating a medium-sized effect in favor of intervention for both pain (SMD=.45; 95% confidence interval .15–.75) and self-reported function (SMD=.46; 95% confidence interval .20–.72).

      Conclusions

      Exercise-based interventions can reduce pain and improve physical function for people awaiting hip replacement surgery but not knee replacement surgery.

      Keywords

      List of abbreviations:

      CONTENT (Consensus on Therapeutic Exercise Training), SMD (standardized mean difference), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)
      An increasing number of hip and knee replacements are performed each year throughout the world.
      • MacWilliam C.H.
      • Yood M.U.
      • Verner J.J.
      • McCarthy B.D.
      • Ward R.E.
      Patient-related risk factors that predict poor outcome after total hip replacement.
      • Jones C.A.
      • Voaklander D.C.
      • Johnston W.C.
      • Suarez-Almazor M.E.
      Health related quality of life outcomes after total hip and knee arthroplasties in a community-based population.
      • Brownlow H.C.
      • Benjamin S.
      • Andrew J.G.
      • Kay P.
      Disability and mental health of patients waiting for total hip replacement.
      • Hirvonen J.
      • Blom M.
      • Tuominen U.
      • et al.
      Health-related quality of life in patients waiting for major joint replacement: a comparison between patients and population controls.
      Surgery is typically successful at reducing pain and improving physical function such as the ability to walk, transfer on and off chairs, and perform domestic duties.
      • Jones C.A.
      • Voaklander D.C.
      • Johnston W.C.
      • Suarez-Almazor M.E.
      Health related quality of life outcomes after total hip and knee arthroplasties in a community-based population.
      • Bachmeier C.J.
      • March L.M.
      • Cross M.J.
      • et al.
      A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery.
      • Callahan C.M.
      • Drake B.G.
      • Heck D.A.
      • Dittus R.S.
      Patient outcomes following tricompartmental total knee replacement: a meta-analysis.
      While surgery has known benefits, improving preoperative health status remains an important goal. First, people awaiting joint replacement surgery of the hip or the knee suffer considerable pain and disability.
      • Jones C.A.
      • Voaklander D.C.
      • Johnston W.C.
      • Suarez-Almazor M.E.
      Health related quality of life outcomes after total hip and knee arthroplasties in a community-based population.
      • Brownlow H.C.
      • Benjamin S.
      • Andrew J.G.
      • Kay P.
      Disability and mental health of patients waiting for total hip replacement.
      In many health care systems, people wait long periods for surgery, which prolongs their suffering and might lead to further deterioration in health-related quality of life.
      • Hirvonen J.
      • Blom M.
      • Tuominen U.
      • et al.
      Health-related quality of life in patients waiting for major joint replacement: a comparison between patients and population controls.
      • Williams J.
      • Llewellyn Thomas H.
      • Arshinoff R.
      • Young N.
      • Naylor C.
      The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team.
      • Ackerman I.N.
      • Bennell K.L.
      • Osborne R.H.
      Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.
      Second, preoperative status predicts postoperative status; people with poorer preoperative physical function have inferior postoperative outcomes when compared with those with better preoperative physical function.
      • Fortin P.R.
      • Clarke A.E.
      • Joseph L.
      • et al.
      Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery.
      • Jones C.A.
      • Voaklander D.C.
      • Suarez-Alma M.E.
      Determinants of function after total knee arthroplasty.
      Consequently, preoperative interventions that reduce pain and improve physical function might be important for both preoperative and postoperative effects.
      It is generally accepted that exercise can reduce pain and improve physical function in those with lower limb arthritis.
      • Fransen M.
      • Crosbie J.
      • Edmonds J.
      Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial.
      International guidelines recommend exercise for treating lower limb osteoarthritis.
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
      • Zhang W.
      • Nuki G.
      • Moskowitz R.W.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, part III: changes in evidence following systematic cumulative update of research published through January 2009.
      Systematic reviews of exercise-based interventions have demonstrated reduced pain and improved physical function for those with mild to moderate knee osteoarthritis
      • Fransen M.
      • McConnell S.
      Exercise for osteoarthritis of the knee.
      and reduced pain in those with mild to moderate hip osteoarthritis.
      • Fransen M.
      • McConnell S.
      • Hernandez-Molina G.
      • Reichenbach S.
      Exercise for osteoarthritis of the hip.
      Considering this, exercise might also be beneficial for those with end-stage hip or knee arthritis awaiting joint replacement.
      A systematic review of studies investigating the effects of exercise for people awaiting joint replacement surgery of the hip or the knee found few postoperative benefits in favor of exercise.
      • Ackerman I.N.
      • Bennell K.L.
      Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review.
      A more recent review
      • Coudeyre E.
      • Jardin C.
      • Givron P.
      • Ribinik P.
      • Revel M.
      • Rannou F.
      Could preoperative rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration of French clinical practice guidelines.
      also found little evidence to support single disciplinary interventions such as exercise-based physical therapy but some evidence to recommend multidisciplinary preoperative rehabilitation. Importantly, both reviews focused on postoperative outcomes, and so the preoperative effects of interventions remain uncertain. Expecting postoperative improvements from preoperative interventions might be unreasonable if no preoperative effects were produced.
      Preoperative exercise-based interventions for those awaiting joint replacement surgery are increasingly prevalent
      • Ackerman I.N.
      • Bennell K.L.
      Current Australian practice in pre-operative physiotherapy prior to total knee replacement surgery.
      and might produce important effects both before and after surgery. Given that previous literature reviews focused on the postoperative effects of exercise-based interventions, and that additional studies have been published since these reviews were completed, the aim of the current review was to determine whether preoperative exercise programs can reduce pain and improve physical function prior to joint replacement surgery of the hip or the knee.

      Methods

      Search strategy

      Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Comprehensive search strategies were individually constructed for each database using subject heading mapping (appendix 1). Typical search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Titles and abstracts identified by the literature searches were screened by 1 reviewer (S.G.) utilizing predetermined eligibility criteria to ascertain potentially relevant trials to be included in the review. Reference lists of retrieved articles were also screened.

      Selection criteria

      Publications were eligible if (1) the preoperative effects of an exercise-based intervention were assessed irrespective of the content, frequency, or location of the intervention; (2) pain and/or physical function was assessed; (3) all participants were on the waiting list for hip or knee replacement surgery; (4) a randomized or quasi-randomized design comparing an exercise-based intervention with a no-intervention group was used; (5) a full report was published; and (6) the study was written in English. An exercise-based intervention was defined as an intervention that involved participants completing more than 1 session of physical exercises such as strengthening, flexibility, and/or aerobic activities. Studies that assessed only the postoperative effects of preoperative exercise programs were excluded, as were studies whose intervention included only education, including education about exercise.

      Assessment of methodologic quality

      The PEDro scale was used to rate the methodologic quality of each study.
      • Sherrington C.
      • Herbert R.D.
      • Maher C.G.
      • Moseley A.M.
      PEDro: a database of randomized trials and systematic reviews in physiotherapy.
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      • Elkins M.
      Reliability of the PEDro scale for rating quality of randomized controlled trials.
      Full-text articles that met the inclusion criteria were independently reviewed against the PEDro criteria by both authors. The authors then compared results and discussed discrepancies in light of the PEDro operational definitions
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      • Elkins M.
      Reliability of the PEDro scale for rating quality of randomized controlled trials.
      until agreement was reached. Consistent with previous reviews,
      • Foley N.C.
      • Teasell R.W.
      • Bhogal S.K.
      • Speechley M.R.
      Stroke rehabilitation evidence-based review: methodology.
      • Valkenet K.
      • van de Port I.G.L.
      • Dronkers J.J.
      • de Vries W.R.
      • Lindeman E.
      • Backx F.J.G.
      The effects of preoperative exercise therapy on postoperative outcome: a systematic review.
      PEDro scores were interpreted as follows: a score of 9 or more indicated excellent methodologic quality, 6 to 8 good methodologic quality, 4 to 5 fair methodologic quality, and <4 poor methodologic quality.

      Quantitative data synthesis

      Meta-analysis was completed for studies with comparable data for outcomes of pain and the most commonly reported measures of physical function including self-reported function, walking speed, and muscle strength. Because studies used different measurement tools, standardized mean differences (SMDs) (small, 0.2; medium, 0.5; and large, 0.8)
      • Cohen J.
      Statistical power analysis for the behavioural sciences. Revised edition.
      were calculated using RevMan 5.1.
      Review Manager (RevMan)
      [Computer program]. Version 5.1.
      Random effects models using postintervention scores for intervention and no-intervention groups were used. Statistical heterogeneity was assessed and considered likely if P was <0.1 for chi-squared testing of the Q statistic and I2 was greater than 50%. Hip and knee participants were analyzed separately because exercise might affect these groups differently.
      Several studies included more than 1 measure of pain or self-reported function. Of these, all except Hoogeboom et al
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      and Oosting et al
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); hence, we selected the WOMAC for inclusion in the meta-analysis because it is a widely used condition-specific measure in hip or knee osteoarthritis trials with acceptable clinimetric properties.
      • Angst F.
      • Aeschlimann A.
      • Steiner W.
      • Stucki G.
      Responsiveness of the WOMAC osteoarthritis index as compared with the SF36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.
      For Hoogeboom
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      and Oosting,
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      we included the Hip disability and Osteoarthritis Outcome Score because it is an arthritis-specific measure with acceptable clinimetric properties.
      • Nilsdotter A.
      • Lohmander L.S.
      • Klassbo M.
      • Roos E.
      Hip disability and Osteoarthritis Outcome Score (HOOS)—validity and responsiveness in total hip replacement.
      Where possible, corresponding authors were contacted to obtain missing data. If measures of variability were not available, we imputed the average SD from other studies if the same outcome measure had been used. The corresponding author of 1 study
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      was unable to provide mean scores and measures of variability for graphically presented data, and as no other study reported appropriate data from which to estimate measures of variability, data from this study could not be included in the meta-analysis. In 1 study,
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      means and SDs were estimated from medians and ranges.
      • Hozo S.P.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, range, and the size of a sample.

      Results

      Included and excluded studies

      Twenty-three trials were identified as highly relevant, of which 5 were subsequently excluded: 1 study
      • Winter S.V.
      • Burch D.
      Effects of preoperative water exercise on total knee replacement patients.
      investigated the effects of preoperative pool-based exercise in those awaiting knee replacement but did not involve a comparison group; 1 study
      • Gstoettner M.
      • Raschner C.
      • Dirnberger E.
      • Leimser H.
      • Krismer M.
      Preoperative proprioceptive training in patients with total knee arthroplasty.
      did not complete a preoperative postintervention assessment of the no-intervention group; full text of another study
      • Wijgman A.J.
      • Dekkers G.H.
      • Waltje E.
      • Krekels T.
      • Arens H.J.
      [No positive effect of preoperative exercise therapy and teaching in patients to be subjected to hip arthroplasty].
      was published in Dutch and communication with the corresponding author revealed that no English version was available; 1 study
      • Gill S.D.
      • McBurney H.
      • Schulz D.L.
      Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial.
      compared 2 forms of exercise but did not include a no-intervention group; 2 studies
      • Topp R.
      • Swank A.M.
      • Quesada P.M.
      • Nyland J.
      • Malkani A.
      The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty.
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      had very similar protocols, and communication with the corresponding authors indicated that data presented by 1 study
      • Topp R.
      • Swank A.M.
      • Quesada P.M.
      • Nyland J.
      • Malkani A.
      The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty.
      was a subset of data presented in the other
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      ; hence, only the larger trial was included in the review. Ackerman and Bennell
      • Ackerman I.N.
      • Bennell K.L.
      Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review.
      reported that participants in another study
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      were a subset of a larger trial
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      ; however, as both articles reported on different outcome measures, both studies were included in the review. The intervention in 1 study
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      was termed therapeutic education and functional readaptation and was based on theories of social learning and self-management. Exercises were taught and practiced in at least 2 of the 4 supervised sessions, and participants were required to complete a daily exercise program. Because exercise was emphasized during the 3-month intervention, the study was included in the review. Eighteen studies therefore satisfied the inclusion criteria and were included in the current review.

      Methodologic quality of the studies

      PEDro scores ranged between 3 and 8 (table 1), with 13 studies considered to have good methodologic quality (ie, a PEDro score of 6–8). It was not possible to blind the participant or the therapist from the intervention; hence, all studies scored 0 for these criteria, reducing the maximum possible PEDro score to 8. Of the 18 studies, 16 or more satisfied the criteria of random allocation, baseline similarities between groups, between-group statistical comparisons, and reporting of point measures and measures of variability. One study
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      did not use random allocation, instead using quasi-random allocation based on geographic availability. Two studies
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      did not complete baseline assessments of the control group; hence, it was not possible to assess baseline similarity between groups for all important variables. One study
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      followed up 83% of the participants, just below the 85% required to satisfy the criteria for follow-up.
      Table 1Methodologic quality of studies
      StudyPEDro Criterion
      1234567891011Total
      Weidenhielm et al
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      110100010115
      Borjesson et al
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      110100111117
      D’Lima et al
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      110100011116
      Rodgers et al
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      100000010113
      Wang et al
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      110100011116
      Gilbey et al
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      110100000114
      Beaupre et al
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      111100101117
      Gocen et al
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      110000111116
      Nunez et al
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      110100100115
      Rooks et al
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      110100100115
      Williamson et al
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      111100111118
      Evgeniadis et al
      • 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.
      111100001116
      Ferrara et al
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      110100111117
      Aoki et al
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      110100111117
      Hoogeboom et al
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      111100110117
      Swank et al
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      110100011116
      Oosting et al
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      111100111118
      McKay et al
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      111100011117
      NOTES. PEDro criteria: 1. Eligibility criteria were specified. 2. Random allocation. 3. Concealed allocation. 4. Baseline similarity between groups. 5. Subject blinding. 6. Therapist blinding. 7. Assessor blinding. 8. Follow-up >85%. 9. Intention-to-treat analysis. 10. Between-group statistical comparisons. 11. Point measures and measures of variability reported.
      Item scoring: 1 = present, 0 = absent. Criterion 1 is not included in the total score.

      Participant characteristics

      Participants were awaiting knee replacement in 12 studies and hip replacement in 7 studies (table 2). One study
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      included participants awaiting either hip or knee replacement. With the exception of 1 study
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      where participants were noticeably younger, participants were typically older adults with average ages of between 60 and 80 years. Most studies had more women than men, and 1 study
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      had only women.
      Table 2Participant characteristics
      StudyType of SurgeryGroupsn
      Number of participants randomized to each group.
      Age (y), Mean ± SDSex % Female
      Weidenhielm et al
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      Unilateral unicompartmental KRIntervention2064±455
      Control2063±545
      Borjesson et al
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      Unilateral KR or high tibial osteotomyIntervention3464±450
      Control3464±550
      D’Lima et al
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      Unilateral TKRIntervention A1068.5±4670
      Intervention B1071.6±6.620
      Control1069.5±6.550
      Rodgers et al
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      Unilateral TKRIntervention1270 (range 63–78)60
      Control1165 (range 50–83)50
      Wang et al
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      Unilateral THRIntervention1568.3±8.260
      Control1365.7±8.469
      Gilbey et al
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      Unilateral THRIntervention3766.7±10.257
      Control3163.3±12.068
      Beaupre et al
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      Primary TKRIntervention6567±760
      Control6667±650
      Gocen et al
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      Primary THRIntervention3046.9±11.545
      Control3055.5±14.427
      Nunez et al
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      Primary TKRIntervention5172.6±6.276
      Control4969.5±6.865
      Rooks et al
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      1. Primary unilateral THR1. Intervention3265±1163
      Control3159±752
      2. Primary unilateral TKR2. Intervention2265±850
      Control2369±857
      Williamson et al
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      Primary KR (total or unicondylar, unilateral or bilateral)Intervention
      Also included acupuncture as a third experimental group that is not included in the current review.
      6070.0±8.852
      Control6169.6±10.054
      Evgeniadis et al
      • 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.
      Primary TKRIntervention
      Also included postoperative exercise as a third experimental group that is not included in the current review.
      2467.1±4.470
      Control2469.4±1.983
      Ferrara et al
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      Primary THRIntervention1163.8±9.064
      Control1263.1±6.958
      Aoki et al
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      Primary TKR (unilateral or bilateral)Intervention1772.3±5.2100
      Control1974.4±6.4100
      Hoogeboom et al
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      Primary THRInvention1077±370
      Control1175±564
      Swank et al
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      Unilateral TKRIntervention3663.1±7.367
      Control3562.6±7.663
      Oosting et al
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      Primary THRIntervention1576.9±6.393
      Control1575.0±6.367
      McKay et al
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      Primary unilateral TKRIntervention1063.5±4.950
      Control1260.6±8.167
      Abbreviations: KR, knee replacement; THR, total hip replacement; TKR, total knee replacement.
      Number of participants randomized to each group.
      Also included acupuncture as a third experimental group that is not included in the current review.
      Also included postoperative exercise as a third experimental group that is not included in the current review.

      Content and design of interventions

      Exercises completed by the intervention groups typically included some form of strengthening, flexibility, and aerobic exercise (table 3). Two studies
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      incorporated “functional task exercise” to simulate common daily activities. For most studies, exercises targeted the lower limbs; 1 study
      • 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.
      included mostly upper limb and trunk exercises. The intervention in 1 study
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      was essentially an unsupervised home exercise program. All interventions included land-based exercises; 4 studies
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      also included pool-based exercises. Two-thirds of the studies reported exercise intensity or exercise progression, typically indicating “moderate”-intensity exercise and progression of exercises according to the patient’s pain response, perceived exertion, and/or improvements in physical capacity. Compliance with the intervention was typically high but was reported by only half the studies.
      Table 3Content and design of interventions
      StudyProgram TypeSupervised Sessions: Group (n) or IndividualSupervised Sessions Conducted byDuration of ProgramFrequency of Supervised ClassesDuration of Each Supervised ClassUnsupervised Home Exercise ProgramExercise IntensityCompliance With Exercise Program
      Weidenhielm et al
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      Land based: strengthening, stretching, aerobicGroup (3–4)PT5wk×3/wk?DailyEx bike 10min at 50 turns/min

      ST: 2×10 reps, ? progression
      ?
      Borjesson et al
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      Land based: strengthening, stretching, aerobicGroup (n=?)PT5wk×3/wk40min×2/wkEx bike 10min w/o resistance

      ST: 2×10 reps; progressed by 10RM principle
      ?
      D’Lima et al
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      Intervention A: Land based: strengthening, stretchingIndividualPT6wk×3/wk45minNoST: ? reps or intensity, reps increased ×1/d

      Arm and leg cycling: Intensity=resting heart rate+(0.4–0.7) maximum heart rate

      Pool based: no details
      ?
      Intervention B: Land based and pool based: strengthening, stretching, aerobic??6wk×3/wk45minNo
      Rodgers et al
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      Land based: strengthening, stretching, aerobic?PT6wk×3/wk?NoST: ? reps

      Initial intensity per “baseline capacity” and “advanced accordingly” at 3wk
      ?
      Wang et al
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      Land based and pool based: strengthening, stretching, aerobic?? exercise physiologist8wk×2/wk1h×2/wkST: (1–3)×10 reps progressed in 5-kg increments, “subjects determined the intensity of their exercise sessions”

      Pool based: no details
      97% of the sessions completed
      Gilbey et al
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      Land based and pool based: strengthening, stretching, aerobicLand: (n=?)

      Pool: group (≤3)
      ? exercise physiologist8wk×2/wk1h×2/wkST: (1–3)×10 reps

      Intensity and progression per ACSM guidelines
      97% of the sessions completed
      Beaupre et al
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      Land based: strengthening, aerobic

      Postoperative education
      ?PT4wk×3/wk≤30minNoEx bike: 5–10min “low resistance”

      ST: 3×10 reps increased to 3×15 reps
      All but 1 participant completed the 12 sessions
      Gocen et al
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      Land based: strengthening, stretching

      Education on ADL
      IndividualPT8wkFortnightly?×3/dST: 10 reps, ? intensity, ? progression?
      Nunez et al
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      Land based: strengthening, flexibility, “general exercises”Individual and group (10–12)“health educator”12wk4 total30–90minDailyST: 10–30 reps, ? intensity, ? progression?
      Rooks et al
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      Land based and pool based: strengthening, stretching, aerobic

      Education on home modifications
      Group

      (n=?)
      PT6wk×3/wk30–60minNoEx bike: 10min at “moderate intensity”

      ST: (1–2)×(8–12) reps, ? progression
      89% of the sessions completed
      Williamson et al
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      Land based: strengthening, stretching, balanceGroup

      (6–10)
      PT6wk×1/wk1hYes (“encouraged”)ST: ? reps

      ? intensity, ? progression
      ?
      Evgeniadis et al
      • 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.
      Land based: strengthening (mostly upper limb and trunk)IndividualPT or orthopedist3wk×3/wk?NoST: (1–3)×(10–14) reps, intensity to “modest fatigue,” resistance progressed when able to perform 15 reps?
      Ferrara et al
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      Land based: strengthening, strengthening, aerobic Postoperative educationIndividual and group (≤3)PT4wk×5/wk60minNoEx bike: 15min at “low or moderate” intensity

      Strengthening: (3–4)×(8–12) reps, ? progression
      ?
      Aoki et al
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      Land based:

      stretching
      Individual? PT11–12wkNoneNADailyStretch 30s 10 times, “keep the knee flexed as much as possible”Exercises completed on 93.1% of the days
      Hoogeboom et al
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      Land based: strengthening, aerobic, functional Postoperative education?PT3–6wk≥×2/wk1hYes, on nontraining daysEx bike: 20–30min

      ST: “sets” of 10–20 reps

      Functional: ? reps

      Intensity moderate to high perceived exertion. Progression to maintain desired perceived exertion
      91% of the sessions completed
      Swank et al
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      Land based: strengthening, stretching?“Research personnel”4–8wk×1/wk?≥×2/wkST: (1–2)×10 reps progressed from “low” to “moderate” resistance. Intensity “moderately fatiguing”90% of the sessions completed
      Oosting et al
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      Land based: “Functional tasks exercise”IndividualPT3–6wk×2/wk30min×4/wkFunctional exercises: 30min, ? reps, intensity and reps “progressively increased over time”

      Intensity 55%–75% max heart rate or 11–13 on Borg scale
      99% of the sessions completed
      McKay et al
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      Land based: aerobic, strengtheningIndividualKinesiologist6wk×3/wk30minNoST: 2×8 reps at 60% of 1 rep max and progressed by 1-kg increments98% of the sessions completed
      Abbreviations: ACSM, American College of Sports Medicine; ADL, activities of daily living; Ex, exercise; max, maximum; NA, not applicable/available; PT, physiotherapist/physical therapist; reps, repetitions; RM, repetition maximum; ST, strength training; w/o, without; ?, information was not clearly stated.
      Seven studies
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      • Gocen Z.
      • Sen A.
      • Unver B.
      • Karatosun V.
      • Gunal I.
      The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      reported including participant education. Education usually included how to prepare for surgery, the use of assistive devices such as crutches or elevated toilet seats, activities to avoid, and although often ambiguously reported, related more to postoperative care. Control groups typically received no intervention and were left to continue their usual activities until surgery. However, participants in 1 control group
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      completed supervised upper limb resistance exercises and aerobic exercises 3 times a week for 6 weeks. Several studies provided control group participants with education; education was usually about postoperative care, although 1 study
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      provided a leaflet on preoperative exercises.
      Interventions for people awaiting hip compared with knee replacement had no consistent differences regarding the frequency of supervised sessions, program duration, or inclusion of a home exercise program. However, 3 of the 5 interventions
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      for people awaiting hip replacement included a pool-based exercise program, whereas only 1 study
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      for people awaiting knee replacement included a pool-based program (and this study was not included in the quantitative data synthesis).
      Interventions did not directly modify analgesia usage. The educational component of 1 study
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      included information regarding the use of analgesia; the authors of the study speculated that the significant increase in analgesia consumption in the intervention group was because of education regarding pain medication. Participants in another study
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      were advised to take the pain medications prescribed by their doctor. Two studies
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      indicated that medication usage did not change during the intervention period. One study
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      recorded medication usage at baseline only. Another study
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      indicated that nonsteroidal anti-inflammatory medications were discontinued the week before surgery.

      Quantitative data synthesis

      Participants awaiting knee replacement

      Ten studies measured pain (fig 1). Measures included the WOMAC,
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      Medical Outcomes Study 36-Item Short-Form Health Survey,
      • 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.
      and pain during walking.
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      One study
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      used a visual analog scale but did not indicate if pain was measured for specific or all activities. Within individual studies, 1 study
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      found a significant effect and this was in favor of the treatment group. When data were combined, there was no significant difference between the treatment and control groups.
      Figure thumbnail gr1
      Fig 1Forest plots of SMDs for knee replacement participants. Abbreviations: CI, confidence interval; IV, independent variable; Std., standard.
      Six studies measured self-reported function using the WOMAC,
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      Oxford Knee Score,
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      or Medical Outcomes Study 36-Item Short-Form Health Survey
      • 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.
      (see fig 1). Within individual studies, 1 study
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • et al.
      The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
      found a significant effect and this was in favor of the treatment group. When data were combined, there was no significant difference between treatment and control groups.
      Six studies
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      measured maximum knee extension strength, and 1 study
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      measured maximum leg press weight (see fig 1). Within individual studies, 1 study
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      demonstrated a significant difference between the treatment and control groups. When data were combined, there was no significant difference between the treatment and control groups.
      Seven studies measured walking speed (see fig 1). Walking speed was measured over distances of 10 meters,
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      30 meters,
      • Aoki O.
      • Tsumura N.
      • Kimura A.
      • Okuyama S.
      • Takikawa S.
      • Hirata S.
      Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis.
      50 meters,
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      15.24 meters (50 feet),
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      and during 4-minute
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      and 6-minute walking tests.
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      Two studies
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      found significant effects in favor of the treatment group; however, when data were combined, there was no significant difference between the treatment and control groups.
      Considerable statistical heterogeneity was found between studies for outcomes of pain, muscle strength, and walking speed. Forest plots (see fig 1) identified the results from Swank et al
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      as noticeably different from those of the remaining studies. Statistical heterogeneity was not apparent if Swank's data
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      were removed from the analysis; when data from the remaining studies were combined, the SMDs remained nonsignificant.

      Participants awaiting hip replacement

      Five studies measured pain using the WOMAC
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      or Hip disability and Osteoarthritis Outcome Score
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      (fig 2). Within individual studies, 1 study
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      found a significant difference between the treatment and control groups. When data from all studies were combined, there was a medium-sized treatment effect (SMD .45; 95% confidence interval .15–.75).
      Figure thumbnail gr2
      Fig 2Forest plots of SMDs for hip replacement participants. Abbreviations: CI, confidence interval; IV, independent variable; Std., standard.
      Six studies measured self-reported function using the WOMAC,
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      Hip disability and Osteoarthritis Outcome Score,
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      or Harris Hip Score
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      (see fig 2). Within individual trials, 2 studies
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      found a significant difference between treatment and control groups. When data were combined, there was a medium-sized treatment effect (SMD .46; 95% confidence interval .20–.72).
      Three studies measured muscle strength using maximum leg press weight,
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      British Medical Research Council scale hip abduction strength,
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      or a combined isokinetic and isometric hip strength score
      • Gilbey H.J.
      • Ackland T.R.
      • Wang A.W.
      • Morton A.R.
      • Trouchet T.
      • Tapper J.
      Exercise improves early functional recovery after total hip arthroplasty.
      (see fig 2). Within individual studies, 1 study
      • Ferrara P.
      • Rabini A.
      • Maggi L.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      found a significant difference between the treatment and control groups. When data were combined, there was no significant difference between the treatment and control groups.
      Three studies measured walking speed using the 6-minute walking test
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      or the 25-meter walk test
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      (see fig 2). Within individual studies, none found a significant difference between treatment and control groups. When data were combined, there was no significant difference between the treatment and control groups.

      Adverse events

      Apart from postexercise soreness, no adverse events were reported as being caused by the exercise interventions although only 5 studies
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Oosting E.
      • Jans M.P.
      • Dronkers J.J.
      • et al.
      Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.
      • D’Lima D.D.
      • Colwell Jr., C.W.
      • Morris B.A.
      • Hardwick M.E.
      • Kozin F.
      The effect of preoperative exercise on total knee replacement outcomes.
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      • Williamson L.
      • Wyatt M.R.
      • Yein K.
      • Melton J.T.K.
      Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
      clearly commented on this. Three studies
      • Wang A.W.
      • Gilbey H.J.
      • Ackland T.R.
      Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.
      The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.
      • Rooks D.S.
      • Huang J.I.E.
      • Bierbaum B.E.
      • et al.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      referred to “complications,” which probably referred to postoperative complications rather than preoperative complications associated with the exercise interventions.

      Discussion

      Systematic reviews of randomized controlled trials are considered by some to be the best single source of information about the effectiveness of health care interventions.
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      • Elkins M.
      Reliability of the PEDro scale for rating quality of randomized controlled trials.
      • Hemels M.E.
      • Vicente C.
      • Sadri H.
      • Masson M.J.
      • Einarson T.R.
      Quality assessment of meta-analyses of RCTs of pharmacotherapy in major depressive disorder.
      Studies included in the current review typically had fair to good methodologic quality, and pooling of the studies’ data indicated that preoperative exercise-based interventions produced positive preoperative effects for people awaiting hip replacement surgery but not knee replacement surgery. People awaiting hip replacement had lower levels of pain and improved self-reported function, with SMDs indicating a medium-sized effect.
      Given differences in biomechanics, impairments, rapidity of progression, and risk factors for people with hip versus knee osteoarthritis,
      • Bennell K.L.
      • Hinman R.S.
      A review of the clinical evidence for exercise in osteoarthritis of the hip and knee.
      exercise might have different effects for people awaiting hip replacement versus knee replacement. The results of the current review support this possibility. However, no study in the current review directly compared the effects of exercise for hip versus knee participants. Hence, other factors, such as differences in the content of the exercise programs or how well exercise was tolerated, might explain why the current review found treatment effects for hip participants but not knee participants. Indeed, the inclusion of pool-based exercise was a notable difference between the interventions for hip versus knee participants. Three of the 5 hip studies included pool-based exercises, whereas only 1 knee study included pool-based exercise, and this study was not included in the data synthesis. Elsewhere, a systematic review comparing land-based exercise with pool-based exercise for people with arthritis found no difference in outcomes.
      • Batterham S.
      • Heywood S.
      • Keating J.
      Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes.
      Significantly, participants in 1 study
      • Gill S.D.
      • McBurney H.
      • Schulz D.L.
      Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial.
      were awaiting joint replacement surgery of the hip or the knee and this study found no postintervention differences between the pool-based and land-based programs for pain and physical function; however, because results for the hip and knee participants were combined in the analysis, the specific effects of land-based and pool-based exercise for hip and knee subgroups remain unknown. Hence, further research is required to clarify whether exercise programs have different effects for people awaiting hip replacement versus knee replacement and/or whether varying the content of the intervention, such as including pool-based exercise, produces different effects.
      The effectiveness of clinical trials depends on the quality of the interventions used.
      • Hoogeboom T.J.
      • Oosting E.
      • Vriezekolk J.E.
      • et al.
      Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis.
      Inadequate or inappropriate intervention content could explain why few individual studies in the current review demonstrated positive effects. For example, according to the overload principle, exercise below a minimum intensity or threshold will not sufficiently challenge the body to produce improvements.
      • Garber C.E.
      • Blissmer B.
      • Deschenes M.R.
      • et al.
      American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
      Many studies in the current review did not adequately report program content or compliance, creating uncertainty whether adequate intensity or compliance with exercise was reached. Furthermore, the rationale for the exercise program content was infrequently described and at times questionable; 1 knee study
      • 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.
      included only 1 lower limb exercise (strengthening of the “femoral flexors”) while the remaining exercises targeted the upper limbs and trunk. In contrast, the control group in another study
      • McKay C.
      • Prapavessis H.
      • Doherty T.
      The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study.
      completed upper limb exercises.
      Recently, the Consensus on Therapeutic Exercise Training (CONTENT) scale was developed using the Delphi method to assess the therapeutic validity of exercise programs.
      • Hoogeboom T.J.
      • Oosting E.
      • Vriezekolk J.E.
      • et al.
      Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis.
      During a systematic review of studies that assessed the postoperative effects of preoperative exercise programs for people awaiting joint replacement surgery, Hoogeboom et al
      • Hoogeboom T.J.
      • Oosting E.
      • Vriezekolk J.E.
      • et al.
      Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis.
      applied the CONTENT scale and found that none of the 12 studies demonstrated adequate therapeutic validity. Given that the current review included these 12 studies, the results of Hoogeboom's review
      • Hoogeboom T.J.
      • Oosting E.
      • Vriezekolk J.E.
      • et al.
      Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis.
      suggest that poor therapeutic validity could be an important reason why many studies in the current review failed to demonstrate beneficial effects.
      Highly standardized “one-size-fits-all” interventions could also explain why few individual studies in the current review demonstrated beneficial effects. Although methodologically rigorous, highly standardized protocols do not allow for individualized treatments.
      • Bennell K.L.
      • Egerton T.
      • Pua Y.H.
      • Abbott J.H.
      • Sims K.
      • Buchbinder R.
      Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for patients with hip osteoarthritis.
      Most studies in the current review used a standardized suite of exercises, with some individualization for pain response, general fitness level, and exercise progression. Bennell et al
      • Bennell K.L.
      • Egerton T.
      • Pua Y.H.
      • Abbott J.H.
      • Sims K.
      • Buchbinder R.
      Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for patients with hip osteoarthritis.
      suggested that an individualized program that allows the therapist to choose the most appropriate combination, difficulty, and intensity level of exercises based on individual and ongoing assessment findings and treatment priorities might yield more effective interventions than 1 suite of exercises for all participants. An individualized assessment-based approach to exercise prescription will also identify patients with the greatest physical impairments and, as others have demonstrated,
      • Hulzebos E.H.
      • Helders P.J.
      • Favie N.J.
      • De Bie R.A.
      • Brutel de la Riviere A.
      • Van Meeteren N.L.
      Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial.
      those with the most potential to benefit from an intervention.

      Study limitations

      Although we conducted a wide-ranging literature search for eligible studies, other studies might exist. Although studies were selected according to predetermined eligibility criteria, only 1 reviewer selected studies for inclusion. Two reviewers might have reduced the potential for error or bias with study selection. Regardless, we believe that the current review represents the most comprehensive collation of evidence to date on the preoperative effects of exercise-based interventions for people awaiting joint replacement surgery of the hip or the knee. Furthermore, we did not assess for publication bias; absent, delayed, or obscurely published studies might exist that were not included in the current review, which increases the potential for inflated effect sizes.
      • Guyatt G.H.
      • Oxman A.D.
      • Montori V.
      • et al.
      GRADE guidelines: 5. Rating the quality of evidence-publication bias.
      We assessed pain and physical function because they are core outcome measures recommended in osteoarthritis trials.
      • Bellamy N.
      • Kirwan J.
      • Boers M.
      • et al.
      Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis: consensus development at OMERACT III.
      However, intervention effects might exist for other important variables not measured in the current review such as psychological well-being.
      Study sample sizes were relatively small, which precluded most studies from being adequately powered to detect small- to medium-sized effects. Small sample sizes also increase the likelihood that baseline differences between groups affected postintervention results. For example, differences between the groups at baseline might cause, or obscure, postintervention effects. Because the meta-analysis compared postintervention scores, baseline differences, including statistically nonsignificant differences, could have affected meta-analysis results and this is a limitation of the analysis.
      For people awaiting knee replacement, meta-analysis revealed significant statistical heterogeneity for outcomes of pain, muscle strength, and walking speed. Forrest plots revealed that Swank et al’s
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      results were noticeably different from those of the remainder of the studies, suggesting that their study is clinically or methodologically different.

      Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011. Available at: www.cochrane-handbook.org.

      The methodologic quality of Swank's study
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      was similar to that of other studies when assessed with the PEDro scale, though notably, assessment was not blinded, which increases the risk of bias and the chance of inflated effect sizes.
      • Fransen M.
      • McConnell S.
      Exercise for osteoarthritis of the knee.
      • Altman D.G.
      • Schulz K.F.
      • Moher D.
      • et al.
      The revised CONSORT statement for reporting randomized trials: explanation and elaboration.
      However, other studies
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • 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.
      had nonblinded assessment yet produced small or negligible effect sizes. Swank excluded 16 potential participants because of “excessive pain with modest exercise,”
      • Swank A.M.
      • Kachelman J.B.
      • Bibeau W.
      • et al.
      Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis.
      (p320) an exclusion criterion not evident in other studies in the current review. It is possible, although untested, that exercise-based interventions are more effective in those with lower levels of knee pain where exercise might be more tolerable.
      Changes in analgesia usage during the study period could have influenced pain and physical function. Few studies measured analgesia usage, and only 2 studies
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.A.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      indicated that analgesia usage was unchanged. Hence, the influence of analgesia on the studies’ results remains largely unknown and confounds our ability to understand the specific nonpharmacologic effects of the interventions.

      Conclusions

      Implications for practice

      Although surgery is indicated when conservative treatment has failed,
      • Burke D.W.
      • O’Flynn H.
      Primary total knee arthroplasty.
      • Berry D.J.
      Primary total hip arthroplasty.
      reports suggest that the proportion of people who actually receive nonpharmacologic interventions before surgery might actually be small.
      • Shrier I.
      • Feldman D.E.
      • Gaudet M.C.
      • et al.
      Conservative non-pharmacological treatment options are not frequently used in the management of hip osteoarthritis.
      • Power J.D.
      • Cott C.A.
      • Badley E.M.
      • Hawker G.A.
      Physical therapy services for older adults with at least moderately severe hip or knee arthritis in 2 Ontario counties.
      The results of the current review indicate that people awaiting hip replacement surgery can benefit from preoperative exercise programs. Because people can wait many months for surgery and might experience further deterioration in health-related quality of life during long waits,
      • Ackerman I.N.
      • Bennell K.L.
      • Osborne R.H.
      Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.
      prescribing preoperative exercise as soon as people are approved for hip surgery could play an important role toward improving preoperative quality of life. However, the hip studies in the current review conducted the intervention shortly before surgery and only assessed preoperative outcomes immediately after the intervention. Hence, it remains unknown whether preoperative programs can lead to sustained preoperative improvements for people awaiting hip joint replacement surgery.
      Two recent systematic reviews
      • Hoogeboom T.J.
      • Oosting E.
      • Vriezekolk J.E.
      • et al.
      Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis.
      • Wallis J.A.
      • Taylor N.F.
      Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery—a systematic review and meta-analysis.
      assessed the postoperative effects of preoperative exercise programs for people awaiting joint replacement surgery and found few postoperative benefits for length of hospital stay, pain, and functional recovery. Given the results of the current review, the absence of postoperative benefits for knee replacement participants is not surprising given the absence of preoperative effects. Although assessing postoperative effects was beyond the scope of the current review, the failure of other recent reviews to find postoperative benefits for hip replacement participants suggests that preoperative benefits might not translate into postoperative benefits. It is possible that the impact of surgery might obscure the changes produced by preoperative exercise.
      There were insufficient studies with distinguishable exercise program content to enable meaningful subgroup analyses comparing different types of exercise programs within the hip and knee groups. Hence, without further research, specific recommendations cannot be made regarding the optimal design of an exercise program. However, an individualized assessment-based approach to exercise prescription is recommended that might include a combination of strengthening, flexibility, and aerobic exercises to address each person’s specific physical impairments.
      • Bennell K.L.
      • Egerton T.
      • Pua Y.H.
      • Abbott J.H.
      • Sims K.
      • Buchbinder R.
      Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for patients with hip osteoarthritis.
      Exercises should be of sufficient intensity, frequency, and duration to produce a therapeutic effect according to the principles of exercise training.
      • Garber C.E.
      • Blissmer B.
      • Deschenes M.R.
      • et al.
      American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
      Pool-based exercises should be considered; however, the potential benefits of pool-based exercise need to be reviewed in light of participants’ ability to access and meet the financial costs of attending a pool. With the exception of pool-based exercise, most exercise programs in the current review required inexpensive equipment or facilities; hence, reproducing these exercises should be feasible in a variety of settings not limited to physiotherapy departments.

      Implications for future research

      Additional research evaluating the preoperative effects of exercise-based programs is required to address the current studies’ limitations such as small sample sizes and unblinded assessment. Research is also required to determine
      • whether exercise has different effects for or is differently tolerated by people awaiting knee replacement versus hip replacement,
      • whether exercise can produce sustained preoperative improvements particularly for people awaiting hip replacement surgery, and
      • the optimal design of exercise-based interventions including the type, frequency, intensity, and duration of the program.

      Appendix 1. Database search strategies

        CINAHL

      • 1.
        exp *Physical Therapy/
      • 2.
        exp *EXERCISE/
      • 3.
        exp *GROUP EXERCISE/
      • 4.
        exp *THERAPEUTIC EXERCISE/
      • 5.
        exp *REHABILITATION/
      • 6.
        exp *HOME REHABILITATION/
      • 7.
        exp *REHABILITATION, COMMUNITY-BASED/
      • 8.
        exp *RESEARCH, REHABILITATION/
      • 9.
        exp *REHABILITATION, GERIATRIC/
      • 10.
        exp *HYDROTHERAPY/
      • 11.
        exp *Aquatic Exercises/
      • 12.
        exp *physical activity/
      • 13.
        exp *physical fitness/
      • 14.
        exp *physical exertion/
      • 15.
        exp *athletic training/
      • 16.
        1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15
      • 17.
        exp HIP/
      • 18.
        exp HIP JOINT/
      • 19.
        exp KNEE/
      • 20.
        exp KNEE JOINT/
      • 21.
        hip.mp. [mp=title, CINAHL subject headings, abstract, instrumentation]
      • 22.
        knee.mp. [mp=title, CINAHL subject headings, abstract, instrumentation]
      • 23.
        exp Hip Surgery/
      • 24.
        exp Knee Surgery/
      • 25.
        exp ARTHROPLASTY/
      • 26.
        exp ARTHROPLASTY, REPLACEMENT/
      • 27.
        exp ARTHROPLASTY, REPLACEMENT, HIP/
      • 28.
        exp ARTHROPLASTY, REPLACEMENT, KNEE/
      • 29.
        exp Joint Prosthesis/
      • 30.
        joint replacement.mp. [mp=title, CINAHL subject headings, abstract, instrumentation]
      • 31.
        arthroplasty.mp. [mp=title, CINAHL subject headings, abstract, instrumentation]
      • 32.
        23 or 24 or 27 or 28
      • 33.
        17 or 18 or 19 or 20 or 21 or 22
      • 34.
        25 or 26 or 29 or 30 or 31
      • 35.
        33 and 34
      • 36.
        32 or 35
      • 37.
        16 and 36

        MEDLINE

      • 1.
        exp *EXERCISE/
      • 2.
        exp *REHABILITATION/
      • 3.
        exp *HYDROTHERAPY/
      • 4.
        exp *EXERCISE THERAPY/
      • 5.
        exp *Swimming/
      • 6.
        exp *Exercise Movement Techniques/
      • 7.
        exp *Physical Therapy Modalities/
      • 8.
        exp *“Physical Therapy (Specialty)”/
      • 9.
        exercise.mp. [mp=title, abstract, CAS registry/ec number word, MeSH subject heading]
      • 10.
        physiotherapy.mp. [mp=title, abstract, CAS registry/ec number word, MeSH subject heading]
      • 11.
        physical therapy.mp. [mp=title, abstract, CAS registry/ec number word, MeSH subject heading]
      • 12.
        exp *SWIMMING/
      • 13.
        exp *EXERTION/
      • 14.
        1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
      • 15.
        exp HIP/
      • 16.
        exp HIP JOINT/
      • 17.
        exp KNEE/
      • 18.
        exp KNEE JOINT/
      • 19.
        hip.mp. [mp=title, abstract, CAS registry/ec number word, MeSH subject heading]
      • 20.
        knee.mp. [mp=title, abstract, CAS registry/ec number word, MeSH subject heading]
      • 21.
        exp Joint Prosthesis/
      • 22.
        exp Hip Prosthesis/
      • 23.
        exp Knee Prosthesis/
      • 24.
        exp “Prostheses and Implants”/
      • 25.
        exp ARTHROPLASTY/
      • 26.
        exp ARTHROPLASTY, REPLACEMENT/
      • 27.
        exp ARTHROPLASTY, REPLACEMENT, HIP/
      • 28.
        exp ARTHROPLASTY, REPLACEMENT, KNEE/
      • 29.
        arthroplasty.mp.
      • 30.
        joint replacement.mp.
      • 31.
        21 or 24 or 25 or 26 or 29 or 30
      • 32.
        15 or 16 or 17 or 18 or 19 or 20
      • 33.
        31 and 32
      • 34.
        22 or 23 or 27 or 28
      • 35.
        33 or 34
      • 36.
        14 and 35

        Embase

      • 1.
        exp *Physiotherapy/
      • 2.
        exp *Physical Activity/
      • 3.
        exp *EXERCISE/
      • 4.
        exp *Kinesiotherapy/
      • 5.
        exp *HYDROTHERAPY/
      • 6.
        exp *REHABILITATION/
      • 7.
        exp *FITNESS/
      • 8.
        exp ARTHROPLASTY/
      • 9.
        exp HIP ARTHROPLASTY/
      • 10.
        exp KNEE ARTHROPLASTY/
      • 11.
        exp JOINT PROSTHESIS/
      • 12.
        exp Knee Prosthesis/
      • 13.
        exp Hip Prosthesis/
      • 14.
        exp HIP/
      • 15.
        exp KNEE/
      • 16.
        14 or 15
      • 17.
        8 or 11
      • 18.
        16 and 17
      • 19.
        exp Total Knee Replacement/
      • 20.
        exp Total Hip Prosthesis/
      • 21.
        exp Knee Surgery/
      • 22.
        exp Hip Surgery/
      • 23.
        joint replacement.mp.
      • 24.
        arthroplasty.mp.
      • 25.
        9 or 10 or 12 or 13 or 18 or 19 or 20 or 21 or 22 or 23 or 24
      • 26.
        1 or 2 or 3 or 4 or 5 or 6 or 7
      • 27.
        25 and 26

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